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2019v1.0
Dental Materials
Clinical Applications for
Dental Assistants and Dental Hygienists
This page intentionally left blank

     
 FOURTH EDITION

Dental Materials
Clinical Applications for
Dental Assistants and Dental Hygienists

W. STEPHAN EAKLE, DDS, FADM

Professor of Clinical Dentistry Emeritus,
Department of Preventive and Restorative Dental Sciences,
School of Dentistry, University of California,
San Francisco, California

KIMBERLY G. BASTIN, CDA, EFDA, CRDH, MS

Assistant Professor and Director of Dental Hygiene,
State College of Florida Manatee-Sarasota,
Bradenton, Florida
3251 Riverport Lane
St. Louis, Missouri 63043

DENTAL MATERIALS: CLINICAL APPLICATIONS FOR DENTAL ASSISTANTS

AND DENTAL HYGIENISTS, FOURTH EDITION ISBN: 978-0-323-59658-9

Copyright © 2021, by Elsevier Inc. All rights reserved.

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or
mechanical, including photocopying, recording, or any information storage and retrieval system, without
permission in writing from the publisher. Details on how to seek permission, further information about the
Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance
Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions.

This book and the individual contributions contained in it are protected under copyright by the Publisher
(other than as may be noted herein).

Notices

Practitioners and researchers must always rely on their own experience and knowledge in evaluating and
using any information, methods, compounds or experiments described herein. Because of rapid advances
in the medical sciences, in particular, independent verification of diagnoses and drug dosages should be
made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors or con-
tributors for any injury and/or damage to persons or property as a matter of products liability, negligence
or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in
the material herein.

Previous editions copyrighted 2016, 2011, 2003.

Library of Congress Control Number: 2020900776

Content Strategist: Joslyn Dumas

Senior Content Development Manager: Luke Held
Senior Content Development Specialist: Kelly Skelton
Publishing Services Manager: Deepthi Unni
Senior Project Manager: Manchu Mohan
Design Direction: Renee Duenow

Printed in Canada

Last digit is the print number: 9 8 7 6 5 4 3 2 1

Reviewers

Jennifer Cooper, RRDH, BSc, MSc Kathy Ann Pierce, CDA, RDA, EFDA, BS
Coordinator, Dental Assisting Faculty, Health Sciences
Fanshawe College Western Iowa Tech Community College
London, Ontario, Canada Sioux City, Iowa

Stephanie Meredith, RDH, BS, MSDH Amanda R. Reddington, LDH, MHA, CDA, EFDA
Program Director, Sarah Whitaker Glass School of Dental Clinical Assistant Professor Dental Assisting and Dental
Hygiene Hygiene
West Liberty University University of Southern Indiana
West Liberty, West Virginia Evansville, Indiana

v
Preface

LIFELONG LEARNING FEATURES

The subject of dental materials is rapidly changing as The chapters have the following components:
researchers and manufacturers develop new materi- • Learning and performance objectives to guide stu-
als and improve those currently in use. Consequently, dents in learning.
dental hygienists and dental assistants are challenged • Key terms listed and defined in the order of their
to keep up with the new materials, their physical presentation in the chapters and highlighted in the
properties, their handling characteristics, and their chapters in colored print.
clinical applications. As important members of the • Basic principles and applications, physical proper-
dental team, they must be adept at placing or assisting ties, and handling characteristics of the dental ma-
in the placement of dental materials, and they play a terials presented in each chapter.
valuable role in the maintenance of dental materials • Generous use of color illustrations and photogra-
once they are in the mouth. Dental hygienists and phy throughout to aid learning.
dental assistants also are instrumental in educating • Helpful clinical tips or precautions regarding the
patients in the home maintenance of restorations and use of the materials, highlighted in boxes set apart
prostheses and what to expect with a new prosthesis. from the main text for emphasis.
As allied oral health providers, dental hygienists and • Illustrated clinical and laboratory procedures pre-
dental assistants play major roles in preventive edu- sented in step-by-step instructions so that students
cation and therapy in most practices. To stay current, can practice common applications of the materials.
they must be lifelong learners who know how to use Notes at the top of the procedure sheets guide the
available resources to update their knowledge. Den- clinician as to precautions for patients or clinicians
tal Materials: Clinical Applications for Dental Assistants and alert the clinician when procedures may not be
and Dental Hygienists provides the foundation for that allowed by all state dental boards.
lifelong learning for the new student and serves as • Competency assessment forms for each procedure to
an important update on new materials and improve- test skills attainment located on the Evolve website.
ments in materials for the practicing assistant or hy- • Review questions to enable students to test their
gienist. In addition, it provides them with sound cri- comprehension of the subject matter and prepare
teria for evaluating steps in the restorative process in for examinations; answers are provided at the end
which they will play a role, such as making accurate of the book.
alginate and elastomeric impressions, cord retraction • Case-based discussion topics that encourage stu-
and selection and application of a matrix for compos- dents to relate what they have learned to the actual
ite and amalgam. application in the dental office. Instructors may
want to use them as topics for group discussions.
• Reference lists at the end of each chapter to help
KEY GOALS students find additional information about the prin-
The goal of Dental Materials: Clinical Applications for ciples, procedures and properties of the dental ma-
Dental Assistants and Dental Hygienists is to provide terials discussed.
students with the following: • Links to instructional videos are available on the
• The principles of dental materials so they can un- EVOLVE website to enhance and reinforce materi-
derstand the rationale for the use of these materials als presented.
• The opportunity to apply newly gained knowledge
through clinical and laboratory procedures
NEW TO THIS EDITION
• The ability to evaluate their work using accepted
criteria • N ew illustrations and clinical photographs throughout
• The opportunity to test their knowledge and pre- • Additional instructional videos with links found on
pare for board examinations the Evolve website to supplement learning from the
• The opportunity to apply critical thinking through text
the use of case-based discussion questions • New Clinical tips and Cautions
• Bioactive dental materials are presented

vi
 PREFACE vii

• E xpanded information on staining and glazing ce- FOR STUDENTS

ramic restorations - Practice Quizzes
• Additional information on mercury safety practices - Competency forms
• Enhanced information on amalgam matrix and - Instructional video links
wedge placement
• Illustrated information on the crystalline structure
A NOTE TO EDUCATORS
of metals
• CAD/CAM technology applied to implant plan- Dental Materials: Clinical Applications for Dental Assis-
ning, placement and restoration including digital tants and Dental Hygienists is written to be easily com-
impressions prehended by students with varying amounts of sci-
• Air polishing for implant cleaning: indications and ence in their educational backgrounds. Learning and
contraindications performance objectives draw the students’ attention
• Suture materials to the important concepts and features of the mate-
• New illustrated procedures: removal of sutures; fab- rials. Key terms are not only listed but also defined
rication of custom impression trays with Triad mate- at the start of each chapter. Helpful clinical tips are
rial; making a wax bite registration; fluoride varnish used throughout the chapters to call attention to clini-
application; and silver diamine fluoride application cal points to which the student may not have been ex-
• Luting cements have been reorganized according to posed, and cautions are noted where appropriate for
their composition and the section on resin cements the safety of both the patient and the clinician. The book
has been expanded to include more on self-adhesive is generously illustrated to help with the comprehen-
resin cements sion of clinical and laboratory procedures, especially
• The section on surgical dressings has been expanded for our visual learners. The procedures help the stu-
and illustrated steps for placement and removal have dents to see how the materials are actually used, and
been added when students apply their newly gained knowledge,
• A section on digital dentures explaining the use of the procedures reinforce learning. Review questions
CAD/CAM technology for denture construction. help reinforce what the students have learned and help
• New information on detection and management of prepare them for board examinations. Case-based dis-
denture sores to aid home care cussion topics can be used for group discussions and
• Use of CAD/CAM Provisional Materials bring the flavor of real-life dentistry to the application
• Introduction to 3-D printing of dental materials.
• Introduction to probiotics Additional material is included on the Evolve
• Expansion of information on whitening products website. Chapter quizzes (270 total questions) help
• Expansion of information on fluoride varnish, and students prepare for classroom and board exams.
­
new material on silver diamine fluoride Competencies are included for each procedure so that
• Expanded information on powders utilized in air students can evaluate their own efforts and also re-
polishing to include glycine and erythritol ceive feedback from their instructors.
• Expansion of information on thumb sucking devices,
palatal expanders, and crossbite correctors.
YOUR COMMENTS, PLEASE
The authors would appreciate suggestions or
EVOLVE comments regarding this book because it is written
An expanded Evolve website is key to this edition. The with your needs in mind. We hope instructors and
Evolve website provides a variety of resources for both students will enjoy this book and gain as much from it
instructors and students. as we have intended.

FOR INSTRUCTORS W. Stephan Eakle, Stephan.

[email protected]
- TEACH Instructor’s Resource Manual (includes an-
Kimberly G. Bastin
swer keys, lesson plans, PowerPoints, and student
[email protected]
handouts)
- Test Bank
- Image Collection
Acknowledgments

The authors express their appreciation to the many A special thanks to our family members Sheila Eakle,
people whose contributions to this edition were in- Rachel, Olivia, Sam and Emi for your energy and in-
valuable. We thank the dental researchers and clini- spiration; to Jimmy ­Bastin who continually provided
cians upon whose work this book is based. We thank encouragement, feedback, guidance, and support; to
them for clinical illustrations that enhance the quality Toni McLeroy a friend and colleague who is always
of this edition and help the learner to visualize what a positive influence and cheerleader; and our friends,
cannot be defined solely by the written word. We thank and colleagues for their patience when we were not
our colleagues for their expertise and suggestions. We available to them and for their enthusiastic and endless
thank the dental manufacturers who provided techni- support throughout this endeavor.
cal information on dental materials and relevant illus- We also owe a debt of gratitude to previous authors,
trated procedures. Without your assistance this edition Bill Bird and Carol Hatrick, who provided the initial
would not have been complete. impetus to write this book and devoted countless
The authors thank the editorial team at Elsevier, hours to conceiving and writing previous editions. We
in particular Joslyn Dumas, Luke Held, Kelly Skelton thank you for your dedication and superb efforts on
and Manchu Mohan for their commitment, encourage- behalf of students and educators.
ment, and tireless efforts in bringing this fourth edition To all of you we remain most grateful.
to fruition.

viii
Contents

1 Introduction to Dental Materials, 1 Secondary Bonds, 27

The Role of the Dental Auxiliary in the Use of The Three States of Matter, 28
Dental Materials, 1 Properties of Dental Materials, 29
Evidenced-Based Dentistry, 2 Physical Properties, 29
The Historical Development of Dental Mechanical Properties, 29
Materials, 2 Chemical Properties, 32
The Agencies Responsible for Standards, 5 Classification of Materials, 32
American Dental Association, 5 Composition, 33
U.S. Food and Drug Administration, 5 Reaction Activated by mixing, 33
International Agencies, 6 Manipulation of Materials, 34
Future Developments in Dental Biomaterials, 6 Ratios of Components, 35
Effect of Temperature and Humidity, 35
2 Oral Environment and Patient Considerations, 8 Mixing of Components, 35
Classification of Dental Materials, 9 Shelf Life, 35
Preventive/Therapeutic Materials, 9 Summary, 35
Restorative Materials, 10
4 General Handling and Safety of Dental Materials in
Auxiliary Materials, 10
the Dental Office, 38
Biocompatibility, 10
Adverse Response, 10 Material Hazards in the Dental Environment, 38
Oral Factors Affecting Dental ­Materials, 11 Exposure to Particulate Matter, 38
Biomechanics, 11 Exposure to Biological Contaminants, 39
Force, Stress and Strain, 11 Bio-Aerosols in the Dental Setting, 39
Force, 11 Dental Bio-Aerosols, 39
Moisture and Acid Levels, 13 Chemical Safety in the Dental
Effect of pH, 13 Office, 40
Galvanism, 14 Hazardous Chemicals, 40
Temperature, 15 Skin and Eyes, 40
Expansion and Contraction, 15 Inhalation, 40
Thermal Conductivity, 15 Ingestion, 42
Retention, 16 Exposure to Bisphenol A, 42
Mechanical and Chemical Retention, 16 Exposure to Mercury, 42
Bonding, 16 Acute and Chronic Chemical ­Toxicity, 42
Microleakage, 17 Acute Chemical Toxicity, 42
Esthetics and Color, 18 Chronic Chemical Toxicity, 43
Oral Biofilm and Dental Materials, 19 Personal And Chemical Protection, 43
Formation of Oral Biofilm, 19 Hand Protection, 43
Biofilm and Oral Disease, 19 Eye Protection, 43
Probiotics, 19 Protective Clothing, 43
Biofilm and Systemic Diseases, 20 Inhalation Protection, 44
Biofilm on Dental Materials, 20 Control of Chemical Spills, 44
Managing the Oral Biofilm, 20 Mercury Spill, 44
Detection of Restorative Materials, 20 Flammable Liquids, 44
Summary, 23 Acids, 44
Eyewash, 44
3 Physical and Mechanical Properties of Dental Ventilation, 44
Materials, 25 General Precautions for Storing Chemicals, 44
Physical Structure, 26 Disposal of Chemicals, 45
Atoms, 26 Empty Containers, 45
Types of Bonds, 26 Hazardous Waste Disposal, 46
ix
x CONTENTS

Dental Laboratory Infection Control, 46 Matrix Systems, 100

Occupational Safety and Health Administration Light-Curing, 102
Hazard Communication Standard, 47 Finishing and Polishing, 106
Hazard Communication Program, 48 Why Composites Fail, 107
Labeling of Chemical Containers and Safety Composite Repair, 109
Data Sheets, 49 Indirect-Placement Composite Resins, 109
Labeling Exemptions, 49 Laboratory-Processed Composites, 109
Eco-Conscience Green Practices, 50 Glass Ionomer Cements, 110
Patient Safety, 51 Conventional Glass Ionomer Cements, 110
Summary, 52 Physical and Mechanical Properties, 111
Packaging, 111
5 Principles of Bonding, 55 Uses for Glass Ionomer Cements, 112
Basic Principles of Bonding, 56 Resin-Modified (Hybrid) Ionomers, 114
Preparation for Bonding Restorations, 56 Nano-ionomers, 114
Bonding to the Etched Surface, 56 Clinical Application of Glass Ionomer
Surface Wetting, 57 Cements, 115
Bond Strength, 57 Compomers, 115
Etching Enamel And Dentin, 58 Giomers, 116
Enamel Etching, 58 Bioactive Dental Materials, 116
Dentin Etching, 59 Summary, 116
Bonding Systems, 63
Classification of Bonding Systems, 64 7 Preventive and Desensitizing Materials, 123
Etch-and-Rinse Bonding Systems Fluoride, 124
(Generations 4 and 5), 64 Topical and Systemic Effects, 124
Self-Etch Bonding Systems Protection Against Erosion, 125
(Generations 6 and 7), 66 Bacterial Inhibition, 125
Modes of Cure of Adhesives, 70 Fluoride and Antibacterial Rinses for the Control
Oxygen-Inhibited Layer, 70 of Dental Caries, 125
Biocompatibility, 70 Methods of Delivery, 126
Compatibility with Other Resins, 70 Safety, 130
Microleakage, 71 Pit and Fissure Sealants, 131
Contamination of Bonding Site, 71 Purpose, 131
Postoperative Sensitivity, 72 Indications, 131
Clinical Applications for Bonding, 72 Susceptibility of Teeth to Fissure Caries, 133
Bonding of Restoration, 72 Composition, 133
Ceramic Bonding and Repair, 73 Working Time, 134
Metal Bonding, 73 Color and Wear, 134
Amalgam Bonding, 73 Placement, 134
Composite Resin Repair, 74 Patient Record Entries, 135
Orthodontic Bracket Bonding, 74 Effectiveness, 136
Bonding of Ceramic Veneers, 74 Troubleshooting Problems with Sealants, 136
Bonding of Endodontic Posts, 74 Glass Ionomer Cement as a Sealant, 136
Summary, 75 Desensitizing Agents, 137
Mechanism of Tooth Sensitivity, 137
6 Composites, Glass Ionomers, and Compomers, 83 Treatment, 137
History of the Development of Composite Resin Categories and Components of Desensitizing
for Dentistry, 84 Agents, 138
Direct-Placement Esthetic Restorative Remineralization, 138
Materials, 85 Products, 138
Composite Resin, 85 Resin Infiltration, 139
Components, 85 Summary, 140
Polymerization, 86
Physical and Mechanical Properties of 8 Teeth Whitening Materials and Procedures, 148
Composites Resins, 87 Teeth Whitening (Bleaching), 148
Classification of Composites by Filler Size, 90 Types of Stains, 148
Other Composite Types, 92 History of Peroxide Whitening, 150
Clinical Handling of Composites, 95 How Whitening Works, 150
How to Match The Shade, 96 In-Office Whitening, 152
Placing The Composite, 98 Vita Bleaching Guide 3D Master, 152
 CONTENTS xi

Home Whitening (Prescribed by The Dentist), 155 10 Dental Amalgam, 192

Home Whitening Process, 155 Dental Amalgam, 193
Over-the-Counter Products, 156 Alloys Used in Dental Amalgam, 193
Non-Dental Options, 157 Silver-Based Amalgam Alloy Particles, 193
Role of the Dental Auxiliary, 157 Setting Transformation (Amalgamation), 194
Potential Side Effects of Teeth Whitening, 157 Properties of Amalgam, 195
Restorative Considerations, 158 Applications for Dental Amalgam, 197
Retreatment, 158 Matrix Systems, 197
Enamel Microabrasion, 159 Use of Matrix Bands, 197
Adverse Outcomes, 160 Sectional Matrix Systems, 202
Summary, 160 Handling Characteristics Of High-Copper
Alloys, 202
9 Dental Ceramics, 167
Manipulation Of Amalgam, 203
Dental Ceramics, 168 Dispensing of Alloy and Mercury, 203
Glass and Non-glass Ceramics, 168 Matrix Application, 204
Advantages and Disadvantages of Ceramic Trituration, 204
Restorations, 168 Working and Setting Times, 204
Glass–Based Ceramics, 169 Placement and Condensation, 205
Porcelain, 169 Burnishing and Carving, 206
Reinforced Glass-Based Ceramics, 170 Checking the Occlusion, 206
Survival Rates for Glass-Based Ceramics, 170 Finishing and Polishing, 206
Non-Glass-Based Ceramics, 170 Use of a Cavity Sealer, 207
Alumina, 170 Longevity Of Amalgams, 207
Zirconia, 170 Repair of Amalgam, 208
Physical And Mechanical Properties, 171 Bonding Amalgam, 209
Flexural Strength, 171 Allergy To Amalgam, 209
Thermal Properties, 171 Mercury Safety Procedures, 209
Optical Properties, 171 ADA Stance on Dental Amalgam Safety, 209
Biocompatibility, 172 Concerns About the Safety of Amalgam, 210
Ceramic Processing Techniques, 172 Restrictions on Amalgam Use, 211
Sintering, 172 Summary, 212
Slip-casting, 172
Heat-Pressing, 172 11 Metals and Alloys, 220
Computer-Aided Machining, 173 Structure of Metals And Alloys, 221
CAD/CAM Technology, 173 Pure Metals, 221
Basic Components of CAD/CAM Systems, 173 Alloys, 221
Incorporating CAD/CAM Technology into Private Properties of Casting Alloys, 223
Practice, 173 Biocompatibility, 224
Role of the Assistant/Hygienist, 175 Porcelain Bonding Alloys, 225
Working with the Laboratory, 175 Porcelain-Bonded-to-Metal
CAD/CAM Restorations, 175 Restorations, 225
Ceramic CAD/CAM Materials, 176 Titanium And Its Alloys, 226
Clinical Applications for Ceramic Materials, 178 Sintered Composite Alloys, 227
Rationale for Selection of Ceramic Materials, 178 Removable Prosthetic Casting Alloys, 227
Veneers, 179 Identalloy Program, 228
Porcelain-Metal Restorations, 180 Solders, 229
Ceramic Inlays, Onlays, and Fixed Partial Gold Solders, 229
Dentures (Bridges), 182 Silver Solders, 229
Finishing and Polishing Ceramic Restorations, Wrought Metal Alloys, 229
183 Preformed Provisional Crowns, 230
Cementation of All-Ceramic Restorations, 184 Metals Used in Orthodontics, 230
Maintenance of All-Ceramic Restorations, 185 Wires, 230
Removal of All-Ceramic Restorations, 185 Brackets and Bands, 231
Shade Taking, 185 Retainers and Removable Orthodontic Appliances, 231
Involving the Dental Assistant/Hygienist and the Space Maintainers, 231
Patient, 186 Metals Used In Endodontics, 232
Steps for Shade Taking, 186 Endodontic Files and Reamers, 232
Devices for Taking the Shade, 188 Endodontic Posts, 232
Summary, 188 Summary, 236
xii CONTENTS

12 Dental Implants, 239 Polishing During Oral Prophylaxis (Coronal

Dental Implants, 240 Polish), 283
Endosseous Implants, 240 Amalgam, 283
Indications for Implants, 241 Composite, 283
Contraindications for Implants, 241 Gold Alloys and Ceramics, 284
Benefits of Implants, 241 Resin/Cement Interface, 284
Implant Components, 241 Implants, 284
Implant Materials, 242 Air Polishing and Air Abrasion, 284
Implant Fixture Designs, 243 Laboratory Finishing and Polishing, 286
Image-Guided Implant Planning and Surgery, 244 Rag Wheel, 286
Implant Planning Software, 244 Felt Cones and Wheels, 287
Advantages of Guided Implant Surgery, 244 Safety/Infection Control, 287
CAD/CAM Technology, 245 Patient Education, 287
Implant Placement And Restoration, 245 Summary, 287
Informed Consent, 245
14 Dental Cement, 293
Surgical Risks, 245
Preparation of the Patient for Surgery, 246 Dental Cements, 294
Postsurgical Instructions, 246 Classification, 294
Preparing the Operatory for Surgery, 246 Uses of Dental Cements, 294
Implant Placement Surgeries, 246 Type I Cements: Luting Agents, 299
Two-Stage Surgical Procedure, 246 Properties of Luting Cements, 299
One-Stage Surgical Procedure, 247 Classification of Luting Agents Cements, 302
Immediate-Placement Surgical Procedure, 247 Water-based Luting Cements, 303
Immediate Loading, 248 Resin-based Luting Cements, 307
Restorative Phase, 248 Oil-based Luting Cements, 311
Implant Impression and Laboratory Components, 248 Bioactive Cements, 312
Impression Procedures, 248 Handling of Cements, 312
Retention of the Implant Crown, 250 Storage, 312
Retention of the Removable Prosthesis, 250 Precementation Check, 312
Mini-Implants, 250 Mixing, 313
Uses for Mini-implants, 252 Working and Setting Times, 313
Bone Grafting, 252 Loading the Restoration, 314
Purpose of Bone Grafting, 252 Removal of Excess Cement, 314
Types of Bone Grafts, 253 Cleanup, Disinfection, and Sterilization, 315
Barrier Membranes, 256 Cement-Associated Peri-Implant
Sinus Lift, 256 Disease, 315
Sutures, 257 Care around Margins, 315
Types of Sutures, 258 Summary, 316
Implant Longevity, 259
15 Impression Materials, 326
Implant Failure, 259
Long-term Success, 259 Overview of Impressions, 327
Implant Maintenance, 260 Types of Impressions, 328
Home Care, 260 Types of Impression Materials, 328
Hygiene Visit, 262 Impression Trays, 328
Summary, 264 Stock Trays, 329
Custom Trays, 330
13 Abrasion, Finishing, Polishing, and Cleaning, 270 Hydrocolloids, 330
Finishing, Polishing, Cleaning, 271 Reversible Hydrocolloid (Agar), 331
Factors Affecting Abrasion, 272 Irreversible Hydrocolloid (Alginate), 331
Mode of Delivery of Abrasives, 274 Making Alginate Impressions, 332
Materials Used in Abrasion, 275 Criteria for Clinically Acceptable Alginate
Preparations Used For Abrasion, 277 Impressions, 336
Finishing And Polishing Procedures, 280 Two-Consistency Alginate System, 336
Margination and Removal of Flash, 280 Elastomers, 336
Amalgam, 281 Use of Adhesive, 338
Finishing And Polishing Amalgam Restorations, 281 Elastic Recovery, 338
Composite, 282 Wettability, 338
Gold Alloy, 282 Polysulfides, 338
Ceramics (Porcelain), 282 Silicone Rubber Impression Materials, 339
 CONTENTS xiii

Polyvinyl Siloxane (Vinyl Polysiloxane), 339 Melting Range, 386

Vinyl Polyether Silicone Hybrid, 344 Flow, 386
Components of Impression Making for Crown Excess Residue, 386
and Bridge Procedures, 345 Thermal Expansion, 386
Gingival Retraction, 345 Classification of Waxes, 386
Making the Impression, 350 Pattern Waxes, 386
Digital Impressions, 351 Processing Waxes, 388
Learning Curve, 351 Impression Waxes, 388
Scanning Devices, 352 Other Waxes Utilized in the Dental
Advantages and Disadvantages of Digital Office, 389
Impressions, 353 Manipulation of Waxes, 389
Soft Tissue Management, 354 Lost Wax Technique, 389
Expanded Use of Digital Impressions, 354 Summary, 390
Inelastic Impression Materials, 354
Dental Impression Compound, 355 17 Polymers for Prosthetic Dentistry, 399
Impression Plaster, 355 Review of Polymer Formation, 400
Zinc Oxide Eugenol Impression Material, 355 Polymers, 400
Impression Wax, 355 Copolymers, 400
Infection Control Procedures, 355 Polymerization, 400
Disinfecting Impressions, 355 Cross-Linked Polymers, 400
Disinfecting Casts, 356 Polymerization Reactions, 400
Sterilizing Impression Trays, 356 Acrylic Resins (Plastics),401
Summary, 357 Uses of Acrylics, 401
Modifiers, 401
16 Gypsum and Wax Products, 374 Properties, 401
Uses and Desirable Qualities of Gypsum, 375 Allergic Reaction, 402
Desirable Qualities of Gypsum Products, 375 Acrylic Resins For Denture Bases, 403
Properties and Behaviors of Gypsum Polymerization Reaction, 403
Products, 376 Digital Dentures, 406
Chemical Properties, 376 Denture Reline Materials (Liners), 408
Production of Gypsum Products, 376 Soft Relining Materials, 408
Physical Properties, 377 Detection and Management of Denture Sores,
Classification of Gypsum Products, 378 409
Impression Plaster (Type I), 378 Home Care, 413
Model Plaster (Type II), 378 Hard Relining Materials, 413
Dental Stone (Type III), 379 Laboratory Reline, 415
Dental Stone, High-Strength/Low Expansion Over-the-Counter Liners, 415
(Type IV), 379 Denture Teeth, 416
Dental Stone High-Strength/High-Expansion Acrylic Resin Teeth, 416
(Type V), 379 Composite Resin Teeth, 416
Metal-Plated and Epoxy Dies and Resin- Porcelain Teeth, 416
Reinforced Die Stone, 380 Characterization of Dentures, 416
Investment Materials, 380 Plastics for Maxillofacial Prostheses, 417
Manipulation of Gypsum Products, 380 Denture Repair, 417
Material Selection, 380 Chemical-Cured Acrylic Repair Material, 417
Proportioning (Water-to-Powder Ratio), 380 Light-Cured Repair Material, 418
Mixing: Spatulation, 381 Custom Impression Trays and Record
Initial Setting Time and Working Time, 381 Bases, 418
Final Setting Time, 381 Chemical-Cured Tray and Record Base
Control of Setting Times, 382 Material, 418
Fabricating and Trimming Diagnostic/Working Light-Cured Tray and Record Base Material, 419
Casts, 382 Infection Control Procedures, 419
Storage, 384 Instructions for New Denture Wearers, 419
Cleanup, 384 What to Expect, 419
Infection Control and Safety Issues, 384 Care of Acrylic Resin Dentures, 420
Separating the Impression from the Cast, 384 Home Care, 420
Trimming, 385 In-Office Care, 421
Composition and Properties of Dental Storage of Dentures, 421
Waxes, 385 Summary, 422
xiv CONTENTS

18 Provisional Restorations, 432 5.1 Enamel and Dentin Bonding Using the Etch-and
Dental Procedures that may Require Provisional Rinse Technique, 76
Coverage, 432 5.2 Surface Treatment for Bonding Ceramic
Criteria for Provisional Coverage, 433 Restorations (Glass-based) or for Ceramic Repair, 77
Maintain Prepared Tooth Position Relative to 5.3 Bonding Orthodontic Brackets, 79
Adjacent and Opposing Teeth, 433 6.1 Placement of Class II Composite Resin
Protect the Exposed Tooth Surfaces and Margins, 433 Restoration, 117
Protect the Gingival Tissues, 434 7.1 Applying Sodium Fluoride Varnish, 141
Provide Function, 434 7.2 Applying Topical Fluoride, 142
Esthetics and Speech, 434 7.3 Applying Silver Diamine Fluoride (SDF), 143
Retention, 435 7.4 Applying Dental Sealants, 144
Properties of Provisional Materials, 435 8.1 In-Office Whitening, 161
Strength, 435 8.2 Clinical Procedures for Home Whitening, 162
Hardness, 435 8.3 Fabrication of Custom Whitening Trays, 164
Tissue Compatibility, 435 10.1 Placing and Carving Class II Amalgam, 212
Esthetics, 435 12.1 Suture Removal, 265
Provisional Crown Materials, 435 13.1 Finishing and Polishing a Preexisting Amalgam
Preformed Crowns, 436 Restoration, 288
Customized Provisional Crowns, 439 13.2 Polishing a Preexisting Composite Restoration, 290
Materials For Custom Provisional 14.1 Zinc Oxide Eugenol Cement (ZOE): Primary and
Restorations, 439 Secondary Consistency, 316
Methacrylate Provisional Materials (acrylics), 439 14.2 Zinc Phosphate Cement: Primary Consistency, 317
Composite Resin Provisional Material, 440 14.3 Zinc Polycarboxylate Cement: Primary
Methods of Fabrication of Custom Provisionals, 442 Consistency, 318
Advanced Technique, 445 14.4 Glass Ionomer Cement: Predosed Capsule, 319
Handling the Provisional Restoration, 446 14.5 Resin-Based Cement for Indirect Restorations:
Cementing the Provisional Restoration, 446 Ceramic, Porcelain, Composite, 321
Removing the Provisional Restoration, 447 14.6 Self-Adhesive Technique for Indirect
Clean-up, 447 Restorations: Ceramic, Porcelain, Composite, 322
Intracoronal Cement Provisional Restorations, 447 15.1 Fabrication of Custom Impression Tray Using
Patient Education, 448 Light-Cured Resin, 358
Home Care Instructions, 448 15.2 Making an Alginate Impression, 361
Summary, 448 15.3 Making a Double-Bite Impression for a Crown, 364
15.4 Bite Registration with Elastomeric Material, 367
19 Preventive and Corrective Oral Appliances, 460 15.5 Wax Bite Registration, 368
Preventive and Corrective Oral Appliances, 460 16.1 Mixing Gypsum Products, 391
Sports Mouth Guards, 460 16.2 Pouring the Cast: Anatomic Portion, 391
Night Guards (Bruxism Mouth Guards), 462 16.3 Pouring the Cast: Art (or Base) Portion, 393
Oral Appliances to Treat Snoring and Obstructive 16.4 Separating the Impression from the Cast, 394
Sleep Apnea, 464 16.5 Trimming Diagnostic Casts, 395
Preventive Orthodontics, 465 17.1 Fabrication of Custom Acrylic Impression Trays, 423
Space Maintainers, 465 17.2 Fabrication of Record Bases with Light-Cured
Interceptive Orthodontics, 465 Acrylic Resin, 425
Thumb Sucking Appliance, 465 18.1 Metal Provisional Crown, 449
Palatal Expansion Appliances, 466 18.2 Polycarbonate Provisional Crown, 451
Crossbite Corrector, 466 18.3 Custom Provisional Coverage: Direct
Orthodontic Tooth Aligners, 466 Technique, 454
Summary, 467 18.4 Intracoronal Cement Provisional
Restoration, 456
Appendix 19.1 Fabrication of a Sports Mouth Guard
(Protector), 468
Answers to Review Questions, 472

Glossary, 474 Appendix, 472

List of Procedures Glossary, 474
4.1 Safety Data Sheet and Label Exercise, 52 Index, 480
Introduction to Dental Materials 1
http://evolve.elsevier.com/Eakle/materials/

Chapter Objectives
Upon completion of this chapter, the student should be able to:
1. Discuss the importance of the study of dental materials for yourself or your practice to ensure you are increasing the
the allied oral health practitioner. potential for successful patient care outcomes?
2. Discuss why it is necessary that the allied oral health 4. Review the historical development of dental materials.
practitioner have an understanding of dental materials in 5. List and compare the agencies responsible for setting
the delivery of dental care. standards and specifications of dental materials.
3. Discuss evidence-based decision-making (EBDM) as it 6. Discuss the requirements necessary for a consumer
relates to dental materials; what questions might you ask product to qualify for the ADA Seal of Acceptance.

The study of dental materials (biomaterials) is the science At present, several states allow for the placement as
covering the evolution, development, properties, manipu- well as care of restorative and other therapeutic agents
lation, care, and evaluation of materials used in the treat- in the patient’s mouth by dental auxiliaries which in-
ment and prevention of dental diseases and the interactions cludes the new category of advance practice dental
of these materials with the tissues of the face and mouth. therapist.
Specifically, it includes principles of engineering, chemistry, In the traditional role, the dental assistant is most
physics, and biology. Dental biomaterials science is continu- directly responsible for the delivery of dental materi-
ally evolving as dentistry keeps up with the requirements for als within specific guidelines outlined by the dental
delivering optimal health care while delivering minimally manufacturer while the dental hygienist’s responsibili-
invasive dentistry. ties more frequently include the care of the restorative
The tooth and the tooth’s supporting structure, esthetics, material once it has been placed and the application
and function are important considerations for the patient’s of some therapeutic and preventive agents. Expanded
overall well being. The dentist, dental assistant, and dental function auxiliaries provide restorative services af-
hygienist should have a working knowledge of why materi- ter the dentist has prepared the tooth for restoration.
als behave as they do and how we can help to maximize their These services may include placement and carving or
performance. Through the understanding of how the basic finishing of the restorative material, placement of re-
principles of biomaterials affect the choice, manipulation, traction cord, and taking the preliminary impression
patient education, and care of all materials used to assist in for crown and bridge restorations and/or endodontic
rendering dental services, the dental team can help to ensure procedures. The dental therapist may provide basic
the ultimate success of a patient’s dental work and contrib- preventive and restorative treatment to children and
ute to their quality of life. adults in affiliation with or under the general supervi-
sion of a dentist. Typically these dental therapists work
primarily in settings that serve low socioeconomic
THE ROLE OF THE DENTAL AUXILIARY IN THE USE populations or in a dental health professional short-
OF DENTAL MATERIALS age area. State regulations determine the training and
Since 1970 efforts have been made to employ allied scope of practice for the expanded function auxiliary
oral health practitioners (also referred to in text as den- and the dental therapist.
tal auxiliaries), dental assistants, and dental hygien- All oral health practitioners must have a complete
ists, in the performance of intraoral tasks to efficiently understanding of the potential hazards in the ma-
deliver health care and to enhance the productivity of nipulation and disposal of materials and be educated
the dentist. Until 1970 only the dental hygienist was to handle them safely. Background knowledge of the
permitted to perform intraoral functions in all states. basic principles of dental materials is also essential to
Although laws vary from state to state virtually every appreciate the selection of a particular restoration or
state has modified, updated, and made changes to its treatment procedure for individual patient application.
state restrictions to allow for the performance of intra- It becomes, in many circumstances, the auxiliary’s role
oral procedures by all allied oral health practitioners. to educate the patient in the reasons that the dentist
1
2 CHAPTER 1 Introduction to Dental Materials

has recommended a particular restorative or therapeu-

tic material or the choices the patient may have for a
particular circumstance.
Scientific
Dental materials are classified as preventive, re- evidence
storative, or therapeutic materials. The search for the
perfect material, designed to prevent disease, treat dis-
ease, or restore tooth structures, continues to elude the
profession. There have been many important improve-
ments in dental materials in recent years; however, de-
spite these improvements, the ideal material does not
yet exist. The perfect material would be biocompatible, Clinician Patient needs,
experience and conditions and
esthetic, bond permanently to the tooth structures, and
expertise preferences
be useful in repairing or regenerating missing tissues.
This may seem an overwhelming task given the
ever-growing variety and changes of materials avail-
able; recommendations for their use or disuse; and FIG. 1.1 The elements of evidence-based dentistry. (From Sakaguchi
rapidly developing techniques in their manipulation, RL, Powers JM: Craig’s Restorative Dental Materials, (ed 13). St. Louis,
placement, and care. Professional journals, weblinks, 2012, Mosby.)
dental materials manufacturers or manufacturer’s rep-
resentatives, and other resources can provide invalu- EBDM into your practice: How does your practice
able information. The knowledgeable dental auxiliary make decisions regarding the techniques, technol-
reviews products recommended and used by their of- ogy, and products used? How do you analyze the
fice to provide a reliable resource for their patients and published scientific literature to make sure a product
the dentist. provides a clinical benefit to the patient? Do you try
product samples before giving them to your patients?
Why Study Dental Materials? How does your office stay informed about the newest
To enhance safety: Appropriate handling and disposal of advances in dentistry? How do you incorporate the
dental materials patient’s needs and choices into your decision-making
To promote awareness: Awareness of the overall success process?
of a particular material’s properties in dental applica- Evidence alone does not replace clinical expertise
tions
or input from the patient. EBDM requires an under-
To maintain materials properly: Recognition of dental mate-
standing of new concepts and the development of new
rials present in oral cavity; effective cleaning, polishing,
and instrumentation skills. The clinician must be able to incorporate the best
To deliver correctly: Accurate knowledge of the behavior research evidence along with clinical expertise and
of a dental material on application, correct manipulation patient preferences. Developing an evidence-based
of material, effective delivery or assistance in delivery of approach to addressing patient problems will greatly
material increase the potential for successful patient care out-
To educate patients: Ability to present options concern- comes by understanding the cause-and-effect relation-
ing dental material choices, maintenance of materials ship between biomaterials selected and the success
present of the treatment rendered. The ADA offers a website
(http://ebd.ada.org/) for dentists and their patients
to access the most current, clinically relevant informa-
EVIDENCED-BASED DENTISTRY tion. This approach is based on scientific research and
The American Dental Association (ADA) defines ev- clinician expertise and is tailored to the patient’s needs
idence-based dentistry as an approach to oral health (Fig. 1.1).
care that requires the judicious integration of sys-
tematic assessments of clinically relevant scientific
THE HISTORICAL DEVELOPMENT OF DENTAL
evidence, relating to the patient’s oral medical history,
MATERIALS
with the dentist’s clinical expertise and the patient’s
treatment needs and preferences. Searches through The concept of using materials for restoration, replace-
the scientific literature identify thousands of citations ment, or beautification to alter the appearance and/or
for materials and techniques in restoring and treating function of the natural dentition predates Christianity.
oral structures. With this wealth of scientific informa- Just as today, the diet of our caveman ancestors was a
tion, evidence-based decision-making (EBDM) helps chief contributor to dental disease. Although they were
the clinician make decisions about what is relevant rarely afflicted with dental caries because of the lack of
to incorporate into practice. The following questions refined sugars, excessive wear from a diet containing
should be asked in order to appropriately incorporate sand, dirt, and grit produced occlusal surfaces of teeth
 Introduction to Dental Materials CHAPTER 1 3

Spring
closure

FIG. 1.3 A denture of carved black and white ivory teeth.

Spring closed denture

FIG. 1.2 A denture with spring closure, much like those worn by
George Washington.

often worn to the pulp with resultant abscess forma-

tion. Examination has revealed mummies that show
loss of teeth due to abscess and periodontal disease
as early as 2500 b.c.e. Research published in the Pro-
ceedings of the National Academy of Sciences has revealed
the presence of toothpicks among the oldest known
human fossils, dating 1.77 million years ago. Much is
found in the literature about treatment options, includ-
ing remedies based on potions and prayer, but no evi-
dence of restorative dentistry exists until around 600
to 300 b.c.e. The Etruscans, who once lived in the area FIG. 1.4 Class V gold foil restoration on the facial surface of the man-
of present-day Tuscany, created bridges of gold rings dibular first premolar.
and natural, as well as, cadaver teeth. By the Chris-
tian Era the Romans, who quite valued their teeth, the primary denture base material until World War II.
had become skilled at restoring teeth with gold shells, Dentures were made from many materials; depicted in
fixed bridges, and partial and full dentures; although (Fig. 1.3) is a denture base elaborately carved in wood
through the Middle Ages and into the mid-1800s most with carved black and ivory teeth.
dental treatment consisted of extraction and artificial Silver paste is first mentioned by the Chinese in 659
replacements. c.e.; more than 1000 years later, in 1800, it was pro-
Casts constructed of plaster from wax impressions duced in France from “shavings from silver cut from
were developed in Prussia in the mid-eighteenth cen- coins mixed with enough mercury to form a sloppy
tury. Hippopotamus ivory bases with human and paste.” Health problems arising from the high mercury
animal teeth replacements were popular. However, content of this early amalgam prompted the American
because it was so difficult to carve ivory and the den- Society of Dental Surgeons in 1846 to pass a resolution
ture bases did not fit well, retention of dentures was not to use amalgam under any circumstances. The dis-
accomplished by joining the maxillary and mandibu- agreement over the value and safety of amalgam came
lar dentures with springs forcing the two parts against to be called the “Amalgam War,” and it did not end
the arches. Pierre Fauchard, considered the father of until 1895 when G.V. Black developed an acceptable
modern dentistry, devotes a portion of his book, The amalgam formula.
Surgeon-Dentist, published in 1728, to this technique. Gold remained popular for the restoration and
George Washington had several sets of such dentures, decoration of teeth and gained in popularity in 1855
losing one tooth after another until, at the time of his when cohesive gold foil, which could be condensed
inauguration in 1789, he had only one tooth left (Fig. directly into the cavity preparation, was introduced
1.2). In France in the late 1700s, work was being done (Fig. 1.4). At the same time dental cements were in-
to improve denture teeth by firing them from porce- troduced. Patterned after a technique for cementing
lain. In 1788 King Louis XVI bestowed on a Parisian tiles to floors, the first mixtures of cements, using
dentist an inventor’s patent for porcelain teeth. For zinc oxide with a weak phosphoric acid, were devel-
denture bases the Goodyear brothers gained a patent oped. In 1907, William Taggart demonstrated a cast-
for rubber called vulcanite in 1844, and this remained ing method to produce gold inlays. In 1932 synthetic
4 CHAPTER 1 Introduction to Dental Materials

resins were introduced; these resins soon replaced in Colorado Springs in 1901, and together with G.V.
rubber as the denture base of choice. At this time Black determined that drinking water was the factor.
synthetic resins also became a popular tooth-colored These caries-free but mottled teeth prompted McKay
alternative and, together with the introduction of to suggest changes in the water supply, leading to the
the acid-etch technique in 1955, evolved into one of first community water fluoridation program in 1945
the most popular of the restorative materials, com- (Fig. 1.5).
posite resins. Whether through the desire for a natural look or
Preventive dentistry had an early beginning as well, more ornamentation, history shows that the appear-
with fluoride first mentioned in 1874 and dispensed in ance of the teeth was important to our early ancestors.
England at this time for the prevention of caries. Fred- King Solomon is said to have complimented Sheba on
erick McKay is credited with noting dental fluorosis her teeth: “thy teeth are like a flock of sheep that are
even shorn, which come up from the washing.” Em-
press Josephine used a handkerchief to conceal her
bad teeth, turning the hankie into a fashion accessory.
In 1295 Marco Polo wrote of the people of southern
China covering their teeth with thin plates of gold.
This use of gold may have suggested the socioeco-
nomic status of the individual as well as serving a
protective purpose. In the mid-1800s, California rail-
road king Charles Crocker had a gold crown, embed-
ded with diamonds to form the cusps, placed on one
of his molars.
The history of dental materials and techniques in
the restoration, replacement, and beautification of our
teeth is full of ingenuity (Table 1.1). Even early man
knew the importance of maintaining these important
FIG. 1.5 Severe dental fluorosis. structures and more often than not suffered the pain

TABLE 1.1    Historical Development of Dental Materials

ERA DEVELOPMENTS
Ancient times 600-300 b.c.e.—Etruscans practice dentistry with artificial teeth and gold work
Middle Ages 700—Chinese medical text mentions “silver paste” for replacement of tooth structure
Sixteenth century 1530—The Little Medicinal Book for All Kinds of Diseases and Infirmities of the Teeth, the first
book devoted entirely to dentistry, is published in Germany. Written for barbers and surgeons
who treated the mouth, it covers practical topics such as oral hygiene, tooth extraction, drilling
teeth, and placement of gold fillings
Eighteenth century Casts constructed of plaster and wax for the construction of dentures with finely carved ivory
teeth, animal and cadaver teeth
Pierre Fauchard introduces the technique of joining maxillary and mandibular dentures with
springs and hinges. This was done to compensate for the weight of the dentures, which made
retention of the maxillary denture virtually impossible
Denture teeth fired from porcelain in France
First dental assistant employed by C. Edmund Kells of New Orleans
Nineteenth century Denture bases made of rubber by the Goodyear brothers
Silver coins mixed with mercury as the first dental amalgam
“Amalgam War”—American Society of Dental Surgeons passes a resolution not to use amalgam
G.V. Black develops an acceptable amalgam formula
Silicate cements developed for esthetic restorations
Cohesive gold foil introduced
Twentieth century Dr. William Taggart develops the method to cast gold inlays
Dr. Alfred Fones opens the first school for dental hygienists
Development of acrylic resin for fillings and dentures
Fluoride placed in community drinking water
Development of the acid-etch technique for bonding
Composites replace silicate cements for esthetic restorations
Light-activated composites
Modern ceramics are developed for esthetic restorative alternatives
First commercial home tooth-whitening product marketed
 Introduction to Dental Materials CHAPTER 1 5

The consumer and dentist alike recognize this im-

portant symbol of a dental product’s safety and effec-
tiveness. The ADA Seal of Acceptance is designed to
help consumers make informed decisions about the
safety and efficacy of products. Consumers can be
confident in products bearing the ADA seal as these
products have undergone voluntary and strict testing.
The ADA review process outlines a broad spectrum of
requirements that must be met to qualify for the ADA
seal. A list of products and guidelines for qualification
for the ADA Seal of Acceptance are available online at
http://www.ada.org.
In July 2006, the ADA began a new program to
evaluate professional dental products: the “ADA
Professional Product Review.” The ADA Professional
FIG. 1.6 The American Dental Association (ADA) Seal of Acceptance.
Product Review is a newsletter which is mailed to ADA
members quarterly with the Journal of the American
Dental Association. This resource is a publication of
associated with their neglect. Through centuries of the ADA’s Council on Scientific Affairs and includes
dental practice dental professionals have been chal- extensive laboratory performance data and clinician
lenged with the restoration of tooth and oral structures feedback.
lost to disease and trauma. The American National Standards Institute (ANIS)
was founded in 1918. The mission of this not-for-profit
organization is to enhance the global competitiveness
THE AGENCIES RESPONSIBLE FOR STANDARDS of U.S. businesses while helping to ensure the safety
Most of the triumphs and atrocities of dentistry were dis- and health of consumers and protection of the environ-
covered by trial and error, mainly at the expense of the ment. The development of ANSI/ADA Specification
patient. It is only in more recent times that the study of Number 41, Recommended Standard Practices for Bio-
dental materials includes standards set forth to evaluate logical Evaluation of Dental Materials, represents the
a material or technique before it is tried in the patient’s establishment of biological tests for dental materials.
mouth. In 1839 the first such attempt was made when
the American Society of Dental Surgeons was formed U.S. FOOD AND DRUG ADMINISTRATION
to fight against the use of amalgam by forbidding its The U.S. Food and Drug Administration (FDA) is
members to use silver amalgam for restoring lost tooth one of the oldest consumer protection agencies and is
structure. In 1930 the first of the American Dental Asso- charged with protecting the public by ensuring that
ciation Specifications was for amalgam alloy. products meet certain standards of safety and efficacy.
The original Pure Food and Drug Act of 1906 did not
AMERICAN DENTAL ASSOCIATION include provisions to ensure medical and dental device
Dentistry continued to try to elevate and regulate the safety or claims. In 1976 the Medical Device Amend-
practice of the profession with the establishment of ments were signed to give the FDA regulatory author-
the American Dental Association (ADA) in 1859. In ity over medical and dental devices that are now clas-
1866 an ADA committee prepared a statement on a sified and regulated according to their degree of risk
toothpaste, claiming “it cut teeth like so much acid.” to the public. Dental materials, considered devices by
By 1930, the ADA had established guidelines for test- the FDA, as well as over-the-counter products sold
ing products and awarded the first Seal of Acceptance to the public, are subject to control and regulation by
in 1931 (Fig. 1.6). Members of the ADA’s Council on the FDA Center for Devices and Radiological Health.
Scientific Affairs and ADA staff scientists reviewed There are three classifications of medical (including
dental drugs, materials, instruments, and equipment dental) devices, grouped according to the amount of
for safety and effectiveness before awarding the ADA control needed to ensure their safety and efficacy:
seal. The ADA seal has evolved since its inception; in Class I: Lowest risk, good manufacturing standards
2005 the ADA decided to phase out the seal for pro- and record-keeping practices, materials such as ex-
fessional products and to award it only to consumer amination gloves and prophylaxis (prophy) paste,
products. Although the ADA review process is strictly and some over-the-counter products.
a voluntary program, more than 300 consumer dental Class II: Products required to meet performance stan-
products carry the ADA Seal of Acceptance. Most com- dards set by the FDA or ADA, products such as
mon among these are toothpaste, toothbrushes, mouth amalgam and composite materials.
rinses, floss and other interdental cleaners, sugar-free Class III: The most regulated devices, which support
chewing gum, and denture adherents and cleansers. or sustain human life; include such products as
6 CHAPTER 1 Introduction to Dental Materials

endosseous implants and bone-grafting materials. Today there are many advances in tissue regenera-
These require premarket approval of the FDA, in- tion; implant therapies (Chapter 12); esthetic adhesion
volving scientific review to ensure their safety and (Chapter 5); and biomechanics to look forward to in
effectiveness. the near future. Nanotechnology will change the prop-
erties of materials by creating functional structures
INTERNATIONAL AGENCIES by controlling atoms and molecules on a one-on-one
Two international agencies, the FDI World Dental basis, allowing us the ability to arrange atoms as we
Federation and the International Organization for desire. Nanoscale fibers will be used to support bone
Standardization (ISO), represent the standards used augmentation, periodontal ligament regeneration,
to develop specifications and testing at the interna- and implant osseointegration (Chapter 12). Nanocom-
tional level. These standards are developed through posites (Chapter 6) will increase the amount of filler
the ISO’s technical committee for dentistry (ISO/TC particles contained within composite restorations, re-
106). In Canada’s Medical Devices Regulations, den- sulting in a higher degree of strength and resistance
tistry manufacturers that apply for a license to distrib- to abrasion. These filler particles are smaller than the
ute materials used in dentistry within Canada must wavelength of light, resulting in higher translucence
provide a valid certificate showing that their quality and a vast range of color options.
management system complies with the ISO standard The ADA, FDA, and ISO are committed to continu-
for quality systems (ISO 13485:2003). To receive such ing to evaluate, test, monitor, and assess risks and
a certificate, manufacturing companies are audited to review claims and labels of all materials used in den-
ensure their procedures are in line with requirements tistry (Chapter 4). Current research is concentrating on
set out in the standard. These international standards bringing technology to the dental office, making den-
are invaluable in supplying today’s high demand for tal appointments faster, minimally invasive, and more
dental materials and devices. comfortable for the patient and resulting in optimum
There have been many advances in the quality and patient-centered care. The allied oral health practi-
efficacy of dental materials; the challenge to dental tioner will continue to play an important role in the
professionals is to use evidence-based practice to criti- successful delivery, manipulation, and maintenance of
cally review the claims, performance, and long-term these and other materials and technologies. Embrace
end-product results of the materials and devices cho- the study of dental materials, for it is the advancement
sen. The input of the allied oral health practitioner is of this science that will ultimately change the way we
imperative in the successful choice of these materials look at the replacement of oral structures. We look for-
to deliver quality service to the patient. ward to the future.

FUTURE DEVELOPMENTS IN DENTAL Case-Based Discussion Questions

BIOMATERIALS
1. Compile a list of 5 to 10 dental products that display
The dental materials used today are much better than the ADA Seal of Acceptance and are found in your local
those used in the past, but they are still far from be- drug store or supermarket.
ing ideal. Materials continue to be developed and How is the seal displayed on these items? Ask family
techniques in their manipulation improved. Despite and friends if the seal is important in their selection of
much more effort in health promotion and disease a dental product. How does the presence of the seal
prevention, dental caries is a major global public affect your recommendation of a particular product?
health problem. Dental restorations are still need- 2. Research a dental product by using the Internet or by
contacting a manufacturer’s representative.
ed. The World Health Organization (WHO) and the
What information is available? What type of research
United Nations Environment Programme (UNEP) has been done? How is the product marketed? What
meeting in 2010 has strengthened the work to reduce assistance is available to the consumer or dental office?
risks to human health and the environment from the
use and release of mercury by recommending alter-
natives to amalgam containing restorations (Chapter BIBLIOGRAPHY
10). Periodontal disease continues to be a leading
American Dental Association (ADA). Home page. Available at
cause of tooth loss despite technologies to improve
http://www.ada.org.
homecare and patient education. Advances in peri- ADA:ADA Dental Product Guide. Available at http://www.
odontal surgery, restorative dentistry, and implant ada.org/en/publications/ada-dental-product-guide/.
therapies have enabled people to retain their teeth ADA:History of Dentistry Timeline. Available at http://
(Chapter 12). The demand for esthetics has driven www.ada.org/en/about-the-ada/ada-history-and-
presidents-of-the-ada/ada-history-of-dentistry-timeline.
the increase in whitening systems (Chapter 8), esthet-
ADA:ADA Policy on Evidence-Based Dentistry. Available at
ic restorations (Chapters 6 and 9), and orthodontic http://www.ada.org/en/about-the-ada/ada-positions-
procedures (Chapters 5 and 19). policies-and-statements/policy-on-evidence-based-dentistry.
 Introduction to Dental Materials CHAPTER 1 7

ADA: ADA Seal Products. Available at http://www.ada.org/ Ring ME: Dentistry: An Illustrated History, New York, 1993, Harry
en/science-research/ada-seal-of-acceptance/ada-seal-prod- N. Abrams.
ucts. U.S. Food and Drug Administration: Home page. Available at
Forrest JL, Miller SA, Overman PR, et al: Evidence-Based Decision http://www.fda.gov.
Making: A Translational Guide for Dental Professionals, Philadel- Wynbrandt J: The Excruciating History of Dentistry. New York,
phia, 2009, Lippincott Williams & Wilkins. 1998, St. Martin’s Press.
International Standards Organization (ISO)/TC 106: Dentistry.
Available at http://www.iso.org/iso/iso_catalogue/catalog
ue_tc/catalogue_tc_browse.htm?commid=51218.
 2 Oral Environment and Patient Considerations

http://evolve.elsevier.com/Eakle/materials/

Chapter Objectives
Upon completion of this chapter, the student should be able to:
1. Discuss the qualities of the oral environment that make it expansion and conductivity of restorative materials with
challenging for long-term clinical performance of dental those of tooth structures.
materials. 8. Explain how mechanical and chemical adhesion, or
2. Describe the long-term clinical requirements of bonding, work to retain restorations.
therapeutic and restorative materials. 9. Describe the factors that determine successful adhesion,
3. List and give examples of four types of biting forces and including wettability, viscosity, film thickness, and surface
the tooth structures most ideally suited to them. characteristics.
4. Define stress, strain, and ultimate strength and compare 10. Describe microleakage and how it can lead to recurrent
the ultimate strength of restorative materials during each decay and postoperative sensitivity.
type of stress to tooth structures. 11. Define biocompatibility and discuss why requirements for
5. Explain how moisture and acidity in the mouth can affect biocompatibility may fluctuate.
dental materials. 12. Describe tooth color in terms of hue, value, and chroma.
6. Explain how galvanism can occur in the mouth and how 13. Discuss the characteristics of oral biofilm and its role in
it can be prevented. the etiology of dental caries and periodontal disease.
7. Discuss thermal conductivity and thermal expansion 14. Explain the importance of detection of restorations and
and contraction, and compare the values of thermal methods for detection.

Key Terms
Adhesion the act of sticking two things together. In dentistry, Dimensional Change a change in the size of matter. For
it is used to describe the bonding or cementation process. dental materials, this usually manifests as expansion
Chemical adhesion occurs when atoms or molecules of caused by heating and contraction caused by cooling
dissimilar substances bond together and differs from cohe- Exothermic Reaction the production of heat resulting from
sion in which attraction among atoms and molecules of the reaction of the components of some materials when
like (similar) materials holds them together they are mixed
Adverse Response an unintended, unexpected, and harm- Fatigue Failure a fracture resulting from repeated stresses
ful or unwelcomed response of an individual to dental that produce microscopic flaws that grow
treatment or biomaterial Film Thickness the minimal obtainable thickness of a layer
Auxiliary Materials materials used to fabricate and maintain of a material. It is particularly important in the context of
restorations, directly or indirectly dental cements
Biocompatible the property of a material that allows it not to Flexural Stress bending caused by a combination of tension
impede or adversely affect living tissue and compression
Biofilm a complex community of oral microorganisms living on Fracture Toughness a measure of the energy needed to
surfaces within the mouth. When these colonies are found on fracture a material
teeth or restorations, they are commonly called dental plaque Galvanism an electrical current transmitted between two
Bonding to connect or fasten; to bind dissimilar metals in a solution of electrolytes
Chroma the intensity or strength of a color (e.g., a bold yel- Hue the color of a tooth or restoration. It may include a mix-
low has more chroma than a pastel yellow) ture of colors, such as yellow-brown
Coefficient of Thermal Expansion the measurement of Insulators materials having low thermal conductivity
change in volume or length in relationship to change in Interface the surface between the walls of the prepa-
temperature ration and the restoration or between two dental
Compressive Force force applied to compress an object materials
Corrosion deterioration of a metal caused by a chemical at- Microleakage leakage of fluid and bacteria caused by mi-
tack or electrochemical reaction with dissimilar metals in the croscopic gaps that occur at the interface of the tooth and
presence of a solution containing electrolytes (such as saliva) the restoration margins

8
 Oral Environment and Patient Considerations CHAPTER 2 9

Opaque optical property in which light is completely ab- Tensile Force force applied in opposite directions to stretch
sorbed by an object an object
Percolation movement of fluid in the microscopic gap of a Therapeutic Materials materials used to treat disease
restoration margin as a result of differences in the expan- Thermal Conductivity the rate at which heat flows through
sion and contraction rates of the tooth and the restoration a material
with temperature changes associated with ingestion of Torsion or Torque a twisting force that combines tensile and
cold or hot fluids or foods compressive forces
Resilience a measure of the energy needed to permanently Translucency optical property in which varying degrees of
deform a material light pass through or are absorbed by an object
Restorative Materials materials used to reconstruct tooth Transparent optical property in which light passes directly
structure through an object
Retention a material’s ability to maintain its position without Ultimate Strength the maximum amount of stress a material
displacement under stress can withstand without breaking
Shearing Force force applied when two surfaces slide Value how light or dark a color is. A low value indicates a
against each other darker color and a high value indicates a brighter color
Solubility susceptible to being dissolved Viscosity the ability of a liquid material to resist flow, e.g.
Strain distortion or deformation that occurs when an object ketchup is more viscous than water
cannot resist a force Vitality a life-like quality
Stress the internal force, which resists the applied force Water Sorption the ability to absorb moisture
Surface Energy the electrical charge that attracts atoms to Wetting the ability of a liquid to wet or intimately contact a
a surface solid surface. Water beading on a waxed car is an example
Tarnish discoloration resulting from oxidation of a thin layer of of poor wetting
a metal at its surface. It is not as destructive as corrosion

To become effective in the selection, manipulation, and Patient concerns, questions, and demands must also play
handling of dental materials it is important that the a part in the decision process. The patient should be brought
auxiliary have an appreciation for the complexity and into the decision process very early. Tooth-colored materials
challenges of the oral environment. Dental biomateri- are frequently requested by the patient, but may present lim-
als placed and used within the oral cavity must be bio- itations in their use under certain circumstances. Patients
compatible, durable, nonreactive under acid or alkaline are frequently looking for the best esthetic choice and may
conditions, compatible with other materials, and estheti- not be aware of the limitation of that choice. The patient may
cally acceptable. Eating by itself introduces hot and cold desire porcelain or composite veneers to cover discolored
extremes, acidic or alkaline foods and beverages, hard or anterior teeth or to close spacing (FIG. 2.1). If the patient
sticky foods, and heavy biting pressure. These factors may has parafunctional habits such as clenching or grinding, the
degrade the materials over time, affect marginal integrity, choice of porcelain may result in the chipping or wearing of
roughen the surfaces, or fracture the restorative materi- the opposing teeth or of the restorations themselves. On the
als. Materials must be selected that have physical and me- other hand, composite veneers may wear down excessively
chanical properties that can hold up in these conditions. under the same conditions. The patient(s) needs to be edu-
The severity of the conditions in the oral environment cated as to the limitations imposed by their particular oral
may vary somewhat from patient to patient and in spe- condition(s) and the appropriate restorative choices in order
cific circumstances. to produce long-lasting results. The auxiliary is frequently
The degree of compatibility may depend on how and/ involved in this education and must have a good under-
or how long the material is expected to survive in the standing of how materials function in the oral environment.
oral environment. Therapeutic materials, those used
to treat disease, are generally used for short periods of
CLASSIFICATION OF DENTAL MATERIALS
time whereas restorative materials, those used to re-
construct tooth structure, are expected to remain in Dental materials may be classified by their use: pre-
contact with tissues for indefinite lengths of time. Con- ventive/therapeutic materials, restorative materials,
sider the following cases. If a therapeutic agent were to and auxiliary materials.
be used to treat a specific condition, such as a denture
sore, it would need to be biocompatible with the tissues PREVENTIVE/THERAPEUTIC MATERIALS
but would not need to last long. If the material were Preventive/therapeutic materials are used to prevent
being used as a permanent restoration, such as a gold disease or trauma or for their therapeutic action on the
crown, biocompatibility and longevity would both be teeth or oral tissues. Included in this category are ma-
required. terials such as pit and fissure sealants to help prevent
10 CHAPTER 2 Oral Environment and Patient Considerations

FIG. 2.1 Closing a diastema (i.e., a space) between teeth #8 and #9 with composite restorative material. (Courtesy of
Dr. Stephan Eakle.)

caries, mouth guards to mitigate the effects of para- fabrication on hard tissues (tooth structure), whereas
functional habits and injury due to athletic activities, it may not be acceptable for use on soft tissues. Some
and materials used for their antibacterial effects such materials may be therapeutic in small quantities or if
as those found in some restorative and base materials. in contact with tissues for short periods of time, but
Also included in this category are fluoride and fluo- also may be irritating or toxic with longer contact or
ride-containing materials to prevent or reduce the pro- in larger quantities or higher concentrations. Topical
gression of caries. fluoride is of great benefit when used according to the
manufacturer’s directions, but can be irritating to soft
RESTORATIVE MATERIALS tissues and even excessively etch enamel if an acidu-
Restorative materials include those materials used to lated version is used. Dentistry is not alone in its at-
repair or replace tooth structure lost to oral disease tention to the development of biocompatible materi-
or trauma or to change the appearance of the teeth. als; orthopedics must consider biocompatibility in the
Restorations are classified as direct and indirect. Di- placement of joint prostheses, as does cardiology in the
rect restorations are placed immediately and directly placement of catheters and prosthetic heart valves. All
into a prepared tooth in a pliable state that then sets must consider the short-term and long-term functional
to harden. This procedure can be done in a single and biocompatible responses of any material.
office visit. Indirect restorations involve customized Postoperative sensitivity is often associated with
tooth replacements that require fabrication outside dental operative procedures. This may be due to the
the mouth usually in a lab. These restorations usu- toxicity of the restorative, preventive, or therapeutic
ally require a second appointment to fit and cement material or bacterial invasion into or near the pulpal
the restoration. tissues.

AUXILIARY MATERIALS ADVERSE RESPONSE

Auxiliary materials include those materials used to fab- A patient may have an adverse response to a dental ma-
ricate and maintain restorations, directly or indirectly. terial. The response may be due to the material itself or
Materials such as impression materials, gypsum, den- may be due to breakdown products of its components
tal waxes, and finishing and polishing materials are in the oral environment. An example of an adverse re-
also included in this category. sponse is seen with patients allergic to some metals, par-
ticularly nickel. There is evidence of nickel allergies in
10% to 20% of the population, particularly in women.
BIOCOMPATIBILITY It is thought that they become sensitized to nickel by
Materials must be biocompatible; that is, they must not wearing jewelry containing it. Some nickel-containing
impede or adversely affect living tissue and should in- alloys are used in dentistry for fabrication of crowns,
teract to the benefit of the patient. The study of dental bridges, partial denture frameworks, or in orthodontic
biomaterials must include a thorough understanding wires. Evidence of allergic reactions to nickel may be
of each material’s biological properties; all materials seen at crown margins of metal-based crowns (FIG. 2.2),
contain potentially irritating ingredients. Responses on a patient’s lips when wearing some orthodontic ap-
may include postoperative sensitivity, toxicity, and hy- pliances, and on a patient’s attached gingiva in contact
persensitivity. A material may be acceptable for use or with the metal framework of a removable prosthesis.
 Oral Environment and Patient Considerations CHAPTER 2 11

and may be intensified by surface roughness on the

porcelain and by parafunctional habits such as clench-
ing or grinding. Dentists must consider the perfor-
mance of a material based on a thorough knowledge
of the material’s properties, the intended application
of the material, and the impacting factors in each pa-
tient’s oral environment.

FORCE, STRESS AND STRAIN

FORCE
A force is a push, pull or twist (or combination of these)
FIG. 2.2 Allergic reaction to nickel. Porcelain-fused-to-metal crowns applied to a material. When a weight is placed on an ob-
have been placed on teeth #9 and 10. The tissue is red and inflamed ject, the weight applies force to that object. The force ap-
and bleeds easily because of chronic inflammation from allergy to the
metal in the crown.
plied at the surface creates stress within the object that
tries to resist the weight. If there was no resistance to the
weight, then the material would be flattened or displaced.
A complete health history, questioning of the patient, Materials used to restore teeth must withstand vary-
and a thorough examination of oral tissues can help to ing degrees of force, or load, applied through muscular
identify hypersensitive individuals. Frequently, several action resulting in the pushing or pulling of a resto-
different materials are used in combination to produce ration by the teeth or food bolus during mastication.
a restoration, such as a porcelain-fused-to-metal crown For some patients the forces come from parafunctional
cemented with glass ionomer cement. The use of multi- habits such as clenching or grinding (called bruxism).
ple materials makes it more difficult to determine which Normal biting force varies among individuals and
material is responsible for the adverse response. In gen- from one area of the mouth to another. Biting force is
eral, materials intended for permanent replacement of largely a measurement of the strength of the muscles of
tooth structures should exhibit no adverse biologic re- mastication and the surface area over which the force
sponses as well as be of benefit to the patient. is applied during the normal chewing of foods. When
In subsequent chapters the limitations as well as clenching or grinding, this force is increased due to the
precautions for the use of each material will be clearly lack of a food cushion and the resultant direct contact
outlined. of tooth surfaces. Normal masticatory forces on the oc-
clusal surface of molar teeth average 90 to 200 pounds
per square inch and can increase to as much as 28,000
ORAL FACTORS AFFECTING DENTAL MATERIALS pounds per square inch on a cusp tip. Masticatory
A number of factors in the oral environment will have forces are greatest in the molar region and gradually
an effect on the functioning and durability of the den- decrease moving toward the anterior part of the mouth
tal materials used in the oral cavity and thus will have from premolars to incisors. Denture wearers apply
an influence on which material the clinician will select. 40% less force than patients with intact dentitions, but
denture wearers whose dentures are supported by im-
plants or roots regain much of the biting force.
BIOMECHANICS A study of the anatomy of teeth reveals that each
The function of a material depends on the physical kind of tooth shape (i.e., incisor, premolar, molar) is de-
and mechanical properties (see Chapter 3 Physical signed to apply specific types of force. The three basic
and Mechanical Properties of Dental Materials) of that types of force are as follows:
material as well as on how the material is being asked • Compressive Force, force applied to compress or
to perform. Designs for restorations require an under- squeeze an object; crushing biting forces. Posterior
standing of the biomechanical properties of the mate- teeth are ideally suited for this type of force. Their
rial. Much like an engineer, the dentist must design a large occlusal surface and multi-rooted base are
dental bridge by taking into consideration the load that well suited to resist a crushing force.
will be placed on the bridge, the length of the span, and • Tensile Force, force applied at each end of a material
the stability of the supporting structures. For example, in opposite directions to stretch an object or pull it
a material may be used successfully to restore anterior apart. When tensile force is applied to a rubber band
teeth, where biting forces are not as strong, whereas it is stretched.
this same material may be undesirable to restore the • Shearing Force, force applied when two surfaces
occlusal surfaces of posterior teeth, where biting forces slide against each other in opposite directions.
are heavier. Excessive wear of a material may occur When the maxillary and mandibular incisors are
when a stronger material applies force against a weak- used for cutting, shearing forces are applied. When
er material such as porcelain against composite resin we use the anterior teeth to bite into food, we slide
12 CHAPTER 2 Oral Environment and Patient Considerations

Stress
Resilience

A B C
Strain
FIG. 2.3 Types of stress and strain. A, Tensile stress pulls and A
stretches a material. B, Compressive stress pushes it together. C,
Shearing stress tries to slice it apart. (From Bird DL, Robinson DS:
Torres and Ehrlich Modern Dental Assisting (ed 11). Philadelphia,
2015, Saunders.)

Stress
the mandibular teeth forward or to the side across Toughness
the the maxillary teeth to shear it off.

Torsion Strain
Another type of force is torsion or torque. It is a twisting B
force that has tensile and compressive forces. This force is FIG. 2.4 Stress-strain curves for a material. A, Dark blue area under
more descriptive of normal masticatory events. When we the curve shows resilience (resistance to permanent deformation) B,
chew we combine compressive, tensile, and shear forces Large area under the curve shows toughness (energy needed to cause
fracture) (From Sakaguchi RL, Powers JM: Craig’s Restorative Dental
resulting in torsion. When a patient wears full dentures, Materials (ed 13). St. Louis, 2012, Mosby.)
he or she may complain that the dentures become dis-
lodged when they chew certain foods. This is because of
torque on the dentures, which are not well suited to with- fixed in position, it may be deformed by the force if the
stand the combination of compressive, tensile, and shear magnitude is great enough, and the object is considered
forces while eating (FIG. 2.3). strained. Stress, then, is the amount of force exerted from
within an object to resist an external force and strain is
Clinical Tip the amount of change that the force has produced in
Dislodging of dentures is often due to tipping forces and the object. When the strain is caused by a compressive
possibly torque that breaks the peripheral seal causing the force the object is shortened while a tensile force causes
loss of suction and results in the movement of the denture the object to lengthen. If the object does not return to its
away from the ridge.
original shape after the stress is removed, it has under-
gone permanent deformation. If the object returns to its
The forces used in chewing a sticky caramel candy original shape, the change is called elastic deformation.
are different from those used in chewing a peanut. The The effect on the object is determined by the size of the
caramel is compressed as the person bites down and it force, the point or area of contact, and the direction in
sticks to the teeth. Then, it is torn apart by tensile forces which the force is applied. If a force is applied over a
as the jaws separate. The peanut is crushed by compres- large surface area, the stress generated is less than if the
sive forces and ground with shearing forces as the upper same force is applied to a small area. The large surface
and lower posterior teeth slide across each other in the area helps to dissipate the impact of the force.
chewing cycle.
Stress-Strain Curve
Flexure Each material has its unique relationship between
Flexure or bending force is a combination of compres- the stresses placed on it and the strains that devel-
sive, tensile, and shear forces. When a long plastic rod op in reaction to those stresses. This relationship is
is flexed into an arch-shape, compression occurs on known as the stress-strain curve. The curve is deter-
the inside surface of the arch and tension occurs on the mined by plotting the amount of deformation that
outside of the arch while shear occurs inside of the rod occurs at each magnitude of applied stress (com-
itself. pressive or tensile loading). It is useful in compar-
ing how materials can withstand loading. Thus, it
Stress and Strain can help in selecting an appropriate dental material,
When a force is exerted on a tooth or restorative mate- for example, to use in restoring the biting surfac-
rial, the tooth or material creates stress to resist the force. es of a lower molar. It can show which material is
Stress is expressed as pounds per square inch (psi) or strong enough and stable enough for that applica-
megapascals (MPa) in the metric system. If an object is tion (FIG. 2.4).
 Oral Environment and Patient Considerations CHAPTER 2 13

P   Ultimate Compressive and Tensile

TABLE 2.1 Strengths of Tooth and Restorative
Compression Structures
Tension ULTIMATE
COMPRESSIVE ULTIMATE TENSILE
STRUCTURE STRENGTH (lb/in2) STRENGTH (lb/in2)
Enamel 56,000 1,500
Dentin 43,000 4,500
Amalgam 45,000-64,000 7,000-9,000
Porcelain 21,000 5,400
Composite 30,000-60,000 6,000-9,000
resin
FIG. 2.5 Stresses on a bridge. (From Anusavice KJ, Shen C, Rawls H:
Phillips’ Science of Dental Materials (ed 12). St. Louis, 2013, Saunders.) Acrylic 11,000 8,000

The normal process of chewing rarely involves may function better in one application than another.
only one type of stress; complex stress combinations As you can see, amalgam and composite resins more
are more common. For example, dental bridges are closely replicate enamel in compressive strength,
subject to flexural stress when compressive forces whereas porcelain falls short. Porcelain is brittle and
placed on the occlusal surface of the bridge bend more likely to fracture under compressive stresses, es-
the bridge downward and tensile forces on the tis- pecially those that are directed onto a small area. (Note:
sue side of the bridge stretch upward in response Porcelain is one type of ceramic material described in
(FIG. 2.5). Chapter 9. It is one of the weaker ceramic materials but
Materials may be suited to one type of stress but fail is very esthetic.)
during another. If the force is exerted over a large area,
the tooth structures can more adequately handle the Fatigue Failure
stress. When the force is exerted over a small area the During mastication, stresses occur repetitively over time.
increase in pressure may result in fracture. Consider the Failures rarely occur in a single-force application; rather,
force exerted on the floor by a woman wearing flat shoes they occur when stress is frequently repeated. These
and then changing into high spike heels. The woman’s repeated stresses may produce microscopic flaws that
weight supported by both types of shoes is the same, so grow over time, resulting in fracture: this is known as
there is no difference in force. However, because there is a fatigue failure. A metal wire bent repeatedly will eventu-
difference in area, the pressure on the surface contacted is ally break; this is another example of fatigue failure. Teeth
drastically different. This is the reason that teeth or resto- and restorative materials under function or bruxism are
rations may fracture when subjected to stresses by small, subjected to repeated stresses by a mixture of forces ap-
very hard objects, such as a popcorn kernel or cherry pit. plied in a variety of directions and intensities. As a re-
sult they may crack or fracture. Additionally, conditions
Fracture Toughness Strength of the oral cavity such as moisture, temperature, and pH
Fracture toughness is a mechanical property of materi- fluctuations may also contribute to fatigue failure.
als that measures the energy needed to fracture a ma-
terial. When increasingly higher forces are applied to
MOISTURE AND ACID LEVELS
a material it will eventually fracture and the point of
fracture is called the ultimate strength. The oral cavity is always in contact with moisture in
the form of foods, saliva, and blood. This moisture can
Resilience vary from acid to alkaline depending on foods, bever-
Resilience indicates the energy needed to permanently ages, medications, and the amount of acid-producing
deform a material. Brittle materials such as compos- bacteria present (biofilm).
ites, amalgam, or ceramics are not resilient and do not
deform readily and will fracture if loaded too much. EFFECT OF pH
Any flaws in the materials will cause stress to concen- The normal resting pH of saliva ranges from 6.2 to 7.0
trate in those areas and ultimately reduce the strength (neutral), but can fluctuate higher or lower by several
of the material leading to fracture. Values of compres- points during the course of a day Many materials that
sive and tensile forces applied to tooth structure and would be compatible in a neutral environment will not
restorative materials are expressed in Table 2.1. Use the be compatible in an acidic one. Some beverages are
table to compare the ultimate compressive and tensile slightly or very acidic. Citrus fruits and sports drinks
strengths of tooth structure types to the various restor- contain citric acid and can attack enamel and some re-
ative materials to understand why a certain material storative materials. Acidulated topical fluorides can
14 CHAPTER 2 Oral Environment and Patient Considerations

FIG. 2.6 “Washed out” glass ionomer restoration on tooth #8 is stained

owing to porosities and the solubility of this restorative material.
FIG. 2.7 Two amalgam restorations. Left: A low-copper amalgam with
severe marginal breakdown. Right: A high-copper amalgam restora-
tion with minimal marginal discrepancy. Both restorations were placed
also attack some materials such as glass ionomer ce- at the same time. (From Anusavice KJ: Quality Evaluation of Dental
ments, composite resins, and ceramics. Restorations: Criteria for Placement and Replacement. Chicago, 1989,
Quintessence Publishing.)
Most materials are adversely affected by moisture
either during placement or in the long-term clinical
behavior of the material. The breakdown of many re- called corrosion. Metals such as steel cannot be used
storative materials is directly related to the effects of in the oral cavity because the metal breaks down in
moisture, acid, and stress. Materials designed for long- the wet environment, becoming iron oxide (commonly
term retention in the mouth must not rapidly deterio- known as rust). When steel is coated first with a bar-
rate under these conditions. rier to corrosive components, the barrier gives steel
its stainless quality. Dental amalgams are particularly
Solubility susceptible to corrosion, causing marginal breakdown
Desirable materials should have low solubility, that is, and discoloration of tooth structures. (See Chapter 10
not susceptible to being dissolved in a solvent, and in Dental Amalgam.) The result of corrosion is also seen
the case of the oral environment saliva is the main sol- on dental instruments that are processed in autoclaves
vent. Gold and porcelain are retained in the oral envi- due to oxidation of the metal’s surface. Corrosion be-
ronment for many years because of their insoluble na- gins at the surface of the metal and migrates deeper
ture. Glass ionomer cement materials, frequently used into the metal than tarnish, that is limited to the surface
as tooth-colored restorations, are much more soluble. and can be seen as discoloration. Corrosion can accel-
They tend to “wash out” or change in mass over time, erate in crevices between tooth and restoration and on
requiring replacement (FIG. 2.6). rough surfaces. Polishing of amalgams to produce a
smooth surface has been recommended to help delay
Water Sorption this process. In high-copper amalgams this may not be
Some materials also have the undesirable characteris- as critical to their longevity since they are more cor-
tic of water sorption or the ability to absorb moisture; rosion resistant than low-copper amalgams (FIG. 2.7).
this may result in staining or a slight swelling of the
material. Staining of resins and acrylics from repeat-
ed exposure to coffee, tea, and other dyed beverages
GALVANISM
is due to water sorption. Dentures placed in a glass An environment containing moisture, electrolytes,
of water will take up the liquid and become slightly and dissimilar metals makes the generation of an
larger. Some acrylics will absorb both odors and tastes electric current possible. The ions in the saliva fa-
from foods due to microscopic porosity in the material. cilitate the movement of electrical current from one
Directions on routine home care can help alleviate this type of metal to another. The phenomenon of elec-
problem for the patient. (See Chapter 17 Polymers for tric current being transmitted between two dissimi-
Prosthetic Dentistry.) lar metals is called galvanism. The current may result
in stimulation to the pulp, called galvanic shock. The
Corrosion classic example of a metal fork touching a metal res-
Metals suffer from the effects of moisture and acidity, toration or the biting on aluminum foil will be famil-
with the exception of noble metals such as gold and iar to anyone with metal restorations, and unfamil-
platinum. The deterioration or dissolution of the metal iar to those who have no metal restorations. Some
in response to a chemical attack (acid), or in an elec- patients may even feel a galvanic shock or report a
trochemical reaction with other metals because of the metal taste when instruments are used against the
moisture and acid present in the oral environment, is surface of a restoration. When it becomes necessary
 Oral Environment and Patient Considerations CHAPTER 2 15

TABLE 2.2   Thermal Properties of Tooth and Restor-

ative Structures
COEFFICIENT THERMAL
OF THERMAL CONDUCTIVITY
Temporary aluminum
EXPANSION (K [mcal cm]/
alloy crown
STRUCTURE (× 10−6/°C) cm2sec°C)
Oral Enamel 11 2.0
fluids Dentin 8 1.30
Gold alloy crown Amalgam 20-28 54
Gold 15 350
Porcelain 15 2.50
Composite resin 26-40 2.60

FIG. 2.8 Galvanism illustration of how dissimilar metals in opposing of expansion and contraction that differ significantly
teeth can create a galvanic current with saliva providing a solution of enough from enamel and dentin that the marginal in-
electrolytes.
tegrity of the restoration may be compromised. The
difference in CTE value of unfilled acrylic and sealants
to place differing types of metal restorations such as with tooth structure is the highest, and the value of
a gold crown in contact with an amalgam restora- gold is the closest to human teeth.
tion, insulation under the restorations in the form Repeated shrinkage and expansion of a restoration
of bases or liners can help to lessen the stimulation. during ingestion of cold and hot fluids and foods pro-
Provisional (temporary) aluminum crowns placed duces the opening and closing of a gap with movement
opposite or adjacent to amalgam or metal crowns of oral fluids between the restoration and the tooth
can also cause this phenomenon (FIG. 2.8). In this surface; a phenomenon called percolation. Percolation
situation the selection of a polycarbonate or acrylic allows the ingress of bacteria and oral fluids and may
provisional crown would be a better choice. In time lead to recurrent caries, staining, and pulpal irritation.
the galvanic stimulation will fade as oxides form
on the surface of the metal, acting as an insulator THERMAL CONDUCTIVITY
against the galvanic current. Thermal conductivity is the rate at which heat flows
through a material over time. Enamel and dentin are
TEMPERATURE poor thermal conductors, whereas metals are excellent
conductors. Gold is one of the best thermal conductors,
EXPANSION AND CONTRACTION even better than amalgam. Nonmetals such as ceramics,
The ingestion of hot and cold foods and beverages and composites, acrylics, and cements are very poor con-
smoking may alter the temperature of the oral environ- ductors. Poor conductors can be used as restorations or
ment. With few exceptions, all forms of matter expand as insulators. For instance, a patient wearing a denture
when they are heated and contract when cooled, re- may not sense the temperature of a liquid because of the
sulting in dimensional change. Atoms or molecules in a insulation produced by the acrylic denture base.
material vibrate over a greater range when the materi- When a metal restoration conducts temperature
al is heated causing it to expand. Acceptable materials changes into the tooth from foods and beverages taken
used as restorations and replacement of tooth structure into the oral cavity, the pulp of the tooth may feel the
should have characteristics of expansion and contrac- resultant stimulation as sensitivity, particularly if the
tion similar to tooth structures. Excessive expansion of overlying dentin is thin. Dentin acts as a natural in-
a restoration within a tooth may result in the fracture sulator, but when it is too thin, temperature changes
of cusps; excessive contraction may result in leakage may be felt by the pulp. Amalgam and gold have much
of fluids and bacteria into the open gaps, resulting in higher values of thermal conductivity than dentin and
sensitivity. Expansion and contraction are measured enamel; a hot cup of coffee may transmit heat read-
as the coefficient of thermal expansion (CTE), the mea- ily through these metals, resulting in pulpal stimula-
surement of change in volume or length in relationship tion. A piece of ice placed on an amalgam restoration
to change in temperature. (Refer to Table 2.2 to review may conduct stimulation to the pulp in as little as 2
the values of thermal expansion.) to 3 seconds. When metal restorations are placed close
Amalgam readily heats up and expands or cools to the pulp of the tooth, material such as a cement is
and contracts with a small temperature change, where- often placed between the tooth structure and the res-
as composite resin is not a good conductor of tempera- toration to act as an insulating base to delay and ab-
ture and requires a greater temperature change to ex- sorb the transfer of temperature. Metals placed against
pand or contract. Both of these materials have rates tissue such as a partial denture framework and some
16 CHAPTER 2 Oral Environment and Patient Considerations

orthodontic appliances can also conduct temperature Conservative

to the soft tissues. undercut
Table 2.2 gives values of thermal expansion and ther-
mal conductivity. Compare values for restorative mate-
rials with those for tooth structures to determine the po-
tential for marginal leakage through percolation and/
or the need for insulation. When there is a large differ-
ence between the CTE for the restorative material, such
as amalgam, and that for the tooth structure the perco-
lation will be greater. Note that whereas composite has Too much
a higher CTE compared with tooth structure, bonding it undercut
to the tooth structure helps to prevent percolation.
In addition to temperature considerations for materi-
als already present in the mouth, it is important to con-
sider the temperature of materials as they are placed
into the mouth. Icy cold water used when mixing al-
ginate may cause the patient pain when the very cold
alginate contacts metal restorations. The components
of some materials when mixed may result in a chemi- FIG. 2.9 The retentive undercuts of a conservative preparation (top)
cal reaction that produces heat. For example, when the and an excessively undercut reparation that compromises the remain-
powder and liquid of a chairside denture reline mate- ing tooth structure (bottom).
rial are mixed, the reaction produces heat (an exother-
mic reaction). If the material is left in the mouth while the remaining tooth structure (a crown) and hold it in
this reaction is occurring, it is possible that the tissues place with a dental cement. Dental cement retains the
could receive a thermal burn. restoration by chemically and/or mechanically con-
necting the two surfaces. Glass ionomer cement will
Clinical Tip
chemically bond to the mineral component of tooth
An exothermic reaction must be minimized by proper structure and can also mechanically retain a crown.
mixing and handling to prevent excess heat from coming
into contact with a susceptible tooth surface. Acrylic used BONDING
to make temporary crowns and bridges in the mouth will
Bonding is a term commonly used when describing
release heat as it polymerizes and sets. If left in the mouth
too long, the heat can damage the pulp or burn any soft the retention of materials. Bonding of materials oc-
tissues it contacts. curs when the tooth surface is prepared with an acid-
etch technique to create microscopic roughness and
pores in enamel and dentin. A fluid bonding material
is then allowed to flow into the roughened surfaces
RETENTION and pores and when hardened it mechanically locks
An important factor in the selection of a material is into the tooth structure. See Chapter 5 Principles of
how it will be retained within or on the tooth. The re- Bonding, Figure 5.9 and 5.10. Restorative materials
tention of a material is its ability to maintain its posi- that adhere chemically to the bonding material are
tion without displacement under stress. Retention may then placed. This technique offers several advantag-
be secured through mechanical, chemical adhesion, or es in producing retention. It requires less removal of
bonding mechanisms between materials. healthy tooth structure because no undercuts are nec-
essary, it produces a stronger retentive force between
MECHANICAL AND CHEMICAL RETENTION tooth and restoration, and it can seal the margin of the
Mechanical retention involves the use of undercuts or restoration to prevent the seepage of bacteria and flu-
other projections into which the material is locked in ids through percolation. (See Chapter 5 Principles of
place. The undercuts used in a typical amalgam prepa- Bonding.)
ration are an illustration of mechanical retention (FIG. Many of today’s restorative materials use a combi-
2.9). Note that the opening of the cavity preparation is nation of mechanical and chemical or bonding adhe-
smaller than the internal floor of the preparation. Once sion for optimal retention. Retention by mechanical
the material is hardened in place, it is retained through undercuts alone will not adequately seal the margins
this design. of a restoration and will frequently place tooth struc-
When a significant amount of tooth structure has ture in jeopardy of fracture when undercuts leave vul-
been removed, undercuts can no longer be success- nerable areas of tooth structure unsupported. Bonding
fully used, because the cusps or other parts of the requires the intimate contact of surfaces to produce the
tooth will be undermined and weakened. At this time best bond strength. The strength of the bond is mea-
the clinician may wish to place a restoration covering sured by applying shearing and tensile stresses.
 Oral Environment and Patient Considerations CHAPTER 2 17

energy of the restoration and tooth. As mentioned

previously, adhesion depends on intimate contact
of surfaces. Even slight contamination can prevent
contact. Debris from the tooth preparation, microor-
ganisms in biofilm, and products of saliva are often
impossible to completely eliminate. Surface irregu-
larities may prevent complete wetting of the surfaces.
Microscopic surface irregularities can trap air as the
adhesive flows over them, resulting in incomplete
wetting of the surface.
Surface energy. The surface energy of liquids is also
FIG. 2.10 Wetting characteristics of a liquid on a solid surface. (From called surface tension. The molecules at the surface of
Van Noort R: Introduction to Dental Materials (ed 14). London, 2013, a liquid or solid are aligned differently than in the cent-
Mosby, p. 53.) er. In the center the molecules are in balance with the
molecules that surround them. At the surface, how-
Factors Affecting Bond Strength ever, there is an imbalance in the attraction between
Several factors can affect this bond strength and the molecules causing them to be attracted to the larger
success of a material as an adhesive. These include mass of molecules in the center. This attraction or force
wetting, viscosity, film thickness, and surface charac- directed inward causes an energy level at the surface.
teristics of the tooth, restoration, and adhesive. With liquids, if the surface energy is high, the liquid
can flow readily over a solid substrate. When liquids
Wetting. Wetting is the degree to which a liquid adhe- bead up on a surface, such as on wax or many plastics,
sive is able to spread over the surface of a tooth and the surface has low surface energy.
restorative material. This wettability is based on the Solids also develop surface energy. When enamel
contact angle between the liquid and the tooth surface. is etched, a high surface energy is created that can
The lower the contact angle the better the liquid adhe- attract liquids across the surface. If newly etched
sive spreads onto the surface of the tooth (FIG. 2.10). enamel comes in contact with just a little saliva, a
(See also Chapter 5 Principles of Bonding.) The Teflon molecular film of saliva is drawn across the surface
surface of cooking equipment exhibits poor wettabil- by the high energy causing contamination. Liquids
ity, that is, the liquids bead up on the surface rather generally wet or spread over high surface energy sur-
than spreading out. The better the adhesive is able to faces better. Metals, ceramics, and enamel have high
spread on the surface of the tooth and restoration, the surface energies.
more retentive it is. Microscopic surface roughness Many situations present conditions that are not fa-
such as that created by etching enamel will increase the vorable for retention of materials. The dentist is respon-
wetting of the surface by the liquid. sible for the mechanical design of the preparation, but is
not solely responsible for other factors. In many states,
Viscosity. Viscosity, that is, the resistance of a liquid allied oral health practitioners routinely place thera-
material to flow, can hinder the ability of a liquid to peutic and restorative materials. In addition, the dental
wet a material. Materials with high viscosity are thick- assistant plays an essential role in delivering materials
er and do not flow well, and therefore may not be ef- and controlling the conditions of the oral environment
fective in wetting an area. Viscosity also can affect the during their delivery. An understanding of the factors
film thickness of an adhesive or cement. that influence retention is essential to achieving a suc-
cessful restoration.
Film thickness. Film thickness is the minimal thick-
ness obtainable by a layer of a liquid material after MICROLEAKAGE
it sets under pressure and is particularly important
in working with dental cements. When cementing a The need for replacement of restorative materials can
crown, if the film thickness of the cement is too great, be significantly influenced by microleakage. The sur-
it may keep the crown from seating completely. A thin face between the walls of the tooth structure (prepara-
film of cement is desirable to allow the cement to com- tion) and the restoration is called the interface. If this
pletely wet the surfaces and for excess material to flow tooth/restoration interface is not sealed there may
from under the crown when it is seated under pressure be a space into which fluids and microorganisms can
during cementation. penetrate. This seepage of harmful materials is called
microleakage and is responsible in part for recurrent
Surface characteristic. Surface characteristics are decay, marginal staining, and postoperative sensitiv-
other factors that affect the adhesive retention of a ity. Microleakage may be due to the deterioration of the
material. They include the cleanliness of a surface, dental material, percolation due to differences in CTE,
moisture contamination, surface texture, and surface or lack of adhesion of the material to the tooth. It is easy
18 CHAPTER 2 Oral Environment and Patient Considerations

FIG. 2.12 Example of metamerism: the apple changes color depend-

ing on the light source used to illuminate it. (From Sakaguchi RL, Pow-
ers JM: Craig’s Restorative Dental Materials (ed 13). Philadelphia,
2012, Saunders, p. 58.)

Hue is the dominant color of the wavelength detected.

FIG. 2.11 Microleakage allows the seepage of fluids and microorgan- Tooth colors are predominantly seen in the yellow
isms into the restoration–tooth structure interface. Microleakage can and brown range.
be seen as a pink dye penetrating along the internal surface of the Chroma refers to the intensity or strength of the color;
Class II composite restoration. (From Sakri MR, Kippal P, Patil BC, teeth are rather pale in color.
Haralur SB: Evaluation of microleakage in hybrid composite restoration
Value describes how light or dark the color is. Teeth
with different intermediate layers and curing cycles. J Dent Allied Sci
5(1):14–20, 2016.) have value ranges at the light end of the value scale.
As we age the tooth value gets darker.
The color of teeth and ceramic and composite resin
to understand why the seepage of bacteria and other restorations is influenced by their optical proper-
fluids between preparation and restoration sets up an ties. Light that reaches the surface of the tooth or
environment for recurrent decay and staining. Postop- restoration can be transmitted through it, absorbed
erative sensitivity may be due to microleakage as well by it, and scattered or reflected by it. If light passes
(FIG. 2.11). (Please also refer to Figs. 5.21 and 6.3 for directly through an object (like window glass) it is
pictures of microleakage.) Tubules found within the transparent. If light is completely absorbed, scat-
hard material of the dentin are filled with fluids under tered, and/or reflected by the object it is opaque.
pressure from the pulp. When the enamel of the tooth is Light is reflected off the surface (called reflectance)
removed fluids can flow out of the much larger dentinal depending on the surface texture and amount of
tubules and outside chemicals and bacteria can flow in polish. Usually teeth and esthetic restorations will
causing irritation of the pulp and sensitivity. Procedures reflect light and transmit light to various degrees
for ensuring the proper seal of the dentinal tubules are giving the tooth or restoration a life-like quality
described in Chapter 5 (Principles of Bonding). called vitality. Manufacturers over time have ad-
justed the components of composite resins so that
they can absorb, transmit, scatter and reflect light to
ESTHETICS AND COLOR
mimic natural tooth structure. The same can be said
Esthetic dentistry is a rapidly growing elective proce- for modern ceramics.
dure which is in high demand and may be of equal if Individuals see these many colors, components,
not greater concern to the patient than function. Our and reflections of color somewhat differently in dif-
eyes sense light through the cone cells in the retina in ferent situations. This phenomenon, known as me-
three different ranges of wavelength: red, green, and tamerism means that colors look different under
blue. Having three types of color-sensing cells doesn’t different light sources (FIG. 2.12). It is important
limit us to just three colors. The stimulation of two or that we have a standardized measure of color such
more types of cone cells, the amount of light they detect, as a shade guide to give us an objective measure
and the interpretation of that light by our brain deter- (FIG. 2.13). It is also important that we produce an
mine the overall response to a particular color. Mixtures environment that reduces the possibility of extrane-
of red, green, and blue light allow you to see many col- ous color reflection producing an inaccurate color
ors. The television mixes these primary colors of light match for the restoration. A detailed discussion on
to produce full color pictures. Three components—hue, shade selection is presented in Chapter 9 (Dental
chroma, and value—describe the resultant color: Ceramics).
 Oral Environment and Patient Considerations CHAPTER 2 19

genus (e.g., S. mutans, S. salivarius) and occupies up to

A 90% of the surface while other early colonizers occupy
the remainder. The early colonizers are mostly gram
positive bacteria (they have a thick cell wall that retains
B a stain used in the laboratory). Within a couple weeks
gram negative bacteria (they have a thin cell wall that
does not retain the stain) begin to proliferate. Later col-
C onizers are mostly anaerobes (they thrive where there
is little or no oxygen) that can contribute to periodontal
disease, and they attach to the growing plaque. As the
bacterial community grows, the adherent bacteria form
a protective matrix from extracellular polysaccharides
they secrete. The matrix can help in protecting them
from competing microorganisms, antibiotics, and anti-
bacterial mouth rinses. A state of microbial homeostasis
FIG. 2.13 Tab arrangements of the Vitapan classical shade guide. (a stable state of equilibrium) forms until it is thrown
Manufacturer’s arrangement according to A, hue, B, value scale, and out of balance by factors affecting the oral environ-
C, lightest to darkest. (From Paravina RD, Powers JM: Esthetic Color
ment, such as change in the host immune system, di-
Training in Dentistry. St. Louis, 2004, Mosby.)
etary changes, or other systemic changes. Oral factors
such as the temperature of the oral cavity, the pH of the
saliva, and available nutrients affect the rate of growth
ORAL BIOFILM AND DENTAL MATERIALS
of the bacterial plaque. The temperature can change
It is important to have a basic understanding of oral bio- rapidly with the introduction of hot or cold foods and
film, what it is, how it functions in health and disease, beverages. The pH can vary from its normal range of
and how to manage it to maintain a healthy mouth. The 6.5 to 7.5 by the introduction of sugars that are metabo-
oral biofilm is a three dimensional, complex, structured lized by certain bacteria with resultant acid production.
community of microorganisms that can be found on Acidic and alkaline foods can also alter the pH, but the
mucous membranes, teeth, intracoronal (fillings) and saliva dilutes and buffers the foods so that gradually
extracoronal (crowns) restorations, dental implants, the saliva returns to its normal range. This pH balanc-
and removable prostheses. Over 700 species of micro- ing may not happen in patients with dry mouth or sa-
organisms can colonize the mouth. These microorgan- liva with low buffering capacity.
isms include bacteria, viruses, and fungi. In any one in-
dividual approximately 200 of these species may exist BIOFILM AND ORAL DISEASE
as part of the normal oral microbiota. Of these, bacteria Most of the bacteria in the biofilm are harmless, but
are found in the greatest numbers and species. pathogens are present in small numbers. If systemic or
The oral biofilm exists in a dynamic symbiotic (ben- oral conditions change, the potential exists for certain
eficial to host and microorganisms) relationship with pathogens for both tooth decay and/or periodontal
the host. The biofilm provides some level of protec- disease to proliferate and cause disease.
tion for the structured community of microorganisms Changes in the diet to consumption of foods high
from invading bacteria, fungi and viruses, and toxic in sugars and fermentable carbohydrates can cause a
substances such as antibiotics or chemicals. The bio- proliferation of acid-producing and acid-tolerant bac-
film also provides a type of circulatory system for the teria such as mutans-type streptococci and lactobacil-
uptake of nutrients (derived from adjacent tissues, li. These bacteria can cause dental caries. Changes in
from salivary secretions, from other microorganisms, other oral factors can cause the growth of periodon-
and from the host diet) and for elimination of meta- tal pathogens leading to gingivitis, periodontitis, and
bolic by-products through water-filled spaces between peri-implantitis.
colonies.
PROBIOTICS
FORMATION OF ORAL BIOFILM Prescribed antibiotics can kill beneficial bacteria as well
Biofilm (or dental plaque) forms on teeth soon after they as pathogens. It can, then, be a challenge to maintain a
erupt. Likewise, it quickly re-forms after a professional healthy level of beneficial bacteria in the mouth and
cleaning and forms on newly placed restorations. The gut. Numerous studies have shown that the introduc-
initial layer on the surfaces of the teeth or restorations tion of beneficial bacteria called probiotics can help.
comes from salivary and gingival crevicular fluid com- Probiotics are live microorganisms that are consumed
ponents such as proteins, glycoproteins, lipids, albu- by an individual to promote health. The bacteria are
min, and mucin and is called the acquired pellicle. That added to milk, yogurt, or sour cream or are available
layer acts as a base to which bacteria can attach. The as tablets, capsules, or drops. Probiotics are becom-
majority of the first colonizers is from the Streptococcus ing more popular as a way to increase the numbers of
20 CHAPTER 2 Oral Environment and Patient Considerations

helpful bacteria to the G.I. tract and even the mouth. MANAGING THE ORAL BIOFILM
By increasing the numbers of beneficial bacteria, they Currently, we do not have a means of totally eliminat-
can help suppress the harmful bacteria. They help pro- ing pathogens in the oral biofilm, but we can manage
mote a healthy digestive tract and immune system. the biofilm so that a healthy mouth can be maintained.
Studies conducted over the past 15 years have The American Dental Association recommends twice
shown beneficial oral effects in managing dental caries daily brushing and daily flossing as a basic minimum
risk by reducing mutans streptococci in plaque and sa- oral hygiene routine. Tooth brushing with a fluoride-
liva; in managing periodontal disease risk by reducing containing paste can be accomplished with manual
periodontal pathogens and thereby, reducing bleed- or power brushing. Interdental cleaning is common-
ing on probing and gingival bleeding; by managing ly done with dental floss, but a variety of other aids
peri-implantitis risks; and by reducing the numbers of are available such as toothpicks, balsa sticks (Stimu-
Candida (a common fungus in the mouth that causes Dents®), interproximal plastic cleaners (GUM Soft-
thrush) by inhibiting its growth. As more evidence is picks®) and oral irrigators (WaterPik®). Additional
made available and guidelines are established on dos- oral hygiene measures may include tongue brushing
age and types of bacterial species to use for specific or scraping. ADA accepted antimicrobial mouth rins-
oral diseases, it is anticipated that general dentists and es, especially those with a combination of essential oils
specialists will begin to use probiotics on a routine ba- (e.g. Listerine®) or chlorhexidine (e.g. Peridex®), can
sis for management of these diseases. be helpful in managing gingivitis and supragingival
plaque.
BIOFILM AND SYSTEMIC DISEASES It is important for denture wearers to clean their
More and more research studies are showing a correla- dentures daily with a denture brush and non-abrasive
tion between periodontal disease and certain systemic paste and use a denture soak to remove the adherent
diseases such as heart disease, diabetes, some respira- biofilm.
tory ailments, and certain complications with preg-
nancy. It is believed that the ulceration of the gingival
sulcus caused by the bacteria in subgingival plaque al- Caution
lows pathogenic bacteria to enter the bloodstream and It is important that the oral health practitioner carefully
affect distant organ systems (FIG. 2.14). identify the locations and types of restorations present in the
patient’s mouth and take precautions to avoid altering their
BIOFILM ON DENTAL MATERIALS surfaces while instrumenting teeth or adjacent restorations.
Biofilm (dental plaque) on oral structures is well doc-
umented as having a primary role in the formation
of dental caries and periodontal diseases. The role
DETECTION OF RESTORATIVE MATERIALS
of biofilm adhesion on dental material is less well
known. Surface roughness has a direct correlation Oral health care professionals must be able to iden-
with biofilm accumulation. Roughness from abrasion, tify restorative materials within the oral environment
coronal polishing agents, hand and ultrasonic scaling, to treat them appropriately. Heavy pressure during
and lack of finishing (smoothing and shaping) and scaling, the use of sonic and ultrasonic scaling (uses
polishing after fabrication or initial placement of a high frequency vibrations) or air polishing (air-driven
restoration are all associated with increased biofilm stream of fine abrasive particles to smooth the surface),
accumulation. Biofilm accumulation at the margins of and inappropriate use of polishing agents may gouge
rough or faulty restorations may, in part, contribute to or scratch the surface of a restoration (FIG. 2.15). The
the development of recurrent caries. Biofilms do not placement of therapeutic agents such as acidulated
accumulate as readily on polished cast alloys and ce- fluoride may etch the surface of the restoration.
ramic restorations, possibly because of their smooth Identification of restorative materials, which may be
surfaces. Amalgam tends to have a biofilm that is less obvious with amalgam materials, may also be difficult
active likely because of the affect of mercury on the when identifying tooth-colored materials such as com-
bacterial population. Control of biofilm accumulation posite resin or ceramics. In addition, restorations may
on dental implants has been shown to play a signifi- be composed of different materials, such as a ceramic
cant role in the ultimate success of the implant. Flu- inlay cemented with resin-based cement. Identification
oride-releasing materials found in some restorations of restorative materials may be by appearance, loca-
can counteract the acids produced by biofilms. Den- tion, tactile sensitivity, and radiography. A well-matched
tures tend to develop a biofilm that is high in Candida tooth-colored restoration may be difficult to distinguish
(a yeast) and is associated with chronic irritation of from natural tooth structures. Well-developed tactile sen-
the underlying oral mucosa known as denture sto- sitivity skills with a dental explorer, adequate illumina-
matitis. Occasionally, the denture stomatitis requires tion, liberal use of air to dry the teeth and restorations,
treatment with antifungal medication to clear it up. and even magnification may be needed to detect some
So, prevention is the best treatment. esthetic restoration. The location of margins, especially
 Oral Environment and Patient Considerations CHAPTER 2 21

FIG. 2.14 Subgingival plaque bacteria and/or their by-products may gain access to distant sites in the body through the
circulatory system and may potentially contribute to systemic inflammation. In this way, a dental biofilm infection may
contribute to various systemic diseases and conditions. (From McNeil J Dent Hygiene vol 81, No 5, Oct 2007 Fig 4)

Once the presence of a restoration is identified, the en-

tire cavosurface margin should be evaluated. The ca-
vosurface margin should be almost undetectable as the
tip of the explorer passes from the restoration to the
tooth. Sealants have a smooth glassy surface covering
the anatomical pits and fissures of the tooth surfaces;
the explorer feels like it is skating on ice. Porcelain has
a very smooth glassy surface, and the explorer glides
easily over the surface (FIG. 2.16). Note the tip of the ex-
plorer as it glides against the margin of the restoration.
Adequate direct illumination and transillumination
are helpful for the detection of many anterior restora-
FIG. 2.15 The scratched surface of these gold crowns is due to inap- tions. With transillumination light can pass through teeth
propriate use of polishing agents. to varying degrees based upon the intensity of the light
and the thickness of the teeth. A mouth mirror placed lin-
those placed subgingivally, make visual inspection of gual to the incisors can reflect the operatory light through
many materials impossible. Drying the teeth well often these thin teeth. The light will not pass through the resto-
makes detection of composites easier. Saliva tends to hide ration as well as enamel so it will stand out. This, along
the distinction between the tooth surface and the margins with the knowledge that most anterior restorations are
of the restoration as well as the differences in the texture prepared from the lingual surface to preserve as much
and luster (shininess) of the restoration surfaces. natural enamel on the facial surface as possible, will help
Tactile evaluation of the tooth surface can be a help- in the identification of many class III and IV restorations.
ful means of clinical assessment. The surface of some Magnification and the liberal use of air will help
composite and glass ionomer restorations may feel to distinguish the glossy surface of enamel versus the
rougher than enamel. Tracing the enamel surface onto more opaque surface of composite and resin restora-
the restoration with the sharp tip of an explorer is tions. (However, highly polished newer generations
the best way to distinguish this difference. The clini- of composites allow them to be polished to a very
cian may detect a smooth surface on the enamel and smooth, lustrous surface similar to enamel.)
a “scratchy” surface on the restoration. This difference Radiographs are a valuable tool for the detection of
may be noticed at the cavosurface margin (the margin restorations and the assessment of restorative compo-
of the cavity preparation that meets the tooth surface). nents. Most modern composites are radiopaque, but
22 CHAPTER 2 Oral Environment and Patient Considerations

FIG. 2.16 The restoration margin in the first drawing extends over the cavosurface margin of the preparation (an over-
hanging margin) causing a trap for food and biofilm and if located on the proximal surface, will make flossing difficult. The
restoration margin in the second drawing does not meet the cavosurface margin of the preparation (a deficient margin)
causing a trap for biofilm and possibly lead to recurrent caries.

FIG. 2.18 Radiograph of the restorations in Fig. 2.17. Note the radi-
opacities: composite #13 DO, amalgam #14, #15, and #17, gold
crown #18 implant and PBM crown #19. Radiolucency of older type
composite is seen in #20 DO.

FIG. 2.17 Tooth-colored restorative materials may be difficult to detect.

Tooth #17 DO amalgam; tooth #18 gold crown over an implant; implant #18 and a porcelain fused to metal crown on
tooth #19 porcelain fused to metal crown; tooth #20 DO composite #19.
restoration. For most difficult-to-detect restorations, it is nec-
essary to use a combination of the above-described
some older ones are radiolucent. Glass ionomers are methods to determine the presence and type of mate-
radiopaque, as are many resin-based cements and ce- rial before clinical procedures are performed.
ramics (FIGS. 2.17 and 2.18 illustrate various types of
restorative materials as seen intraorally as well as their Conditions for Assessing Restoration
corresponding radiographic appearance). Note that the •  ry field
D
restoration on tooth #20 is an older radiolucent type of • Good lighting
composite material whereas the composite on #13 is • Sharp explorer
a radiopaque type. The other radiopaque restorative • Radiographs
materials include the amalgam restorations seen on • Magnification
• Good knowledge of the material
teeth #14, #15, and #17, as well as the gold crown on an
 Oral Environment and Patient Considerations CHAPTER 2 23

understanding of the limitations as well as the criteria

SUMMARY for selection of therapeutic and restorative materials.
The oral environment presents unique challenges to With this knowledge he or she can educate the patient
the successful use of dental materials as restorative about the materials used in their mouths as well as se-
and therapeutic agents. An understanding of the limit- lect and properly manipulate and maintain materials
ing factors in this environment and an appreciation for to ensure their ultimate success.
how these limitations affect the selection of materials
are essential to the successful use of dental materials.
INSTRUCTIONAL VIDEOS
Materials used must be biocompatible, exhibit long-
term clinical durability, and be esthetically accept- See the Evolve Resources site for a variety of educa-
able. No one material is superior in all of these areas. tional videos that reinforce the material covered in this
The allied oral health care practitioner must have an chapter.

Get Ready for Exams!

Review Questions 7. C orrosion is of greatest concern for which of the follow-

ing restorative materials?
Select the one correct response for each of the following a. Gold
multiple-choice questions. b. Composite resin
1. The safe interaction of a dental material with the rest of c. Amalgam
the body is defined as the material’s d. Porcelain
a. radioactivity 8. Surface discoloration of a metal restoration is called
b. carcinogenicity a. corrosion
c. biocompatibility b. tarnish
d. therapeutic reaction c. crystallization
2. The study of dental materials includes knowledge of d. metallurgy
a. the chemical reactions of the material 9. Restorative materials with values of thermal conductiv-
b. the physical reactions of the material ity similar to enamel include
c. the ways to manipulate the material a. gold
d. all of the above b. composite resin
3. The internal reaction to an externally applied force is c. amalgam
called d. silver
a. strain 10. Susan has just had an MOD amalgam placed on tooth
b. stress #30. When biting, this tooth is in contact with a gold
c. hardness crown on tooth #3. Susan complains of electric shock
d. elasticity sensation and metal taste. This is most likely due to
4. When increasingly higher forces are applied to a mate- a. galvanism
rial it will eventually fracture and the point of fracture is b. corrosion
called c. tarnish
a. fatigue fracture d. metamerism
b. tensile strength 11. Microleakage may be responsible for
c. ultimate strength a. recurrent decay
d. compressive fracture b. marginal staining
5. Material subject to repeated stresses such as in masti- c. postoperative sensitivity
cation may be subject to fracture due to d. all of the above
a. flexural stress 12. Excessive film thickness of cements may cause
b. force exerted over a large area a. an increase in retention
c. forces stretching an object b. a decrease in marginal leakage
d. fatigue failure c. improper seating of the restoration
6. Which of the following restorative materials is the most d. fracture of the restoration
soluble? 13. The leakage of fluids and debris extending along the
a. Amalgam tooth-restoration interface is called
b. Glass ionomer a. metamerism
c. Porcelain b. trituration
d. Acrylic
Continued
24 CHAPTER 2 Oral Environment and Patient Considerations

Get Ready for Exams!—cont’d

c. microleakage 16. T he term that describes the intensity of color is
d. deformation a. hue
14. Colonies of bacteria growing on the teeth are called b. value
a. principle invaders c. chroma
b. parasites d. opacity
c. dental plaque 17. Oral biofilm is
d. primary intruders a. a slick film of mucus that develops on surfaces
15. Color shades can vary depending on the incident light within ther mouth
or source of light. This effect is called b. composed of bacteria only
a. spectrum c. considered normal or healthy when non-pathogens
b. chroma keep harmful microbes in balance
c. meniscus d. is a complex organization of microorganisms on oral
d. metamerism surfaces and restorations
For answers to Review Questions, see the Appendix.

Case-Based Discussion Topics 3. L

 ook into a mirror, or position yourself to examine
someone else’s mouth, and check the following:
1. A 45-year-old businessman comes to your dental a. Check how tooth surfaces contact on the posterior,
office with the chief complaint of having to wear a middle, and anterior teeth when in normal occlu-
maxillary removable partial denture. He wishes to have sion, biting edge-to-edge on anterior teeth, and
this removable prosthesis replaced with a fixed bridge. moving the jaw laterally and front to back.
Examination reveals that the partial denture replaces Which forces are being exerted by these teeth and when?
teeth #6 through #11. b. Check for metal and resin restorations. Place a
Discuss the stresses that would be placed on a bridge of piece of ice on the enamel of a tooth, on the metal
this span. restoration, and on the resin restoration.
2. A 25-year-old school teacher comes to your office How long does it take to feel sensation to the pulp for
with the chief complaint of losing a distal-incisal each? What is this property called?
class IV composite from tooth #9. She explains that c. Look at the gingival, middle, and incisal/occlusal
this restoration has been in place for only a few third of anterior and posterior teeth.
days. How does the color of the area change; is there a change in
Discuss the factors that might affect the bond strength of translucency or opacity? Place something bright red close
this restoration and what you can do to help prevent this to the teeth, and direct the dental lamp or other bright light
from happening again. onto the teeth. How do these factors affect the color?

BIBLIOGRAPHY Twetman S, Jørgensen MR, Keller MK: Fifteen years of probiotic

therapy in the dental context: what has been achieved? J Calif
Anusavice KJ: Phillips’ Science of Dental Materials (ed 12). Phila- Dent Assoc 45(10):539–545, 2017.
delphia, 2013, Saunders. Powers JM, Wataha JC: Dental Materials: Foundations and Applica-
Bird DL, Robinson DS: Torres and Ehrlich Modern Dental Assisting tions (ed 11). St. Louis, 2017, Elsevier.
(ed 11). Philadelphia, 2015, Saunders. Sakaguchi RL, Powers JM: Fundamentals of materials science.
Gurenlian JR: The role of dental plaque biofilm in oral health. J In Craig’s Restorative Dental Materials (ed 13). St. Louis, 2012,
Dent Hyg 81(5):116, 2007. Mosby (Chapter 4).
Marsh PD: Ecological events in oral health and disease: new op- Van Noort R: Principles of adhesion. In Introduction to Dental
portunities for prevention and disease control? J Calif Dent Materials (ed 4). London, 2013, Mosby (Chapter 1.9).
Assoc 45(10):525–537, 2017.
Physical and Mechanical Properties of Dental
Materials 3
http://evolve.elsevier.com/Eakle/materials/

Chapter Objectives
Upon completion of this chapter, the student should be able to:
1. Define primary and secondary bonds and give an 8. E xplain the difference between toughness and resilience.
example of how each determines the properties of the 9. Define brittleness and discuss how this property applies
material. to restorative dental materials.
2. Describe the three forms of matter and give a defining 10. Define viscosity and thixotropy and describe the clinical
characteristic of each. significance of each.
3. Define density and explain the relationship of density, 11. Differentiate between therapeutic, preventive, and
volume, and crystalline structure. restorative materials.
4. Define hardness and describe how hardness contributes 12. List and describe the three main types of restorative
to abrasion resistance. dental materials.
5. Define elasticity and give an example of when elasticity is 13. Describe the reaction stages a material undergoes to
desirable in dental procedures. acquire its final state.
6. Relate stiffness and proportional limit, and describe how 14. Describe the variables in the manipulation of a material.
these properties apply to restorative dental materials.
7. Define ductility and malleability and explain how these
characteristics contribute to the edge strength of a gold
crown.

Key Terms
Primary Bonds strong bonds with electronic attractions; Young’s Modulus or Elastic Modulus measures the resis-
ionic bonds, covalent bonds, metallic bonds tance of a material to being deformed.
Secondary Bonds weaker bonds than primary bonds; Resilience the ability of a material to absorb energy without
hydrogen bonds, van der Waals forces, London Dispersion permanent deformation
Forces Toughness the ability of a material to resist fracture
Brittle hard materials that break easily when stress is ap- Ductility the ability of an object to be pulled or stretched
plied. They break suddenly with little plastic deformation, under tension without rupture
e.g., glass. Malleability the ability to be compressed and formed into a
Density the measure of the c weight of a material compared thin sheet without rupture
with its volume Edge Strength the ability of a material to withstand fracture
Hardness the resistance of a solid to penetration at a thin edge, such as at margins of a restoration
Ultimate Strength the maximum amount of stress a material Durability the ability of a material to withstand damage due
can withstand without breaking to pressure or wear
Elasticity the ability of a material to recover its shape com- Viscosity the ability of a liquid material to resist flow
pletely after deformation from an applied force Thixotropy a characteristic of some gels and liquids that
Elastic Deformation deformation of a material that recovers they will flow more readily under mechanical force such as
its original shape and size when the force is removed mixing, stirring, or shaking.
Elastic Limit the greatest stress a structure can withstand Direct Restorative Materials restorations placed directly
without permanent deformation into a cavity preparation
Plastic Deformation deformation of a material causing Indirect Restorative Materials materials used to fabricate
permanent changes in size or shape due to an applied restorations outside the mouth that are subsequently
force placed into the mouth
Yield Stress the stress at which plastic deformation begins; Permanent Restorations restorations expected to be
also called yield point on a stress-strain curve long-lasting
Stiffness a material’s resistance to deformation

25
26 CHAPTER 3 Physical and Mechanical Properties of Dental Materials

Temporary Restorations restorations expected to last Final Set Time the time needed for the reaction that begins
several days or weeks when the material is mixed to go to completion, and the
Intermediate Restorations restorations expected to last material hardens to its permanent state
several weeks to months Chemical Set Materials materials that set through a timed
Mixing Time the amount of time allotted to bring the com- chemical reaction with the combination of a catalyst and base
ponents of a material together into a homogeneous mix Light-Activated Materials materials that require light in the
Working Time the lapse of time from the start of mixing the blue wave range to initiate a reaction
material until it begins to harden and is no longer workable Dual Set Materials materials that polymerize either from
because it has reached its initial set exposure to light in the blue wave range or from a chemi-
Initial Set Time coincides with the end of working time and cal reaction
is the time at which the material can no longer be manipu- Shelf Life the useful life of a material before it deteriorates or
lated in the mouth changes in quality

To predict how a material will react under oral conditions, it their outer orbits. Atoms attempt to form the most sta-
is necessary to have an understanding of its physical prop- ble configurations possible by filling their outermost
erties. Chapter 2 (Oral Environment and Patient Consid- orbits with electrons when bonding with other atoms.
erations) discussed how the oral environment could affect To do this, they will transfer or share electrons.
and challenge the properties of dental materials. This chapter
discusses how those properties are achieved, how they influ- TYPES OF BONDS
ence the clinician’s choice of a material, and how and when Two categories of bonds are formed between two at-
properties can be manipulated. Both physical and mechani- oms; strong bonds are called primary bonds and weak-
cal properties must be considered when choosing the best er bonds are called secondary bonds.
restorative dental material. Physical properties are those
properties of materials that can be measured and observed Primary Bonds
without having to change the composition of the material Primary bonds are the strongest bonds that hold at-
and they help describe it. Physical properties include proper- oms together because they involve the transferring or
ties such as color, thermal conductivity, and solubility. Me- sharing of electrons. The three types of primary bonds
chanical properties are properties that define the material’s (Fig. 3.2) are:
ability to perform in the oral environment and resist stresses • Covalent bonds
and strains. Mechanical properties are considered a subset of • Ionic bonds
physical properties and include properties such as elasticity, • Metallic bonds
ductility, durability, and ultimate strength.
Electrochemical properties are seen in the reactions of ma- Covalent Bonds
terials as they set or their reactions to corrosive elements in Covalent bonds represent a type of bond that occurs
the oral environment and their chemical stability and dura- when two nonmetal atoms share electrons in their out-
bility in the mouth. er shells, creating full shells for both (Fig. 3.2B). Many
To begin a discussion of the properties of dental materials, covalent bonds form gasses (hydrogen molecule, H2)
it is important to begin with a review of the physical struc- or materials with low melting points. Covalent bonds
ture of matter. occurring in a network configuration are very strong.

Structure of atom
PHYSICAL STRUCTURE
ATOMS
Atoms are the basic building blocks of matter. They Proton
are composed of particles called neutrons, protons,
and electrons (Fig. 3.1). Protons have positive electrical Neutron
charges; electrons have negative charges and neutrons
have no electrical charges. Neutrons and protons being
heavier than electrons form the nucleus in the center
Electron
of the atom. Electrons are found in orbits (also called
shells) around the nucleus. It is the outermost orbit in
which electrons (called valence electrons) will interact
with other atoms. The numbers and configuration of
electrons in their orbits affect how reactive they are Nucleus
with other atoms. Some atoms have space within their FIG. 3.1 The atomic structure. Heavy neutrons and protons form the
nucleus of the atom and electrons circle around the nucleus in shells
outer orbits while other atoms have extra electrons in
or orbits.
 Physical and Mechanical Properties of Dental Materials CHAPTER 3 27

Na Cl

Na+ Cl-

Shared electrons
A Ionic bond B C
FIG. 3.2 Primary Bonds. A. Ionic bond, characterized by electron transfer from one element (Na) to another (Cl). B.
Covalent bond, characterized by electron sharing and very precise bond orientations. C. Metallic bond, characterized by
electron sharing and formation of a “cloud” of electrons that bonds to the positively charged nucleus in a lattice. (From
Anusavice KJ, Shen C, Rawls H: Phillips’ Science of Dental Materials (ed 12). St. Louis, 2013, Saunders.)

Diamond is a good example of a strong network co- Combinations of Primary Bonds

valent bond; it is hard and has a high melting point. Many materials contain more than one type of primary
Some materials are made up of chains of covalent bond.
bonds; polymers used in plastic and rubber are good
examples of long chains of covalently bonded atoms. SECONDARY BONDS
Secondary bonds, broadly called van der Waals forces,
Ionic Bonds are very different than primary bonds. Unlike primary
When atoms gain or lose electrons they become electri- bonds, no transfer or sharing of electrons occurs. Sec-
cally charged and are called ions. Positively charged ondary bonds are forces found between molecules in
(+) ions are called cations and negatively charged (-) the same material (i.e., attractions between water mol-
ions are called anions. Ions that have opposite charges ecules) rather than forces that bond atoms (together
have electrostatic attractions for each other. When they into a molecule) such as covalent bonding of hydrogen
combine, one atom gives up electrons from its outer and oxygen atoms to form a water molecule. The sec-
shell and the other atom gains electrons. The energy ondary bonds are created by various types of electric
that holds these atoms together to form a molecule is dipoles. A dipole is created when electrons are un-
called ionic bonding. Salt or sodium chloride is an ex- equally shared between atoms within a molecule form-
ample of ionic bonding (Fig. 3.2A). ing positive and negative charge centers at each end of
Materials bonded in this way, such as ceramics, are the molecule causing an electrical imbalance. Second-
usually brittle when they are pulled or bent and are poor ary bonds are much weaker than primary bonds.
electrical conductors. Ionic bonding can also be seen in Three examples of secondary bonds include
gypsum products and phosphate-based cements. • Hydrogen bonds (dipole-dipole forces)
• Permanent dipoles
Metallic Bonds • Temporary dipoles
When atoms join to form metals, they bond in an en-
tirely different manner than with covalent or ionic Hydrogen Bonds
bonding, but they still attempt to form stable outer or- Hydrogen bonds are dipole-dipole inactions. They ex-
bits. Multiple atoms in a lattice arrangement share a ist in molecules where electrons are not shared equally
large pool of valence electrons that move throughout and thus have electrical poles. In the case of water,
the material. This sea of electrons passing among the hydrogen is attracted to the larger oxygen atom. Al-
atoms produces what is called metallic bonding (Fig. though electrons are shared between the hydrogen and
3.2C). Imagine filling a bucket with marbles and then oxygen atoms, these electrons are unbalanced, spend-
adding water. The marbles are arranged in a structured ing more time around the oxygen atom. This causes a
manner and the water fills the spaces between them. partial negative charge on the oxygen side of the mol-
The water is like the sea of electrons that is shared by ecule, and a partial positive charge on the hydrogen
the metal atoms represented here as marbles. side setting up two opposite electromagnetic poles
It is this type of bonding with freely flowing elec- called a dipole. They act like a magnet attracting op-
trons that is responsible for many of the physical prop- posite charges. These bonds are responsible for many
erties seen with metals such as their strength or ability of the properties of water such as solvent properties,
to conduct heat and electricity, to be formed into shapes cohesion (sticks to itself), adhesion (sticks to other ma-
such as coins or jewelry (malleable), or stretched into terials), and density. Hydrogen bonds are the strongest
wires (ductile) like those used in orthodontics. of the secondary bonds but still much weaker than pri-
mary bonds.
28 CHAPTER 3 Physical and Mechanical Properties of Dental Materials

Permanent Dipoles THE THREE STATES OF MATTER

Permanent dipoles in a molecule have positive and Matter exists in three states or phases:
negative charge centers that do not fluctuate and the • Solid
molecule must consist of atoms from different ele- • Liquid
ments. A permanent dipole is formed when one atom • Gas
in a molecule has a stronger electron attraction than Solids have the strongest attraction between atoms
another atom and, therefore, becomes more negative and molecules and have both shape and volume; a liq-
in its charge. Then, the other atom becomes more posi- uid has volume but no definite shape; and a gas has
tive in its charge. This electrical imbalance creates an neither definite shape nor volume. Most materials are
electric dipole. When the attraction between dipoles in mixtures of more than one state of matter. For example,
adjacent molecules causes them to interact, they form plaster is a mixture of both a solid and a liquid, and
weak bonds between the molecules. Hydrochloric acid fluoride foams are a mixture of a liquid and a gas (air)
(HCl) is an example of a polar molecule where the mol- under pressure. Gases are used mostly as propellants
ecules are held together by permanent dipole-dipole in dispensing or mixing dental materials. Therefore,
forces. this chapter will limit the discussion to the general
properties common to solids and liquids.
Temporary (Induced) Dipoles
All atoms and molecules have electron clouds. Within Solids
a bond the electrons are in constant motion and can In solids the atoms are packed tightly together and this
oscillate. For brief nanoseconds electrons may be clus- restricts their movement providing them with a fixed
tered more to one side creating a charge that quickly shape. Primary bonds hold the atoms of solids togeth-
disappears. The temporary negative charge will attract er, giving them strength and stability. Solids maintain
a temporary positive charge from a nearby molecule, their shape and resist forces that try to deform them.
a process called the London dispersion force of at- Solids are found in two main forms: crystalline or
traction. For example, the interaction between iodine amorphous. Crystalline solids have an ordered three-
molecules is a temporary dipole bond. The London dimensional symmetrical pattern or lattice network
dispersion force is the weakest of the secondary bonds. that repeats throughout the crystal (Fig. 3.3). There are
It is responsible for the condensation of nonpolar at- 14 different types of lattice structures. Many minerals
oms or molecules into liquids or solids with a drop in such as table salt are crystalline solids. Because of their
temperature. structure crystalline solids cannot be compressed into
smaller shapes. Within the lattice structure all bonds
Types of Bonds between particles are equal so that when heat is ap-
plied all the bonds are broken at the same time pro-
PRIMARY BONDS ducing a definite melting point. Ice transforms from a
Strong bonds that bind atoms of a molecule
solid state to a liquid state at its melting point of 0o C at
1. Ionic bonds—one atom gives up electrons and another
atom gains electrons in the outer shell
standard atmospheric pressure.
2. Covalent bonds—two nonmetal atoms share electrons Noncrystalline solids called amorphous solids have
in their outer shell atoms in nonrepeating arrangements similar to liq-
3. Metallic bonds—multiple atoms in a lattice configura- uids. They do not have a definite melting point but
tion share a sea of electrons that move throughout the soften gradually as heat is applied. Examples of amor-
lattice. phous solids include many dental waxes and glass-
SECONDARY BONDS type ceramics.
Weak bonds that are adhesive forces acting between
molecules (broadly called van der Waals forces)
1. Permanent dipole interactions—negatively charged Lattice points
pole in one atom attracts positively charged pole in an
adjacent atom to form weak bonds
2. Temporary dipole interaction—constantly circulating
electrons in one molecule cluster briefly causing a nega-
tive charge that attracts a positive charge form a nearby
molecule; called London dispersion force. The weakest
of the secondary bonds.
3. Hydrogen bonds—dipole-dipole interaction involving
hydrogen atoms where a positive electromagnetically
charged atom (commonly hydrogen) attracts a strongly
negatively charged atom (adjacent dipole) to bind Simple cubic lattice cell
hydrogen to a larger atom (i.e., oxygen). These are the FIG. 3.3 Lattice network in a crystalline solid. Depicted is a simple
strongest of the secondary bonds. cubic lattice cell. (From Lattice Structures in Crystalline Solids by Rice
University.)
 Physical and Mechanical Properties of Dental Materials CHAPTER 3 29

Liquids (see Chapter 2 Oral Environment and Patient Consid-

Unlike the molecules of a solid, molecules in a liquid erations, section on Esthetics and Chapter 9 Ceramics,
state are not confined to patterns; therefore, liquids section Optical Properties and section Shade Taking).
can easily change shape and can flow. The study of Density is a measure of the weight a material has
this flow is the science of rheology. Fluid flow can be compared with its volume. It is a measure of the com-
steady or unsteady, and flow has a major influence on pactness of matter, or how much mass is squeezed into
the handling or delivery of dental materials. For exam- a given space. A brick and a sponge of the same di-
ple, impression materials that are placed around the mensions have the same volume but the brick is much
prepared tooth must flow readily to capture the fine denser (Fig. 3.4). The sponge has many large air spaces
details of the preparation while impression materials throughout. If you squeeze the sponge, the volume
that are placed in the impression tray should exhibit and the air spaces are reduced and the sponge becomes
less flow. The movement of a liquid will depend on the denser (less spacing is seen between atoms). The close
characteristics of the liquid and the surface on which spacing of the crystalline structure gives the greatest
it is placed. Chapter 2 defines these characteristics and density. Enamel is the densest of the tooth structures,
their relationships in the discussion of bonding. and gold is a dense restorative material.
Viscosity is the resistance of a liquid to flow. Values
of viscosity depend on the nature of the fluid; thin liq- MECHANICAL PROPERTIES
uids have low viscosity and thicker liquids have high Mechanical properties are a subset of physical proper-
viscosity. Water flows readily, and therefore has very ties. They are physical properties that are seen when a
low viscosity, whereas higher viscosity liquids (tree load or force is applied to a material. They include such
sap, for example) have greater ability to resist flow. The properties as hardness, stress, strain, fatigue, strength,
viscosity of liquids usually decreases as the tempera- elasticity, stiffness, resilience, toughness, ductility, mal-
ture increases. Some viscous liquids will flow more leability, and durability.
readily under stress (a property called thixotrophy), for Hardness is the resistance of a solid to penetration.
example, when they are mixed, shaken, stirred, or ma- Hardness is also used to define a material’s resistance to
nipulated. Fluoride gels are often advertised as thixo- wear and abrasion. The hardness of a dental structure or
tropic. This gives the operator control of the gel while material determines the extent to which it is scratched by
it is in the delivery tray, so that it does not drip out an abrasive material. Enamel and porcelain, two of the
when inserted into the patient’s mouth. Once the mate- hardest materials, are more resistant to being scratched
rial is in the mouth, the patient is instructed to chew on than are cementum and dentin, or composite resins and
the tray, decreasing the material’s viscosity and allow- gold crowns. For this reason it is very important that the
ing it to flow into pits and fissures and interproximally type of restorative material or tooth surface be determined
to improve penetration into all surfaces. first, before beginning procedures with abrasive agents.
Gypsum products when mixed with water are a
slurry (a watery mixture) that can be poured into an Hardness tests. There are several tests designed to
impression to create a solid cast when it hardens. Some measure the hardness of materials, and they all meas-
materials like waxes appear solid but are really super- ure the material’s resistance to being indented. Knoop
cooled liquids. They can be caused to flow under load- hardness is the value usually given for dental materi-
ing forces or can deform under light stresses. als. The testing head is shaped like a pyramid for the
Liquids when heated eventually vaporize or boil. Knoop and Vickers tests, a cone for the Rockwell test,
Water transforms from a liquid state to a gas state and a ball for the Brinell test. The Knoop test uses low-
(steam) at its boiling point of 100 ℃ at standard atmo- er pressures for pressing the diamond head into the
spheric pressure. The lower the atmospheric pressure, material than the Vickers test, so it can be used to test a
the lower will be the boiling point. variety of materials including thin or brittle materials

PROPERTIES OF DENTAL MATERIALS

Properties of dental materials are of three basic types:
physical, mechanical, and chemical (or electrochemical).

PHYSICAL PROPERTIES Low density High density

Physical properties are those properties that can be ob-
served and measured without changing the composition
of the material. Physical properties include such things
as melting and boiling points, density, viscosity, ther-
mal conductivity, and thermal expansion (see Chapter FIG. 3.4 The sponge on the left is porous and low in density while the
2 Oral Environment and Patient Considerations, section brick on the right lacks porosity and is very dense. So, the brick weighs
on Temperature), and optical properties such as color more even though the two are about the same in volume.
30 CHAPTER 3 Physical and Mechanical Properties of Dental Materials

C Elastic region
B
Fractures Plastic region
A
D
Stress A B

Stress
Strain Strain

A B
FIG. 3.5 Stress-strain curve A, Curve for brittle materials. Brittle material reaches its elastic limit (A) and then quickly
fractures (B) with added stress. B, Curve for ductile materials. Ductile material reaches its elastic limit (A) and begin to
distort (B). This plastic deformation continues until the material reaches its breaking stress (C). Unlike brittle materials, it
fails slowly until it reaches its fracture point (D).

such as ceramics. The size of the indentation is meas- progressive recovery is important in the controlled
ured and the hardness is calculated based upon this movement of teeth.
size. The smaller the indentation, the harder is the ma- The relationship between stress and strain is useful
terial. The Vickers test is used mostly for testing metals. for comparing properties of materials so the best mate-
Stress develops within a material when a force is rial can be selected for a given application. The rela-
applied (see Chapter 2 Oral Environment and Patient tionship can be plotted on a graph with values of stress
Considerations, section on Force, Stress and Strain). on the vertical axis and values of strain on the horizon-
The larger the area over which the force is distributed, tal axis. The resultant curve plotted on the graph repre-
the less will be the stress. Stress can occur singularly or sents a behavior of a material when subjected to a load.
in various combinations depending on the directions It provides useful information about the strength and
of the applied forces. ductility of materials and can compare the response of
When a solid is subjected to an external force of different materials to the same load. The stress-strain
sufficient magnitude, it undergoes change in size and curve for each material is unique, but it is possible to
shape and is considered strained. The amount of stress find some characteristics in common among various
placed on a material at the time it breaks is known as groups of materials. For example, stress-strain curves
its ultimate strength. A material does not necessarily for brittle materials or ductile materials have similar
have to break when subjected to an external compres- characteristics (Fig. 3.5). The stress-strain curve for
sive, shearing, or tensile force; it may deform. If this brittle materials such as porcelain has only an elastic
deformation is not permanent and the material recov- region followed by fracture of the material. There is no
ers from the force completely, it has good elasticity and yield point and the ultimate strength and the fracture
has undergone elastic deformation. A rubber band is strength are the same. Young’s modulus measures the
an example of a material with elasticity. Plastic de- resistance of a material to being deformed. The stiff-
formation, on the other hand, occurs when a force or ness of a material, i.e., the lack of elasticity, means that
stress produces an irreversible change in a solid mate- it resists being deformed and it is measured by Young’s
rial’s shape or size. modulus (also called elastic modulus). Stiffer materi-
Not all materials return to their original shape when als have a higher modulus; enamel has a high modu-
the deforming force is removed. Materials that do not lus. Restorative materials should have a modulus that
return to their original shape have exceeded their elas- is compatible with tooth structure. We usually do not
tic limit and start to permanently (or plastically) de- want dental restorations to bend or compress when a
form. The stress at which plastic deformation begins is force is applied, so materials such as amalgam, com-
called the yield stress. Rubber can be deformed quite posite resin, and ceramics should be stiff.
a bit before permanent deformation occurs. Elasticity Resilience is the amount of energy a material can
is important for impression materials, which must be absorb without permanent deformation. Impression
stretched over tooth or bony undercuts without per- materials and orthodontic wire must be resilient to be
manent deformation. Elasticity is important for ortho- successful. When an impression is removed from the
dontics, where wires and springs are deformed and the patient’s mouth it needs to deform to be slipped over
force they generate in returning to their original shape the contours of the oral structures. To be an accurate
moves teeth. These wires do not recover immediately; impression it is equally important that the material re-
rather, they recover over a period of time and with turns completely to the original shape of the oral struc-
some degree of permanent deformation. This slow tures impressed.
 Physical and Mechanical Properties of Dental Materials CHAPTER 3 31

FIG. 3.6 Ductility. Stainless steel is an example of a very ductile metal.

When placed under enough stress, it will elongate significantly before it
fractures. (Courtesy Fastenal Company, Winona, MN.)

Toughness is the ability of a material to absorb ener-

gy without fracture; restorative materials must exhibit
toughness. Brittle materials have limited toughness
because small amounts of deformation will cause frac-
ture. Traditional porcelain restorations are much more FIG. 3.7 Malleability. The two coins are made from a malleable metal
likely to fail on the occlusal surfaces of posterior teeth and were originally the same size. The left side of the top coin has been
than are gold restorations. Newer ceramic materials pounded with a hammer to a thin edge without breaking. This property
is is an indication of malleability. (Courtesy Dr. Steve Eakle.)
such as zirconia are very tough.
Pulling or stretching of orthodontic wire under ten-
sile stress is a measure of its ductility (Fig. 3.6), that is,
the amount of dimensional change it can withstand
without breaking. Gold is very ductile since it can be
elongated close to 20%. Materials with poor ductil-
ity are classified as brittle. These materials are much
weaker when subjected to tensile forces than to com-
pressive forces. Porcelain is brittle and cannot under-
go much tensile stress without fracture; its ultimate
strength is about equal to its elastic limit. Gold is not
only ductile, but it is malleable too (Fig. 3.7). Malle-
ability means that it responds easily to compressive
stress and can be hammered into a thin sheet without
fracture. The combination of malleability and ductil-
ity gives this metal the ability to resist fracture even at
fine margins, giving gold edge strength. These charac-
FIG. 3.8 An amalgam restoration with severe breakdown of the mar-
teristics allow for the superior edge strength of gold gins creating a space or ditch between the amalgam and the cavity
crowns. Amalgam does not have good edge strength. preparation. (Courtesy of S. Geraldeli. From Anusavice KJ, Shen C,
If an insufficient amount of amalgam is present at the Rawls H: Phillips’ Science of Dental Materials (ed 12). St. Louis, 2013,
edge of a restoration, the forces of mastication will Saunders, p. 357.)
likely cause fracture of the material at the margin (Fig-
ures 3.8 and 3.9). In most cases noble metals tend to be
ductile and malleable, but ceramics are brittle. Ceram- over time from repeated chewing forces placed on
ics and composites are described as brittle, because them (Fig. 3.10).
they will sustain little strain before they fracture. Durability refers to the ability of a material to with-
Fatigue occurs within a material when it is sub- stand damage due to pressure or wear. Both porcelain
jected to repeated stresses and can result in a sudden and metal are very durable, resilient, and tough and
failure or fracture of the material. Microscopic flaws can absorb stress without breaking. Porcelain is brittle,
or cracks develop within the material that progress however, and cannot withstand shearing stresses as
with repeated loading. This can be seen when a strip well as metals. Metals are very durable but not as es-
of metal is bent back and forth repeatedly until it thetic as porcelain. All-ceramic crowns have replaced
breaks. Likewise, weak cusps of a tooth may fracture porcelain in many applications, and provide excellent
32 CHAPTER 3 Physical and Mechanical Properties of Dental Materials

mechanical properties as well as esthetics. Amalgam Chapter 2 Oral Environment and Patient Consider-
is durable and provides longevity and a cost-effective ations, section Moisture and Acid Levels and Chapter
alternative. Amalgam restorations lack esthetics and 10 Amalgam, Fig. 10.3). A very common form of cor-
contain mercury, which some offices have chosen to rosion seen in your neighborhood is a rusting iron
eliminate from their environment. Composites provide gate, nail, or other iron object. Oxygen in the air oxi-
a durable option in areas where esthetics are important, dizes the iron and forms iron oxide, otherwise known
but can they stain and do not resist abrasion as well as as rust. The iron has been chemically changed.
the other restorative choices. The new nanocomposite Galvinism (see Chapter 2 Oral Environment and
materials have improved this restorative choice. To ad- Patient Considerations, section Galvinism) is an elec-
equately evaluate the best restorative choice, durabil- trochemical reaction that occurs when two dissimilar
ity and esthetics are both important. metals contact each other in the presence of a solution
containing electrolytes (such as saliva). It acts like a bat-
CHEMICAL PROPERTIES tery and produces an electric current causing the patient
Chemical properties are those that involve a chemical to experience electric shocks and/or a metallic taste.
reaction that changes the material into one or more
different materials. Atoms have been rearranged and CLASSIFICATION OF MATERIALS
a new material is formed. Some of the chemical reac-
tions in the mouth involve an electrical current and Restorative dental materials can be classified by their
these are called electrochemical reactions. Corrosion composition and divided into the categories of metals
is the most common electrochemical property seen in and their alloys, ceramics, and polymers.
the oral cavity and is seen most often with metals (see Metals have properties such as strength, ability to
Force conduct electricity and heat, malleability, ductility, and
luster. Metals and their alloys are used for amalgam
restorations, implants, partial denture frameworks,
and crowns and bridges.
Ceramics are strong but generally are rigid and brit-
tle and melt at high temperatures. They are poor con-
Margin ductors of heat and electricity. Ceramics are popular
fracture
for esthetic crowns and veneers.
Polymers can occur in long chains that give cer-
tain properties depending on how the chains are
linked to each other. Some polymers can be flex-
ible, easily shaped, and rubbery, while others can be
FIG. 3.9 Chipping of the margins of an amalgam restoration. Amalgam hard, rigid, and difficult to mold into shapes. They
is a brittle material. If a thin edge of amalgam is left overlapping the can be used for denture bases and denture teeth, for
enamel at the margin after carving, this excess amalgam may fracture example.
away under chewing forces creating ragged margins or a gap that col- Composite resins are combinations of polymers and
lects plaque. (From Anusavice KJ, Shen C, Rawls H: Phillips’ Science
of Dental Materials (ed 12). St. Louis, 2013, Saunders, p. 357.)
ceramics. The polymer component allows the material

A B
FIG. 3.10 Material fatigue. A, Crack develops and propagates under cusp as it flexes under repeated chewing pressure.
B, Fatigue fracture of ML cusp of lower 2nd molar. (Courtesy Dr. Steve Eakle.)
 Physical and Mechanical Properties of Dental Materials CHAPTER 3 33

to adapt to the walls of the cavity preparation and be generally used when there is other ongoing treatment
shaped, while the ceramic component adds wear resis- such as orthodontics or implant therapy that is needed
tance and provides color and other optical properties before a permanent restoration is required.
for esthetics.
Materials also can be classified by their application,
COMPOSITION
how they will be used and fabricated, and their ex-
pected longevity. As stated in Chapter 2, they may be Materials may be classified by their composition. Com-
preventive, therapeutic, or restorative: ponents and the reactions of those components may
Preventive materials: Preventive materials are directed aid classification of materials. Many types of dental
toward preventing the occurrence of oral disease, materials require the combination of two components
trauma to teeth and jaws, and promoting oral health. to form the resulting final material. These initial two
Fluorides, pit and fissure sealants, and polyethylene components may begin as water and powder, liquid
materials for sports guards are preventive materials. and powder, paste and liquid, paste and paste, or paste
Therapeutic materials: Therapeutic materials are used in and initiator (blue light). Dental plaster begins with
the treatment of disease and include materials such water and powder components. Composite restora-
as medicated bases or topical treatments for peri- tions may require a paste, with blue light as an initia-
odontal disease. tor. Many of these components are classified as catalyst
Restorative materials: Restorative materials represent and base; the catalyst is responsible for the speed at
the largest classification. This classification applies which the reaction occurs and is often the liquid com-
to any filling, inlay, crown, bridge, implant, or par- ponent. Components may be measured and dispensed
tial or complete denture that restores or replaces as catalyst and base or packaged in predosed amounts.
lost tooth structure, teeth, or oral tissue. Restorative
materials may be used for short-term (temporary Clinical Tip
crowns, cements) or for long-term use (permanent
Standardization of measurements in predose packages
restorations, prosthetic, implant, and orthodontic
eliminates the errors produced in measuring.
appliances).
Restorations may be further classified as direct re-
storative materials or indirect restorative materials.
Direct restorative materials are fabricated directly in
REACTION ACTIVATED BY MIXING
the mouth, whereas indirect restorative materials are When components are mixed together, a reaction oc-
fabricated outside the mouth (often in dental laborato- curs. This reaction may be physical, involving the
ries, using replicas of the patient’s dentition) and then evaporation or cooling of liquid, or it may be chemi-
placed in the patient’s mouth. cal, creating new primary bonds. Most reactions of the
Some materials such as amalgams and composites two components result in a solid structure. Before the
may be fabricated directly in the mouth. Other materi- material reaches its ultimate solid state, the process
als, because of convenience or toxicity or other physi- goes through stages: the manipulation stage and the
cally harmful characteristics, need to be fabricated in- reaction stage. Both stages are defined in units of time.
directly, outside the mouth, and then placed into the The manipulation stage includes the mixing time and
oral environment. Porcelain, for instance, needs to be working time, and the reaction stage includes the ini-
fired to temperatures higher than 1000 °F, making indi- tial set and final set times. Mixing time is the length of
rect fabrication necessary. time the dental auxiliary has to bring the components
Materials are classified by longevity, that is, how together into a homogeneous mix. To allow the clini-
long they are expected to hold up in the oral cavity. cian the full working time, mixing times must be strict-
Although all materials will degrade, wear, or fracture ly observed. The working time is the time from mixing
over time, permanent restorations are expected to be a the material until it begins to harden and is no longer
long-lasting replacement for missing, damaged, or dis- workable because it has reached its initial set. The ini-
colored teeth. Temporary restorations, also called pro- tial set time coincides with the end of working time
visional restorations, are used for short periods of time, and it occurs when the material no longer can be ma-
several days to weeks. They function in the place of nipulated in the mouth. The final set time is that time
the permanent restoration to protect the teeth, prevent needed for the reaction that begins when the material
sensitivity and unwanted tooth movement, maintain is mixed to go to completion, and the material hardens
the health and contours of the periodontal tissues, in its permanent state (Fig. 3.11).
enable the patient to function normally, and provide Mixing and working times often offer some control
temporary esthetics in the prepared area. Intermediate variables. Mixing slowly and cooling the components
restorations, like provisional restorations, are placed may increase the working time; the addition of more
for a limited time; however, the time may extend from catalyst may decrease the working time. Control of
several weeks to months. These restorations are not ex- these variables is important for some situations. For
pected to replace tooth structure permanently and are instance, when working with pediatric patients, or
34 CHAPTER 3 Physical and Mechanical Properties of Dental Materials

Mixing time Working time Initial set Final set

Mix material Manipulate in mouth Can no longer manipulate Permanent state

FIG. 3.11 Timing for a procedure from mixing to final set.

patients who have a limited opening, decreasing the

working time would be desirable. When one is work-
ing with a large amount of restorative material, an in-
crease in the working time may be required, so that
the material can be manipulated for a longer time. The
amount of working time also may be controlled by how
the reaction stage is initiated. Chemical set materials
are those that set through the timed chemical reaction
of a catalyst and base. Once the two components come
in contact with each other, the chemical reaction begins
and continues through the reaction stage. The clinician
has little or no control of the time, except cooling the
material before mixing. For this reason many clinicians
have selected light-activated systems for their materi-
als. Light-activated materials use a light source in the
blue light range to initiate the reaction stage (Fig. 3 12, FIG. 3.12 Light curing unit that emits light in the blue wave range is
and see Chapter 6, section on Light Curing for a de- used to cure light-activated material in the mouth.
tailed discussion). Both components are present in the
material but do not react until the material comes in manipulation instructions for dental cement, including
contact with the blue light source, thus giving the clini- units of time.
cian unlimited working time. Dual set materials have Variables in the manipulation of the material begin
a slow chemical set that is activated when components with the ratios of the components.
are mixed but the set can be accelerated by light cur-
ing. This gives the clinician much more control of the Manipulation of Dental Cement for
working time and gives assurance of complete setting Cementation of a Crown, Expressed in Units
in deeper or more difficult-to-access areas of the mouth of Time
or preparation.
The setting times, initial and final, are important to MANIPULATION STAGE
the auxiliary as well as the clinician. The material must Powder-to-liquid ratio: 2 scoops of powder to 4 drops of
not be disturbed after the initial set has occurred. Mois- liquid
Mixing time: Mix all of the powder aggressively into the
ture and pressure controls are frequently important
liquid for about 30 seconds
during the initial set. Moisture contamination, from
Working time: Spread the cement over all the internal
saliva and blood, during the initial set time may have surfaces of the crown; the working time is 2.5 minutes
an adverse effect on many dental materials, causing
them to fail. Continued firm pressure from biting force REACTION STAGE
or from holding the material firmly in the mouth is es- Initial set time: Wait 2 minutes after placement; remove the
excess cement with an appropriate instrument. Knotted
sential for materials needing intimate contact with the
floss can be used in the interproximal areas
tooth, such as dental cements. The final set of the mate- Final set time: Oral set time is approximately 6 minutes.
rial may occur while the patient is still in the office or
several hours later. Many amalgam restorations reach
their final set 8 hours or more after placement. Appro-
priate patient postoperative instructions on when and
MANIPULATION OF MATERIALS
what to eat, what to avoid, or how to place pressure on Manipulation of a material’s components is an impor-
the restoration are essential to avoid fracture of these tant consideration for the dental auxiliary. It is through
materials. The accompanying box gives an example of this manipulation that the final characteristics of the
 Physical and Mechanical Properties of Dental Materials CHAPTER 3 35

material are achieved. Some materials offer some vari-

ation in their manipulation; others are very technique
sensitive and even the slightest variation will have a B
detrimental effect on the final product. Variables in the
manipulation of the material begin with the ratios of
the components.

RATIOS OF COMPONENTS
The manufacturer, using the weight or volume of the
components, recommends specific ratios. Many mate-
rials are produced as separate components that need A
to be measured and dispensed according to manufac-
turers’ recommendations. Manufacturers also produce
materials in pre-measured units, eliminating the need
to measure and dispense the components, thus stan- C
dardizing the ratios. Changing the ratios of the ma-
terials by adding more catalyst may result in a faster FIG. 3.13 Types of material mixing. A, Device called a triturator is used
reaction; increasing the amount of water or liquid com- to mix encapsulated, pre-measured materials. B, A gun-type automix-
ponent may also result in a less dense, weaker material. ing dispenser mixes materials contained in a two-barrel cartridge (one
These ratio changes are variables that permit the clini- barrel with base and one with catalyst) by expressing them through a
mixing tip. C, Powder and liquid hand-mixed material that will be mixed
cian to alter manipulation and reaction times for some
on a paper pad (or a slab) with a metal spatula. A scoop for the powder
materials but are contraindicated with other materials is seen on the pad.
because of adverse effects. Manufacturers give direc-
tions as to when variation is needed and how much
variation in ratio the material can withstand without in sealed containers. Some materials require refrigera-
adverse results. The auxiliary is most often respon- tion to prolong their useful life, and others need to be
sible for measuring and dispensing the components; protected from direct light and may be packaged in
strict adherence of ratios is required for some materials light-blocking containers. Always refer to manufactur-
whereas others allow some flexibility. ers’ directions to determine conditions of storage and
expiration. Check with the dental supplier to see that
EFFECT OF TEMPERATURE AND HUMIDITY materials are shipped under conditions that will not
External variables such as the temperature of the mate- adversely affect the shelf life such as seasonal temper-
rial and the room temperature and humidity can also ature variations. The expiration date for all materials
play an important part in the manipulation of materials. stored in the office should be monitored carefully. Ma-
In general, high temperatures and humidity will accel- terials should be organized such that older materials
erate the reaction of a material’s components, and low are used before new shipments to prevent them from
temperatures and humidity will retard the reaction. expiring. Many materials will lose their potency or
fail to set properly if they have passed their expiration
MIXING OF COMPONENTS date. While some materials may be able to be used a
How the components of a material are mixed, that is, few months beyond their expiration date, it is risky to
quickly or slowly, on a paper pad or a glass slab, or by use them, because they may lack their optimum per-
hand-mixing or using automix dispensers, will affect formance and the treatments they were used with may
the final material and its consistency (Fig. 3.13). Mate- fail. The American Dental Association requires materi-
rials mixed slowly on cool glass will usually produce a als that meet its specifications to stamp a date of pro-
slower reaction. Automixed materials will give a more duction on the packaging of the material.
consistent result because the materials are mixed by
equipment in a standardized manner with controlled SUMMARY
proportions, eliminating the variables of human error.
The physical structure of a material helps to define
the characteristics expected from that material. The
SHELF LIFE success of dental materials is directly related to the
The shelf life of a material refers to the length of time a choices the dental auxiliary makes in selecting and
material can be stored before it becomes unsuitable for manipulating the components while keeping in mind
use. The shelf life varies from material to material and those variables that cannot be altered. Controlling
will be impacted by how it is stored. Temperature ex- variables of manipulation and reaction stages has be-
tremes and high humidity should be avoided. Plaster come increasingly important with more sophisticat-
and other gypsum products will begin to deteriorate if ed materials and more challenging clinical situations.
exposed to high humidity. Material should be stored Hand-mixing of materials allows for some control of
36 CHAPTER 3 Physical and Mechanical Properties of Dental Materials

manipulation and reaction stages. However, incon- is important to refer to manufacturers’ directions for
sistencies in mixing and time demands have become instruction on storage, proportioning, and mixing,
problematic in many clinical situations. Manufactur- and on variables that may be altered to produce the
ers are producing materials in a variety of forms to best final results for a given clinical scenario.
address these concerns. Pre-measured materials are
manufactured to standardize the amount of catalyst
INSTRUCTIONAL VIDEOS
and base included in the mix, thus preventing incon-
sistencies in resultant physical properties. Automix See the Evolve Resources site for a variety of educational videos
materials standardize the amount of catalyst and that reinforce the material covered in this chapter.
base and produce a consistent homogeneous mix. It

Get Ready for Exams!

Review Questions c. malleability

d. ductility
Select the one correct response for each of the following
7. Resistance to flow is known as
multiple-choice questions.
a. viscosity
1. A defining characteristic of a solid is that it has b. film thickness
a. shape and volume c. density
b. shape only d. curing
c. neither shape nor volume
8. Thixotropic materials are those that
d. volume but no shape
a. have poor viscosity
2. The type of primary bond where atoms share electrons b. flow under mechanical forces
in their outer shells is called c. flow at higher temperatures
a. atomic bond d. flow at lower temperatures
b. covalent bond
9. Mixing time is the length of time from
c. ionic bond
a. the beginning of mixing to the end of setting time
d. metallic bond
b. the beginning of mixing to the initial set time
3. The correct term for describing the maximal amount of c. the beginning of mixing to the beginning of working
stress a material can withstand without breaking is time
a. toughness d. the beginning of mixing to the end of working time
b. elasticity
10. A material mixed slowly on a cooled glass surface will
c. ultimate strength
a. have a shorter working and setting time
d. ductility
b. have a shorter working and longer setting time
4. When the weight of a material increases in relationship c. have a longer working and setting time
to its volume, this is described as d. have a longer working and shorter setting time
a. elastic For answers to Review Questions, see the Appendix.
b. resilient
c. dense
d. hard Case-Based Discussion Topics
5. Hardness determines the material’s ability to 1. M
 ary Smith has come to your office for a crown prepa-
a. deform an object ration on tooth #18. The dentist has recommended a
b. break an object porcelain-fused-to-metal crown for this area. The tooth
c. be easily compressed is prepared with a tapered margin and a final impression
d. resist scratching taken.
6. When deformation is not permanent and a material How would the stiffness of the impression material affect the
recovers, it has good accuracy of the final impression? If Mary grinds or clenches
a. toughness her teeth, how will this affect the new restoration and resto-
b. elasticity
 Physical and Mechanical Properties of Dental Materials CHAPTER 3 37

Get Ready for Exams!—cont’d

rations on the opposing teeth? Why is metal’s edge strength What cement control variables would be desirable if this was a
an important characteristic for this preparation? multiunit bridge? How might these variables be manipulated?
2. Bill Miller is scheduled for an orthodontic appointment; 4. While attending your state dental convention, you find
he has been in full orthodontic treatment for several a great deal on dental plaster. To take advantage of this
months, resulting in the alignment of his teeth. offer, you must buy five 25-pound containers. When the
Give two important properties of the orthodontic wire used plaster is delivered to the office, you find that there is
in this movement. How do these properties contribute to not enough space to store the material, so it is decided
this movement? to store it in the dentist’s garage. Although the material
3. You have been asked to prepare cement for a final in the first container has normal setting reactions, mate-
cementation appointment. rial in containers opened later are inconsistent in their
working and setting times.
What may account for these inconsistencies?

BIBLIOGRAPHY Powers JM, Wataha JC: Dental Materials: Foundations and Applica-
tions (ed 11). St. Louis, 2013, Elsevier.
Anusavice KJ, Shen C, Rawls H: Phillips’ Science of Dental Materi- Sakaguchi RL, Powers JM: Craig’s Restorative Dental Materials (ed
als (ed 12). Philadelphia, 2013, Saunders. 13). St. Louis, 2012, Mosby.
Bird DL, Robinson DS: Modern Dental Assisting (ed 12). St. Louis, Van Noort R: Introduction to Dental Materials (ed 4). St. Louis,
2018, Elsevier. 2013, Mosby.
Darby ML, Walsh MM: Dental Hygiene: Theory and Practice (ed 4).
St. Louis, 2015, Saunders.
4 General Handling and Safety of Dental
Materials in the Dental Office
http://evolve.elsevier.com/Eakle/materials/

Chapter Objectives
Upon completion of this chapter, the student should be able to:
1. Identify five job-related health and safety hazards for 5. D escribe the basic infection control methods for the
employees in dental offices, and explain the methods of handling of dental materials in the treatment area.
prevention for each one. 6. Identify the concepts and benefits of going green in the
2. Explain the components of the Occupational Safety and dental practice.
Health Administration Hazard Communication Standard. 7. Discuss how the ADA Top Ten Initiatives of sustainability
3. Describe the ways that chemicals can enter the body. can be incorporated into a general dental practice.
4. Describe the employee and employer responsibility for
safety training.

Key Terms
Particulate Matter extremely small particles (e.g., dust from Flash Point the lowest temperature at which the vapor of a
dental plaster or stone) volatile substance will ignite with a flash; a low flash point
Personal Protective Equipment (PPE) gloves, masks, gowns, means that a substance can catch fire easily
eyewear, and other protective equipment for the employee Ignitable a material or chemical that can erupt into fire easily
Bio-Aerosol a cloudlike mist containing droplets, tooth dust, Corrosive usually an acid or strong base that can cause dam-
dental material dust, and bacteria of a particle size less age to metals and equipment, a gradual chemical destruc-
than 5 microns (μm) in diameter tion of metallic materials, as the rusting of metal instruments
Splatter small particles that may contain blood, saliva, oral Reactive the reaction of opposing chemical substances that
particulate matter, water, and microbes creates a different end product
Hazardous Chemical a chemical that can cause burns to Safety Data Sheet (SDS) printed product reports from the
the skin, eyes, lungs, etc., is poisonous, or can cause fire manufacturer containing important information about the
Toxicity the degree to which a product or a chemical can chemicals, hazards, handling, cleanup, and special PPE
cause damage to the body related to a product
  

Dental health care personnel use a wide variety of MATERIAL HAZARDS IN THE DENTAL
chemical-containing dental materials for patient treat- ENVIRONMENT
ment and laboratory procedures. All chemicals are
capable of causing harmful effects if they are absorbed EXPOSURE TO PARTICULATE MATTER
into the human body. The safety of the patient and the During the manipulation of many dental materials, par-
dental professional handling dental materials is of para- ticulate matter can be generated. Items such as gypsum
mount concern. Safety for the work environment is a products, alginate, microblasting (sandblasting with very
shared commitment of the dental team and the patient. fine particles) materials, and pumice may generate dust
Clinicians should be very familiar with the regulations during handling. Gypsum models, processed acrylic,
for safe practice in the prevention of transmission of porcelain, and various restorative materials may generate
potentially pathogenic microbes to both patients and dust during the grinding and polishing processes. Pneu-
dental personnel. This chapter concentrates on how to moconiosis is a fibrotic lung disease that can be caused
prevent exposure to potentially hazardous materials. by chronic exposure to these dusts. Black Lung Disease
All dental personnel must understand the safe use, clean- is the diagnosis for coal miners who got this disease
up, and disposal methods for all the materials used in from inhaling coal dust. It is important for each person
the dental office. This chapter also discusses compliance handling and manipulating these materials to have and
with governmental regulations and explains health and use the proper personal protective equipment (PPE) such
safety procedures. as dust or surgical masks, eyewear, gowns, and (when

38
 General Handling and Safety of Dental Materials in the Dental Office CHAPTER 4 39

appropriate) hair covering or tieback. Appropriate ex-

haust ventilation in dental laboratories where grinding or
trimming of materials is performed is equally important.

Material Hazards in the Dental Office

•  xposure to particulate matter
E
• Exposure to biological contaminants
• Exposure to airborne contaminants
• Exposure to toxic effects of chemicals
• Exposure to mercury

EXPOSURE TO BIOLOGICAL CONTAMINANTS

A
Dental personnel come in contact with a variety of mi-
croorganisms via exposure to blood, body fluids, or oral
and respiratory secretions. These microorganisms may
include hepatitis B virus (HBV), hepatitis C virus (HCV),
human immunodeficiency virus (HIV), herpes simplex
virus (HSV), or other viruses and bacteria. Dental per-
sonnel can be protected from the occupational transmis-
sion of infectious diseases through strict adherence to
the requirements of the Occupational Safety and Health
Administration (OSHA) and the Canadian Centre for
Occupational Health (CCOH) Bloodborne Pathogens
Standard, and to the infection control guidelines i­ssued
by the Centers for Disease Control and Prevention
(CDC). A further excellent resource for the dental team B
is the Organization for Safety, Asepsis, and Prevention
FIG. 4.1 A, Overgloves are used to prevent cross-contamination when
(OSAP). Most U.S. states have regulations specific to in- multiple-use dental material containers and dispensers are handled. B,
fection control for dentistry. It is imperative the dental Syringe is barrier protected with a disposable plastic cover.
auxiliary is familiar with both state and federal regula-
tions and guidelines. Dental personnel must consider the
possibility that equipment, storage containers, and dental
materials may become contaminated during handling.
Therefore it is important to use proper barrier protection
such as overgloves or plastic covers when handling bot-
tles, cans, or tubes that contain many of the dental materi-
als used in a modern dental practice (Fig. 4.1).
Areas and equipment in each operatory must be
clearly marked so that dental personnel know which
area or item is potentially contaminated thus allowing
the necessary precautions be taken in handling that
item. If you are unsure, use a protective covering or
disinfect the item with the appropriate germicide.

BIO-AEROSOLS IN THE DENTAL SETTING FIG. 4.2 Aerosol and droplets generated by ultrasonic scaler procedures.
(Photo © Hu-Friedy Mfg. Co., Inc. [Chicago, IL]; used with permission.)
A bio-aerosol (bio, living; aerosol, mist) is a cloudlike
mist containing microbes such as bacteria, viruses, oral fluids, blood, dental materials, powder, latex par-
molds, fungi, and yeast. Airborne microorganisms can ticles, and dust from metal, composites, and hygiene
be found in any building. Air conditioning systems, procedures (Fig. 4.2). Particles that exit the patient’s
humidifiers, carpets, wall coverings, and plants can mouth during dental procedures can be separated into
easily become microbial breeding grounds. two categories. Those particulates that are greater in di-
ameter than 50 microns (μm) can be considered splatter.
DENTAL BIO-AEROSOLS The larger splatter particulates can land on the provider’s
In addition to the usual sources of airborne microorgan- eyewear, skin, and PPE; or on other spaces and equip-
isms, bio-aerosols and splatter in the dental office are ment and on the floor in the treatment area as far away as
even more complex. This is because the aerosols and 3 feet. The smaller particulates (less than 50 μm) are the
splatter created during many dental procedures contain aerosols. These remain airborne from minutes to hours
40 CHAPTER 4 General Handling and Safety of Dental Materials in the Dental Office

and can be the source of respiratory infection if inhaled. CHEMICAL SAFETY IN THE DENTAL OFFICE
The bio-aerosols and splatter created by the dental hand-
piece, ultrasonic scaler, and by air abrasion procedures HAZARDOUS CHEMICALS
can contain particles of human teeth, oral fluids, bacteria A hazardous chemical is defined as any chemical that
and viruses, old restorations, lubricating oil, and abrasive has been shown to cause a physical or health hazard.
powder. The use of a slurry of certain air-water powder It can be any substance which can catch fire, react, or
products during hygiene procedures (use of the ultra- explode when mixed with other substances, or is cor-
sonic scaler and air polishing) has been implicated in the rosive or toxic. It is the chemical manufacturers’ and
creation of bio-aerosols. Aerosols are generated from soft importers’ responsibility to assess the hazards of their
tissue treatments with lasers and electrosurgical units products and pass this information on to consumers
and may contain gases, tissue debris, and other infectious through the Safety Data Sheet (SDS). Many dental ma-
materials. Aerosols can also be generated in the labora- terials contain more than one chemical (Fig. 4.3).
tory during grinding and polishing procedures.
Recommendations for the reduction of bio-aerosols How Chemicals Enter the Body
during dental procedures include the use of prepro- • Inhalation
cedural rinses before treatment, high-volume suction, • Direct contact with the skin or eyes
use of rubber dam when possible, as well as the reduc- • Absorption through the skin
tion of biofilm prior to procedures by coronal polish- • Ingestion (eating or drinking)
ing, or by brushing and flossing. • Invasion directly through a break in the skin
When the amount of bio-aerosol in the environment
exceeds the capacity of the air filtration system, allergens,
toxins, irritants, and infectious agents will continue to build SKIN AND EYES
up. Dental personnel can suffer from allergic responses, in- The skin is an effective barrier for many chemicals;
fectious diseases, and respiratory problems as a result of however, some chemicals are absorbed through the
prolonged exposure to bio-aerosols and chemical irritants. skin. In general, the skin must be in direct contact with
the chemical for this to happen. Absorption also may
Clinical Tip occur directly through a break in the skin such as cuts,
Make sure the clinical or laboratory environment where aero­ open sores, or chapped hands. After repeated contact
sols are generated is well ventilated and the air is not recycled with some chemicals, a skin disease called dermatitis
in the system. Use PPE appropriate for the type of aerosol may occur. Adverse occupational reactions in the form
exposure, i.e., special high-filtration masks may be needed. of hand or facial dermatitis are not uncommon in den-
tal personnel. These reactions seem to be most often
Management of Bio-Aerosols in the Dental associated with exposure to acrylates, formaldehyde,
Environment latex, and rubber additives which can be the result of
exposure to dental materials or the components that
The effects of bio-aerosols can be minimized in dental make up PPE.
offices through the following procedures: Other chemicals, such as acids, can break down the
• Monitor HVAC (heating, ventilation, and air-conditioning)
outer layer of the skin, causing burns, and are extreme-
systems to ensure optimal performance for the removal
ly harmful to the eyes. In the bonding technique for
of particulates and to eliminate excess moisture.
• Clean the air filtration system frequently. all ceramic crowns, hydrofluoric acid is used to etch
• Use proper oral and laboratory evacuation and ventilation the prosthesis to enhance the bond to the tooth. Hy-
techniques during bio-aerosol–producing procedures. drofluoric acid (HF) is extremely dangerous; anyone
• Use a vacuum dust collection system during dust-pro- handling this acid must be well informed about the
ducing laboratory procedures. risks and safety requirements in handling the mate-
• Use high-volume suction during all intraoral procedures rial and how to handle potential accidental exposure.
that produce aerosol. Eye exposure may result in permanent damage or even
• Use rubber dams (to minimize exposure to oral fluids). blindness. Flushing the eyes at the eyewash station for
• Use preprocedural mouth rinses. at least 15 minutes and immediate medical attention
• Conduct preprocedural removal of biofilm through coro-
are recommended. Exposure to HF is not limited to
nal polishing, brushing, and flossing.
contact with the skin and eyes; inhalation of this potent
• Wear appropriate PPE:
• Masks acid is of equal concern. Adequate ventilation must be
• Protective clothing such as an overgown or lab jacket used.
• Proper eyewear and face shields
• Gloves; minimize the use of latex products and use INHALATION
powder-free gloves Inhalation of materials via gases, vapors, or dusts
• Keep all containers tightly covered. is a common route of chemical exposure for dental
• Pour chemicals rather than spraying. personnel. Some chemicals can cause damage di-
• Use lids on ultrasonic cleaners and other chemical rectly to the lungs in the form of pneumoconiosis.
containers. Among dental personnel, prolonged exposure to
 General Handling and Safety of Dental Materials in the Dental Office CHAPTER 4 41

SAMPLE LABEL

QUICK CODE _______________________________

Product Name________________________
} Product
Hazard Pictograms

CARD
Identifier

}
Company Name_______________________
Street Address________________________

}
City_______________________ State_____ Supplier
Postal Code______________Country_____ Identification
Emergency Phone Number_____________
Hazard Communication Standard Labels Signal Word
OSHA has updated the requirements for labeling of Keep container tightly closed. Store in a cool, Danger
well-ventilated place that is locked.
hazardous chemicals under its Hazard Communication Keep away from heat/sparks/open flame. No smoking.
Only use non-sparking tools.

}
Standard (HCS). As of June 1, 2015, all labels will be Use explosion-proof electrical equipment.
Take precautionary measures against static discharge. Highly flammable liquid and vapor. Hazard
required to have pictograms, a signal word, hazard and Ground and bond container and receiving equipment. May cause liver and kidney damage. Statements
Do not breathe vapors.
precautionary statements, the product identifier, and Wear protective gloves.
supplier identification. A sample revised HCS label, Do not eat, drink or smoke when using this product. Precautionary
Wash hands thoroughly after handling. Statements
identifying the required label elements, is shown on the Dispose of in accordance with local, regional, national,
international regulations as specified. Supplemental Information
right. Supplemental information can also be provided
In Case of Fire: use dry chemical (BC) or Carbon Dioxide (CO ) Directions for Use
on the label as needed. fire extinguisher to extinguish. __________________________________
OSHA 3492-02 2012

__________________________________
First Aid __________________________________
For more information: If exposed call Poison Center.
If on skin (or hair): Take off immediately any contaminated
(800) 321-OSHA (6742) Fill weight:____________ Lot Number:___________
clothing. Rinse skin with water.
Gross weight:__________ Fill Date:______________
www.osha.gov
Expiration Date:________

B
FIG. 4.3 Modern Dental Assisting: A, Hazard Communication Standard pictograms. B, Sample label. (From Occupa-
tional Safety and Health Administration. Available at http://www.osha.gov/dsg/hazcom/index.html.)

dusts containing metal or silica has led to pneumo- or kidneys, where they may cause damage. PPE such
coniosis. Other chemicals may not directly affect the as masks or a proper respirator and adequate ventila-
lungs but are absorbed by the lungs and sent via the tion must be considered and used as appropriate for
bloodstream to other organs such as the brain, liver, each procedure.
42 CHAPTER 4 General Handling and Safety of Dental Materials in the Dental Office

risk has long been established and each office using

INGESTION mercury-containing amalgam procedures must take
Ingestion (swallowing) is another way that chemicals precautions to eliminate exposure to the dental per-
can enter the body. Eating in an area where chemicals sonnel. Precautions must be taken in the dispensing
are used, and eating with hands that are contaminated of the material, placement of the material, condens-
with chemicals, are common ways of ingesting harm- ing and carving of the material, handling and storage
ful chemicals. In the dental laboratory, many proce- of amalgam scrap, and removal of existing amalgam
dures are performed that produce contaminants such restorations. Because of these precautions many offices
as metal grindings and gypsum products. It is essential have begun to phase out the use of mercury-containing
to not eat in the clinical or laboratory area and food materials (see Chapter 10 Amalgam). The ADA Coun-
should not be stored in the same refrigerator as oth- cil on Scientific Affairs review of the literature on amal-
er dental materials. It is also important to wash your gam safety has concluded that the “scientific evidence
hands thoroughly after contact with any chemical. supports the position that amalgam is a valuable,
In many cases, the use of special protective gloves is viable and safe choice for dental patients.”
indicated, and they must be removed and the hands
washed before food is handled. Precautions When Working with Mercury
• W ork in a well-ventilated space.
EXPOSURE TO BISPHENOL A • Avoid direct skin contact with mercury.
Bisphenol A (BPA) is a chemical currently used to harden • Avoid inhaling mercury vapor; use high-volume evacu-
plastics, and to line water pipes, and metal food and bev- ation whenever removing old amalgam restorations or
erage cans. As a result, almost everyone is exposed daily adjusting new materials.
to BPA. An association has been found between higher • Store mercury in unbreakable, tightly sealed containers
BPA levels in the urine of young adults and children and away from heat.
increased diagnosis of diabetes, obesity, cardiovascular • When preparing amalgam for restorations, use pre-
loaded capsules. (This avoids exposure during mea-
disease, and liver abnormalities. This is possibly the re-
surement of mercury.) Stock multiple sizes of amalgam
sult of BPA’s weak estrogenic properties; however, the capsules to minimize amalgam waste.
current position of the U.S. Food and Drug Administra- • When mixing amalgam, always close the cover before
tion (FDA) is that BPA is not a health concern. starting the amalgamator.
BPA is found in polycarbonate plastics and epoxy • Reassemble amalgam capsules immediately after
resins. A form of epoxy resin containing BPA is used in dispensing the amalgam mass. (The used amalgam
some dental sealants and composites. Resins containing capsule is highly contaminated with mercury and is a
the BPA derivative bis-DMA are more likely to release significant source of mercury vapor if left open.) Place
some BPA at low levels over those containing another empty amalgam capsule in a airtight container marked
BPA derivative, bis-GMA. Glass ionomer sealants do “Amalgam Capsule Waste for Recycling.”
not produce BPA residue. Dental products are less likely • Store leftover scrap amalgam (i.e., unused amalgam) in
a tightly closed container.
to cause exposure to BPA than consumer products made
• Disinfect scrap amalgam (amalgam that has been
with plastic and epoxy resin. The U.S. Department of retrieved from dental unit traps) in a solution of bleach
Health and Human Services and the American Dental and water. Then place the amalgam in the container
Association (ADA) have called for more research to un- with other scrap alloy.
derstand the potential human health effect of BPA expo- • Clean spills, using appropriate procedures and equip-
sure, especially in young children. ment; do not use a household vacuum cleaner or high-
There are recommended steps to reduce the inci- velocity evacuation (HVE). (Dangerous fumes from the
dence of BPA exposure during sealant and composite mercury can be released into the air.)
placement. Each of these steps is also important for a • Place contaminated disposable materials into polyethyl-
successful restorative result: ene bags, seal them, and dispose of them according to
1. Properly cure the resin—under-cured resin releases state/province and local regulations.
BPA.
2. Wipe off the uncured (air-inhibited) resin layer after
curing—this reduces BPA exposure by 95%.
ACUTE AND CHRONIC CHEMICAL TOXICITY
3. Use good placement technique with rubber dam
isolation or four-handed dentistry with high-vol- The toxicity of a chemical, and thus its harmfulness,
ume suction. depends directly on the dose, length of exposure, and
4. Use high-volume suction when adjusting sealants, frequency of exposure.
composites, or orthodontic brackets.
ACUTE CHEMICAL TOXICITY
EXPOSURE TO MERCURY Acute chemical toxicity results from high levels of ex-
There is a known health risk to dental health care posure over a short period of time. This frequently is
personnel from exposure to elemental mercury. This caused by a large chemical spill in which the exposure
 General Handling and Safety of Dental Materials in the Dental Office CHAPTER 4 43

is sudden and unexpected. The effects of this type of

toxicity are felt right away. The symptoms of acute
overexposure to chemicals may include dizziness,
fainting (syncope), headache, nausea, and vomiting.

CHRONIC CHEMICAL TOXICITY

Chronic chemical toxicity results from repeated ex-
posures, usually to lower doses, over a much longer
period of time such as months or years. The effects of
chronic toxicity can include cancer, neurologic deficits,
and infertility.
For example, a single exposure to a high concentra-
tion of benzene may cause dizziness, headache, and
unconsciousness; long-term daily exposure to low lev-
els of benzene may eventually cause leukemia. Anoth-
er example is that of beryllium, a metal used in partial
denture frameworks. When grinding beryllium frame-
works for adjustment, one must avoid inhaling the
FIG. 4.4 Nitrile utility gloves, because they are resistant to chemicals,
dust because it is a toxic hazard which can lead to lung
are used to handle disinfectants, acids, and hazardous chemicals.
disease. A proper mask or respirator must be worn. (Courtesy Lab Safety Supply, Janesville, WI.)

PERSONAL AND CHEMICAL PROTECTION

before a latex reaction can be distinguished from
HAND PROTECTION sensitivity to some other chemical. To ensure patient
Appropriate hand hygiene is the most important step treatment gloves maintain their integrity and protec-
that the health care personnel can take to prevent tive features, they should be worn no longer than 60
the transmission of infectious diseases in the dental minutes and be changed when moisture on the inter-
setting. When routine dental treatment is being per- nal surface is visible, become tacky on the exterior
formed hand washing with plain soap, hand antisepsis surface, or become ripped or torn.
with antimicrobial soap, or cleansing with an alcohol
hand rub should be utilized. Alcohol handrubs may EYE PROTECTION
be effective; however, soap and water is necessary to Serious damage to the eyes, including blindness, may
clean the hands when they are visibly soiled with dirt, result from chemical accidents. It is necessary to pro-
blood, or bodily fluids. tect the eyes from exposure to all dental materials
Fingernail integrity is an integral part of hand hy- including fumes and splashes while chemicals such
giene. Nails should be short with smooth edges not as alcohol or methyl methacrylate monomer, acid, or
extending beyond fingertips. Artificial nails, tips, and other solvents are poured. The acids used for bonding
extenders are not recommended as they may harbor procedures can be splashed into the eyes during rins-
bacteria. If nail polish is worn, it should be main- ing from the etched teeth. Protective eyewear with side
tained with a smooth appearance. Once fingernail shields and splash shields are available from many
polish has become chipped or nails grow out showing manufacturers and must be worn when handling ma-
margins of the polish at the cuticle, bacterial growth terials and in patient care settings.
is encouraged.
Procedure gloves (patient treatment gloves) worn PROTECTIVE CLOTHING
during patient care do not provide adequate protec- Protective clothing such as disposable overgowns or
tion when chemicals are handled. When exposed to laboratory jackets should be worn over uniforms and
chemical disinfectants, antiseptics, resins, and bond- personal clothing to protect the clinician from blood-
ing agents the patient treatment gloves may degrade. borne pathogens and dental materials. The most ef-
When degradation of gloves occur, contaminates and fective overgowns and laboratory jackets button up to
chemicals can be pulled through the glove like a wick the neck, cover the legs to the top of the knee when in
and onto the hands. Chemical-resistant gloves such both a seated or standing position, and have elastic at
as nitrile utility gloves are recommended for wear the wrist. Water-resistant overgowns are more effective
during chemical handling (Fig. 4.4). With the many in protecting the clinician than laboratory jackets as the
materials on the market, the manufacturer’s SDS in- lab jackets are not impervious to liquids. Overgowns
structions should be consulted to determine the com- and lab jackets are not to leave the facility once worn
patibility of the glove material with various chemi- and potentially contaminated by blood-borne patho-
cals. Some individuals develop sensitivity to latex; gens. Overgowns should be disposed of or sterilized as
however, a proper dermatologic diagnosis is required indicated by the manufacturer. Lab jackets should be
44 CHAPTER 4 General Handling and Safety of Dental Materials in the Dental Office

laundered in the dental office or processed by a laundry

service that specializes in handling biohazardous items.
When manipulating chemicals, the type of chemical
that is being used should guide the selection of protec-
tive clothing. A rubber or neoprene apron should be
worn when one is mixing or pouring chemicals that
are caustic; can stain; or would saturate, penetrate, or
damage regular fabric.

INHALATION PROTECTION
Patient treatment masks are necessary to protect the clini-
cian not only from the spread of infection but particulate
matter described earlier in the chapter. During routine
dental treatment the mask should be changed after every
patient, every sixty minutes, or when it becomes damp or FIG. 4.5 Mercury spill kit. Note its compact size for convenient storage.
wet. The necessity to change the mask frequently stems (Courtesy of Lab Safety Supply Inc. [Janesville, WI].)
from the mesh in the mask beginning to break down after
twenty minutes which causes the protection of the clini- burns or damage. Flushing with water immediately is
cian to decrease the longer the mask is worn. essential to prevent severe injury.
The masks worn during patient care may or may not
provide adequate protection when one is working with EYEWASH
chemicals, depending on the quality of mask. The face- OSHA regulations require an eyewash unit to be in-
mask should be fluid repelling and provide respiratory stalled in every place of employment where chemicals
protection. If the job requires frequent pouring or mix- are used. A wide variety of styles are available. The
ing of chemicals, sensitive or allergic individuals might standard eyewash unit attaches directly to existing
need a National Institute of Occupational Safety and faucets for emergencies yet still allows normal faucet
Health (NIOSH)–approved dust and mist respirator use. When turned on, the eyewash unit will irrigate the
facemask. Several masks are on the market for person- eyes with a soft, wide flow of water as necessary to
nel with sensitive skin; these masks are free of dyes and bathe away contaminants without causing additional
chemicals and have a lint-free cellulose inner layer. damage. As an employee, you must be trained in prop-
er use of the eyewash station. It is recommended that
CONTROL OF CHEMICAL SPILLS eyewash stations be inspected frequently to ensure
water flow. Some manufacturers suggest running them
MERCURY SPILL for several minutes periodically to discharge any po-
Mercury spill kits should be available in all dental offic- tential built-up biofilms or infectious agents. A posting
es that use amalgam for restorations (Fig. 4.5). Exposure of suggested times for eyewashing after an exposure
to even small amounts of mercury is very hazardous to (Table 4.1) and directions for the proper use of the par-
workers’ health. Mercury can be absorbed through the ticular type of eyewash unit should be placed nearby
skin or by the inhalation of mercury vapors. the eyewash station (Fig. 4.6).
The spill kit for small amounts of mercury should
contain mercury-absorbing powder, mercury sponges, VENTILATION
and a disposal bag. A mask and utility-type gloves Good ventilation is a necessity when dealing with any
should be worn when cleaning a mercury spill. type of chemical. Dental offices should be equipped with
special exhaust systems for fumes and dust in the labora-
FLAMMABLE LIQUIDS tory and in radiographic processing areas. For example,
Many solvents used with dental materials have a very vapors from chemicals used in radiographic processing
low flash point and can easily ignite when used near can cause contact dermatitis and irritation of eyes, nose,
open flame such as a Bunsen burner or an alcohol torch. throat, and respiratory tract. Other laboratory areas may
Take extreme caution when using flammable products be laden with fine dust particles from grinding or chemi-
(e.g., the liquid monomer for acrylic or acetone). The cal vapors such as from acrylic monomer or pickling acid
SDS for each product describes the flammability of that (used to remove oxides from cast metals).
product.

ACIDS
GENERAL PRECAUTIONS FOR STORING
As mentioned previously, phosphoric, hydrofluoric,
CHEMICALS
and hydrochloric acids are used during manipulation
of various dental materials. Splashing any of these All dental materials contain chemical components,
acids on the skin, eyes, or clothing can cause severe and some are more hazardous than others. Careful
 General Handling and Safety of Dental Materials in the Dental Office CHAPTER 4 45

Table 4.1    OSHA Recommendations for Eyewashing

CHEMICAL EXPOSURE TO THE EYE TIME PERIOD FOR EYEWASHING
Non-irritants or mild irritant 5 minutes
Moderate to severe irritant 15 to 20 minutes
Nature of contaminate unknown 20 minutes
Corrosives 30 minutes
Strong alkalis (sodium, potassium, or calcium hydroxide) 60 minutes

A B
FIG. 4.7 Examples of single-use items (dental floss, fluoride var-
FIG. 4.6 A, Faucet-mount eyewash and eye/face-wash station. B, nish, temporary restorative materials, cement cartridge, and etching
Wall-mounted eyewash station showing inspection record. (A, Cour- solution).
tesy of Lab Safety Supply Inc. [Janesville, WI]. B, Courtesy of Dr. Mark
Dellinges.)

dangerous chemical reaction could occur. Follow the la-

bel and the SDS on how to dispose of empty containers.
use and storage of dental materials is essential to en-
(Safety Data Sheets are discussed later in this chapter.)
sure these products retain their therapeutic activity
and identity. Changes in the chemical composition of
materials can occur for many reasons. When changes Tips to Aid in the Safe Use and Effectiveness
take place, the product may no longer retain its ef- of Dental Materials
fectiveness. Expiration dates must be reviewed and
out-of-date material should be disposed of properly. Follow instructions: The manufacturer has already deter-
A basic “safe” policy for the storage of dental med- mined the best methods of protective packaging and
ications and chemicals is to keep them in original storage. Therefore the manufacturer’s instructions for
storage, manipulation, and protection should be fol-
containers when possible and a dry, cool, dark place
lowed.
where they are not exposed to direct sunlight. Many
Light, heat, and air: Exposures to light, heat, and air
single-dose products have been developed to elimi- are the prime factors in the deterioration of many
nate cross-contamination and reduced effectiveness bonding solutions. Changes in color, viscosity, or
of the product due to evaporation or contamination curing time are the most common signs of
(Fig. 4.7). deterioration.
Expiration date: The substance’s expiration date
DISPOSAL OF CHEMICALS should always be noted. To maintain the proper
chemical reactions, materials should be replaced
EMPTY CONTAINERS when the expiration date is reached. Also,
Even empty containers can be hazardous because they new supplies should always be stocked behind
the current inventory so that the oldest product is used
often hold residues that can burn or explode. Never fill
first.
an empty container with another substance because a
46 CHAPTER 4 General Handling and Safety of Dental Materials in the Dental Office

HAZARDOUS WASTE DISPOSAL hazardous wastes. The solutions from the wet pro-
A waste is considered hazardous if it has certain prop- cessing of dental radiographs are not permitted in
erties or chemicals that could pose dangers to human the public sewer systems, and if they are disposed
health and the environment after being discarded. In of in private septic systems, they can cause those
general, waste is classified as hazardous if it has any of systems to fail. The disposal limits, either down the
the following characteristics: drain or in landfill, of x-ray film, lead foil, disin-
Ignitable: The substance is ignitable if it is flammable or fectants, and acid etch are also regulated by either
combustible. county or state regulatory agencies and can vary
Corrosive: The substance is corrosive if it is highly acid- widely throughout the United States.
ic (pH less than 2.0) or basic (pH greater than 12.5). An example of a regulation that can improve waste-
(Water has a pH of 7.0, which is neutral.) water and groundwater is the regulation requiring use
Reactive: The substance is reactive if it is chemically un- of the amalgam separator. The Environmental Protec-
stable or explosive, reacts violently with water, or is tion Agency mandated under the Clean Water Act that
capable of giving off toxic fumes when mixed with in July 2017 dental practices must control amalgam
water. waste through the use of amalgam separators certified
Toxic: The substance is toxic if it contains arsenic, by the International Organization for Standardization
barium, chromium, mercury, lead, silver, or certain (ISO, standard 11143). These separators can remove 95%
pesticides. (Note: Dental amalgam, asbestos, lead of the amalgam “fine” waste and prevent it from going
foil, and radiographic processing solutions are ex- into the sewer system. Mercury from dental amalgam
amples of hazardous waste that may be regulated can end up in the soil, atmosphere, and groundwater
differently by individual states and provinces.) through several routes including wastewater discharges
Listed by the U.S. Environmental Protection Administra- from dental practices as well as throwing out amalgam
tion (EPA) and the Canadian Environmental Protec- scrap in the office waste. Mercury from dental amal-
tion Agency (CEPA): Several hundred chemicals are gams may also be released through the burial and cre-
listed by the EPA/CEPA as hazardous chemicals. mation of individuals with amalgam restorations. The
amount of mercury released from dental amalgam and
the result of the conversion into the ecosystem is highly
Guidelines for Minimizing Exposure to Chem-
variable. The aquatic and soil contribution of mercury
ical Hazards in the Dental Office
from dental amalgams is considered to be very low and
• K eep a minimum amount of hazardous chemicals in the there have been several improvements to the regulation
office. in the disposal of scrap amalgam in many states. The
• Read the labels and use only as directed. ADA has provided a “best practices management” for
• Store according to the manufacturer’s directions. handling amalgam with the intent of reducing amalgam
• Keep containers tightly covered. release into the environment (Table 4.2).
• Avoid mixing chemicals unless consequences are known.
• Wear appropriate personal protective equipment (PPE)
when handling hazardous substances. DENTAL LABORATORY INFECTION CONTROL
• Wash hands immediately after removing gloves.
• Avoid skin contact with chemicals; immediately wash OSHA mandates that the dental laboratory have the
skin that has come in contact with chemicals. same infection control protocols as the dental office.
• Maintain good ventilation. Dental laboratories may be a part of the dental office
• Do not eat, drink, smoke, apply lip balm, or insert con- or may be off-site and owned and operated by den-
tact lenses in areas where chemicals are used. tal laboratory technicians not employed by the office.
• Keep vaporizing chemicals away from open flames and Effective communication must be established with fa-
heat sources. cilities within the office or off-site to prevent disease
• Always have an operational fire extinguisher handy. transmission from contaminated items entering the
• Know and use proper cleanup procedures. dental laboratory. In addition, dental laboratories are
• Keep neutralizing agents available for strong acid and
obligated to make sure that the products delivered
alkaline solutions.
• Dispose of all hazardous chemicals according to SDS
back to the dental operatory are free of contaminants.
instructions. Dental laboratory technicians must adhere to the same
standard precautions for the prevention of health-re-
lated diseases from the materials they handle.
Regulations for hazardous waste disposal vary For example, impressions, casts, and dental prostheses
among states and provinces, and heavy fines may be are often moved back and forth between laboratories and
imposed for those individuals who knowingly vio- dental operatories. These items may be contaminated
late regulations. More important than the legal pen- with blood and saliva which allows microorganisms to
alties are the environmental damage and the pollu- be transferred to the laboratory environment and back to
tion of surface and groundwater that can result from the dental operatory. Microbes have been cultured from
improper handling, transportation, and disposal of set gypsum dental casts for up to 7 days.
 General Handling and Safety of Dental Materials in the Dental Office CHAPTER 4 47

Table 4.2    American Dental Association (ADA) Best Management Practices for Amalgam Waste
DO DON’T
Use pre-capsulated alloys and stock a variety of capsule sizes Use bulk mercury
Recycle used disposable amalgam capsules Put used disposable amalgam capsules in regular trash, bio-
hazard, or infectious waste containers
Salvage non-contact amalgam, store, and recycle Put non-contact amalgam waste in regular trash, biohazard, or
infectious waste containers
Salvage contact amalgam pieces from restorations after Put contact amalgam waste in regular trash, biohazard, or
removal for recycle infectious waste containers
Use chair-side traps, vacuum pump filters, and amalgam Rinse devices containing amalgam over drains and sinks as
separators to capture amalgam and recycle their contents amalgam waste may be lost and travel into the city water
system
Recycle teeth that contain amalgam restorations (ensure the Dispose of extracted teeth that contain amalgam restorations
amalgam recycler will accept the extracted teeth and verify if in regular trash, biohazard, or infectious waste containers
the teeth require disinfection)
Manage amalgam waste through recycling Flush amalgam waste down the drain or toilet
Use wastewater line cleaners that minimize dissolution of Use bleach or chlorine containing cleaners to flush wastewater
amalgam lines

Good communication and standardized protocols

are essential for effective infection control. If there is
ever a doubt as to the status of an incoming or outgo-
ing case, the appropriate disinfection process must be
completed before the item may be handled or placed in
the patient’s mouth.

Infections Control Communication between

Laboratory and Dental Office
• D isinfection status of incoming and outgoing cases
• Utilization of appropriate shipping and receiving
containers
• Designated receiving and shipping areas and protocols
• Designated production areas

All equipment used in the dental laboratory must

be single-use items or handled with standard precau-
tions for prevention of cross-contamination. Even
though cases are appropriately disinfected before en-
tering the production area, dental lathes, handpiec-
es, burs, brushes, rag wheels, and other laboratory FIG. 4.8 Picture of a lathe splash hood lined with a disposable bag,
a removable dish for a new mix of pumice, and sterilized rag wheels
equipment should be disinfected or sterilized daily.
attached.
The dental lathe should be protected with a func-
tional shield surrounding the lathe to prevent spatter,
aerosols, and the possibility of flying debris (Fig. 4.8). OCCUPATIONAL SAFETY AND HEALTH
Appropriate PPE must be worn in the dental lab- ADMINISTRATION HAZARD COMMUNICATION
oratory to protect individuals from biological con- STANDARD
taminants, bio-aerosols, and chemical contact and in-
halation. Appropriate ventilation and/or air-suction OSHA has created standards to protect the safety of
motors are important for these areas. workers. Dental office personnel should be very fa-
The dental office and dental laboratory must follow miliar with the Bloodborne Pathogens Standard. This
the same infection control guidelines to protect health section addresses the standard that protects workers
care personnel and patients from bloodborne patho- who are at risk of chemical exposure: the Hazard Com-
gens. Standard precautions, appropriate personal pro- munication Standard.
tective equipment, and good communication between OSHA issued the Hazard Communication Stan-
the laboratory and the office are all components of suc- dard because employees have “the right and the need
cessful infection control protocols. to know” the identity and hazards of chemicals that
48 CHAPTER 4 General Handling and Safety of Dental Materials in the Dental Office

they use in the workplace. The Hazard Communica- added to the office, it must be added to the chemical
tion Standard, also known as the Employee Right to list and the SDS for that product must be placed in the
Know Law, requires employers to implement a hazard SDS file.
communication program. The office will frequently appoint a staff member to
be the hazard program coordinator. This person will
be responsible for maintaining the chemical inventory
HAZARD COMMUNICATION PROGRAM and updating the SDS file.
OSHA has been enforcing a Hazard Communication
Standard (HCS) since 1983. A chemical hazard com- Safety Data Sheets
munication program has five parts: the written pro- The basic elements of the safety sheet uses a combi-
gram, the chemical inventory, the Safety Data Sheet nation of signal words and standardized pictograms
(SDS), labeling of containers, and employee training. to communicate hazards associated with a specific
chemical (Fig. 4.3). Safety Data Sheets (SDSs) contain
Written Hazard Communication Program health and safety information about each chemical
The written program must identify by name all em- in the office. SDSs provide comprehensive technical
ployees who are exposed to hazardous chemicals and information and are a resource for employees/pro-
identify the person responsible for the program. In ad- viders who work with chemicals. They describe the
dition, it must describe how chemicals are handled in physical and chemical properties of a material; health
the workplace, must include a description of all safety and environmental health hazards; protective mea-
measures and an explanation of how one should re- sures; precautions for safe handling, use, and storage;
spond to chemical emergencies such as spills or expo- emergency and first aid procedures; and spill-control
sures, and include staff training. measures. The manufacturers of products must pro-
vide SDSs, and an SDS must be obtained for every
Chemical Inventory chemical used in the office. Manufacturer’s typically
The chemical inventory is a comprehensive list of ev- enclose the SDS in the box with delivery of the prod-
ery product used in the office that contains chemicals, uct. SDSs should be organized in binders so that em-
including amalgam, bonding agents, disinfectants, ployees/providers have ready access to them and can
and impression materials. Each time a new product is easily locate a particular SDS (Box 4.1).

Box 4.1  Explanation of the Safety Data Sheet

HAZARD COMMUNICATION SAFETY DATA SHEETS Section 7, Handling and storage lists precautions for
The Hazard Communication Standard (HCS) requires safe handling and storage, including incompatibilities.
chemical manufacturers, distributors, or importers to provide Section 8, Exposure controls/personal protection
Safety Data Sheets (SDSs) (formerly known as Material Safe­ lists OSHA’s Permissible Exposure Limits (PELs); ACGIH
ty Data Sheets or MSDSs) to communicate the hazards of Threshold Limit Values (TLVs); and any other exposure limit
hazardous chemical products. As of June 1, 2015, the HCS used or recommended by the chemical manufacturer, im­
will require new SDSs to be in a uniform format, and include porter or employer preparing the SDS where available as
the section numbers, the headings, and associated informa­ well as appropriate engineering controls; personal protective
tion under the headings below: equipment (PPE).
Section 1, Identification includes product identifier; man­ Section 9, Physical and chemical properties lists the
ufacturer or distributor name, address, phone number; emer­ chemical’s characteristics.
gency phone number; recommended use; restrictions on use. Section 10, Stability and reactivity lists chemical sta­
Section 2, Hazard(s) identification includes all hazards bility and possibility of hazardous reactions.
regarding the chemical; required label elements. Section 11, Toxicological information includes routes
Section 3, Composition/information on ingredients in­ of exposure; related symptoms, acute and chronic effects;
cludes information on chemical ingredients; trade secret claims. numerical measures of toxicity.
Section 4, First-aid measures includes important Section 12, Ecological information1
symptoms/effects, acute, delayed; required treatment. Section 13, Disposal considerations
Section 5, Fire-fighting measures lists suitable extin­ Section 14, Transport information
guishing techniques, equipment; chemical hazards from fire. Section 15, Regulatory information
Section 6, Accidental release measures lists emer­ Section 16, Other information, includes the date of
gency procedures; protective equipment; proper methods of preparation or last revision.
containment and cleanup.
NOTE: Since other Agencies regulate this information, OSHA will not be enforcing Sections 12 through 15(29 CFR 1910.1200(g)(2)).
Employers must ensure that SDSs are readily accessible to employees.
See Appendix D of 1910.1200 for a detailed description of SDS contents.
From OSHA.gov.
 General Handling and Safety of Dental Materials in the Dental Office CHAPTER 4 49

Necessary Parts of a Hazard Communication system is required, and a variety of styles are avail-
Program able on the market (Fig. 4.10) (Procedure 4.1). Even
affixing to the new container a photocopy of the la-
•  ritten hazard communication program
W bel from the original container is acceptable. The
• Inventory of hazardous chemicals most important considerations are that the labeling
• Safety Data Sheet (SDS) for all chemicals system should be easy to use, in legible condition,
• Labeling of containers and provide all the information from the original
• Employee training
label including words, pictures, and symbols. All
employees must be properly trained to understand
and read the labels.
LABELING OF CHEMICAL CONTAINERS AND
SAFETY DATA SHEETS
LABELING EXEMPTIONS
The responsibility for labeling of chemicals is with
the manufacturer or distributor. Containers must be Some products, such as pharmaceuticals directly dis-
labeled to indicate manufacturer’s name, address, pensed to the patient by the pharmacy and drugs in-
and telephone number; product name or identifier; tended for personal consumption by the employee for
signal words for warning or hazards; hazard state- use in the workplace (such as aspirin), are exempt.
ments; and precautionary statements and pictograms Other examples of exempted products are food, al-
(Fig. 4.9). coholic beverages, and cosmetics packaged for con-
All chemicals in the dental office must be labeled. sumer use.
In many cases, the manufacturer ’s label is suitable.
However, when the chemical is transferred to a dif- National Fire Protection Association Labels
ferent container, the new container must also be la- The National Fire Protection Association (NFPA) has
beled. For example, when a concentrated chemical a labeling system that is frequently used to label con-
such as acrylic monomer is transferred to a small tainers of hazardous chemicals. This system consists
bottle for use in the treatment area or laboratory, of blue, red, yellow, and white diamonds filled with
the bottle must be labeled. No official labeling numerical ratings from 0 to 4. Categories are identified
as follows: health (blue); flammability (red); reactivity
(yellow); and special hazard symbols, such as “OXY”
for oxidizers (white).
HAZARDOUS MATERIALS
CLASSIFICATION

HEALTH HAZARDS FLAMMABILITY HAZARDS

4 – Rapidly or completely vaporize
4 – Can be lethal
and burn readily
3 – Serious or permanent injury
3 – Ignite readily in ambient
2 – Temporary incapacitation or
conditions
residual injury
2 – Ignite when moderately heated
1 – Significant irritation
1 – Require preheating for ignition
0 – No hazard beyond
0 – Will not burn under
ordinary
normal fire conditions
combustibles

SPECIAL HAZARDS INSTABILITY HAZARD

Oxidizers OX 4 – May detonate or have
Water Reactives W explosive reaction
Simple Asphyxiants SA 3 – Shock and heat may
detonate or cause
explosive reaction
2 – Violent chemical change at
elevated temperatures
1 – Unstable if heated
0 – Normally stable

FIG. 4.9 Hazard Communication Standard pictograms. Secondary FIG. 4.10 Labeling of chemical transferred to a secondary container.
chemical container labeling. (From Bird DL, Robinson DS: Modern (From Bird, D, Robinson D: Modern Dental Assisting (ed 12). St. Louis,
Dental Assisting (ed 11). St. Louis, 2015, Elsevier.) 2018, Elsevier)
50 CHAPTER 4 General Handling and Safety of Dental Materials in the Dental Office

Guidelines for Chemical Labeling Responsibilities of the Hazard Program

Coordinator
The label must contain the following information:
• Name, address, and phone number of the manufac- • R  ead and understand the Hazard Communication
turer or responsible party Standard.
• Product name or identifier • Implement the written hazard communication
• Signal word for warning or hazard program.
• Hazard statement • Compile a list (chemical inventory) of products in the
• Precautionary statement office that contain hazardous chemicals.
• Pictogram(s) • Obtain Safety Data Sheets (SDSs).
• Update the SDS file as new products are added to the
Employee Training office inventory.
Employee training is essential for a successful hazard Inform other employees of the location of the
communication program. Staff training is required (1) SDS file.
when a new employee is hired, (2) when a new chemical • Label containers appropriately.
product is added to the office, and (3) once a year for all • Provide training to other employees.
continuing employees. Records of each training session
must be kept on file and retained for at least 5 years. Al-
though the dentist is responsible for providing the train- ECO-CONSCIENCE GREEN PRACTICES
ing, the hazard program coordinator is responsible for
routinely following these safety precautions. What about protecting your office and the envi-
The chemical training program for employees must ronment? The process of preventing the transmis-
include the following: sion of disease and performing dental procedures
• Use of hazardous chemicals involves equipment and products that produce
• All safety practices, including all warnings waste, consume excess energy, and use toxic chem-
• Required personal protective devices icals. To a­ ccomplish this there are traditional and
• Safe handling and disposal methods environmentally friendly products, supplies, and
procedures available. The average dental practice
Outline for a Hazard Communication Training ­disposes of hundreds of pounds of paper and ­plastic
Program waste each year. There must be effective compro-
1. Discuss requirements of the Hazard Communication mises to maintain an eco-friendly practice while
Standard. not compromising the safety of the patient. Chris H.
2. Prepare a written communication plan for the office Miller (­ Indiana University School of Dentistry, Indi-
(location, use, etc.). anapolis, IN) has developed a list of green ­infection
3. Explain the hazards of the chemicals. control “do’s and don’ts” as they relate to recyclable
4. Ensure that employees can interpret warning labels and and biodegradable materials, energy and water con-
the Safety Data Sheet (SDS). servation, waste management, and infection control
a. Product identifier, chemical name, code number or standards.
batch number
b. Signal work—indicates the severity of the hazard
c. Pictogram—OSHA has designated eight pictograms
(Box 4.2 provides examples of two of the eight Eco-Friendly Do’s and Don’ts
pictograms) THE DO’S
d. Hazard statement—nature of the hazard • Choose reusables instead of disposables when
e. Precautionary statements—how to minimize or possible.
prevent adverse effects resulting from exposure, • Use alcohol hand rubs instead of hand washing. If
storage, or handling of a hazardous chemical hands are visibly soiled, clinical staff must perform hand
f. Name, address, and phone number of the manufac- washing as alcohol hand rubs will not physically remove
turer, distributor, or importer. debris.
5. Discuss how to obtain more information. • Use trigger/pump sprays instead of aerosols.
6. Discuss taking measures to protect oneself and others: • Establish better inventory control to eliminate
a. Office safety procedures discarding excess product past its expiration
b. Available personal protective equipment (PPE) date.
c. Instructions for reporting accidents and emergencies • Ensure accurate mixing of chemicals and prepare
d. Information about first aid amounts based on use-life and shelf-life.
e. Information regarding proper storage • Switch to digital instead of film x-ray.
7. Present methods and observations that can be used to • Ensure sterilizers and cleaning units are full to reduce
detect the presence or release of a hazardous chemical. number of cycles per day.
8. Provide a question-and-answer opportunity. • Use products made from recycled materials.
9. On completion, ask employees to sign a training record • Use products that are recyclable.
that will remain in their personnel file.
 General Handling and Safety of Dental Materials in the Dental Office CHAPTER 4 51

BOX 4.2  OSHA Pictograms

THE DONT’S
The dental auxiliary is most frequently responsible
• Don’t use paper (i.e., biodegradable) instead of plastic for ordering supplies. Choosing cost-effective greener
surface barriers, because paper will allow penetration of options to address environmental contamination and
moisture and microbes. waste may begin with small steps and gradually build
• Don’t reuse standard sterilization wraps and pouches, to an office that is environmentally responsible.
because they were not designed to maintain sterility
after more than one use.
• Don’t use woven cloth (e.g., denim) as sterilization wraps PATIENT SAFETY
and then reuse it, because it is not a good microbial barrier. It is extremely important for the health care provid-
• Don’t use a disinfectant that has a reduced concentration of er to consider the safety of the patient while care is
an active ingredient unless there is evidence of its efficacy.
given and various materials and chemicals are used.
• Don’t shorten cleaner or sterilization cycles just to save energy.
• Don’t reuse items that are sold as disposable.
First consideration should be given to protection of
the patient’s eyes. It is recommended that protective
eyewear be supplied to the patient if he or she does
Dental facilities can do their part to sustain the environ-
not wear glasses. The same type of general protective
ment while continuing to prevent disease transmission. We
eyewear as used by the practitioner will do. Patient
are all encouraged to “reduce, reuse, recycle, and rethink.”
protective eyewear should be washed and disinfect-
ed between patients. Although some patients prefer
dark glasses to shield their eyes from the dental unit
American Dental Association Council on light, most providers prefer to use clear lenses so they
Dental Practice “Go Green” Subcommittee can observe the patient’s eyes and facial expressions
Recommendations during treatment as a clue to the patient’s level of
comfort (Fig. 4.11).
Top Ten Initiatives
• Install an amalgam separator. Caution
• Turn off equipment when not in use.
• Reuse paper scraps. Be certain that protective eyewear has been dried thoroughly
• Use recycle bins and create a “Green Team” to bring after treatment with disinfectant, to avoid inadvertent
items to recycle centers. contamination of the patient’s skin or eyes.
• Recycle shredded confidential patient information.
• Convert to digital technology. Another vital safety consideration is the patient’s
• Install solar or tinted shades. airway. The use of high-velocity evacuation (HVE) and
• Install locked or programmable thermostats. a rubber dam whenever possible is excellent practice.
• Install high-efficiency light bulbs. During rinsing of chemicals such as acid for etching,
• Use nontoxic cleaners and don’t use too much the patient may experience an unpleasant, bitter taste
disinfectant.
and may have a gagging reaction. The patient should be
52 CHAPTER 4 General Handling and Safety of Dental Materials in the Dental Office

can occur when these materials and chemicals are used.

The SDS is the best source of this information along
with the directions for use supplied with the product
manufacturer.

SUMMARY
The management of a safe environment in the dental of-
fice is the responsibility of the employer and of all who
work there. The safe use of any chemical or material is
the responsibility of the user at the time. The safety of
the patient is the responsibility of the dental team. Famil-
iarity with each material or chemical used by the dental
team is a must. This text provides general and technical
FIG. 4.11 Patient and clinician wearing protective eyewear; a protec- information, but specific hazards are best determined by
tive light shield is being used.
referring to the manufacturer’s instructions and the SDS.
Keep yourself informed, keep up to date with the stan-
dards, and continue to inquire “how can I protect myself,
warned of this taste, and the rinse should be controlled patients, fellow workers, and the environment,”?
to minimize discomfort.
Patients are more aware than ever before of the vari-
ous chemicals and filling materials that are used in the INSTRUCTIONAL VIDEOS
dental practice. It is essential that the dental auxiliary be See the Evolve Resources site for a variety of educational videos
as familiar as possible with hazards and reactions that that reinforce the material covered in this chapter.

Procedure 4.1 Safety Data Sheet and Label Exercise

See Evolve site for Competency Sheet. 2. What is the manufacturer’s name, address, and
emergency phone number? (This information is
Consider the following with this procedure: safety glasses are
found in the product identification section of the
recommended for the patient, PPE is required for the operator,
SDS.)
ensure appropriate safety protocols are followed, and check your
3. What precautionary statements should be included
local state guidelines before performing this procedure.
on the label? (This information is found in the
Use the information found on the Safety Data Sheet exposure controls/personal protection section of
(SDS) for acid etchant (conditioner) for pit and fissure the SDS.)
sealant. 4. What hazard pictograms and signal word should
be included? (This information is found in the
EQUIPMENT/SUPPLIES hazards identification section of the SDS.)
SDS for product and labeled product 5. What is the hazard statement(s) associated
Pen with this product? (This information is found
Secondary label (Refer to FIG. 4.3) in the hazard identification section of the
SDS.)
PROCEDURE STEPS What supplemental information should be included?
1. What is the product name and identifier? (This
information is found in the product identification
section of the SDS.)
 General Handling and Safety of Dental Materials in the Dental Office CHAPTER 4 53

Get Ready for Exams!

Review Questions 6. E yewash stations are:

a. never to be tested because they create a mess
Select the one correct response for each of the following b. best used at the end of the day for tired eyes
multiple-choice questions. c. required to have a posted set of instructions
1. When one is working with dental materials, the most d. best used in an emergency only if the employee has
common work-related health and safety hazards are: had training in their use
a. exposure to mercury, exposure to particulate mat- 7. What are the best ways to minimize exposure to chemi-
ter, exposure to perfume, and exposure to airborne cal hazards in the dental office?
contaminants a. Read the label and place in a secondary container to
b. exposure to particulate matter, exposure to biologi- keep the original fresher
cal contaminants, exposure to noise, exposure to b. Place in a secondary container to keep the original
perfume, and exposure to airborne contaminants fresher, and keep a log of all chemicals ever purchased
c. exposure to particulate matter, exposure to biologi- c. Read the label, and store according to the manufac-
cal contaminants, exposure to perfume, and expo- turer’s directions
sure to airborne contaminants d. Place in a secondary container to keep the original
d. exposure to mercury, exposure to particulate matter, fresher, and store according to the manufacturer’s
exposure to biological contaminants, and exposure directions
to toxic effects of chemicals For answers to Review Questions, see the Appendix.
2. The proper PPE to be worn during handling of dental
materials that can generate particulate matter consists of:
a. safety glasses, surgical or special dust mask, heavy-
Case-Based Discussion Topics
duty utility gloves, and overgloves 1. D iscuss the various items in an SDS. Take out an SDS
b. lab coat or overgown, surgical or special dust mask, for a sealant kit and identify all of the precautions
heavy-duty utility gloves, and vinyl examination required for handling the various components and iden-
gloves tify the pictograms used.
c. safety glasses, lab coat or overgown, surgical or What if it is light-cured versus chemical-cured?
special dust mask, and heavy-duty utility gloves
2. Regarding secondary labeling:
d. safety glasses, lab coat or overgown, and surgical or
Discuss the requirements and exceptions to the use of sec-
special dust mask
ondary labels.
3. There are multiple hazards associated with the use
3. Discuss some of the aerosols and bio-aerosols used in
of the dental lathe in the laboratory, which is NOT a
the dental office.
­hazards associated with the use of the dental lathe?
Give examples of procedures that are most likely to gener-
a. Flying debris
ate these aerosols, and describe how they can be elimi-
b. Aerosols
nated or reduced. (Hint: Don’t forget about disinfecting
c. Spatter
and sterilizing procedures and the treatment performed
d. Mercury vapor
on patients.)
4. Ways in which chemicals can enter the body include:
4. Patient safety:
a. inhaling, through cuts in the skin, and by touching
Discuss the various procedures that must be in place to en-
the product of a reaction
sure patient safety.
b. swallowing, inhaling, and by touching the product of
a reaction 5. Cross-contamination:
c. swallowing, inhaling, and through cuts in the skin Describe the procedures used to control cross-contami-
d. swallowing, through cuts in the skin, and by touch- nation and health care personnel exposure to the various
ing the product of a reaction materials that may be passed from a dental office to a den-
tal laboratory. For example, what can you do to prevent
5. What is the most important step the dental auxiliary can
cross-contamination and bacterial exposure of the dental
take to prevent the transmission of infectious disease?
office and laboratory personnel and patient from a dental
a. Wear a dust and mist respirator face mask
impression?
b. Utilize nitrile utility gloves
c. Practice appropriate hand hygiene
54 CHAPTER 4 General Handling and Safety of Dental Materials in the Dental Office

BIBLIOGRAPHY Powers JM, Wataha JC: Dental Materials: Properties and Manipula-
tion (ed 10). St. Louis, 2013, Mosby.
American Dental Association (ADA) Best Management Practices Terézhalmy GT, Huber MA: Environmental infection con-
for Amalgam Waste. Available at http://www.ada.org/∼/­ trol and in oral healthcare settings. A Continuing Edu-
media/ADA/Member%20Center/Files/topics_­amalgamwa cation Course offered at dentalcare.com. Available at
ste_brochure. http://www.dentalcare.com/en-US/dental-education/ce-c
Association (ADA) Council on DentalAmerican Dental Associa- ourses/ce363
tion (ADA) Council on Dental Practice, American Dental As- Terézhalmy GT: Clinical Practice Guideline for an Infection
sistants Association (ADAA): Go green: It’s the right thing to Control/Exposure Control Program in the Oral Healthcare
do. The Dental Assistant March/April 2012. Setting. A Continuing Education Course offered at dental-
Bird DL, Robinson DS: Modern Dental Assisting (ed 12). Philadel- care.com. Available at http://www.dentalcare.com/en-
phia, 2018, Elsevier/Saunders. US/dental-education/ce-courses/ce342
Bird DL, Robinson DS: Modern Dental Assisting (ed 11). Philadel- U.S. Department of Labor: Hazard Communication Standard: La-
phia, 2014, Elsevier/Saunders. bels and Pictograms. 2013. [OSHA Brief] DSG BR 3636.
Cuny E: Changes to the OSHA hazard communication standard: are Wallace S, St. Cyr W: Sustainability challenge, Dimensions of Den-
you ready? Inside Dental Assisting, November/December 2013. tal Hygiene, March 2014;12(3):23–24,26.
Donaldson K: Is your office environmentally responsible? RDA
Magazine, 2011.
Jacks M: Protecting Yourself. Dimensions of Dental Hygiene 9(8), RESOURCES
August 2011, 26–29. Canadian-Wide Standard (CWS) on Mercury for Dental Amal-
MacDonald G: Chemical hazards: regulations, identification and gam Waste. Available at http://www.ccme.ca/ourwork/wat
resources. J Calif Dent Assoc 17(12), 1989. er.html?category_id=118
Miller C, Long T, Molinari J: Protect against oral aerosols and International Organization for Standardization (ISO).
splatter, Dental Products Report, 2009. Dentistry—Amalgam Separators (ISO 11143). Available at
Miller CH: Infection Control and Management of Hazardous Materi- http://www.iso.org/iso/catalogue_detail.htm?csnumb
als for the Dental Team (ed 6). St. Louis, 2009, Mosby. er=42288 (2008).
Mount GJ, Hume WR: Appendix 1. In: Preservation and Restora- Organization for Safety, Asepsis, and Prevention (OSAP): Home
tion of Tooth Structure. St. Louis, 1998, Mosby. page. Available at http://www.osap.org/
Principles of Bonding 5
http://evolve.elsevier.com/Eakle/materials/

Chapter Objectives
Upon completion of this chapter, the student should be able to:
1. Discuss the effects of acid etching on enamel and dentin. 10. D iscuss the adverse effects of microleakage at
2. Describe the basic steps of bonding. restoration margins.
3. Explain the differences between bonding to enamel and 11. Describe how to bond ceramic veneers.
bonding to dentin. 12. Describe the bonding of orthodontic brackets.
4. Discuss the significance of the smear layer. 13. Explain the differences in bonding to enamel, dentin,
5. Describe“wet”dentin bonding. metal, and ceramic.
6. Compare etch-and-rinse and self-etch bonding techniques. 14. List the factors that contribute to tooth sensitivity after
7. Explain how the hybrid layer is formed and its importance bonding.
in bonding to dentin. 15. Etch enamel and dentin with phosphoric acid as
8. Explain how universal adhesives differ from etch-and permitted by state law.
rinse and self-etch adhesives. 16. Apply a bonding system to etched enamel and dentin as
9. Discuss the factors that interfere with good bonding. permitted by state law.

Key Terms
Bond or Bonding to connect or fasten; to bind. Items are Smear Layer a tenacious surface layer of debris resulting
jointed together at their surfaces in three main ways: by from cutting the tooth during cavity preparation. It is com-
mechanical adhesion (physical interlocking), by chemical posed mostly of fine particles of cut tooth structure
adhesion, or by a combination of the two Bonding Agent a low-viscosity resin that penetrates porosi-
Adhesion the act of sticking two things together. In dentistry ties and irregularities in the surface of the tooth or restora-
the term is used frequently to describe the bonding or tion created by acid etching for the purpose of facilitating
cementation process. Chemical adhesion occurs when at- bonding
oms or molecules of dissimilar substances bond together. Hydrophilic an attribute that allows a material to tolerate the
Adhesion differs from cohesion, in which attraction among presence of moisture
atoms and molecules of like (similar) materials holds them Hydrophobic an attribute that does not allow a material to
together tolerate or perform well in the presence of moisture
Etching or Conditioning terms used interchangeably to Etch-and-Rinse (also called Total-Etch) Technique a
describe the process of preparing the surface of a tooth or clinical technique that includes etching of both enamel and
restoration for bonding. The most common etching mate- dentin as a separate step from the application of bonding
rial (etchant) is phosphoric acid agents. Products that use this technique are called Etch-
Primer a low-viscosity resin applied as the first layer to pen- and-Rinse Bonding Systems.
etrate etched surfaces to enhance bonding Self-Etch Bonding System a bonding system that does not
Cure or Polymerize a reaction that links low molecular use a separate etching procedure with phosphoric acid.
weight resin molecules (monomers) together into high The acid is contained in the resin primer and no rinsing is
molecular weight chains (polymers) that harden or set. needed
The reaction can be initiated by strictly a chemical reaction Selective etching technique where enamel is etched first
(self-cure), by light in the blue wave spectrum (light-cure), with phosphoric acid prior to the application of self-etch
by a combination of the two (dual-cure), or by heat acidic primers that lack sufficient acidity to produce a good
Wetting ability of a liquid to wet or intimately contact a solid etch of the enamel
surface. Water beading on a waxed car is an example of Universal Bonding System a bonding system capable
poor wetting of bonding to tooth structure as well as most restorative
Wet Dentin Bonding bonding to dentin that is kept moist dental materials.
after acid etching to facilitate penetration of bonding resins Hybrid Layer a resin-dentin layer formed by intermixing of
into the etched dentin the dentin bonding agent with collagen fibrils exposed by

55
56 CHAPTER 5 Principles of Bonding

acid etching and the etched dentin surface. It serves as an differences in expansion and contraction rates of the tooth
excellent resin-rich layer onto which the restorative mate- and the restoration with temperature changes
rial, such as composite resin, can be bonded Contamination contact with a substance that interferes with
Oxygen-Inhibited Layer (also called air-inhibited layer) a bonding or lessens the chemical or mechanical properties
layer of unset resin on the surface of a polymerized resin (e.g., contamination of the etched surface of the tooth with
that is prevented from curing by contact with oxygen in the saliva before bonding)
air Hydrodynamic Theory of Tooth Sensitivity theory that
Microleakage leakage of fluid and bacteria that occurs at explains how pain is caused by movement of pulpal fluid
the interface of the tooth and the restoration margins and in open (unsealed) dentinal tubules. Actions that cause
is caused by microscopic gaps a change in the pressure on the fluid within the dentinal
Percolation movement of fluid into and out of the mi- tubules stimulate a pain response from nerve fibers in
croscopic gap of the restoration margin as a result of the odontoblastic processes that extend into the dentinal
tubules from the pulp
  

Adhesive materials are used on a daily basis in the mod- example, bonding resin is placed on the etched tooth
ern dental practice. Adhesive materials are beneficial for surface before light-curing. Manufacturers often use
many restorative and preventive procedures. They provide the word “bond” in the trade names of their bonding
a seal between the tooth and the restoration and seal the resins, such as Prime & Bond NT (Dentsply Sirona) and
dentinal tubules to reduce postoperative sensitivity. They OptiBond Solo Plus (Kerr Corporation).
enhance retention of the restoration so that more conserva-
tive preparations can be made, and they may increase the PREPARATION FOR BONDING RESTORATIONS
strength of the prepared tooth to resist fracture. Materials The first step in the bonding process involves prepara-
bonded to tooth structure may themselves be more resis- tion of the surface of the tooth or the restoration (or
tant to fracture than materials that are not bonded. For ex- both) to receive the material that will be bonded to it.
ample, porcelain veneers are thin, brittle and fragile until Preparing the tooth surface usually includes removing
they are bonded to the tooth, and then they are very fracture plaque and debris first. This is best done with a slurry
resistant. of pumice and water applied with a bristle brush or
Adhesives are used for a wide variety of dental proce- rubber cup (Fig. 5.1). Avoid prophy paste since it may
dures. The dental auxiliary must be familiar with the terms contain flavoring oils that interfere with etching. Then,
and processes used in bonding of various restorative and etching or conditioning the enamel or dentin (or both)
preventive materials, to be knowledgeable, effective members with an acid is done next. The most commonly used
of the dental team. The dental assistant will be involved in acid is phosphoric acid in concentrations ranging from
helping the dentist perform bonding procedures many times 10% to 38%. Acid removes mineral from the surface to
each day. In some states trained hygienists and assistants create roughness or microscopic porosity.
may etch tooth structure and apply bonding agents and
place sealants and composite resins. Additionally,the dental BONDING TO THE ETCHED SURFACE
hygienist may perform periodontal treatments that might af- When a resin bonding agent or primer is flowed over
fect bonded restorations. Therefore it is important that the the etched surface, it penetrates into the microscopic
dental auxiliary understands the properties and handling pores. When it hardens (cures or polymerizes), it cre-
characteristics of the bonding materials and the processes ates projections called resin tags that lock into the tooth,
involved in their use. creating a mechanical bond called micromechanical re-
tention. The resin bonding agent will then chemically
bond to other resins placed over it, such as compos-
BASIC PRINCIPLES OF BONDING ite resin. The chemical bond, called a primary bond, is
In dentistry, the term bond, or bonding, is used in sev- a true adhesion between atoms or molecules of the
eral ways. It is used to describe the process of attaching composite resin and the bonding resin. (See Chapter 3
restorative materials, such as a composite resin, to a Physical and Mechanical Properties of Dental Materi-
tooth by adhesion (the attraction of atoms or molecules als for a discussion on types of bonds.) The chemical
of two different contacting surfaces). When describing bond is stronger than a physical bond, called a second-
cosmetic restorations such as porcelain or composite ary bond, which is a weak physical attraction between
veneers, patients often use the term “bonding,” for ex- two surfaces such as the adhesion of paint to a metal
ample, “The dentist is bonding my front teeth.” Bond- surface. Roughening the metal surface by sandblast-
ing also is the basis for several other dental procedures, ing increases the adhesion of the paint by mechanical
such as the placement of orthodontic brackets and retention, much in the way that acid etching rough-
fixed retainers. It is used to describe some of the ma- ens the surface of the enamel to achieve mechanical
terials used in the process of placing restorations. For retention.
 Principles of Bonding CHAPTER 5 57

A B
FIG. 5.1 Cleaning the tooth before bonding. A, Slurry of pumice and water used to remove plaque, pellicle and debris
prior to acid etching. B, Rubber cup with slurry of pumice used at low speed to clean the enamel surface before bonding
procedures.

SURFACE WETTING
Acid etching also increases the ability of liquids to wet
the surface of the tooth by creating high surface ener-
gy. High surface energy helps to attract the resin to the
etched surface. The adhesive must have a surface ten-
sion that is lower than the surface energy of the etched
enamel. High surface energy can also attract contami- On wettable surfaces, there is
nants (such as saliva), so good isolation is important. A a tendency to spread uniformly
If saliva contamination occurs, drying the surface will
leave residues that will interfere with the bond. The
surface must be re-etched.
Good wetting increases the intimate contact of the
bonding resin with the etched tooth structure, improv-
ing the penetration of resin to form tags and thereby
improving the bond. Surfaces that are poorly wetted
will cause beading of the liquid, similar to water on a
newly waxed car. Each bead of water stands up on the
surface of the car with a high angle of contact. On an On non-wettable surfaces,
unwaxed car, the water easily spreads out and has a B moisture tends to bead

low angle of contact (Fig. 5.2). Bonding agents are usu- FIG. 5.2 Acid etching of enamel increases its ability to be wetted by
a resin bonding agent, resulting in a stronger bond. A, A low contact
ally not very viscous (thick), so they will flow readily
angle indicates good wetting as the liquid spreads over the surface.
and wet the etched surface. B, A high contact angle indicates poor wetting as the liquid beads on
the surface like water on a waxed car.
BOND STRENGTH
The strength of the bond obtained is usually measured
by determining the force needed to separate the two Bonding to enamel usually achieves consistently
joined materials. The force needed to break the bond high bond strengths of around 30 MPa (4500 psi). The
is divided by the cross-sectional area of the bonded bond strength to dentin is usually less than to enamel
surfaces to arrive at the value for the bond strength. and varies according to how mineralized the dentin
Most bond tests pull the bonded materials apart (ten- is and how deep into the dentin the cavity prepara-
sile bond strength) or apply forces at approximately 90 tion extends. The dentin near the dentinoenamel junc-
degrees to the bonded interface of the materials until tion (DEJ) has fewer dentinal tubules (about 15,000 to
the bond fails (shear bond strength). The value for the 20,000/mm2), occupying 14% of the dentin surface, and
bond strength is reported as megapascals (MPa). One they are smaller in diameter than in the dentin closer to
megapascal equals 150 pounds per square inch (psi). the pulp. Deeper dentin contains more tubules (about
Choosing materials with good bond strengths to tooth 45,000 tubules/mm2) and they are larger in diameter,
structure can enhance the longevity of the restoration occupying 20% to 30% of the dentin surface. Fluid
and potentially allow for more conservative prepara- flows from the pulp into the tubules on a constant ba-
tions, because cutting into healthy tooth structure to sis. Therefore deeper dentin will be wetter from the
create mechanical locks can be minimized. flow of pulpal fluid through the tubules. Wetter dentin
58 CHAPTER 5 Principles of Bonding

with more and larger holes (tubules) is more difficult

to bond to consistently than is shallower dentin. Water
will cause a deterioration of the dentin adhesives over-
time. The restoration may stay in place but the dentin
adhesive layer may have become porous.

Durability of the Bond

How long the bond lasts is more important than how
high the initial bond strength is. Over time, exposure
of the bonding agents to moisture may cause them
to degrade (hydrolyze). In addition, repeated stresses
on the bond caused by chewing pressures and tem-
perature changes that cause different amounts of
expansion and contraction between the restoration
and the tooth structure (measured by the coefficient
of thermal expansion) will gradually cause fatigue
failure of the bond. (Fatigue failure is similar to tak-
ing a piece of metal and repeatedly bending it back
and forth until it breaks.) When composite resin is
placed and polymerized, it shrinks and can put stress FIG. 5.3 An etched enamel surface as seen in this scanning electron
(as much as 20 MPa or 3000 psi) on the bond of the micrograph has numerous peaks and valleys and surface roughness
that provide retention and greatly increase the surface area for bond-
resins to the tooth. In addition, hot and cold foods or
ing. (From Phillips RW, Moore BK: Synthetic resins. In: Elements of
beverages can cause composite resin to expand and Dental Materials for Dental Hygienists and Dental Assistants, Philadel-
contract much more so than the tooth (about four phia, 1994, Saunders.)
times more). If the bond fails, the restoration could
leak, causing sensitivity in the tooth or leading to re- acid. Proteins, lipids, and water in small quantities are
current caries. found in microscopic spaces between the crystals.
Bonds fail in one or more of the following locations: Etching of enamel removes a small portion of the
1. failure occurs within the bonding resin (cohesive surface, reduces the ends of the enamel rods, and
failure) opens microscopic porosities between adjacent rods
2. failure occurs within the tooth structure or restora- (Fig. 5.3). Etching creates a highly roughened surface
tion (also cohesive failure but not with the bonding with many tiny spaces and micropores into which the
resin) bonding resin can lock. The durability and strength of
3. failure occurs at the interface between the bonding the bond to the enamel depends on how well the etch
resin and the tooth structure or restoration (adhe- pattern is developed. Among the many different acids
sive failure). tested, phosphoric acid provides the best etch pattern.
It is thought that proteolytic enzymes called matrix Bond strengths to enamel from phosphoric acid etch-
metalloproteinases can cause breakdown of the resin ing range from 20 to 50 MPa, depending on which test
bond to dentin. To stop the effect of these proteolytic of bond strength is used.
enzymes, chemicals that inhibit them are being test-
ed. One of these inhibitors is chlorhexidine. The dura- Caution
bility of the bond may be enhanced by scrubbing the Do not rub or scrub the enamel surface with a hard
dentin with chlorhexidine before bonding. Further instrument after etching. The portions of the enamel rods
testing and a protocol on how to use it appropriately exposed by etching are very fragile and will break with light
are needed. pressure. If this occurs, the available sites for resin tag
formation will be greatly reduced and thus will affect the
strength of the bond.
ETCHING ENAMEL AND DENTIN
ENAMEL ETCHING Etching Times
Michael Buonocore introduced acid etching of enamel The enamel of permanent teeth is usually etched for
into dentistry in the 1950s after observing industrial ap- 20 to 30 seconds with 37% phosphoric acid. Although
plications of 85% phosphoric acid on metal to enhance etching times as short as 10 seconds appear to give good
adhesion of paints and resins. Enamel is composed of clinical results in some teeth, research results suggest
thousands of rods (prisms) that extend from the dentin that 20 to 30 seconds is optimal. Highly mineralized
to the tooth surface in a radial fashion. Each rod has teeth may be more resistant to etching and may require
many millions of crystals composed of hydroxyapatite up to 60 seconds of etching. Primary teeth should be
with about 20% carbonate inclusions. These carbonate etched for longer periods (60 seconds or more), be-
imperfections add to the solubility of the crystals in cause the surface of the enamel has a prism pattern
 Principles of Bonding CHAPTER 5 59

Smear layer

Smear plug

FIG. 5.4 Acid-etched enamel surfaces for bonding appear frosty white. Dentinal
tubule

FIG. 5.6 Cutting of tooth structure with a rotary instrument forms a

layer of cutting debris called the smear layer, as seen in this scanning
electron micrograph. It is removed by acid etching so that it does not
interfere with the formation of a bond. (Courtesy of Grayson Marshall,
University of California School of Dentistry [San Francisco, CA].)

collagen matrix woven throughout the mineral com-

ponent (hydroxyapatite) and a system of dentinal tu-
bules through which fluids from the pulp flow.
FIG. 5.5 Gel acid etchant in a syringe with a dull needle delivery tip. The
gel has been dyed blue as a visual aid for its placement and removal. Smear Layer
When a cavity preparation is cut with rotary or hand
that is not as well structured, is considered aprismatic instruments, a layer of cutting debris forms on the sur-
(without a regular prism pattern), and is more resistant face of the cut dentin and enamel. This layer, called the
to deep resin tag formation. The etched surface should smear layer, is composed mostly of cut tooth structure
have a frosty appearance when dried (Fig. 5.4). How- (hydroxyapatite and collagen) and may also contain
ever, when a cavity preparation involves the etching plaque, bacteria, saliva, and even blood (Fig. 5.6). The
of both enamel and dentin, and the preparation is left smear layer sticks tenaciously to the dentin surface,
slightly moist for wet dentin bonding, it cannot be de- plugs the openings of dentinal tubules greatly re-
termined whether the enamel has a frosty appearance. ducing the permeability of the dentin, and cannot be
washed off with use of an air-water spray. The smear
Etchant Liquid or Gel layer is about 2 microns (μm) thick and interferes with
The acid etchant comes as a liquid or a gel. Often, color- the formation of a bond to dentin. (A coarse diamond
ing agents are added so the practitioner can see where bur will produce a thicker smear layer than a fine dia-
the etchant is on the tooth. Liquid etchants are usu- mond or carbide bur.)
ally applied with a brush, a small cotton pellet, or a Bonding systems that use phosphoric acid to etch
small sponge. Gels are more popular because they stay the enamel and dentin dissolve the smear layer and
in place, whereas liquids tend to run without control. rinse it away. Bonding systems that use acidic prim-
Gels contain silica as a thickener. They are usually ap- ers to etch the enamel and dentin penetrate the smear
plied by brush or dispensed from a syringe through a layer and incorporate it into the bonding agent, since
fine needle or brush tip (Fig. 5.5). The recommended there is no rinsing used with these systems. Regard-
rinsing time for acid gels is approximately 10 seconds less of the etching method, the smear layer is removed
or longer. Rinsing times shorter than 5 seconds may or modified so the bonding agents can penetrate the
not remove residual silica. Rinsing times for liquid etched surfaces. Early bonding systems that did not
etchants can be shorter—5 to 10 seconds. etch the dentin had low bond strengths to dentin be-
cause the smear layer was in the way.
DENTIN ETCHING
The dentin has higher water and organic content Phosphoric Acid Etching of Dentin
(about 50% by volume) than does enamel (only about Etching dentin with phosphoric acid dissolves the
12% by volume) and lower mineral content (about 50% smear layer and smear plugs in the tubules first, and
by volume) compared to 88% for enamel. It contains a then dissolves portions of the hydroxyapatite crystals
60 CHAPTER 5 Principles of Bonding

A 30kv 2.00kx 5.0 959 B 3 m

C 0.6 m

FIG. 5.7 A, Normal dentin with dentinal tubules. B, Acid etching of the dentin removes some of the mineral exposing the
collagen fibers of the matrix, as seen in this scanning electron micrograph. C. Higher magnification of collagen fibrils. (A,
from Sakaguchi R, Powers J: Craig’s Restorative Dental Materials, ed 13, St. Louis, Elsevier. B and C, From Heymann
H, Swift E, Ritter A: Sturdevant’s Art & Science of Operative Dentistry, ed 6, St. Louis, 2013, Elsevier.)

from the surface of the dentin, creating a porous sur- result of bacterial invasion from dental caries causing
face and exposing the meshwork of collagen fibrils that irritation of the odontoblasts (cells in the pulp that pro-
are part of the dentin matrix (Fig. 5.7, B, C). Because duce dentin) which have extensions into the tubules.
dentin is not as highly mineralized as enamel, it should The irritated odontoblasts try to protect themselves
be etched for shorter periods, typically for 10 seconds. from the irritant and lay down a protective mineral
With a 10-second etch, mineral is removed up to 5 μm wall. Also as part of the caries process, some of the
in depth from the area between the tubules (intertu- mineral that is removed from the dentin as it is demin-
bular dentin) and from around the periphery of the eralized gets deposited into the tubules. Sclerotic den-
tubules (peritubular dentin) as well as in the opening tin can also occur from injury to odontoblasts during
of the tubules. Acid that goes into the tubules is neu- cavity preparation for deeper restorations.
tralized by the fluids that flow from the pulp. When Studies have also shown that dentin of people over 55
hydroxyapatite is removed from the dentin surface, it is more mineralized than that of younger people. Sclerot-
leaves a roughened, porous surface (but not the same ic dentin being more mineralized is harder than normal
as with enamel, because there are no rods or prisms) dentin and has a glassy appearance. These factors make
and exposes collagen fibrils. it more difficult to etch. To add some surface rough-
When etching both enamel and dentin as in a coro- ness for bonding, some clinicians use a diamond bur to
nal cavity preparation, it is best to apply the acid to the abrade it before etching. Some studies suggest pre-etch-
enamel first for 10 seconds, and then to the dentin for 10 ing the sclerotic dentin with phosphoric acid for 10 to 15
seconds. That way enamel will be etched for a total of seconds before using self-etching bonding systems.
20 seconds and dentin only 10 seconds. Etching dentin
for 20 seconds or longer opens the tubules too wide and Moist dentin for bonding. After etching acid is removed
removes hydroxyapatite mineral to too great a depth. by rinsing for at least 10 seconds. A gentle stream of
Over-etching will expose too much collagen matrix, air is used to remove excess water. However, the den-
causing it to act as a thick barrier and making it more tin is left slightly moist so that it glistens but without
difficult to coat the dentin and seal the tubules with the any puddles of water (Fig. 5.8). It is critical at this stage
resin bonding agent. Over-etching dentin can result in a not to over-dry the dentin. The dentin surface must be
weaker bond and in post-treatment sensitivity. moist to keep the collagen fibrils fluffed up. If the dentin
is dried too much, the collagen fibrils collapse and form
Etching sclerotic dentin. Sclerotic dentin is dentin in a dense surface that occludes the tubules and blocks ad-
which the dentinal tubules have become highly calci- equate penetration by the dentin bonding resin. On the
fied by way of minerals deposits. This can occur as a other hand, too much water remaining on the etched
 Principles of Bonding CHAPTER 5 61

10-30 µm
A B

FIG. 5.8 Moist dentin for bonding after rinsing off acid. It should glisten
with moisture but not have any puddles of water. (From Heymann H, C
Swift E, Ritter A: Sturdevant’s Art & Science of Operative Dentistry, ed
6, St. Louis, 2013, Elsevier.)
FIG. 5.9 Bonding to enamel. A, Unetched enamel rods B, Etched
enamel rods C. Bonding resin mechanically bonding to etched enamel
dentin dilutes the resin primer, makes it difficult for rods. (© Elsevier Collection.)
the resin to displace the water trapped in the collagen
fibrils and produces a potential pathway for leakage.
Both over-drying and under-drying can produce an
incomplete sealing of the dentinal tubules and a much
weaker bond, because the dentin-resin interface will
separate more easily. A good dentinal seal helps elimi-
nate bacterial leakage and postoperative sensitivity.

Etching Enamel and Dentin (Etch-and-Rinse

Technique with 37% phosphoric acid)
Enamel Dentin
Etching Time 20 seconds 10 seconds
Rinsing Time 10 seconds 10 seconds
Moisture Content for Very dry Slightly moist (but
Bonding no puddles)
Clinical Appearance Frosty white Glistening
(Fig. 5.4) (Fig. 5.8)

Clinical Tip
To restore moisture to overdried dentin, soak a cotton pellet FIG. 5.10 A bonding resin placed on etched enamel penetrates the
porous surface and forms resin extensions or tags that lock into the
in water and place it on the dentin for 10 to 20 seconds.
enamel and form a mechanical bond. This scanning electron micro-
Rewetting the dry dentin will allow the collapsed collagen graph shows the resin tags left after the enamel was dissolved away.
fibrils to re-expand. If you wet it by squirting water on the (From Phillips RW, Moore BK: Synthetic resins. In: Elements of Dental
dentin, then you will have to blow the excess water off and Materials for Dental Hygienists and Dental Assistants, Philadelphia,
may overdry it again. 1994, Saunders.)

created by acid etching (Fig. 5.9). The liquid may sim-

Enamel and Dentin Bonding ply be an unfilled resin or may include small amounts
Enamel bonding resins. Bonding agents are low-viscos- of very tiny filler particles to enhance the strength of
ity resins that flow well into the microscopic porosities the resin.
and irregularities of the etched surfaces. When bond- Resin tags. When the resin is cured by a chemical
ing to enamel alone, the process is much simpler than process or by light activation, it locks into the micro-
bonding to dentin and the enamel can be dried com- scopic spaces and irregularities, producing resin tags
pletely. Etching of enamel creates a high-energy, low- that are 10 to 20 μm long and 5 to 6 μm in diameter
tension surface that makes the surface easier to wet. A (Fig. 5.10). The resin tags secure the resin to the enamel
high-energy surface attracts the molecules in the resin and create a very strong bond (shear bond strength
bonding agent to improve penetration into the porous, of more than 20 MPa). The length of the resin tags is
etched enamel. Bonding to enamel alone requires only determined in part by the orientation of the etched
a low-viscosity liquid resin monomer that will pen- enamel rods. If the enamel on the surface of the tooth
etrate into the spaces on and between enamel rods is etched (as with bonding orthodontic brackets), then
62 CHAPTER 5 Principles of Bonding

the rods are etched on their ends and the resin penetra- However, if the dentin is dried, the fibrils collapse into
tion is deep. In a class I cavity preparation, the sides of a thick mass that prevents the bonding resin from pen-
the enamel rods on the walls of the preparation have etrating the etched dentin. A primer is more important
been exposed. When the sides of the rods are etched, on dentin than enamel because the primer contains
the penetration of the resin is much shallower (about hydrophilic groups that penetrate wet, etched dentin
5 to 10 μm long). Even though there is a difference in and keep the meshwork of collagen fibrils expanded so
the length of the resin tags between end-etched rods that the adhesive resin can penetrate.
and side-etched rods, the bond strengths are not sig-
nificantly different. Solvents. For the resin to penetrate through the water
Contaminants on the surface, such as saliva or on moist dentin, it must be dissolved in a solvent that
blood, can dramatically lower the strength of the bond can penetrate water and carry the resin with it. The
to the enamel. This is one major reason why good isola- solvents allow the resins to penetrate water on the
tion is so important. If enamel becomes contaminated dentin and in the dentinal tubules, and to penetrate
after etching, it must be re-etched for 10 to 15 seconds around collagen fibrils and into porosities in the tooth
before the bonding process is continued. Because most surfaces created by etching. The solvents are primar-
restorative procedures involve etching both enamel ily acetone, ethanol (ethyl alcohol), or a combination
and dentin, a dentin primer and a bonding resin that of ethanol and water. In general, the solvent is the
can be used on both the etched enamel and dentin are largest portion of the bonding agent, making up 60%
preferred. or more of the material. Acetone is a highly volatile
solvent. Its rapid evaporation may require that two or
Clinical Tip more coats of the bonding resin be applied to ensure
Good isolation is critical for good bonding. A major cause adequate sealing of the dentin. An example of a bond-
of bond failure leading to microleakage, recurrent caries ing resin with acetone is Prime & Bond NT (Dentsply
and loss of retention of the restoration is contamination Sirona). Ethanol evaporates more slowly, so it may
of the etched tooth surface. If the etched tooth surface is need a longer drying time. An example of a bond-
contaminated by saliva or blood, rinse thoroughly, re-isolate ing agent with ethanol is OptiBond Solo Plus (Kerr
and re-etch for 10 to 15 seconds. Corporation). All bottles of bonding agents should be
recapped immediately after the material is dispensed,
Dentin Bonding Resins to prevent evaporation of the solvent, which leads to
Resin components. Dentin bonding resins can be gradual thickening of the resin left in the bottle with
viewed as two components. The first is a resin prim- less ability to penetrate etched dentin. Unit-dose
er that penetrates etched dentin and enamel and lays (single-use) packaging of bonding resins avoids some
down a resin layer. The primer is composed of hydro- of these problems associated with bonding resins in
philic (water-tolerating) monomers and molecules that bottles, as well as infection control issues.
allow it to penetrate water. HEMA (2-hydroxylethyl After the primer is placed, it is dried before it is
methacrylate) is commonly used as a primer mono- cured to remove the solvent and the remaining wa-
mer. The second component is an adhesive resin that is ter. The resin adhesive bonds to the resin primer and
applied over the primer. The adhesive resins common- provides a resin-rich layer that will chemically bond to
ly used are bis-GMA (bisphenol-A-glycidyl dimethac- hydrophobic (water-repelling) resin restorative materi-
rylate), TEGDMA (triethylene glycol dimethacrylate), als such as composite resin that are placed over it. See
and urethane dimethacrylate (see Chapter 6 Compos- Procedure 5.1 for bonding to enamel and dentin.
ites, Glass Ionomers, Compomers).
The two resins chemically bond to each other, that is, Self-etching technique. Bonding systems that do not
the initial resin bonding material prepares (or primes) use phosphoric acid etching instead use an acidic
the tooth surface, much in the way that a primer is ap- primer that etches and primes in the same step. Acidic
plied to wood before painting so that the paint will primers (being hydrophilic) use water as a solvent. The
adhere better. The second resin then chemically bonds water allows the acid component to ionize and become
to the primer. In an effort to simplify the bonding tech- active for etching tooth structure. Water can also rewet
nique, many manufacturers have combined the primer the collagen fibrils if they have collapsed from drying
and bonding resin into one bottle to eliminate one step to allow penetration by the primer. No rinsing and
in the process. drying are needed after the acidic primer is applied.

“Wet” dentin bonding. Bonding to moist dentin Clinical Tip

(“wet”dentin bonding) was the first technique to Bonding resins should not be dispensed before the operator
achieve good bond strengths to dentin. As mineral is is ready to place them. Otherwise, the solvent (such as
removed from the surface of the dentin by acid etch- acetone or ethanol) will evaporate prematurely, leaving a
ing, the fibrils of the collagen matrix are exposed. By bonding resin with reduced ability to penetrate moist dentin.
keeping the dentin moist, the fibrils stay spread out.
 Principles of Bonding CHAPTER 5 63

used, and they were light-cured. The dentin still was

Benefits of Bonding Restorations
not etched, so the bonding resin placed on dentin was
• E nhances retention of the restoration merely bonding to the smear layer. The resulting bonds
• Allows more conservative cavity preparations to dentin were very weak bonds (2 to 6 MPa). Later in
• Regains some of the strength of the tooth lost by cavity the 1980s, it was discovered that the smear layer was
preparation interfering with the ability of the bonding resins to
• Strengthens brittle restorative materials such as porce- bond to dentin. Acidic components of the bonding sys-
lain veneers
tems (third generation) were used to remove the smear
• Seals the dentinal tubules
• Reduces microleakage and the associated sensitivity or
layer, but the dentin was not adequately etched and
recurrent caries it was dried. So, bonding resins did not penetrate the
dentin surface in a meaningful way. Therefore bond
strengths were still relatively low (bond strength of 12
BONDING SYSTEMS to 15 MPa).
History of the Development of Bonding Systems By the start of the 1990s, etching both enamel and
Bonding systems for enamel and dentin have under- dentin with phosphoric acid was an accepted tech-
gone rapid changes over the past four decades (Box nique, first called the total-etch technique but now
5.1). The composites that became commercially avail- commonly called the etch-and-rinse technique. Not
able in the early 1960s were placed without etching or only was the smear layer removed, but the surface of
bonding agents. By the beginning of the 1970s, dentists the dentin was etched and kept moist, allowing for
were beginning to etch the enamel with acid and place the penetration of hydrophilic resin primers into the
a self-cured, unfilled bonding resin on the enamel only. etched dentin surface. The bond strength to dentin in-
This is considered to be the first generation of bonding creased to about 20 to 30 MPa. John Kanca introduced
agents. A number of different acids were tested, but the “wet” dentin bonding technique in the United
phosphoric acid gave the best results. Great concern States. Primer and bonding resins were applied sepa-
was expressed about putting a strong acid (like phos- rately (two bottles—fourth generation) or combined
phoric acid) on dentin for fear of damaging the pulp. into one bottle (fifth generation).
The dentin was covered with a liner such as calcium By the latter part of the 1990s, primers with acidic
hydroxide for protection. components that could etch enamel and dentin (called
By the late 1970s and early 1980s, both enamel and self-etching systems) were introduced and were light-
dentin bonding resins (second generation) were being cured or dual-cured (both light and chemical cures).

Box 5.1  Time Line of Development of Bonding Systems

Enamel Etch: 1960s and 1970s—dentin was not etched. Self-Etch (No Rinse):
Bonding agents attached to etched enamel, and the smear Sixth generation
layer blocked adhesion to dentin. First and second genera- Late 1990s—Type I—2 bottles. Primer applied, and then
tions of bonding systems adhesive resin
Products: First generation—Cervident (S.S. White); sec- Early 2000s—Type II—2 bottles. Primer and adhesive
ond generation—Scotchbond (3M ESPE), Dentin Adhesit mixed and applied
(Ivoclar Vivadent) Products: Sixth generation
↓ Type I—AdheSE (Ivoclar Vivadent), Clearfil SE Bond (Ku-
Etch-and-Rinse (Enamel and Dentin Etch and Rinse): raray America), UniFil Bond (GC America), ONE-STEP PLUS
1980s—smear layer was removed by etching dentin but with Tyrian SPE (BISCO), OptiBond Solo Plus self-etch adhe-
bonding agents could not penetrate dried, collapsed colla- sive (Kerr Dental)
gen layer. Third and fourth generations of bonding systems Type II—Adper Prompt L-Pop Self-Etch Adhesive (3M
Early 1990s—”wet” dentin bonding introduced. Two- ESPE), Touch&Bond (Parkell), Tenure Uni-Bond (DenMat),
bottle (fourth generation) bonding systems. Highest bond Xeno III (Dentsply International)
strengths (but technique sensitive) ↓
Products: Third generation: Scotchbond II (3M ESPE), 2002—One-bottle (all-in-one, seventh generation) sys-
Tenure (DenMat), XR-Bond (Kerr Dental) tems—etching, priming, and bonding combined
Fourth generation: Scotchbond Multi-Purpose (3M ESPE), Products: iBond (Heraeus Kulzer)
OptiBond FL (Kerr Dental), ALL-BOND 2 (BISCO) 2011 (approximately) Universal adhesives were introduced—
Mid-1990s—one-bottle systems (fifth generation). High capable of bonding to both tooth structure and many den-
bond strength. Unit-dose packaging available tal materials. Two-bottle systems were introduced first:
Products: Prime & Bond NT (Dentsply International), Opti- Futurabond DC (VOCO), Xeno IV Dual Cure (Dentsply), Clearfil
Bond Solo Plus (Kerr Dental), ExciTE (Ivoclar-Vivadent), Ad- DC Bond (Kuraray America), Later, one-bottle systems were
per Single Bond Adhesive (3M ESPE) introduced: Scotchbond Universal Adhesive (3M ESPE), All-
↓ BOND Universal (BISCO), Prime&Bond Elect (Dentsply).
Data from Nazarian A: The progression of dental adhesives [online continuing education]. Dental CE Digest, 2007. PennWell
Publications.
64 CHAPTER 5 Principles of Bonding

Separate steps for etching with phosphoric acid and used in the dentin primer because it is a hydrophilic
rinsing and drying were eliminated with the self-etch- monomer that can very effectively penetrate etched
ing primers. These systems had primer and bonding dentin, facilitate formation of the hybrid layer and en-
resin in separate bottles (sixth generation). hance bond strength. It is soluble in acetone, ethanol
In the early 2000s, improvements were made in self- and water, which are the solvents used commercially
etching materials so that components were contained for the resin adhesives.
in one bottle (“all in one” adhesives—seventh genera-
tion) and did not require mixing. Around 2010, another All Bonding Systems Have These Things in
class of bonding resins was developed that could not Common
only bond to tooth structure but also to restorative ma-
terials such as ceramics and metal and these have been • A n acid etchant
called universal bonding agents. • A dentin primer
• A bonding resin (adhesive resin)
CLASSIFICATION OF BONDING SYSTEMS
Each generation of adhesive systems has consisted of ETCH-AND-RINSE BONDING SYSTEMS
better materials or simpler procedures. The variety (GENERATIONS 4 AND 5)
of combinations of primers and adhesives has gotten Etch-and-rinse (also called all-etch or total etch) re-
simpler but can still be confusing to the beginner until fers to phosphoric acid etching of both enamel and
some experience in using the materials is gained. An dentin with a separate step that includes rinsing off
easier way to view the current adhesive systems rather the acid. After the acid is rinsed off, the dentin is left
than by their generations is to categorize them into slightly moist (glistening but no water puddles), so
one of three basic groups: etch-and-rinse bonding sys- that the collagen fibrils stay fluffed up. The etch-and-
tems, self-etch bonding systems and universal ­bonding rinse technique became successful when hydrophilic
­systems (Table 5.1). These three bonding systems all resin monomers (HEMA) were added to the primer
have an acidic etchant, a primer for the dentin and a and adhesive. The hydrophilic monomers facilitated
resin adhesive. HEMA (hydroxyethyl methacrylate) is the penetration of the adhesive resin into the moist

TABLE 5.1    Etch-and-Rinse and Self-Etch Bonding Systems: Application and Commercial Products
ETCH-AND-RINSE SELF-ETCH (NO RINSE)
Fourth generation: 2 bottles Fifth generation: 1 bottle Sixth generation: 2 bottles or Seventh generation: 1 bottle
(3 steps) (2 steps) chambers (2 steps) (1 step)
Step 1. Etch, rinse, and Step 1. Etch, rinse, and gently Step 1. Etch and prime, apply Step 1. Etch, prime, and
gently air dry. Leave air dry. Leave dentin moist acidic monomer, lightly air bond (all in one bottle),
dentin moist dry gently air dry, light cure
Step 2. Apply primer, gently Step 2. Apply primer/ bonding Step 2. Apply bonding resin,
air dry resin, gently air dry, light cure gently air dry, light cure
Step 3. Apply bonding resin,
gently air dry, light cure
Strongest, most reliable Strong bonds to enamel and Strong bonds to dentin Strong bonds to dentin
bonds to enamel and dentin
dentin
Reliably etches enamel Reliably etches enamel Bonds to enamel are not Only a few products reliably
strong, especially uncut etch enamel. “Selective
enamel. “Selective etch” etch” advisable
advisable
Scotchbond Multi-Purpose Adper Single Bond Plus (3M AdheSE (Ivoclar Vivadent) AdheSE One (Ivoclar Viva-
(3M ESPE) ESPE) Adper Prompt L-Pop (3M dent)
ALL-BOND 3 (BISCO) Bond-1 (Pentron) ESPE) Adper Easy Bond (3M ESPE)
Bond-It (Pentron) DenTASTIC UNO (Pulpdent) ALL-BOND SE (BISCO) Clearfil S3 Bond Plus (Kura-
DenTASTIC All-Purpose ExciTE (Ivoclar Vivadent) Brush&Bond (Parkell) ray America)
(Pulpdent) Gluma Comfort Bond (Heraeus Futurabond DC (VOCO)
Gluma Solid Bond (Heraeus Kulzer) Clearfil SE Bond (Kuraray G-Bond (GC America)
Kulzer) IntegraBond (Premier) America) iBond (Heraeus Kulzer)
OptiBond FL (Kerr) ONE-STEP PLUS (BISCO) Nano-Bond (Pentron) OptiBond All-In-One (Kerr
Perma/Quick (Ultradent) OptiBond Solo Plus (Kerr) OptiBond Solo Plus SE (Kerr Corporation)
Syntac (Ivoclar Vivadent) PQ1 (Ultradent) Corporation) Xeno V+ (Dentsply)
Prime & Bond NT (Dentsply) Peak SE (Ultradent)
Xeno III (Dentsply)
Adapted from Anusavice KJ, Shen C, Rawls HR: Table 12-1. In: Phillips’ Science of Dental Materials, ed 12, St. Louis, 2013, Elsevier.
 Principles of Bonding CHAPTER 5 65

dentinal tubules and peritubular dentin. Drying with

air is done at this stage to remove the volatile solvents
from the resin and any remaining water. The resin is
then light-cured (or chemical-cured).

Hybrid Layer
The layer that is formed by the intermixing of dentin bond-
ing resin with collagen fibrils and the etched dentin sur-
face is called the hybrid layer (first described by Japanese
researchers Fusayama in the late 1970s and Nakabayashi
in the early 1980s), because it is a combination (or hybrid)
of dentin components and resin. The resin-rich hybrid lay-
er facilitates bonding of the composite resin to the tooth
through a chemical resin-to-resin bond (Fig. 5.11).
All of the current bonding systems work by micro-
mechanically locking into etched enamel and by form-
ing a hybrid layer with dentin. FIG. 5.12 Two-bottle etch-and-rinse bonding system. Components:
Because the serous-like fluid in the dentinal tubules primer, adhesive resin, etchant in syringe with delivery tips, micro-tip
neutralizes the etching acid, the walls of the dentinal brushes and disposable mixing well. (OptiBond FL, Courtesy Kerr Corp.)
tubules are etched mostly around the opening and not
very far into the tubules. As a consequence, long resin primer, and it is light-cured. The two-bottle etch-and-
tags extending into the tubules do not add much to the rinse systems provide the strongest bonds to dentin of
retention of the resin because they are not bonded to the all the bonding systems, assuming the technique is fol-
walls. Most of the retention comes from penetration into lowed carefully. If over-etching, under-etching, over-
the etched mineral of the intertubular (between tubules) drying or under-drying of the dentin occurs, then the
and peritubular (surrounds a tubule) dentin and around bond strength can be diminished. Examples of two-
the collagen fibrils. Most systems use light-cured resins. bottle total-etch systems include Scotchbond Multi-
Purpose Plus (3M ESPE), OptiBond FL (Kerr Corpo-
Two-Bottle Adhesive Systems (Fourth Generation) ration) seen in Fig. 5.12, ALL-BOND 2 (BISCO), and
The two-bottle systems have three basic steps in their ProBOND (Dentsply Caulk/Dentsply International).
procedure: (1) acid etch (and rinse), (2) application
of primer, and (3) application of bonding resin. After One-Bottle Adhesive Systems (Fifth Generation)
the etch procedure, the primer is applied, dried, and With one-bottle systems, after etching the primer and
light-cured. Then, the bonding resin is applied over the bonding resin are already mixed together and applied

Composite
resin
Hybrid
layer

Resin tag

Dentin
and tubules

FIG. 5.11 When a bonding resin is applied to etched dentin, it penetrates the exposed collagen matrix and dentinal
tubules. An intermingling of resin with etched dentin forms a hybrid layer. This layer provides a resin-rich layer for bond-
ing with other resins such as composite resin. (Courtesy of Jorge Perdigão, University of Minnesota School of Dentistry
[Twin Cities, MN].)
66 CHAPTER 5 Principles of Bonding

in one step, dried, and light-cured. Examples of one- systems use acidic primers to demineralize dentin
bottle etch-and-rinse bonding systems include Bond-1 and there is no rinsing, it is easier for the primer and
(Pentron), ExciTE F (Ivoclar Vivadent) seen in Fig. 5.13, adhesive resin to penetrate the full depth of demin-
IntegraBond (Premier Dental Products), PQ1 (Ultra- eralization. With etch-and-rinse systems, the phos-
dent Products), and ONE-STEP (BISCO). phoric acid may be left on too long and the primer
Many bonding systems have a chemical activator cannot penetrate the more deeply etched surface, or
that can be mixed with the bonding resin to allow it if the etched surface is dried too much, the collagen
to chemically cure as well as light-cure. When both will collapse and prevent primer and adhesive pen-
modes of cure are available at the same time, the mate- etration. The unsealed dentin can contribute to post-
rial is called dual-cure. operative sensitivity.
Self-etching bonding systems by not need-
SELF-ETCH BONDING SYSTEMS (GENERATIONS ing rinsing and drying steps eliminate the risk of
6 AND 7) over- or under- rinsing or drying, factors that can
Bonding systems have been developed that do not re- adversely affect the bond and cause post-treatment
quire the use of phosphoric acid etching and rinsing sensitivity.
and partial drying steps. One- and two-bottle bonding The acidic primers are categorized as mild (pH
systems incorporate acidic groups (typically carboxylic 2 or above), moderate (pH 1 to 2), and strong (pH
acid) in a resin primer that will etch enamel and dentin 1 or less). Systems with primers that are mildly
and at the same time, prime them with resin without acidic have weak bonds to enamel, especially uncut
the need for rinsing and drying. These are called self- enamel, but strong bonds to dentin. Studies using
etching bonding systems. the scanning electron microscope have shown that
The primers use water as a solvent to ionize the the etching pattern on enamel is shallow, resulting
acidic monomer. Etching of the dentin with acidic in poor micromechanical retention of the resin. Sys-
primers dissolves the smear layer without deeply tems with primers that are strongly acidic demon-
demineralizing the dentin and opening the tubules. strate bond strengths similar to those with etch-and-
Etching is not as deep as with etch-and-rinse systems. rinse bonding systems.
The acid component gradually shifts in pH to neutral To ensure a good bond to uncut enamel, many man-
and is i­ncorporated into the polymerized resin, as ufacturers recommend “selective etching,” meaning
are the dissolved tooth mineral and the smear layer. that enamel only should be etched with phosphoric
When the solvent has evaporated, the adhesive layer acid before the application of the self-etching bonding
is thin and not very strong. Applying two coats of ad- materials (Fig. 5.14). If dentin is also etched with phos-
hesive resin can increase the bond strength. Self-etch- phoric acid, and then a self-etching bonding system is
ing adhesives need a longer drying time of at least 10 used, a good seal with the dentin may not occur. The
seconds a­ fter application in order to evaporate all of phosphoric acid will etch the dentin deeper than the
the water solvent. Water left behind will degrade the primer and bonding resin from the self-etch system
bond over time. can penetrate.
While etch-and-rinse systems have the highest
bond strengths, self-etch systems have less postoper-
ative sensitivity because they directly seal the dentin
without rinsing and drying steps. Because self-etch

C
FIG. 5.14 Methods of etching (top to bottom): self-etch with acidic
FIG. 5.13 One-bottle etch-and-rinse bonding system available in unit primers; selective etch of enamel and etch-and-rinse (total etch) with
dose, bottle or pen dispenser (ExciTE F, Courtesy Ivoclar Vivadent). phosphoric acid (seen as blue gel). (Courtesy VOCO.)
 Principles of Bonding CHAPTER 5 67

Two-Bottle Self-Etch Bonding Systems require that two or more coats should be applied to
The two-bottle self-etching adhesive systems may the preparation, because they may not adequately
be applied by two different methods depending on cover the etched dentin with one coat. Many manu-
how they were manufactured. With type I self-etch facturers also recommend scrubbing the primer into
adhesives, an acidic water-soluble primer is applied the dentin for 20 seconds. Follow the manufacturer’s
first, and then covered with a light-cured adhesive recommendations as to how many coats to apply and
resin that contains nanosized filler particles (Fig. whether scrubbing into dentin is needed. Many one-
5.15). Examples of type I self-etch adhesives in- bottle self-etching bonding systems require refrigera-
clude Clearfil Liner Bond (Kuraray America), Adper tion to prevent the bonding agent from degrading. The
Scotchbond SE Self-Etch Adhesive (3M ESPE), and bottle should be removed about 30 minutes before use
AdheSE (Ivoclar Vivadent). With type II self-etch to allow it to return to room temperature. Cooling of
adhesives, a drop of acidic primer from one bottle the material will affect the dynamics of polymerization
is mixed with one drop of adhesive resin from the and also make the material so viscous that it will not
other bottle and applied to the prepared tooth. Ex- flow readily. Most of these systems are available in a
amples of type II self-etch adhesives include ALL- bottle or unit-dose container. Examples of one-bottle
BOND SE (BISCO), and Xeno III (Dentsply Caulk/ bonding systems include Xeno V+ (Dentsply), Opti-
Dentsply International). Bond All-In-One (Kerr Corporation), iBond Self Etch
(Heraeus Kulzer), All-Bond SE (BISCO), Adper Easy
One-Bottle Self-Etch Bonding Systems Bond Self-Etch Adhesive (3M ESPE), and AdheSE One
With one-bottle self-etch adhesive systems (“all-in- (Ivoclar Vivadent). Fig. 5.17 illustrates self-etch adhe-
one” seventh generation), the adhesive resin is already sive systems.
combined with the acidic primer and does not require Etch-and-rinse systems are preferred for indirect
mixing (Fig. 5.16). Many of the self-etching primers restorations (such as porcelain veneers) when mostly
enamel is available for bonding, because phosphoric
acid provides the most retentive etch in enamel. Self-
etch systems are preferred for direct composites when
mostly dentin is available, because they produce great-
er bond strength to dentin and reduce post-operative
sensitivity.

Clinical Tip
One-bottle systems (that combine primer and adhesive
resin) whether they are etch-and-rinse or self-etch tend
to produce a resin adhesive layer overlying the hybrid
layer that is too thin. Applying at least two coats is
recommended.

Universal Bonding Systems

FIG. 5.15 Type 1 self-etching two-bottle adhesive system—bottle 1 is Manufacturers continue to simplify and improve their
acidic primer and bottle 2 is bonding resin. Also available in unit-dose
packaging. (OptiBond eXTRa, Courtesy Kerr Corporation.)
bonding systems. In the past few years, they have de-
veloped bonding materials that are called universal
bonding systems. While there is currently no consen-
sus as to what constitutes a universal bonding system,
in general, universal adhesives bond not only to tooth
structure but also to a variety of restorative materials
such as ceramics, noble and base metals and compos-
ites. While the universal adhesives can bond to these
restorative materials, not all products develop a strong,
lasting bond.
Universal adhesives are very versatile and most
can be used with etch-and-rinse, self-etch and selec-
tive-enamel etch techniques. The key ingredient in all
universal bonding systems is a phosphate ester that
allows them to bond to tooth structure, ceramics and
metals. Phosphate esters are also acidic and capable
FIG. 5.16 All-in-one self-etching primer/adhesive seen in one bottle or of etching tooth structure. Universal adhesives have
unit-dose dispensing. (OptiBond All-In-One, Courtesy Kerr Corporation.) a pH that ranges from 2.2 to 3.2 depending on the
68 CHAPTER 5 Principles of Bonding

Etch and rinse adhesives Self-etch adhesives

4th-generation 6th-generation
Three-step Two-step
(2 bottles)
Conditioner Primer Adhesive resin Self-etching primer Adhesive resin

5th-generation 7th-generation
Two-step One-step
(One bottles
or Self-etching primer/
Conditioner Combined primer- blister pack) adhesive Self-etching adhesive
adhesive resin 2 components 1 component
to be mixed
FIG. 5.17 Summary of self-etch adhesive systems. (Adapted from Cardoso MV,de Almeida Neves A, Mine A, et al: Cur-
rent aspects on bonding effectiveness and stability in adhesive dentistry. Aust Dent J, 2011;56(Suppl 1):31–44.)

product. Products with a pH in this range are capable

of etching and bonding to dentin. The ability to etch
enamel adequately for bonding varies from product
to product. To be safe, selective enamel etching may
be used.
Some universal bonding systems require that an ac-
tivator be added to the adhesive in order for it to be
compatible with other manufactures’ self- and dual-
cured resin restorative materials and resin cements.
The acidity of the adhesive can deactivate the chemi-
cals needed for self-curing and will not permit the res-
ins in the self-cure/dual-cure restorative materials or
cements to cure properly without adding an activator.
Small quantities of microscopic filler particles com- FIG. 5.18 Universal adhesive system. Unit dose package. (Futurabond
posed of colloidal silica are added to increase the U, Courtesy VOCO.)
strength of the adhesive resin. The filler size ranges
from 0.8 to 0.0007 μm. The smallest fillers are referred
Clinical Tip
to as nanofillers. To put the size of these nanofillers
into perspective, the following comparisons are made: Some clinicians use phosphoric acid gel to clean the interior
the diameter of a human hair is approximately 40 of ceramic restoration after try-in in the mouth. However, the
etchant needed to create a surface roughness for bonding
μm, a bacterium is about 2 μm, and a virus is about
is 8% to 10% hydrofluoric acid.
0.1 μm. See Chapter 6 for an in-depth discussion of
fillers. Some universal adhesives also have fluoride
Universal adhesives are manufactured as one-
compounds that are claimed by manufacturers to be
bottle or two-bottle systems or may be packaged in
released over time to aid in the prevention of recur-
unit-dose blister packs. Examples of one-bottle sys-
rent caries at the margins of restorations. However, the
tems are Scotchbond Universal Adhesive (3M ESPE),
quantities of fluoride released are generally too small
All Bond Universal (BISCO), and Prime&Bond Elect
to have a therapeutic effect.
(Dentsply Sirona) Two-bottle systems include Futur-
Bonding to zirconia (a non-glass ceramic, see
abond DC (VOCO) and OptiBond XTR (Kerr Corp).
Chapter 9 Dental Ceramics) is challenging. Etching
Futurabond Universal Bond (VOCO) is a two com-
with hydrofluoric acid (8% to 10%) may create a pow-
ponent system packaged in a unit-dose blister pack
dery residue that is difficult to remove and may in-
(Fig. 5.18).
terfere with bonding. To aid bonding, some clinicians
sandblast the internal surface (intaglio) of the ceramic
Clinical Tip
restoration. The bond from some universal adhesive
alone may prove to be less than desirable. Many clini- Many self-etching and universal adhesive products recommend
cians and researchers think that a separate primer de- scrubbing the primer into the dentin for 20 seconds. Be sure to
review the manufacturer’s recommendations in order to obtain
veloped specifically for zirconia should be used, such
the best results with each product you use.
as Z-Prime Plus (BISCO).
 Principles of Bonding CHAPTER 5 69

Clinical Application of Universal Bonding Adhesive Sirona)(CAD/CAM is discussed in Chapter 9, Den-

A universal bonding adhesive, when applied to a tal Ceramics) and a resin-base ceramic material (Lava
cavity preparation and to the interior (intaglio) of an Ultimate Restorative, 3M ESPE) . The restoration was
indirect restoration, can provide resin-coated surfaces tried in to check margins, contours and proximal con-
for cementation of the restoration with resin cement. tacts. Next, the restoration was polished and inter-
The resin bonding adhesive on the tooth and restora- nal surfaces were sandblasted for micromechanical
tion will bond chemically with the resin cement form- retention. Selective etching of the enamel margins of
ing a durable bond. the cavity preparation was done for 15 seconds with
The following sequence of clinical images (pro- 37% phosphoric acid, then rinsed and dried, but leav-
duced by Dr. Daniel Poticny, Grand Pairie, TX) in Fig. ing the dentin moist. Next, a universal adhesive was
5.19 depicts how the above scenario works. The maxil- applied to the entire cavity preparation and scrubbed
lary first molar was treated for a fractured d
­ istolingual into the dentin surface for 20 seconds using a micro-
cusp. After the tooth was prepared a digital image was tip brush. The same treatment was applied to the in-
made and the restoration was designed and milled ternal surface of the restoration. Silane treatment of
using CAD/CAM equipment (CEREC AC, Dentsply the restoration was not needed because the universal

A B C

D E F

G H I

AFTER

J K
FIG. 5.19 A, The tooth was prepared and a digital impression was made with the CEREC AC (Sirona Dental Systems) CAD/
CAM system. B, The CAD/CAM restoration was milled in-office using a Lava Ultimate Restorative block (3M ESPE) (shade A3
HT), and then tried-in for fit. C, The universal bonding adhesive, adhesive resin cement (RelyX Ultimate), etchant, dispensing
well and microbrush applicators as set-up prior to the procedure. D, Selective enamel etching with phosphoric acid was done
for 15 seconds. Bonding adhesive (Scotchbond Universal Adhesive [3M ESPE]) was dispensed into the well. F, Universal
adhesive was scrubbed into the cavity preparation with a microtip applicator. G, Universal adhesive was scrubbed into the
intaglio surface of the restoration. H, Adhesive resin cement [RelyX Ultimate, 3M ESPE]) was injected into the preparation. I,
Cement flowed evenly from the margins upon seating. J, Excess cement was cleaned with a mini-sponge and removed from
the interproximal with knotted floss. K,The final restoration after polishing. (Courtesy of Dentistry Today and Dr. Daniel Poticny.)
70 CHAPTER 5 Principles of Bonding

adhesive contains silane.(Silane is a coupling agent when the composite is cured. The uncured layer will
that helps to bind the ceramic to resin.) Adhesive resin actually help facilitate a chemical bond between the
cement (Rely X Ultimate Adhesive Resin Cement, 3M bonding resin and the composite resin. When the ox-
ESPE) was used to cover all surfaces of the prepara- ygen-inhibited layer is exposed to the mouth as with
tion and the restoration was seated under pressure to sealants, many clinicians prefer to wipe it off because
force out excess cement and assure complete seating. it can impart an unpleasant taste.
Excess cement was removed with a mini-sponge and
the proximal contact area was cleared with floss. Oc- BIOCOMPATIBILITY
clusal high spots were adjusted and final polish was Acid etching dentin is unlikely to cause pulpal irrita-
accomplished with diamond polishing paste. tion because it is limited in its depth of penetration.
The hydroxyapatite is etched less than 7 μm in depth
Clinical Tip and acid entering the dentinal tubules is buffered to
Many of the self-etch systems recommend “selective neutral by components of dentinal fluids and hydroxy-
etching” of the enamel with phosphoric acid in order to apatite. However, acid and acidic primers should not
ensure a good etch and bond to enamel. be placed directly on a pulpal exposure.
Bonding and restorative materials are well tolerated
To get the best results from the bonding system you by the teeth. However, components of the bonding
are using: systems can irritate the skin, mucosa, and eyes. Acidic
• Review the manufacturer’s instructions components can cause burns. Some dental personnel
• Be meticulous in your technique develop allergies to the materials, especially HEMA.
• Maintain good isolation Personal protective equipment should be used when
• Use enough drying time with an air stream to evap- handling these materials. Use of the rubber dam will
orate the solvent and remove water from “wet” minimize contact with the patient’s oral mucosa. Any
dentin—at least 10 seconds area of contact with the skin should be washed with
• Use fresh material. Refrigeration may extend the soap and water. An eyewash station should be avail-
shelf-life. Remove from the refrigerator half an hour able to treat accidental exposure to the eyes. Most of
before use. the undesirable effects are the result of contact with
• Use unit-dose packaging when possible. If using bot- the unpolymerized components. Once the materials
tles, recap immediately after dispensing materials. are polymerized the risks of untoward reactions are
much less.
MODES OF CURE OF ADHESIVES
Adhesive systems are cured (polymerized) by meth- Caution
ods similar to those used for composite resins. There Resins, solvents, and acids in the bonding systems can
are three modes of curing for the resin bonding agents. irritate the skin, mucosa, or eyes, and therefore caution
The most commonly used mode is a light-cure process should be taken when these materials are applied. Materials
that uses a light in the blue wave range to activate a on skin or mucosa should be washed thoroughly. Eye
chemical (a photosensitizer, camphorquinone) that re- protection should be worn by the patient and PPE worn by
acts with an initiator (a tertiary amine) to set off the the operator and assistant.
polymerization reaction (see Chapter 6 for an in-depth
discussion of resin polymerization). The second mode
is a self-cure process in which a chemical reaction oc-
Caution
curs when two resins are mixed together, one of which A small portion of the population may have an allergic
contains benzoyl peroxide as an initiator. The third response to acrylate resins. Precautions are to be followed
mode is a dual-cure process that uses a combination of because these resins may penetrate commonly used gloves.
self-cure and light-cure ingredients. Dual-cured resins
can be activated by light or can cure chemically with-
out application of the curing light. COMPATIBILITY WITH OTHER RESINS
Etch-and-Rinse Systems
OXYGEN-INHIBITED LAYER Two-bottle bonding systems are compatible with light-
On the surface of the polymerized bonding resin is cure, self-cure, and dual-cure composites. One-bottle
a very thin coating of uncured resin. The resins used bonding systems are compatible with light-cure com-
for composites and sealants will also form this layer posites. They are not compatible with self-cure com-
of uncured resin on their surfaces. Polymerization is posite core materials or resin cements, because the
inhibited where the surface is exposed to oxygen in the bonding agents are acidic and that interferes with the
air (this layer is called the oxygen-inhibited layer, or set of the composite or resin cement. One-bottle bond-
air-inhibited layer). Once the composite resin is placed ing systems require that an activator be mixed with the
over the bonding resin, its presence will exclude air, bonding resin in order for it to be compatible with self-
and that uncured layer on the bonding resin will cure cure and dual-cure composites and resin cements.
 Principles of Bonding CHAPTER 5 71

Self-Etch Systems to decay under the restoration and increase sen-

Type I self-etching bonding systems (primer ap- sitivity of the tooth. Pulpal irritation comes more
plied first followed by bonding resin) are generally from bacteria entering from microleakage than from
compatible with light-cure, self-cure, or dual-cure chemical components of the bonding or restorative
composites, but the type II bonding systems (prim- materials.
er and bonding resin mixed together, then applied) Contaminants are substances that interfere with
are not. Light-cured all-in-one bonding systems the enamel or dentin bonding, such as saliva, blood,
are also not compatible with self- and dual-cured the smear layer, or oils from the dental handpiece or
composites, but dual-cured all-in-one systems are from prophy pastes. Contaminants can contribute to
compatible. microleakage when they are not properly removed
before and during the bonding process. Microleakage
Clinical Tip can have other causes, such as shrinkage of compos-
ite resins when they cure (see Chapter 6) or restora-
Before placing a composite core for a crown preparation,
tions placed without bonding, such as conventional
check the manufacturer’s fact sheet for compatibility of the
bonding system with self-cured and dual-cured composite amalgam restorations (see Chapter 10). When restor-
core materials. ative materials expand and contract with temperature
variations (the change in volume of the restoration is
called the coefficient of thermal expansion) at a different
rate from the tooth structure, percolation can occur, in
Three Main Steps of Bonding Systems
which fluids and bacteria percolate or flow into and
All bonding systems have three main steps in common: out of the gap at the interface of the restoration and
• Etching with either phosphoric acid or an acidic primer the tooth. Cold foods such as ice cream or beverages
• Priming with hydrophilic monomers in a solvent that cause contraction of the restoration and widening of
penetrates etched surfaces the gap, and hot foods or beverages cause expansion
• Bonding with hydrophobic bonding resins to seal of the restoration and reduction of the gap. Percola-
etched surfaces and to chemically bond to composite
tion can lead to (1) pulpal irritation with tooth sen-
resin or resin luting cements
sitivity, (2) staining at the margins, and (3) recurrent
caries.
MICROLEAKAGE
CONTAMINATION OF BONDING SITE
Restorations can leak when they are not completely
For successful bonding, good isolation and soft tis-
sealed at their margins (junction of the restoration
sue management are essential. Saliva and blood are
with the tooth surface). Leakage usually occurs at
the most common sources of contamination in the
the microscopic level (called microleakage) and per-
oral cavity. If the newly etched surface becomes con-
mits fluids, bacteria, and debris to enter the cavity
taminated, rinse it thoroughly and re-etch for 10 to 15
preparation (Fig. 5.20). Microleakage can contribute
seconds.
Astringents and hemostatic agents (e.g., alumi-
num chloride and ferric sulfate; see Chapter 15 [Im-
pression Materials] for more detailed information)
used to control bleeding from the gingiva can inter-
fere with bonding, lower bond strengths and lead to
microleakage. Instead, the soft tissues can be infil-
trated with a local anesthetic containing epineph-
rine (in patients who can tolerate epinephrine) to
constrict the local blood vessels and capillaries and
stop the bleeding.
Avoid using a temporary cement containing eu-
genol for provisional restorations. Eugenol interferes
with the set of resins and will cause a drop in bond
strength. Clean the teeth with a slurry of pumice to
remove residual eugenol before bonding. Do not use
FIG. 5.20 Seen is a longitudinal section through a molar that has cervi- prophy paste because it may contain flavoring oils that
cal composite restorations on the right- and left-hand sides. When a can interfere with bonding.
good bond is not formed between the tooth and the composite, fluids Carbamide peroxide and hydrogen peroxide whit-
and bacteria can seep between them, a process called microleakage.
ening agents can leave residual oxygen in the tooth
The tooth was soaked in a dark dye to show areas of microleakage.
The restoration on the right shows leakage, as indicated by dye pen- structure that interferes with the bond. Wait 1 to 2
etration; the one on the left does not. (Courtesy of Larry Watanabe, weeks after whitening before performing bonding
University of California School of Dentistry [San Francisco, CA].) procedures.
72 CHAPTER 5 Principles of Bonding

the tubules and elicit a pain response. This dentinal

Factors That Prevent Good Bonding
fluid movement caused by pressure changes is called
• A surface that is overly wet does not allow good pen- the hydrodynamic theory of tooth sensitivity and was
etration of the bonding resins into the etched enamel described by M. Brännström.
and dentin. The following conditions can contribute to this
• An overly dry etched dentin surface causes the col- sensitivity:
lagen fibrils to collapse and cover the dentin surface so • The tooth has been over-dried (desiccated) during
that the bonding resins cannot penetrate to reach the
the bonding process, trapping air in the dentinal tu-
etched dentin and the tubules.
• Blood or saliva on the etched enamel or dentin will in-
bules; when the patient bites down, the restoration
terfere with the ability of the bonding resin to penetrate compresses the dentin, putting pressure on the air
the surface. in the tubules.
• Failure to saturate dentin with a bonding resin will • The dentin has been over-etched and is not ad-
result in voids and incompletely sealed dentin. This can equately sealed with priming and bonding resins.
result in reduced bond strength and sensitivity because Open tubules allow pressure on the column of fluid
tubules are open. within the tubules.
• Failure to adequately cure the bonding resin will cause • The composite resin restoration is cured in incre-
the resin to separate from the enamel or dentin. ments that are too large, causing contraction stress
• Moisture from the air-water lines can wet the enamel on the tooth cusps or causing the composite resin to
and dentin at the wrong step in the bonding process,
leak as it pulls away from the walls and floor of the
resulting in loss of a proper bond and seal.
• Oil lubricants expelled from the handpiece onto
cavity preparation as it shrinks (see Chapter 6).
the tooth during preparation will prevent the bond- Less postoperative sensitivity is found with
ing ­resins from adhering to the etched enamel and self-etching bonding systems compared with etch-
dentin. and-rinse bonding systems. Self-etching bonding
• Recently applied whitening or topical fluoride agents systems have the advantage of eliminating sepa-
can affect the enamel so that it is more difficult to etch rate etching, rinsing, and drying steps that might
or to bond to. Studies have shown that the bond to introduce errors of over-etching or under-etching
recently whitened enamel is not as strong. Fluoride and over-drying or under-drying that contribute to
makes the surface of the enamel more resistant to be- postoperative sensitivity. The acidic primer in the
ing etched by acid. self-etch systems etches and primes the dentin with
• Eugenol in cements for provisional restorations will
a hydrophilic resin in the same step. The depth of
interfere with the set of resin bonding agents and com-
posite resins.
etching with acidic primer is shallower than with
• Aluminum chloride– and ferric sulfate–containing phosphoric acid and the primer penetrates to the
astringents (e.g., Gingi-Aid [Belport] and Astringe- depth of its etch, achieving a good seal of the den-
dent or ViscoStat [Ultradent]) used to control gingival tin and its tubules.
bleeding will interfere with the set of the bonding For both etch-and-rinse and self-etch materials, it is
agents. important to carefully follow each manufacturer’s in-
structions for use to ensure that the dentinal tubules
are sealed and post-treatment sensitivity is avoided.
POSTOPERATIVE SENSITIVITY These are technique-sensitive materials, and poor at-
Some patients may experience transient tooth sen- tention to detail can create a weak or inadequate bond
sitivity after a bonded restoration is placed (also that may lead to failure of the restoration and pain for
see Chapter 6). This usually occurs for only a short the patient.
time—a few hours to a few days. The pain response
comes from odontoblasts that lie in the pulp at its Clinical Tip
junction with the dentin. The odontoblasts have pro- When bonding to preparations with large areas of enamel
cesses that extend about one third of the way up the remaining, etch-and-rinse systems are preferred. When
dentinal tubules, and the tubules contain a column bonding mostly to dentin, self-etch systems are preferred.
of pulpal fluid. The odontoblastic processes have Selective etching (with phosphoric acid) of enamel when
pressure receptors that can only interpret in a pain- using self-etching systems is recommended to ensure
ful response any change in pressure in this column of satisfactory enamel etch pattern for bonding.
pulpal fluid. One primary reason for the sensitivity
is unsealed dentinal tubules. Phosphoric acid etching CLINICAL APPLICATIONS FOR BONDING
removes the smear layer and smear plugs in the tu-
bules leaving open tubules. If they are not properly BONDING OF RESTORATION
sealed during the dentin bonding process, a number After the initial bonding resin is cured on the tooth,
of things can influence the pressure on the fluid in other adhesive bonding resins or resin cements can
 Principles of Bonding CHAPTER 5 73

be used to attach restorations to the tooth by way of METAL BONDING

resin-to-resin chemical bonds (see Procedure 5.1). Res-
torations that are not made of resin, such as metal or Metal bonding is used to create better retention of met-
ceramic products, require treatment of their surfaces al to a tooth during the cementation (luting) of a resto-
to allow them to bond to the resin on the tooth (see ration such as a crown. (See Chapter 11 Casting Metals,
Procedure 5.2). A description of bonding with com- Solders, and Wrought Metal Alloys for a description
posite restorations and glass ionomers can be found of metals and Chapter 9 for porcelain-bonded-to-metal
in Chapter 6. Glass ionomers do not require a separate restorations.) Metal bonding is also used for placement
bonding agent. After the smear layer is removed with of a composite veneer over metal for cosmetic reasons,
a mild acid (typically 10% polyacrylic acid), the glass or for covering metal exposed when porcelain frac-
ionomer chemically bonds directly to the mineral com- tures from a porcelain-bonded-to-metal crown.
ponent of enamel and dentin.
Laboratory and clinical techniques. To bond to the met-
CERAMIC BONDING AND REPAIR al of a crown or resin-bonded (Maryland) bridge, the
Ceramic restorations are retained much better if they metal surface is roughened by sandblasting or with a
are bonded to the tooth rather than if they are merely coarse diamond bur to create micromechanical reten-
cemented (Procedure 5.2). Bonding also helps mini- tion. The surface of the metal can also be treated by elec-
mize microleakage that can contribute to sensitivity trochemical etching in the laboratory or by depositing a
or recurrent caries. On occasion, ceramic restorations thin layer of tin through an electroplater. The latter two
will chip and need repair instead of replacement. Tech- methods are often used for metal preparation before
niques have been developed to permit repair of por- cementation of a resin-bonded bridge. Noble metals in
celain and other glass-based ceramics (see Chapter 9) particular, such as gold, need to be tin-plated for an ef-
in the mouth, usually when the repair will not be sub- fective bond to the resin. Although, in practice many
jected to heavy chewing forces. clinicians simply sandblast the interior to provide mi-
cromechanical retention. Once the metal surface is pre-
Clinical Technique. The process of bonding compos- pared, it is cleaned and dried before it is coated with
ite to glass-based ceramics is similar to bonding to the bonding resin for cementation. These cements are
enamel or dentin. The difference lies in the etchant usually self-cured or dual-cured (see Chapter 14 Dental
used and the surface preparation completed on the Cement) because the metal blocks the curing light.
ceramic restoration before application of the bonding For repair of a porcelain-bonded-to-metal crown or
resin. Some operators prefer to roughen the surface bridge with fractured porcelain and exposed metal (see
of the ceramic with a diamond bur or by sandblast- Figure 9-10 in Chapter 9 for an example), the porcelain
ing before applying the acid. To bond to ceramics, and metal are prepared as described previously in the
the acid most commonly used is hydrofluoric acid in section Ceramic Bonding and Repair. Next, a one-step
a syringe designed for intraoral or extraoral use. Af- bonding resin is applied, thinned with air, and light-
ter the surface of the ceramic is etched and rinsed, a cured for 20 seconds. An opaque masking resin is then
solution of silane is applied for 60 seconds, and then applied to the metal to keep it from showing through
the surface is dried to evaporate the solvent. Silanes and causing a gray appearance of the overlying com-
are coupling agents that react with the glass in the posite. It is light-cured for 20 seconds. Finally, a com-
ceramic and leave a coating of vinyl that will bond posite resin that matches the color of the porcelain is
to the resin in the bonding agent. Next, the bonding selected, applied, light-cured, finished, and polished.
resin is placed and light-cured, and the final com-
AMALGAM BONDING
posite restorative material is placed and finished
(see Chapter 9). Traditionally, amalgam is retained in the cavity prepa-
This repair technique will not work with non-glass ration by mechanical retention with undercuts and
ceramics such as zirconia or alumina. They need spe- grooves placed in sound tooth structure. In the 1990s
cial treatment. bonding of amalgam to the cavity preparation became
popular because laboratory studies showed that mi-
Caution croleakage could be reduced and the strength of the
prepared tooth and retention of the restoration could
Hydrofluoric acid is used to etch porcelain and other glass-
be increased. With increased retention, cavity prepara-
based ceramics for cementation or repair, and it is a highly
caustic solution. Hydrofluoric acid also can etch adjacent
tions could be more conservative because sound tooth
ceramic, composite, and glass ionomer restorations, as well structure did not need to be removed to create under-
as tooth structure, and can burn soft tissues. Take precautions cuts. However, clinical studies monitoring the bonded
to properly isolate the area to be bonded. Protect the tissues amalgams for as long as 6 years found no difference be-
and restorations adjacent to the area being etched. tween bonded and non-bonded amalgams in terms of
74 CHAPTER 5 Principles of Bonding

marginal integrity, recurrent caries and fracture of the phosphoric acid develops a better etch pattern for a
tooth, or restoration. Few clinicians presently bond their strong bond.
amalgams.
Clinical technique. Confirm that the bonding system is
COMPOSITE RESIN REPAIR compatible with the resin cement that will be used. Af-
A large multi-surface composite restoration, a com- ter the veneers have been tried in and any adjustments
posite veneer, or a large incisal angle composite may made, rinse off the try-in paste from the veneers and
have a minor defect of the margin, a small chip, or tooth surfaces and dry the surfaces.
a small amount of recurrent caries. It may be more
conservative and cost-effective to repair the existing Tooth preparation. Etch the prepared enamel for 30 sec-
composite rather than replace it. However, the older onds with 37% phosphoric acid. If dentin is exposed,
the composite is, the weaker will be its bond to new etch it for 10 seconds only. Apply a bonding resin to the
composite. In order to achieve a clinically acceptable tooth and thin with the air syringe. Too thick a coat will
union, the old composite surface to be repaired is not allow the veneers to seat fully.
roughened with a diamond bur or by sandblasting.
Next, the composite surface and tooth structure in- Veneer preparation. Ceramic (glass-based) surfaces to
volved in the preparation are etched with phosphoric be bonded are prepared by etching with hydrofluoric
acid before application of the bonding system. After acid (5% to 10% concentrations are preferred) for 60
the bonding resin has been applied and cured, new seconds, rinsing it off, and drying. The acid creates
composite can be placed. micromechanical retention in the surface of the ce-
ramic. Silane is applied for 60 seconds and then dried.
ORTHODONTIC BRACKET BONDING The bonding resin is applied in a thin coat and further
Orthodontic brackets have replaced bands for many thinned with the air syringe. Do not cure it. Apply
uses, especially in the anterior part of the mouth. Be- the resin cement evenly to the veneers. If the veneers
cause brackets cannot be used with conventional ce- are thin, use the resin cement in the light-cure mode.
ments, they must be bonded to the enamel using ad- If the veneers are thick or opaque, then use the ce-
hesive materials. Bonding of orthodontic brackets is ment in the dual-cure mode (mix base and catalyst).
done with plastic or metal brackets, which have a re- Some clinicians like to use flowable composite as the
tentive mesh (see Fig. 5.32 in Procedure 5.3) or a series cement.
of knobs to lock in the resin adhesive, or with ceramic
brackets that have a pre-etched bonding surface. The Seating the veneers. Seat the veneers starting with the
adhesive bonding resins are self-cured, light-cured, or two central incisors, next the laterals incisors, and fi-
dual-cured. Because the metal or ceramic material will nally the canines. Use a small brush to wipe away the
not allow light to reach and cure the resin cement un- gross excess cement but stay short of the margins to
der the bracket directly, the light is cast from mesial, prevent removing cement from under the edge of the
distal, and lingual, as well as facial, directions to cure margin. Use a spot cure or wave cure (curing light is
the resin by light that has passed through the enamel. waved over the veneer surfaces) for 3 seconds to gel
the resin cement without fully curing it to allow easy
Clinical Technique. Direct bonding of orthodontic cleanup. Clear the cement from the interproximal areas
brackets is explained and illustrated in Procedure 5.3. with floss. Use a #12 scalpel blade or a narrow, sharp
Some clinicians use an indirect method of application sickle scaler to remove excess cement from the mar-
of brackets. With the indirect method, brackets are gins. Complete the cure of the resin cement. Use extra
aligned on the diagnostic cast in the same position as fine finishing diamond burs to complete the finish of
they will be placed on the teeth and held with sticky the margins. (Other techniques, materials, and instru-
wax. Then a matrix, often constructed from impression ments may be used. This is presented as an example of
putty, is formed over the brackets and the teeth on the one technique.)
cast. The brackets are picked up in the matrix and, at Note: Veneers made from ceramic materials, such
the time of bonding, are oriented in the same manner as zirconia (e.g., Lava; 3M ESPE), will require special
on the teeth as they were previously on the cast. treatment and primers to prepare the veneer surface
for cementation (see Chapter 9). See Table 5.2 for a
BONDING OF CERAMIC VENEERS summary of bonding for ceramic restorations.
Ceramic veneers are a relatively conservative means
of achieving anterior esthetics. They can be used to BONDING OF ENDODONTIC POSTS
change the shape and color of the teeth, close diaste- Posts are placed within the roots of endodontically
mas, straighten the alignment of teeth, and lengthen treated teeth to retain dental materials used to build
chipped or worn teeth. Usually, the tooth substrate up the teeth (core buildup) when coronal tooth struc-
that the veneer will be bonded to is mostly enamel. The ture is inadequate for restoration with a crown. The
etch-and-rinse bonding systems are preferred because posts are made of a variety of materials and can be
 Principles of Bonding CHAPTER 5 75

TABLE 5.2    Bonding to All-Ceramic Restorations: A Summary

PROCEDURE STEPS FELDSPATHIC PORCELAIN LITHIUM DISILICATE ALUMINA ZIRCONIA
Etch ceramic Hydrofluoric acid 60 Hydrofluoric acid 60 No etch. No etch.
seconds seconds Sandblast to roughen Sandblast to roughen
Rinse Yes Yes No No

Silane Yes (unless universal ad- Yes (unless universal No, if universal adhesive No, if universal adhesive
hesive contains silane) adhesive contains contains silane contains silane
silane)
Bonding agent Apply etch-and-rinse Apply etch-and-rinse Apply special primer and Apply special primer
adhesives adhesives universal adhesive and universal adhe-
sive
Cement Light- or dual-cured resin Light- or dual-cured Self-adhesive resin ce- Self-adhesive resin ce-
cement resin or self-adhesive ment; resin-modified ment; resin-modified
resin cement glass ionomer; or glass ionomer; or
special primer, universal special primer, uni-
bonding agent, and versal bonding agent,
resin cement; and resin cement
Adapted from Farah JW, Power JM: Bonding Agents—2008. The Dental Advisor, 2008;25:1–9.

categorized into two general types: metal and non- done using amalgam or one of the bonded composite
metal. Metal posts are made of cast gold, stainless core materials (see Chapter 6). The operator will place
steel, titanium alloy, or pure titanium (see Chapter 11 the core buildup and then the tooth can be prepared
Casting Metals, Solders and Wrought Metal Alloys). for a crown once the buildup has set.
Nonmetal posts are made of fibers of carbon or glass Metal and ceramic posts may be sandblasted to en-
encased in resin or zirconium-based ceramic. The hance the bond of the cement to the roughened surface
posts are bonded to the root with dentin bonding res- of the post. Posts made of zirconia require a special
ins and resin cements following the manufacturer’s primer to allow them to be bonded with resin cement.
recommendations. Fiber-reinforced resin posts chemically bond to the res-
in cement. Some clinicians suggest treating the resin
Clinical technique. When it is determined that an end- post surface with silane to improve the bond with the
odontically treated tooth needs a post, the dentist pre- resin cement.
pares one or more roots with specially shaped drills
that shape the root canal to the shape of the post. The Clinical Tip
prepared canal is etched with phosphoric acid for 10 Resin cement remaining on the mixing pad cannot be
to 15 seconds. The acid is thoroughly rinsed off and reliably used as a guide for final set of the cement within
excess water is removed with paper points. The dentin the canal. Many of the resin cements will not set when they
is left slightly moist (glistening but without puddles). are in thin layers exposed to oxygen in the air. The cement
in the canal is not exposed to air and will set readily, but the
A dentin primer is placed in the canal and air-dried
cement on the mixing pad may not.
to drive off any remaining water and the volatile
solvents in the primer. (A universal system could be
used on the tooth and post.) Next, self-curing or dual-
SUMMARY
curing composite resin cement is applied to both the
canal and the post. (Make sure the bonding system Bonding has a wide variety of uses in the modern den-
and resin cement are compatible.) The post is inserted tal practice. Present day bonding systems are similar
into the prepared canal and is held under hand pres- in their basic bond to the tooth. They bond to enamel
sure until the cement has cured. Self-etching bonding by micromechanical retention into the etched enamel
systems should not be used, because the acidity of the surface, and they bond to etched dentin by formation
primers will prevent the resin cement from setting. of a resin-rich hybrid layer. This resin-rich layer allows
However, self-adhesive resin cements (have a bond- other resins to bond to it by chemical resin-to-resin
ing resin within the cement) are popular alternatives bonding. Thus composite resins can be retained by
to phosphoric acid etching and application of bond- bonding to the hybrid layer and to the etched enamel
ing resins. that has been primed with resin. Non-resin materials
If the post is manufactured (pre-formed) rather than such as ceramic and metal restorations can be bonded
a cast metal dowel with a core already attached, the to the hybrid layer and to resin-primed enamel by res-
buildup of missing coronal tooth structure may be in adhesives (cements) after their surfaces have been
76 CHAPTER 5 Principles of Bonding

appropriately prepared. The setting reactions of bond- more acidic. The acidic primers seal the dentin as they
ing resins can be self-activated by mixing components demineralize the surface and no rinsing is required.
together, light-activated by stimulating photo-initi- As a result, the self-etching systems have less postop-
ators with high-intensity blue light, or dual-cured (a erative sensitivity. Universal systems can be used with
combination of the two processes). etch-and-rinse, self-etch and selective etch techniques,
Bonding systems can be placed into three general and they can bond to most restorative materials. To get
categories: etch-and-rinse, self-etch and universal. good results with any bonding system careful attention
Etch-and-rinse systems generally provide stronger to the manufacturer’s recommendations is required.
bonds to enamel and dentin but are prone to postop-
erative sensitivity due to the technique requirements
INSTRUCTIONAL VIDEOS
of the etching, rinsing and drying process. Self-etch
systems initially had weaker bonds to uncut enamel See the Evolve Resources site for a variety of educa-
and required selective etching, but some newer sys- tional videos that reinforce the material covered in this
tems have solved that issue by using primers that are chapter.

Procedure 5.1 Enamel and Dentin Bonding Using the Etch-and Rinse Technique

See Evolve site for Competency Sheet. 2. Etch cavity preparation with phosphoric acid: 10
seconds for dentin and 20 to 30 seconds for enamel
Consider the following with this procedure: safety glasses are
(Fig. 5.22).
recommended for the patient, PPE is required for the operator,
NOTE: Start applying the etchant to the enamel
ensure appropriate safety protocols are followed, and check your
first, and then to the dentin. Overetching dentin will
local state guidelines before performing this procedure.
open the tubules too much and remove too much min-
eral (hydroxyapatite) from the dentin surface.
EQUIPMENT/SUPPLIES (FIG. 5.21) 3. Rinse with water for at least 10 seconds.
• Rubber dam setup or cotton rolls and bibulous pads 4. Blot or gently air-dry enamel and dentin for 2-3
• Dappen dishes or wells for bonding agents seconds (removing any puddles).
• Disposable brushes for applying bonding agents NOTE: Do not over-dry the dentin because the col-
and 37% phosphoric acid (if not in a dispenser) lagen matrix will collapse and prevent adequate pene-
• Bonding agent, curing light tration of the bonding resin into the tubules and etched
• Restorative material—composite dentin. Dentin should be glistening (moist) with no
puddles. If only enamel is etched, it should be dried
PROCEDURE STEPS thoroughly and should appear frosty.
1. Isolate the field. 5. Saturate the etched surface with the bonding resin
NOTE: Rubber dam is preferred because it can pro- (Fig. 5.23).
vide the best isolation for the longest time. Cotton rolls NOTE: Some bonding resins are administered as
and bibulous pads can also be used. Moisture inter- a one-bottle/one-step application and others require
feres with the formation of a good bond. two bottles/two steps—with each component applied

FIG. 5.22 (Courtesy of Alton Lacy, University of California School of

FIG. 5.21 Dentistry [San Francisco, CA].)
 Principles of Bonding CHAPTER 5 77

Procedure 5.1 Enamel and Dentin Bonding Using the Etch-and Rinse Technique—cont’d

6. Apply a gentle air stream to thin the resin and to

remove volatile solvents and water.
NOTE: The bonding resin is not as strong as the
composite, so it should not be allowed to puddle in
the preparation and cause weakness in the restora-
tion. The solvent that the bonding resin was dissolved
in must be removed by applying a stream of air, oth-
erwise the resin may not set completely. Likewise, air
is used to evaporate any remaining water from the
moist dentin.
7. Light-cure for 10 to 20 seconds. The cavity
preparation is now ready for placement of a
restoration.
FIG. 5.23 (Courtesy of Alton Lacy, University of California School of NOTE: The tip of the light wand is usually held
Dentistry [San Francisco, CA].) about 1 mm from the surface. The curing time may
vary with newer, high-intensity curing lights. If the
separately. If the bonding resin contains acetone as its light tip cannot be placed close to the restoration
solvent, it is particularly volatile. Do not dispense it surface, then a longer curing time may be needed.
until you are ready to apply it to the etched tooth or Follow the manufacturer’s recommendations. The
most of the solvent may have evaporated. Also, be sure enamel and dentin surfaces have been physically
to recap the bottle immediately to keep from changing bonded with resin bonding agent and will bond to
the consistency of the bonding resin and its ability to resin restorative materials, such as composite, placed
penetrate moist etched dentin. Use of unit-dose am- on top of them by resin-to-resin chemical bonding.
pules eliminates this problem.

Procedure 5.2 Surface Treatment for Bonding Ceramic Restorations (Glass-Based)

or for Ceramic Repair

See Evolve site for Competency Sheet.

Consider the following with this procedure: safety glasses are
recommended for the patient, PPE is required for the operator,
ensure appropriate safety protocols are followed, and check your
local state guidelines before performing this procedure.

EQUIPMENT/SUPPLIES (FIG. 5.24)

• High- and low-speed handpieces with prophy
attachment
• Dappen dish with flour of pumice and rubber
prophy cup
• Isopropyl alcohol or acetone, hydrofluoric acid,
silane, enamel and dentin bonding resin
• 37% phosphoric acid, resin luting cement, curing light FIG. 5.24

PROCEDURE STEPS
1. Isolate area to be bonded and clean tooth with slurry NOTE: For ceramic repair, roughen the surface with
of flour of pumice. Try in ceramic restoration for fit. a coarse diamond bur or sandblasting at low pressure
NOTE: Isolation is necessary to prevent moisture to enhance micromechanical retention. Follow steps 3
contamination of the surfaces during bonding. Pum- through 5.
ice removes any plaque or pellicle that might interfere 3. Apply hydrofluoric acid to the cavity side of the
with etching and bonding. ceramic for 1 minute to etch it.
2. Clean the internal surface of the ceramic 4. Rinse with water for 10 seconds and dry with air
with alcohol or acetone to remove salivary (Fig. 5.25).
Continued
contaminants from the try-in.
78 CHAPTER 5 Principles of Bonding

Procedure 5.2 Surface Treatment for Bonding Ceramic Restorations (Glass-Based)

or for Ceramic Repair—cont’d

5. Apply silane to etched ceramic for 60 seconds, can be used. For ceramic repair, apply composite resin
and then dry with air to remove alcohol solvents. and build up to full contour in increments. Light-cure
NOTE: Silane allows bonding of resins to the each increment for 40 seconds. Some high speed cur-
treated ceramic surface. Some ceramics may require ing lights with high light intensity might alter these
­special primers for bonding. Check the manufacturer’s recommended curing times. Check manufacturer’s
recommendation. recommendations.
6. Apply bonding resin to ceramic, but do not light-
cure it.
NOTE: The thickness of the bonding resin may pre-
vent proper seating of the restoration if cured at this
stage. For ceramic repair, the bonding agent should be
light-cured for 20 seconds.
7. Steps 7 to 10 are the same as in Procedure 5.1
for enamel and dentin preparation for bonding.
Etch the tooth surfaces to be bonded with 37%
phosphoric acid: 20 to 30 seconds for enamel and
10 seconds for dentin.
8. Rinse with water for 10 seconds.
NOTE: If the surface is enamel only, dry thoroughly.
If dentin is to be bonded, leave both enamel and dentin
slightly moist. Trying to dry the enamel may overdry
the dentin.
9. Apply enamel-dentin bonding resin (Fig. 5.26). FIG. 5.26 (Courtesy of Alton Lacy, University of California School of
Blow the bonding resin thin with air. Dentistry [San Francisco, CA].)
NOTE: Do not allow it to pool in the preparation or
it will interfere with seating of the restoration.
10. Light-cure for 20 seconds.
11. Apply resin cement to the restoration and seat it
(Fig. 5.27).
12. Remove gross excess cement, then light-cure for 3
seconds to cause the resin to partially set. Remove
remaining excess resin (Fig. 5.28).
13. Light-cure for 40 to 60 seconds or longer if needed
for final set.
NOTE: Self-cured or dual-cured resins are used for
cementation of inlays, onlays, or crowns because the
thickness of the restoration prevents adequate penetra-
tion of the light. With thin veneers, a light-cured resin
FIG. 5.27 (Courtesy of Alton Lacy, University of California School of
Dentistry [San Francisco, CA].)

FIG. 5.25 (Courtesy of Alton Lacy, University of California School of FIG. 5.28 (Courtesy of Alton Lacy, University of California School of
Dentistry [San Francisco, CA].) Dentistry [San Francisco, CA].)
 Principles of Bonding CHAPTER 5 79

Procedure 5.3 Bonding Orthodontic Brackets

See Evolve site for Competency Sheet. NOTE: This bonding resin acts to prepare or prime
the enamel to allow adhesion of the resin adhesive
Consider the following with this procedure: safety glasses are
paste that holds the bracket in place. The bonding
recommended for the patient, PPE is required for the operator,
resin and the adhesive resin chemically bond to each
ensure appropriate safety protocols are followed, and check your
other.
local state guidelines before performing this procedure.
6. Apply light-cured adhesive resin to the metal mesh
on the back of the bracket (Fig. 5.32), and place the
EQUIPMENT/SUPPLIES (Fig. 5.29) bracket in the location prescribed by the dentist,
• Basic setup using bracket placement pliers. An orthodontic
• Low-speed handpiece, prophy angle, rubber cup, scaler can be used to adjust the position of the
and slurry of pumice bracket and remove excess resin.
• Etchant (37% phosphoric acid), light-cured NOTE: The resin adhesive does not chemically
bonding resin bond to the bracket, but it will physically lock into the
• Curing light, lip retractors
• High-volume evacuator (HVE) tip, cotton rolls
• Orthodontic brackets, bracket placement pliers, scaler

PROCEDURE STEPS
1. Inform the patient of the procedures to be done.
Clean the facial surfaces of the teeth to be bonded
with pumice slurry in a rubber cup.
NOTE: Pumice removes adherent plaque and or-
ganic pellicle that might interfere with proper etching
and bonding.
2. Place lip retractors or cotton rolls to isolate the
anterior teeth for bracket placement.
NOTE: Moisture from the lip mucosa will interfere
FIG. 5.30
with bonding.
3. Apply etching solution or gel for 30 seconds to that
portion of the enamel that will receive the bracket.
4. Rinse the etchant off with water and thoroughly
dry the enamel (Fig. 5.30).
NOTE: Properly etched enamel should appear
frosty or chalky white. Because no dentin is involved,
the enamel is dried thoroughly.
5. Apply a thin coating of liquid bonding resin to the
etched enamel and light-cure for 20 seconds (Fig. 5.31).

FIG. 5.31

FIG. 5.29 FIG. 5.32

Continued
80 CHAPTER 5 Principles of Bonding

Procedure 5.3 Bonding Orthodontic Brackets—cont’d

mesh on the back of the bracket. Some brackets are the resin underlying the bracket. High intensity curing
­manufactured with the adhesive applied at the factory lights may alter the curing times.
and are covered with a plastic cover that is stripped 8. Repeat the procedure to complete the placement of
away at the time of placement. all of the brackets (Fig. 5.33).
7. Light-cure the adhesive resin for 40 to 60 seconds, NOTE: Typically, the six anterior teeth are all etched
directing the light from mesial, distal, incisal, and primed at the same time. Brackets may be bond-
cervical and lingual toward the bracket. ed individually or placed together and light-cured
NOTE: Although the metal of the bracket blocks individually.
penetration of the light directly, the translucency of 9. The arch wire and elastic or wire ligatures can be
the enamel allows light to transmit through it to cure placed after all brackets are bonded (Fig. 5.34).

FIG. 5.33 FIG. 5.34

Get Ready for Exams!

Review Questions 4. O ne of the following statements about etch-and-rinse

bonding resins is true. Which one?
Select the one correct response for each of the following a. Water is the most common solvent used with these
multiple-choice questions. bonding resins.
1. The acid used most commonly to etch tooth structure b. They form the best hybrid layer with dry dentin.
for bonding procedures is c. They chemically bond to the composite resin.
a. Citric d. They chemically bond to the dentin.
b. Hydrochloric 5. Self-etching bonding systems
c. Hydrofluoric a. Use 37% phosphoric acid as the etchant
d. Phosphoric b. Use acidic primers to etch the tooth structure
2. Which one of the following statements about bonding to c. Require rinsing after etching
enamel is true? d. Generally etch enamel equally as well as dentin
a. Bonding is achieved by micromechanical retention. 6. Etch-and-rinse bonding systems
b. Bonding is achieved by chemical bonds. a. May result in tooth sensitivity caused by overdrying
c. Bonding is achieved by resin tags penetrating the or overetching
collagen matrix. b. Do not require a separate etching and rinsing step
d. Bonding to enamel is less reliable than bonding to c. Do not require drying of the primer
dentin. d. Do not provide a good etch of uncut enamel
3. Bonding to dentin by the etch-and-rinse technique 7. With the etch-and-rinse system when bonding to dentin,
a. Is best on dentin that has been etched with 37% one of the following statements is true. Which one?
phosphoric acid for 30 seconds a. The dentin surface should be thoroughly dried after
b. Is stronger when the dentin is well dried after etching etching and rinsing.
c. Is inhibited by formation of the hybrid layer b. The surface of the etched, rinsed, and lightly dried
d. Is best accomplished when the dentin is kept moist dentin should be “glistening.”
after etching
 Principles of Bonding CHAPTER 5 81

Get Ready for Exams!—cont’d

c. T he surface of prepared dentin should have visible a. R etention to the metal is enhanced by roughening
water droplets. the surface with a coarse diamond bur, by sandblast-
d. Once you have dried the etched surface, it cannot ing, by electrochemically etching, or by tin-plating.
be rewetted. b. Bonding agents are not needed because the com-
8. Dentin sensitivity can be caused by posite resin sticks to the metal.
a. Pressure changes in the column of fluid within the c. An opaque resin is applied before the composite resin
dentinal tubules to mask the metal and prevents a gray color from show-
b. Stimulation of odontoblastic processes within the ing through the slightly translucent composite resin.
dentinal tubules d. Light-curing materials can be used.
c. Open (unsealed) dentinal tubules For answers to Review Questions, see the Appendix.
d. Overetching or overdrying of the dentin
e. All of the above Case-Based Discussion Topics
9. The smear layer
a. Is a tenacious layer of cut tooth debris on the sur- 1. A 24-year-old graduate student needs two occlusal
face of enamel and dentin sealants on his lower first molars and a composite resin
b. Is easily removed by rinsing with water restoration to repair toothbrush abrasion on the facial
c. Is necessary for good bonding root surface of his maxillary left canine.
d. Is not removed when bonding by the etch-and-rinse Discuss the similarities and differences in bonding to enamel
technique for the sealants and to dentin for the composite resin.
10. All of the following statements about bonding to repair 2. A 50-year-old female attorney is in need of a ceramic
fractured porcelain on a crown are true except one. onlay on her mandibular left first premolar.
Which one is this exception? Discuss the differences in the mechanisms and procedural
a. The surface is cleaned and roughened. steps used to bond to enamel and dentin as opposed to
b. 10% phosphoric acid is used to etch the porcelain. bonding to a glass-based ceramic (lithium disilicate) onlay.
c. Silane is applied after etching to enhance the bond 3. A 42-year-old male factory worker comes to the dental
of adhesive resins to the porcelain. office with a chief complaint of tooth sensitivity after
d. Composite resin is usually used to restore the frac- recent placement of a class II posterior composite resin
tured portion. restoration on the lower right second molar. He com-
11. Which one of the following does not interfere with the plains that the tooth hurts when he bites on it and when
formation of a good bond? cold drinks or cold air hits the tooth.
a. Saliva on the etched enamel or dentin Discuss the likely causes of the sensitivity and the measures
b. Oil lubricant from the handpiece that can be taken to prevent postoperative tooth sensitivity
c. Moist dentin after rinsing etchant off and lightly after bonding procedures.
drying 4. A 65-year-old retired schoolteacher needs restoration of
d. Flavoring agents in prophy paste both mandibular first molars, which have root caries on the
12. Which type of bonding system has been shown to con- facial root surfaces. The caries extends beneath the crest
sistently provide the greatest bond strengths to enamel of the gingiva so that isolation with a rubber dam is not
and dentin? possible. The patient wants tooth-colored restorations.
a. Three-step, two-bottle etch-and-rinse (fourth Discuss the requirements for ensuring a good bond.
generation) 5. A 35-year-old female stockbroker comes to the den-
b. Two-step, one-bottle etch-and-rinse (fifth generation) tal office with a chief complaint of having chipped the
c. Two-step, two-bottle self-etch (sixth generation) mesial corner off her right maxillary central incisor
d. One-step, one-bottle self-etch (seventh generation) porcelain-fused-to-metal crown by accidentally biting
13. When endodontic posts are bonded into root canals, on a fork. Examination reveals a 2 mm × 1 mm loss of
the bonding resin should not be porcelain without exposure of underlying metal.
a. Self-curing Discuss the materials and procedures in their proper se-
b. Light-curing quence of use to repair the crown in the office.
c. Dual-curing 6. A 23-year-old college student comes to the dental office
d. Applied in a thin layer complaining of sensitivity to cold foods and air on her lower
14. All of the following are correct steps for bonding orthodon- right first molar. The pain is limited to the cervical part of
tic brackets except one. Which one is this exception? the tooth at the gingival crest, which has receded 3 mm.
a. The tooth surface is cleaned with pumice. The problem appears to be caused by toothbrush abrasion
b. The enamel is etched with 37% phosphoric acid for of the root from brushing too hard. The patient is a needle
approximately 30 seconds. phobic and does not want an injection of local anesthetic.
c. The enamel is rinsed and left slightly moist. The dentist wants to apply a bonding resin to the area.
d. A resin adhesive may be used to bond the bracket. Why is the area of abrasion sensitive? Discuss which bond-
15. When bonding composite resin to metal that is exposed ing materials to select. Which technique (etch-and-rinse or
after the overlying porcelain has fractured, which one of self-etch) will likely cause the patient the least amount of
the following is false? pain? How do these materials work for root sensitivity?
82 CHAPTER 5 Principles of Bonding

BIBLIOGRAPHY Nazarian A: The progression of dental adhesives [online ­continuing

education]. Dental CE Digest. 2007, PennWell Publications.
Alex G: Universal Adhesives: the next evolution in adhesive Ozer F, Blatz MB: Clinical applications of self-etching and
dentistry? Compendium of Continuing Education in Den- etch-and-rinse adhesive systems. Inside Dentistry, 2013.
tistry, 2015. Phillips RW, Moore BK: Adhesion and elasticity. In Elements of
Anusavice KJ, Shen C, Rawls HR: Bonding and bonding agents. Dental Materials for Dental Hygienists and Dental Assistants.
In Phillips’ Science of Dental Materials (ed 12). Philadelphia, Philadelphia, 1994, Saunders.
2013, Saunders. Poticny DJ: Adhesive systems continue to evolve: a case report.
Bird DL, Robinson DS: Dental liners, bases and bonding systems. Dentistry Today, 2013. Available at http://www.dentistrytod
In Modern Dental Assisting (ed 12). St. Louis, 2018, Elsevier. ay.com/dental-materials/9217-adhesive-systems-continue-
Farah JW, Powers JM: Bonding agents—2008. The Dental Advisor, to-evolve-a-case-report.
25(1–9), 2008. Powers JM, Wataha JC: Bonding agents. In Dental Materials:
Ferracane JL: Direct esthetic anterior restoratives. In Materi- Foundations and Applications (ed 11). St. Louis, 2013, Elsevier.
als in Dentistry. Philadelphia, 2001, Lippincott Williams & Retief DH: Effect of conditioning the enamel surface with phos-
Wilkins. phoric acid. J Dent Res., 52:333, 1973.
Heymann HO, Swift EJ, Ritter AV: Fundamental concepts of Sakaguchi RL, Powers JM: Materials for adhesion and luting. In
enamel and dentin adhesion. In Sturdevants’s Art and Science Craig’s Restorative Dental Materials (ed 13). Philadelphia, 2012,
of Operative Dentistry (ed 6). St. Louis, 2013, Mosby. Mosby.
Lane JA, Hughey SJ, Gregory PN, et al.: Is your dental adhesive Silverstone LM: The acid-etch technique: In vitro studies with spe-
forgiving? How to address challenges. Compend Contin Educ cial reference to the enamel surface and the enamel-resin in-
Den, 37(10), 2016. terface. In Proceedings from the International Symposium on Acid
Nakabayashi N, Nakajima K, Masuhara E: The promotion of ad- Etch Technique. St. Paul, MN, 1975, North Central Publishing.
hesion by resin infiltration of monomers into tooth structure. Strassler HE: Contemporary resin adhesives. Inside Dentistry,
J Biomed Mater Res, 16:265, 1982. October 2014.
Composites, Glass Ionomers, and Compomers 6
http://evolve.elsevier.com/Eakle/materials/

Chapter Objectives
Upon completion of this chapter, the student should be able to:
1. Describe the various types of composite resin restorative 10. L ight-cure a composite resin restoration following
materials. recommended exposure times and use proper
2. Discuss the advantages and disadvantages of each type precautions for eye/retina protection.
of composite resin. 11. As permitted by state law, finish and polish a class III
3. Discuss the similarities and differences among composite restoration.
chemical-cured, light-cured and dual-cured 12. Discuss the procedural differences between direct and
composite resins. indirect composite restorations.
4. Describe how fillers affect the properties of composites. 13. Describe the composition of glass ionomer restoratives
5. Explain why incremental placement of composite resin is and their uses, advantages and disadvantages.
recommended. 14. Explain the effects of fluoride-releasing, resin-modified
6. Describe the factors that determine how long an glass ionomer restorations in the prevention of recurrent
increment of composite resin should be light-cured. caries.
7. Place a sectional matrix for a class II composite. 15. List the components of compomers.
8. Select an appropriate type of composite for a class II 16. Describe the uses of compomers.
cavity preparation. 17. Compare the clinical applications of composite resin
9. As permitted by state law, place a composite in a class II restorative materials with glass ionomer cement
cavity preparation. restorative materials

Key Terms
Direct-Placement Esthetic Materials tooth-colored Light-Cured Composites single-paste composites that
­materials that can be placed directly into the cavity polymerize when a photosensitive chemical is activated by
­preparation without being constructed outside of the light in the blue wave range
mouth first Depth of Cure the depth to which light from a curing unit
Composite Resins direct-placement, tooth-colored materi- can penetrate and cure composite resin
als composed of an organic resin matrix, inorganic filler Dual-Cured Composites composites that contain compo-
particles, a coupling agent, and coloring pigments nents of light-activated and chemically activated materials.
Organic Resin Matrix thick liquids made up of two or more When the two parts are mixed together, it polymerizes by
types of organic molecules (polymers) that form a matrix a chemical reaction that can be accelerated by blue light
around filler particles activation
Inorganic Filler Particles fine particles of quartz, silica, Incremental Placement a technique for composites that
or glass that give strength and wear resistance to a places and cures small increments individually to re-
material duce the overall polymerization shrinkage and shrinkage
Silane Coupling Agent a chemical that helps to bind the stress in the restoration and permit curing throughout the
filler particles to the organic matrix increment
Pigments coloring agents that give composites their color Elastic Modulus a measure of the stiffness of a material; the
Monomers high molecular weight molecules that act as higher the elastic modulus the stiffer the material
building blocks to link by covalent bonds to form larger, Macrofilled Composites an early generation of composites
complex molecules known as polymers that contained large filler particles ranging from 10 to 100
Polymerization the joining of monomers end-to-end to form microns (μm)
chains or networks of polymers often causing a material to Microfilled Composites composites that contain very small
harden filler particles averaging 0.04 μm in diameter
Self-Cured Composites composites that polymerize by a Hybrid Composites composites that contain both fine fill (2
chemical reaction when two filled resin pastes are mixed to 4 μm) and microfill (0.04 to 0.2 μm) particles to obtain
together the strength of a macrofill and the polishability of a microfill

83
84 CHAPTER 6 Composites, Glass Ionomers, and Compomers

Microhybrids hybrid composites that contain fillers that are Indirect-Placement Esthetic Materials tooth-colored ma-
smaller fine-particle (0.04 to 1 μm) and microsized fillers terials that are used to construct restorations outside of the
Nanohybrids microhybrids to which nanosized fillers have mouth in the dental laboratory or at chairside on replicas of
been added the prepared teeth. They are later cemented to the teeth
Universal Composites composites that have physical and Glass Ionomer Cements (GICs) self-cured, tooth-colored,
mechanical properties such as strength and polishability fluoride-releasing restorative materials that bond to tooth
that allow them to be used in both the anterior and poste- structure without an additional bonding agent
rior parts of the mouth Resin-Modified (or Hybrid) Glass Ionomer a glass iono-
Nanocomposites composites that contain all nanosized mer to which resin has been added to improve its physical
fillers to enhance physical properties properties
Flowable Composites light-cured, low-viscosity composite Nano-Ionomers glass ionomers that contain nanosized filler
resins particles to enhance their physical properties
Bulk-Fill Composites composites with greater depth of Compomer composite resin that has polyacid, fluoride-
cure that permit placement in large increments up to 4 mm releasing groups added
thick instead of the standard 2 mm; their use speeds up Bioactive Dental Materials materials that interact with living
the filling process tissue and are used to remineralize and repair dentin.
  

Composites have for some time overtaken amalgams as the materials include composite resins, glass ionomer ce-
most frequently placed direct restorations. The use of com- ments, resin-modified glass ionomer cements, and com-
posites has grown exponentially over the past three decades. pomers. Indirectly placed composite resin restorations are
In 1999 approximately 86 million composites were placed discussed as well. Guidelines for selection of the shade of
in the USA. By 2006 approximately 146 million composites these materials to obtain satisfactory cosmetic results also
were placed in the USA (ADA Survey of Dental Services). are discussed.
Manufacturers have continually improved composites by
making them easier to handle, more durable, esthetic, and
HISTORY OF THE DEVELOPMENT OF COMPOSITE
color stable. Other esthetic materials such as glass ionomer
RESIN FOR DENTISTRY
cements and compomers have also been developed and im-
proved upon, providing the dental team with a wide selec- For the first half of the twentieth century, amalgam and
tion of esthetic materials and colors for the restoration of gold were the primary restorative materials for poste-
carious or damaged teeth and for cosmetic enhancement. rior teeth. Some anterior teeth also had metal restora-
With the capability of bonding restorative materials to tooth tions that were visible when the patient smiled in the
structure, advances in esthetic materials and techniques form of gold margins of three-quarter crowns, class III
have improved the ability of the dental team to deliver the and V gold foils and inlays, or amalgams. Silicate ce-
esthetic results that patients demand. The dental team must ment, introduced in 1873, was the first tooth-colored
keep current with the rapid changes that occur with materi- restorative material but was not widely used until the
als and techniques. Good listening skills are needed to deter- early 1900s. Although it was somewhat esthetic, it was
mine the types of esthetic services the patient is requesting so relatively soluble in the mouth and washed out over
that the dental team and the patient are working in concert time. In the latter half of the twentieth century, vari-
toward the same goal. Esthetic materials must be carefully ous direct-placement tooth-colored restorative materi-
selected so that their properties are compatible with the pa- als were introduced. Initially, chemical-cured, unfilled
tient’s oral condition and occlusion. Dental hygienists and acrylic resins were used, but they leaked, wore down
dental assistants must understand the properties of these quickly, and became discolored.
materials, so that as important members of the dental team In 1955, Michael Buonocore introduced the acid etch
they can help the dentist to assess the performance of the res- technique for bonding the acrylic to enamel. In 1962
torations and can alert the dentist when they perceive that Rafael L. Bowen developed bis-GMA resin monomer
a restoration may be failing. They need to be familiar with that is still used in many composites today. Silica par-
the physical properties of the materials so that they do not ticles were added to bis-GMA to reinforce it and make
damage the restorations during routine oral hygiene, coro- it more wear resistant, and this became the basis of the
nal polishing, and preventive procedures. They need to know composite resin used in dentistry. In 1963, chemical-
the handling characteristics of the esthetic materials so that cured composite resin (Addent, 3M Dental Products)
they can assist the dentist in their placement or can perform was introduced. The early composite resins were avail-
steps in their placement, finish and polish as permitted by able in a very limited number of shades, were rough
state dental practice acts. and worn out quickly, discolored, and shrank exces-
This chapter describes the physical and mechani- sively when they cured. Resin bonding agents had not
cal properties, clinical applications, advantages, and been developed yet, so the restorations leaked and
shortcomings of directly placed esthetic materials. These postoperative sensitivity and recurrent caries were
 Composites, Glass Ionomers, and Compomers CHAPTER 6 85

common occurrences. In an effort to have more control Filler Particles

over the working time, composites cured by ultravio- The addition of filler particles to the organic resin has
let light were developed. Later, composites cured by several functions. Fillers make the composite stronger
visible light were introduced. Most of the improve- and more wear resistant. By reducing the amount of
ments that have occurred in composites to the present resin, fillers help to reduce the amount of shrinkage
have been related to reducing shrinkage, using smaller that occurs when the resin matrix polymerizes, or sets.
fillers to enhance polishing and wear resistance, im- Fillers can also be used to control the translucency of
proving the selection of colors, increasing durability, the composite by their effect on the scattering of light.
improving handling properties, and delivery methods. The amount of filler and the size and shape of the filler
will affect the viscosity of the composite and how it
handles. Reducing the amount of resin by adding filler
DIRECT-PLACEMENT ESTHETIC RESTORATIVE reduces thermal expansion and contraction and de-
MATERIALS creases water sorption (uptake) that softens the resin
Esthetic materials are those that are tooth colored. Di- and makes it more likely to wear.
rect-placement esthetic materials are those that can be The fillers used in many composite resins are com-
placed directly into the cavity preparation or onto the posed of glass, quartz, silica, or ceramic. Fillers may be
tooth surface by the clinician without first being con- modified with ions to improve their characteristics. To
structed outside of the mouth. The direct-placement make the composite resin restoration show up (appear
esthetic materials used most commonly are as follows: radiopaque) on radiographs, heavy metal ions may be
• Composite resin added to the filler particles. Nanosized filler particles
• Glass ionomer cement are synthesized from zirconia (a ceramic material) and
• Resin-modified glass ionomer cement (also called silica. Glass fillers are the least inert of the fillers. They
hybrid ionomer) are leached slowly from the composite by dietary acids
• Compomer and by application of acidulated phosphate fluoride in
the dental office.
Important factors for the durability of the composite
COMPOSITE RESIN resin are the size of the filler particles and the ratio or
A composite is a mixture of two or more materials with weight of the filler to the matrix. As a general rule, the
properties superior to any single component. Compos- higher the filler content, the stronger and more wear re-
ite resins are tooth-colored restorative materials that sistant the restoration will be and the less it will shrink
are used in both the anterior and posterior parts of the when polymerized. The amount of filler in a compos-
mouth. They are composed mainly of an organic resin ite resin usually is reported by the manufacturer as the
matrix and inorganic filler particles joined together by percent of filler by weight (weight %) in the resin.
a silane coupling agent that sticks (adheres) the par- Composites can be classified by the size of the filler
ticles to the matrix. Also added are initiators and ac- particles they contain (Fig. 6.1). Wear of the composite
celerators that cause the material to set and pigments is related to the filler particle size, the amount of filler
that give color to the material and match tooth colors.
Composite resins are commonly called composites and Filler
also can be referred to in the dental literature as resin particle
composites. Resin
matrix
COMPONENTS
Resin Matrix A
The most commonly used resin for the matrix of com-
posites is bis-GMA (bisphenol-A-glycidyl dimethacry-
late), produced by reacting glycidyl methacrylate with
bisphenol-A. Another resin that is used for the com-
posite matrix is urethane dimethacrylate (UDMA).
These resins are thick liquids made up of two or more B
types of organic molecules called oligomers. To reduce
viscosity and allow loading with filler particles, a low
molecular weight monomer, such as TEGDMA (trieth-
ylene glycol dimethacrylate), is added.
Monomers are organic molecules (that make up the C
oligomers) with double carbon bonds that link togeth-
FIG. 6.1 Variety of filler sizes that are combined in the composite resins
er by an addition reaction to form a polymer. When the and contribute to their classification names. A, Macrofilled; B, micro-
polymerization reaction goes to completion, the result is filled; C, hybrid—a combination of micro fillers (about 0.4 μm) and small
a cured composite resin. fillers (about 1-4 μm).
86 CHAPTER 6 Composites, Glass Ionomers, and Compomers

Pigments
Inorganic pigments are added in varying amounts to
develop a variety of colors that approximate the basic
colors of teeth or specialized colors. Pigmented resins
(also called coloring resins) can be used to cover discol-
orations or dark dentin, or to hide the graying effect of
Smooth surface Irregular surface due a metal post in a root canal–treated tooth. Pigments are
at time of placement to erosion and loss of also used to characterize a restoration when the tooth
and surface polish filler particles
being restored or adjacent teeth have white spots as
FIG. 6.2 Wear of composite surface. At left, smooth surface at the time with mild fluorosis (see Chapter 7 Preventive and De-
of placement and surface polish. At right, rough surface caused by
wear and loss of filler particles at the surface.
sensitizing Materials) or other special characteristics.
Coloring resins are usually lightly filled and come in
a variety of colors including blue, white, orange/yel-
low, pink, light and dark brown, ochre, and clear. An
example is Vit-l-escence Colors (Ultradent Products).

POLYMERIZATION
Polymerization is the chemical reaction that occurs
when low molecular weight resin molecules called
monomers join together end-to-end to form long-chain,
high molecular weight molecules called polymers. For
composite resins, activation of the polymerization pro-
cess can be done chemically (chemical-cured), or by
light (light-cured), or by a combination of the two (du-
al-cured). During polymerization, regardless of meth-
od, an activator (chemical or light) causes an initiator
molecule to form free radicals (highly charged mol-
ecules that have unpaired electrons). The monomers
(called dimethacrylates; e.g., bis-GMA) have carbon-
FIG. 6.3 Worn composite with staining at the margins indicative of micro-
to-carbon double bond (C=C) functional groups. The
leakage. Opposing occlusion has worn the composite down, and numer- free radicals break one of the carbon-to-carbon double
ous pits have developed as bits of the composite have fractured out. bonds to form a single bond and another free radical.
That free radical can cause the same reaction with an-
in the resin, and the amount of resin between particles. other monomer to add to the polymer chain (called ad-
Large filler particles tend to get pulled from the resin dition polymerization). As the monomers link together
matrix at the surface (called plucking) when the resto- into chains, the volume of resin decreases, so the net
ration is under function or abraded by food and tooth result is shrinkage (called polymerization shrinkage).
brushing, resulting in wear of the remaining resin
matrix and a rough surface. Smaller particles are not Cross-linking of polymer chains. Polymer chains have
as easily plucked from the resin and therefore cause small groups of atoms (called branches) hanging off
fewer voids that contribute to wear. Smaller particles their sides. When side groups of adjacent polymer
can be packed closer together, thereby exposing less of chains share electrons, they form covalent bonds that
the resin matrix to wear (Figs. 6.2 and 6.3) and increas- link (called cross-linking) the chains together (Fig. 6.4).
ing the number of filler particles that can be added to Cross-linking of polymers produces a much stronger,
the resin matrix. The smaller the particles, the smooth- stiffer material than is formed with single-chain poly-
er the surface of the composite will be after finishing mers. (See Chapter 17 for a more detailed description
and polishing and the longer it will be able to retain of polymer formation and properties.)
its luster.
Modes of Cure
Coupling Agent Chemical cure. Chemically cured composite resins, or
A coupling agent is used to provide a stronger bond self-cured composites, are two-paste systems supplied
between the inorganic fillers and the resin matrix. This in screw-type syringes or cartridges. One paste, called
coupling agent is silane, which reacts with the surface the base, contains composite and benzoyl peroxide as
of the inorganic filler and with the organic matrix to al- an initiator. The other paste, called the catalyst, con-
low the two to adhere to each other. Good adhesion of tains composite and a tertiary amine as an activator.
the two is necessary to minimize loss of filler particles Equal parts of these two pastes are mixed together,
and to reduce wear. The silane is applied to the filler and the polymerization reaction begins. The reaction
surface before the filler is added to the resin monomer. could go to completion very quickly, but chemicals
 Composites, Glass Ionomers, and Compomers CHAPTER 6 87

Linear Branched Crosslinked

FIG. 6.4 Diagrams of linear, branched, and cross-linked polymers. Adjacent linear polymer chains are linked by cova-
lently bonded atoms from short side chains (branches). (From Anusavice KJ, Shen C, Rawls HR: Phillips’ Science of
Dental Materials (ed 12). St. Louis, 2013, Elsevier.)

called inhibitors are added to each paste to slow down of filler used, and the type of material the light must
the reaction. The operator has a limited amount of time pass through to reach the composite (such as enamel,
(working time—usually about 2 minutes in the mouth) dentin, ceramic). A composite restoration that is not
to place the restoration before it becomes too stiff to completely cured can lead to microleakage and recur-
manipulate. Once the initial set occurs, the material rent caries.
should not be manipulated or the properties of the
restoration will be degraded. Disposable mixing sticks Dual cure. Dual-cured composites are two-paste sys-
are usually supplied with the composite contained in tems that contain the initiators and activators of both
screw-type syringes. Because the two pastes must be light-activated and, to a lesser extent, chemically acti-
manually mixed, air can be incorporated into the mate- vated materials. The advantage is that when the two
rial, causing voids or porosity in the restoration. pastes are mixed together and placed in the tooth,
Composites in cartridges come with mixing tips that the curing light is used to initiate the setting reaction,
automatically mix the two pastes as they are extruded and the chemical setting reaction continues in areas
from the cartridge (see Fig. 6.12). This “automixing” not reached by the light to ensure a complete set. This
greatly reduces the introduction of air into the mixed dual-cure process is very helpful when one is build-
composite and provides the correct proportions of each ing up an endodontically treated tooth and placing
material. The composites most commonly found in composite core material into the canal space. The cur-
cartridges are those used as core materials for crowns. ing light might not reach the material in the canal,
but the composite material will cure chemically on
Light cure. Light-cured composites are the most com- its own.
mon type of composite resin used in private practice.
Many clinicians prefer light-cured composite resin, PHYSICAL AND MECHANICAL PROPERTIES OF
because it requires no mixing and the operator can COMPOSITE RESINS
control the working time by deciding when to apply Important properties of composites include the
the curing light. An intense visible light in the blue following:
wave range activates these materials. Blue light with • Biocompatibility
a wavelength of about 470 nanometers (nm) activates • Strength
an initiator (camphorquinone) that, in the presence of • Wear
an accelerator (an organic amine), causes the resin to • Polymerization shrinkage
polymerize. These components are both present in the • Degree of conversion
composite but do not react until the light triggers the • Thermal conductivity
reaction. Inhibitors are also present to reduce the effects • Coefficient of thermal expansion
of the operatory light on a premature setting. Howev- • Water sorption
er, some manufacturers’ materials are still sensitive to • Elastic modulus
direct operatory light. The operator may choose to turn • Radiopacity
the operatory light away from the mouth when placing
the composite. Biocompatibility
Newly placed composite resins can release chemicals
Depth of cure. The ability of the light to penetrate the that, in deep cavity preparations, could pass through
composite and cure it (called the depth of cure) is lim- the dentinal tubules into the pulp, causing an inflam-
ited in depth. Just how far the light can penetrate and matory reaction. When the tubules are sealed by den-
cure is affected by several factors: the length and inten- tin bonding agents or protected with a base or liner,
sity of the light application, the distance the composite there is no problem. Composites can release compo-
is located from the light, the thickness of the compos- nents into the oral cavity as well. Water or other sol-
ite, the color of the composite, the amount and type vents in the diet can dissolve out unbound monomers
88 CHAPTER 6 Composites, Glass Ionomers, and Compomers

and other additives, and some components can leach margins. More recent research indicates that the mate-
out as the composite degrades over time. rial does not shrink toward the light. Chemical-cured
Bisphenol A is a polymer that can be found in some composites cure toward the center of the bulk of the
composites and fissure sealants. The concern with bi- material; light-cured materials have this tendency as
sphenol A is that it can mimic the effects of estrogen well, but are also influenced by the cavity shape (con-
and cause the development of secondary female char- figuration factor or C-factor) and size with minimal in-
acteristics or stimulate certain cancer cells. As with fluence by the location of the light.
most chemicals there is a certain concentration and
repeated exposure needed to induce cellular changes. Clinical consequences of polymerization shrinkage.
Research reports suggest that the level of bisphenol A As composite polymerizes and shrinks it tends to pull
released by composites is very low and does not rep- toward the walls of the cavity preparation that are
resent a health threat to individuals. Researchers con- bonded. When an increment of composite is placed
tinue to investigate this issue. in contact with two opposing walls (like a class I or II
Polished composites are well tolerated by surround- preparation with buccal and lingual enamel walls) and
ing soft tissues. A very few individuals may be aller- cured, the shrinking composite will stress the bonds to
gic to one or more of the components of the material, the two walls and may end up pulling away from one
and for these individuals another restorative material of the walls. This will cause a gap at the margins that
must be chosen. Formaldehyde may be formed as a by- allows microleakage (leakage on a microscopic level)
product of polymerization and may cause soft tissue of fluid and bacteria at the margins with possible tooth
reactions that resemble lichen planus which can affect sensitivity or future staining at the margins and recur-
mucous membranes causing white striations that may rent caries. Shrinking composite that is well bonded
be accompanied by erythema (redness from irritation) to buccal and lingual cavity walls can also put tension
and are called lichenoid reactions. on the cusps of the tooth, pulling them slightly toward
each other. This causes discomfort when the patient
Strength bites down. The bond to enamel is a strong one. When
Most of the composites commonly used today are the composite shrinks near the cavosurface margins
similar in compressive strength. They are not as strong in enamel, occasionally some of the enamel rods pull
in compression as amalgam but are stronger than away from the tooth. The result of this microscopic
glass ionomers. In terms of tensile and shear strength, cracking of the enamel can be seen as a white line
microfill composites are weaker than hybrids and around the margin.
nanocomposites.
Reducing the effects of polymerization shrinkage. The
Wear greater the resin content of the composite, the greater
Composites wear faster than amalgams. Recent im- the shrinkage will be. One way to reduce polymeriza-
provements have made the latest generation of com- tion shrinkage is to place more filler in the composite so
posites more wear resistant than early composites, there will be less resin. Microfill composites and flow-
and they are beginning to approach the wear rate of ables have more resin monomer and therefore shrink
amalgams under normal function. Filler content has more than hybrids and nanocomposites. Hybrids have
an effect on the wear rate. Composites with a lower a combination of larger filler particles and smaller
volume of filler (microfills and flowables) wear faster ones. The smaller particles fill in the spaces between
than more heavily filled materials. Wear can result the larger particles. There is a limit as too how much
from abrasion by foods or toothbrushing or by con- filler can be placed into the resin matrix. Too much fill-
tact with opposing teeth during eating or bruxing. The er will make the composite too stiff to manipulate, and
wear from the opposing teeth is much more destruc- some of the physical and mechanical properties may
tive. Bruxers (people who grind their teeth) will wear be diminished.
down composites at a much faster rate than amalgam. Another way to reduce polymerization shrinkage
Therefore, it is recommended that posterior compos- is to use pre-polymerized filler. To make these fillers,
ites not be used for very large restorations that are not high concentrations of microfillers and nanofillers are
protected in the functional occlusal range by surround- forced into a resin matrix under pressure and heat, and
ing tooth structure. then cured. The highly filled clumps of resin are then
ground into large filler particles (about 30 to 60 μm).
Polymerization Shrinkage These large particles already have undergone poly­
Polymerization shrinkage refers to the shrinkage that merization shrinkage. They are loaded into a resin ma-
occurs when the composite is cured (polymerized). It trix along with other micro- or nanofillers to make a
was once thought that light-cured composites shrank micro- or nanohybrid composite. This composite when
toward the curing light, and a great effort was made to polymerized will shrink less because a portion of its
correctly place the light probe in order to draw the ma- volume has already been polymerized by way of the
terial toward the cavity wall to minimize leakage at the pre-polymerized particles.
 Composites, Glass Ionomers, and Compomers CHAPTER 6 89

A B C
FIG. 6.5 Incremental placement of composite to minimize polymerization shrinkage and ensure complete cure of com-
posite. A, First increment has been placed horizontally (gray area) in a thin layer on the gingival floor and light-cured. B,
Second increment has been placed diagonally and light-cured. C, Third increment has been placed diagonally on the
opposite wall and light-cured. (From Anusavice KJ, Shen C, Rawls HR: Phillips’ Science of Dental Materials (ed 12). St.
Louis, 2013, Elsevier.)

The effects of polymerization shrinkage can be mini- polymerizes most of the resin monomer is converted
mized by placing the restoration in small incremental into polymer, but some remains unconverted. With a
layers, avoiding joining opposing walls with one incre- higher rate of conversion the physical and mechanical
ment, and curing each layer separately. For most mod- properties of the resin improve: the resin will be stron-
erately sized or large cavity preparations, the composite ger, resist wear better, and be more color stable.
resin should be placed in increments about 2 mm thick;
this is referred to as incremental placement. The benefits Thermal Conductivity
of this are twofold. First, it minimizes polymerization Composite resin will transmit hot and cold tempera-
shrinkage, because the shrinkage of the first increment tures much like the natural tooth structure. So, its
is made up for by the application of the next increment thermal conductivity is compatible with the teeth and
and continues with each successive increment. Second, much lower than that of metal, such as amalgam or
it permits light from the curing unit to adequately pen- gold. It is therefore a biologically protective material
etrate and thoroughly cure each increment (Fig. 6.5). for the dental pulp.
Another way to manage shrinkage in the cavity is to
do an indirect composite restoration (one that is pre- Coefficient of Thermal Expansion
pared and cured outside of the mouth). The shrinkage Ideally the coefficient of thermal expansion (CTE) of
occurs in the restoration before it is placed in the tooth; the filling material would be the same as that of the
then the restoration is cemented in place with a thin tooth structure. In the case of composite, the CTE is
layer of a low-viscosity resin cement such as that used greater, and therefore it will undergo a greater change
to cement veneers. This thin layer of cement will have in dimension than will the adjacent tooth structure.
minimal shrinkage. This can result in debonding and leakage of the res-
Last, polymerization shrinkage can be reduced by toration. The greater the filler content, the lower the
using low-shrinking monomers. Several products are CTE; the greater the resin content, the greater the CTE.
undergoing testing and one resin, silorane, is commer- Microfilled composites and flowable composites have
cially available in Filtek LS (3M ESPE). Its polymeriza- a higher CTE than do packable or hybrid varieties.
tion shrinkage is less than 1%. However, it takes twice
as long to polymerize and requires its own bonding Elastic Modulus
agent. It is not compatible with most methacrylate- The elastic modulus (also referred to as the E-modulus
based bonding agents. Another low shrinkage com- or Young’s modulus) is a measure of the stiffness of a
posite using a dimer-based material is N’Durance composite and is determined by the amount of filler.
(Septodont). Its polymerization shrinkage is less than The greater the volume of filler, the stiffer (higher elas-
2% and it is compatible with most bonding agents. tic modulus) and more wear resistant the restoration
will be. This is an important consideration for selec-
Degree of Conversion tion of the type of composite. For example, an occlu-
The degree of conversion of a resin indicates the per- sal restoration on a posterior tooth must have greater
centage of carbon-to-carbon double bonds that have wear resistance than a class V gingival restoration. In
undergone conversion to single bonds during forma- fact, the stiffer material is probably contraindicated at
tion of the resin polymer. The composite resin transi- the gingival margins, because it does not have the flex-
tions from a paste to a solid mass. As the composite ibility needed in that area. Microfilled and flowable
90 CHAPTER 6 Composites, Glass Ionomers, and Compomers

A B
FIG. 6.6 X-rays of two types of composites A, Older anterior composites that lacked heavy metals in the filler particles so
they are radiolucent and appear to be missing. B, A class II composite on tooth #29 DO that is radiopaque.

composites have fewer particles and more resin. They Over time, the filler particle size has become smaller
deform more readily under function and therefore can and smaller, the number of filler particles placed in the
break more easily. Microfills generally are used in non– resin has increased, and polymerization shrinkage has
stress-bearing restorations. decreased. As a result, composite restorations have be-
come more durable, leak less, polish better, and match
Water Sorption the teeth better. One way to classify composites is by
The resin matrix absorbs water from the oral cav- the size of the filler particles they contain.
ity over time. The greater the resin content, the more
water is absorbed. Therefore, microfills and flowables Macrofilled Composites
tend to have greater water sorption. The water can The first generation of composite resins used relatively
soften the resin matrix, leading to gradual degradation large particles as fillers, ranging in size from 10 to 100
of the material (called hydrolysis). Water also causes microns (μm). These composites are called macrofilled
some expansion (hydroscopic expansion) of the com- composites. The large particles make these composites
posite over the first week after placement. difficult to polish, and they become rough as filler par-
ticles are lost at the surface under function or the resin
Radiopacity wears, exposing the large particles. They are generally
Metals such as lithium, barium, or strontium are stronger than composites with smaller particles. Be-
added to the filler to make a restoration more opaque cause of their roughness and rapid wear, macrofilled
when viewed on a radiograph. However, some older composites are no longer widely used. The first two
composite materials do not have any of these additives macrofilled composites on the market were Adaptic
and might appear radiolucent on radiographs (Fig. (Johnson & Johnson) and Concise (3M ESPE).
6.6). Clinicians may have a difficult time determining
whether there is recurrent caries around such radiolu- Microfilled Composites
cent composites, because the caries also appears some- Microfilled composites were developed to overcome
what radiolucent on radiographs. the problems that arose with larger particle size. They
Quartz is not radiopaque, but it is sometimes used became commercially available in the late 1970s. As
as filler for composites used in the anterior part of the the name implies, microfilled composites have fillers
mouth, because it has good optical properties that can that are much smaller than those in macrofilled com-
enhance the color match to the tooth. It allows light posites. Microfill particles average about 0.04 μm in di-
to be transmitted through the restoration more readily ameter and range in size from 0.03 to 0.5 μm. Several
and to pick up coloration from the surrounding tooth small particles have a larger total surface area than one
structure, making for a better color match. large particle of similar weight. It is difficult to load a
large volume of microfillers in the resin matrix because
CLASSIFICATION OF COMPOSITES BY FILLER of this large surface area. Therefore the volume of filler
SIZE in microfilled composites is only 35% to 50%, as op-
Composite resins have undergone a steady progres- posed to 70% to 85% with many other composites. A
sion in their development to improve their properties. lower filler volume results in a composite with poorer
 Composites, Glass Ionomers, and Compomers CHAPTER 6 91

physical properties (i.e., weaker, with greater polymer- they contain both large fillers (2 to 4 μm) and 5% to 15%
ization shrinkage, and more wear). To help overcome microfine fillers (0.04 to 0.2 μm). The combination of the
these shortcomings, some manufacturers mix microfill- two filler sizes produces a strong composite that polish-
ers into a resin, polymerize (cure) it, and grind the hard- es well. The microfine particles fill in between the larger
ened material into particles ranging from 10 to 20 μm. particles to allow higher filler content (70% to 80% by
Then they use these particles (consisting of pre-polym- weight). These composites have universal application
erized resin and microfillers) as the filler so that they in that they can be used well in both the anterior and
can get more microfillers into the resin and improve its posterior parts of the mouth. Most manufacturers have
physical properties. Alternative methods to increase the stopped making hybrid composites because improved
numbers of microfillers that can be loaded into the resin products have reduced the demand for them. However,
include clumping the microfillers together by heating 3M ESPE still has its hybrid, Z100, available.
them or by condensing them into large clumps.
When polished, the microfilled composites produce Microhybrids
a very smooth, shiny surface, unlike the rougher mac- The hybrids were improved on by the use of even
rofilled composites. However, because of their poorer smaller particles (75% smaller than 1 μm). These hy-
physical properties, they are not suitable for stress- brids are called microhybrids, because they contain a
bearing sites such as for class I, II, and IV (incisal edge mixture of small particles (0.04 to 1.0 μm) and micro-
repair) restorations (Table 6.1). Microfilled composites fine particles (0.01 to 0.1 μm). Microhybrids can contain
include Renamel Microfill (Cosmedent), Heliomolar high filler content (70% by volume), because microfine
(Ivoclar Vivadent), and EPIC-TMPT (Parkell). particles fill in spaces between small particles. Popu-
lar microhybrids include Esthet-X (Dentsply Sirona),
Hybrid Composite Venus (Heraeus Kulzer), Point 4 (Kerr Dental), Tetric
In the late 1980s, the next generation of composites was Ceram (Ivoclar Vivadent), and Filtek Supreme (3M
introduced. They are called hybrid composites, because ESPE).

Table 6.1    Classification of Dental Caries (or Cavity Preparations)

CLASS OF CARIES LOCATION OF CARIES
Class I Pits & fissures –posterior teeth; lingual of maxillary incisors
Class II Proximal surfaces of posterior teeth
Class III Proximal surfaces of anterior teeth
Class IV Proximal surfaces of anterior teeth & the incisal angle
Class V Cervical third of anterior & posterior teeth
Class VI Incisal edges of anterior teeth; cusp tips of posterior teeth
CLASSES ILLUSTRATION OF CARIES LOCATION
Class I

Class II

Class III

Class IV

Class V

Class VI
92 CHAPTER 6 Composites, Glass Ionomers, and Compomers

Nanohybrids luster long-term. They have handling characteristics

Soon after the microhybrids, the nanohybrids were and physical and mechanical properties similar to mi-
introduced. Nanohybrids are microhybrids with nano- cro- and nanohybrids.
sized particles added. Their particle sizes range from Optically, the nanocomposites are very esthetic.
0.005 to 0.020 μm. The ability to add increased numbers They are more translucent, because the filler particles
of filler particles reduces the amount of resin. With less are smaller than the wavelength of visible light, and
resin, these composites shrink less when polymerized. the light passes through rather than being absorbed.
Shrinkage has been reduced from roughly 2% to 3% Light is also scattered by the multitude of particles,
with earlier composites to about 1% with some of the so the composite tends to blend in better with the sur-
nanohybrids. They are strong composites that can be rounding tooth structure. Examples of nanocompos-
polished to a high shine, and they retain that shine bet- ites are Filtek Supreme Ultra and Filtek Supreme XTE,
ter than earlier composites. Examples of nanohybrids both from 3M ESPE.
include Esthet-X HD (Dentsply Sirona), Aelite Aesthet- Continuing improvements. Each generation of com-
ic Enamel (BISCO), Filtek Supreme Ultra (3M ESPE), posite represents some improvement in physical,
Tetric EvoCeram (Ivoclar Vivadent), Clearfil Majesty mechanical, or chemical properties, handling charac-
ES-2 (Kuraray), and Premise (Kerr Dental). teristics, polishability, or ability to match the teeth. Re-
The nanohybrid composites are called universal search on other methods to improve the properties of
composites because they are esthetic, wear resistant, the composite resins includes the use of fibers embed-
and strong and therefore can be used in both the ante- ded in the resin to reinforce it and the use of crystals to
rior and posterior parts of the mouth. increase strength.
Composite kits may contain anywhere from 10 to 30
Nanocomposites or more shades (colors). Most kits have shades that are
Nanofilled composites, or nanocomposites, have filler slightly translucent to mimic enamel and shades that
particles that range in size from 5 to 75 nanometers are more opaque to mimic dentin. Shades that are more
(nm). They are about a thousand times smaller than translucent are available to mimic incisal translucency,
conventional fillers, which are approximately 1 μm. It is and opaque shades are available to block out or hide
difficult to imagine how small these particles are. One discolorations or darker dentin. Very light shades have
nanometer is one billionth of a meter. These particles been made to match teeth that have been whitened.
are so small that they cannot be produced like the other
fillers, by grinding down larger chunks of glass, quartz, OTHER COMPOSITE TYPES
or ceramic materials. Instead, they are produced syn- Flowable Composites
thetically by a chemical building up of the fillers from Flowable composites are low-viscosity, light-cured
molecular-size structures of zirconia and silica. resins that may be lightly filled (about 40%) or more
Nanocomposites have a combination of individual heavily filled (up to 70%). Initially, the particle size
spheroidal particles and clusters of these particles pro- was in the range of those for hybrid composites. How-
duced by fusing the particles together at their edges ever, nanosized fillers are also being used in flowable
(Fig. 6.7). The spaces between the particles in the clus- composites.
ter are filled with silane, which helps bind the clusters
to the resin matrix. Nanoclusters range in size from 0.6 Delivery. These composites flow readily and can be
to 1.4 μm. The extremely small size of the filler par- delivered directly into cavity preparations by small
ticles allows many more of them to be packed into the needle cannulas attached to the syringes in which they
resin and more closely together than in the other types are packaged. Because of their low viscosity, they adapt
of composites. This high filler content (about 78% by well to cavity walls and flow into microscopic irregu-
weight) reduces polymerization shrinkage (1.4% to larities created by diamond and carbide burs.
1.6%) and provides strength (and fracture toughness)
so that they can be used in both anterior and poste- Uses. They are well suited for use in conservative den-
rior applications. They have excellent polishability tistry (i.e., minimal preparations), where they readily
and with improved wear resistance will maintain their flow into the narrow preparations created with small
diameter burs, diamonds and lasers. Many dentists use
them in place of conventional pit and fissure sealants.
Nanocluster They are more wear resistant than most lightly filled
sealants, because their filler content is higher. They are
useful as liners in large cavity preparations, because
Nanomer
they adapt to the preparation better than more viscous
materials such as hybrid and packable composites.
FIG. 6.7 Illustration of nanofilled composite with nanomers and nano-
clusters. (From Sakaguchi RL, Powers JM: Craig’s Restorative Dental Flexibility. Their low elastic modulus allows them to
Materials (ed 13). St. Louis, 2012, Elsevier.) cushion stresses created by polymerization shrinkage
 Composites, Glass Ionomers, and Compomers CHAPTER 6 93

A B
FIG. 6.8 Restoration of class V erosion lesion. A, Erosion lesion pretreatment. B, Lesion restored with flowable com-
posite. (From Powers JM, Wataha JC: Dental Materials: Properties and Manipulation (ed 10). St. Louis, 2013, Elsevier.)

TABLE 6.2    Four Classification Methods for Composites

CLASSIFICATION METHOD MICROFILL MICROHYBRID NANOCOMPOSITE FLOWABLE HYBRID
1. Filler amount (volume %) 30-50 60-70 78 30-55
2. Particle size (μm) Macro (10-100) Fine (0.1-10) Micro (.01-0.1) Nano (0.001-0.01)
3. Matrix composition Bis-GMA Bis-GMA or UDMA Silorane(low shrinkage) Bis-GMA or UDMA
4. Polymerization method Self- or light-cured Self- or light-cured Light-cured Light-cured
Bis-GMA, bisphenol-A-glycidyl dimethacrylate; UDMA, urethane dimethacrylate.

or heavy occlusal loads when they are used as an in- bond directly to dentin without the need for a separate
termediate layer under hybrid and packable compos- bonding agent, since the bonding agent is incorporat-
ites. (The lower the elastic modulus, the more flexible ed into the composite. See Table 6.2 for classification of
the material; the higher the elastic modulus, the stiffer composites by four different criteria.
the material.) They are useful for restoration of cervi-
cal noncarious lesions caused by toothbrush abrasion, Pit and Fissure Sealants
acid erosion, or abfraction (from occlusal stresses, such Pit and fissure sealants are low-viscosity resins that
as bruxing [grinding of teeth], which lead to flexing of vary in their filler content from no filler to more heav-
the tooth) (Fig. 6.8). In cervical restorations flowable ily filled resins that are essentially the same as flow-
composites tend to flex when the tooth flexes. Stiffer able composites. They are used to prevent dental caries
composites often fall out when the tooth flexes. For in pits and fissures of teeth (see Chapter 7 Preventive
toothbrush abrasion lesions, the patient should have Materials).
the heavy toothbrushing habits corrected first. Oth-
erwise, the flowable composites may wear rapidly if Bulk-Fill Composites
the patient continues to brush too hard. Examples of Bulk-fill composites were developed to speed up the
microhybrid flowable composites are Point 4 Flow- placement process of the composite restoration. In-
able (Kerr Dental), Filtek Supreme Plus Flowable (3M stead of having to place and cure multiple increments,
ESPE), Gradia Flowable (GC America), and Virtuoso the clinician can place one large increment and cure it.
Flowable (DenMat). Examples of nanohybrid flowable This is a significant time savings and is the main rea-
composites are Herculite Ultra Flow (Kerr Dental), son these materials have quickly become popular.
Nexcomp Flow Nano Hybrid (Meta Dental Corp), and
Filtex Supreme Plus Flow (3M ESPE). Depth of cure. The challenges of the bulk-fill composite
are to have a depth of cure that permits increments of 4
Properties. Lightly filled flowable composites wear mm or more, to not shrink excessively, to flow well into
more readily, are weaker, and shrink more (about 4% all aspects of the preparation without voids, to have
to 6%) when polymerized than hybrid composites acceptable physical and mechanical properties, and to
(<3%), However, flowable composites too are being be esthetic with good polishability. To achieve a greater
improved to make them stronger and more durable depth of cure manufacturers have done one or more
with less shrinkage. Some manufacturers have devel- of the following: increased the translucency, reduced
oped self-adhesive flowable composites (Vertise Flow the amount of filler, or changed the chemical makeup
[Kerr Dental] and Fusio Liquid Dentin [Pentron]) that to enhance polymerization when curing is initiated.
94 CHAPTER 6 Composites, Glass Ionomers, and Compomers

Because the bulk-fill composites are more translucent, each other as the composite is packed into the prepara-
they do not match the tooth shade very well. Addi- tion giving them a stiff consistency and make them less
tionally, with reduced filler they wear more readily. likely to stick to the composite placement instrument.
For these two reasons, translucency and reduced filler, They are used in posterior teeth for class I and II restora-
bulk-fill composites may need to be covered with a ve- tions, because they are slightly stronger and more wear
neer of a more wear resistant and color matching com- resistant than most hybrids that contain less filler. They
posite such as a micro- or nanohybrid. were marketed as substitutes for amalgams because of
Bulk-fill has limitations on its use in the proximal their stiffness and were also called condensable com-
box of class II restorations, because the depth of the posites. However, packable is the preferred term since
box is often 6 or 7 mm, far beyond its curing capability. they cannot truly be condensed like amalgam. Their
In this case, more than one increment should be used physical properties show no significant improvement
in the proximal box. over traditional universal composites. They are not
widely used but are still available as QuiXX (Dentsply
Polymerization shrinkage. Polymerization shrinkage Sirona), Solitaire 2 (Heraeus Kulzer), SureFil (Dentsply
of bulk-fill composites has been reduced by adding Sirona), Tetric Ceram HB (Ivoclar Vivadent), and Alert
special modifiers that relieve stress in the restoration (Pentron).
during curing or by adjusting the size, number, and
composition of the filler. The shrinkage for bulk-fill Core Buildup Composites
composites is in the range found with other high-vis- Core buildup composites are heavily filled composites
cosity composites (about 1.3% to 2.4%). used in badly broken-down teeth needing crowns. They
replace missing tooth structure lost from dental caries
Formulations. Bulk-fill composites are found in two or tooth fracture so that there is adequate structure to
consistencies—flowable and viscous nanohybrids. retain a crown. These composites can be light-cured,
Flowables adapt well to the internal portions of the self-cured, or dual-cured. They often contain pigments
preparations, whereas viscous nanohybrids must be that colorize them so that they can be easily differenti-
carefully manipulated into the line angles and under- ated from natural tooth structure (Fig. 6.9). Dentin-col-
cut areas. One manufacturer uses a sonic device to ored core materials are used when all-ceramic crowns
manipulate the composite (SonicFill; Kerr Dental) into are to be placed. An amalgam core buildup would cre-
the preparation. The sonic energy makes the compos- ate an esthetically unacceptable dark discoloration un-
ite less viscous, so that it flows readily and adapts to der the all-ceramic crown, as light passes through the
all aspects of the preparation. When the sonic device porcelain and reflects off the amalgam.
is turned off, the composite regains its thicker viscos- Core composites are strong and can be bonded to
ity and can be sculpted and carved. Other common tooth structure to minimize bacterial leakage and in-
brands of bulk-fill composites include Tetric EvoC- crease retention. However, mechanical retention in the
eram Bulk Fill (Ivoclar Vivadent), QuiXX (Dentsply remaining tooth structure is necessary, because bond-
Sirona), Reveal HD Bulk (BISCO), and Filtek Supreme ing alone is not strong enough to resist the forces placed
Ultra (3M ESPE). Flowable versions include HyperFIL- on the crown. The tooth can be prepared immediately
DC (Parkell), SureFil SDR flow (Dentsply Sirona), and after the composite core is placed and polymerized.
Venus Bulk Fill (Heraeus Kulzer). In general, shade se- The materials are packaged in compules (also called
lection is very limited, with most manufacturers offer- “ampoules”), syringes, and cartridges with automix-
ing only one to four shades. ing tips similar to impression materials (see Fig. 6.12).

Light-curing bulk fill composite. To achieve the desired

depth of cure, the curing light must be used for the
recommended time. Check the light wand tip to make
sure it is free of residual composite debris that could
limit the transmission of light. Light exposure times for
fast-curing lights such as an argon laser or plasma arc
curing light, typically suggested as 5 to 10 seconds for
curing, may be too short to adequately cure a bulk-fill
composite to its depth; curing times may need to be
extended.

Packable Composites
Packable composites are highly viscous materials that
contain a high volume of filler particles (as much as FIG. 6.9 Composite core material with color contrasting to the tooth
90% by volume). The filler particles are long, rough, structure for easy identification during crown preparation. (Courtesy of
irregular fibers (about 100 μm in length) that bind on Dennis J. Weir [Novato, CA].)
 Composites, Glass Ionomers, and Compomers CHAPTER 6 95

Some core materials are supplied in syringes that have Protemp 3 Garant (3M ESPE), Luxatemp (Zenith/
two chambers (one for base and one for catalyst). An DMG America), and Integrity (Dentsply Sirona).
automixing tip is attached to the syringe to mix the Rubberized urethane is a new type of provisional
material. A small delivery tip can be added to the mix- composite resin that is similar to bis-acrylic in its set-
ing tip to deliver the mixed composite directly into the ting characteristics, radiopacity, and curing shrinkage.
preparation. However, many of its properties have been improved
Examples of composite core materials include because of the addition of a rubber molecule to the di-
Build-It FR (Pentron), Clearfil Photo Core (Kuraray urethane resin. It has increased flexural strength and is
America), CompCore AF (Premier Dental), CoreRe- less brittle, so it holds up better for longer-span bridg-
store2 (Kerr Dental), FluoroCore 2+ (Dentsply Sirona), es. It is more impact resistant under occlusal loading
and ParaCore Automix (Coltène/Whaledent). and is more flexible, so it is easy to insert and remove.
It is commercially available as Tuff-Temp (Pulpdent).
Both bis-acrylic and rubberized urethane materials
Clinical Tip
are available in several shades. They are dual-cured
Not all light-cured bonding agents are compatible with materials, so they can be chemically cured (about 90
chemical-cured composites, so follow the manufacturer’s to 120 seconds); if a clear matrix is used, they can be
recommendations when selecting a bonding agent for the
light-cured as well. They can be repaired easily with
core material.
flowable composites to add to contact areas and mar-
gins. They can be shaped and adjusted with acrylic
Provisional (Temporary) Restorative Composites burs, abrasive disks, and finishing diamonds. They
Provisional (temporary) crowns and bridges hold the can be polished with abrasive rubber points or wheels
prepared teeth in position so they do not drift and and polishing pastes or painted with a resin glaze to
change their proximal contact position or occlusal rela- provide a smooth, shiny surface.
tion with the opposing teeth (see Chapter 18). Provi- See Table 6.3 for a description of composite resin
sional restorations also have the following functions: types on the basis of their properties.
(1) they provide esthetics in the smile zone, (2) main-
tain proper speech, (3) allow proper function for chew- CLINICAL HANDLING OF COMPOSITES
ing, (4) maintain proper form for oral hygiene, (5) pro- Uses of Composite Resins
tect exposed dentin, and (6) provide a good marginal Composites are used in all classes of restorations, from
seal. class I through class VI. Although previously used
Until the last decade or so, acrylic resins (polymeth- mostly for class III and class V esthetic restorations,
ylmethacrylates) were widely used for the construction these materials are very popular for posterior as well
of provisional onlays, crowns, and bridges. They are as anterior restorations. Advantages and disadvantag-
inexpensive, but they exhibit wear, shrink significantly es of the various types of composites can be found in
on polymerization, and release heat as they cure. They Table 6.4. Composite materials are also used for pro-
have an unpleasant odor and taste, can discolor, and visional restorations, core buildups, fiber-reinforced
are messy to use. posts, and laboratory-fabricated onlays and bridges.
Newer provisional materials made with bis-acrylics
and rubberized urethane have improved physical and Selection of Materials
mechanical properties. Bis-acryl composite resin is easy Several criteria can be used for the selection of com-
to handle and comes in a two-tube cartridge with auto- posite resins for restorations. When used in the an-
mixing tips. It can be dispensed directly into the matrix terior part of the mouth in non–stress-bearing areas,
(or carrier) for a provisional restoration. It exhibits very selection is usually based on the ability of the material
little shrinkage on curing and is radiopaque. It is more to match the color of the teeth and to achieve a high
brittle than acrylic resin and tends to break more eas- polish. Microfills and microhybrids and nanohybrids
ily with longer-span bridges. Common brands include are well suited for this purpose. When incisal edges or
other stress-bearing areas are being restored, one of the

TABLE 6.3    Comparison of Properties of Composite Resins

POLYMERIZATION FLEXURAL COMPRESSIVE
COMPOSITE SHRINKAGE STRENGTH STRENGTH POLISHABILITY WEAR RESISTANCE
Macrofills Low High High Low Low
Microfills Moderate Moderate Moderate High Low
Hybrids (nano) Low High High High High
Bulk fill Low High High Moderate Moderate
Flowables High Low Low High Low
96 CHAPTER 6 Composites, Glass Ionomers, and Compomers

TABLE 6.4    Posterior Composite Resins: Advantages and Disadvantages

ADVANTAGES DISADVANTAGES
Durable (but not for as long as amalgam) More costly than amalgam
Placed in one appointment Wear is slightly greater than with amalgam
Good compressive strength Shrinks when cured
Tooth colored May leak, especially on root surfaces
Preparation more conservative than amalgam Technique sensitive—patient may have sensitivity to cold or biting if
restoration not properly placed
Bonding helps to support the surrounding tooth Not a good choice for very large restorations

micro- or nanohybrids should be considered, because own teeth. So, if a restoration is the same value as the
they are stronger than microfills. In the stress-bearing natural dentition but is slightly off in its color or chro-
areas of the posterior part of the mouth, again, one of ma, it will be better accepted by the patient than if the
the hybrid composites is usually chosen for its strength restoration is too dark or too light.
and wear resistance. Flowable composites should not
be used in areas subjected to stress or abrasion, be- Involving the Dental Assistant/Hygienist and the
cause they are relatively weak and wear more rapidly. Patient
The dentist often relies on the chairside assistant or hy-
HOW TO MATCH THE SHADE gienist to help obtain a good color match for restora-
Selecting the Shade tions with composite or ceramics. Three pairs of eyes
The dental assistant or hygienist may be asked to assist (doctor, assistant, and patient) are usually better than
the dentist in obtaining the appropriate shade for a res- one. Each person may interpret color differently. In ad-
toration. Selection of an inappropriate shade will result dition, color-blindness (or the inability to correctly per-
in a mismatch to the patient’s dentition. A poorly cho- ceive certain colors) is more common in males (about
sen shade will likely result in a re-make of the restora- 8% of males) than females. Involving the patients in
tion to satisfy the patient’s esthetic expectations. This shade taking helps the clinician in determining wheth-
is disappointing for all involved and usually results er their expectations can be met. Matching shades can
in additional chair-time and possibly an additional be very difficult, because many teeth do not match the
appointment. Therefore, it is important for all clinical standard shade guides.
members of the dental team to have an understanding
of what goes into the perception of color and how to Lighting for Shade Taking
match the variation of shades within a single tooth. The lighting in which the shade is viewed is very im-
portant. Shade matching should be done in two differ-
Color Characteristics: Hue, Chroma, and Value ent types of light, because the perception of shade may
When teeth are viewed for shade taking, three charac- vary in different lights, a phenomenon called metamer-
teristics should be taken into consideration: hue, chro- ism. Most dental offices have fluorescent or incandes-
ma, and value (see Chapter 2, section on Esthetics): cent lights (or both). Fluorescent lights emit more blue
• Hue is the color of the tooth and may include mix- light, and incandescent lights emit more yellow light.
tures of colors, such as yellow-brown. It is determined Some dentists install color-corrected light bulbs (at col-
by the wavelength of light that is reflected from or or temperature 5500 K) to help in shade taking. Ideally,
transmitted through the tooth. On a color wheel, the the laboratory should also have color-corrected light-
wavelengths of light range progressively from the ing. A natural north light is considered a good light for
shorter violet wavelengths to blue, green, yellow, and shade taking. However, early morning and late after-
red at the long end of the wavelength range. noon natural light contains more yellow and orange
• Chroma is the amount or intensity of color present; light and less green and blue. If possible, the shade
for example, a bold yellow has more chroma than a should also be taken while in the type of lighting that
pastel yellow. The more chroma, the more intense the patient is in most often. The bright light from the
the color (hue) will be. dental unit will tend to increase the perceived bright-
• Value is the amount of lightness or darkness of the ness of the shade and decrease the color intensity, so it
tooth (some describe it as the grayness of the tooth). should be turned off or moved away from the mouth.
A tooth with low value is darker and one with high
value is brighter. Also, as the chroma increases, the Matching the Shade
value will decrease. A neutral background is important, so that the colors
Patients tend to notice differences in value (or do not distract the eye and alter the perceived shade. A
brightness) more than differences in hue or chroma pastel-blue patient bib is a good color for shade taking.
when they assess how well a restoration matches their Female patients should be requested to remove lipstick
 Composites, Glass Ionomers, and Compomers CHAPTER 6 97

and colorful makeup, because these colors may influ- Shade Guides
ence the shade. Colorful clothes should be covered. Select the appropriate shade guide for the material
The room in which the shade is selected should not that will be used. Many manufacturers of composites
have brightly colored walls or decorations. The ideal include a shade guide with color tabs that can be used
color for the area in which the shade will be matched to help in shade selection. Sometimes these color tabs
is a neutral gray. are not an exact match to the composites they repre-
In general, the shade should be taken before the sent. Therefore, it is a good practice to apply and cure a
tooth is prepared and before a rubber dam or other small quantity of the composite selected onto the clean,
isolation is placed. The color of the rubber dam can in- moist tooth before the tooth is isolated and dried. Some
terfere with accurate matching, and teeth dry out and practitioners prefer to make their own custom shade
become lighter when under the dam or when isolated guides directly from the composite material, because
with cotton rolls. For best shade matching, the teeth these will be more accurate representations of the true
should be clean, free of stain, and moist. composite colors.
The shade tab should be moist and held in the same
plane as the surface of the teeth being matched, not in
Clinical Tip front of the teeth or behind them; otherwise the light
Prior to Taking the Shade: reflected off the tooth and the tab will be slightly dif-
• Have the patient remove lipstick and colorful makeup ferent (Fig. 6.10). The tab should be viewed under dif-
• Cover bright, colorful clothing with a neutral colored bib ferent lighting conditions. Do not stare at the color for
such as pastel blue
longer than a few seconds at a time, because the retina
• Place the patient in a neutral colored room
• Remove debris and surface stain from the teeth
adjusts for red and yellow colors, and the brain’s per-
• Do not isolate the teeth; keep them moist ception of the color will be off. Looking at a pastel-blue
• Move the dental unit light away from the mouth object (such as a pastel-blue patient bib) after each
shade tab was once recommended, but it causes blue
color retinal fatigue. Instead, look at a neutral gray
color for a few seconds.

A B

C D

FIG. 6.10 Shade selection for composites. A, Hold shade guide up to the teeth and look for the shade that is the closest
match. B, Hold that shade tab next to the tooth to be restored to confirm the match. C, If unsure of an exact match,
place a small amount of composite in the two closest shades on the tooth. D, Light-cure the composite so that its final
shade can be compared with the tooth. Select the closest match. On occasion, a couple of shades will need to be mixed
together to get a good match.
98 CHAPTER 6 Composites, Glass Ionomers, and Compomers

The patient, dentist, and assistant should view the increment of composite resin will chemically bond to
tabs and rank them as to the closest match for lightness the resin bonding agent on the enamel and dentin. Each
or darkness (value) and color intensity (chroma). If the additional increment will bond to the previously placed
color intensity of the tooth is low, it may be more diffi- increment of composite as long as good isolation is
cult to determine the color. In this case, the cervical area maintained and no contaminants are introduced. When
of a tooth with a more intense color, such as a maxillary resins polymerize, there is a thin layer of unpolymer-
canine, should be used to help pick the initial color. It is ized resin on the surface because contact with oxygen in
often necessary to take separate shades for the cervical the air inhibits the cure. This “air-inhibited” layer looks
portion of the tooth, for the occlusal surfaces of poste- shiny and feels slippery. This thin, unset layer facilitates
rior teeth, and for the incisal edges of anterior teeth. chemical bonding with the next layer of composite. It
Some clinicians find it helpful to arrange the shade will set when the layer placed over it excludes air and
guide tabs by value from lightest to darkest, and then then is cured. The completed restoration comprises a se-
they select the three shades closest to the tooth in val- ries of layers of resin-based materials that are all chemi-
ue. From there, they narrow the selection to the one cally bonded to each other and micromechanically (me-
that most closely matches the tooth color. chanically locking into microscopic irregularities created
by acid etching) bonded to the tooth structure. Starting
from the dentin side of the restoration and progressing
Clinical Tip
toward the composite, there are resin tags in the tubules,
A good use of time is to take the shade after the injection the resin-rich hybrid layer, the adhesive resin layer, and
of local anesthetic, while you are waiting for the patient to the composite resin restoration (Fig. 6.11). In most cases,
get numb.
the final thin, air-inhibited layer on the surface of the
composite is removed during finishing and polishing. It
may have an unpleasant taste and should be wiped off
PLACING THE COMPOSITE with gauze before the patient leaves if finishing and pol-
Thickness of Composite Increments ishing are not required (as with pit and fissure sealants).
Most composites should be placed in small increments
about 2 mm thick. Bulk fill composites can be placed in Contaminants
increments about 4 mm thick. Newly etched dentin is kept moist for “wet” dentin
bonding. However, before and after bonding, any
Light-Curing the Increments form of extraneous moisture (water, saliva, fluid from
If the composite resin is placed in too thick an incre- the gingival sulcus [i.e., space between the gum and
ment, the light might not penetrate completely, and the tooth], or blood) should be kept away from the tooth
composite might not cure all the way to the bottom. until the restoration has been completed. Contamina-
Longer curing times may be required for increments tion requires removal of the contaminant and re-etch-
greater than 2 mm thick. Even with a long curing time ing for 10 to 15 seconds. Alcohol should not be used
some light-curing units may not have the output needed to wet the composite placement instrument to keep
to cure to the bottom of large increments (>4 mm). More the composite from sticking, because it weakens the
powerful curing lights might be able to cure greater composite. Use of a little of the bonding agent or other
thicknesses of material. Interproximal areas may need
additional time to cure completely because of the more
difficult access of the area to the direct path of the light. It
is good practice to cure the interproximal composite res-
toration again from both facial and lingual surfaces after
the metal matrix band is removed to ensure complete
curing in the bottom of the box form of the preparation.
Darker shades also require a longer curing time, because
the light is more readily absorbed by the dark color and
does not transmit through the material as readily as
through lighter-colored materials. Composites that are
heavily filled also will take longer curing times because
the filler tends to disperse the light rather than allowing
it to transmit through the composite to its full thickness.

Resin-to-Resin Bonding FIG. 6.11 Scanning electron micrograph of a traverse section of

Etched enamel and dentin are infiltrated with resin bonded composite restoration after the tooth has been dissolved
away. Layers from the top are (C) composite, (A) adhesive layer, (H)
bonding agents to form a resin-rich layer. The resin- hybrid layer, and (T) resin tags that had gone into the dentinal tubules.
infiltrated dentin is called the hybrid zone or hybrid (From Sakaguchi RL, Powers JM: Craig’s Restorative Dental Materials
layer (see Chapter 5 Principles of Bonding). The initial (ed 13). St. Louis, 2012, Elsevier.)
 Composites, Glass Ionomers, and Compomers CHAPTER 6 99

unfilled resin on the instrument to prevent sticking can Dispensing and Cross-Contamination
dilute and thin the composite, making it weaker and Light-cured composites are supplied in compules or
more likely to wear. Special composite instruments are syringes. All of these containers are opaque so that the
made with a coating of nonstick materials to help with material is not affected by light. Some offices prefer
the stickiness problem. They should be reserved for single-use (unit-dose) items such as composite com-
composite placement, because once they get scratched pules (small containers of composite resin that fit into
they lose their nonstick quality. IRM, which contains a delivery gun) that can be disposed of after the proce-
eugenol, and liners, bases, or temporary cements con- dure to minimize the risk of cross-contamination. Re-
taining eugenol should not be used with composites, usable syringes require careful handling to ensure that
because eugenol inhibits the set of resins. they are not contaminated during the procedure. The
delivery tip on syringes of flowable composites should
Layering (Stratification) of Composite be disposed of in a sharps container after use, and the
Many dentists prefer to apply layers of composite of syringes should be recapped and sprayed or wiped
different shades or degrees of opacity or translucency with disinfectant. Composite in screw-type syringes
to obtain a good match to the natural teeth. This pro- should be dispensed after the shade is selected and
cess is called layering or stratification. Teeth are usu- covered in a light-protected container until use (Fig.
ally not one color throughout, but a variety of colors 6.12). Chemical-cured composites come in screw-type
and can be described as three general areas. (1) The tubes or two-container cartridges. They require similar
cervical part of the tooth is closest to the dentin color. dispensing measures to prevent cross-contamination.
This is because the translucent enamel is thinnest in If the composite is stored in the refrigerator, it should
the cervical part of the tooth, and light passing through be removed an hour or more before its planned use to
it reflects back the color of the dentin. The dentin color allow it to return to room temperature. Cold compos-
is the bulk of the color of the tooth and can range from ite will be stiff, less likely to stick to the placement in-
yellow to orange to red or mixtures of those colors. The struments but more difficult to adapt to the wall of the
dentin color of composite is usually the most opaque cavity preparation. Composite syringes or compules
and is useful for blocking out stains from amalgam can be placed in warm water to increase the flow of
or tooth discolorations. (2) The middle of the tooth is the material. Devices (e.g., Therma-Flo; Vista Dental
called the body area. Its color is a result of light interact- Products) are commercially available for warming the
ing with both enamel and dentin. The enamel in this composite. Manufacturers claim it makes highly filled
area is thicker than in the cervical area. (3) The incisal composites flow like flowable composites.
part of the tooth is mostly enamel and will be more
translucent. Often the interplay of the light with the
Clinical Tip
translucent enamel will produce a bluish tint to the
enamel. Cusp tips of posterior teeth are not translucent Placing a composite syringe or compule in warm water will
like anterior teeth but will appear lighter in color than increase its flow. Putting it in the refrigerator before use will
make it stiffer; consequently, it will not stick to the placement
the cervical or body areas.
instrument as much.
Dentists can select dentin, body, and enamel shades
and apply them in layers to simulate the natural tooth
colors with their opacities and translucencies. When
faced with a challenging color match, dentists may
choose to do a trial run or mock-up on the unetched
tooth. The colors selected are applied in the desired
layers and light-cured. The results can be seen and
modified, if necessary, before the tooth is restored.
Because the tooth has not been etched, the mock-up
material will come off easily. The restoration can be
characterized to replicate white spots, stains in occlu-
sal fissures, or bluish incisal translucency. Special tints
or stains made for composite can be used.

Shelf Life
The shelf life of composites varies with the type of
resin used and the manufacturer. In general, avoiding
heat and light can extend shelf life. Manufacturers usu-
ally recommend refrigerating the material. The aver-
FIG. 6.12 Dispensing systems for composites. Clockwise from top
age shelf life is 2 to 3 years if stored properly. Check the to bottom: Dual cartridges with auto-mixing tip, screw-type syringe,
label on the container that the composite came in to see injection-type syringe, dual syringe with auto-mixing tip and compules
the expiration date. delivered by a dispensing gun.
100 CHAPTER 6 Composites, Glass Ionomers, and Compomers

MATRIX SYSTEMS in the office to the desired diameter. With the T-band
Matrix systems for operative dentistry are com- (Pulpdent), flanges of metal that form the T shape can
prised of components such as metal or plastic be folded and crimped around the band at the desired
bands, wedges, and pressure rings (also called diameter. T-bands are thin, soft brass or stainless steel
separator rings) that help to adapt and shape the and have been used in pediatric dentistry for decades
restorative material. The matrix is used most often (Fig. 6.13).
when restoring the proximal surface of a tooth. It is The curing light is placed from the occlusal surface
also used for extensive direct restorations such as with metal bands for initial curing; then it is placed
complex composites or amalgams and crown build- from the facial and lingual surfaces after the matrix
ups. On occasion, a matrix is used when restoring band is removed. Any of these matrices can be used
cervical lesions with composite or glass ionomer with chemical-cured composites as well.
cement.
Wedges
Matrix Bands Wedges are placed interproximally and hold the ma-
The purpose of the matrix band is to help contain trix band against the tooth to seal the gingival mar-
the restorative material within the preparation dur- gin, so that the restorative material does not extend
ing placement and to develop natural contours and out of the cavity preparation and cause an overhang.
contact areas. Matrix bands for anterior teeth are usu- Wedges are usually placed from the lingual side, be-
ally clear plastic (polyether or celluloid), and they cause the lingual embrasure is usually the widest.
may be pre-contoured (e.g., Bioclear; Bioclear Matrix On occasion, wedges will need to be placed via both
Systems) to help shape the proximal surface of the buccal and lingual approaches to secure the band
restoration or straight strips (Mylar Strips; Keystone against the tooth without gaps at the gingival mar-
Industries). Pre-contoured forms are also available gin. Wedges are usually inserted with pressure to
for repairing a proximal surface involving an incisal create some separation of the teeth to make up for
angle. the thickness of the matrix band. Otherwise, when
Whole crown forms (e.g., Strip Crown Forms; the band is removed from the interproximal area
3M ESPE) can be used when the entire crown must after placement of the restoration, a space will ex-
be built up. The stock crown form is trimmed to fit ist between the restoration and the adjacent tooth
the remaining tooth structure, and then filled with (an open contact) leading to food impaction and
composite. After etching and application of bonding periodontal disease. Placing a wedge before cavity
agent, it is pressed onto the remaining tooth struc- preparation will help protect the gingival papilla
ture and cured. The crown form is slit and peeled and prevent bleeding during the preparation. It also
away. initiates separation of the teeth.
Matrix bands for posterior teeth are made of soft Wedges are made of wood or plastic and are
metal (typically stainless steel in thicknesses ranging color-coded for their size. Plastic wedges may be
from 0.02 to 0.045 mm) that is flat or pre-contoured opaque or transparent. The newer generations of
or of clear pre-contoured polyester (e.g., SuperMat plastic wedges (Wedge Wands [Garrison Dental So-
Matrix [Kerr Dental] and Composi-Tight Clear Bands lutions]; V4 Wedge [Ultradent Products]) have an
[Garrison Dental Solutions]). The bands may go en- advantage over the wooden wedges, because they
tirely around the tooth (circumferential) or just on a are shaped to conform better to the embrasure space
proximal surface (sectional). Sectional bands fit only and to the tooth. The Wedge Wand has a long handle
on one proximal surface at a time, as with mesioc- attached to the end of the wedge to facilitate place-
clusal or distocclusal cavities. Circumferential bands ment. The handle can be bent at 90 degrees to aid in
may be difficult to fit around a tooth that has only placement from the lingual side in the molar region.
one proximal surface prepared. A tight contact with After the wedge is put firmly into place, the handle
the adjacent tooth on the unprepared proximal side can be twisted off. Transparent wedges are used on
makes it difficult to slip the band down between the proximal surfaces when a clear matrix band is used
teeth. Placing a wedge in the interproximal space to for restoration of light-cured composites. The clear
separate the teeth can help in slipping the band be- wedge allows light transmission to cure the mate-
tween the unprepared teeth. Circumferential bands rial at the gingival margin; an opaque wedge would
are also difficult to use on a tooth that has been block the light (Fig. 6.14).
clamped for a rubber dam. Some of the sectional ma-
trix bands have a tab on the occlusal edge to make Sectional Matrix Systems
placement easier. Some of the bands have cervical ex- Sectional matrix systems used for class II compos-
tensions used for proximal boxes that extend subgin- ite resins usually are equipped with a selection of
givally. Circumferential metal bands can also be pre- pre-contoured sectional bands of various widths
welded into loops (Denovo Dental) or spot-welded appropriate for premolars or molars, a pressure
 Composites, Glass Ionomers, and Compomers CHAPTER 6 101

A B

C
FIG. 6.13 Matrix bands. A, Sectional metal matrix bands with some having cervical extensions. B, Clear plastic band.
C, T-Bands. (A and B, Courtesy of Garrison Dental Solutions, Spring Lake, MI; C, From Bird DL, Robinson DS: Modern
Dental Assisting (ed 11). St. Louis, Elsevier.)

A B
FIG. 6.14 Wedges. A, Wooden anatomic wedges. B, Plastic contoured wedges. (B, Courtesy of Garrison Dental Solu-
tions, Spring Lake, MI.)
102 CHAPTER 6 Composites, Glass Ionomers, and Compomers

ring, and ring placement forceps. Some systems Cervical Matrices

supply plastic wedges and forceps for handling the Plastic matrices are available for cervical composite
matrix band as well. Some of the bands have cervi- or glass ionomer restorations (Hawe Transparent Cer-
cal extensions for deep box forms. The matrix sys- vical Matrices [Kerr Dental], 360° Triodent Cervical
tems have a metal ring that is opened with forceps Matrices [Ultradent Products], Root Form [Directa],
like a rubber dam clamp and placed on the tooth to BlueView Cervical Matrix [Garrison Dental Solu-
engage the interproximal embrasures of a class II tions]) (Fig. 6.16). These matrices are placed over the
preparation. The ring has metal tines or soft rubber composite or glass ionomer (including resin-modified
that holds the sectional matrix band firmly against glass ionomer cement) to give it form and then the
the buccal and lingual surfaces of the tooth, and it restorative material is cured. The Contour-Strip Ma-
applies pressure to the teeth to cause some sepa- trix Band (Ivoclar Vivadent) is a preformed, U-shaped
ration (Procedure 6.1; and see Fig. 6.26). Once the band that is slipped subgingivally to help contain
band, wedge, and ring are in place, the band should and contour the gingival margin of these cervical
be burnished against the adjacent tooth surface to restorations.
ensure firm contact.
Popular sectional matrix systems include the Com- LIGHT-CURING
posi-Tight 3D Fusion Sectional Matrix System (Garri- Light-cured composite resins must receive the correct
son Dental Solutions), Palodent Plus Sectional Matrix amount of radiant energy at the right exposure time
System (Dentsply Sirona), and Triodent V4 Sectional and the right wavelength in order for them to poly­
Matrix System (Ultradent Products). The rings in merize completely. If the composite resin does not re-
these newer systems have a notch in the cervical ex- ceive this correct curing combination, then it will have
tent of the ring so they fit right over the wedge. The poorer physical and mechanical properties and will
matrix bands are anatomically contoured to shape the not hold up as well clinically. The result could be (1) a
contact areas and embrasures, and the rings adapt restoration with a shorter life span due to breakdown
them to the tooth while applying pressure to separate of the margins, (2) recurrent caries, (3) excessive wear,
the teeth for a solid contact (Fig. 6.15). The Triodent (4) fracture of the restoration, (5) discoloration of the
V4 system has a novel metal matrix band that has composite, or (6) lack of retention. The light source
hundreds of tiny windows that are resin-filled. These comes from a light-curing unit that may be built into
windows allow light to transmit to the composite the dental unit or free-standing. Free-standing units
during light-curing. have a handheld light guide (also called a wand) at-
If more than one proximal surface on a tooth is to tached to a base by a cord or may detach from a re-
be restored (i.e., a mesio-occluso-distal [MOD] restora- charging base and contain a battery pack.
tion), a sectional band could be placed on each proxi-
mal surface and pressure rings could be stacked one Light Factors Affecting the Cure
over the other. Otherwise, one proximal surface could Among the factors that can affect the cure of a restora-
be restored, and then the other. tion are the following: (1) short curing times, (2) inad-
equate light output, (3) the wrong wavelength of light,
Circumferential Matrix Systems and (4) an incorrectly positioned light guide. Surveys
The Tofflemire circumferential matrix system is well of dental offices have found that many of the light-cur-
established and very popular for amalgam restora- ing units had a reduced output of radiant energy. (At
tions. It is very difficult to use this system with class least 300 to 400 milliwatts [mW]/cm2 is needed.) The
II composites and achieve a good proximal contact light source may weaken in intensity with time and
area. Composite shrinks when it cures, and it can- should be checked periodically with a radiometer (Fig.
not be condensed against the matrix band as amal- 6.17). Other causes for reduced output are chipped or
gam can, so more separation of the teeth is needed to otherwise damaged light guides and debris such as
create a firm contact area. If a circumferential band, bonding agent or composite resin stuck to the tip of
like the Tofflemire band, is used, heavy wedging is the guide. Plastic barriers put over the light guide may
required to create enough separation of the teeth to also reduce the output, particularly if the seam of the
make up for the thickness of the band in both me- plastic cover is across the tip. Test the light output with
sial and distal interproximal spaces. In addition, the a radiometer with the barrier in place to see what effect
band is flat and needs to be contoured to the adja- it might have.
cent tooth to help form an anatomic contact area.
Pressure rings could be placed on mesial and dis-
Clinical Tip
tal embrasures to help with separation of the teeth,
but it is more difficult to place where the Tofflemire Periodically check the output of the curing light with a
retainer is connected to the band. Tofflemire bands radiometer to make sure it has not diminished. Inadequate
output will adversely affect the composite restoration.
and retainers are discussed in depth in Chapter 10
Dental Amalgam.
 Composites, Glass Ionomers, and Compomers CHAPTER 6 103

A B

D
C
FIG. 6.15 Sectional matrix systems. A, Sectional matrix set up with wedges, pressure ring (Triodent V3, Dentsply Caulk),
sectional matrix band, and ring forceps. B, Sectional matrix system applied clinically. C, Pressure ring (Composi-Tight
3D XR, Garrison Dental Solutions), for sectional matrix to create slight separation of the teeth to ensure a firm contact. D,
Pressure ring and sectional matrix band in place. (Courtesy of Garrison Dental Solutions, Spring Lake, MI.)

the restoration. The light guide should be held about

1 mm away initially and then almost in contact after
a second or two. The tip of the light guide should
be positioned at 90 degrees to the composite surface
so the light shines directly on the composite. How-
ever, it is not always possible to position the guide
at this angle or close to the composite surface. The
shape and size of the light guide may be a limiting
factor in the ability to position the tip ideally. When
restoring molars in patients who cannot open fully
or if matrix bands are in the way, the closeness to the
restoration and the light guide angulation may be
compromised.

Curing in proximal box. A proximal box may be 6

to 7 mm deep; most light guides cannot reach the
FIG. 6.16 Cervical matrices. (BlueView Cervical Matrix, courtesy of bottom of such a box, and therefore the tip will be
Garrison Dental Solutions, Spring Lake, MI.) several millimeters away from the increment of com-
posite on the gingival floor. Therefore, the curing
Position of the Light Guide time should be increased when (1) the light guide
The technique used to light-cure composite resin may angulation is compromised, or (2) it is positioned
also affect the amount of radiant energy that reaches further away from the composite than is ideal. In
104 CHAPTER 6 Composites, Glass Ionomers, and Compomers

FIG. 6.17 Radiometer used to test the output of the curing light.
(Courtesy Kerr Dental.)

addition, the composite in a proximal box should be

cured through the enamel from the buccal and lin-
gual sides after the matrix band is removed. Class III
FIG. 6.18 LED wand-type recharging curing light. (Demi Ultra, courtesy
restorations should also be cured from the facial and of Kavo Kerr Group, Charlotte, NC.)
lingual surfaces. It is thought that the high level of
recurrent caries (much higher than with amalgam)
seen at the gingival margin of the proximal box in a to be checked periodically with a radiometer to make
class II composite may be due, in part, to incomplete sure it will provide an adequate cure. The bulb output
curing of the composite or bonding agent at the bot- should be 400 to 800 mW/cm2 so if it drops below 300
tom of the box. Therefore, an increased curing time is mW/cm2, it should be replaced. Halogen units with
recommended (time will depend on the light inten- special turbo tips may generate as much as 1300 mW/
sity of the unit). cm2.
For curing lights with a heat output, a stream of cool
Types of light-curing units. Light-curing units are of air should be directed across the restoration while it is
four different types (Fig. 6.18): being cured to minimize heating the pulp.
• Quartz-tungsten-halogen (QTH or halogen, as they
are commonly called)
• Light-emitting diode (LED) Clinical Tip
• Argon laser To test the halogen curing light for heat output, put the light
• Plasma arch curing (PAC) tip on your fingernail and turn on the light for 20 seconds. If
These four types of curing lights can vary in their you can feel your nail getting hot, then your unit produces
enough heat to cause some pulpal sensitivity in deep
light intensity and the light spectrum (range of wave-
preparations. Use a stream of cool air on the composite
lengths) they produce.
during curing to help reduce the heat delivered to the
Simple LED curing units have the lowest inten- tooth.
sity of light and do not generate heat. The diodes can
last as long as 5000 hours, and rechargeable batteries
ensure portability and convenience. LED units emit
blue light (within the visible light range) at 450 to Rapid curing. Rapid curing greatly speeds up the
490 nm in wavelength. Newer versions of the LED procedure, because conventional curing of many
units can generate an energy output of about 1000 small increments each for 20 to 40 seconds increases
mW/cm2. At present, they are the most popular cur- the total time required. PAC and argon laser lights
ing light units. provide the fastest cure, but they also transmit heat
Halogen lights are next to lowest in light intensity. to the composite and the tooth. PAC lights are very
The halogen light bulb delivers a blue light that ranges intense (about 1000 mW/cm2) and are filtered to re-
from 400 to 500 nm in wavelength. The initiator, cam- duce heat. Argon laser lights are the most intense
phorquinone, absorbs light between 460 and 480 nm. and are marketed as high-speed curing units requir-
The halogen bulb generates heat so an internal fan is ing only 5 seconds for up to a 5-mm increment of
built into the unit. The bulb lasts about 100 hours but composite. Rapid curing will occur in the upper 2
deteriorates over time; the intensity therefore needs to 3 mm of the composite increment. Much of the
 Composites, Glass Ionomers, and Compomers CHAPTER 6 105

composite resin below that level will not cure com- in the shape of a gun. Many units have the capability
pletely, because the light is scattered and absorbed of being used remotely rather than being plugged into
and the intensity greatly diminishes. Thus, addition- an electrical outlet, because they have rechargeable
al curing time will be needed to achieve a complete batteries.
cure beyond 2 to 3 mm.
Light-Curing Methods
Match the curing light to the composite. Composites There are many representatives in the marketplace
that use camphorquinone (CQ) as the photoinitia- of the four types of light-curing units mentioned,
tor are usually well matched with the curing units. and there are many “bells and whistles” available
However, some composites use different photoinitia- with each type. In addition, several methods are
tors. The narrow light wave spectrum of argon lasers used for curing composite restorations with these
(490 nm) and most LED units (450 to 490 nm) may lights. These methods are used in an attempt to
be a mismatch for these non–CQ-initiated compos- minimize the stress on the bond created by poly­
ites, so they will not cure completely. Broadband merization shrinkage. One method is called soft-
LED units that have a broad light spectrum and a start curing. The theory is that a slow rate of curing
higher intensity have been made to correct this prob- will allow the resin to flow as the polymer chains
lem. Halogen lights have a broad light spectrum (400 are being formed and, thereby, reduce the curing
to 500 nm) and will cure all of the current compos- shrinkage stress. There are three forms of soft-start
ites. PAC light units are the least common of the four curing: (1) ramped, (2) stepped, and (3) pulse-delay.
types. They have a very intense light, are filtered to Ramped curing starts with low light intensity, grad-
reduce heat, and have a broad spectrum of light (400 ually increases to high intensity over a 10-second in-
to 500 nm). terval, and then remains constant for the rest of the
Typical curing times for LED and halogen lights exposure. Stepped curing starts at low intensity for
for thin layers are 20 to 40 seconds for each 2-mm 10 seconds, and then immediately goes to maximal
increment. Longer curing times are needed for (1) intensity for the rest of the exposure. Pulse-delay
thicker increments, (2) bulk-fill composites, (3) very curing starts with a brief low-intensity exposure,
light bleaching shades, (4) darker composites, (5) then delays for shaping the restoration, and finally
opaque composites, (6) heavily filled composites, or completes the exposure with a long exposure at high
(7) composites located farther from the light probe intensity. Some clinicians want to speed up the cur-
than is ideal. The amount of additional time de- ing process and use very fast curing called turbo cur-
pends on the type and intensity of the light being ing. However, high-intensity exposure even for short
used. The intensity of the light diminishes rapidly intervals will generate higher stress during curing.
the farther away the composite is from the tip of the Newer high-speed or variable-intensity light units
light guide. should use the curing times recommended by the
manufacturers. Only recently have some manufac-
Factors requiring longer curing times for composite resins: turers started to give guidance on curing times for
• Increments thicker than 2 mm (or 4 mm for bulk-fill their materials.
composites)
• Very light shades for whitened teeth
Desirable Features for Your Curing Light
• Opaque shades
• Easy to use
• Darker shades
• Simple infection control procedures
• Heavily filled composites
• Broad spectrum output to cure all composites
• Composites located farther from the light tip than ideal
• High output for effective polymerization
• Has a radiometer to test output
Areas of composite that lie just outside the borders • Wide curing tip angled at 900 with short height for ac-
of the light guide tip (typically 8 mm in diameter) cess in the posterior
should be cured separately. Wider tips are available • Durable
and may be useful when curing broad areas such as
occlusal composites or sealants or anterior veneers. Eye protection. The blue light emitted from a cur-
The wider the tip, the more divergent the light beam ing unit can be damaging to the retina of the eye.
will be, so longer curing times may be needed. Some With curing units increasing in their light intensity
manufacturers provide narrow diameter tips for the risk for damage becomes greater if precautions
reaching into proximal box preparations or other are not taken. A prolonged blast of blue light direct-
tight spaces. ly into the eye can cause immediate and irreversible
The light guide on the curing unit is often glass, damage to the retina. Repeated low-level exposure
glass encased in metal, or a type of plastic. Some cur- over time can accelerate aging of the retina and con-
ing units are in the configuration of a wand; others are tribute to macular degeneration. Protective glasses
106 CHAPTER 6 Composites, Glass Ionomers, and Compomers

with filters that block the blue light should be worn

Precautions
by those in the operatory—the operator, assistant,
and patient. Some offices use an orange filter shield • Inadequate light output: It is important to check halogen
that is held between the operator and the light. Some light–curing units frequently (monthly), because the light
bulbs will deteriorate over time and will not produce an
units have a filter that attaches to the light guide.
adequate cure. Other light units should also be tested
Looking directly at the light, even briefly, should be periodically. In addition, light probes can darken with
avoided. application of surface disinfectants or sterilization or can
become chipped or scratched and may not transmit light
Infection control methods. In many offices the light as well. If composite or a bonding agent has come in
guide and handle (or the entire unit, depending on contact with the light tip and hardened on it, this will im-
the type) are covered with a disposable barrier such pede the light output. Light output can be measured with
as a clear plastic cover. The cover will also prevent commercially available radiometers (light meters). Some
bonding agent, composite resin, blood, and other light units have a built-in light meter for periodic testing.
debris from sticking to the tip of the guide. The • Premature set of composite: The operatory light can
ideal unit is one with a removable light guide that cause an initial set of the surface of the composite as it
is being placed. Once this has happened, the compos-
can be autoclaved and has smooth surfaces that
ite can no longer be manipulated, but it is not cured
can be wiped down with disinfectant. Autoclaving through the depth of the material. The operatory light
may cause some residue to accumulate on the tip should be moved farther from the composite or tempo-
of the light guide, but it can be polished off. Some rarily turned away from the field, so that the direct light
disinfecting solutions may cause clouding of glass- is not shining in the patient’s mouth. Operators using
fibered light guides and can discolor the plastic cas- headlamps should turn them away or use a filter on the
ing of the unit. Check with the manufacturer for the light. Some manufacturers have added chemicals to
recommended disinfectant. inhibit premature polymerization by ambient light.
• Eye protection: The operator is cautioned to use a light-
shielding protective device to protect the eyes of the
Guidelines for Light-Curing patient and the staff. Protective eyewear that filters the
• P rovide eye protection to those exposed to the light. light should be used by the patient, assistant, and op-
• Position the patient so as to provide best access for the erator. The intense blue light has the potential to cause
light to the restoration. damage to the retina with direct exposure.
• Check the light guide tip for damage or debris. • Heat generation: Some curing lights (halogen, argon
• Use curing times and output modes recommended by laser, and PAC) generate a certain amount of heat when
the manufacturer. applied to the tooth, and composite resins release
• Err on the side of using longer curing times than heat (exothermic reaction) when they polymerize. The
shorter. combination of the two heat sources has the potential
• Direct the light at 90 degrees to the composite surface. to elevate the temperature of the pulp in deep cavities
• Start curing with the tip about 1 mm from the compos- that have less than 1 mm of dentin over the pulp. An
ite surface and move closer after the surface has cured. increase in pulpal temperature of about 6°C has the
Use longer curing times when the tip is farther away potential to cause an inflammatory reaction in the pulp
from the composite. and even death of the pulp. A protective liner or base
• When close access to the composite is limited (as with may be needed before placing the composite.
a class II proximal box), supplement with curing from
buccal and lingual sides after the matrix is removed.
• With high-intensity curing units and extended exposure
FINISHING AND POLISHING
times, blow an air stream over the tooth to prevent
overheating. Pause for a couple of seconds between Finishing is the process used to correct irregularities in
curing cycles. contour, remove excess material, and smooth the mar-
Adapted from Ferracane JL, Watts DC, Ernst C-P, et al: Effective use of dental
gins and external surfaces. Polishing takes the process
curing lights: A guide for the dental practitioner. ADA Professional Prod Rev, a step further by removing scratches by the step-wise
8:2–13, 2013.
application of sequentially finer abrasives to produce a
glossy, very smooth surface. The smooth surfaces pro-
duced with polishing resist plaque retention and make
cleaning with floss and brush much simpler (see Chap-
Caution ter 13 Abrasion, Finishing, and Polishing).
Do not look directly at the light when curing materials.
Before starting the finishing and polishing process, the
Stabilize the light tip using finger rests before you look restoration should be dried and inspected for (1) integ-
away from the light to prevent it from drifting away from the rity of margins, (2) surface voids, (3) over- or undercon-
restoration. toured surfaces, and (4) snug proximal contacts, if pres-
Use a light shield or filtering eyewear to protect the eyes. ent. If a rubber dam is being used, the inspection should
Have the patient close his or her eyes, or provide filtering be done while the dam is still in place. This is a prime
eyewear. opportunity to make corrections to the restoration before
 Composites, Glass Ionomers, and Compomers CHAPTER 6 107

the surface becomes contaminated. If surfaces have been tiny abrasive silicon carbide polishing particles), e.g.,
contaminated with saliva or blood, re-isolation is needed Jiffy brush (Ultradent Products), to produce a high
and the surfaces should be rinsed and dried. The area shine on occlusal surfaces. Very fine disks can be used
of the composite to be repaired and the adjacent tooth on facial, lingual, and accessible proximal surfaces.
surface are prepared. Then, start as though preparing to Very fine abrasive strips can also be used on proximal
place the composite for the first time with acid etching, surfaces. Some operators will give a final polish with
application of bonding agent and composite. a soft brush and polishing paste to gain a high luster
(Fig. 6.19).
Finishing
Excess composite can be removed with multi-fluted Clinical Tip
carbide finishing burs, fine and ultrafine diamond The finishing process will be much easier if care is taken
burs, and abrasive disks. Small excesses at the gin- during composite placement to carefully develop contours
gival margin or interproximal can be removed with and not grossly overfill the cavity preparation.
special composite knives, a #12 surgical scalpel blade,
flame-shaped carbide or diamond burs, or abrasive
Surface Sealers
strips. Carbide and diamond finishing burs and disks
Some clinicians prefer to add an unfilled resin to the
should be used at slow speeds with gentle, controlled
surface of the composite after finishing and polishing.
(finger rest), intermittent strokes moving from tooth
This surface sealer is thought to reseal margins that
to restoration so as not to ditch the margins or flatten
might have been opened by polymerization shrinkage
contours. With intracoronal restorations the surround-
and to fill in any surface porosities created by small
ing tooth structure is the guide to developing the con-
voids or air pockets in the composite that were uncov-
tours and shaping the occlusal anatomy. When using
ered by finishing. Finishing itself may introduce mi-
finishing strips to finish the gingival margin on the
crocracks on the surface and the low-viscosity, unfilled
proximal surface, be sure the strip is not so wide as to
resin can help fill and repair them.
engage the contact area. Otherwise, it may produce a
To place the unfilled resin, the surface of the com-
weak or open contact. Narrow strips are commercially
posite is rinsed and dried thoroughly; it and the sur-
available, or wide strips can be cut in half lengthwise.
rounding enamel are etched for 15 seconds, and then a
When using abrasive disks on convex surfaces as with
thin layer of the unfilled resin is applied and thinned
cervical restorations, smaller disks should be used and
further with a gentle stream of air and light-cured for
their angulation to the tooth should be changed to fol-
20 seconds. Thick layers might interfere with the oc-
low the tooth contours. Otherwise, the restoration may
clusion. Interproximal contacts should be flossed to
be flat rather than convex like the tooth. Some opera-
ensure that resin has not been trapped. Some manu-
tors prefer flame-shaped diamonds to finish the con-
facturers are marketing an unfilled resin as a replace-
vex surfaces. Egg-shaped or football-shaped carbide
ment for polishing, because a smooth, glossy surface is
and diamond finishing burs can be used to finish and
obtained. However, the unfilled resin does wear off in
contour the occlusal surfaces of posterior teeth and the
about a year, leaving an improperly polished surface
lingual surfaces of anterior teeth.
that can collect plaque and accelerate wear.
Finishing is considered complete when (1) all flash
Composite resin has many applications in restor-
(excess composite extending over the cavosurface
ative dentistry. It is a versatile and very esthetic mate-
margins) has been removed, (2) the cavosurface mar-
rial, but it must be handled properly to maximize its
gins are flush and smooth-feeling to the explorer, (3)
longevity in the harsh environment of the mouth.
the axial contours have been refined, (4) the occlusal
anatomy shaped, and (5) the occlusion adjusted. Only WHY COMPOSITES FAIL
when all of the surfaces have been properly finished
It has been estimated that 60% of all operative dentist-
and contoured should polishing be started.
ry work done is to replace failing restorations. Studies
Polishing have shown that amalgam restorations outlast com-
Polishing of composites can be achieved by the use of posite restorations in similar applications. Composite
successively finer abrasive disks and interproximal fin- restorations are more technique sensitive than amal-
ishing strips; rubber polishing points, cups, and disks gam restorations. However, composite resins have
impregnated with abrasives; and polishing pastes. A gained in popularity for posterior applications because
highly polished surface will not be achieved if steps patients demand esthetic restorations, and they have
are skipped in progressing from coarser to finer pol- concerns about metals, especially mercury.
ishers. As with finishing, the polishers should be used The average lifespan for composite resin restora-
by moving from tooth to composite using similar light tions (both anterior and posterior) is 5.7 years. Two
and intermittent strokes to prevent the generation of of the most common reasons for failure of light-cured
heat. Polishing cups or points are used on the occlusal composites are (1) fracture of the restoration and (2) re-
and other accessible surfaces. Some operators like to current caries. Composites are also replaced because of
use polishing brushes (bristles are impregnated with excessive wear, breakdown and leakage at the margins,
108 CHAPTER 6 Composites, Glass Ionomers, and Compomers

A B

C D

E F

G
FIG. 6.19 Finishing and polishing. A, Fine diamond bur used to reduce excess composite and smooth margins. B and
C, Fine disks used to smooth and contour the composite. D, Narrow metal finishing strip used to smooth margins and
contour the embrasure surfaces. E, Very fine disk used to polish the facial surface. F and G, Rubber polishing points
used to polish the facial and lingual surfaces. (From Contouring, Finishing and Polishing Anterior Composites, by K. Wil-
liam Mopper, DDS, from manuscript in Inside Dentistry, March 2011.)
 Composites, Glass Ionomers, and Compomers CHAPTER 6 109

discoloration, and fracture of the tooth. One of the ma- LABORATORY-PROCESSED COMPOSITES
jor problems with class II composites is recurrent caries An impression of the preparation, opposing cast, bite
at the gingival margin of the proximal box. Certainly, registration (or digital versions of these items taken
patient factors such as poor diet, poor oral hygiene, with an optical scanner) and a prescription with the
and bruxism can contribute to recurrent caries and proper shade are sent to the laboratory for construc-
fracture, but also operator errors are important causes. tion of the restoration. There are several advantages to
Operator errors include poor cavity preparation, inad- having the restoration constructed in the laboratory.
equate isolation, over- or underetching, improper rins- The technician can process the composite material un-
ing and drying of the tooth, poor incremental place- der heat and pressure. This creates a restoration that is
ment techniques, open proximal contacts, overheating denser, polymerized more completely, and is tougher.
the pulp, and inadequate curing of the bonding agent The polymerization shrinkage occurs outside of the
or composite resin. mouth, and then the restoration is cemented with a
thin layer of resin cement. Shrinkage from the thin
COMPOSITE REPAIR layer of resin cement is much less than would have
Many clinicians who practice minimally invasive den- occurred with a composite that is cured in the tooth.
tistry will attempt to repair existing composites rather Therefore, less stress is created internally on the com-
than replace them when there are only minor defects at posite and the walls of the cavity preparation. Micro­
the margins or small areas of chipping. Usually, these are leakage should be reduced.
larger composites that are otherwise in good condition. Blocks of composite for CAD/CAM milling have
There are no long-term clinical trials that indicate how also been processed under heat and pressure to gain
effective the repair of an existing composite is in the oral the advantages discussed for laboratory processed
environment. However, studies with 2- to 3-year follow- composites.
up show good success rates with repair of margins.
The protocol for repairing a newly placed compos- Materials for Indirect Composites
ite differs from that for an older composite. A repair Different types of composite materials can be used:
done at the same visit as the initial placement (e.g., the 1. Conventional composite
patient bites down and fractures a corner off the mar- 2. Fiber-reinforced composite, which contains a fiber
ginal ridge just after the restoration has been placed) mesh composed of carbon Kevlar (similar to the
will have a chemical union between the repair and the material used in bulletproof vests), glass fibers, or
initial composite, because there will still be unreacted polyethylene for improved strength
methacrylate to join with the new addition. Howev- 3. Particle-reinforced composite, which is heavily
er, the older the composite gets, the fewer unreacted filled (70% to 80% by weight) with particles of nano-­
methacrylate groups will be present. So, the repair sized ceramic filler. An advance in CAD/CAM
will need to rely more heavily on mechanical retention composite blocks is Lava Ultimate (3M ESPE) (see
than bonding. The bond of the new composite to the the section CAD/CAM Technology in Chapter 9).
old composite in this case will be less than 50% of the Lava Ultimate is a composite that is composed of
initially placed composite. The most successful repairs nanoceramic fillers in a heat-treated, highly cross-
occur when there is enamel rather than dentin on the linked resin matrix. It has high flexural strength,
tooth side of the repair. increased wear resistance, long-lasting polish, and
stain resistance. Its initial strength is greater than
INDIRECT-PLACEMENT COMPOSITE RESINS blocks of feldspathic or leucite-reinforced porcelain
Indirect-placement esthetic materials are tooth-colored (see Chapter 9), is not as brittle, and is less prone to
materials that are constructed outside of the mouth cracking under functional loads. It causes less wear
(chair-side or in the laboratory), and then cemented in of the opposing enamel than ceramic materials. It
place. Composites can be used for indirect methods as can be repaired with conventional nanohybrid com-
well as direct. Some indirect-placement composite res- posites. It can be used to fabricate onlays, inlays,
torations are fabricated on a die (replica of the prepared and veneers. It is not recommended for full cover-
tooth) and others are designed and milled from a block age crowns, because it is somewhat flexible under
of composite material using CAD/CAM (computer- chewing forces causing the cement bonds to break.
assisted design/computer-assisted machining) tech- After adjustments it can be re-polished with rubber
nology (see Chapter 9 Dental Ceramics). The finished polishing points, and then with extrafine (5 μm) dia-
restoration is tried in the mouth, adjusted, and bonded mond polishing paste on a bristle brush for a high
into place with bonding agent and resin cement. Indi- shine.
rect materials were developed to try to eliminate the
problems associated with polymerization shrinkage, Indirect chairside technique. An impression is made
such as marginal leakage, post-treatment sensitivity, of the prepared tooth with alginate. Immediately, a
and recurrent caries, and to reduce the wear seen with fast-setting die stone or a polyvinyl siloxane die ma-
direct composites. terial (e.g., Mach-2 Die-Silicone, Parkell) is injected
110 CHAPTER 6 Composites, Glass Ionomers, and Compomers

A B

C D

FIG. 6.20 Indirect composite technique—making the restoration at chairside. A, Pretreatment mesio-occluso-distal
(MOD) amalgam restoration in the lower first molar. B, Tooth prepared for MOD composite inlay. C, Polyvinyl siloxane die
of the preparation from an alginate impression. D, Composite inlay prepared outside of the mouth at chairside. E, Com-
posite inlay after cementation with a resin cement. (Courtesy of Alton Lacy, University of California School of Dentistry
[San Francisco, CA].)

into the impression. The resulting die is used to

make the restoration with light-cured composite
CONVENTIONAL GLASS IONOMER CEMENTS
material at the chairside. The composite restora- Glass ionomer cements (GICs) were introduced in the
tion is seated into the preparation and adjusted. It early 1970s by Wilson and Kent. GICs are self-cured,
is removed from the mouth and polished on the die. fluoride-releasing materials that bond to tooth struc-
Then it is cemented with resin cement in the same ture directly without a bonding agent. They are made
manner as laboratory-processed composite inlays by mixing a water-soluble polyacrylic acid (pH 1.0)
(Fig. 6.20). with fluoroaluminosilicate glass powder (base). An
acid-base reaction occurs when the liquid and powder
are mixed. The acid is neutralized by the base and fluo-
GLASS IONOMER CEMENTS
ride and other ions are released.
Glass ionomer cements are categorized in two main Several GIC materials have been developed and
forms: classified for use in dentistry:
• Conventional glass ionomers Type I: Luting (cementation) agents
• Resin-modified glass ionomers (also called hybrid Type II: Restorative materials
ionomers) Type III: Liners and bases for cavity preparations
 Composites, Glass Ionomers, and Compomers CHAPTER 6 111

The materials in these three types are similar in from in-office applications, fluoride rinses, or fluo-
chemical composition, but the size of the powder ride toothpaste and re-release it, thereby acting as
particles and the ratios of powder and liquid are a fluoride reservoir. The assumed caries-preventing
different. effects of the fluoride released from glass ionomer
cements have not been proved in clinical studies
PHYSICAL AND MECHANICAL PROPERTIES but are based on laboratory test results. Fluoride
Glass ionomers have some highly desirable character- has some antibacterial properties as well, and it is
istics, as well as some drawbacks: thought to suppress the streptococci associated with
Biocompatibility: Glass ionomers are tolerated well tooth decay.
by surrounding soft tissues and are considered kind Solubility: Among the less desirable properties of GICs
to the pulp. is their sensitivity to moisture uptake or loss during
Bond to Enamel and Dentin: GICs bond directly to the the first 24 hours after placement. They are highly
enamel and dentin. They are the only restorative soluble during this time and should be covered with
materials that form an ionic (chemical) bond to a protective varnish. They also are prone to crack
tooth. The carboxyl group of the polyalkenoic acid or craze (develop numerous shallow cracks on their
chemically bonds to calcium in the tooth hydroxy- surface) if dried too much during the first 24 hours.
apatite. With GIC there is no intermediate bonding Earlier generations of the glass ionomers could not
agent that can hydrolyze over time as with compos- be finished until they had completely set after 24
ites. GICs shrink about 2% to 3%, but because they hours. Newer materials can be finished within a few
set gradually, they do not generate the great internal minutes of their set and are not as sensitive to mois-
stresses that might break bonds to the tooth, as com- ture uptake or loss.
posite resins do with their rapid set. They absorb Thermal expansion and contraction: They have thermal
water over time and this helps to offset the contrac- expansion and contraction similar to tooth structure
tion. Therefore, glass ionomers maintain their seal and stiffness (modulus of elasticity) comparable to
to the tooth better. dentin.
On a tooth surface that has been prepared with a Thermal protection: They are good insulators against
carbide or diamond bur or hand instrument, a smear temperature extremes.
layer forms (see Chapter 5). As with resin bonding Compressive and tensile strength: They have a moder-
agents in order for the GIC to bond to the tooth, the ately high compressive strength but are weaker in
smear layer must be removed. To remove only the tension and are relatively brittle in thin sections.
smear layer and not the calcium in the surface of the New formulations that use modified polyacrylic
preparation, a weak acid (usually 10% polyacryl- acid have better fracture toughness, but they still
ic acid) is applied for 10 seconds, and then rinsed should not be used in stress-bearing areas such as
and lightly dried. Phosphoric acid used to etch the occlusal surfaces and incisal edges for permanent
tooth before application of bonding agents should teeth.
not be used on dentin. It is too aggressive and re- Wear resistance: Glass ionomers wear faster than com-
moves not only the smear layer but also removes a posite resins. Their surface gets rougher over time.
layer of hydroxyapatite from the dentin. That leaves They cannot be polished to as smooth a surface as
collagen exposed. The GIC cannot bond to the col- composites.
lagen, and therefore no bond is formed. The res- Radiopacity: They are more radiopaque than dentin.
toration may leak, have postoperative sensitivity, Color: Glass ionomers are more opaque than compos-
and may fall out. ites. Translucency and the number of colors avail-
Although the bond strength of GIC to the tooth is able have improved over the years.
about one-fourth that of composite, the bond in
non-stressed areas is adequate. The seal to the tooth, PACKAGING
however, is superior on dentin compared with that GICs are supplied in three ways: (1) hand-mixed pow-
achieved with composite, and thus microleakage der and liquid, (2) encapsulated powder and liquid,
is minimized. On root surfaces where maximal es- and (3) two-paste systems. The powder and liquid
thetics is not necessary, GIC should be considered can be measured and mixed quickly (usually less than
instead of composite. For noncarious cervical le- 30 seconds) at chairside on a paper pad, and then de-
sions (abrasion/abfraction/erosion) the root surface livered on an instrument into the cavity preparation.
is usually very smooth and difficult to bond to. A The material also comes in capsules with premeasured
carbide or coarse diamond bur should be used to powder and liquid. The capsule is activated by ruptur-
roughen the surface before removing the smear layer ing a membrane that separates the powder from the
and placing the GIC. liquid. The capsule is placed in a triturator and is mixed
Fluoride release: GICs release an initially high level of at speeds and times recommended by the manufactur-
fluoride for the first few days, and then the fluoride er. The capsule is then inserted into a gun-type applica-
levels fall to low levels. They can absorb fluoride tor and delivered into the cavity preparation through
112 CHAPTER 6 Composites, Glass Ionomers, and Compomers

a nozzle on the capsule. The third method of delivery improve their wear resistance and strength. However,
is a paste-paste system. Very fine glass powder is used the gain in strength is still inadequate to use them in
in the pastes to provide a creamy consistency to the stress-bearing areas. Because they are dark gray in col-
mixed pastes. The two pastes are contained in a two- or, cermets are used in locations where esthetics is not
chambered cartridge and are dispensed in equal por- a concern and as core buildup materials when the bulk
tions onto a paper pad. The pastes are quickly mixed of the subsequent crown will be supported by tooth
together and applied to the preparation. A variation of structure.
the third delivery method uses a two-chambered car-
tridge with two pastes that are mixed with an automix- Liners and bases. Glass ionomer liners are materials
ing tip and delivered directly into the cavity prepara- used to cover the dentin for pulpal protection from
tion with a fine nozzle. chemicals within other restorative materials or acid
The GICs are manufactured in a variety of shades etchants. They have low powder content and are ap-
but not in the wide selection available with composites. plied in thin layers that are relatively weak. Glass iono-
mer bases are used to rebuild missing dentin within
USES FOR GLASS IONOMER CEMENTS the cavity preparation and provide thermal protection
Luting Cements for the pulp, especially with metal restorations such as
(See also Chapter 14 Dental Cement.) Glass ionomer amalgam. They are usually much thicker layers than
luting cements were once very popular because they liners. They have a higher powder content and stron-
are pulpally kind, bond to tooth structure, release flu- ger mechanical properties.
oride, and have a low film thickness, so crowns can be
seated easily. Their use has decreased since the intro- Lamination or “sandwich” technique. On occasion,
duction of hybrid ionomer cements and resin cements glass ionomer is used in combination with another
that have better physical and mechanical properties restorative material to gain the best properties of
(stronger and less soluble). These newer and stron- each material. In 1985 John McLean described a lam-
ger hybrid ionomer cements are also used to cement ination technique (called the “sandwich” technique)
orthodontic brackets and have the advantage over with GIC and composite resin. It is most commonly
resin cements of releasing fluoride into the surround- used when the proximal box of a deep class II cavity
ing enamel. The objective is to help prevent decalcifi- preparation has the gingival floor located on the root
cation seen as white lines around brackets or bands, rather than enamel. GIC is placed as the first layer
which often occurs when patients’ oral hygiene ef- on the gingival floor of the proximal box. Glass iono-
forts are poor. mer can obtain a better seal to the root than com-
posite and additionally will release fluoride into the
Restorative Materials surrounding root surface to resist secondary decay.
Glass ionomer restoratives are used in non–stress-bear- Composite resin is used to complete the restoration
ing areas, because they are weak in tensile strength and (Fig. 6.22).
are not as wear resistant as composites. They are used
for restoration of root caries, because they bond to the Clinical Tip
root better than composites and release fluoride to re-
Before applying glass ionomer cement to a cavity
sist recurrent caries. They are useful for restoration of
preparation, remove the smear layer that forms when
noncarious cervical lesions (such as toothbrush abra-
a preparation is cut. Use a conditioner (typically 10%
sion), because they can be placed conservatively with- polyacrylic acid) for 10 seconds on enamel and dentin.
out the need for cutting away sound tooth structure to Rinse and lightly dry. The clean surface will allow the glass
create mechanical locks in the tooth to retain the res- ionomer to bond to the calcium in the tooth surface. Do not
toration, as is necessary with amalgam. Studies show use phosphoric acid. It is too aggressive on dentin and will
that they are better retained than composites in class remove the calcium from the surface and expose collagen.
V preparations. They can be used in anterior class III GIC cannot bond to collagen.
cavities when color match is not an issue. Encapsulat-
ed materials are desirable, because powder-to-liquid
ratios are improved. Mixing is done in a triturator and Glass ionomer cement (GIC) as fissure sealant. Glass
provides a consistent mix with less trapped air than is ionomer cements have been used as fissure sealants
seen with hand-mixing. The mixed material can also because of their fluoride release. Some GICs (Fuji VII
be dispensed directly into the cavity from the capsules, and Fuji Triage, GC America) have been formulated
which have a dispensing tip attached (Fig. 6.21). to have very high fluoride content (about six times
as much as regular GIC). Studies have shown that
Cermets. In the 1980s GIC restoratives called cermets they are not retained as well as resin sealants. GIC
(e.g., Ketac Silver [3M ESPE]; Miracle Mix [GC Amer- is fairly thick and does not penetrate fissures as well
ica]) were developed to improve on the properties of as resin sealants. However, those who advocate the
GIC. These products have silver particles added to use of GIC suggest that it will provide fluoride to
 Composites, Glass Ionomers, and Compomers CHAPTER 6 113

A B

D E
C
FIG. 6.21 Delivery systems for glass ionomer cements (regular and resin-modified). A, Glass ionomer may be supplied as
powder and liquid in containers with powder measuring spoons (liner and luting at top left and right, respectively) or as
powder and liquid premeasured in capsules. The encapsulated material is mixed in a triturator and delivered by a gun dis-
penser (bottom). B, Paste-paste resin-modified GIC dispenser. C, Glass ionomer may also come in a paste-paste system
with a dispenser that distributes the proper proportions (the green clicker system). D, Packaging of single-unit automix
capsule for two-paste resin-modified GIC. E, Two-paste capsule activated and in delivery gun with dispensing nozzle
extended. (B-E, From Sakaguchi RL, Powers JM: Craig’s Restorative Dental Materials (ed 13). St. Louis, 2012, Elsevier.)

Sandwich technique high fluoride-containing materials are also used as

in a Class II cavity preparation provisional restorations in caries-active patients who
need caries control measures before final restorations
are placed.
Composite resin
Atraumatic restorative treatment. In developing coun-
Glass ionomer tries with rural villages or in areas of high poverty in
the United States where dental treatment is not avail-
able, dental caries often goes untreated, and serious
Glass ionomer (GI) is “sandwiched” and painful abscesses can occur. The atraumatic re-
between the tooth and composite. GI storative treatment (ART) technique allows non–den-
seals better on the root while composite is tally trained personnel to help stop or slow down the
more wear resistant and esthetically
progression of open carious lesions without the use of
pleasing.
dental drills. The way it works is that treating person-
FIG. 6.22 Sandwich technique with glass ionomer “sandwiched” nel dig out as much decay as they can from frank open
between the tooth and composite restoration.
cavities with whatever implements they have. Next,
they mix specially formulated high-viscosity GIC (e.g.,
the newly erupted tooth surface and make it more Ketac Molar [3M ESPE] or Fuji IX [GC America]). The
resistant to future caries. Newly erupted enamel mix is rolled between the fingers into a ball and is
does not contain as much mineral, including fluo- pressed by hand into the cavity. The patient bites down
ride, as enamel that has been exposed to saliva for while the material is still soft, to establish the occlu-
some years. Saliva is a supersaturated solution of cal- sion. Excess material is wiped away. Although a less
cium and phosphate ions and contains fluoride from than ideal procedure, it helps to maintain teeth when
drinking water, toothpaste, and other sources. These no other options are available.
114 CHAPTER 6 Composites, Glass Ionomers, and Compomers

Vitrebond (3M ESPE) and Fuji Lining LC (GC America).

Glass Ionomer Cements
RMGIC luting cements include Fuji Plus (GC America),
ADVANTAGES Nexus RMGI (Kerr Dental), and RelyX Plus (3M ESPE).
• Chemically bond to enamel and dentin
• Release fluoride NANO-IONOMERS
• Take up fluoride to act as a fluoride reservoir Nanoparticle technology has also been applied to
• Reduced microleakage on dentin RMGICs to improve their physical properties. These
• Reduced postoperative sensitivity nano-ionomers, or nano-GICs, have improved esthet-
• Biocompatible ics (they match tooth colors better), increased wear re-
• Expand and contract similar to tooth structure
sistance, and improved polishability. Ketac Nano (3M
DISADVANTAGES ESPE) was introduced in 2007. It is a two-paste system
• High wear rate in a dual-chamber cartridge that is extruded onto a pad
• Too weak for stress-bearing restorations and hand-spatulated. The filler particles are nanosized,
• Less esthetic (more opaque) than composites silane-treated silica particles and zirconia-silica nano-
• Cannot polish as well as composite—surface rough clusters similar to those found in nanocomposites. A
• Initially sensitive to water loss or uptake
newer version (Ketac Nano Quick) is packaged as a pre-
measured two-paste system in an automixing capsule,
and the mixed material can be dispensed directly into
RESIN-MODIFIED (HYBRID) IONOMERS
the cavity preparation. Dispensing systems for resin-
To improve on the physical and mechanical properties modified glass ionomers can be seen in Fig. 6.21, A-D.
of glass ionomers, resin mostly in the form of 2-hydroxy-
ethyl methacrylate (HEMA) has been added. These CLINICAL APPLICATION OF GLASS IONOMER
materials are called resin-modified (or hybrid) glass ion- CEMENTS
omers because they are a blend of resin and glass iono- GIC restorative materials are popular for use in prima-
mer. Resin-modified glass ionomers (RMGICs) are used ry teeth for most classes of cavity preparation, because
for many of the same applications as regular glass ion- the teeth are usually exfoliated (shed) before exces-
omers. They have some properties of composites and sive wear can become a problem. They can be used for
many of the properties of glass ionomers. Resin makes crown buildups when half or more of the tooth struc-
them stronger, more esthetic, more polishable, and ture remains to help support the crown. Otherwise,
more wear resistant. They are more esthetic than GIC, they lack the strength necessary to reliably support the
because they are not as opaque. Once the resin polym- crown on their own. They are very useful for restor-
erizes, it protects the material from exposure to mois- ing root caries because they provide a better seal to the
ture and drying while the acid-base reaction goes to root than composite resins (Fig. 6.23).
completion. The polymerized resin makes the RMGIC As previously mentioned, the smear layer must be
less soluble and gives it early strength. RMGICs can removed from the prepared enamel and dentin to al-
be finished immediately after placement. They release low the formation of a chemical bond between the GIC
fluoride into the surrounding tooth structure and into and the calcium on the surface. After the smear layer
the saliva, and they can absorb fluoride from fluoride is removed with a mild acid (polyacrylic acid condi-
products to act as a fluoride reservoir and gradually re- tioner), and rinsed off, the preparation is lightly dried,
release the absorbed fluoride. Their thermal expansion not totally desiccated. The GIC is applied to the clean
and contraction is similar to tooth structure. surface and a chemical bond will form.
Resin-modified glass ionomers are available as light- The GIC can be delivered to the cavity preparation di-
cured materials. Light polymerization of the resin com- rectly from the nozzle of the capsule, or, if hand-mixed,
ponent occurs in a similar fashion to composite resins. it is picked up on an instrument and placed in the prep-
Most of these materials also have a chemical cure of the aration. It can be contoured somewhat with a plastic in-
resin in the absence of light, as well as the acid-base re- strument or with a cervical matrix. Unlike composite,
action of the glass ionomer cement. The chemical cure GIC is not very viscous and cannot be readily shaped
allows for final curing in locations where light cannot before it sets. Typically, the cavity preparation is slightly
reach, but it takes longer to cure than when light acti- overfilled and final contouring is accomplished with
vated. For example, if the margin of a gold crown with carbide or diamond finishing burs under water spray.
caries was repaired with glass ionomer cement, the ce- It is important when placing the GIC to stop manipu-
ment up under the margin would not be accessible to lating it when the initial gel stage begins. The gel stage
the curing light because of the gold but would chemi- can be identified by a loss of shininess of the material and
cally cure in a few minutes. Examples of restorative an increase in viscosity. Working time varies from 1.5 to
RMGICs are Fuji II LC (GC America), Riva Light Cure 3 minutes, depending on the manufacturer and whether
(SDI), and Photac Fil (3M ESPE). or not the material is regular or fast set. Even light-cured
RMGIC is formulated for use as lining cement and hybrid GIC starts to gel in less than 3 minutes in the
luting cement as well. Examples of GIC liners are oral cavity when not exposed to the curing light. After
 Composites, Glass Ionomers, and Compomers CHAPTER 6 115

A B
FIG. 6.23 Restoration of root surface lesion. A. Abrasion/erosion lesion on mandibular second premolar B. Lesion
was restored with resin-modified glass ionomer cement. (Courtesy Dr. Thomas J. Hilton, Portland, OR.)

approximately 5 minutes, the new formulations of con- added to enhance the level of fluoride release, but this
ventional GICs can be contoured and finished with car- is still much less than with glass ionomers.
bide or diamond finishing burs or abrasive disks. Light- Compomers for restorations are available as a light-
cured RMGICs can be finished right away. It is best to cured single paste that is packaged in compules or sy-
apply a protective varnish that is usually furnished with ringes or in a flowable form much like flowable compos-
the material or to coat it with an unfilled resin surface ites. Common brands include Dyract eXtra (Dentsply
sealer. Even though the material has gone to its initial set, Sirona) (see Fig. 6.24) and Compoglass F (Ivoclar Viva-
an acid-base reaction still occurs for several hours within dent). Compomers are made for luting as well and are
the material. The coating protects it from excessive up- manufactured as a powder and liquid or as a two-paste
take of moisture from the saliva. Core buildup GICs can dual cartridge with automixing capability. Luting agents
be reduced as part of the crown preparation after the ini- may be chemical-cured, light-cured, or dual-cured.
tial set. They will be protected by the provisional crown The setting reaction in restorative compomers oc-
until the final crown is cemented. The glass ionomer ce- curs in two phases. Phase 1 is similar to that of the
ments have grown in popularity as their handling char- light-activated composite resins and forms a resin net-
acteristics, esthetics, and ease of use have improved. work encompassing the fillers. This causes the mate-
rial to harden in the cavity preparation. Phase 2 is an
acid-base reaction that occurs more slowly over sev-
COMPOMERS eral days as the restoration absorbs water.
Compomers are essentially composite resins that have Compomers do not bond to tooth structure through ion
been modified with polyacid. The resin component exchange as glass ionomers do. Acid etching and primer
contains polycarboxylic acid and methacrylates to-
gether. This provides methacrylate groups for cross-
linking as with composites and carboxyl groups for
the acid-base reaction as with glass ionomers, hence
the name compomers. The idea was to join the good
qualities of the composite (namely strength, wear re-
sistance, esthetics, and polishability) with the fluoride
release of the glass ionomer. Light-activation chemicals
are included to make the compomers light-cured. The
fillers (about 45% to 65% filled by volume) are glasses
similar to those used in composites, along with some
fluoride-releasing silicate glasses, and range in size
from 0.8 to 5.0 μm. The release of fluoride, however, is
not the same as with the glass ionomers, because the
resin binds these fillers together as soon as the light
activation starts the curing process. Fluoride release is
delayed for some months and does not seem to be at all
comparable to that of the self-cured or light-cured glass
ionomers. Likewise, there is little or no recharging of
the compomer with fluoride as with glass ionomers. FIG. 6.24 Compomer restorative material. Dyract eXtra (Dentsply
Some compomers have fluoride-releasing monomers Sirona) in compules. (Courtesy Dentsply Sirona.)
116 CHAPTER 6 Composites, Glass Ionomers, and Compomers

TABLE 6.5    Comparison of Properties of Direct Esthetic Restorative Materials

COLOR BONDING AGENT FLUORIDE COMPRESSIVE FLEXURAL
MATERIAL MATCH NEEDED RELEASE WEAR RATE POLISHABILITY STRENGTH STRENGTH
Glass ionomer Low No High High Low Low Low
Hybrid ionomer Medium No Medium Medium Medium Medium Medium
Compomer High Yes Low Medium High Medium Medium
Microfill composite High Yes No High High Medium Medium
Hybrid (nano) composite High Yes No Low High High High
Adapted from Craig RG, Powers JM, Wataha JC: Dental Materials: Properties and Manipulation, ed 7, St. Louis, 2000, Mosby.

or adhesive are indicated during placement of the com- bone. Bioactive dental cements were introduced in the
pomers. The bond strength to dentin is about the same as mid 1990s with ProRoot MTA (Dentsply, Tulsa Dental
that of a hybrid glass ionomer. The bonding agents will Specialties) for root sealing and repair.
reduce the chances of fluoride leaching from the material In dentistry the term bioactivity has come to mean
into the dentin. Research indicates that they have about the ability of a material to form apatite-like substance on
the same cervical margin adaptation as composite resins. its surface when exposed to body fluid such as saliva.
They can be used in most situations where a microfilled The dental biomaterials with this apatite-forming abil-
composite would be used, that is, mostly for low stress– ity used in clinical applications fit into two groups: cal-
bearing class III and V restorations. Finishing and polish- cium silicates and calcium aluminates. When powders
ing is accomplished the same as for composites. of these materials are mixed with water they undergo
an acid-base reaction that culminates in an alkaline pH
when set. The higher pH tends to stimulate more bioac-
GIOMERS tivity. Their physical strength and mechanical properties
Giomers are relatively new hybrid restorative materials. are similar to conventional glass ionomer cement. Calci-
The name “giomer” is derived from the words “glass ion- um ­aluminate– and calcium silicate–based cements have
omer” and “composite” as these new materials have some been shown to have some degree of bonding to dentin.
of the desirable properties of each. Giomers release fluo- These bioactive cements have been used primarily as lin-
ride but less of it and at a slower rate than glass ionomers. ers and pulp capping materials (TheraCal LC, BISCO),
They can be recharged with fluoride from toothpaste or bases (Biodentine, Septodont), and luting cements (Cer-
mouth rinse to act as a fluoride reservoir. They obtain anir, Doxa) to remineralize and stimulate repair of den-
their fluoride from fillers that are a product of the reaction tin and as endodontic sealer (EndoSequence BC Sealer,
between fluoroalumino silicate glass and polyalkenoic Brasseler USA) or root repair materials (ProRoot MTA).
acid. These pre-reacted glass ionomer fillers are added to More recently, the bioactive materials have been
a urethane resin that has silica fillers. The filled resin com- added to resins to promote bioactivity. One product,
ponent provides good handling properties, esthetics, and Activa (Pulpdent), claims to be a bulk fill, bioactive
polishability. Like composites and compomers, they are composite that penetrates and seals dentin and stim-
light-cured and require the use of a bonding agent. ulates apatite formation. Newer bioactive materials
Giomers are packaged as single-paste syringes or show promise but need to establish a sound clinical
flowables. The first manufacturer (Shofu) to market a record before gaining widespread acceptance.
restorative giomer has it in three forms: Beautifil II—a
paste, Beautifil Flow Plus—a flowable material available
SUMMARY
in no-flow and low-flow viscosities, and Beautifil Bulk
Flowable—a bulk-fill flowable material. They are use- Composite resins are very popular direct-placement
ful for the restoration of cervical carious and noncarious esthetic materials. They have a wide variety of uses in
lesions and for all classes of cavities in primary teeth. both the anterior and posterior parts of the mouth. They
Because these materials are relatively new, not much is are esthetically pleasing and durable restorative materi-
known about their long-term clinical performance. als that are rapidly replacing amalgam as the material
Table 6.5 compares the properties of the direct es- of first choice in posterior teeth. They have applications
thetic restorative materials (except for giomers because in all classes of cavity preparations and many cosmetic
they are newer materials and not widely used). applications. They can be used to close anterior diaste-
mas as a conservative alternative to porcelain veneers.
Indirect composites also have applications where re-
BIOACTIVE DENTAL MATERIALS duced shrinkage and added strength can be achieved
Bioactive materials interact with living tissues. One of by processing the material in the laboratory or by using
the first bioactive materials was a bone grafting ma- preprocessed composite blocks for CAD/CAM technol-
terial, Bioglass, which formed chemical bonds with ogy. Glass ionomer cement restorative materials are not
 Composites, Glass Ionomers, and Compomers CHAPTER 6 117

as esthetically pleasing and strong as composite resin of either material. Like giomers, they are not widely
and cannot be polished to a high shine, but they offer used. Bioactive materials with the capability to repair
the advantages of bonding directly to the tooth with- and remineralize damaged dentin show much promise.
out a bonding agent and providing a better seal to the
root structure. They have wide applications in pediatric
INSTRUCTIONAL VIDEOS
dentistry and for restoration of root caries in the elderly.
Compomers are materials that are closer to composites See the Evolve Resources site for a variety of educational
than to glass ionomers but do not have the best qualities videos that reinforce the material covered in this chapter.

Procedure 6.1 Placement of Class II Composite Resin Restoration

See Evolve site for Competency Sheet. small amount of composite in the closest shade and
light-curing it on the tooth for 20 seconds.
Consider the following with this procedure: safety glasses are
NOTE: Shade is taken before the rubber dam is
recommended for the patient, PPE is required for the operator,
applied, because the color of the dam might interfere
ensure appropriate safety protocols are followed, and check your
with taking an accurate shade, and the teeth might dry
local state guidelines before performing this procedure.
out under the dam and appear lighter. Lipstick should
be removed, and brightly colored clothing should be
EQUIPMENT/SUPPLIES (FIG. 6.24) covered with a pale blue or gray patient bib to prevent
• Rubber dam setup the colors from influencing the perceived shade.
• Curing light and light shield 3. Apply the rubber dam.
• Composite placement instruments NOTE: Cotton roll isolation can be used, but a rub-
• Light-cured nanohybrid composite resin ber dam provides more reliable isolation. Moisture
• Bonding agent and finishing glaze from the breath can affect the bond adversely.
• Mixing wells or Dappen dish 4. Rinse and dry the cavity prepared by the dentist.
• Finishing burs, diamonds, disks 5. Apply a sectional matrix, wedge, and pressure ring
• Articulating paper in paper forceps (Fig. 6.26).
• Local and topical anesthesia setup
• High-volume evacuator tip
• High- and low-speed handpieces
• Shade guide
• Etchant and applicator
• Matrix system and wedges
• Polishing points, cups, paste

PROCEDURE STEPS
1. Apply topical anesthetic. Local anesthetic is
administered.
2. Take a composite shade. Hold the shade guide
close to the patient’s mouth and select two or three
shade tabs that are close to the patient’s tooth color.
Moisten and check each tab individually against FIG. 6.26 (Courtesy of Dr. William Liebenberg. North Vancouver, BC,
the tooth under room light (and natural light, if Canada.)
possible) (Fig. 6.25). Verify the shade by taking a

NOTE: A Tofflemire matrix can be used, but it is

much more difficult to obtain tight contact when both
mesial and distal interproximal spaces have matrix
band in them at the same time. The wedge helps close
the matrix band at the gingival margin to prevent over-
hang of composite, and it helps separate the teeth to
make up for the thickness of the matrix band so that
firm contact with the adjacent tooth can be established.
The pressure ring helps adapt the matrix against the
facial and lingual surfaces of the tooth and helps sepa-
FIG. 6.25
rate the teeth slightly.

Continued
118 CHAPTER 6 Composites, Glass Ionomers, and Compomers

Procedure 6.1 Placement of Class II Composite Resin Restoration—cont’d

6. Apply etchant to enamel first for 10 to 20 seconds, dentin primer is usually light-cured for 10 to 20 sec-
and then apply it to dentin for 10 seconds (Fig. 6.27). onds before placement of the bonding resin. Some den-
NOTE: Etching dentin for longer than 10 seconds tists prefer to use a base or liner on the dentin before
will overetch it and contribute to weaker bond strength acid etching.
and postoperative sensitivity by opening the tubules 9. Dry gently and light-cure for 20 seconds.
excessively. A self-etching bonding system could be NOTE: Drying at this step removes water and vola-
used instead, and no rinsing would be needed (see tile solvents from the resin.
Chapter 5). 10. Apply composite resin in small increments, starting
7. Rinse thoroughly and dry lightly so that the dentin with the proximal box (Fig. 6.29). Each increment
remains slightly moist (glistening but no pooling of should be no more than 2 mm thick and light-cured
water). for 20 to 40 seconds.
NOTE: Drying the dentin will cause collapse of the NOTE: Small increments are used to minimize the
collagen fibrils and interference with penetration of the effects of polymerization shrinkage and to allow the
dentin primer into the tubules and etched dentin sur- light to cure the increment all the way through. Dark
face (see Chapter 5). or opaque shades are more difficult for the light to
penetrate and require longer curing times. Increase
the curing time when the light probe is more than 1
mm from the composite. Some curing lights may have
an initial low setting that ramps up to a high intensity
to minimize shrinkage and stress within the material.
Some very high intensity curing lights require less cur-
ing time. Manufacturers’ recommendations should be
followed.

FIG. 6.27 (Courtesy of William Liebenberg. North Vancouver, BC,

Canada.)

8. Apply dentin primer/bonding resin with a brush

applicator as directed by the manufacturer (dentist’s
choice of one- or two-bottle bonding materials) and
thin with a gentle stream of air (Fig. 6.28).
NOTE: See Chapter 5 for one- and two-bottle dentin
primers and bonding resins. When the dentin primer
FIG. 6.29 (Courtesy of William Liebenberg. North Vancouver, BC,
and bonding resin are applied in separate steps, the Canada.)

11. Remove the pressure ring, wedge, and matrix

band after the cavity preparation is slightly
overfilled with composite and cured. Cure the
proximal box for an additional 20 to 40 seconds
from the facial and the lingual sides. Contour
the occlusal surface and remove excess material
with finishing diamond and carbide burs. Disks
and interproximal finishing strips are used on the
proximal surfaces (Fig. 6.30). Check the contact
area with floss to ensure solid contact and no
overhang at the gingival margin.
NOTE: The composite in the proximal box should
FIG. 6.28 (Courtesy of William Liebenberg. North Vancouver, BC,
Canada.)
be cured again from the facial and lingual sides af-
ter removal of the matrix and wedge, because these
 Composites, Glass Ionomers, and Compomers CHAPTER 6 119

Procedure 6.1 Placement of Class II Composite Resin Restoration—cont’d

FIG. 6.30 (Courtesy of William Liebenberg. North Vancouver, BC, FIG. 6.31 (Courtesy of William Liebenberg. North Vancouver, BC,
Canada.) Canada.)

materials may have partially blocked light transmis-

sion to the floor of the box, causing an incomplete cure
of the composite.
12. Remove the rubber dam. Check occlusal contacts
with articulating paper and adjust.
NOTE: A high restoration can cause a sore tooth by
stressing the periodontal ligament, or a tooth that is
temperature sensitive.
13. Polish surfaces with polishing points, cups and
brushes at low speed. A polishing paste can
be used to produce a highly polished surface
(Fig. 6.31).
NOTE: Some operators prefer to apply a finishing FIG. 6.32 (Courtesy of Dr. William Liebenberg. North Vancouver, BC,
glaze to the composite. A finishing glaze is an unfilled Canada.)
resin that bonds to the composite resin. Its purpose
is to reseal the margins if polymerization shrinkage seconds, rinsed, and dried. A brush is used to apply a
has caused composite to pull away from the enamel very thin layer of glaze so as not to interfere with the
margin, and it fills in any small voids in the surface occlusion. It is light-cured for 20 seconds.
that contribute to wear and staining. When the glaze
is used, the tooth is isolated with cotton rolls, and
the composite and adjacent enamel are etched for 10

Get Ready for Exams!

Review Questions c. Coupling agent

d. Fillers
Select the one correct response for each of the following
2. Composite resins are often classified according to
multiple-choice questions.
their
1. The major components of composite dental materials a. Strength
include all of the following except one. Which one is this b. Polishability
exception? c. Resin content
a. Bonding agent d. Filler particle size
b. Resin matrix
Continued
120 CHAPTER 6 Composites, Glass Ionomers, and Compomers

Get Ready for Exams!—cont’d

3. T he shortcomings of flowable composites as com- 10. W hich one of the following types of composites is the
pared with more viscous microhybrid composites weakest and should not be used in stress-bearing tooth
include all of the following except one. Which one is surfaces?
this exception? a. Hybrid
a. They are weaker. b. Microfill
b. They wear faster. c. Nanofill
c. They shrink more when polymerized. d. Nanohybrid
d. They are more difficult to polish. 11. Heavily filling the resin matrix with nanosized fillers
4. The purpose of a silane coupling agent for composite particles will reduce which one of the following?
resins is a. Curing time
a. To improve the bond between the filler particles and b. Strength of the material
the resin matrix c. The esthetics
b. To help the composite retain its color d. Polymerization shrinkage
c. To reduce the oxygen-inhibited layer 12. Which one of the following composites is most difficult
d. To help the various layers stick together to polish to a high shine?
5. The curing light requires repair a. Hybrid
a. If it causes a slower set of a dark-color composite b. Microhybrid
b. If it has not been tested c. Nanohybrid
c. If a 2-mm-thick piece of composite does not cure d. Macrofilled composite
through the bottom at the recommended exposure time 13. Which one of the following types of composites gener-
d. If the light appears blue ally will shrink the most when polymerized?
6. Polymerization shrinkage of a composite a. Bulk-fill composite
a. Is cause for alarm b. Microhybrid
b. Is greater than 10% of the volume c. Flowable composite
c. Can be minimized by placing and curing a series of d. Nanocomposite
small increments 13. Common effects of polymerization shrinkage of com-
d. Has no effect on the final restoration posites may include all of the following except one.
7. Fillers are composed of all of the following except one. Which one is this exception?
Which one is this exception? a. Microleakage
a. Quartz b. Death of the pulp
b. Alumina c. Microcracking of enamel causing white lines around
c. Silica the margins
d. Glass d. Postoperative sensitivity
8. Which one of the following statements about a coupling 14. Methods used to minimize polymerization shrinkage
agent is false? include all of the following except one. Which one is this
a. It minimizes the loss of filler particles. exception?
b. It reduces wear. a. Cure the composite rapidly with a high-intensity light.
c. It prevents filler from sticking to the resin. b. Use prepolymerized filler clusters.
d. It is made of silane. c. Use composite with a high filler content.
9. All of the following will increase the wear of a d. Place composite using small increments.
composite restoration except one. Which one is this 15. All of the following circumstances may require a longer
exception? curing time for a composite except one. Which one is
a. Use of large filler particles this exception?
b. Incompletely curing the composite a. Use of an opaque shade
c. Use of small amount of filler particles b. Use of increments of composite greater than 2 mm
d. Saliva contamination of the etched enamel c. Placement of the curing light tip 6 to 8 mm from the
composite
d. Composite placed in a class III preparation on #8
mesial
 Composites, Glass Ionomers, and Compomers CHAPTER 6 121

Get Ready for Exams!—cont’d

16. W hat allows a new increment of composite to stick to c. A re closer to composite resins in their makeup than
the previously cured increment? to glass ionomers
a. Mechanical retention d. Are like glass ionomers in that they do not require a
b. Chemical resin-to-resin bond separate bonding agent
c. Addition of a bonding agent to the cured increment For answers to Review Questions, see the Appendix.
d. The silane coupling agent
17. The function of the wedge placed interproximally with a Case-Based Discussion Topics
class II preparation includes all of the following except
one. Which one is this exception? 1. A 24-year-old aspiring actress comes to the dental office
a. Stop bleeding seeking replacement of occlusal amalgams in her man-
b. Create slight separation of the teeth dibular molars, because they are visible when she talks
c. Seal the matrix band against the tooth at the gingival and sings. She does not grind her teeth.
margin From among the esthetic materials discussed in this chapter,
d. Protect the gingival papilla during cavity which ones have properties that would make them suitable
preparation for use in this situation? Which ones are more suitable for
18. One of the advantages of glass ionomer compared to anterior class III or V cavities?
composite is 2. A 75-year-old retired plumber who is taking medication
a. The ability to finish it immediately to control his blood pressure is found on examination to
b. That it has higher strength than composite because have a dry mouth and numerous root caries.
of the glass fillers Which types of direct-placement esthetic materials dis-
c. That it uses the same bonding agents as cussed in this chapter would have the greatest advantage for
composites restoring root caries? Why? How do these materials bond to
d. That it has been shown to release fluoride tooth structure?
19. Which one of the following statements about glass iono- 3. A 43-year-old nurse comes to the office complaining of
mer cement (GIC) is false? tooth sensitivity to air, cold, and sweets. Examination
a. GIC chemically bonds to the mineral of the tooth. reveals several deep noncarious, cervical lesions caused
b. GIC releases fluoride. primarily by heavy toothbrushing with stiff bristles. No
c. GIC functions well for class II restorations in adults. dental caries is present.
d. GIC reduces microleakage at margins of a restora- Considering that resistance to wear is an important physical
tion on the root. property, are lightly-filled, flowable composites suitable ma-
20. Resin-modified (hybrid) glass ionomers have all of the terials? Why or why not? What other materials could be used
following advantages over conventional glass ionomers successfully in this situation?
except one. Which one is this exception? 4. A 57-year-old secretary comes to the dental office for a
a. Stronger periodic examination and prophylaxis. She has maxillary
b. Less sensitive to moisture when set anterior composite veneers and class V glass ionomers
c. Can be finished at the same appointment in her maxillary premolars.
d. Contain quartz fillers like some composites What must the dental hygienist and dental assistant be con-
21. Nano-ionomers have all of the following properties cerned about when treating patients who have esthetic com-
except one. Which one is this exception? posite and glass ionomer restorations present in their mouths?
a. Improved esthetics 5. An 18-year-old volleyball player was hit in the mouth with
b. Increased wear resistance an elbow by one of her teammates. Tooth #9 was fractured
c. Improved polish at the mesioincisal edge creating a 4 mm by 4 mm loss of
d. Greater strength than nanocomposites tooth structure. The patient is being seen on an emergency
22. Compomer restorative materials basis and the dentist asked you to set up the operatory.
a. Release as much fluoride as glass ionomer materials Which types of composites would work well for this situation?
b. Are only self-cure resins Why? Which type of composite should be avoided? Why?
122 CHAPTER 6 Composites, Glass Ionomers, and Compomers

BIBLIOGRAPHY Mount GJ, Hume WR: Glass-ionomer materials, composite res-

ins, and rigid materials used in tooth restoration. In Preser-
Anusavice KJ, Shen C, Rawls HR: Resin-base composites. Phillips’ vation and Restoration of Tooth Structure. Philadelphia, 1998,
Science of Dental Materials (ed 12). St. Louis, 2013, Saunders. Mosby.
Bird D, Robinson D: Restorative and esthetic dental materials. Mousavinasab SM: Biocompatibility of composite resins. Dental
In Modern Dental Assisting (ed. 12). St. Louis, 2018, Elsevier. Res J, 8:S21–S29, 2011.
Christensen GJ: Does your curing light have the most desirable Nagaraja UP, Kishore G: Glass ionomer cement—the different
characteristics? Clinicians Report, Spring, 1–2, 2017. generations. Trends Biomater Artif Organs, 18:158–165, 2005.
Donly KJ, Segura A, Weffel JS: Evaluating the effects of fluoride- Powers JM, Wataha JC: Direct esthetic restorative materials. In
releasing dental materials. J Am Dent Assoc, 130:819, 1999. Dental Materials: Properties and Manipulation (ed 10). St. Louis,
Ferracane JL: Dental Composites in Materials in Dentistry (ed 2). 2013, Mosby.
Philadelphia, 2001, Lippincott Williams & Wilkins. Radz GM: Direct composite resins. Inside Dentistry, 7(7):108–114,
Ferracane JL, Watts DC, Ernst CP, et al: Effective use of dental 2011.
curing lights: A guide for the dental practitioner. ADA Profes- Roberson TM, Heymann HO, Swift EJ: Biomaterials. In Sturde-
sional Prod Rev 8:2–12, 2013. vant’s Art and Science of Operative Dentistry (ed 5). St. Louis,
Glazer HS, Lowe R, Strassler HE: Rubberized-urethane composite 2006, Mosby.
for provisional restorations. Inside Dentistry, 8(6):78–82, 2012. Sakaguchi RL, Powers JM: Restorative materials—composites
Jefferies SR: Bioactive dental materials: composition, properties and polymers. In Craig’s Restorative Dental Materials (ed 13).
and indications for a new class of restorative materials. Inside St. Louis, 2012, Mosby.
Dentistry, 12(2), 2016. Shah P: Composite roundup: the basics of bulk fill. Dental Prod-
Leinfelder KF, Bayne SC, Swift EJ: Packable composites: over- ucts Report, 2013.
view and technical considerations. J Esthet Dent, 11(5):234– Wilson AD, Kent BE: A new translucent cement for dentistry:
249, 1999. The glass ionomer cement. Br Dent J, 132:133–135, 1972.
Marshall GW, Marshall SJ, Bayne SC: Restorative dental mate-
rials: scanning electron microscopy and x-ray microanalysis.
Scanning Microsc, 2(4):2007–2028, 1988.
Preventive and Desensitizing Materials 7
http://evolve.elsevier.com/Eakle/materials/

Chapter Objectives
Upon completion of this chapter, the student should be able to:
1. Describe the applications of fluoride in prevention. 10.  pply sealants to teeth (as permitted by state law).
A
2. Explain how fluoride protects teeth from caries. 11. Recite causes of tooth sensitivity.
3. Discuss the various methods of fluoride delivery. 12. Explain how desensitizing agents work.
4. Explain the benefit of using an antibacterial rinse in 13. List the types of materials used to treat sensitive teeth.
conjunction with fluoride. 14. Apply desensitizing agents to sensitive teeth (as
5. Describe the antibacterial effects of chlorhexidine. permitted by state law).
6. Apply topical fluoride gel, foam, varnish, or silver diamine 15. Explain the process of remineralization of enamel.
fluoride correctly (as permitted by state law). 16. Describe how products for remineralization work.
7. Describe how sealants protect pits and fissures from 17. Explain how resin infiltration of the early white spot lesion
dental caries. works.
8. List the components of sealant material. 18. Apply remineralizing products (as permitted by state law).
9. Recite the steps for applying sealants.

Key Terms Defined within the Chapter

Antibacterial Mouth Rinse liquid used to rinse the oral cav- Fluorapatite tooth mineral that results when fluoride is incor-
ity to reduce or suppress bacteria associated with dental porated into the tooth
caries or periodontal disease Fluoride naturally occurring mineral that helps protect tooth
Cariogenic substances or microorganisms that promote structure from dental caries
dental caries Fluorosis enamel condition caused by consumption of
Demineralization action that removes mineral from the excessive levels of fluoride
tooth, usually caused by acids Over-the-Counter (OTC) available in retail or drug stores
Dental Caries a disease process whereby bacteria in plaque without a doctor’s prescription
metabolize carbohydrates and produce acids that remove Prevention/Preventive Aids chemicals, devices, or pro-
mineral from teeth and permit bacteria to invade the tooth cedures that inhibit, reduce, or eliminate disease or tooth
and do further damage destruction in the oral cavity
Desensitizing Agent a chemical that seals open dentinal Remineralization process that replaces mineral lost from
tubules in order to reduce tooth sensitivity to air, sweets, the tooth by an acid attack
and temperature changes Sealant a protective resin that is bonded to enamel to pro-
Erosion loss of tooth mineral caused by dietary or gastric tect pits and fissures from dental caries
acids, not by bacterial metabolism (caries process) Substantivity property of a material that has a prolonged
therapeutic effect after its initial use

CAMBRA (caries management by risk assessment) is now assistants and hygienists about the prescription or over-
a common practice in many dental offices. Dental auxilia- the-counter (nonprescription) agents the dentist has recom-
ries play important roles in assisting the dentist to prevent mended for the prevention of tooth decay and periodontal
disease and maintain the health of patients. They can gather disease and, therefore, they must have a working knowledge
information about caries risk factors, and educate patients of these products. In addition, the auxiliary is often asked by
about the disease processes and the measures needed to pre- the dentist to dispense, apply, or fabricate devices such as
vent the disease. Materials needed to prevent dental diseases fluoride trays for home use and to deliver these prevention/
are widely used in the dental office. Fluorides, antibacterial preventive aids or devices to the patient. In many states, the
mouth rinses, silver diamine fluoride, and sealants are im- dental assistant or hygienist, when properly certified and/
portant preventive measures for caries management and are or licensed, can apply sealants and other preventive prod-
discussed in detail in this chapter. Patients often ask dental ucts prescribed by the dentist. The indications for sealants,
123
124 CHAPTER 7 Preventive and Desensitizing Materials

application techniques, and troubleshooting guides are dis-

cussed. It is essential that all members of the dental team
are familiar with the mechanism of action and a­ pplication
of these products. This chapter also presents information on
desensitizing and remineralizing agents. Clinical and labo-
ratory procedures for many of these topics are included.

FLUORIDE
Fluoride is a naturally occurring mineral found in
many forms in the modern world. It may be found in
well water, in food that has absorbed fluoride from the
soil, and as an additive in many over-the-counter den-
tal products or those prescribed by dentists and phy-
FIG. 7.1 Severe fluorosis. Note enamel defects and discolorations.
sicians. Consumption of excess fluoride during tooth (Courtesy of Steve Eakle, University of California, San Francisco [San
formation may lead to a condition known as fluorosis. Francisco, CA].)
Severe fluorosis can cause brown staining and pitting
of the enamel surface (called mottled enamel) (Fig. 7.1)
and is found where high levels (more than 2 parts The tooth crystals are not pure hydroxyapatite
per million [ppm]) of fluoride occur naturally in the but contain inclusions of carbonate, which makes
drinking water. Mild or moderate fluorosis may create them much more soluble in acid. When bacteria in
opaque white spots or bands on the teeth. High levels the plaque on the tooth surface metabolize cooked
of fluoride in the water supply usually cause fluoro- starches or sugars, they produce acids. The acids
sis, but it may also be caused by children swallowing remove more mineral (demineralization) than the
excess amounts of fluoride toothpaste or by iatrogenic amount of mineral coming into the tooth from the sa-
(doctor-induced) factors such as overly prescribed flu- liva. When these acid attacks are repeated over time,
oride drops or tablets. the surface becomes more porous and allows bacte-
In fact, observations in 1901 by a young dentist, ria to enter the tooth. This is the start of the caries
Frederick McKay, of unsightly brown stains on the process.
teeth of residents of Colorado Springs eventually led Ingested fluoride that enters the developing tooth
to the discovery of the preventive effects of fluoride. bud can come from multiple sources such as drink-
Eight years after his initial observations, McKay was ing water, foods, beverages, or fluoride supplements
able to convince renowned dental researcher G.V. prescribed by the dentist or pediatrician. For years
Black to collaborate with him on an epidemiological it has been thought that fluoride incorporated into
study to determine the cause of this stain. Black and the teeth at the time of development was the main
McKay discovered that stained and mottled enamel reason for the lowering of dental caries (tooth de-
occurred during the development of teeth, not af- cay) rates seen in areas of water fluoridation. While
terward. They also discovered that teeth affected by fluoride incorporated into developing teeth does
the stain were surprisingly resistant to tooth decay. It have a very important effect, work by Featherstone
took 30 years before it was discovered that the brown and others (1990) and epidemiological studies have
staining was the result of high levels of fluoride in the shown that fluoride’s greatest anticaries benefit is
drinking water. The accepted optimal level of fluo- gained from topical fluoride exposure after the teeth
ride in drinking water for the US is 0.7 mg/L or ppm. have erupted. Fluoride in the saliva surrounding the
The anti-caries effect of fluoride initiated the trans- teeth is incorporated into the surface of enamel crys-
formation of dentistry into a prevention-oriented tals during remineralization (replacing minerals lost
profession. from the tooth surface) to form a surface veneer con-
taining fluorapatite, which has much lower solubil-
TOPICAL AND SYSTEMIC EFFECTS ity than the original tooth mineral. The pH (a mea-
The enamel and dentin of the tooth are composed of tiny sure of acidity) at which tooth mineral dissolves is
mineral crystals (hydroxyapatite) within a protein–lipid 5.5 (7.0 is neutral pH—neither acid nor base). How-
matrix. Microscopic gaps or pores between these mil- ever, when the tooth mineral is converted to fluor-
lions of crystals are filled with protein, lipid, and wa- apatite, the pH at which it dissolves is lowered to
ter. It is in these matrix gaps that small molecules such 4.5 (a lower number indicates that it is more acidic;
as lactic acid and ions such as hydrogen, calcium, and e.g., stomach acid has a pH of less than 1.0). There-
phosphate are allowed to pass. There is a constant inter- fore fluoride makes it more difficult for the acids
change of mineral ions between the tooth surface and produced by cariogenic (decay-causing) bacteria in
the saliva. Usually, the minerals entering the surface plaque to demineralize tooth structure and cause
balance the minerals coming out of the tooth surface. dental caries.
 Preventive and Desensitizing Materials CHAPTER 7 125

FIG. 7.3 Chlorhexidine oral rinse (Peridex). (From Darby ML, Walsh
FIG. 7.2 Erosion from stomach acid. Note severe loss of enamel and MM: Dental Hygiene: Theory and Practice, ed. 4, St. Louis, 2015,
dentin from the teeth due to chronic vomiting. (Courtesy of Steve Eakle, Elsevier.)
University of California, San Francisco [San Francisco, CA].)

In a recent study published in Langmuir, the journal sugars and cooked starch, some of the fluoride present
of the American Chemical Society (Loskill et al., 2013), in the plaque fluid combines with hydrogen ions from
researchers found yet another way in which fluoride the acid to become HF and rapidly diffuses into the
helps to fight cavities. They tested how strongly Strep- cell. Once in the alkaline cytoplasm of the cell, the HF
tococcus mutans bacteria adhere to smooth hydroxy- again separates into fluoride ions and hydrogen ions.
apatite before and after treatment with fluoride. They These ions disrupt the enzyme activities essential to
found that fluoride reduced the adhesive force of the the functioning of bacteria and cause their death.
bacteria to the hydroxyapatite surfaces.
Other than dietary sources, topical fluorides come FLUORIDE AND ANTIBACTERIAL RINSES FOR
from fluoride toothpastes and mouth rinses, and fluo- THE CONTROL OF DENTAL CARIES
rides applied in the dental office in the form of liquids, Studies have shown that fluoride alone is not as effec-
gels, foams, and varnishes. There is evidence that fluo- tive in managing dental caries as when it is used in
ride from drinking water, toothpastes, mouth rinses, conjunction with an antibacterial mouth rinse. Thera-
and some foods remains in the saliva for several hours peutic mouth rinses help suppress bacteria associated
and has a prolonged topical effect. Some of the fluo- with dental caries but are not meant to be substitutes
ride that is ingested returns to the mouth by way of for daily mechanical plaque removal.
the saliva. Chlorhexidine gluconate is a bisbiguanide that is ef-
fective against a broad spectrum of microorganisms. In
PROTECTION AGAINST EROSION several European countries, it is used at a concentra-
Highly acidic foods and beverages such as citrus fruits, tion of 0.2%, but in the United States, the maximum
sodas, and wine can contribute to loss of tooth mineral concentration allowed in an oral rinse by the U.S. Food
that is called erosion. Erosion differs from caries in that and Drug Administration (FDA) is 0.12%. It is a pre-
bacteria are not involved and most of the tooth mineral scription mouth rinse that is available commercially
loss is at the surface. It is important to maintain a well- through several companies. The most common trade
balanced diet to minimize excess acidic foods. Some names are Peridex (3M ESPE) (Fig. 7.3), Periogard
medical conditions also cause erosion of the teeth by (Colgate-Palmolive), and Oris CHX (Dentsply Interna-
causing stomach acid to enter the mouth (Fig. 7.2). tional). It is one of the most effective agents for reduc-
Examples are acid reflux (burping up stomach acid), tion of plaque (55%) and gingivitis (45%). Chlorhexi-
anorexia nervosa (body wasting from extreme diet- dine kills bacteria by binding strongly to the bacterial
ing and forced vomiting to purge food and keep from cell membrane, causing it to leak and lose its intracel-
gaining weight), and bulimia (chronic forced vomiting lular components. It binds very strongly on many sites
to control weight gain after binge eating). By making in the oral cavity, including the mucous membranes
the tooth structure less soluble in acids, fluoride pro- and plaque, and is released slowly, giving it a pro-
vides some degree of protection against erosion, but longed effect (called substantivity). The antibacterial
repeated acid attacks will overcome the beneficial ef- effect from a single dose is greatest for several hours
fects of fluoride. after use, but it may last for a few days. It is used in
the management of many bacteria associated with
BACTERIAL INHIBITION periodontal disease and also is effective in suppress-
Fluoride interferes with the essential enzyme activity ing Streptococcus mutans strains (S. mutans) associated
of bacteria. Although the fluoride ion has been shown with dental caries. The current recommended rinsing
not to cross the bacterial cell wall, it can travel through regimen to control dental caries, as suggested by an or-
it in the form of hydrofluoric acid (HF). As decay-caus- ganization of western U.S. dental schools, is as follows:
ing bacteria produce acids during the metabolism of Rinse nightly for 1 minute with approximately 10 ml
126 CHAPTER 7 Preventive and Desensitizing Materials

FIG. 7.4 Alcohol free Chlorhexidine oral rinse (Peroex). (Courtesy of FIG. 7.5 Listerine antiseptic mouthrinse available over-the-counter
Sunstar.) (OTC).

of plaque scores by about 25% and gingivitis by 30%

of 0.12% chlorhexidine for 1 week each month. Repeat with use of these compounds. In some patients, these
the cycle monthly until the dentist, who is monitoring compounds cause a burning sensation in the tissues
bacterial cultures of S. mutans strains and lactobacilli, and a bad taste. Flavoring agents have been added in
determines that further rinsing is not needed. an attempt to overcome the taste problem.
The side effects associated with this product are the
formation of a brown stain (see Chapter 8, Fig. 8.3) on the METHODS OF DELIVERY
teeth and tongue; on glass ionomer, compomer, and com- Dietary Fluoride Supplements
posite restorations; and on artificial teeth. It has a bitter Fluoride may be obtained through drinking water, either
taste and may affect the taste of some foods. Some flavor- naturally occurring or in fluoridated water supplies. In
ing agents have been introduced to offset the bitter taste. non-fluoridated communities, dentists and physicians
The solution contains alcohol, which might be harsh for may prescribe fluoride supplements for children in the
individuals with sensitive mucous membranes. A non- form of tablets, drops, or lozenges (Fig. 7.7). Consider-
alcohol version is available (GUM Paroex chlorhexidine ation should be given to the total fluoride exposure the
gluconate oral rinse from Sunstar Inc.) (Fig. 7.4). Stain- child receives from other sources, such as school rinse
ing seems to be more rapid in some individuals. Diet and programs, toothpaste, or prepared foods with fluoride.
brushing habits are thought to play an important role in There is a schedule that recommends daily doses of
how rapidly staining occurs. More frequent professional fluoride supplements based on the child’s age and the
teeth cleaning and polishing is usually necessary for pa- fluoride content of the community water supply. Supple-
tients who use these compounds routinely. ments are not desired when the community water supply
The longest-used antibacterial mouth rinse agents has a fluoride content that is higher than 0.6 ppm. Tablets
are the phenolic compounds, also called essential and lozenges should be sucked to gain a topical effect. A
oils. The best-known product is Listerine (Johnson & portion of systemically ingested fluoride, including that
Johnson) (Fig. 7.5), which has received the American in drinking water, is returned to the oral cavity by way of
Dental Association (ADA) Seal of Acceptance. It is a the saliva, thereby contributing to a topical effect.
combination of phenol-related essential oils (thymol, In small communities where fluoridation of the water
eucalyptol, and menthol) mixed in methylsalicylate in supply is not economically feasible, an alternative is to add
a 26.9% hydroalcoholic vehicle. The antibacterial ac- fluoride to table salt. This type of fluoridation has been used
tion of these compounds is a result of their alteration for more than five decades in Switzerland. This method has
of the bacterial cell wall. Listerine now has products been endorsed by the World Health Organization. Potas-
on the market which do not contain alcohol and only sium fluoride and sodium fluoride are added to table salt
contain essential oils (Fig. 7.6). These products are best at a concentration of 250 to 300 ppm. The salivary fluoride
for patients who cannot use alcohol products or have levels of the individuals using the fluoridated salt is simi-
xerostomia as alcohol can dry the oral tissues. lar to individuals drinking fluoridated water. This form of
Listerine has not been shown to be an effective anti- fluoridation can be used in areas of the world where other
caries rinse, but clinical studies have shown reduction preventive measures for oral health are not available.
 Preventive and Desensitizing Materials CHAPTER 7 127

FIG. 7.7 Fluoride tablets. (From Bird DL, Robinson DS: Modern Dental
Assisting, ed 12, St. Louis, 2018, Elsevier.)

FIG. 7.6 Listerine Zero antiseptic mouthrinse without alcohol available

over the counter (OTC).

In-Office Fluoride Applications (Topical)

Children with newly erupted permanent teeth and
children and adults at high risk for caries are good can-
didates for professionally applied fluorides. The den-
tal hygienist is most often the professional applying
the fluoride in conjunction with dental prophylaxis. In
some states properly trained dental assistants can also
play this important role.
FIG. 7.8 Advantage Arrest Silver Diamine Fluoride in bulk and single
dose containers. (Courtesy of Oral Science.)
Silver diamine fluoride. Silver diamine fluoride (SDF)
was approved in 2014 by the FDA for use in treating used in children, geriatrics, and vulnerable popula-
dentinal hypersensitivity. SDF has been used in other tions (Table 7.1).
countries for over 80 years and silver alone has been
used for over 100 years in healthcare. Fluoride has an Application. One drop of SDF will treat 1-5 teeth. The
anti-cariogenic effect while the silver has antimicrobial solution should be applied using a microbrush and
effects. The combination of fluoride and silver together placed on the identified area for 60 seconds (Fig. 7.9;
as active ingredients in silver diamine fluoride pro- Procedure 7. 3).
duces a product which allows fluoride to strengthen Only areas of decay are to be treated with SDF.
and remineralize the tooth while the antimicrobial Good isolation is required as the silver in the solution
silver kills bacteria to prevent biofilm from forming will stain soft tissue and rough or unfinished margins
on the tooth. This discovery has caused dental profes- of composites and crowns. It should also be noted that
sionals to use SDF off label for these benefits. Current the silver will stain surfaces, clothing, and skin. Upon
evidence indicates SDF is effective in arresting caries in application SDF, the area of decay will turn dark brown
over 90% of lesions when applied two times annually. or black in color (Fig. 7.10).
SDF is supplied as a colorless liquid in an 8 ml bottle For this reason SDF is recommended in posterior
(Advantage Arrest) or unit dose container (Fig. 7.8). Both regions or on deciduous teeth where esthetics are not
contain silver at 25%, fluoride at 5%, ammonia at 8%, and a concern. Some clinicians cover the area treated with
water at 65%. The label indicates the SDF is a 38% solu- SDF with a composite or glass ionomer to lighten the
tion which is established by combining the silver, fluo- darkness caused by the treatment.
ride, and ammonia percentages. Ammonia is added to There are no established guidelines for the number of
the solution to stabilize the high concentration of fluoride applications or frequency of application. The manufactur-
suspended in the water. The pH of SDF is very basic at 10 er recommends waiting one week between repeated ap-
on the pH scale. The average shelf-life is three years. plications. Current research has evaluated effectiveness
SDF is a trauma free and inexpensive method to after one application versus two applications two times a
arrest dental caries in all populations. It is frequently year. After one application SDF effectively arrested more
128 CHAPTER 7 Preventive and Desensitizing Materials

than 65% of active caries the while two applications an- they can be applied rapidly and do not have the un-
nually resulted in a caries arrest rate over 90%. pleasant side effects of nausea, vomiting, and gagging
often seen with tray application of foam or gel. Fluo-
Sodium fluoride varnish. Fluoride varnishes have be- ride varnish has been shown to be an effective caries
come the most common form of fluoride application preventive agent, with caries reduction of 18% to 77%
used in the dental office. Varnishes are applied directly depending on frequency of application, oral hygiene
onto the surfaces of teeth (Procedure 7.1). These var- and diet of the individual, and other factors.
nishes were introduced more than 30 years ago, their
advantage being that they would hold the fluoride Gels and foams. Topical gels or foams (Fig. 7.12)
against tooth surfaces longer than other products. The that are applied for 4 minutes in disposable trays
FDA has approved varnishes for use in treating den- ­(Procedure 7.2) were historically the most commonly
tin hypersensitivity; however, they are primarily used used fluorides in the dental office; however, varnishes
worldwide as an in-office topical fluoride treatment have now taken their place as the most common. This
to prevent caries. They are available as 5.0% sodium is due to the quick application of varnishes and the
fluoride (22,600 ppm fluoride) in a resin carrier or as continual fluoride release over an extended period of
1% difluorsilane (1000 ppm fluoride) in polyurethane. time. Some manufacturers market topical fluorides
They remain on the teeth for 1 to 3 days if the patient suggesting they can be applied for only 1 minute.
brushes gently. Varnishes are particularly useful for A 1-minute application is not recommended by the
direct application to early dental caries that can rem- ADA. Evidence-based dentistry indicates the 1-minute
ineralize (Fig. 7.11). They supply a high concentration application delivers approximately 85% of the fluo-
of fluoride to the porous demineralized enamel. They ride that a 4-minute application delivers. However, a
can be applied directly around orthodontic bands and 1-minute application is appealing to clinicians man-
brackets to help prevent the formation of white spots aging small children with active tongues and profuse
(evidence of demineralization) caused by inadequate salivary flow, and patients who tend to gag easily.
plaque removal. Fluoride varnishes have replaced This is another reason varnishes have increased in
the use of foams and gels in the dental office, because popularity.

Table 7.1   Indications and Contraindications for use of

Silver Diamine Fluoride
INDICATIONS CONTRAINDICATIONS
Active carious lesions True silver allergy
Lack of access to dental Ulcerations or sores on soft
care tissues
Inability to tolerate Concern for esthetics
conventional dental care
Multiple lesions requiring Pregnancy FIG. 7.9 Areas of decay on deciduous teeth being treated with Sil-
extensive dental treatment ver Diamine Fluoride (SDF). (Courtesy of Affiliated Children’s Dental
over a period of time Specialists.)

FIG. 7.10 Picture A (on left) area of decay. Picture B (on right) staining on of tooth structure after application of Silver
Diamine Fluoride (SDF). (Courtesy of Oral Science.)
 Preventive and Desensitizing Materials CHAPTER 7 129

Fluoride varnish 2-4 times a year for When used once or twice a year, topical fluoride
high-risk children and adults treatments have been shown to produce 20% to 26%
caries reduction. Before fluoride varnish became pop-
ular, acidulated phosphate fluoride (APF) was once
used frequently with children, because it contains
12,300 ppm fluoride and has good uptake in the enam-
el. Two percent neutral sodium fluoride (NaF) contains
9000 ppm fluoride and is used more often with adults,
because the phosphoric acid in APF tends to etch the
surface of restorations made of porcelain, composite
resin, glass ionomer, or compomer. The phosphoric
acid will also worsen root sensitivity in those patients
who are experiencing it by dissolving plugs that block
the dentinal tubules.

Self-Applied Topical Gels and Pastes

Self-applied fluoride gels and pastes are recommended
for individuals who are at high risk for dental caries.
They are also used for orthodontic patients to prevent
caries and decalcification around brackets and bands
that cause permanent white spots and lines on the
enamel. These white spots are unsightly and repre-
FIG. 7.11 Fluoride varnish with tri-calcium phosphate. (From Darby sent the early stages of the caries process (demineral-
ML, Walsh MM: Dental Hygiene: Theory and Practice, ed. 4, St. Louis, ization of enamel by bacterial acids). Elderly patients
2015, Elsevier.) who take medications that dry up their salivary flow
are at very high risk for caries, especially on exposed
root surfaces, and can receive benefit from gels used at
home. Self-applied gels are available by prescription
as 1.1% neutral sodium fluoride (5000 ppm fluoride)
or 0.4% stannous fluoride (900 ppm fluoride) (Fig. 7.13
& Fig. 7.14).
Stannous fluoride may cause some staining of the
surfaces of the teeth, and it delivers less fluoride ion
to the teeth.
Fluoride gels can be brushed on the teeth or ap-
plied in custom fluoride trays. Custom fluoride trays
can be made with the same thermoplastic material
as whitening trays (see Procedure 8.2 Clinical Proce-
dures for Home Whitening in Chapter 8 Teeth Whit-
ening Materials and Procedures). Four minutes of use
in a custom tray is much more effective than 1 minute
of brushing with the gel, because the tray prevents
FIG. 7.12 In-office fluoride foams. (Courtesy of Procter & Gamble.) saliva from quickly diluting the gel and removing it

High concentration 5000 ppm fluoride

toothpaste/gel for caries high-risk
clients from age 6 years and older

FIG. 7.13 Sample prescription fluoride products. (From Darby ML, Walsh MM: Dental Hygiene: Theory and Practice, ed.
4, St. Louis, 2015, Elsevier.)
130 CHAPTER 7 Preventive and Desensitizing Materials

from contact with the teeth. The custom trays, how- Over-the-Counter Fluoride Rinses
ever, involve some additional expense for the time Over-the-counter (OTC) fluoride rinses have been
required to make impressions, pour casts, and con- demonstrated to provide 28% caries reduction when
struct the trays. Children younger than 6 years of age used in a daily rinse program. Rinses are available as
should not use these gels, because they tend to swal- 0.05% sodium fluoride (225 ppm fluoride) (Fig. 7.15).
low too much of the gel. In place of a brush-on gel, Patients typically are instructed to rinse with 10 ml
some manufacturers have made prescription tooth- for 30 to 60 seconds, spit out the excess, and not rinse,
pastes containing 1.1% neutral sodium fluoride. The eat, or drink anything for at least 30 minutes. Fluoride
idea is that the prescription toothpaste will aid com- rinse is often used just before bedtime so that a resi-
pliance, because the patient will not have to brush due of fluoride can remain in the saliva during sleep.
the teeth first and then brush again with a gel, but Parents should supervise children using these rinses
can achieve both at the same time. Self-application by to prevent the child from swallowing them. Prescrip-
school-aged children has produced significant caries tion rinses contain 0.2% sodium fluoride or 0.63%
reduction (about 24%). stannous fluoride.

Fluoride-Containing Toothpaste
Studies with Crest toothpaste conducted in the 1950s
first established the caries-preventive capability of
fluoride in toothpaste. Many studies conducted since
then have shown sodium monofluorophosphate
(MFP) and sodium fluoride to be more effective and
chemically stable than stannous fluoride. The fluoride
content of most toothpastes is about 1000 ppm. Chil-
dren younger than 6 years of age should be supervised
when brushing and should be given only a pea-sized
amount of toothpaste once a day. Toothpaste for chil-
dren is available with much lower fluoride content.
They tend to swallow the paste and run the risk of
mild fluorosis of the permanent teeth if they consume
too much.

Fluoride-Containing Prophylaxis Pastes

Prophylaxis pastes contain pumice as an abrasive to
remove surface stains and plaque/biofilm from the
teeth. In the process, they remove a small amount of
the fluoride-rich enamel surface. It is thought that
FIG. 7.14 MI paste, calcium and phosphate product for home use. some of the lost fluoride can be regained by incor-
(From Darby ML, Walsh MM: Dental Hygiene: Theory and Practice, ed. porating fluoride in the paste. The most common
4, St. Louis, 2015, Elsevier.) fluoride additive is 1.23% APF. These pastes have not
received the ADA Seal of Acceptance as effective for
caries prevention, because studies have not shown
them to be effective for this purpose. In some dental
offices, polishing the teeth after prophylaxis is not
routinely done, to avoid removing that fluoride-rich
surface layer.

SAFETY
All fluorides should be used as directed and kept out
of small children’s reach for safety reasons. The lethal
dose for a child weighing 20 pounds is approximately
700 to 1500 mg of sodium fluoride. Therefore, it is rec-
ommended that prescriptions for dietary supplements
of fluoride contain no more than 120 mg to avoid the
risk of a fatal overdose. Dental auxiliaries should real-
FIG. 7.15 Sample of over the counter fluoride rinse. (From Darby ML, ize that overdoses causing acute illness can occur from
Walsh MM: Dental Hygiene: Theory and Practice, ed. 4, St. Louis, topical applications of fluoride as well. If it is deter-
2015, Elsevier.) mined that a child has consumed an excessive amount
 Preventive and Desensitizing Materials CHAPTER 7 131

of fluoride, vomiting should be induced and milk of some dentists are reluctant to use sealants for fear of
magnesia should be given to bind to the fluoride ions. sealing undetected caries. There is ample evidence
Cow’s milk could be given to slow absorption from the in the dental literature to indicate if caries is inad-
stomach. The child should be taken to the emergency vertently sealed in the pits and fissures, the caries
room of the nearest hospital. The most common reac- process stops, because bacteria are cut off from their
tion seen in the dental office or shortly after leaving nutrients. Going and co-investigators found mostly
the office when a child has swallowed fluoride gel is negative bacterial cultures (no growth) in teeth with
nausea and vomiting. The fluoride, particularly with carious dentin that has been sealed with Nuva-Seal
the acidulated gel, irritates the stomach (see Procedure for 5 years. Treatment of carious teeth with sealants
7.2 for the clinical technique for in-office topical fluo- resulted in an 89% reversal from a caries-active to a
ride application). Table 7.2 lists common in-office and caries-inactive state. Those sites that remained cari-
home-use fluoride products. ous had significantly fewer viable bacteria than un-
sealed carious control sites. Handelman and co-in-
Caution vestigators demonstrated a decrease of 2000-fold in
viable bacteria that could be recovered from carious
Parents with children under age 6 years should be advised
dentin in pits and fissures that were sealed for 2 years
to carefully supervise their children when brushing with
compared with unsealed control teeth. They demon-
fluoride-containing toothpaste. Children at this age tend to
swallow the paste and over time could consume enough strated that small caries inadvertently sealed in the
fluoride to cause mild fluorosis. Only a pea-sized portion of tooth and monitored on radiographs for 2 years not
paste should be used. only did not progress, but in some cases partially re-
paired. However, only incipient enamel caries should
be considered for the sealant procedure. If a sealant
PIT AND FISSURE SEALANTS leaks because it is not properly placed, caries can oc-
cur beneath it. More advanced caries should be treat-
PURPOSE ed by conservative restorative procedures rather than
Sealants are unfilled or lightly filled resins (see Chapter with sealants.
6) that are used to seal the noncarious pits and fissures
of deciduous and permanent teeth. The sealant is a pre- INDICATIONS
ventive measure to reduce or eliminate dental caries in The lack of an accurate means of predicting where car-
the pits and fissures. The widespread use of fluoride ies will occur has complicated the process of select-
has caused a significant reduction in dental caries in ing which teeth should be sealed and which should
children who receive regular dental care, but not neces- not. Because some individuals will remain caries-free
sarily in low-income children. Although the overall car- throughout their lifetime, it is not indicated to seal all
ies rate has dropped, the greatest benefit from fluorides posterior teeth. The dentist should use his/her clinical
has been seen on smooth enamel surfaces. Most caries judgment based on specific criteria to determine which
(about 88%) in children is found in pits and fissures. teeth should be sealed. Consideration should be given
The nature of the shape of the pits and fissures makes to the age, oral hygiene, caries risk, diet, fluoride his-
them vulnerable to dental caries. Pits and fissures are tory, and tooth type and morphology.
often deep, narrow channels in the enamel surface that Although the main thrust of sealant therapy is aimed
can extend close to the dentinoenamel junction (Fig. at permanent teeth, primary molars may also be sealed to
7.16). They collect bacteria and food debris that cannot reduce the caries rate and prevent premature tooth loss.
be removed by toothbrushing, so dental caries can oc- Approximately 44% of caries in primary teeth occurs in
cur readily in these locations. Sealants are not as widely the pits and fissures of the molars. Although the occlusal
used as they should be. Increasing sealant placement morphology of primary molars is flatter and less fissured
is part of the national health initiative and included than that of permanent molars, sealants are still indicated
as part of “Healthy People 2020.” Among low-income if deep or stained fissures are found and if the child has a
children, use of sealants is only about 30%, and this is high incidence of caries or high caries risk.
the high caries risk group that could benefit most from Permanent teeth should be sealed if there is/was ev-
sealants. idence of caries susceptibility in the primary dentition
Sealants have been shown in numerous studies to or the patient has a high caries risk. Teeth with steep
be an effective and conservative means of prevent- cuspal inclines and deep, sticky fissures are more likely
ing caries in pits and fissures by blocking bacteria candidates for sealants than teeth with shallow cusps
and food products from entering them. The Ameri- and highly coalesced (fused together) pits and fissures
can Dental Association encourages sealant applica- (Fig. 7.17). Molars decay three to four times more fre-
tion because sealants have been shown to effectively quently than premolars, undoubtedly as a result of
reduce caries. Caries is often difficult to detect in the more complex occlusal morphology. Premolars are
its early stages in pits and fissures. For this reason, not generally high-risk teeth, and sealants should be
132 CHAPTER 7 Preventive and Desensitizing Materials

TABLE 7.2    Common In-Office and Home-Use Fluoride Products

FLUORIDE FREQUENCY OF
USE PRODUCT CONTENT (ppm) COMMON BRANDS USE PRECAUTIONS
In-office 1.23% APF gel 12,300 NUPRO APF Gel, Foam (Dentsp- Twice a year Gastrointestinal upset,
treatment or foam ly) vomiting if swallowed;
DentiCare Gel, Foam (Medicom) may etch esthetic
Topex 60 Second Fluoride Gel, restorations; not for
Foam (Sultan Healthcare) children younger than
age 3 yr
2.0% NaF 9,000 Oral-B Neutra-Foam (Procter & Twice a year Gastrointestinal upset,
Gamble) vomiting if swal-
NUPRO Fluoride Oral Solution lowed; not for children
(Dentsply) younger than age 3 yr
DentiCare Foam (Medicom)
Topex Neutral pH Fluoride Gel,
Foam (Sultan Healthcare)
38% SDF 44,800 Advantage Arrest (Elevate Dental Twice a year Staining of soft tissues
Care) and margins of resto-
rations, discoloration of
tooth after application
to carious lesion
5% NaF 22,600 Duraflor Halo (Medicom) Colgate 2-4 times Nausea with extensive
varnish Duraphat (Colgate-Palmolive) per year application in patients
Flor-Opal (Ultradent) depending with sensitive stom-
NUPRO White (Dentsply) on caries achs
Vanish (3M ESPE) risk
DuraShield (Sultan Healthcare)
Prescription 1.1% NaF 5,000 Colgate PreviDent (Colgate- Daily Not for children younger
home use gel or Palmolive) than age 6 yr
toothpaste Oral-B NeutraCare (Procter &
Gamble)
DentiCare Gel (Medicom)
Fluoridex (Philips Oral Health-
care)
Topex Take Home Care (Sultan
Healthcare)
0.4% SnF2 gel 900 Colgate Gel-Kam (Colgate- Daily May cause surface stain-
Palmolive) ing of teeth; not for
Oral-B Stop (Procter & Gamble) children younger than
DentiCare Gel (Medicom) age 6 yr
Perio Plus (Oral Dent Pharma)
Topex (Sultan Healthcare)
0.2% NaF rinse 900 Oral-B Fluorinse (Procter & Weekly Not for children younger
Gamble) than age 6 yr
Colgate PreviDent Dental Rinse
(Colgate-Palmolive)
NUPRO Fluoride Rinse
(Dentsply)
Over-the- 0.05% NaF 250 ACT (Chattem) Daily Not for children younger
counter Colgate FluoriGard (Colgate- than age 6 yr
home use Palmolive)
0.02% NaF 100 Listerine Smart Rinse (Johnson Daily Not for children younger
& Johnson) than age 6 yr
Crest Pro-Health (Procter &
Gamble)
Toothpaste 1,100 Numerous brands and Daily Not for children younger
0.24% NaF manufacturers than age 6 yr
Toothpaste 1,000 Numerous brands and Daily Use pea-sized amount
0.8% MFP manufacturers with children younger
than age 6 yr
APF, acidulated phosphate fluoride; SDF, silver diamine fluoride; MFP, sodium monofluorophosphate; NaF, sodium fluoride; SnF2, stannous fluoride.
 Preventive and Desensitizing Materials CHAPTER 7 133

  Filler Content and Color of Commercial

TABLE 7.3
Sealants
FILLER CONTENT, BRAND NAME
% BY WEIGHT (MANUFACTURER) COLOR
No filler Conseal Clear (SDI) Clear
Delton (Dentsply Sirona) Clear, white,
Helioseal (Ivoclar Viva- amber
dent) Clear, white
Lightly filled Clinpro (3M ESPE) White when
(6%-8%) Conseal F, (SDI) set
Natural Elegance (Henry White
Schein) White
Seal-Rite Low Viscosity Off-white
(Pulpdent)
FIG. 7.16 Section of tooth showing a long, narrow fissure contain-
ing debris. A sealant is present and covers the opening of the fissure. Heavily filled Delton Plus (Dentsply) White
(Courtesy of Steve Eakle, University of California, San Francisco [San (30%-70%) Embrace WetBond Off-white,
Francisco, CA].) (Pulpdent) tooth-
Guardian Seal (Kerr colored
Dental) White
Helioseal F (Ivoclar White
Vivadent) Pearly white
Grandio Seal (VOCO) White, tooth
Ultraseal XT plus (Ultra- colors A1,
dent) A2, clear

• U pper and lower second premolars

• Upper laterals and upper first premolars
• Upper centrals and lower first premolars
Taken as a group, caries occurs most often in up-
per and lower molars, accounting for 85% to 90% of pit
and fissure caries.

COMPOSITION
Sealants are chemically similar to composite resins.
Their resin component is based on a dimethacrylate
monomer that is either bisphenol A-glycidyl methac-
rylate (bis-GMA) or urethane dimethacrylate (UDMA).
Polymerization of the resin occurs either solely by
chemical reaction (self-cure) or by light activation
(light-cure) (see Chapter 6). Self-cure is by the con-
ventional peroxide-amine system, which requires the
mixing of two components. Light-cured sealants are
FIG. 7.17 Enamel without significant fissures (well coalesced). (Cour- one-component systems that are polymerized by blue
tesy of Steve Eakle, University of California, San Francisco [San Fran- light. The vast majority of sealants in use today are
cisco, CA].) light-cured. Many manufacturers add very small filler
particles to the sealants to make them more wear re-
applied selectively when specific indications are pres- sistant. Sealants are not as heavily filled (see Table 7.3
ent. On occasion, maxillary central and lateral incisors for sealant filler content) as most composites, because
have deep lingual pits that require sealing. However, they would be too viscous to flow into the narrow fis-
emphasis is placed on sealing first and second molars sures. Some of the filler particles used in sealants may
as a priority. be radiopaque and may allow the sealants to be seen
on x-rays. Many sealants, however, are radiolucent (see
SUSCEPTIBILITY OF TEETH TO FISSURE CARIES Chapter 6).
Teeth most susceptible to pit and fissure caries are list- In 1996 a study done at the University of Granada
ed in the order of their risk for decay: (Granada, Spain) called into question the safety of den-
• Lower molars—about 50% of the caries occurs in tal sealants because of the presence of bisphenol A (BPA)
these teeth in the saliva of patients after placement of sealants. Bi-
• Upper molars—about 35% to 40% sphenol A can interfere with estrogen (a hormone that
134 CHAPTER 7 Preventive and Desensitizing Materials

regulates reproduction and development) and may and trapped air. Some clinicians prefer to open the fis-
have other adverse health effects. In this study only one sures with a small-diameter carbide or diamond bur to
sealant was tested, but the resin in that sealant (bisphe- look for decay, remove debris, and allow better penetra-
nol A dimethacrylate) is not representative of the resins tion of the sealant.
used in most sealants (bis-GMA or UDMA). Bis-GMA
releases very little bisphenol A and UDMA has none. PLACEMENT
In 2008 the ADA issued a statement indicating that The ADA Council on Scientific Affairs does not rec-
peer-reviewed evidence shows that dental resin mate- ommend routine opening of fissures with cutting in-
rials leach out only very low levels of BPA and do not struments before sealant placement. The technique
constitute a health risk for patients. (See also Chapter 6 of placement of sealants requires attention to detail
regarding concerns about bisphenol A.) (see Procedure 7.4). This technique has many steps
in common with the placement of other bonded res-
torations (see Chapter 5 Principles of Bonding and
Caution Chapter 6 Composites, Glass Ionomers, and Com-
Do not stare directly at the curing light. There is potential pomers). The surface must first be cleaned with
for damage to the retina with repeated exposures. An pumice to remove any surface debris that would in-
appropriate filter should be used to protect the eyes. terfere with acid etching or bonding. Retention of the
sealant is obtained by etching the enamel with 37%
phosphoric acid to roughen it and to open pores in
WORKING TIME the enamel for penetration of the resin sealant. After
Self-cured sealant polymerizes to final set within ap- etching, rinsing, and drying of the enamel, isolation
proximately 2 minutes from the start of mixing of the of the field is very important. Etching enlarges the
two components, the initiator and the accelerator. An size and volume of pores in the enamel and roughens
experienced operator can apply the material to one or the surface so that the sealant can penetrate and me-
two quadrants of posterior teeth with one mix of ma- chanically lock into these spaces. Some clinicians like
terial, so it has the advantage of being applied faster to use a drying agent after etching and rinsing to re-
than light-cured material on a comparable number of move any remaining water in the fissures held there
teeth. Light-cured material requires a 20-second appli- by capillary action. Drying agents usually consist of
cation of light on each tooth to polymerize the seal- alcohol. They will mix with the water, and when they
ant if a standard halogen light is used. LED and laser evaporate, they will carry off the excess water with
curing lights can be much more intense and require them.
less curing time (see Chapter 6 Light Curing Units).
Follow the manufacturer’s recommendations for cur- Use of Bonding Agent
ing times. Light-cured material has the advantages of Studies have shown that application of an enamel
allowing the operator to place and cure the material bonding resin before placement of the sealant en-
when the operatory is ready and not requiring mix- hances the retention and seal. Bonding resins are low-
ing prevents the incorporation of bubbles into the viscosity resins that can flow readily into the fissures
material. and microscopic porosities created by acid etching (see
Chapter 5). Resin-containing sealant will then adhere
COLOR AND WEAR to the bonding resin by a chemical resin-to-resin bond.
Manufacturers provide sealants in a variety of colors. However, many clinicians have not yet started using
Sealants may be clear, amber, tooth colored, or opaque bonding agents with sealants, because this is a relative-
white. Patients usually prefer the clear or tooth-colored ly new finding. The sealant is applied to the pits and
sealants, but it is easier for the dental team to identify fissures and surrounding enamel and is cured.
the presence of the sealants at the time of placement
and at subsequent examination visits if they contrast
with the tooth color. Sealants are subject to wear from Clinical Tip
the occlusion. Sealants that contain no inorganic filler Application of a resin bonding agent after etching the
particles will wear faster than those that have filler par- enamel will increase the retention of sealants!
ticles added. Some clinicians use flowable composites
as sealants, because they are more heavily filled and
therefore more resistant to wear, while at the same time
Caution
having adequate flow to enter the fissures. Wear does
not create much of a problem as long as the fissure re- Place etchant with care to avoid etching adjacent teeth or
mains sealed. If part of the fissure is uncovered, repair restorations. Matrix strips could be placed between adjacent
teeth, but careful application will prevent inadvertent etching.
is recommended.
Avoid contact with the patient’s eyes or skin. Protective
Sealants seldom flow to the bottom of long, narrow eyewear should be used by all.
fissures because of the presence of debris (see Fig. 7.16)
 Preventive and Desensitizing Materials CHAPTER 7 135

Oxygen-Inhibited Layer teeth, but careful application of etchant will prevent

The cured sealant will have a very thin film of un- this from occurring. Care should also be taken to
cured resin on its surface. The surface will appear avoid contact of the acid with the eyes and skin of
shiny and will be wet to the touch, because the set the patient and operator. Both should wear protec-
of the resin at its surface is inhibited by contact with tive eyewear.
oxygen in the air. This film is called the oxygen- or air-
inhibited layer. It should be wiped off with gauze or a Bite Interference by Sealant
cotton roll, because it might have an unpleasant taste If a sealant layer is too thick (often described as“high
to the patient. sealant”), it might cause interference with the bite of
the patient. Unfilled sealants that are too high will
Caution wear down in a few days or weeks. Sealants with filler
Recap sealant and bonding agent bottles promptly to particles are much more wear resistant. Ideally, all high
prevent loss of volatile monomers that would create a very sealants should be adjusted to be compatible with the
viscous liquid that cannot penetrate fissures and etched patient’s bite. Otherwise, sore teeth or jaws may result.
enamel. Articulating paper should be used to identify the high
spots, and an appropriate carbide or diamond bur can
Any moisture on the tooth could result in failure be used to adjust them.
of the sealant. Moisture could come from saliva, an
air-water syringe that leaks water into the air stream, PATIENT RECORD ENTRIES
or even moisture from the patient’s breath. Failure The sealant procedure should be carefully document-
may be seen as immediate loss of the sealant, com- ed in the patient’s chart. Chart entries should include
plete or partial loss of the sealant seen at subsequent the following:
visits, or retained sealants that are leaking and could • The date
result in dental caries beneath the sealant. Maxil- • Patient (18 years of age or older) or parental consent
lary and mandibular second molars are the teeth as obtained
that most frequently lose sealants, probably because • Type of isolation
they are the ones for which it is difficult to maintain • Teeth and surfaces sealed
isolation when a rubber dam is not used. In addi- • Materials used including percentage of phosphoric
tion, moisture from the patient’s breath could coat acid (etchant) and brand of sealant used
the etched enamel and interfere with the bond of the • Statement that the patient or parent was informed
sealant. of the need for periodic inspection and maintenance
of the sealants
Clinical Tip • Any adverse events, such as acid splashed on the
Maintaining good isolation is critical to the success of
oral tissues or face, causing a burn, or difficulty with
sealants. Moisture from saliva or even the breath can affect isolation or patient management that may lead to
their retention. The most common sites where sealant is sealant failure
lost in the first 6 months are the maxillary and mandibular Sealant Retention Studies have shown that reten-
second molars, and these are the sites where isolation is tion rates are better when four-handed techniques
most difficult to maintain. are used for the placement of sealants. Having an
extra pair of hands to help maintain isolation and
place or cure the sealants is a definite bonus. In many
Remineralization of Etched, Unsealed Enamel states, dental hygienists and dental assistants can
One concern that has been raised about etching be licensed or certified to place sealants. State den-
enamel surfaces for placement of sealants is that if tal practice act guidelines must be followed as to the
the sealant comes off, the exposed surface is more oral health care providers permitted to place sealants
caries susceptible. Studies have shown that the and adjust the occlusion on a high sealant. The dental
etched enamel begins remineralization after a 24- hygienist can play an important role in the mainte-
hour exposure to saliva by deposition of calcium nance of sealants by carefully checking them at hy-
phosphate salts. In areas where sealants wear away, giene visits.
resins tags remaining in the enamel provide some
caries protection.
Clinical Tip
Etching Precautions Avoid placing sealant on adjacent unetched enamel. After
Care should be taken in placement of the acid the sealant is cured it will look sound, but leakage will occur
etchant so that adjacent teeth are not etched and the under the unetched portion of the sealant. When the patient
soft tissues are not exposed to the acid. Mylar ma- returns for the periodic oral examination there will be dark
staining under the sealant in those areas and the leakage
trix strips or metal matrix bands can be placed in the
may lead to the development of caries.
interproximal spaces to prevent etching of adjacent
136 CHAPTER 7 Preventive and Desensitizing Materials

Table 7.4    Advantages and Disadvantages of Chemical-Cured and Light-Cured Sealants

CHEMICAL-CURED (SELF-CURED OR AUTOPOLYMERIZING) SEALANTS
ADVANTAGES DISADVANTAGES
• N o need for curing light. • S etting time can vary greatly with variations in room tem-
• No risk of damage to the retina from the curing light. perature; the warmer the material, the faster the set.
• Sealants can be applied to several teeth without having to • Setting time of 2 minutes may be too long if there is trouble
go back and individually cure each one with a light. maintaining a dry field or controlling a hyperactive child.
• Mixing two liquids together introduces bubbles into the
material that could produce voids in the completed sealant.
• The viscosity (thickness) of the material increases continu-
ously from the start of mixing. When the material is applied
to several teeth, the ability of the material to flow well into
tight fissures diminishes with time and a new mix may be
needed.
LIGHT-CURED SEALANTS
ADVANTAGES DISADVANTAGES
• M aterial sets in a short period of time (typically 20 sec- • The curing light can cause damage to the retina if protec-
onds). This is particularly useful when one is working on an tion is not used.
active child or is trying to control heavy salivary flow. • The curing light and filter are added expenses.
• Time for application is not limited as with chemical-cured • Only the material directly under the light tip is completely
sealants. cured, so that when several teeth are done, the total curing
• Mixing is not required, so fewer bubbles are introduced into time may be significantly increased and it may be difficult to
the material. manipulate the light tip to reach the distal pits of maxillary
• Viscosity remains low throughout the application period second molars in small mouths.
until light is applied.

EFFECTIVENESS
Carefully placed sealants are very effective at prevent-
ing decay in the pits and fissures. Simonsen (1991)
monitored sealants for 15 years after placement and
found them to be highly effective (Table 7.4).
In that study, sealants were placed on permanent
posterior teeth; this procedure was followed by pe-
riodic examinations. If sealants were completely or
partially lost, they were not replaced or repaired. (In
dental practice, lost sealants would be replaced.) At
the end of 15 years, more than 68% of teeth were
caries free compared with 17% in a control group
with no sealants. A much greater reduction in car-
ies could have been obtained by replacement of lost
sealants.

TROUBLESHOOTING PROBLEMS WITH

SEALANTS FIG. 7.18 Too much sealant was applied and excess blocks the proxi-
Most sealant failures occur within the first 3 to 6 mal embrasure. (Courtesy of Steve Eakle, University of California, San
Francisco [San Francisco, CA].).
months, and all or part of the sealant comes off. The
worst failure is a sealant that leaks but remains in
place. The leak can go undetected and can decay sig- GLASS IONOMER CEMENT AS A SEALANT
nificantly underneath the sealant before it is detected. Glass ionomer cements have been used as sealants
Placing too much sealant can result in excess material because of their adhesion to enamel and their release
flowing into the embrasure space between adjacent of fluoride into the surrounding tooth structure. How-
teeth (Fig. 7.18). Once the sealant is cured, the contact ever, the retention rate for glass ionomer sealants is
area is blocked and the patient would not be able to rather low. One rationale for their use is to provide
floss it. See Table 7.5 for potential problems and their protection from caries by sealing the fissures and pro-
causes and ways to solve the problems. viding fluoride to the surface of the enamel while the
 Preventive and Desensitizing Materials CHAPTER 7 137

TABLE 7.5    Troubleshooting Problems with Sealants

PROBLEM CAUSE SOLUTION
Sealant has come off when retention Surface contamination (likely saliva) Maintain good isolation and re-etch and
is checked at placement visit apply the sealant
Sealant blocks the contact area Too much sealant was appliedLack of Use just enough sealant to cover fissure
finger rest to control placement and 1 mm beyond. Use good finger rest.
Remove excess material before curing
it. Remove hardened sealant in contact
area with a scaler
Sealant has holes in surface Air bubbles in wet sealantVigorous Carefully dispense material to avoid bub-
scrubbing with application brush bles. Gently work sealant into fissures
with brush or explorer. Repair by working
fresh sealant into holes with explorer tip
(re-etch first if isolation was lost)
Sealant layer is too high, interfering Too much sealant was applied Do not puddle the sealant. Use just
with bite enough to cover the fissure and 1 mm
beyond

tooth is going through the eruption process, which can the work of dietary or stomach acids (erosion), (3)
be somewhat slow for molars. Then, after the tooth is loss of tooth structure in the cervical part of the
fully erupted, a resin sealant could be placed. Current tooth by abfraction (grinding of the teeth, which can
recommendations from the ADA Council on Scientific cause bending of the teeth at the microscopic level
Affairs after a review of the dental literature indicate with breaking away of enamel and dentin in the
that resin-based sealants are the preferred materials for cervical area), and (4) scaling and root planing pro-
pit and fissure sealants. cedures. It is estimated that 15% of the population
experiences tooth sensitivity. If the dentinal tubules
become plugged, the sensitivity stops. Acidic foods
DESENSITIZING AGENTS and beverages, toothbrushing, or scaling and root
Many patients experience sensitivity in their teeth to cold planing procedures can remove the plugs and cre-
foods or beverages, sweets, or cold air. Professionally ap- ate sensitivity again. Citrus fruits and their juices can
plied or OTC materials applied to the teeth by the patient readily remove mineral from the surface of the teeth
to reduce or eliminate the sensitivity are called desensitiz- and open plugged dentin tubules. Besides being
ing agents. Dental hygienists and assistants may be called acidic they contain citrate that binds and removes
on to apply certain types of desensitizing agents or to ex- calcium from the teeth and saliva, so remineraliza-
plain to the patient the causes of the sensitivity. tion is slowed. Desensitizing agents (Fig. 7.19) have
been developed to treat sensitivity. However, not all
MECHANISM OF TOOTH SENSITIVITY causes of tooth sensitivity respond to desensitizers.
Teeth may become sensitive when the gingiva has Causes of tooth sensitivity such as dental caries, a
receded and dentinal tubules are exposed to the oral cracked tooth, a high restoration, or a leaking resto-
cavity. Ordinarily, the root surface has a thin protec- ration cannot be treated by desensitizers and need
tive coating of cementum. When the cementum gets corrective measures.
worn away, the dentinal tubules are exposed. Odon-
toblasts (cells in the pulp that lay down dentin) line
the pulp and have extensions within the dentinal tu- Common Causes of Root Sensitivity
bules that contain nerve endings. When some stimu- •  oot caries
R
lus causes the fluid within the tubules to move, the • Toothbrush abrasion
sensitive nerve endings are deformed, causing them to • Erosion by acids
fire and produce a quick, localized sharp pain (this is • Abfraction associated with bruxism
the hydrodynamic theory of dentin sensitivity). Tem- • Scaling and root planing
• Leaking restoration on the root
perature, usually cold, and sugars and acidic foods are
common offenders.

Common Causes of Sensitivity TREATMENT

Common causes of exposed dentin include the fol- Treatment is currently centered around two main mo-
lowing: (1) roots abraded by improper toothbrush- dalities: (1) occluding (plugging) the open tubules and
ing (see Chapter 13 Abrasion, Finishing, and Polish- (2) desensitizing the nerve endings. Plugging the open
ing, Fig. 13.14), (2) loss of enamel and dentin through ends of the dentin tubules will reduce fluid movement
138 CHAPTER 7 Preventive and Desensitizing Materials

restoration, prior to or after a prophylaxis or scaling

and root planing procedure, or for teeth with gingival
recession and exposed root surfaces that are hyper-
sensitive to touch or temperature. One of the side ef-
fects of teeth whitening can be tooth sensitivity dur-
ing the whitening process. Some whitening products
include chemicals, such as potassium nitrate or fluo-
ride, that reduce or eliminate the sensitivity during
whitening.

CATEGORIES AND COMPONENTS OF

DESENSITIZING AGENTS
Various desensitizing agents are available. They may
be categorized as (1) toothpastes, (2) fluoride gels and
varnishes, (3) inorganic salt solutions, (4) resin primers
and bonding agents, (5) mineralizing agents, and (6)
glass ionomer surface sealer (Table 7.6). Desensitizing
toothpastes usually require repeated use over several
days or weeks to achieve some relief. The relief will
FIG. 7.19 Various desensitizing agents. (Courtesy of GlaxoSmith- only continue as the toothpaste is used. If the patient
Kline [Brentford, UK]; courtesy of Procter & Gamble Co. [Cincinnati,
OH].)
discontinues the use of the desensitizing toothpaste,
the sensitivity will return. Fluorides also may take a
while before results are seen. Some of the inorganic
Desensitizing agent blocking dentinal tubules
salts that precipitate into the open dentinal tubules and
seal their openings will have immediate results; others
Dentinal tubule may take repeated applications. The resin desensitiz-
with natural fluid ing agents will have immediate results if all of the open
tubules are sealed. A reduced level of sensitivity may
Area of plug remain if some of the tubules are still open. Desensitiz-
formed as a result ing systems using bonding resins may require etching
of chemical of the surface first, sometimes creating additional tem-
reaction porary sensitivity, particularly with rinsing and ap-
plication of air. However, self-etching dentin primers
are available that do not require rinsing after etching
Open Surface of
(see Chapter 5). The duration of relief varies greatly,
dentinal exposed dentin
tubules from a few days to close to 1 year. None of these agents
provides permanent relief. The duration of relief can
A B be prolonged if the original cause of the sensitivity is
FIG. 7.20 Illustration of (A), open dentinal tubules and (B), a desensitiz- eliminated. That is, the poor toothbrushing habit, the
ing agent that forms a precipitate that occludes the dentinal tubules. acidic diet, or the teeth grinding must be curtailed; oth-
erwise, the desensitizing agent will be removed and
and stop pressure on the nerve endings. This may be the tubules reopened. If a patient has a history of sen-
done by a chemical or mechanical blocking process. sitivity, the dental hygienist must provide the patient
Fluoride compounds in toothpastes, gels, or solutions with one of the desensitizing agents after scaling and
are applied to the sensitive teeth. Ferric or potassium root planning. Chronically sensitive root surfaces may
oxalate solutions are used to precipitate oxalate crys- require restoration with glass ionomers, compomers,
tals in the open tubules (Fig. 7.20). Chemical solutions or composites to provide definitive relief.
containing resin are also applied to block the tubules.
Some materials actually create a bond with the dentin
REMINERALIZATION
(dentin bonding agents) or mineralize the openings of
the exposed tubules (amorphous calcium phosphate Remineralization is the process of repairing the surface
pastes). Some desensitizing agents, potassium nitrate of tooth structure that has lost mineral because of expo-
in particular, work by passing through the dentinal sure to dietary, environmental, gastric, or bacterial acids.
tubules to the pulp and acting directly on the nerve.
Potassium depolarizes the nerve so it cannot fire and PRODUCTS
cause pain. Some of the products used to treat tooth sensitivity can
Desensitizing agents are used in several different also be used to help remineralize the tooth. As previously
ways. They may be used at the time of placement of a discussed, fluorides are helpful in the remineralization
 Preventive and Desensitizing Materials CHAPTER 7 139

TABLE 7.6    Desensitizing Agents

PRODUCT CATEGORY PRODUCT NAME MANUFACTURER ACTIVE INGREDIENT
Toothpastes Sensodyne Deep Clean GlaxoSmithKline Potassium nitrate
Sensodyne True White Potassium nitrate
Sensodyne Rapid Relief Stannous fluoride
Sensodyne Complete Protection Stannous fluoride
Sensodyne Repair and Protect Stannous fluoride
Colgate Sensitive Colgate-Palmolive Potassium nitrate
Crest Sensi-Relief Whitening Procter & Gamble Potassium nitrate
Colgate PreviDent 5000 Colgate-Palmolive 1.1% sodium fluoride
Colgate Duraphat 5000 ppm Colgate-Palmolive 1.1% sodium fluoride
Clinpro 5000 3M ESPE 1.1% sodium fluoride
Colgate Gel-Kam Colgate-Palmolive 0.4% stannous fluoride
Fluoride varnish FluoroDose Centrix 5% sodium fluoride
Vanish 3M ESPE 5% sodium fluoride
NUPRO Fluoride Varnish Dentsply 5% sodium fluoride
Colgate Duraphat Colgate-Palmolive 5% sodium fluoride
Duraflor Medicom 5% sodium fluoride
Fluor Protector Ivoclar Vivadent Fluorsilane compound
Inorganic salts D/Sense Crystal Centrix Calcium oxalate, potassium nitrate
BisBlock BISCO Oxylates
Potassium nitrate UltraEZ Ultradent 3% potassium nitrate plus 0.11%
sodium fluoride
Relief ACP Philips Oral Healthcare Potassium nitrate, amorphous cal-
cium phosphate
Resin agents Gluma Desensitizer Heraeus Kulzer 5% glutaraldehyde, 35% HEMA
MicroPrime B Danville Materials HEMA, 0.5% sodium fluoride
HurriSeal Beutlich HEMA, 0.5% sodium fluoride
Pain-Free F Parkell 4-META resin, fluoride (3000 ppm)
All-Bond DS BISCO NTG-GMA and BPDM primers
Seal & Protect Dentsply Prime & Bond NT with 7% filler
Mineralizing agents SootheRx 3M ESPE Calcium sodium phosphosilicate
Teeth Mate Kuraray America Calcium phosphates
MI Paste GC America Amorphous calcium phosphate
Glass ionomer surface Vanish XT 3M ESPE Glass ionomer cement
sealer
BPDM, biphenyl dimethacrylate; HEMA, 2-hydroxyethyl methacrylate; 4-META, 4-methacryloxyethyl trimellitate anhydride; NTG-GMA, N-(p-tolyl)glycine glycidyl meth-
acrylate.

process. Because tooth mineral is largely calcium and with a high-penetration resin (Icon-Infiltrant; DMG
phosphate, products that contain calcium and phos- America). First, the right type of lesion is selected. The
phate can help replace lost tooth mineral. The main lesion should be on accessible smooth surfaces of the
ingredients of these products are amorphous calcium enamel, with no break or cavitation of the surface of
phosphate or calcium sodium phosphosilicate. One the carious lesion. Interproximal early lesions can be
product combines fluoride and amorphous calcium treated but are more difficult technically, because they
phosphate in a varnish (MI Varnish; GC America) (Fig. are not readily accessible. Next, the area is isolated and
7.21). The varnish will prolong the exposure of the cov- the surface of the lesion is cleaned with pumice. Then
ered tooth surfaces to both components. Glass ionomer 15% hydrochloric acid is applied for 2 minutes, extend-
cements, because they release fluoride, are also helpful. ing 2 mm beyond the borders of the lesion. The acid is
washed off, the surface is dried, and an ethanol drying
RESIN INFILTRATION agent is applied for 30 seconds followed by air drying.
A novel approach to halting progression of the early Next, the penetrating resin is applied in two applica-
smooth surface white spot carious lesion is to infil- tions, totaling 4 minutes, and light-cured after each ap-
trate the lesion with a low-viscosity resin. As bacte- plication. Not only does the resin obliterate porosities
rial acids attack the enamel the surface and the body in the enamel, it makes the white spot lesion much less
of the developing carious lesion become more porous. visible (Fig. 7.22). Although long-term clinical trials
The objective for this new approach is to prevent car- have not been done with this technique, the available
ies progression by blocking the porosity in the enamel research supports this conservative approach.
140 CHAPTER 7 Preventive and Desensitizing Materials

FIG. 7.21 Sample of MI Varnish. (Courtesy of GC Corporation.)

SUMMARY
Conservative dentistry mandates that the allied oral
health practitioner be familiar with the use of the
various preventive materials available. By perform-
ing caries risk assessment and using topical applica-
tions of fluoride, as well as fluoride and antibacterial
rinses, early caries can be arrested and tooth structure
can often be remineralized. Sealants placed to protect
pits and fissures of teeth are recognized as being ef-
fective in the prevention of tooth decay. Desensitizing
agents are more important now than ever before, be-
FIG. 7.22 Before and after images of white spot lesions and their
cause people are retaining their teeth longer, and as a
improvement after the use of resin infiltration (Icon-infiltrant). (Courtesy
of DMG America.) result are subject to the factors that produce root sen-
sitivity. These agents provide relief to patients whose
teeth have gingival recession and exposed dentin that
Clinical Tip subjects them to chronic or episodic pain.
A current list of desensitizing agents approved by the
ADA can be found at the public information section of the
ADA website at www.ada.org under the topic ADA Seal of INSTRUCTIONAL VIDEOS
Acceptance. Many of the products available in drugstores See the Evolve Resources site for a variety of educa-
have not yet received the ADA Seal of Acceptance. tional ­videos that reinforce the material covered in this
chapter.
 Preventive and Desensitizing Materials CHAPTER 7 141

Procedure 7.1 Applying Sodium Fluoride Varnish

See Evolve site for Competency Sheet. NOTE: Do not use saliva ejector or high-volume
evacuation to gather excess fluids or varnish from the
EQUIPMENT/SUPPLIES patient’s mouth. The varnish will clog the suction lines
over time.
• Basic examination set-up
• Sodium fluoride varnish
• Applicator brush
• 2×2 gauze squares
• Air water syringe tip
• Disposable cup

PROCEDURE STEPS
1. Open fluoride varnish container and mix solution
with applicator brush if slight separation has
occurred.
NOTE: Product does expire. Clinician should in-
spect product and discard if past manufacturer’s expi-
ration date.
2. Hand patient cup for use at conclusion of
application of varnish.
3. Remove excess fluids from the mouth prior to
FIG. 7.23 (Courtesy of Dentistry Today.)
application of varnish.
4. Dry excess saliva from teeth by wiping dentition
8. Instruct the patient to refrain from eating foods
with 2×2 gauze square or lightly blowing air with
which are extremely hot, crunchy, or contain
air-water syringe.
alcohol as all can remove the varnish from the
5. Apply small amount of varnish to each tooth
tooth surface.
using applicator brush (Fig. 7.23).
9. Instruct the patient to brush their teeth
NOTE: Read manufacturer’s instructions for rec-
normally to remove all varnish from the tooth
ommended application. Some manufacturers recom-
surface.
mend painting one surface of the tooth (i.e., facial or
NOTE: Varnish may remain on the teeth for 1 to 3
lingual).
days if the patient brushes gently.
6. Once all teeth have been painted, have the
10. Provide patient with the homecare instructions
patient rub their tongue along all surfaces of the
sheet available from the manufacturer.
teeth to assist in distribution of varnish into the
NOTE: Each manufacturer provides homecare in-
interproximal areas.
struction sheets with their products to be distributed
7. Have patient expectorate into disposable cup.
to the patient at the conclusion of treatment.
142 CHAPTER 7 Preventive and Desensitizing Materials

Procedure 7.2 Applying Topical Fluoride

See Evolve site for Competency Sheet. If present, perform scaling procedure before
proceeding.
EQUIPMENT/SUPPLIES (Fig. 7.24) NOTE: Do not polish teeth with premanufactured
prophylaxis paste. Flavoring oils deposited on the
• Disposable trays of various sizes
surfaces of the teeth may reduce the absorption of
• Topical fluoride foam or gel
fluoride.
• Air-water syringe
3. Seat the patient upright.
• Watch or timer
NOTE: This reduces the amount of gel going down
• Cotton rolls
the patient’s throat.
• Saliva ejector
4. Load trays with fluoride (Fig. 7.26). Do not overfill,
• High-volume evacuation (HVE) tip
because that will cause excess fluoride to run into
the patient’s mouth.
NOTE: Follow appropriate guidelines for the age of

FIG. 7.26
the patient.
5. Place trays in the patient’s mouth (Fig. 7.27). Place
cotton rolls between the trays and have the patient
close on the cotton rolls to keep the trays in place.
6. Place the saliva ejector in the mouth on the cheek

FIG. 7.24

PROCEDURE STEPS
1. Select appropriate disposable tray for the size of
the patient’s mouth (Fig. 7.25).
2. Examine the patient for the presence of calculus.

FIG. 7.27

side or between the trays, in the space created by

the cotton rolls (Fig. 7.28).
NOTE: The taste of the gel or foam and the presence
of the trays will greatly increase the flow of saliva.
7. Time the fluoride application.
FIG. 7.25
 Preventive and Desensitizing Materials CHAPTER 7 143

Procedure 7.2 Applying Topical Fluoride—cont’d

8. Remove the trays after the appropriate time has

passed. Remove excess gel/foam and saliva from
the patient’s mouth by HVE.
9. Instruct the patient not to rinse, eat, or drink for 30
minutes.
NOTE: Fluoride circulating in the saliva will con-
tinue to have a topical effect for a few hours after
treatment.

FIG. 7.28

Procedure 7.3 Applying Silver Diamine Fluoride (SDF)

See Evolve site for Competency Sheet NOTE: Dental dam, cotton rolls, or dry angles can
be used to isolate the area being treated.
EQUIPMENT/SUPPLIES 3. Dry area with 2x2 gauze square
NOTE: Drying area with air-water syringe is
• Basic examination set-up
not recommended as this may cause the patient
• Silver diamine fluoride
sensitivity.
• Lubricant ie: Palmer’s Cocoa Butter or Vaseline to
4. Place microbrush into dappen dish to absorb a
prevent staining of tissues
small amount of SDF.
• Plastic dappen dish
5. Apply SDF to area of caries (see Fig. 7.9).
• Microbrush
NOTE: Keep SDF from touching unwanted areas
• Air-water syringe
such as gingival tissues and face as it will stain. If
• Watch or timer
staining of the face occurs, immediately wipe face with
• Cotton rolls, dry angles
hydrogen peroxide. This will reduce the staining that
• 2×2 gauze squares
occurs on the face; however, the stain will subside on
• Saliva ejector
its own without wiping with peroxide.
• High-volume evacuation (HVE) tip
6. Keep isolated and allow to dry for 60 seconds.
• Super floss
7. Remove excess with 2×2 gauze square.
• Bite block
NOTE: Some patients complain of a metallic after-
PROCEDURE STEPS taste due to the silver content in the solution.
8. Inspect areas of decay to ensure all susceptible
1. Dispense one drop of SDF into plastic dappen dish.
areas have absorbed the SDF (see Fig. 7.10).
NOTE: One drop of solution will treat 1-5 teeth.
NOTE: Glass ionomer can be placed over the tooth
NOTE: Glass dappen dish may react with the SDF.
treated with SDF to reduce the discoloration that oc-
2. Isolate area to be treated with SDF.
curs. (See Chapter 6 for benefits of glass ionomer.)
144 CHAPTER 7 Preventive and Desensitizing Materials

Procedure 7.4 Applying Dental Sealants

See Evolve site for Competency Sheet.

EQUIPMENT/SUPPLIES (FIG. 7.29)

• Basic examination setup
• Prophy setup: slow-speed handpiece with prophy
angle, prophy cup, or bristle brush
• High-volume evacuation (HVE), saliva ejector tips,
and air-water syringe tip
• Dental dam setup (check for latex allergy);
alternative isolation: cotton rolls and holder
• Flour of pumice or special prophy paste without
fluoride or oils
• Dappen dish for pumice and mixing well for
sealant, if supplied in bulk
• Curing light if using light-cure sealant, and light
shield FIG. 7.30
• Sealant material: Self-cure or light-cure
• Etching solution/gel: 35% phosphoric acid
• Applicator brush or tips (some sealant materials
have an applicator)
• Articulating paper, dental floss
• Bullet-shaped finishing bur or polishing stone

FIG. 7.31

FIG. 7.29
PROCEDURE STEPS
1. Place dental dam or cotton rolls and saliva ejector
to isolate teeth to be sealed.
NOTE: Moisture contamination with saliva or wa-
ter can cause a loss of or leaking sealant.
2. Clean the surfaces of the teeth to be sealed with
pumice or oil/fluoride-free paste (Fig. 7.30). FIG. 7.32
3. Use three-way syringe and HVE to rinse and dry
teeth thoroughly. Remove any retained polishing NOTE: Some teeth need longer etching times, such
paste (Fig. 7.31). as primary teeth and teeth with fluorosis.
NOTE: Some dentists prefer to clean out the fissures 5. Rinse with water for 10 to 15 seconds.
with a small round or needle-shaped bur or diamond 6. If using cotton rolls, carefully replace them or dry
rotary instrument. This allows them to inspect the fis- them out with the HVE.
sures for the presence of caries. NOTE: Be certain that saliva does not contaminate
4. Place etchant on enamel to be sealed for 20 to 30 the freshly etched surfaces or the enamel will need to
seconds (Fig. 7.32). be re-etched for 15 seconds.
 Preventive and Desensitizing Materials CHAPTER 7 145

Procedure 7.4 Applying Dental Sealants—cont’d

7. Dry the teeth thoroughly.

NOTE: Properly etched enamel should appear
frosty (Fig. 7.33). If not adequately etched, re-etch for
an additional 30 seconds. The fissures in Fig. 7.33 were
opened minimally with a small bur before etching.
8. Apply sealant according to the manufacturer’s
instructions.
NOTE: Sealant should be gently worked into the
pits and fissures to displace trapped air. It should cov-
er the entire fissure but should not overfill the groove
pattern because that will probably interfere with the
occlusion. FIG. 7.34

10. Check with an explorer to ensure that all fissures

and pits are covered, no holes in the material
exist, and sealant is well retained. Apply more
material, if needed.
11. Remove dental dam or cotton rolls and
thoroughly rinse.
12. Check occlusion with articulating paper and
adjust sealant where needed.
NOTE: Follow state laws as to which health care
practitioners are allowed to do adjustment.
13. Check contact areas with floss.
FIG. 7.33
NOTE: Excess material may have blocked these areas.
9. Cure appropriately for the required length of time 14. Check retention at each subsequent visit.
(self-cure or light-cure) (Fig. 7.34). NOTE: Sealants should be checked for partial or
NOTE: If light-curing, each area under the light complete loss. Make sure fissures are still covered.
probe should be cured for at least 20 seconds. High- With retained sealants, check periphery for staining
powered curing lights may require less time. Follow that may indicate leakage. Extensive decay can occur
the manufacturer’s recommendations. under leaking sealants if not detected early. Replace
lost or leaking sealants.

Get Ready for Exams!

Review Questions 3. W hen enamel is remineralized with fluoride,

a. It is a different color
Select the one correct response for each of the following b. The fluoride contains a poison that kills all bacteria
multiple-choice questions. associated with dental caries
1. Fluoride helps to protect the teeth from decay by which c. The resultant remineralized crystal is more resistant
one of the following? to acids
a. Neutralizing bacterial acids d. All of the calcium is replaced
b. Making the enamel more resistant to bacterial acids 4. Fluorosis is always considered to be:
c. Deflecting sugars from the tooth surface a. Destructive to the teeth
d. Removing bacterial plaque from the tooth surface b. Very unsightly
2. When tooth enamel first begins to demineralize, what c. A sign that the person has ingested more than the
is one of the corrective measures that can be taken to optimal amount of fluoride
stimulate remineralization? d. A sign that the person will need to have whitening
a. Stop eating foods with proteins and amino acids and restorations
b. Use a daily rinse containing fluoride 5. Nightly home fluoride treatment with 1.1% sodium fluo-
c. Brush with baking soda and salt ride as a brush-on gel or in custom trays is indicated for:
d. Check the labels on food packages to determine a. Children younger than 6 years of age
whether they contain fluoride b. Adolescents with one or two pit and fissure caries

Continued
146 CHAPTER 7 Preventive and Desensitizing Materials

Get Ready for Exams!—cont’d

c. M iddle-aged women going through menopause b. The occlusion

d. Elderly patients taking medications that cause dry c. The contact areas with adjacent teeth
mouth d. All of the above
6. Sealant material is: 16. The most common reason for loss of a sealant shortly
a. Indicated for all permanent molars after placement is which of the following?
b. Used for protection of smooth surface caries a. Inadequate etching time
c. An unfilled or lightly filled resin b. Inadequate curing time
d. Never in need of replacement once it is placed c. The sealant material was bad
7. When a dental sealant is placed, the technique: d. Saliva contamination after acid etching
a. Is exactly the same as bonding to dentin 17. How should the surface of the enamel appear after acid
b. Requires the field to be kept dry etching?
c. Can be done by dental hygienists and assistants in a. Frosty white
all states b. Shiny
d. Always requires the use of a curing light c. Bright gray
8. Which one of the following is the best candidate for a d. Slightly yellow
sealant? 18. What does acid etching do to the surface of the
a. A newly erupted tooth with numerous deep fissures enamel?
b. A tooth with shallow pits and fissures a. It creates a roughened, irregular surface
c. A tooth with decay into the dentin b. It leaves a smooth, clean surface
d. A molar with stained fissures in a 50-year-old patient c. It evenly removes about half the enamel
9. If caries in a fissure is undetected and is inadvertently d. None of the above
covered by a well-placed sealant, what will happen? 19. The most important requirement for successfully bond-
a. Caries will progress rapidly ing sealants to enamel is:
b. Caries will progress slowly a. Good isolation to prevent saliva contamination
c. Caries will stop progressing b. A high concentration of acid for etching
10. Very small filler particles are added to sealant material c. Long etching times (60 seconds or longer)
for which purpose? d. Long drying times (20 to 40 seconds)
a. To improve the esthetics 20. Studies show caries to occur in pits and fissures most
b. To decrease wear of the sealant often in which group of teeth?
c. To increase adhesion to the enamel a. Permanent maxillary incisors
d. To block the opening of the fissure b. Permanent premolars
11. How is the surface of the tooth prepared before acid c. Permanent molars
etching for sealant placement? 21. How does a sealant adhere to the etched enamel
a. The patient is asked to brush her/his teeth surface?
b. The teeth are wiped with gauze a. Micromechanical retention
c. A fluoride gel is applied b. Chemical bond to the surface
d. The surfaces are cleaned with pumice c. By shrinking; when polymerized it tightly grips the
12. The acid most commonly used to etch the enamel for surface
sealant placement is which one? d. The sealant is very sticky and adheres to the surface
a. Citric acid like glue
b. Phosphoric acid 22. The main purpose of most desensitizing agents:
c. Hydrochloric acid a. Is to close the openings of the enamel rods to prevent
d. Nitric acid temperature and osmotic changes in the enamel fluids
13. The tip of the light wand of the curing light should be b. Is to help the dental hygienist keep the patient com-
held how close to the sealant? fortable during the dental prophylaxis procedure
a. In contact with the sealant c. Is to plug the openings of the exposed dentinal
b. Very close—about 1 mm away from the surface tubules
c. About 0.5 inch away d. When added to toothpaste, is to improve the taste
d. With a good light it doesn’t matter how far away you are and keep it from burning the gingiva
14. All of the following except one are reasons why pits and 23. What ingredient in Silver Diamine Fluoride stains the
fissures are so susceptible to caries. Which one is the decayed portion of the tooth and anything it comes in
exception? contact with?
a. The enamel lining them is always very thin a. Fluoride
b. They retain bacteria and food debris b. Ammonia
c. Toothbrush bristles cannot reach into the fissures to c. Silver
clean them d. Water
d. They are often deep and narrow 24. Application of Silver Diamine Fluoride __________ times
15. After placement of a sealant, which of the following per year has shown to arrest caries at 90%.
should be checked? a. 1
a. The sealant surface for voids or porosities b. 2
 Preventive and Desensitizing Materials CHAPTER 7 147

Get Ready for Exams!—cont’d

c. 3 Discuss which of the antibacterial rinses this man should

d. 4 use. Discuss the type of fluoride regimen he should be using.
25. Fluoride varnish can remain on the teeth for ________ Explain the rationale for each of these recommendations.
days with light brushing. 3. A 56-year-old business executive comes to the dental
a. 1 to 3 office for her annual examination and cleaning. Her
b. 1 to 2 chief complaint is that her front teeth are yellowing and
c. 1 thinning on the incisal edges. She also notes sensitiv-
For answers to Review Questions, see the Appendix. ity to cold, sweets, and air on the roots of her maxillary
premolars in areas of gingival recession. Question-
ing reveals that she loves lemons. She eats about five
Case-Based Discussion Topics
lemons each week and uses lemon juice frequently in
1. A 14-year-old female high school student with no cooking and on her salads.
restorations comes to the dental office with poor oral Discuss the origin of her complaints and preventive and ther-
hygiene and early caries in the fissures of her mandibu- apeutic measures that should be recommended for her.
lar first molars. An analysis of her diet reveals frequent 4. A 3-year-old girl is brought to the dental office with baby
consumption of sodas and between-meal snacking on bottle tooth decay on the maxillary anterior teeth. The
sugary foods. mother said the girl does not complain about the teeth
Discuss preventive measures that should be recommended being sore but her mother does not want her to be in
for this young woman and the rationale for their use. What pain if teeth are left untreated.
diet recommendations would you recommend for her? Discuss how the teeth can be treated and how the decay can
2. A 75-year-old retired plumber who takes medication for be prevented in the future. Explain how you would describe
hypertension comes to the dental office with moderate the necessary treatment to the parent and what post-op in-
marginal gingivitis, root caries, and a complaint of dry structions would be provided.
mouth.

BIBLIOGRAPHY Handelman SL, Leverett DH, Espeland MA, et al: Clinical ra-
diographic evaluation of sealed carious and sound tooth sur-
American Dental Association (ADA): Council on scientific af- faces, J Am Dent Assoc 113:751–754, 1986.
fairs: evidence-based clinical recommendations for the use of Healthy People 2020. Available at: Healthypeople.gov
pit-and-fissure sealants, J Am Dent Assoc 139:257–267, 2008. Idon Pl, Esan TA, Bamise CT, Mohammed ASA, et al: Dentine
Azuma Y, Ozasa N, Ueda Y, et al: Pharmacological studies on hypersensitivity: review of a common oral health problem, J
the anti-inflammatory action of phenolic compounds, J Dent AM Dent Assoc 2:16, 2017.
Res 65:53–56, 1986. Li Y: Dentin hypersensitivity: diagnosis and strategic approach-
Bird DL, Robinson DS: Oral health and prevention of dental dis- es, Inside Dentistry, 2013.
ease. In Modern Dental Assisting, ed 12, Missouri, 2018, Elsevier. Loskill K, Zeitz C, Grandthyll S, et al: Reduced adhesion of oral
Collins FM, Florman M: Fluoride Guide, Penwell Continuing Ed- bacteria on hydroxyapatite by fluoride treatment, Langmuir
ucation Course, 2010. 29:5528–5533, 2013.
Crespin, Shuman I: Fluoride and Other Preventive Therapies; Mandel JD: Chemotherapeutic agents for controlling plaque and
Maintain­ing Oral Health at Each Stage of Life, Penwell Continu- gingivitis, J Clin Periodontol 15:488–498, 1988.
ing Education Course, 2017. Oong E, Griffin SO, Kohn WG, et al: The effect of dental sealants
Darby ML, Walsh MM: Dental caries management by risk as- on bacteria levels in caries lesions, J Am Dent Assoc 139:271–
sessment. In Dental Hygiene Theory and Practice, ed 4, St. Lou- 278, 2008.
is, 2015, Elsevier Saunders. Paris S, Meyer-Lueckel H: Inhibition of caries progression by
Eakle WS, Featherstone JD, Weintraub JA, et al: Salivary fluo- resin infiltration in situ, Caries Res 44:54–57, 2010.
ride levels following application of fluoride varnish or fluo- Robinson DS, Bird DL: Preventive dentistry, Modern dental assist-
ride rinse, Community Dent Oral Epidemiol 32:462–469, 2004. ing, ed 12, St. Louis, 2017, Elsevier.
Featherstone JD: Prevention and reversal of dental caries: role of Simonsen RJ: Retention and effectiveness of dental sealant after
low-level fluoride, Community Dent Oral Epidemiol 27:31–40, 1999. 15 years, J Am Dent Assoc 122:34–42, 1991.
Going RE, Loesche WJ, Grainger DA, et al: The viability of mi- Strassler HE: Dentin hypersensitivity: an update on diagnosis
croorganisms in carious lesions five years after covering with and etiology, Inside Dentistry, 2014.
a fissure sealant, J Am Dent Assoc 97:455–462, 1978. Trushkowsky RD, Garcia-Godoy F: Dentin hypersensitivity: dif-
Griffin SO, Jones K, Gray SK, et al: Exploring four-handed de- ferential diagnosis, tests, and etiology. Compend Contin Educ
livery and retention of resin-based sealants, J Am Dent Assoc Dent, 2014
139:281–289, 2008.
 8 Teeth Whitening Materials and Procedures

http://evolve.elsevier.com/Eakle/materials/

Chapter Objectives
Upon completion of this chapter, the student should be able to:
1. Describe how whitening materials penetrate the tooth. 7. D escribe the methods to whiten nonvital teeth.
2. Compare and contrast the whitening materials used for 8. Discuss the relative effectiveness of whitening products
in-office, take home, and OTC home use. and whitening toothpastes in removing stains from teeth.
3. Describe the precautions to take to protect the oral 9. Demonstrate proper fabrication of home whitening trays.
tissues when applying in-office power whitening 10. Explain to a patient how home whitening products are
products. used.
4. List the steps in the procedures for in-office power 11. Identify clinical situations in which enamel microabrasion
whitening. might be used.
5. List the potential side effects of in-office power whitening. 12. Explain how enamel microabrasion works.
6. List the potential side effects of home whitening.

Key Terms
Whitening a cosmetic process that uses chemicals to Nonvital tooth: no longer has a living pulp and ceases to
remove discolorations from teeth or to lighten them give response to electrical stimuli or temperature changes
Extrinsic Stains stains occurring on the tooth surface Walking bleach technique whitening technique for nonvital
Intrinsic Stains stains that are incorporated into the tooth teeth in which whitening materials are sealed inside the
structure, usually during the tooth’s development tooth crown for a few days and the patient “walks” around
Vital tooth has a living pulp, which produces response to with the whitening material in place
temperature change or electrical stimuli Enamel Microabrasion a process that uses hydrochloric
Power whitening in-office whitening procedure that uses acid and an abrasive such as pumice to remove shallow
strong whitening agents and may use a high-intensity light discolorations of the enamel
source to accelerate the whitening process

Teeth darken as part of the aging process; although, some about the excellent services they have received from a knowl-
teeth are discolored from medications or chemicals incorpo- edgeable, caring staff.
rated into the developing enamel and dentin. In a society
where many strive to maintain their youthful appearance,
TEETH WHITENING (BLEACHING)
patients desire to regain their brighter, whiter smiles. This
has caused an explosion in the demand for cosmetic dental Controlled research and case studies indicate that
services. The use of whitening products has increased dra- ­ hitening with peroxide products is safe and effective.
w
matically over the past quarter century. Whitening of teeth Many stains and discolorations of the teeth can be re-
has become a significant part of many dental practices. moved or lightened by whitening procedures. How-
Whitening can be done as an in-office procedure or as a home ever, some stains are more difficult to remove than
procedure supervised by the dentist. The dental auxiliary, others.
depending on the state dental practice act, can perform many
of the procedures associated with the whitening process, TYPES OF STAINS
such as making impressions and custom trays, delivering Teeth may be discolored by extrinsic stains on the tooth
and demonstrating use of the home whitening materials to surface, intrinsic stains incorporated internally into the
the patient, providing home use instructions and precau- tooth structure (often when the tooth is developing), or
tions, and helping with various steps in the in-office whiten- a combination of both (Table 8.1). Long standing ex-
ing procedure. They can answer questions patients have trinsic stains can penetrate the enamel to become in-
about whitening. This team effort can help in the growth of trinsic stains which makes the removal of the stain
the practice as pleased patients tell their friends and relatives more difficult.
148
 Teeth Whitening Materials and Procedures CHAPTER 8 149

TABLE 8.1    Causes and Colors of Extrinsic and Intrinsic Discoloration

CAUSE COLOR
Extrinsic Stain
Poor oral hygiene Yellow, brown, green, black
Coffee, tea, red wine, colored cola drinks, foods Brown to black
Tobacco products and betel leaf chewing Yellow-brown to black
Antimicrobial rinse (chlorhexidine) Brown
Intrinsic Stain
Medications during Tooth Development
Tetracycline Brown, gray, black bands
Fluoride White, brown spots or bands
Medications after Tooth Development
Minocycline (tetracycline-type drug) Brown, gray
Diseases/Conditions during Tooth Development
Conditions such as purpura (a blood disorder) Red, brown, purple
Trauma Blue, black, brown
Pulpal Changes
Pulp canal obliteration Yellow
Pulp necrosis with hemorrhage Gray, black
Pulp necrosis without hemorrhage Yellow, gray-brown
Other Causes in Nonvital Teeth
Trauma during pulp extirpation Gray, black
Tissue remnants in the pulp chamber Brown, gray, black
Restorative dental materials Brown, gray, black
Endodontic materials (not currently in use in USA) Gray, black
Combination Intrinsic/Extrinsic Stains
Aging Yellow
Adapted with permission from Hayward VB: Current status and recommendations of dentist-prescribed, at home tooth whitening. Contemp Esthet Rest Pract
1999;3(suppl):2—9.

Extrinsic Stains
Some common foods or drinks that are known to con-
tribute to extrinsic staining of the teeth include coffee,
tea, red wine, colored cola drinks, grape juice, and ber-
ries. Poor oral hygiene accompanied by pigment-pro-
ducing bacteria and food stains can also produce ex-
trinsic stains of varying colors (Fig. 8.1). Tobacco
products and betel leaf chewing also contribute to
staining of the teeth (Fig. 8.2).
Antimicrobial mouth rinses such as chlorhexidine can
contribute to surface staining (Fig. 8.3). Some extrinsic
stains limited to the surface can be removed, in part, by
toothbrushing, whitening dentifrices, and whitening
mouth rinses. The dental hygienist can remove other
FIG. 8.1 Extrinsic stain on the teeth. Greenish stain as a result of
stains by (1) hand or ultrasonic scaling, (2) coronal pol- accumulation of plaque, pellicle, food debris, and pigment-producing
ishing, or (3) air polishing (using a spray of sodium bi- bacteria. (Courtesy of Dr. Steve Eakle, University of California, San
carbonate or aluminum trihydroxide under air pressure). Francisco, CA.)
More stubborn stains that have penetrated the enamel
surface cannot be polished or scaled away. These may development or hereditary conditions, or they may be
require whitening products (peroxides) to remove them. age-related. Developmental disturbances can result
from trauma to the developing teeth, illness with high
Intrinsic Stains fever, and excessive intake of fluoride or certain
Intrinsic stains are internal and may be a result of medications. Intrinsic stains such as age-related
­
developmental disturbances of the teeth during
­ ­discolorations that are yellow or light brown are easier
150 CHAPTER 8 Teeth Whitening Materials and Procedures

FIG. 8.4 Discolored teeth restored with Porcelain Veneers. (Courtesy of

Huefner Sensational Smiles.)

FIG. 8.2 Extrinsic stains on the teeth. Dark brown stains are the result
of poor oral hygiene due to frequent smoking. (Courtesy of Dr. Steve composites must be used to eradicate the discolor-
Eakle, University of California, San Francisco, CA.) ation (Fig. 8.4).

HISTORY OF PEROXIDE WHITENING

In the mid-1960s some periodontists began applying
peroxide in strips to aid in healing of gingival tissues
following periodontal treatment. Soon after, ortho-
dontist Bill Klusmier began using that approach by
having his patients apply Gly-Oxide (GlaxoSmith-
Kline) containing 10% carbamide peroxide to the inte-
rior of their orthodontic positioners to reduce gingival
inflammation. Quite by accident he discovered that
their teeth were also whiter. The discovery was largely
ignored until the 1980s when general dentist John
Munro directing his patients to use a 10% carbamide
peroxide solution to reduce gingival inflammation no-
ticed that their teeth became whiter. He developed a
FIG. 8.3 Extrinsic stains on the teeth. Light brown stains on the technique to fabricate a vacuum-formed plastic tray to
teeth are a result of chlorhexidine antimicrobial mouthrinse. (From contain the peroxide solution. He collaborated with a
teethandmouth.blogspot.com. Courtesy of Asanka.)
manufacturer resulting in the first commercial whiten-
ing preparation in 1988. Heymann and Haywood in
1989 introduced the technique of “nightguard bleach-
to whiten than blue-gray and black stains. Blue-gray, ing” using a much more viscous solution to which
gray-black, and yellow-brown stains are often caused Carbopol, a thickening agent, was added. It allowed
during tooth development by chemicals or drugs, such the whitening agent to remain in the tray much longer
as tetracycline or doxycycline (see Fig. 8.11). As a con- and increased the whitening time. Later in 1989 Dan
sequence, they are incorporated deep within the den- Fischer created a very thick whitening gel of carb-
tin and are also found in the enamel. Other antibiotics amide peroxide called Opalescence (Ultradent Prod-
that are cycline derivatives can cause discoloration of ucts) and the use of night guard whitening became
teeth in adults as well. Externally applied, vital whit- wildly popular.
ening usually takes much longer to lighten tetracycline
stains and achieve an acceptable result. Whitening HOW WHITENING WORKS
may make white spots from mild fluorosis less appar- The enamel of the tooth crown is composed almost en-
ent by making the whole tooth whiter. tirely of mineral (97% by weight) with microscopic
A single dark tooth should be radiographed and spaces between the enamel rods that contain water and
tested for vitality: even if the tooth is symptom free, organic material (Fig. 8.5). Stains accumulate within
the pulp may have died. Stains associated with end- these small spaces in the enamel over time that may
odontically treated teeth may require internal whit- also penetrate to the dentin. Whitening occurs when a
ening. Some stains such as those caused by amalgam type of peroxide or other whitening material passes
or dental caries are resistant to whitening. For stains through the spaces in the enamel and reaches the den-
that cannot be removed by whitening, tooth-colored tin, where it releases oxygen free radicals that oxidize
restorative means such as veneers, crowns, or the stains and subsequently lighten the color of the
 Teeth Whitening Materials and Procedures CHAPTER 8 151

dentin. This process can be accelerated by the use of liquids or gels in concentrations ranging from 10% to
low-intensity heat or high-intensity light, such as with 35%, but some 44% gels are also available. Carbamide
a conventional composite curing light, a laser, or a peroxide is a weaker oxidizing agent than hydrogen
high-intensity plasma arc light. Open carious lesions peroxide. A 10% carbamide peroxide gel breaks down
and leaking restorations can allow the whitening into 3.35% hydrogen peroxide and 6.65% urea. The
agents to penetrate too deeply into the tooth and pulp- urea further breaks down into ammonia and water
al irritation may result. and increases the pH value of the solution, subse-
Some manufacturers have suggested that acid etch- quently providing beneficial side effects of slowing
ing the enamel before application of the whitening demineralization by bacterial acids as part of the car-
chemical may enhance the penetration of the whiten- ies process. Carbamide products also contain either
ing material by increasing the permeability of the carbopol or glycerine base which slows the release of
enamel. Research has shown that this does not im- hydrogen peroxide making it work for a longer peri-
prove whitening, and it can contribute to additional od of time.
complications, such as increased sensitivity and sur-
face wear. Etching may necessitate polishing the enam- Pretreatment Evaluation. Prior to starting the whit-
el before the patient is dismissed, because of the sur- ening process a thorough evaluation must be done
face roughness it creates. that includes radiographs and a clinical examination
to determine the following: cause of the stains, other
Whitening Materials treatment needs before whitening, alternatives to
Depending on the manufacturer, current whitening whitening, and the ideal whitening procedures for
products are based on either hydrogen peroxide or the specific patient’s problem. Dental caries, leaking
carbamide peroxide. Some products also contain addi- restorations, abscessed teeth, and root resorption
tives such as potassium nitrate, amorphous calcium should all be addressed before starting the whiten-
phosphate (ACP), casein phosphopeptide-ACP, calci- ing process. If gingival recession has occurred and
um sodium phosphosilicate, arginine calcium carbon- root surfaces are exposed, the patient should be in-
ate, tri-calcium phosphate, and fluoride to help reduce formed that it is more difficult to whiten the root
sensitivity. surface and whitening may not be successful on
these surfaces. White spots such as mild fluorosis
Hydrogen Peroxide. Hydrogen peroxide products are will not be removed by whitening but may be less
available as a liquid, varnish, or gel in concentrations noticeable when the surrounding tooth surfaces are
ranging from 5% to 40%. Gels usually stay put best due whitened.
to viscosity while liquids can more readily seep under
a rubber dam and cause tissue burns. Varnishes typi- Treatment Methods. There are three main treatment
cally remain in place for a specific period of time due to options for patients who wish to whiten their teeth.
a clear protective coating placed over them. Personal Treatment may be done as follows:
protective equipment (PPE) should be worn by pa- 1. In the dental office, by the dentist and staff
tients, operators, and auxiliaries when performing in- 2. At home, with the dentist prescribing and dispens-
office hydrogen peroxide whitening procedures. ing whitening materials for the patient to use
3. At home, with the patient purchasing over-the-
Carbamide Peroxide. Carbamide peroxide products counter whitening products and using them with-
are popular for home whitening and are available as out professional supervision

FIG. 8.5 The porosity of the enamel surface may be seen by scanning electron microscopy. An enlargement of the same
image is seen on the right. (Courtesy of Dr. Ole Fejerskov, Aarhus University, Denmark.)
152 CHAPTER 8 Teeth Whitening Materials and Procedures

IN-OFFICE WHITENING to the site as soon as it is discovered. Many manufac-

Whitening of Vital Teeth turers of in-office whitening provide Vitamin E oil as
In-office whitening is ideal for patients who want re- part of the kit.
sults quickly. Advantages of treatment in the dental of- A high-concentration gel of 35% (or 45%) carbamide
fice include direct supervision by the dentist and the peroxide is more controllable than liquid hydrogen
staff, elimination of patient compliance issues, control peroxide. All of these high-concentration products re-
over the whitening process, and ability to discontinue quire the use of isolation consisting of a dental dam
treatment if a problem arises. Whitening is done in the and gingival protection with petroleum jelly, or paint-
dental office for both vital and nonvital teeth. A vital on light-cured dental dam materials (such as Opal-
tooth has a living pulp, which produces response to Dam; Ultradent Products) (Fig. 8.7). Prior to complet-
temperature change or electrical stimuli. ing a whitening procedure, it is best to record the
Whitening involves the use of various strengths of starting shade of the patient’s teeth via a Classic Vita
hydrogen peroxide solutions and gels or carbamide shade guide (Fig. 8.8). Intra-oral before and after pho-
peroxide gels. For years whitening was done by means tos should be taken for in-office and take-home whit-
of a liquid consisting of 35% hydrogen peroxide and ening procedures (Procedure 8.1). Vita also has a guide
the application of a heating lamp. This method can be for bleaching purposes—see image below the classic
effective for single-tooth whitening, but it is a time- guide. Also the classic guide can be arranged by value
consuming process and is technique sensitive. If any of so that shades go from light to dark to make compari-
the liquid contacts the soft tissues, it can cause a chemi- sons easier.
cal burn that will turn the affected tissue white, cause
VITA BLEACHING GUIDE 3D MASTER
sloughing of the tissue and may be painful (Fig. 8.6). If
gingival tissue is affected, Vitamin E oil (obtained by Power Whitening
breaking open a vitamin E capsule) should be applied In-office “power whitening” (use of strong whitening
agents which may be activated by high-intensity light)
has become a popular procedure, because it can be
completed in one visit, and there is no need to rely on
patient compliance as with home-use systems. Many
patients simply do not want to spend the time to whit-
en their teeth at home for several hours a day over a
period of two or more weeks. Special curing lights,
light-emitting diode (LED) light, plasma arc light, or
argon laser light may be used with the power whiten-
ing in-office systems. Some older systems utilized ul-
traviolet (UV) lights and the clinician must be aware if
this type of light is being utilized as there are addition-
al precautions to take with the patient. When using a
UV light additional protection is needed on the pa-
tient’s lips and nose. It would be best to have the pa-
FIG. 8.6 Chemical burn of gingiva from contact with high-concentra- tient provide a sunscreen of choice to limit allergies or
tion hydrogen peroxide. (Courtesy of Dr. Steve Eakle, University of Cali-
breakouts. (Fig. 8.9); the treatment time is usually 45-60
fornia, San Francisco, CA.)

A B
FIG. 8.7 Resin dam material (OpalDam; Ultradent Products) to protect gingiva from whitening agent. A, Material applied
from syringe with needle cannula, then light cured. B, Material peels right off after use. (Courtesy of Ultradent Products,
Inc. [South Jordan, UT].)
 Teeth Whitening Materials and Procedures CHAPTER 8 153

FIG. 8.8 Classic Vita Shade Guide. (Courtesy of Vita.)

FIG. 8.9 In-office “power” whitening. Patient has protective barriers for
minutes. Systems that use light activation of hydrogen oral tissues and eyes. High-intensity light (Zoom, Philips Oral Health-
peroxide products include Zoom (Philips USA) and care) is used to speed whitening. (Courtesy of Philips Oral Healthcare,
Stamford, CT.)
LaserSmile (Biolase Technology),
Research shows that the use of high intensity light
is not necessary for whitening to occur and at best it have a recommended number of applications per
may hasten the process. The important factors are visit which is established by the manufacturer and
the concentration of the whitening material and the usually fall into a range of 2 to 3 applications. Appli-
contact time with the tooth surface. Due to the high cations may need to be repeated until the desired
intensity light not being essential to successful whit- whiteness is achieved; however, the maximum num-
ening, there are products which have been devel- ber of applications should not be exceeded in one
oped that do not use a high-intensity light. Systems visit as the patient will develop sensitivity. Some pa-
using these products include Perfection White (Pre- tients need more than one visit to achieve the white-
mier Dental Products), Opalescence Xtra Boost (Ul- ness they desire.
tradent Products), Illumin (Dentsply), and Niveous
Caution
(Shofu Dental). Whitening materials should be
stored in the refrigerator to prolong their limited High intensity whitening lights and lasers may generate heat
shelf life. that can irritate the pulp and contribute to post-treatment
sensitivity.
Newer whitening systems are available which uti-
lize an electrical current to activate the whitening gel
or accelerate the whitening process. A special mouth- It is important to remember that teeth dehydrate
piece is required to deliver the electrical current when they are isolated for a period of time and ap-
without a light or heat. Hydrogen peroxide gels uti- pear whiter than they will be after several hours
lized in dental whitening systems must be main- when they have rehydrated. Dehydration of the
tained at a lower pH (5.5) in order to stabilize the teeth can also contribute to an increase in sensitivi-
materials and increase their shelf-life. The systems ty during the procedure. It typically takes at least 2
that use the electrical current to activate the whiten- weeks for the shade to stabilize. So, if a patient is to
ing gel and increase the whitening process work by have cosmetic restorative treatment after whitening
increasing the pH (10.8) of the hydrogen peroxide procedures, waiting a minimum of 2 weeks before
whitening gel with the electrical current produced in matching the shade of whitened teeth is recom-
the whitening tray, thus allowing the whitening gel mended. Bonding procedures including the place-
to lighten stains in the teeth more quickly. As with ment of composite restorations should not be at-
other in-office whitening systems the tissues must be tempted on newly whitened teeth, because residual
protected from the peroxide gel as a chemical burn whitening materials may still be present in the
can occur. The paint-on light-cured dental dam ma- tooth structure which can prevent proper bonding.
terials are the most user friendly with the design of Again, a 2-week wait is recommended before
the mouthpiece used to deliver the electrical bonding.
current. Whitening results from in-office procedures will not
Some patients may need a longer whitening time last indefinitely. Manufacturers of in-office whitening
or additional visits depending on the type of discolor- recommend supplying patients with custom trays and
ation they present with. Patients who desire maximal whitening materials for home use when a “touch up”
whiteness may need additional treatments or home is desired. One study found that home whitening for 5
whitening to achieve the shade they desire. Most sys- days, 8 hours per day, with 10% carbamide peroxide
tems recommend home tray whitening to comple- was equivalent to 1 hour of treatment in the office with
ment in-office treatment. Power-whitening systems 25% hydrogen peroxide.
154 CHAPTER 8 Teeth Whitening Materials and Procedures

In-Office Power Whitening Process

• Isolate teeth with a rubber dam or liquid-dam
• Retract the lips and use a dental napkin to protect skin
around the mouth
• Provide the patient with protective eye wear, ideally with
side shields
• Deliver the peroxide whitening gel to the teeth
• Spread the gel over the facial surfaces of the teeth with
an applicator brush FIG. 8.10 Intrinsic stain in a maxillary central incisor as a result of
• Activate the whitening gel with the recommended light trauma leading to pulpal death. Staining is due to blood products
source entering the dentinal tubules. (Courtesy of Dr. Steve Eakle, University
• After 20-30 minutes remove the gel with suction and of California, San Francisco, CA.)
apply a new coating of gel
• Repeat this process for a total of 2-3 times
• Once the process is complete, thoroughly remove all gel, breakdown products of the pulpal tissue or hemoglo-
remove barriers, inspect tissues, and apply vitamin E
bin from blood in the pulp escapes into the surround-
oil as needed
• Apply desensitizing agents supplied with the whitening kit
ing dentinal tubules. Chemicals from these tissues
• Provide the patient with post-treatment instructions (e.g., iron sulfide from hemoglobin) cause intrinsic
staining of the dentin which can turn the tooth dark
(Fig. 8.10). Whitening of nonvital teeth in the dental
Caution office typically involves teeth that have undergone
The teeth must not be anesthetized during whitening root canal therapy. Whitening of nonvital teeth re-
procedures in order for the patient to provide feedback to the quires removing the restoration from the endodontic
clinician pertaining to sensitivity. If the teeth are anesthetized access cavity (the hole through which the root canal
painful stimuli produced by heat or the peroxide solutions therapy was performed) and whitening internally
does not occur and permanent pulp damage may result. through this access. The tooth is isolated with a rub-
ber dam to prevent whitening solutions from contact-
Caution ing and burning soft tissues. A 30% to 35% hydrogen
peroxide solution or gel is placed in the pulp chamber
With the use of high-concentration whitening materials the
on a saturated cotton pellet. A hot instrument is
patient and chairside personnel should all wear PPE and
avoid splashes to the skin that could cause burns.
plunged into the cotton several times to activate the
peroxide.
An alternative approach is the “walking bleach”
Whitening Varnish technique, in which a commercially prepared bleach-
As with in-office power whitening, whitening var- ing (whitening) gel or paste made in the office from
nish has become a popular procedure. It can be sodium perborate monohydrate (e.g., Oral-B Amosan;
completed in one visit, it is not as technique sensi- Procter & Gamble) and 30% hydrogen peroxide is
tive as power whitening, and only remains on the sealed into the pulp chamber with a temporary resto-
teeth for 30 minutes rather than an hour like the ration. With the paste, both the sodium perborate
power whitening. The teeth are isolated and the monohydrate and hydrogen peroxide products release
gingiva protected with a resin dam material (see oxygen that helps whiten the tooth. When the patient
Fig. 8.7). After isolated the teeth are painted with a returns in 2 to 7 days, the whitening material is re-
20% hydrogen peroxide whitening varnish. Once all moved, and a composite or amalgam restoration is
the teeth on the maxillary and mandibular arches placed in the endodontic access cavity.
have been painted with the varnish, a sealant layer
is painted over the varnish to keep it in place. After Risk of Root Resorption. All internal whitening pro-
30 minutes the teeth can be brushed or the varnish cedures require that a seal be established at the base
can be wiped off. Teeth whitening can be continued of the endodontic access preparation just coronal to
at home with whitening gel used in custom trays. the level of gingival attachment to the tooth. This is
The ­whitening varnish is considered a jump start to done to prevent whitening material from leaking
­home-whitening procedures or may be used as a out through open dentinal tubules or accessory ca-
touch-up. nals into the periodontal ligament. There have been
cases of external root resorption that occurred when
Whitening of Nonvital Teeth the whitening agent activated an inflammatory re-
A nonvital tooth no longer has a living pulp and ­ceases action in the periodontal tissues. External root re-
to give response to electrical stimuli or temperature sorption is an attack on the root surface by cells and
changes. When the pulp of a tooth dies, the necrotic enzymes in the periodontal tissues. It can actually
 Teeth Whitening Materials and Procedures CHAPTER 8 155

eat a hole through the root, and the patient may lose
the tooth.

HOME WHITENING (PRESCRIBED BY

THE DENTIST)
Home whitening (also called night guard bleaching) is
a popular and cost-effective means of whitening the
teeth, but the treatment interval is much longer com-
pared with in-office treatment (Procedure 8.2). The
chemical that is used in home whitening systems is
either 10% to 45% carbamide peroxide or 6% to 15%
A
hydrogen peroxide. Carbamide peroxide products
break down into two active ingredients, hydrogen
peroxide and urea (an aqueous solution). Hydrogen
peroxide breaks down into oxygen and water. Some
whitening products have potassium nitrate added to
reduce tooth sensitivity. Amorphous calcium phos-
phate (ACP) may be added to home whitening to in-
crease tooth whitening efficacy and decrease dentinal
hypersensitivity. Non-peroxide gels are also available
and claim not to cause tooth sensitivity or gingival
irritation, as peroxide products may do with some
patients.
B
HOME WHITENING PROCESS
FIG. 8.11 Intrinsic stains.Teeth with tetracycline stains: A, before home
The gel is placed in a custom-formed soft, thin plas- whitening; B, after home whitening. (Courtesy of Ultradent Products,
tic tray and is worn by the patient for periods as Inc. [South Jordan, UT].)
short as 15 minutes twice daily or as long as over-
night. The higher the concentration of the whitening
material, application time is decreased. Trays may or custom whitening trays still fit appropriately, no
may not have spaces, called reservoirs, built into gingival burning has occurred, and take a new shade
them to hold the whitening material. Many offices to verify progress.
use reservoirs, but some studies suggest that they Whitening agents suggested for night-time applica-
may not be needed. Trays should be trimmed to fol- tion include Nupro White Gold (Dentsply), Nite White
low the contour of the gingival crest on the facial Turbo (Philips USA), and Opalescence PF (Ultradent
aspect of the dentition to avoid contact of the gel Products) which is for day- or nighttime whitening
with the gingiva, because gingival irritation may re- and another daytime product is Natural Elegance
sult (Procedure 8.3). Trimming the tray to follow the (Henry Schein).
contour of the gingival crest on the lingual is not
necessary, as the lingual aspect of the teeth will not Length of Treatment
be whitened. The length of treatment varies for each patient de-
The home whitening process is as effective as the pending on his or her discoloration and sensitivity.
in-office process but takes much longer and is some- Yellow and light brown stains that are caused by ag-
times used as a follow-up to the in-office procedure, ing or foods can usually be whitened more easily in
which “jump-starts” the whitening process. Home about 2 to 4 weeks. Brown or orange stains caused
whitening trays are recommended to be worn daily by systemic or development disturbances are more
to achieve optimum results. Hydrogen peroxide so- difficult to whiten resulting in a 1 to 3 month whiten-
lutions oxidize stain more quickly reducing wear ing time period. The dark gray, brown, or bluish
time to 15 minutes to 1 hour according to the per- stains of tetracycline are the most resistant to whit-
centage of solution. Carbamide peroxide solutions ening and may take as long as 6 months to whiten
oxidize stain slower increasing wear time to 30 min- (Fig. 8.11). Intrinsic stains in bands or striations may
utes to 8 hours according to the percentage of solu- not whiten evenly or at the same rate. Sometimes
tion. The whitening gels used in custom trays are this difference will make the defect become more
most effective during the first 2 to 4 hours of use and apparent.
gradually diminish in effectiveness. The recom-
mended time for follow-up visits during treatment Informed Consent
is every 2 to 3 weeks, and the procedure is performed Whether whitening procedures are performed in the
under the supervision of the dentist. At the follow- office or prescribed for home use, it is essential that the
up appointment, the auxiliary will ensure the patient be informed of the risks and benefits of
156 CHAPTER 8 Teeth Whitening Materials and Procedures

FIG. 8.12 1 – Removal of whitestrip from plastic backing. 2 – Placement of strip on facial aspect of dentition. 3 – Appear-
ance of teeth upon removal of strip. (Courtesy of Proctor & Gamble.)

treatment and the alternatives to whitening, such as OVER-THE-COUNTER PRODUCTS

restorative procedures. Standardized informed con- Over-the-counter (OTC) teeth whitening products are
sent forms can be used or the dentist can create one. of four basic types:
The patient should sign the informed consent only af- 1. Whitening strips
ter potential detrimental side effects and limitations of 2. Paint-on whitening pastes
treatment have been presented and all the patient’s 3. Whitening gels applied in stock trays
questions have been answered. The signature of the 4. Rinses
patient should be witnessed and then the consent With the use of over-the-counter products, profes-
signed by the dentist or staff member. A copy should sional supervision is not provided during whitening.
be given to the patient and one copy entered into the In addition, no professional evaluation is done before
patient’s record. whitening to ensure that decay and leaking restora-
tions are repaired. Individuals with preexisting sensi-
tive teeth might worsen their condition.
Caution
Side effects from home whitening include irritation of oral Whitening Strips
tissues and throat from contact with the gel, hypersensitive Whitening strips (e.g., Crest 3D Whitestrips; Procter &
teeth, and sore muscles and jaw joints if trays are worn Gamble and Rembrandt Fast Whitening; Ranir) have
overnight. become very popular and are the most widely used
OTC whitening products (Fig. 8.12). They do not re-
quire the construction of whitening trays. The product
Indications for Whitening typically consists of clear, flexible strips containing
• D iscolored teeth 10% peroxide gel and special polymers that help them
• Surface staining adhere to the teeth. They are placed over the teeth and
• Isolated white or brown discoloration which is shallow in worn for 30 minutes at a time, once or twice daily. The
the enamel shorter treatment time may be beneficial for patients
who have developed sensitivity with longer treatment
times when using trays. The strips are thin and do not
Contraindications for Whitening interfere with speech. Research indicates that OTC
Not everyone is a candidate for whitening procedures. Here whitening strips are just as effective as whitening with
are some reasons why: carbamide peroxide in custom trays, at a considerable
• Allergy to the products reduction in cost. Early versions of whitening strips
• Pregnant or nursing covered only the anterior six teeth in each arch; pa-
• Open carious lesions tients who wanted to whiten additional teeth needed
• Cracked enamel to resort to night guard whitening or they would use
• Excessive dental work on front teeth unless patient multiple whitestrips to extend the whitening to the
is prepared to replace restorations that will no longer back of the mouth. However, more recent versions of
match the whitened teeth whitening strips are longer and cover more teeth.
• Actively leaking restorations
• Sensitive teeth
• Use of medications causing photosensitivity (light-acti-
Paint-On Whitening Materials
vated systems could not be used) Paint-on materials are viscous liquids applied directly
• Inability to follow directions to the enamel surface of the tooth with a brush. First,
• Unrealistic expectations the user must air or towel-dry the teeth. Then the solu-
• Under the age of fifteen (15) tion is painted onto the teeth and in 30 seconds to 1
• Inability to provide informed consent minute, the liquid solidifies. The patient needs to keep
the mouth open until the material dries. Some
 Teeth Whitening Materials and Procedures CHAPTER 8 157

products are applied during the day and should be left ROLE OF THE DENTAL AUXILIARY
on for at least 30 minutes. It is recommended that these The dental auxiliary can play an important role in the de-
materials be applied twice a day to achieve maximal livery of whitening services to patients. In addition to
benefit. Because it is directly exposed to saliva (unlike chairside assisting for in-office whitening, assistants and
the gel in strips or trays), the whitening material may hygienists can be active oral health providers for home
be diluted or may come off. Although paint-on prod- whitening. They can help assess the patient for oral con-
ucts work, they are not known to be as effective as ditions that would contraindicate whitening procedures.
tray-applied whitening products or whitening strips. They can perform several important clinical procedures,
such as obtaining a shade, (see Procedure 8.2) making
Over-the-Counter Tray Whitening Systems ­alginate impressions, and pouring casts, as well as fabri-
Several tray whitening systems are sold directly to the cation of the whitening trays (see Procedure 8.3). As per-
public by manufacturers. The trays in these systems mitted by state dental practice acts, they may provide
are preformed stock trays or thermoplastic trays that whitening services in the office. They can discuss home
are heated in boiling water and adapted to the teeth, care remedies for tooth hypersensitivity, and advise the
much like “boil and bite” sports guards (see Chapter patient on foods and beverages that cause staining.
19 Preventive and Corrective Oral Appliances). These It is important that the patient be fully informed of
trays are often poorly fitting and are not properly the pros and cons of whitening. The assistant or hygien-
trimmed to prevent excess material from contacting ist can provide this information to the patient before the
the gingiva. Ill-fitting trays can irritate the gingiva. The dentist completes the informed consent. In addition, the
whitening agent in these OTC systems is usually 10% auxiliary can provide the patient with instructions for
to 22% carbamide peroxide gel. proper use of the whitening agent and care of the trays.

Tooth Whitening Toothpastes POTENTIAL SIDE EFFECTS OF TEETH

Most of the toothpastes on the market that claim to WHITENING
whiten teeth do so by removing surface stains with Sensitivity
abrasives such as hydrated silica or calcium carbonate Tooth sensitivity is usually short term and can occur
rather than penetrating the enamel to reach the dentin from the whitening process. The sensitivity can be
and whitening the teeth. In addition to mild abrasives managed by shortening the whitening time each day,
some manufacturers add peroxides to their dentifrices using a lower concentration of whitening agent, or by
to help with the whitening effect. stopping the whitening process for a few weeks. The
sensitivity is likely caused by whitening agent pene-
Tooth Whitening Rinses trating through the enamel to the dentinal tubules or
Whitening rinses on the market (i.e. Crest 3-D White, by passing through open dentinal tubules on exposed
Listerine Healthy White, and Colgate Optic White) root surfaces and into the pulp, causing irritation.
contain hydrogen peroxide as the active ingredient. Studies have shown that peroxides can penetrate
The use of the product on a long-term basis is intended enamel and dentin and reach the pulp within a matter
to remove surface stains. The whitening rinses are still of minutes. Reversible pulpitis may occur with whiten-
fairly new with limited clinical studies to back up their ing procedures; however, the pain associated with the
claims. inflamed pulp will subside as whitening procedures
are discontinued. Hydrogen peroxide can be damag-
NON-DENTAL OPTIONS ing to cells with prolonged exposure or high
Whitening has become so popular that it is now an of- concentrations.
fered whitening services in retail settings, such as mall Foods and beverages such as citrus fruits and their
kiosks, salons, and spas. These venues have come un- juices, sodas, vinegar, and other acidic foods should
der scrutiny by the dental community in several states be avoided as long as the teeth are sensitive. Acids
resulting in actions to limit delivery of whitening ser- tend to open dentinal tubules in exposed root surfac-
vices by licensed dental healthcare providers. The ra- es by dissolving plugs of salivary mucins and debris.
tionale for limiting these non-dental professionals Desensitizing products such as fluoride, potassium
from providing whitening services is due to the fact nitrate, amorphous calcium phosphate (ACP), casein
that they are not educated in disease screening, infec- phosphopeptide-ACP, calcium sodium phosphosili-
tion control, or emergency procedures. cate, arginine calcium carbonate, tri-calcium phos-
phate, or other desensitizing agents as previously de-
Caution scribed (see Chapter 7 Preventive and Desensitizing
The U.S. Food and Drug Administration (FDA) does not Materials) can be useful to reduce symptoms. In some
require testing for OTC bleaching and whitening products. cases brushing with desensitizing toothpaste for two
Manufacturers are not regulated for these products. weeks before whitening is started will reduce
sensitivity.
158 CHAPTER 8 Teeth Whitening Materials and Procedures

Other Side Effects lighten with whitening of the teeth. If they have
Other possible side effects include irritation of the gin- tooth-colored restorations in visible areas of the
giva, mucosa, and throat from excess whitening mate- mouth that match the teeth before whitening, the res-
rial coming out of the trays. Gingival irritation can occur torations will appear darker after whitening the teeth,
if the trays are not trimmed appropriately and the trays because the surrounding tooth structure will be light-
rub the tissues. If patients wear the whitening trays er. Some patients have whitened their teeth so much
overnight, they may experience some soreness of the that the shades found in regular composite kits may
muscles of mastication and temporomandibular joints if not be light enough to match the color of the whit-
the trays cause them to clench or grind or slightly dis- ened teeth. Several manufacturers have now devel-
place the condyles (heads of the mandible) from the oped whitening shades for composite materials. Some
joints. whitening gels that are mildly acidic may cause slight
roughness of the surface of some composites, com-
Home Whitening Instructions Given in pomers, or glass ionomers. Most whitening materials
the Dental Office available now are pH balanced, and therefore con-
cerns about etching certain restorative materials are
AT THE WHITENING SESSIONS diminished. During the whitening process, patients
1. Brush and floss. should be advised to limit their intake of foods and
2. Place a small amount of whitening gel in the front of beverages that can stain the teeth, including coffee,
each tooth section of the tray. Too much gel in the tray
tea, red wine, colored cola drinks, and berries or ber-
will be displaced by the teeth and may irritate oral tis-
sues and throat.
ry juices. Smoking can also contribute to staining of
3. Place the tray over the teeth and seat it gently. Remove the teeth.
excess gel with a toothbrush or paper towel.
4. Wear the tray for the time prescribed by the dentist. Clinical Tip
5. At the end of the whitening session, remove the tray,
rinse the mouth with water, and use a toothbrush to A period of at least 2 weeks is needed after whitening to allow
remove residual gel. the color of the teeth to stabilize before esthetic restorations
6. Clean the tray under running water with a toothbrush. are placed. Also, the bond to newly whitened surfaces is
Liquid soap may be used. Shake off water. Place the tray weaker than when the teeth are allowed to stabilize.
in a storage container with the lid open to allow the tray
to air-dry. Keep out of the reach of children and pets.
Contraindications: Whitening Is Not for
ADDITIONAL INFORMATION Everyone
1. Store whitening gel in a cool dry location, out of direct
sunlight. The following people should not attempt to whiten their teeth:
2. Whitening is not recommended while pregnant or • People allergic to whitening or tray materials
nursing. • Pregnant or nursing individuals
3. Avoid coffee, tea, red wine, colored cola drinks, berries, • People with open carious lesions, leaking restorations,
and tobacco, because they can cause staining of teeth. or cracked teeth
4. Whitening results usually last 1 to 3 years. Gradual re- • People with hypersensitive teeth
staining may necessitate occasional re-whitening. • People with many tooth-colored restorations who do
5. Keep the whitening trays for future use; it should only not want to replace them when whitening of the teeth
be necessary to buy additional whitening agent for make them look darker
re-whitening. • People taking medications that make them photosensi-
6. If tooth sensitivity or other problems develop, call the tive should not have light-activated whitening as they
office for guidance. may get skin irritation or burns
• People with unrealistic expectations about what whiten-
ing can do
RESTORATIVE CONSIDERATIONS • Adolescents under 15 years of age with recently erupt-
ed permanent teeth whose enamel is still porous and
Before the whitening process is started, cavities
would allow too much penetration of whitening material
should be filled and leaking restorations replaced to causing sensitivity
prevent excessive penetration of whitening agent • People who are mentally incapable of giving informed
through the dentinal tubules, which might irritate the consent
pulp and cause sensitivity. Whitening may be done as
a pre-restorative procedure to whiten the teeth before
composite bonding procedures, veneers, or porcelain RETREATMENT
crowns. However, research has shown that bonding Both in-office and home whitening will fade with
to newly whitened surfaces will be weaker than if the time. One study found a relapse of approximately
teeth are allowed to stabilize for a couple of weeks. 40% at 1 year with in-office whitening. While another
Prior to whitening procedures patients need to be in- study evaluating at-home tray whitening found a
formed that the color of existing restorations will not 26% relapse at 18 months. Some offices provide home
 Teeth Whitening Materials and Procedures CHAPTER 8 159

whitening kits to their patients who have undergone surrounding enamel. When these discolorations are
in-office whitening in anticipation that they will want of concern to the patient one conservative approach
to re-whiten or touch-up their teeth over time as re- to their removal is called enamel microabrasion. The
treatment may be required to maintain the whiteness. lesions should be shallow to leave an adequate thick-
Typically, patients may find that in 1 to 3 years they ness of enamel after discoloration removal. The sur-
will want to do some additional whitening. With in- face of the lesion is cleaned with pumice. Then an
office whitening, this often means that patients will acid slurry made of flour of pumice and 6% hydro-
have to pay the full bleaching fee again. With home chloric acid (diluted from muriatic acid purchased at
tray whitening, patients need only purchase addi- a hardware store or a commercial preparation such
tional whitening solution if they keep their custom as PREMA [Premier] or Opalustre [Ultradent]) is ap-
whitening trays. plied to the discoloration for 1 minute. Next, the
slurry is agitated with a ribbed rubber cup (prophy
angle) revolving slowly (about 500 rpm) for an ad-
ENAMEL MICROABRASION ditional 1 minute. The acid slurry is then rinsed off
A variety of noncarious discolorations can occur in the tooth. Repeat the process if the spot is not gone.
the enamel. They may be caused by mild fluorosis, Do not repeat more than three times as too much
hypermineralized spots that occurred during enamel enamel will be removed. If the spot still remains, an-
development, or previous carious white spot lesions other approach, such as covering the spot with com-
that have remineralized but are still whiter than the posite, might be needed (Fig. 8.13).

A B

C D

E F

G
FIG. 8.13 Microabrasion. A, Before treatment: white enamel discoloration. B, Preparation (roughening) of tooth with bur.
C, Isolation of teeth with dental dam. D, Application of microabrasion compound. E, Application of microabrasion at slow
speed. F, Removal of microabrasion compound. G, After treatment: staining is considerably reduced. After microabra-
sion, a course of home whitening can further reduce the staining. (From J Appl. Oral Sci, 22(4):347–354, 2014.)
160 CHAPTER 8 Teeth Whitening Materials and Procedures

ADVERSE OUTCOMES providing whitening services and advice to patients,

Care must be taken when performing microabrasion clinicians must be knowledgeable about in-office, pre-
to prevent burns to the soft tissues from the acid. If scribed home whitening, and OTC products, including
treatment is too aggressive or too prolonged, so much their indications and contraindications and potential
enamel will be removed that the yellow dentin will side effects. Staining of the teeth caused by tetracycline
show through the thinned enamel and the teeth will or blood products from nonvital teeth can be the most
look much yellower than before treatment was initi- difficult to remove. Patients need to be advised of po-
ated. The pulp may be irritated by penetration of tential limitations of treatment and other pros and cons
acid, or by heat generated if the rubber cup is used before providing their informed consent to treatment.
with too much pressure and speed. As with any den- Dental assistants and hygienists are important team
tal procedure, the established treatment protocol members in providing these popular cosmetic
must be followed as recommended to avoid adverse procedures.
outcomes.
INSTRUCTIONAL VIDEOS
SUMMARY See the Evolve Resources site for a variety of educa-
Whitening of teeth for cosmetic reasons is a popular tional videos that reinforce the material covered in this
aspect of cosmetic dentistry. To be effective in chapter.
 Teeth Whitening Materials and Procedures CHAPTER 8 161

Procedure 8.1 In-Office Whitening

See Evolve site for Competency Sheet.

EQUIPMENT/SUPPLIES (FIG. 8.14)

• Basic examination setup
• Prophy setup: Low-speed handpiece with prophy
angle, prophy cup, flour of pumice
• Tooth shade guide
• Dental dam setup (check for latex allergy)
• Tissue-protective material (petroleum jelly or
manufacturer’s coating or foam)
• High-strength whitening material (varies with
manufacturer)
• High-intensity light, curing light, laser, or heat FIG. 8.15
source (depending on whitening material type)
• Appropriately tinted safety lenses or light shield NOTE: Holes must be of appropriate size and spac-
• Timer or watch ing to prevent leakage. Invert the edge of the dam
• Three-way syringe and high-volume evacuation around each tooth to form a seal, so that whitening
material will not contact the gingiva.
6. Use waxed floss to help tuck in the dam
interproximally. Use a hand instrument to invert
the dam around each tooth.
7. Place high-strength whitener as provided by the
manufacturer (usually 35% hydrogen peroxide)
and follow specific directions as to time and
light/heat source application (Fig. 8.16 and 8.17).
Be aware of developing tooth or gum sensitivity
during the procedure. Respond accordingly.

FIG. 8.14

(HVE) with disposable tips

• Waxed dental floss, 2 × 2 gauze
• Optional: Extraoral or intraoral camera for taking
photographs

PROCEDURE STEPS
1. Obtain informed consent: One copy for the patient
and one for the chart. FIG. 8.16
2. Clean the teeth with flour of pumice or
nonfluoride/oil polishing paste.
3. Determine the starting shade and record. A NOTE: Tooth sensitivity may be due to overheating
photograph may also be taken, if desired. of the tooth, previously exposed root areas, or penetra-
4. Place tissue protection on the gingiva tion of strong whitener into vital dentin. Gum sensitiv-
and interdental papillae according to the ity may be caused by a chemical burn from the whit-
manufacturer’s directions. ening agent. Mild sensitivity usually goes away in a
NOTE: The gingiva is often coated with petroleum few days. Severe burns to the gingiva or mucosa can be
jelly or other protective layer under the dental dam in painful and cause tissue necrosis that may take weeks
case the dam leaks. to heal. Mild burns with surface whitening of the gin-
5. Place the dental dam, isolating the teeth to be giva heal quickly.
whitened (Fig. 8.15).
Continued
162 CHAPTER 8 Teeth Whitening Materials and Procedures

Procedure 8.1 In-Office Whitening—cont’d

8. Rinse off the whitener, wipe clean with 2 ×

2 gauze, and examine for shade. Repeat the
application of whitener as needed to achieve the
desired shade.
NOTE: Teeth appear whiter with the dental dam in
place because of the contrast in color and the dehydra-
tion that occurs under the dam. The true color appears
after the teeth are rehydrated with saliva. Color stabil-
ity is achieved 2 weeks after whitening.
9. Additional appointments may be needed to
achieve the tooth whiteness goal.
NOTE: Desired results cannot always be achieved.
Some stains are more resistant to whitening.
FIG. 8.17

Procedure 8.2 Clinical Procedures for Home Whitening

See Evolve site for Competency Sheet. NOTE: Dental caries, sensitive teeth, and leaking
restorations may need correction before whitening to
EQUIPMENT/SUPPLIES (Fig. 8.18) prevent further sensitivity or pulpal problems.
2. Discuss the pros and cons of whitening. Obtain
• Basic setup for examination
informed consent.
• Rubber mixing bowl and spatula
NOTE: A signed informed consent form signifies that
• Alginate, measures for water and powder
the patient fully understands what is involved, has had his
• Dental plaster or stone
or her questions answered, and agrees to the treatment.
• Alginate impression trays
3. Record the patient’s tooth shade (Fig. 8.19). Take
• Tooth shade guide and camera (optional)
photographs with a shade tab next to the teeth, if
• Home whitening kit and instructions
desired.

FIG. 8.19 (Courtesy of Ultradent Products, Inc. [South Jordan, UT].)

FIG. 8.18

PROCEDURE STEPS NOTE: Many manufacturers include a shade card

that can be used to match the initial shade and later
First Appointment
to compare it with the whitened shade at future visits.
1. Dentist examines the teeth and arches for type 4. Select impression trays of the correct size and make
of discoloration and oral conditions that might alginate impressions.
influence the success of whitening. Potential areas 5. Rinse the impressions, spray with disinfectant or
of concern are corrected or planned for correction. immerse in suitable disinfectant for 15 minutes,
 Teeth Whitening Materials and Procedures CHAPTER 8 163

Procedure 8.2 Clinical Procedures for Home Whitening—cont’d

wrap in wet paper towel, and seal in zippered

plastic bag.
6. Pour impressions with dental stone using a
vibrator to minimize bubbles. (Block out the
tongue and palatal area with a wet paper towel
to make trimming the casts easier when making
trays.) Trays are fabricated in the office (see
Procedure 8.3) or sent to a commercial laboratory.

Second Appointment
7. Insert trays for fit and comfort.
8. Demonstrate loading of trays with gel, tray
insertion, and removal of excess gel (Fig. 8.20
FIG. 8.22 (Courtesy of Ultradent Products, Inc. [South Jordan, UT].)
through 8.22).
NOTE: Written instructions are important because
9. patients sometimes forget what they have been told.
11. Schedule a follow-up appointment in 2 to 3 weeks
following initial delivery. Determine and record
tooth shade at each subsequent visit (Fig. 8.23).
The procedure should be continued until the
desired shade is achieved.

FIG. 8.20 (Courtesy of Ultradent Products, Inc. [South Jordan, UT].)

FIG. 8.23 (Courtesy of Ultradent Products, Inc. [South Jordan, UT].)

NOTE: Whitening will not change the color of exist-

ing tooth-colored restorations (composite, glass ionomer,
compomer, or porcelain). The patient must understand
that these restorations will appear darker than the sur-
FIG. 8.21 (Courtesy of Ultradent Products, Inc. [South Jordan, UT].) rounding whitened teeth and may need to be replaced to
achieve the desired cosmetic result. Not all stains respond
Demonstrate cleaning of trays after a whitening
to whitening, and patients may not achieve the desired
session.
results. Cosmetic restorative procedures are done after
10. Give verbal and written instructions. Review
whitening has stabilized for a period of 2 weeks or longer.
possible side effects. Dispense home whitening kit.
164 CHAPTER 8 Teeth Whitening Materials and Procedures

Procedure 8.3 Fabrication of Custom Whitening Trays

See Evolve site for Competency Sheet. 2. Allow the casts to dry, and then apply reservoir
material (e.g., LC Block-out Resin, Ultradent
EQUIPMENT/SUPPLIES (FIG. 8.24) Products) to the facial surfaces of the teeth (on the
cast) to be whitened.
1. Casts (models) of patient’s dentition
3. Light-cured block-out resin is applied to the facial
2. Whitening reservoir material: Light-cured block-
surfaces of the teeth to be whitened in a thin layer
out resin
about 1 mm thick. It should extend 1 mm short of
3. Vacuum former
the gingival crest and the interproximal embrasures
4. Two sheets of 6 × 6-inch by 0.02- or 0.035-inch-thick
(Fig. 8.26).
thermoplastic vinyl tray material
4. Resin on each tooth should be cured for 10 seconds
5. Fine-tipped scissors for trimming the trays
with a curing light, or the entire cast can be placed
in a Triad light-curing unit (Dentsply Sirona) for 1
minute.

FIG. 8.24 FIG. 8.26 (Courtesy of Ultradent Products, Inc. [South Jordan, UT].)
PROCEDURE STEPS
NOTE: The reservoir is left short of the gingival
1. Trim casts to eliminate much of the facial
crest so the tray will seal in that area and prevent whit-
peripheral border. If the maxillary cast has a palatal
ening agent from contacting the gingiva.
area, drill a hole in the deepest part of the palate or
5. Clamp a sheet of thermoplastic vinyl tray material
grind away most of the palatal area (Fig. 8.25).
in the frame of the vacuum-forming unit (Fig. 8.27).
Raise the frame until it is just below the heating
element. Turn on the heating element.

FIG. 8.25 (Courtesy of Ultradent Products, Inc. [South Jordan, UT].)

NOTE: Ledges or concave areas on the casts that

trap air when the molten tray material is lowered over
the casts will prevent good adaptation of the tray to the FIG. 8.27 (Courtesy of Ultradent Products, Inc. [South Jordan, UT].)
cast and result in a poorly fitting tray that leaks whiten-
ing gel into the patient’s mouth. Before pouring stone 6. Place one cast in the center of the platform
into the alginate impressions, block out the tongue and (it contains many holes) of the vacuum
palate areas with a wad of wet paper towel. This will former.
save time trimming stone away from these areas later.
 Teeth Whitening Materials and Procedures CHAPTER 8 165

Procedure 8.3 Fabrication of Custom Whitening Trays—cont’d

FIG. 8.28 (Courtesy of Ultradent Products, Inc. [South Jordan, UT].) FIG. 8.29 (Courtesy of Ultradent Products, Inc. [South Jordan, UT].)

7. When the vinyl material has heated and sagged

an inch or more (Fig. 8.28), lower the frame to the
platform and turn on the vacuum. The molten
material will be pulled down tightly over the cast.
NOTE: If a pocket of air is trapped under the vinyl,
push it out by adapting the tray to the cast by hand
with a wet paper towel while the material is still soft
and the vacuum is on.
8. Allow the tray material to cool for at least 1
minute before removing it from the frame. Place
it under cold running water to cool
thoroughly.
9. Trim excess material away from the cast with
scissors. Remove the cast from the tray.
FIG. 8.30 (Courtesy of Ultradent Products, Inc. [South Jordan, UT].)
10. Use fine scissors to trim the tray so that it extends
over the teeth just to the gingival crest (Fig. 8.29).
11. Repeat the process for the other cast.
It should have a scalloped appearance as it traces
12. Wash the trays with soap and water. Spray the
the outline of the gingival crest (Fig. 8.30).
NOTE: If the tray extends over the gingiva on the trays with surface disinfectant and store until
facial surfaces, whitening agent can contact the gin- delivery in a zippered plastic bag marked with
giva and irritate it. patient’s name.
166 CHAPTER 8 Teeth Whitening Materials and Procedures

Get Ready for Exams!

Review Questions c. Sore muscles of mastication or TMJs

d. Temperature sensitivity
Select the one correct response for each of the following
8. The most difficult stains to remove are:
multiple-choice questions.
a. Coffee stains
1. What type of whitening solution is painted on the tooth b. Chlorhexidine stains
structure and held in place for thirty minutes with a sealer? c. Red wine stains
a. Power whitening d. Tetracycline stains
b. Home whitening
9. After whitening, how much time should the patient wait
c. Whitening varnish
until a shade is selected for permanent restorations?
d. Whitestrips
a. 1 week
2. Whitening of teeth works: b. 2 weeks
a. By removing surface stains c. 3 weeks
b. By penetrating both enamel and dentin and oxidizing
10. Which one of the following statements about whitening
the stain
strips is true?
c. By sealing surface porosities so that stain cannot
a. Strips are less effective than paint-on whitening
enter the tooth surface
products
d. By creating a white coating on the surface of the
b. Strips are typically worn for 4 to 6 hours at a time
enamel
c. Strips interfere with speech
3. In-office whitening: d. Strips are just as effective as home tray whitening
a. Is superior in results to home whitening with 10 to 15% carbamide peroxide
b. Produces equivalent results to home whitening but is For answers to Review Questions, see the Appendix.
faster
c. Does not cause tooth sensitivity
d. Has no effect if the whitening agent contacts the gingiva Case-Based Discussion Topics
4. The active ingredient in most in-office and OTC whiten- 1. A 35-year-old housewife has been using an over-the-
ing products is: counter whitening system with trays adapted to the
a. Sodium bicarbonate teeth after the material is boiled in water. She has been
b. Ammonia wearing the trays while she sleeps. She comes to the
c. Phosphoric acid dental office complaining of sensitivity in her teeth,
d. Peroxide inflamed and painful gingivae, and sore jaw muscles.
5. Which one of the following can remove intrinsic stains? Discuss possible causes for each of her complaints and
a. Prophy cup with polishing paste make recommendations to treat the problems and prevent
b. Hydrogen peroxide their recurrence.
c. Air polishing with sodium bicarbonate powder 2. A 16-year-old high school student has just become a
d. Ultrasonic scaling cheerleader. She wishes to have a brighter smile for her
6. Whitening procedures should be avoided if the patient public appearances.
has any of the following except one. Which one is the Which whitening systems would be appropriate? What are
exception? the potential side effects on patients this young? What meas-
a. Open carious lesions ures can be employed to minimize the side effects?
b. Gingivitis 3. A 45-year-old plumber has high caries activity because he
c. Hypersensitive teeth snacks on Snickers bars while he is out on house calls. He
d. Inability to give informed consent has a new girl friend and wants to whiten his dull teeth.
7. Undesirable outcomes from home whitening include all What things should be considered before he starts whitening
of the following except one. Which one is the exception? procedures? If he has anterior composites placed to restore
a. Soft tissue irritation carious teeth, should they be done before or after whitening?
b. Root abrasion Why?

BIBLIOGRAPHY Darby ML, Walsh MM: Stain management and tooth whitening. In
Dental Hygiene Theory and Practice, ed 4, St. Louis, 2015, Elsevier.
American Dental Association (ADA): Council on Scientific Affairs: Haywood VB: Current Status and Recommendations for Dentist-
Statement on the Safety and Effectiveness of Tooth Whitening Prescribed, at-home Tooth Whitening, Contemp Esthet Rest
Products. Available at: https://www.ada.org/en/about-the- Pract 3(1):2-9, 1999.
ada/ada-positions-policies-and-statements/tooth-whitening- Kugel G: Effective tooth bleaching in 5 days: using a combined
safety-and-effectiveness. in-office and at-home bleaching system, Compend Contin Educ
American Dental Association (ADA): Council on Scientific Af- Dent 18(4):378, 380-3, 1997.
fairs: Tooth Whitening/Bleaching: Treatment Considerations Kwon SR: Innovation in tooth whitening, Dimensions of Dental
for Dentists and Their Patients. Available at: https://www. Hygiene 16(01):18, 21-23, 2018.
ada.org/∼/media/ADA/About%20the%20ADA/Files/ Magid KS: In-office power bleaching with a plasma arc curing
whitening_bleaching_treatment_considrations_for_patients_ light, Contemp Esthet Rest Pract (9):14-20, 1999.
and_dentists.ashx. Mennito AS, Austin M, Wright M: Academy of Dental Learning
Bird DL, Robinson DS: Preventive, restorative and cosmetic den- and OSHA Training. Tooth Whitening: Comprehensive Re-
tistry. In Modern Dental Assisting, ed 12, St. Louis, 2018, Elsevier. view and Clinical Guidelines, 2012.
Dental Ceramics 9
http://evolve.elsevier.com/Eakle/materials/

Chapter Objectives
Upon completion of this chapter, the student should be able to:
1. Discuss the attributes and shortcomings of dental 8. D escribe common causes for failure of ceramic
porcelains. restorations.
2. Compare the clinical applications of restorations made 9. Finish and polish ceramic restorations without generating
from porcelain with those made from lithium disilicate. too much heat or stress in the material.
3. Explain why crowns made from zirconia can be used to 10. Compare the relative strengths of feldspathic porcelain,
restore molars. lithium disilicate, and zirconium.
4. Describe the methods used to process ceramic 11. Explain how CAD/CAM technology is used to fabricate a
restorations. ceramic crown.
5. Present a rationale for the selection of ceramic materials 12. List the clinical applications for all-ceramic restorations.
for restorations used in the anterior and posterior parts of 13. Prepare the ceramic rest Lithium Disilicate Ceramics
the mouth. oration for bonding with resin cement.
6. Describe how porcelain bonds to metal for porcelain- 14. Assist the dentist in cementing an all-ceramic crown or
fused-to-metal (PFM) crowns. veneers.
7. Select the appropriate cement for use with glass-based 15. Properly prepare the conditions in the operatory for
ceramic materials. shade taking.
16. Assist the dentist in shade taking.
Key Terms
Ceramics materials composed of inorganic metal oxide together at high temperatures to form a hard, uniform,
compounds, including porcelain and similar ceramic mate- glasslike material
rials that require baking at high temperature to fuse small Lithium Disilicate Ceramics glass-based ceramics with
particles together lithium disilicate fillers to enhance physical and mechanical
Crown an indirect restoration that covers all or part of the properties, especially flexural strength
coronal tooth structure (extracoronal) and is composed of Zirconia a non-glass polycrystalline ceramic that is the stron-
metal, ceramic, or a combination of the two. It can also gest ceramic used in dentistry
cover an implant Flexural Strength strength required to resist bending of a
Fixed Bridge a dental prosthesis that replaces one or more bar of ceramic material to its point of fracture
missing teeth and is cemented to adjacent natural teeth or Fracture Toughness material’s ability to resist fracture from
implants. It is composed of the same materials as crowns crack propagation
Inlay an indirect restoration composed of ceramic, compos- Sintering fusion of ceramic particles at their borders by heat-
ite resin, or metal that is fitted to a cavity preparation that is ing them to the point that they just start to melt
within the crown of a tooth (intracoronal) Slip-Casting process whereby ceramic powder is mixed
Onlay restoration that is similar to an inlay but covers or with a water-based liquid to form a mass or slip. The slip is
replaces one or more cusps pressed into a form and baked at high temperature
Veneers thin layer of ceramic or composite resin that is Heat-Pressing pressing molten ceramic material into a mold
bonded to the facial surfaces of teeth to improve their at high temperature and pressure
color, shape, size, or length CAD/CAM computer-assisted design/computer-assisted
Glass-Based Ceramics ceramic materials with a silica (glass) machining that uses a scanning device to capture an
matrix with or without fillers such as leucite or lithium disilicate image of the preparation and is integrated with computer
Non–Glass-Based Ceramics crystalline-based ceramics software to design and a milling device to cut restorations
without a glass matrix from blocks of restorative dental material
All-Ceramic Restoration ceramic restoration with no metal Porcelain-Metal Restoration restoration that has a metal
core core over which porcelain is fused at high temperature.
Porcelain a tooth-colored ceramic material composed of Commonly referred to as porcelain-fused-to-metal (PFM)
crystals of feldspar, alumina, and silica that are fused or porcelain-bonded-to-metal (PBM)

167
168 CHAPTER 9 Dental Ceramics

Amalgam and gold were the main restorative materials un- design/computer-assisted machining (CAD/CAM) tech-
til ceramics were introduced into dentistry over a hundred nology, clinical applications, attributes, and shortcom-
years ago. Ceramics were first used for the fabrication of den- ings of esthetic ceramic materials. The rationale for the
ture teeth, and then Charles Land introduced porcelain jack- selection of ceramic materials for various clinical appli-
et crowns and inlays in the 1900s. Land’s porcelain jacket cations is presented. The principles for adjusting, finish-
crowns were very esthetic but the porcelains of the time were ing, polishing, and cementation of ceramic restorations
brittle and tended to crack when used in high-function areas are reviewed. Guidelines for selection of the shade of these
of the mouth. In the late 1950s porcelain was fused to a metal materials to obtain satisfactory cosmetic results also are
core to make esthetic crowns much stronger. In Europe in discussed.
the 1970s, the first computer-aided design/computer-aided
manufacturing (CAD/CAM) system was developed using
DENTAL CERAMICS
ceramic blocks to produce inlays and onlays. In 1987 the
first chairside CAD/CAM system (CEREC 1, Siemens Den- The general term ceramics is used to describe porcelain
tal) was introduced. Also in the 1980s, the introduction of and a variety of materials that are similar in appear-
a castable glass-based ceramic launched numerous innova- ance to porcelain but vary in their composition, mode
tions in ceramic processing. of fabrication, and physical and mechanical properties.
Within the past three decades all-ceramic materials have Dental ceramics can be classified in a variety of ways
been introduced that are much stronger than the original based on their composition, processing method, fusing
porcelains, and with some improvements in esthetics. As temperature, microstructure, translucency, fracture re-
a result, the use of all-ceramic restorations has dramati- sistance, and abrasiveness.
cally increased while the use of the less esthetic porcelain-
fused-to-metal crowns has decreased. At present, ceramic GLASS AND NON-GLASS CERAMICS
materials are used for a variety of restorations, such as To simplify the understanding of dental ceramics they
crowns, fixed bridges, inlays, onlays, and veneers. Se- will be classified in this chapter into two broad catego-
lection of the type of material to be used depends, in part, ries according to their composition: glass-based and
on the extent of damage to the tooth, the stresses that will non–glass-based materials.
be placed on the restoration, and the esthetic requirements • G lass-based ceramics have silica as a main compo-
of the patient. nent and have a glassy matrix. They include feld-
By enhancing the ability to bond restorative materials spathic porcelains, leucite-reinforced ceramics, and
to metal and tooth structure, advances in esthetic materi- lithium disilicate ceramics. They are more esthetic
als and techniques have assisted the dental team in deliv- than the non–glass-based ceramics.
ering the esthetic results that patients demand. The den- • N on–glass-based ceramics are crystalline in nature
tal team must keep current with the rapid changes that and composed of simple or complex oxides with no
occur in materials and techniques. Good listening skills glassy matrix. They include alumina and zirconia.
are needed to determine the types of esthetic services the They are the strongest of the ceramics.
patient is requesting, so that the dental team and the pa-
tient are working in concert toward the same goal. Es- ADVANTAGES AND DISADVANTAGES OF
thetic materials must be carefully selected, so that their CERAMIC RESTORATIONS
properties are compatible with the patient’s oral condition Esthetic restorations can be made from composite
and occlusion. resin, ceramics with a metal substructure (core), or en-
Dental hygienists and dental assistants must under- tirely ceramics.
stand the properties of these materials, so that as im- The primary advantage of all-ceramic restorations is
portant members of the dental team, they can help the their esthetics, because there is no metal substructure
dentist to assess the performance of the restorations and to hide. Other advantages over direct-placement resto-
alert the dentist when they perceive that a restoration rations such as composite resin, glass ionomer cement,
may be failing. The dental auxiliary needs to be familiar or amalgam include their biocompatibility, wear resis-
with the physical properties of materials, so that they do tance under function, color stability, stain resistance,
not damage the restorations during routine oral hygiene, and the ability to precisely place contacts and con-
coronal polishing, and preventive procedures. Dental as- tours of the restorations. All-ceramic restorations are
sistants need to know the handling characteristics of es- rapidly becoming the restorations of choice for many
thetic materials, so that they can either assist the dentist clinicians.
in their placement or perform steps in their placement as Disadvantages of all-ceramic restorations com-
permitted by state dental practice acts. In addition, they pared with direct-placement restorations include their
will be called on to assist in shade taking for the restora- brittleness (can lead to fracture), wear of the opposing
tions and steps in CAD/CAM procedures if used in the enamel or restorations, difficulty or inability to repair
office. them in the mouth, the need for two appointments (ex-
This chapter describes the physical and mechanical prop- cept for chairside CAD/CAM restorations), and the
erties, processing methods including computer-assisted difficulty of polishing them in the mouth.
 Dental Ceramics CHAPTER 9 169

Alumina Porcelain
Alumina porcelain was developed in 1965 by J.W.
McLean and T.H. Hughes to enhance (about double)
the fracture resistance compared with conventional
feldspathic porcelain. It is also a glassy type of porce-
lain that is about half aluminum oxide by weight in
a melted glass (silica) matrix. It is fabricated by first
dry-pressing it on a refractory die (die capable of with-
standing high temperatures), then sintering it at high
temperature.

Uses of Porcelain
Porcelain is manufactured in a variety of colors.
The different colors (called shades) are produced
by the addition of metal oxides to create the differ-
FIG. 9.1 Sintering. In the scanning electron micrograph porcelain par- ent shades that will match the teeth. The laboratory
ticles can be seen that have partly melted at high temperature and technician selects powders based on the shade pre-
fused at their points of contact. This is sintering. (From Rosenstiel SF, scription provided by the dentist. These porcelains
Land MF: Contemporary Fixed Prosthodontics, ed 5, St Louis, 2016, were initially used for all-porcelain jacket crowns.
Elsevier.)
These jacket crowns were very esthetically pleasing
but had a high fracture rate. At present, the feld-
GLASS-BASED CERAMICS spathic porcelains have a variety of uses. They are
Glass-based ceramics are the most esthetic of the ce- used to cover (or veneer) a metal core to fabricate
ramic materials. porcelain-fused-to-metal (PFM) crowns and to ve-
neer high-strength ceramic cores such as zirconia.
PORCELAIN Zirconia is opaque and lacks the vitality of natural
Porcelain is a term that has been used in dentistry for tooth structure, so it is not very esthetic but it is very
many years to describe glass-like tooth-colored dental strong. Veneering it with feldspathic porcelain can
materials. Some people use the term interchangeably produce a more esthetic crown with a strong core.
with ceramics, but porcelain is actually a subgroup Feldspathic porcelain is also used for very esthetic
of ceramic materials composed of feldspar, silica or anterior veneers that can be rather thin, allowing for
quartz, and kaolin. Ceramic materials that are high in conservative preparations.
glass content are very esthetic, because their optical Porcelain veneers are most successful when they are
properties mimic those of enamel and dentin. How- bonded to enamel. Enamel is rigid and provides a firm
ever, they are brittle and more prone to fracture than support for the veneer. A metal or ceramic core also
newer low-glass, reinforced glass, or non-glass ceram- provides rigid support for porcelain. Dentin, however,
ics. Their flexural strength is no more than 20% of that is not as rigid. If the support for the veneer is mostly
of the strongest non-glass ceramics. dentin, the failure rate with feldspathic porcelain in-
creases. If the dentin flexes slightly under functional
Feldspathic Porcelain loads, either the bond between the veneer and the den-
Until advances in ceramic materials over the past four tin will fail or the veneer will break. If dentin is the
decades were made, the dental ceramic material most base for the veneer, then a stronger esthetic material
commonly used was feldspathic porcelain manufac- should be selected.
tured from fine crystalline powders of alumina, feld-
spar, and silica oxide (or quartz, 44% to 66%) mixed with Fusing Temperatures
a flux of sodium or lithium carbonate. As the powder Porcelains can be classified according to their fusing
is heated to certain critical temperatures, the porcelain temperature as high fusing (1294 °C to 1371 °C, or 2360
particles fuse together (sinter) at their points of contact °F to 2500 °F), medium fusing (1093 °C to 1260 °C, or
to form a type of glass (Fig. 9.1). Examples of feldspathic 2000 °F to 2300 °F), and low fusing (871 °C to 1066
porcelain include Ceramco 3 (Dentsply), EX-3 (Norita- °C, or 1600 °F to 1950 °F). High-fusing porcelains are
ke), Halo (Shofu), and VITA VM13 (Vident/VITA). used most often for the manufacture of denture teeth
(see Chapter 17 Polymers for Prosthetic Dentistry, Fig.
17.17). Medium-fusing porcelains are used for some
Feldspathic porcelain is the oldest of the porcelains used all-ceramic restorations. Low-fusing porcelains are
in dentistry (introduced in the early 1900s). It is the most used for veneering metal in PFM crowns and to fabri-
esthetic but the weakest of the ceramic materials in use. cate some all-ceramic restorations.
170 CHAPTER 9 Dental Ceramics

REINFORCED GLASS-BASED CERAMICS

NON–GLASS-BASED CERAMICS
Because porcelains were prone to fracture, stronger
ceramic materials were developed. The most common Non–glass-based ceramics are crystalline-based with
of these stronger glass-based ceramics are leucite-rein- no glass matrix and are composed of oxides of alumina
forced ceramics (IPS Empress; Ivoclar Vivadent) and and/or zirconia with minor amounts of other compo-
lithium disilicate ceramics (IPS e.max and IPS Empress nents to improve their properties.
II; Ivoclar Vivadent). Reinforcing the material with
ALUMINA
leucite crystals or lithium oxide has more than tripled
their fracture resistance. The reinforced ceramics re- A non-glass material with a crystalline matrix (com-
quire a bit more thickness in order to achieve the de- posed of alumina) was developed as an alternative to
sired esthetics. the PFM crown and the first product was In-Ceram
Alumina (Vident/VITA). It was the first all-ceramic
Lithium Disilicate material that could be used for both anterior and pos-
Lithium disilicate ceramic is composed of quartz, terior crowns and anterior short-span bridges. While
lithium dioxide, alumina, phosphor oxide, potassi- it had higher strength, it was less translucent, and
um oxide, and small amounts of other components. therefore was less vital looking. An alternative alumi-
The resulting glass ceramic has high strength, good na material is solid sintered alumina (Procera; Nobel
marginal integrity, and biocompatibility and, unlike Biocare). The resulting ceramic material has very high
porcelain, can be used in both the anterior and pos- flexural strength, about three times that of the glass-
terior parts of the mouth. It is a very esthetic materi- based materials.
al because of its high translucency caused by the low To provide increased translucency a new material
refractive index of the lithium disilicate crystals (the was developed with an alumina/magnesia matrix
crystals let light pass through rather than dispersing called spinel. In-Ceram Spinell (VITA North America)
it). Because of its favorable properties lithium dis- gives up some of the flexural strength of alumina ce-
ilicate ceramic has become very popular for veneers ramic but is more esthetic for anterior crowns.
and esthetic anterior and posterior crowns. It also Alumina ceramic systems have been replaced for the
can be used for short-span fixed bridges if not sub- most part by zirconia and lithium disilicate because of
jected to excessive forces, as with people who grind their higher failure rate when used for molar crowns.
their teeth (bruxers). It has high flexural strength (ap-
ZIRCONIA
proximately 300 MPa), and heat-pressing (pressing a
molten ingot into a mold) makes it more resistant Zirconia (zirconium oxide) ceramics are the strongest
to crack propagation. It is manufactured in a variety ceramic materials currently used in dentistry. They
of shades and comes as ingots for the heat-pressed have the highest flexural strength (Table 9.1) and frac-
(890 to 920 °C, or 1634 °F to 1688 °F) technique (e.g., ture toughness, at least twice as strong as the alumi-
IPS Empress 2 or IPS e.maxPress, Ivoclar Viva- na-based ceramics. Like lithium disilicate they can be
dent) or ceramic blocks for CAD/CAM milling (IPS heat-pressed or machined. Common brand names in-
e.max CAD). clude Lava (3M ESPE), Cercon (Dentsply), and VITA
YZ (Vident/VITA). Zirconia can be used in the anterior
Cementation. As with the other glass-based materials, and posterior parts of the mouth for single-unit crowns
restorations made from lithium disilicate should be or as cores for three-unit bridges.
bonded to the tooth with resin cement for maximum
strength. They are first etched with hydrofluoric acid Cementation
gel and then coated with silane before applying a resin Because of their high strength, zirconia crowns can be
bonding agent or a self-adhesive resin cement. The cemented with conventional cements or bonded with
length of time for etching is dependent on the type resin cements. Zirconia restorations are not etched or si-
of glass-based material and the concentration of the lanated before cementation. They do not respond to acid
hydrofluoric acid. Overetching may produce a friable etchants like the glass-based ceramics, and attempts at
surface that is difficult to bond to. Check the manufac- etching might produce a powdery residue on the in-
turer recommendations. terior of the crown that is difficult to remove and may
interfere with bonding. Several manufacturers have de-
SURVIVAL RATES FOR GLASS-BASED CERAMICS veloped primers for preparing the interior of the crown
Glass-based ceramic inlays, onlays, and veneers have for use with resin cements. Zirconia primers include
a 5-year survival rate of 93-98% and 64-95% at 10 years. Metal/Zirconia Primer (Ivoclar Vivadent), Z-PRIME
When used for full crowns limited to the anterior part Plus (BISCO), and Clearfil Ceramic Primer (Kuraray
of the mouth, the survival rate is also high for the rein- America). Some clinicians have reduced the protocol for
forced glass materials. These materials owe their high bonding zirconia to three steps: 1. Sandblasting the inte-
success rate to the fact that they can be bonded to enam- rior; 2. Applying primer; and 3. Bonding with adhesive
el and dentin for support. resin cement.
 Dental Ceramics CHAPTER 9 171

Table 9.1    Strength of Various Types of All-Ceramics

FLEXURAL FRACTURE TOUGHNESS
CERAMIC TYPE COMMON BRANDS ESTHETICS STRENGTH (MPa)* (MPa · m0.5)
Feldspathic porcelain Ceramco Very high 120-130 0.78
VITA VMK
Duceram LFC
Leucite-reinforced glass ceramic IPS Empress High 104-160 1.2-2.4
Lithium disilicate glass ceramic Empress II Moderately high 262-306 3.0
IPS e.max
Glass-infiltrated alumina Procera Alumina Moderate-to-low 340-700 3.2-4.4
In-Ceram (alumina)
Zirconia Lava Moderate-to-low 800-1300 4.0-6.3
Cercon unless veneered
VITA YZ with more esthetic
Procera Zirconia material
IPS e.max ZirCAD
*Approximate, depending on processing.

Improving the Esthetics of Zirconia flexural strength. Lithium disilicate has the highest
Zirconia is a much more opaque ceramic than lithium flexural strength of these glassy materials. The non–
disilicate ceramic. To achieve better esthetics, a layer glass-based ceramic materials have very high flexural
of veneering porcelain can be added to the zirconium strengths. Zirconia has the highest flexural strength of
core. If the crown fractures, it is usually caused by a the crystalline materials and also has the highest frac-
fracture of the porcelain veneer or a separation of the ture toughness. See Table 9.1 for a comparison of mate-
porcelain from the zirconia. The porcelain veneers chip rial strengths.
at the rate of 6-10% for crowns at 5 years and 3-36% for
fixed bridges at 5 years. THERMAL PROPERTIES
An alternative to layering porcelain is to heat-press Ceramic materials act as insulators in that they do not
a fluorapatite glass-ceramic material onto the zirconia conduct heat or cold readily, as do metallic restora-
core. A more recent development is high-translucency tions. They will, however, expand or contract when
zirconia that can be used as an all-zirconia crown with- subjected to temperature changes. The degree to which
out the need for porcelain layering in many posterior they expand or contract is called the coefficient of ther-
applications. Examples of these more translucent zir- mal expansion (CTE). The higher the CTE, the more the
conia materials include BruxZir (Glidewell Laborato- ceramic expands or contracts with temperature chang-
ries) and Lava Plus (3M ESPE). es. This change in dimension is not critically important
with a restoration made from a single material. How-
Glass-based ceramics are the most esthetic and mimic the ever, when two ceramic materials are used jointly in a
optical properties of enamel and dentin. However, they have restoration, as with porcelain veneer of a zirconia core
low values for flexural strength. The higher the crystalline
or porcelain bonded to a metal core (as with a PFM
component added to the glass matrix, the greater is the
strength, i.e., lithium disilicate (IPS e-Max, Ivoclar Vivadent).
crown), the two materials must have compatible CTEs.
Non-glass (crystalline) ceramics have the highest flexural Otherwise, the veneering ceramic material may frac-
strength but are not as esthetic and are more opaque. The ture. The laboratory technician must carefully select
strongest of these materials is zirconia, but it is commonly materials for their compatibility because not all ceram-
veneered with porcelain to use where esthetics is important. ics have the same CTE.

OPTICAL PROPERTIES
PHYSICAL AND MECHANICAL PROPERTIES Transparency
Transparent materials allow light to pass through in an
FLEXURAL STRENGTH unaltered path, i.e., window glass (see Fig. 9.2). Since
Ceramic materials are stiff and brittle, and these prop- transparent materials do not resemble tooth structure
erties contributed to the fracture of weak feldspathic there is little need for them in dentistry.
porcelains in early clinical applications. Newer ceram-
ic materials are much stronger. Although ceramic ma- Translucency
terials are generally stronger when compressive forces Translucent materials allow light to pass through the
are applied, it is their flexural strength that is more surface and into the body of the material; some of the
important for resisting fracture. Glass-based ceramic light is reflected back out, unlike a transparent mate-
materials such as the porcelains have relatively low rial that allows light to pass all the way through it.
172 CHAPTER 9 Dental Ceramics

less so than alloys or resins. Lithium disilicate shows

some initial toxicity in cell cultures that fades with time.
Non-glass ceramics have shown no toxicity to date, and
zirconia has been successfully used as implant fixtures.

CERAMIC PROCESSING TECHNIQUES

A variety of techniques may be used to fabricate all-
ceramic restorations, depending on the type of ceramic
material that will be used. Ceramic restorations can be
made by sintering, slip-casting, heat-pressing, or com-
puter-aided machining.

SINTERING
Sintering occurs when ceramic particles are heated to
the point that they melt and fuse to adjacent particles
at their borders (see Fig. 9.1). Methods such as firing
the ceramic in a vacuum are needed to reduce poros-
ity and in turn produce a stronger material. To achieve
FIG. 9.2 Optical properties (From Powers JM, Wataha JC: Dental Mate­ the desired match to the natural tooth, other ceramic
rials: Properties and Manipulation, ed 11, St. Louis, 2017, Elsevier.) materials called stains and glazes are added and fired
to join with the previous layer of ceramic. Alumina-
Glass-based ceramic materials are more translucent based ceramic and feldspathic porcelain that has been
than non-glass ceramics and as a result mimic enamel reinforced with leucite are the most commonly used
better. materials for the sintering process. Both of these ma-
terials have higher flexural and compressive strength
Reflectance compared with traditional feldspathic porcelain. As
The surface of a ceramic material may reflect light that ceramic processing techniques advance, sintered all-
hits it. How much light is reflected is influenced by the ceramics are being used less, in favor of heat-pressed
surface texture and polish and the basic structure of or computer-aided machined ceramics.
the ceramic material. The portion of the light that is not
reflected passes into the ceramic and is either absorbed SLIP-CASTING
or passes through it. Slip-casting is a processing technique whereby the ce-
ramic powder is mixed with a water-based liquid to
Opacity form a stable suspension called the slip and pressed
Opaque ceramic materials do not allow light to pass onto a porous refractory die that soaks up much of the
through them. The light is absorbed or reflected. Non- water. The slip is then fired at high temperature (1150
glass ceramic materials are the most opaque. These °C, or 2102 °F) to create a porous ceramic core. This
materials are the least esthetic of the ceramic materials core is then infiltrated with molten glass by capillary
and must be veneered with more translucent, glassy action to make a dense strong core to which conven-
materials to be used for anterior restorations. tional porcelains can be added to develop the desired
color and degree of translucency or opacity.
Vitality The slip-casting technique can be used with zirco-
Glass-based ceramic crowns have a more lifelike ap- nia-based, spinel-based (magnesium aluminum ox-
pearance (sometimes called vitality) than PFM crowns. ide), or alumina-based ceramic materials. Zirconia-
They appear vital (similar to natural teeth) because based ceramics have the highest flexural strength of
they are fluorescent, that is, they emit light in the vis- these materials and are several times stronger than the
ible wave spectrum when ultraviolet light hits them. ceramic cores made from aluminum oxide that were
They are also opalescent because they take on a bluish introduced in the 1960s. They also have fewer defects
tinge when light reflects off of them, and an orange- from processing. Ingots of this glass-infiltrated mate-
yellow tinge when light passes through them. rial can be processed with CAD/CAM units making
for a simpler technique.
BIOCOMPATIBILITY
Ceramic materials are considered to be among the most HEAT-PRESSING
biocompatible of the restorative dental materials. Clini- Heat-pressing uses the lost wax technique, similar to
cal studies have not shown an adverse tissue response to that used to cast gold crowns into an investment mold
these materials. Glass-based ceramic materials will leach developed from a wax pattern that was burned out in an
some components in minute amounts over time; much oven (the lost wax technique is discussed in Chapter 16
 Dental Ceramics CHAPTER 9 173

Gypsum and Wax Products). Pressable ceramic ingots there are several manufacturers for CAD/CAM systems
are made of crystalline particles in a glass matrix. An for the dental office and the dental laboratory. The two
ingot of the desired shade is heated until it becomes a most popular chairside systems in the USA are CEREC
thick liquid. Then, it is pressed into the mold at high 3D (Dentsply Sirona) and E4D (D4D Technologies).
temperature (about 1160 °C, or 2120 °F) and pressure
(0.4 MPa), making a denser restoration. To complete BASIC COMPONENTS OF CAD/CAM SYSTEMS
the restoration, it can be color-stained and glazed. If the CAD/CAM systems have three basic components: (1)
material is used as a core or framework, conventional an optical scanner, (2) a computer with design software,
feldspathic porcelain can be added to complete the color and (3) a milling device (Fig. 9.3). The optical scanner
and contour, and surface stains can be added. can make “impressions” (digital images) of tooth prep-
A leucite-based ceramic has been used for this pro- arations, opposing teeth and the occlusal relationship
cess since the 1990s. Commonly known brands are that are integrated with computer software (for details
IPS Empress (Ivoclar Vivadent) and Finesse (Dentsply on digital impressions see Chapter 15). The computer
Sirona). An improvement in strength was made with software then designs the restoration to fit the prepa-
the introduction of a lithium disilicate–based ceramic ration, establishes proper contours and contacts, and
(IPS Empress II and later versions called IPS e.max; shapes the restoration to fit the opposing occlusion.
Ivoclar Vivadent). These materials have been used for Improvements in the software permit the operator to
inlays, onlays, crowns, veneers, and short-span fixed view the designed restoration in three dimensions and
bridges in low stress areas. rotate it in all directions so that each aspect can be in-
spected. The dentist, hygienist, or assistant can modify
COMPUTER-AIDED MACHINING the design as needed, using the design tools provided.
Various pre-processed ceramic materials are available The design is fed into a computer-controlled machine
in blocks for use with CAD/CAM technology. An opti- that uses diamond instruments to mill an all-ceramic
cal impression of the prepared tooth is made and either restoration from a block of ceramic material (Fig. 9.4).
used in the dental office or transmitted to the dental lab-
oratory. A computer software program is used to design INCORPORATING CAD/CAM TECHNOLOGY INTO
the restoration to establish the contours, proximal con- PRIVATE PRACTICE
tacts, occlusal contacts, and margins. A block of the ce- Benefits of Chairside CAD/CAM Systems
ramic material in the appropriate shade is selected and There are a number of benefits that dental practices can
placed into a milling machine. A computer, using the de- derive from using the chairside CAD/CAM systems:
sign created, instructs the milling device to cut out the • A three-dimensional image of the tooth preparation
restoration. Depending on the material selected, heat can be viewed on the computer monitor from sev-
processing may be required to complete the firing of the eral different angles. The dentist or auxiliary can then
ceramic material. Custom staining and glazing of the modify the preparation as needed before processing
restoration may be done to achieve maximal esthetics. the restoration, so potential errors can be eliminated.
• The opposing teeth can be viewed in occlusion with
the designed restoration and measurements of the
CAD/CAM TECHNOLOGY restoration thickness can be made before milling,
Advances in technology over the past three decades Thickness of the ceramic can be increased or de-
have led to the development of sophisticated comput- creased as needed and contours can be modified
er-aided design and computer-aided machining (CAD/ with the design software.
CAM) for general industry and for dental applications. • The impression procedure is simplified because
The technology now has widespread acceptance. Ini- no cord packing or impression material is needed.
tially, CAD/CAM technology in dentistry was used Many potential sources of error are eliminated.
solely for crown and bridge restorations. Preformed • The completed design of the restoration can be
ceramics or resin ceramic blocks or disks are used to viewed and approved before milling is started.
fabricate a variety of restorations including inlays, • Machining eliminates the human error sometimes seen
onlays, veneers, crowns, and bridges. As the technol- with processing steps done by a laboratory technician.
ogy has advanced and full arch scanners have become • Perhaps the most attractive feature is that dental of-
available, many other applications have emerged in- fices that have these systems can prepare and de-
cluding surgical guides, custom implant abutments, liver the restoration in the same visit. Patients like
orthodontic aligners, custom braces, orthodontic ap- this convenience, and this can be a practice-building
pliances, and complete and partial dentures. feature. This improves office efficiency and greatly
In 1986 the CEREC (Chairside Economical Restora- speeds up the process. The patient needs to be given
tion of Esthetic Ceramic) system was the first to be intro- anesthesia for only one visit; digital scanning of the
duced to dentistry. The manufacturer (originally Sirona preparation speeds the “impression” process and
Dental Systems, Long Island City, NY, and now Dentsply no impression materials are needed; no die needs
Sirona) has continually improved the system. Presently, to be poured; no temporary crown is needed; and
174 CHAPTER 9 Dental Ceramics

A C

G
E I

J
H

K
FIG. 9.3 CAD/CAM in-office system for making all-ceramic restorations. A, CAD/CAM in-office control unit with attached
camera captures and stores images of the prepared teeth and bite relationship. Software designs the restoration and
directs the milling unit on how to sculpt the restoration. B, Cracked lower first molar needing restoration. C, Cracked
molar prepared for a ceramic onlay. D, Camera captures images of the prepared molar. E, The image of the molar and
the margins marked in blue. F, Bite registration placed over the prepared molar. Its image will be captured, and computer
software will configure the occlusal relationship with the ceramic onlay. G, Computer-generated occlusal contacts (blue)
made from the bite registration. H, Milling unit that will sculpt the ceramic onlay from a ceramic block of the selected
shade. I, Ceramic blocks in a variety of shades and sizes. J, Unpolished ceramic onlay tried on the molar to confirm its
fit. K, Ceramic onlay after it has been polished and cemented. (Courtesy of Dentsply Sirona and Todd Ehrlich [private
practice in Bee Cave, TX] for clinical photographs.)
 Dental Ceramics CHAPTER 9 175

A B
FIG. 9.4 Milling the restoration. A, Ceramic block is placed in the milling machine. B, Diamond instruments mill the restoration
from the ceramic block according to the design feed from the computer software. (CEREC MC XL, Courtesy Dentsply Sirona.)

one cycle of breakdown and setup of the operatory laboratory, where the technician scans a die made from
with disposable supplies is eliminated. There is no the impression (or scans the impression itself), designs
laboratory fee, so with all of the areas of cost savings the restoration, and feeds the information to the milling
the system eventually pays for itself. machine. The technician can apply custom stain, and
The very basics for operating a CAD/CAM system then polish or glaze the restoration and, if needed, stack
can be learned in a 2-day hands-on course. However, or press porcelain to high-strength cores.
to become proficient and apply all of the features the
systems offer, additional training and practice will be Drawbacks of Introducing Chairside CAD/CAM
needed. Scheduling for restorative procedures that will into the Practice
use the system will need to be altered to accommodate Introducing a new technology to the practice is not
the one-appointment mode. Initially longer appoint- without certain drawbacks:
ments will be needed until the dentist and the staff be- • There is the initial expense of the system, periodic
comes proficient with the system. Consideration will software updates, and routine maintenance. The
need to be made that at the same visit both prepara- dentist must determine how many esthetic resto-
tion and cementation will take place as well as the steps rations are typically done in the practice or will be
needed to finish, polish, stain, and glaze the restoration. done once the new equipment is installed. Is this go-
ing to be a cost-effective purchase or will it sit in a
ROLE OF THE ASSISTANT/HYGIENIST corner and collect dust?
Many of the steps can be delegated by the dentist to • There is a significant learning curve that must be
her/his team members who also have undergone accommodated in the practice schedule. As a result
training. Training courses are available that are geared there may be an initial loss of production. Patients
specifically for assistants or hygienists. Appropriately may have extended time in the office waiting for
trained assistants or hygienists are capable of using new learners to use the system and process the res-
the optical scanner to capture images of the prepared torations in a single visit. When things do not go as
and adjacent teeth and the opposing occlusion. They planned both the staff and the patient can get frus-
can mark the location of the margins and design the trated. So, the patient should be informed ahead of
restoration. They can initiate milling of the restoration, time that the appointment may be a long one.
polish it, stain and glaze it if necessary, and prepare • To provide good color matching of the restoration to
the restoration for bonding or conventional cementa- the dentition, custom staining may be needed. This
tion as dictated by the material selected. will require additional training and the purchase of
a glazing oven.
WORKING WITH THE LABORATORY • There are certain clinical scenarios in which an op-
Sirona has reported approximately 18% of dentists in tical scanner will not be effective, such as prepa-
the United States use chairside CAD/CAM technology. rations with deep subgingival margins. These
The utilization of CAD/CAM technology by dental lab- situations may need cord placement or soft tissue
oratories has exceeded chairside use. Dentists who have modification with a laser or electrosurgery to ex-
optical scanners but do not have milling machines in pose the margins.
their offices can electronically transmit digital images to
a commercial laboratory using the CAD/CAM equip-
CAD/CAM RESTORATIONS
ment to have a ceramic restoration made. For those of-
fices without a scanner or milling device, a conventional CAD/CAM technology can be used to produce mono-
impression is made of the prepared teeth and sent to the lithic (all the same material) single-unit inlays, onlays,
176 CHAPTER 9 Dental Ceramics

crowns, and veneers. In addition, it can be used to make ProCAD (Ivoclar Vivadent), composed of glass infiltrat-
ceramic cores for crowns and bridges that are subse- ed 40% with leucite, were available. Glass-based ceramic
quently veneered with porcelain or other ceramic mate- blocks are available as monochromatic (all one color) or
rial. A few manufacturers have developed multi-colored multicolored layers (examples are VITABLOCS TriLuxe
blocks with layers that mimic enamel and dentin. Pro- [Vident/VITA] or IPS Empress CAD Multi [Ivoclar
visional (temporary) restorations can be fabricated from Vivadent]) and are available in low and high translucen-
acrylic blocks. Implant abutments and metal partial den- cy. The resulting restorations are very esthetic and rela-
ture frameworks can also be milled. Properly designed tively strong once they are bonded. Lithium disilicate
restorations made with the use of CAD/CAM technol- blocks (IPS e.max CAD; Ivoclar Vivadent, introduced in
ogy require fewer remakes; shorter seating time and ad- 2006) are the strongest of the glass-based ceramics and
justments; and better contours, contacts, and occlusion. can be used for posterior crowns and three-unit fixed
Restorations have good marginal integrity which falls bridges (from premolars to anterior) and are esthetic
within the 50-micron (μm) parameter established by the enough to be used for anterior crowns and veneers.
American Dental Association.
Non-Glass Ceramic CAD/CAM Materials
CERAMIC CAD/CAM MATERIALS Non-glass ceramics are used mostly as machinable
Ceramic blocks made for CAD/CAM use have been pro- blocks. Aluminum oxide–based ceramics includes Pro-
duced under well-controlled conditions so that they are cera AllCeram (Nobel Biocare), In-Ceram AL Block (Vi-
uniformly dense with no porosity. Porosities are weak dent/VITA), and inCoris AL (Sirona). Zirconia-based ce-
points in the material that lead to the development of ramics include Lava (3M ESPE), In-Ceram YZ (Vident/
small cracks that propagate and eventually cause fracture VITA), and IPS e.max ZirCAD (Ivoclar Vivadent). They
of the restoration. Pre-produced blocks eliminate the vari- have very high flexural strength (750 to 1200 MPa) and
ations and errors that can occur with conventional labo- high fracture toughness. They are not very esthetic and
ratory procedures. Blocks contain bar codes that indicate must be veneered with more esthetic ceramics to be used
the density of each block so calculations can be made by in the anterior or visible areas in the posterior part of the
the computer software to allow for shrinkage that occurs mouth. They serve well as high-strength cores for crowns
when the restoration is given its final oven firing. and bridges (Fig. 9.5). To overcome the opacity of zirco-
Blocks of the appropriate materials can be used to nia restorations 3M ESPE has developed a high-translu-
generate inlays, onlays, crowns, fixed bridges, veneers cency zirconia material (Lava Plus) that is matched to
and implant abutments. In general, monolithic resto- the VITA shade guides. This should reduce the need for
rations are stronger than veneered restorations (a core veneering to achieve esthetics in many applications.
of one material and a veneer of another material). Ve-
neered restorations have the potential to chip or sepa- Processing the Material
rate at the junction of the veneer material and the core Milling the Blocks Blocks of hard, fully sintered, high-
material (called delamination). strength materials consisting of lithium disilicate, alu-
mina, and zirconia are difficult and time-consuming to
Glass-Based CAD/CAM Materials machine (called hard machining) to their final processed
Machinable blocks of glass-based ceramic materials are form. Milling them can quickly wear out the milling tools
available for fabrication of inlays, onlays, crowns, and and create residual flaws at the surface. To make them
veneers. The first and only ceramic CAD/CAM mate- easier to machine they are not processed (sintered) com-
rial available until 1997 was glassy feldspathic porcelain pletely until after they are milled (called soft or green ma-
(VITABLOCS Mark II, Vident/VITA). Later, blocks of chining). Some milling units can cut out a full crown in

A B
FIG. 9.5 Ceramic bridge teeth #8-#10 (Lava, 3M ESPE). A, Zirconia substructure. B, Veneered with more translucent
ceramic for esthetics. (Courtesy of 3M ESPE and V. Bonatz.)
 Dental Ceramics CHAPTER 9 177

approximately five minutes. IPS e.max CAD blocks, for Sometimes the fusion is not complete and the stain or
example, are only partially sintered and the blocks appear glaze can wear off. It wears off faster on occlusal surfac-
blue or purple (Fig. 9.6). The CAD blocks have a bar code es than facial surfaces. If the stain wears off, the result
that tells the computer software how large the milled res- will be a mismatch in color or if the glaze wears off, the
toration should be based upon the shrinkage that will oc- result is a rough restoration. Polishing the restoration to
cur during final sintering and allows for it during milling. a high shine instead of applying a glaze would solve the
Some milling units can cut the blocks dry, but many issue of a rough restoration caused by loss of the glaze.
units use constant water spray as a coolant. After mill-
ing the fit is verified and the restoration is finished and Resin Hybrid Ceramics
polished. Abrasive rubber wheels and points can be Hybrid resin nanoceramic materials (Lava Ultimate [3M
used and a high gloss achieved with diamond paste on ESPE] (Fig. 9.8); VITA Enamic [Vident/VITA], Shofu
bristle brushes. Instead of polishing, some clinicians Block HC [Shofu] and GC Cerasmart [GC America])
prefer to apply a spray-on glaze which is fused to the
restoration in a ceramic oven.

Firing the blocks. Once milling is complete, the restora-

tions are fired in a ceramic oven to fully sinter them and
transform them to the selected color. Materials such as
zirconia once took as long as two hours to sinter mak-
ing them impractical for same-appointment delivery.
However, advances in ovens have made firing of zir-
conia restorations possible in as little as 30 minutes de-
pending on their size and thickness (Fig. 9.7).

Stains and glazes. Color modifiers called stains contain

metal oxides and are used on the surface to characterize
a restoration by mimicking discolorations, white spots,
fine crack lines in enamel, stains in grooves or other
imperfections needed to match the natural dentition.
They are also used to improve the color of the restora-
tion when a preformed block does not provide an exact
color match. A glaze provides a glossy, enamel-like sur-
face. Stains and glazes are applied in thin layers on the
surface of the restoration and fired at the time of final FIG. 9.7 Firing and glazing oven. (CEREC SpeedFire, Courtesy
sintering. They are heated in a ceramic oven to a point Dentsply Sirona.)
that allows them to fuse with the ceramic restoration.

A B
FIG. 9.6 (Top to bottom) Partially sintered block (purple) of lithium dis- FIG. 9.8 Hybrid resin nanoceramic. A, CAD/CAM block, and B, com-
ilicate ceramic, and glazed crown (IPS e.max CAD, Ivoclar Vivadent) pleted onlay. (Lava Ultimate; images courtesy 3M ESPE.)
178 CHAPTER 9 Dental Ceramics

have been developed that combine desirable proper- sign before esthetic treatments are started. Although
ties of both composite resin and nanosized ceramic fill- the dentist has the final responsibility, the dental as-
er particles. They are easy to mill and polish to a high sistant or dental hygienist may be called on to inform
shine and do not need to be oven fired. Hybrid resin the patient about the pros and cons of various dental
nanoceramic materials produce tough, durable restora- materials.
tions that are not abrasive to the opposing teeth. They
are available in several common Vita Classic shades RATIONALE FOR SELECTION OF CERAMIC
consisting of high and low translucency options. They MATERIALS
are stain and wear resistant and color stable. They are Porcelain
indicated for single-unit anterior and posterior crowns, Porcelains (powder/liquid application) are used more
inlays, onlays, and veneers. Because they are relatively for anterior teeth. They (Ceramco 3, EX-3, VITA VM13,
new, long-term clinical studies are not yet available on and Halo) are used to make porcelain veneers and serve
their clinical performance. well once they are bonded to the enamel and used in
low-stress areas. The risk for fracture and debonding is
SUMMARY OF CAD/CAM STEPS FOR PRODUCING A higher if they are bonded to dentin. They are used as
RESTORATION veneers on cores made from stronger but less esthetic
• Complete the preparation using principles for all-ceram- materials such as alumina, zirconia, or metal. They are
ic restorations prone to fracture if used in posterior teeth for inlays or
• Use the optical scanner to obtain an image of the onlays or for anterior crowns.
preparation lined up with the path of insertion of the
restoration. Some scanners require coating the prepa- Leucite-Reinforced Ceramics
ration with a powder to enhance scanning accuracy
Leucite-reinforced ceramics (IPS Empress) are esthetic
• Use the computer software to design the restoration:
and are available as machinable blocks (VITABLOCS
mark margins and establish restoration contours on the
computer screen Mark II, IPS Empress CAD) or pressable ingots. They
• Use the software to simulate occlusal excursions work well for inlays, onlays, thicker veneers, and an-
• Select block of the correct shade of the ceramic mate- terior crowns if they are bonded. They are not strong
rial and place it in the milling machine enough to hold up as posterior crowns.
• Program the milling machine for the material being used
and activate the machine Lithium Disilicate
• If the milled restoration was in the green (or soft) state, it Lithium disilicate (IPS e.max and e.max CAD) has twice
will need to be fired to complete the sintering process the strength and fracture toughness of IPS Empress and
• Characterization with surface stains can be accom- has enough translucency that it can be used in the ante-
plished while applying the overglaze
rior or posterior part of the mouth for any solitary resto-
• Try in the completed restoration
• Cement the restoration after etching internally and ap-
ration. It can be used for three-unit bridges from the pre-
plying silane (zirconia should not be etched or silanated. molars to the anteriors. The manufacturer says it can be
It has special primers) cemented with conventional luting agents, but for maxi-
• Check and adjust the occlusion as needed after mal strength it should be bonded.
cementation
Alumina and Zirconia.
The non-glass ceramics, alumina (Procera and In-Ce-
ram) and zirconia (Lava, Cercon, In-Ceram Zirconia,
CLINICAL APPLICATIONS FOR CERAMIC IPS e.max ZirCAD, and Procera AllZirkon), are very
MATERIALS strong materials but being somewhat opaque are not
Many of the newer ceramic materials such as lithium esthetic for use in the anterior part of the mouth. The
disilicate and zirconium are much stronger than por- alumina materials show an increased risk of fracture
celain and have replaced its use in many clinical ap- when used for molar crowns, and therefore their use
plications. They are finding wider applications and are should be limited to anteriors and premolars, serving
strong enough to be used in the posterior part of the well as inlays and onlays. Their opacity can be useful
mouth in many (but not all) individuals. People who in hiding the discoloration of endodontically treated
grind their teeth apply greater stress to ceramic mate- teeth. Zirconia is a suitable alternative for PFM crowns.
rials and are at greater risk of fracturing it. However, All-zirconia crowns, inlays, and onlays can be used to
some patients are willing to accept the risk of fracture provide esthetic restorations for bruxers who would
to achieve the high esthetics of all-ceramic crowns. It otherwise destroy the weaker ceramic materials. Zir-
is very important that patients be made fully aware conia crowns can be made more esthetic by veneering
of the fracture risks of using porcelain or other ceram- with porcelain. There is some risk (>5%) of chipping of
ics, so they can make informed decisions about their the veneering porcelains. Zirconia can be used for cores
care. When the patient has multiple ceramic restora- for three-unit bridges and for implant abutments in the
tions, use of an occlusal guard is recommended. Many anterior smile zone. See Table 9.2 for a summary of in-
offices use informed consent forms that patients must dications and contraindications for dental ceramics.
 Dental Ceramics CHAPTER 9 179

Table 9.2    Indications and Contraindications for Use of Various Types of Ceramics
CERAMIC TYPE COMMON BRANDS MAIN USES OTHER USES CONTRAINDICATIONS
Feldspathic Ceramco PFM ceramics Single surface inlays in Inlays, onlays, crowns,
porcelain VITA VMK Anterior veneers low-stress sites bridges (except as
Duceram LFC metal ceramic veneers)
Leucite-reinforced IPS Empress Anterior use for single Low-stress inlays and Bridges
glass ceramic crowns or veneers crowns in premolars High stress: Bruxers
Lithium disilicate Empress II Anterior and premolar Anterior veneers High stress: Bruxers
glass ceramic IPS e.max crowns Bridges no farther back Bridges involving molars
Anterior bridges than premolars
Glass-infiltrated Procera Alumina Posterior crowns Anterior bridge sub- Translucent anterior ap-
alumina or In-Ceram (alumina, Bridge substructure to structure to 3 units plications: Veneers and
zirconia zirconia) 3 units crowns
Zirconia with or Lava Posterior crowns and Implant abutments in Where high translucency
without veneering Cercon bridges the smile zone is needed: Anterior
ceramic VITA YZ Posterior bridge sub- veneers, crowns, or
Procera Zirconia structure bridges
IPS e.max ZirCAD Bruxers
BruxZir Solid Zirconia
PFM, porcelain-fused-to-metal.
Adapted from Anusavice KJ, Shen C, Rawls HR: Dental Ceramics (Table 18-3). In: Phillips’ Science of Dental Materials, ed 12, St. Louis, 2013, Saunders.

VENEERS if the incisal edge is involved, at least 1.0 mm at the

Veneers are thin layers (like press-on nails) of esthetic incisal edge. Esthetic demands might require greater
materials that are used to improve the appearance of reduction to correct overlapping teeth or to hide dark
the teeth. They are bonded to the fronts of the teeth, teeth or discolorations. Pressed ceramic veneers are
most often anterior teeth and premolars. They can be thicker than feldspathic porcelain veneers and there-
used to lighten the color of teeth, cover stains, repair fore require a deeper preparation of the tooth. They
chips or other defects, lengthen worn teeth, increase are very esthetic for covering mild discolorations but
the size of small teeth, close spaces (diastemas), or re- are too translucent for very dark teeth. CAD/CAM-
shape crooked teeth so that they look as though they produced veneers of lithium disilicate (IPS e.max) are
are in proper alignment. strong and can be made thinner than pressed ceramics.
The most commonly used materials are directly Ultrathin porcelain veneers that require no preparation
placed composite resins or indirect (made in the labo- of the teeth are heavily marketed by their manufacturers.
ratory) glass-based ceramics. Indirect ceramic veneers Although no preparation may be needed in select cases,
are made in the laboratory of traditional feldspathic in many cases patients might end up with bulky, over-
porcelains (called porcelain laminate veneers or sim- contoured veneers, if adequate space is not created for the
ply porcelain veneers), pressed ceramics, or computer- veneering material. With an ultrathin material, it is also
assisted machined ceramics, such as IPS e.maxCAD. more difficult to mask dark underlying tooth structure.
Ceramic veneers are more durable than composite ve- Porcelain veneers can be made to be slightly trans-
neers: their surface does not discolor over time, they lucent to let the color of the underlying tooth come
are more wear resistant, and they are stronger. through, or more opaque to hide the color of a darker
The first porcelain veneers were used in the 1930s, natural tooth. Dark teeth are more challenging to cover
mostly for Hollywood movie stars. Because bonding with veneers and still achieve an esthetic result. Use
to tooth structure by acid-etch techniques did not be- of some opaque porcelain (up to approximately 15%)
come commercially available until the 1960s, these helps to hide the darkness, but too much opaqueness
Hollywood veneers were just stuck on the teeth with will cause a loss of the vitality produced by translucen-
the available denture adhesives. Embarrassing situa- cy that mimics natural enamel. Because of their thin-
tion could occur if the veneers became dislodged! ness, veneers may not be the best mode of treatment
to esthetically improve the appearance of very dark
Clinical Consideration for Veneers teeth. On occasion, whitening of the dark teeth may be
Until the advent of the newer ceramic materials, porce- attempted first, to reduce the darkness before veneers
lain veneers were the most widely used veneers. They are placed. Otherwise, all-ceramic crowns might be
can be made relatively thin and require a minimal a better option for improving the appearance of very
reduction of the enamel by 0.5 mm on the facial and, dark teeth and still achieving an optimal esthetic effect.
180 CHAPTER 9 Dental Ceramics

Try-in of veneers. Veneers are tried on the teeth, using

water or a try-in gel on the surfaces that contact the
teeth. The gel is a water-soluble material that occupies
the air space between the veneer and the tooth surface.
Without the water or gel, light transmitted through
the veneer will be scattered by the air space, altering
the appearance of the veneer. The gels can be clear or
slightly shaded to correspond to shades of bonding
resins. Before they are bonded to the teeth, the ceramic
veneers are somewhat fragile, because they are very
thin. They must be handled with care when they are
A
tried on the teeth to confirm the fit or to adjust the con-
tact areas. They might crack if too much pressure is
applied to them. Once they are bonded, they gain sup-
port from the underlying tooth structure and greatly
increase in strength.

Caution
Handle veneers carefully! They are very fragile until bonded!

Cementation of veneers. Veneers are bonded to the

teeth with resin cements, using the acid-etch technique,
and a resin bonding agent (Fig. 9.9). The resin cements B
come in a variety of colors, including a clear resin. If
needed, a resin color can be selected to slightly alter
the final appearance of the veneer to help mask the
color of the underlying tooth. To get the resin to stick
to the porcelain, the internal surface of the veneer is
roughened by etching it with hydrofluoric acid. A cou-
pling agent, called silane, is added to the etched porce-
lain surface to enhance the bond and form a chemical
union between the porcelain and the resin cement (see
Chapter 5, Procedure 5.2).
Once the tooth surface and the internal veneer sur-
face have been properly prepared, the resin cement is C
placed on the veneer and is carefully seated while an
FIG. 9.9 Placement of porcelain veneers to correct a large diastema.
attempt is made to avoid trapping air. The veneer is A, Pretreatment photograph showing large midline diastema. B, Maxil-
lightly vibrated with an instrument or finger to fully lary anterior teeth prepared for veneers. Retraction cord is in place.
seat it and dislodge any entrapped air bubbles. Excess C, After cementation of veneers with a resin cement. (Courtesy of
cement can be removed from the margins at this stage Dentsply International [York, PA].)
with small brushes, or the curing light can be waved
over the surface for 3 or 4 seconds to cause the resin to the 1950s, all-porcelain jacket crowns or metal crowns
slightly gel but not fully cure. The gelled excess resin with acrylic or porcelain facings were used most often
can then easily be removed with an explorer or #12 in the esthetic zone of the mouth. Acrylic facings stained
surgical blade. Some additional finishing and polish- and wore down over time. Cemented porcelain facings
ing might be required. Various techniques are avail- often fractured or became uncemented (bonding was
able for this last step, using combinations of finishing not available at the time). The main advantages of the
strips and disks, carbide and diamond finishing rotary combination of porcelain and metal are the strength and
instruments, and rubber polishing points or diamond durability given to the restoration by the bond between
polishing pastes. a metal internal core and the esthetic external porcelain
covering. The restorations are strong enough to be used
PORCELAIN-METAL RESTORATIONS in the posterior part of the mouth, where biting forces
Before strong, esthetic ceramics were developed, the are greater than in the anterior part, and can be provid-
most commonly used restorations in fixed (crown and ed as single crowns or multi-unit bridges. The survival
bridge) prosthodontics were combinations of porcelain rate at 5 years for porcelain-metal restorations is about
and metal (porcelain-metal restorations). Before the de- 94%. Trying to hide the metal core with porcelain can
velopment of the porcelain-fused-to-metal technique in present some esthetic challenges. Additionally, a small
 Dental Ceramics CHAPTER 9 181

Diagram of longitudinal section through

(A) All-ceramic crown
(B) Porcelain-bonded-to-metal crown
Oxidized
metal

Opaque Base/core
porcelain ceramic

Body Gingival/dentin
porcelain porcelain

Enamel/occlusal
A porcelain
FIG. 9.10 Porcelain failure with porcelain-bonded-to-metal (PBM)
crown. The metal is exposed, as is a portion of the opaque layer of
porcelain used to prevent metal from showing through the more trans- Porcelain Cast metal core
lucent outer layers of porcelain. (Courtesy of Dr. Steve Eakle, University margin with metal lingual
of California, San Francisco.) collar
Gingival
dentin Opaque layer
percentage of patients may have allergies to some of the shade
metals used for the core.
Enamel/occlusal
B porcelain
Application of Porcelain to the Metal Core
The method for layering porcelain on a metal core is FIG. 9.11 Section through A, an all-ceramic crown and B, a porcelain-
bonded-to-metal crown, showing the layers of porcelain and the metal
similar to that for a ceramic core or for building up
substructure of the crown.
porcelain on a die. Low-fusing porcelain (i.e., Ceram-
co 3, Dentsply Sirona) is used for the bonding of por-
celain to metal. These restorations are referred to as to be used fuses at low, medium, or high temperature. The
porcelain-fused-to-metal (PFM) or porcelain-bonded- porcelain particles melt at their borders and fuse togeth-
to-metal (PBM) restorations. The metals that are used er (sintering) and also wet the metal oxides. The oxides
as the core for PBM/PFM crowns are alloys of specific and porcelain chemically fuse together and mechanically
metals that will form an oxide layer as the metal is interlock. Sintering results in shrinkage of the porcelain
heated. When porcelain is applied to the metal and mass by about 25% to 40%. Then additional layers of
the two materials are heated together, the porcelain porcelain called body and incisal porcelains are built up or
chemically fuses to the oxides on the metal, forming stacked to simulate dentin and enamel colors and translu-
a durable bond. The metal alloys are classified as high cency and condensed with a stacking instrument to help
noble (precious), noble (semiprecious), or base (non- eliminate porosity (Fig. 9.11). The incisal porcelain is more
precious) metal alloys, based on the presence and translucent, so the body color shows through readily and
amount of gold, palladium, and other precious metals has a greater influence on the final appearance. The layers
(see Chapter 11 Casting Metals, Solders, and Wrought of porcelain are fired in the oven until they fuse to each
Metal Alloys). The metal in the area where the porce- other and to the underlying opaque porcelain.
lain is to be bonded is usually relatively thin, approxi-
mately 0.3 to 0.5 mm thick. Firing Porcelain
A color of porcelain is selected that corresponds to After completion of the layering of colors, the con-
the color or shade that matches the patient’s denti- densed porcelain on the metal coping is heated to a
tion. The first layer of porcelain applied to the metal few hundred degrees to remove residual water. This
is opaque porcelain that keeps the metal oxide color process is called the drying stage and is done before
from showing through the porcelain and is the main final firing. A programmable porcelain oven is used
color used for the crown (Fig. 9.10). Base metals often to gradually raise the temperature. If the temperature
form darker oxides that are more difficult to hide with is increased too quickly the water vapor (steam) can
opaque porcelain. cause the condensed mass to blow apart.
The porcelain comes as a powder that is mixed into a Next, the porcelain is fired at high temperature and
paste with de-ionized water or a water-based liquid, or vacuum. The temperature at which the porcelain is fired
may be in a paste form already. The porcelain paste is ap- is determined by the type of porcelain being used and
plied (or stacked) on the metal and shaped. Then it is vi- its components (see manufacturer specifications). The
brated with an instrument to reduce porosity and blotted porcelain is low fusing and is first heated to approxi-
to remove excess moisture. The oxidized metal and porce- mately 900 °C to partially fuse (sinter) the particles (see
lain are heated under a vacuum to remove air and increase Fig. 9.1). As the glass matrix softens, it flows and reduces
density at temperatures ranging from 870 °C to 1370 °C porosities. If it is held at firing temperature too long, the
(1598 °F to 2498 °F), depending on whether the porcelain glass will slump and the restoration will lose its shape.
182 CHAPTER 9 Dental Ceramics

less abrasive to opposing tooth structure and can be

re-polished more easily after adjustments.

Porcelain Failures
Most porcelain failures result from small cracks in the
porcelain that develop when the porcelain is put under
occlusal loading, and they propagate (spread) over time
until the porcelain gives way. Other modes of failure
are caused by problems related to the chemical bond
between the porcelain and the metal oxides. The oxide
layer may be too thick or inadequate in quantity and
FIG. 9.12 PFM crowns #6 to #11 with glazed surfaces that resemble quality, leading to failure at the interface of the porcelain
the luster of the natural teeth in the lower anterior. (From Rosenstiel SF,
Land MF: Contemporary Fixed Prosthodontics, ed 5, St. Louis, 2016, and metal. It is important that the coefficients of thermal
Elsevier.) expansion of the porcelain and the metal be compatible.
The best arrangement is for the porcelain to have slight-
Proper programming of the oven will eliminate the ly less thermal expansion than the metal. This will keep
slumping issue, but not all porosity will be eliminated. it from cracking at the metal-porcelain interface and will
Typically, a porcelain restoration has 10-30% porosity. reduce the chance of failure (see Fig. 9.10).
It is important to use the correct time and temperature When porcelain failures occur in non–stress-bearing
for the firing cycle as an inadequate or too great a tem- areas, repairs may be possible using composite resin
perature can greatly reduce the flexural strength of the and bonding techniques, but the repairs are not as
restoration. Additionally, the development of translu- strong as the original bonded porcelain (see Chapter
cency occurs only after firing at the proper temperature 5) and may fail if put under too much biting pressure.
and time. After firing has been completed, the resulting The alternative is to do expensive replacements of the
restoration will have shrunk about 25% because of the entire crown or bridge.
fusion of the porcelain particles.
CERAMIC INLAYS, ONLAYS, AND FIXED PARTIAL
Glazing DENTURES (BRIDGES)
After final contouring of the crown, another firing Ceramic inlays, onlays, and fixed bridges are placed
maintaining the temperature at the fusing temperature in the functional areas of the mouth, and therefore
for a while will produce a surface glaze. The surface strength is an important factor. Feldspathic porce-
layer of porcelain will heat first allowing it to melt and lains are not the materials of choice, because they are
run together producing a dense, shiny, smooth surface weaker than leucite- or zirconium-based ceramics.
(Fig. 9.12). Firing must be stopped at this point to pre- Heat-pressed materials are commonly used, but CAD/
vent the interior from heating up too much and caus- CAM-produced zirconium materials are gaining in
ing the whole restoration to shump. Some technicians popularity because of their high strength. Ceramic
use a layer of special translucent porcelain that fuses at materials with a more opaque core (such as Procera
relatively low temperatures to form the glazed surface. Zirconia [Nobel Biocare] or In-Ceram [Vident/VITA])
This is called overglazing. may be selected to hide discolorations from root canal
therapy or tetracycline stains.
Color Modification It is important for the clinician to identify the junc-
Stains are used with veneering porcelain for the same tion of the tooth and the margins of any of these ce-
purposes as for all-ceramic restorations, that is, they ramic restorations when removing excess cement or
can characterize the restoration and improve color when doing scaling or root-planing procedures. The
matching. hand scaler or ultrasonic tip used at high settings
may cause chipping of the margins if the clinician is
Re-polishing not careful. However, properly fabricated and adjust-
The porcelain surface, once it has been fused under ed ceramic restorations should present minimal prob-
temperature, is very hard and smooth. When porce- lems for the clinician who is doing these procedures.
lain or PBM restorations are delivered, the proximal If significant overhang or catching of the margins is
contacts or occlusal surfaces often must be adjusted. noted, the assistant or hygienist should alert the den-
These restorations could be returned to the labora- tist, who may correct them or prescribe replacements.
tory to be reglazed (refired at porcelain-fusing tem-
peratures to form a glassy surface) before cementing.
Because this is seldom practical, various abrasives Clinical Tip
have been developed for polishing the porcelain
Ultrasonic scalers, if improperly applied, can chip and craze
surface after adjustment (see Chapter 13 Abrasion,
margins of esthetic materials.
Finishing, and Polishing). Low-fusing porcelains are
 Dental Ceramics CHAPTER 9 183

FINISHING AND POLISHING CERAMIC strengthening) due to its crystalline arrangement that al-
RESTORATIONS lows it to deflect cracks that are forming so they do not
Two important factors in wear of the opposing denti- propagate through the material. However, if too much
tion by ceramic restorations are the crystalline grain heat is generated in finishing and polishing, a shift occurs
(particle) size of the ceramic material and the smooth- in the material that negates this “crack-healing” property.
ness of the ceramic surface (Fig. 9.13, A and B). Modern
ceramic materials such as lithium disilicate and zirconia Principles of Finishing and Polishing Ceramics
ceramics have smaller grain size than porcelains, are Some basic principles of finishing and polishing den-
less abrasive, and can be polished smoother. Zirconia tal ceramic materials should be followed. First, heavy
that has been glazed will cause more wear of opposing pressure should be avoided; use a light touch. Second,
enamel surfaces than highly polished zirconia, because low speed should be used with water spray. Following
the glaze is thin and will wear away with time leaving both of these principles will minimize the generation
a rough, unpolished surface. Once the occlusal surface of heat and surface and subsurface damage.
of a restoration has been adjusted with a diamond bur
the roughness of the surface can be very abrasive to the Sequential finishing and polishing. When trying to
opposing enamel or restorative material. It is impera- achieve a smooth surface it is important to follow a prop-
tive to re-establish the surface smoothness through er sequence progressing to fine and yet finer abrasive
careful finishing and polishing techniques. finishing and polishing instruments. Steps cannot be
Adjustment of ceramic materials with coarse diamond skipped. Larger scratches must be sequentially reduced
burs can create surface and subsurface damage that can to smaller and smaller scratches until they are no lon-
lead to propagation of cracks and future chipping or frac- ger perceptible. Several manufacturers have developed
ture of the restoration over time from repeated occlusal special finishing and polishing instruments designed for
loading (i.e., eating or bruxing). Coarse diamond burs use with porcelains, lithium disilicate, or zirconia (e.g.,
should not be used to adjust the surface because the larger Dialite, Dialite LD, and Dialite ZR; Brasseler USA).
diamond particles leave a rougher surface that is more dif-
ficult to re-polish, and they tend to generate heat that can Use of polishing pastes. Polishing pastes contain fine
damage the ceramic. Fine diamond burs are recommend- abrasives to create a very smooth surface after use of
ed. Zirconia has a unique property (called transformation polishing instruments. Pastes containing aluminum

A B

C
FIG. 9.13 Wear of opposing teeth by porcelain. A, Teeth #10 and #11 have PBM crowns; B, the porcelain on the PBM
crowns extends onto the lingual surfaces of #10 and #11; C, the patient is a bruxer and displays excessive abrasion of
the teeth opposite the porcelain. Adjacent teeth show moderate incisal attrition. (Courtesy of Steve Eakle, University of
California, San Francisco.)
184 CHAPTER 9 Dental Ceramics

oxide are safe to use on porcelain. If the objective is to These materials can be sandblasted internally with 50-
produce a high shine or luster, a diamond polishing μm alumina at a pressure of 20 to 30 psi (pounds per
paste with very fine particles should be used. As with square inch) (too much pressure can cause damage to
most products, follow the manufacturer’s recommen- the ceramic) to provide a roughened surface to me-
dations for which pastes to use on the various ceramic chanically interlock with the cement. (Glass-based ce-
materials. ramics should not be sandblasted, because it will cause
microscopic cracks in the surface.) Zirconia and alumi-
Clinical Tip na ceramic materials do not need silane treatment, but
Generation of heat during adjustment, finishing, and may be treated with special primers with acidic adhe-
polishing of ceramics can cause damage that may progress sive monomers to improve the bond with resin cement.
to fracture of the restoration. Use rotary instruments at low
speed with water spray and light pressure. Preparing the Tooth
The prepared tooth surfaces are wiped with a wet cot-
ton pellet to remove any remnants of try-in materials.
CEMENTATION OF ALL-CERAMIC If any bleeding has occurred, the tissue can be infil-
RESTORATIONS trated with local anesthetic with epinephrine to con-
All of the glass-based ceramic materials (porcelain, leu- strict the capillaries, or a hemostatic agent can be used.
cite-reinforced ceramic, and lithium disilicate ceramic) Ferric sulfate hemostatic (e.g., Astringedent; Ultra-
should be bonded to the teeth with resin cement. They all dent) should be avoided because it will interfere with
can be etched with acid (usually hydrofluoric) to facilitate resin bonding and may cause discoloration under the
bonding them to tooth structure. Bonding them to a rigid ceramic restoration. Next, the tooth surface (enamel,
substrate greatly enhances their resistance to fracture. dentin, or both) is conditioned according to the manu-
facturer’s instructions for the bonding materials being
Try-in of Restoration used. A bonding agent is applied to seal open dentinal
The delivery of ceramic restorations begins with good tubules and to establish a hybrid layer for bonding
isolation. Use of the rubber dam is ideal but not ­always with the resin cement. An alternative to the etch-and-
practical, so alternatives such as the Isolite (Isolite Sys- rinse bonding agent is a self-etch bonding agent that
tems) or absorbent pads and cotton rolls may be used. eliminates the need for phosphoric acid etching (see
Next, the provisional restoration is removed, bits of ad- Chapter 5). A self-adhesive resin cement (e.g., Maxcem
herent cement are picked off with an explorer or other Elite [Kerr Dental]; RelyX Unicem [3M ESPE]) elimi-
instrument and the prepared tooth surfaces are cleaned nates the need for a separate bonding agent.
with pumice and water on rubber cups or brushes,
then rinsed and dried. The restoration is tried in and Cementation of the Restoration
interproximal contacts are adjusted. For veneers and The resin cement systems commonly used with ceram-
other translucent restorations, a water-soluble try-in ic restorations are dual-cured, so if the light from the
paste, glycerin, or K-Y Jelly is used to verify the col- curing unit is unable to reach all of the cement, it will
or and to determine the color of resin cement to use. cure chemically on its own. Many light-cured bonding
The underlying tooth color can affect the color of the agents are not compatible with dual-cured resin ce-
bonded restoration. For zirconia and alumina restora- ments; make sure a compatible bonding agent is used
tions, their opaqueness hides the color of the under- (see the manufacturer’s recommendations).
lying tooth. For weaker materials such as porcelain or The resin cement is mixed (most are supplied in au-
leucite-reinforced ceramics, the occlusion should not tomixing cartridges) and applied to the internal part of
be checked until after cementation because it might the restoration. Use enough to coat all of the walls of
crack. The occlusion is checked on the mounted dies the restoration and the margins. Do not overfill a crown
before cementation (unless processed by CAD/CAM because the hydraulic pressure created in trying to dis-
for which there are no physical dies). place the cement when seating the crown may prevent
the restoration from seating completely. Wipe away ex-
Preparing the Restoration cess cement with a small brush. Use the curing light for
Glass-based ceramics. If the laboratory has not al- about 3 seconds over the area of the margins to cause
ready etched the internal surface (intaglio) of the res- the resin to gel but not set completely. This is called tack
toration, then apply hydrofluoric acid for 5 minutes curing and will facilitate easy removal of any remaining
(leucite-reinforced materials require only 1 minute), excess cement. After the excess is removed, a 60-second
and then rinse and dry. After etching, silane coupling cure (halogen light) or less with high-intensity lights (la-
agent is applied to the intaglio of the restoration for 60 ser or plasma arc light) is used to accelerate the set. With
seconds, and then air dried. opaque restorations of zirconia or alumina the light may
be ineffective for reaching cement under the restoration,
Non-glass ceramics. Non-glass materials (alumina but the chemical-cure component of the cement will al-
and zirconia) do not etch well with hydrofluoric acid. low it to set in a couple of minutes.
 Dental Ceramics CHAPTER 9 185

Zirconia and alumina have such high strength Clinicians are faced with the task of removing the fail-
that they do not have to be bonded. They can be ing restoration. Gold crowns can readily be removed
cemented with conventional cements such as resin- by sectioning them with a carbide bur. Nonprecious
modified glass ionomer cement. This cement is often metal crowns can present a problem because of their
used because it bonds to the tooth, releases fluoride, hardness, and special metal-cutting burs have been de-
is moderately strong, has thermal expansion similar veloped to address this.
to the tooth, and cleans up easily. However, if the Porcelain restorations can be removed by section-
tooth preparation is not very retentive (short walls ing with a coarse diamond bur. PFM crowns can be
or over-tapered), then resin cement should be used removed by using a combination of coarse diamond
with bonding to the tooth and internal sandblasting burs and metal-cutting burs. First, a pathway through
of the crown to aid retention. It has been suggested the porcelain to the metal is created with the diamond
that lithium disilicate crowns do not need bonding bur. The pathway should be wide enough so that the
because of their strength, but they are not as strong as metal cutting bur can be used without touching the
zirconia. Therefore, to minimize the risk of fracture it adjacent porcelain. (The porcelain will dull the car-
is prudent to bond them. bide bur quickly.) Then, the metal-cutting bur cuts
through the metal until the crown is in two segments.
MAINTENANCE OF ALL-CERAMIC The segments are pried apart with a thick instrument
RESTORATIONS (a large spoon, small screwdriver, or crown removal
The patient should be given home care instructions instrument).
for proper brushing and flossing around ceramic res- The high-strength ceramic materials (lithium dis-
torations. For bridges additional hygiene aids such as ilicate and zirconia) are very difficult to remove with
floss threaders, interproximal brushes, or Oral-B Su- conventional diamond burs. Some manufacturers have
perfloss (Procter & Gamble) may be recommended. developed diamond burs specifically for cutting lithi-
Patients should be advised against biting on hard um disilicate and zirconia (e.g., ZR-Diamonds; Komet
objects or food with the ceramic restorations. As pre- USA). These diamonds reduce the time needed to re-
viously discussed, some ceramic materials are more move these high-strength crowns by about half.
fragile than others. At periodic recall appointments
recheck the occlusion, review the gingival health, and
SHADE TAKING
make sure no excess cement remains.
Care should be taken when working around ceramic The dental assistant or hygienist may be asked to as-
crowns. When providing in-office fluoride treatments sist the dentist in obtaining the appropriate shade
to adults with ceramic restorations, the hygienist needs for a restorative procedure. An inappropriate shade
to select a fluoride product that is not acidic. Acidu- selection will result in a mismatch to the patient’s
lated fluoride products can etch ceramic surfaces. Like- dentition. Usually, the restoration will need to be re-
wise, when doing bonding procedures on adjacent turned to the dental laboratory for a remake or for
teeth avoid allowing etching gels to touch the ceram- reapplication of porcelain. This is disappointing for
ics because they will roughen the surface. Ultrasonic all involved and usually results in an additional labo-
scalers should be used with care around ceramic res- ratory fee and the in-office expense of an additional
torations so as not to induce heat damage or initiate appointment. Therefore, it is important for all clinical
microcracks at the margins. Patients who grind their members of the dental team to have an understand-
teeth or have edge-to-edge bites should be provided ing of what goes into the perception of color, how to
with occlusal guards to help protect the anterior ce- accurately match the variety of shades within a single
ramic crowns and veneers. Restorations made entirely tooth, and how to communicate this to the dental
from zirconia (called monolithic) may be the exception technician.
because of their remarkable strength. However, if the Patients tend to notice differences in value more
restoration has a zirconia core and is veneered with than differences in hue or chroma when they assess
porcelain for esthetics, then the overlying porcelain how well a restoration matches their own teeth. So, if a
could chip or break. restoration is the same brightness as the natural denti-
tion but is slightly off in its color or color intensity, it
Caution will be better accepted by the patient than if the res-
toration is too dark or too light. Teeth with different
Avoid acid etchants and acidic fluorides on ceramic
restorations. They will roughen the surface of the ceramic.
colors could have the same value (or brightness), yet
have different intensity of color. Likewise, teeth with
the same color can vary in brightness. For example, in
REMOVAL OF ALL-CERAMIC RESTORATIONS the classic VITA shade guide, A3 and D3 are similar in
The average life span of a crown is about 10 to 15 years, color, but A3 is brighter than D3. As teeth darken with
and some fail sooner for a variety of reasons (such as age, patients who were once in the A shade range may
recurrent caries or fracture of the ceramic material). transition into the D shades.
186 CHAPTER 9 Dental Ceramics

A B
FIG. 9.14 Two popular commercial shade guides that use different methods for selecting the shade: A, VITA Classical
A1-D4 with whitening shades. B, VITA Toothguide 3D Master. (Courtesy of VITA North America, Yorba Linda, CA.)

INVOLVING THE DENTAL ASSISTANT/HYGIENIST Incisal

AND THE PATIENT
The dentist often relies on the chairside assistant or hy- Opaque
gienist to help in shade taking. Having the doctor, as- Body
sistant, and patient working together to determine the
shade often gets a result all can be happy with.
The dental assistant can get the dental office envi- Neck
ronment ready for taking the shade by:
• Having the patient remove lipstick and colorful
makeup
• Covering bright, colorful clothing with a neutral
colored bib such as pastel blue
• Placing the patient in a neutral colored room
• Removing debris and surface stain from the teeth
• Keeping the teeth moist; not isolating the teeth until
ready to begin preparation
• Turning off or moving the dental unit light away
from the mouth FIG. 9.15 Color arrangements in a typical porcelain shade tab. (From
• Headlamps should also be turned off. Rosenstiel SF, Land MF: Contemporary Fixed Prosthodontics, ed 5, St
Louis, 2016, Elsevier).
The most popular shade guides are the VITA Lu-
min system (VITAPAN Classical or VITA 3D-Master; • P lace the shade tab in the same plane as the teeth,
VITA North America) (Fig. 9.14) and Chromascop (Ivo- not in front or behind
clar Vivadent). With the VITA guides shades in the A • View the teeth and tab for no more than 5 seconds at
range are reddish brown, B shades are reddish yellow, a time
C shades are grey, and D shades are reddish grey. In • Rest the eyes between viewings by staring at a neu-
general, the shade should be taken before the tooth is tral gray color
isolated or prepared. Some clinicians arrange the tabs • Pick the best 3 shade tabs quickly
by value from highest to lowest. A typical shade tab • With the input of patient, doctor, and assistant, se-
is composed of several colors arranged to simulate a lect the best of the 3
natural tooth. An opaque color is used as a backing on • If possible, use photography to aid the lab technician.
the tab for the color of the body of the tooth crown and Place the shade tab next to the teeth in the photo.
the color of the root (also called the neck) but does not • Note tooth factors the lab will need to characterize
include the incisal portion that is typically translucent (see Characterizing the Shade below)
(Fig. 9.15). The patient, dentist, and assistant should view the
tabs and rank them as to the closest match for color in-
STEPS FOR SHADE TAKING tensity and lightness or darkness. It is often necessary
The following steps should be used when taking the to take separate shades for the cervical portion of the
shade of the teeth: tooth, for the occlusal surfaces of posterior teeth, and
• Use natural light when possible for the incisal edges of anterior teeth (Fig. 9.16).
• Use cheek retractors for an unobstructed view of the
teeth Characterizing the Shade
• Raise the patient to view the teeth at eye level to use In addition to the shade, the surface luster and texture
the color-sensitive part of the retina should be noted. As a person ages, the slight convexi-
• Wet the shade tab and the teeth to remove surface ties and concavities on the surface of the teeth become
texture differences smoother from wear and reflect light differently than
 Dental Ceramics CHAPTER 9 187

B
Fig. 9.17 Shade guide for taking dentin shades. A, Dentin shade guide
and B, dentin shade tabs used to match dentin from the prepared
tooth. (From Rosenstiel SF, Land MF: Contemporary Fixed Prosth­
odontics, ed 5, St. Louis, 2016, Elsevier.)

technician if a digital photograph of the teeth is trans-

B
mitted. If photography is used, the shade tab should
FIG. 9.16 Shade taking for porcelain restorations. A neutral gray is be included in the picture, because some photographs
considered a good color to look at to refresh the retina while shade will be a little more red or blue than the actual color.
taking. A, Shade guide placed near the mouth to select the basic color The bright operatory light should not be used to illu-
(hue). B, The shade tab in the right color is compared with the teeth to
minate the patient’s mouth, as this will cause the re-
be matched; select the color with the proper value (darkness or bright-
ness) and chroma (intensity of color). corded image to appear lighter. The shade tab should
be in the same plane as the tooth to be matched, so that
highly textured teeth. Textured teeth tend to scatter it will be in the same focus as the teeth, that is, it should
light. Luster is the degree to which the surface appears not be in front of the teeth or outside of the mouth and
shiny and reflects light. The laboratory technician can will have the same illumination as the teeth when flash
add surface glazes to ceramic to create a shiny surface photography is used. The flash used should be rated
and can add texture to scatter light. for a good color rendering (index above 93).
The amount of translucency of the enamel and its lo- On occasion, some teeth are not a close match to
cation (e.g., incisal edge) should also be communicated the shade tabs. This requires that the technician see
to the laboratory. The laboratory technician may need to the teeth, so that he or she can custom blend different
place layers of opaque porcelain to mask darkly colored shades of porcelain or use surface stains to match the
dentin when fabricating all-ceramic restorations. The color. The patient may be sent to the laboratory, or the
opacity will cause of loss of vitality in the restoration. technician may come to the operatory for this “custom”
The technician may need to produce the perception of shade taking. This is particularly true for whitened
translucency by using color modifiers to tint the porce- teeth. Whitening of teeth has become very popular,
lain (e.g., blue tints may produce a hint of translucency). and the whitened colors of teeth may not match ex-
Teeth may have opaque white spots or lines, stained isting shade guides. So, shade guides with whitening
cracks, wear facets, and other characteristics that should shades that are extra light (low chroma and high value)
be conveyed to the laboratory if the patient is trying to should be used. Even with these whitening shades, it
match existing teeth. The process of incorporating into may be difficult to match the color of whitened teeth.
the restoration texture, translucency, opacity, and the
many other tooth features is called characterization. Dentin Shade Matching for All-Ceramic
A written description and drawing of the shade dis- Restorations
tribution (called shade mapping) and location of trans- Some of the all-ceramic restorations are relatively trans-
lucency and any special characterizations, surface lucent. A special shade guide for dentin color is used to
texture, and luster should be sent to the laboratory help the technician in the fabrication of a crown (Fig.
to help guide the technician. Often it is helpful to the 9.17). Cosmetically, it might be important to hide dark
188 CHAPTER 9 Dental Ceramics

dentin with opaque ceramic colors to achieve a light- With proper training, the dental assistant or hygienist
er color in the restoration. The final shade of the all- can operate the device and acquire the shade. This
ceramic restoration is influenced by the shade of the ce- increases office efficiency and consistency of shade
ramic coping (substructure for a crown) or framework matching. The accuracy of the shade taken by these
(for a bridge), the veneering porcelain or ceramic, the devices can potentially save time and expense associ-
prepared tooth shade, and the shade of the luting ma- ated with sending the crown back to the laboratory;
terial (conventional cement or bonded resin). this can make for a more satisfied patient. Advances in
technology are making communication with the labo-
DEVICES FOR TAKING THE SHADE ratory simpler and more accurate.
Because of the complexity involved in achieving a good
shade match of a ceramic material to the natural tooth,
SUMMARY
a number of devices have been introduced that help in
obtaining an accurate reading of the shade of the teeth. A wide variety of tooth-colored esthetic materials are
These devices use optical readers (spectrophotometers) available to the dental team to use to restore a patient’s
to determine the correct shade (Fig. 9.18). Having the dentition. Patients demand high-quality restorations
information captured by an optical device removes the with a close match to their existing teeth, or in some
subjectivity of the individual trying to interpret the shade cases, they demand restorations that produce a lighter,
and trying to describe the shade to the dental laboratory youthful smile. Newer ceramic materials have broad-
technician. This eliminates the extraneous light sources ened the choices the clinician has for esthetic restora-
and conflicting colors in the room or on the patient that tions. CAD/CAM technology is providing new av-
confuse the human eye’s perception of color. One such enues for the dental team to provide esthetic dentistry
device, the VITA Easyshade V (Vident/VITA), can match with the potential for making many procedures faster
the shade it records with the company’s popular brand of and easier on patients.
VITA porcelains. These devices can provide a map or lay- It is important that all members of the dental team
out of the subtle variations in shade within a given tooth. understand the handling characteristics, physical

A B

C
FIG. 9.18 Shade taking device. A, Easyshade V device. B, Device used to take the shade. C, Digital display of the shade
captured by the device. (Courtesy of VITA North America, Yorba Linda, CA.)
 Dental Ceramics CHAPTER 9 189

properties, and potential shortcomings of these ma- can dull the surface of the restoration and change the
terials. Before working in the patient’s mouth, it is esthetic effect of the original restoration, making for
wise to review the dental charting section of the pa- an unhappy patient. Neutral sodium fluoride prod-
tient’s record or perform a brief oral inspection to de- ucts or fluoride varnish can be used as alternatives.
tect the presence of esthetic restorations. Drying the Certain abrasives used for coronal polishing can also
teeth with an air syringe can help reveal some of the adversely affect the surface luster of composites and
materials, because they may have a different luster porcelain. The radiographic appearance may be dif-
than the enamel, or margins may be more readily vis- ferent with each of the various esthetic restorative
ible once the saliva has been removed. The selection materials. As new esthetic materials are adopted in
and use of proper polishing and scaling devices are the practice, it is important to become familiar with
an important consideration for the hygienist and the their handling characteristics, physical properties,
chairside assistant when working around these resto- uses, and precautions.
rations. Ultrasonic scalers have the potential to chip
or craze the margins of all-ceramic or composite res- INSTRUCTIONAL VIDEOS
torations. When applying topical fluoride, it is impor-
tant to keep in mind that the surfaces of these esthetic See the Evolve Resources site for a variety of educa-
restorations can be affected by the use of acidulated tional videos that reinforce the material covered in this
fluoride solutions and gels. The use of these products chapter.

Get Ready for Exams!

Review Questions 5. A n in-office CAD/CAM system for ceramic restorations

provides all of the following advantages except one?
Select the one correct response for each of the following Which one?
multiple-choice questions. a. The restoration does not have to be fabricated in an
1. Porcelain restorations have outside laboratory.
a. Great stain resistance b. A provisional crown is not needed.
b. Low wear resistance c. The procedure can be completed in one visit.
c. High strength d. Local anesthesia is not needed.
d. Easy reparability 6. The basic color of the tooth is called the
2. Porcelain bonds to metal by which one of the following a. Base shade
mechanisms? b. True value
a. Micromechanical retention much like resin bonded c. Chroma
to etched enamel d. Hue
b. Penetration through the surface of the 7. All of the following should be avoided when taking the
metal shade of a tooth except one. Which one?
c. Fusion with oxides on the surface of the metal a. Lipstick on the patient
d. Shrinkage when fired so that it locks onto b. Brightly colored clothing
the metal c. Dirty teeth (covered with plaque)
3. The main advantage of all-ceramic crowns over porce- d. Neutral wall colors in the room
lain-bonded-to-metal crowns is 8. All of the following materials should be avoided around
a. Their superior esthetics ceramic restorations except one. Which one?
b. Their strength a. Acidulated topical fluoride products
c. Their ease of cementation b. Alginate impression material
d. The ease of taking shades c. Coarse prophy paste
4. The main drawback of feldspathic porcelain for all-por- d. Acid etchant
celain crowns is 9. The impression for a CAD/CAM crown typically is
a. Their tendency to fracture a. Done with alginate
b. Their opacity b. Done with polyvinylsiloxane impression material
c. The difficulty involved in making them c. Done with polyether impression material
d. That shrinkage when fired makes them difficult to fit d. Done by capturing an image of the prepared tooth
to the prepared tooth with an optical scanner

Continued
190 CHAPTER 9 Dental Ceramics

Get Ready for Exams!—cont’d

10. W hen preparing a porcelain-fused-to-metal crown, the 18. W hich of the following ceramic materials is not etched
technician applies feldspathic porcelain in layers to the by hydrofluoric acid in preparation for cementation but
metal coping. The initial layer is may be sandblasted internally instead?
a. Translucent porcelain to mimic enamel a. Zirconia
b. Body porcelain to mimic dentin b. Lithium disilicate
c. Opaque porcelain to hide the oxidized metal c. Feldspathic porcelain
11. On occasion, special porcelain stains are used on the d. Leucite-reinforced porcelain
surface of the porcelain. These stains contain metal 19. Porcelain veneers are bonded to the tooth with resin
oxides and are used to cement. This provides the opportunity to do all of the
a. Create a shiny, smooth surface following except one. Which one?
b. Mimic white spots or fine crack lines to resemble a. Increase the strength of the restoration
adjacent teeth b. Increase the retention of the restoration
c. Hide flaws created in the porcelain by firing it at high c. Slightly modify the shade of the cemented restora-
temperatures tion with a colored resin cement
12. Which one of the following statements about porcelain d. Whiten the tooth with the acid etchant
veneers is false? 20. All of the following considerations should be applied
a. Porcelain veneers are more durable than composite when finishing or polishing a ceramic material except
veneers. one. Which one?
b. Porcelain veneers must be handled carefully when a. Use slow speed
one is trying them on, because they are very fragile b. Use a coarse diamond bur for adjustments
until bonded to the tooth. c. Use light pressure
c. It is difficult to mask a darkly colored tooth with a d. Progress from medium abrasives to finer ones
porcelain veneer. 21. All of the following are processing methods for ceramic
d. Porcelain veneers are usually cemented with zinc materials except one. Which one?
phosphate or glass ionomer cement. a. Sintering
13. When assisting the dentist with taking the shade of a b. Heat pressing
tooth, the dental assistant should c. Cold curing
a. Dry the teeth thoroughly d. CAD/CAM
b. Shine the operatory light directly on the teeth 22. When one is taking photographs of the teeth to send to
c. Cover brightly colored clothing with a pastel, neutral- the dental laboratory to help convey the correct shade,
colored bib what is the proper location for the shade tab in the
d. Stare at the tooth and shade guide intensely for photograph?
at least 30 seconds to let the eyes adjust to the a. Outside of the mouth
colors b. Inside the mouth and in front of the teeth
14. Which one of the following ceramic materials is the c. In the same plane as the tooth being matched
strongest and most fracture resistant? d. None of the above (the shade tab does not have to
a. Leucite-reinforced porcelain be included in the photograph)
b. Zirconia For answers to Review Questions, see the Appendix.
c. Feldspathic porcelain
d. Lithium disilicate Case-Based Discussion Topics
15. Which one of the following ceramic materials is the
most opaque and, therefore, the least esthetic? 1. A 57-year-old secretary comes to the dental office for a
a. Feldspathic porcelain periodic examination and prophylaxis. She has maxillary
b. Lithium disilicate anterior composite veneers and all-ceramic crowns on
c. Zirconia her mandibular incisors.
d. Leucite-reinforced porcelain Describe the factors that might contribute to fracture of the
16. For anterior ceramic restorations the ceramic material porcelain restorations. What must the dental hygienist and
used at the incisal edge tends to be which one of the dental assistant be concerned about when treating patients
following? who have esthetic composite and porcelain restorations pre-
a. Opaque sent in their mouths?
b. Highly reflectant 2. An active 80-year-old woman comes to the dental
c. Translucent office for preparation of her maxillary anterior and
d. Transparent premolar teeth for porcelain veneers. She wants to
17. The lightness or darkness of a color is referred to as lighten her teeth but wants to keep the same color
which one of the following? (hue). She is wearing brightly colored clothing and
a. Chroma lipstick.
b. Value What steps can the dental assistant or hygienist perform to
c. Hue help in the initial shade taking? Under what lighting condi-
d. Radiance tions should the shade be taken?
 Dental Ceramics CHAPTER 9 191

Get Ready for Exams!—cont’d

3. A 60-year-old male postal worker was hit in the mouth What materials could be used to satisfy her esthetic needs?
by a falling package in the warehouse. The mesio-incisal Of the ceramic materials, which would be most likely to frac-
edge of a porcelain-fused-to-metal crown on tooth #8 ture in her mouth and which would be most likely to survive
was fractured. He would like to have it fixed. her bruxing?
What are his treatment options? If he desires that it be 5. A 25-year-old fashion model has large mesial and distal
fixed at today’s visit, what materials could be used? What class III composites on tooth #8, which have turned
must he be told regarding the long-term prognosis of a brown; the composites are visible when she smiles. She
repair? wants to get rid of the composites and the discoloration.
4. A 30-year-old business executive has several large The dentist has recommended a porcelain-fused-to-
occlusal amalgam restorations on her lower molars metal crown. The fashion model wants an all-porcelain
and premolars that are visible when she speaks. She crown to maximize the esthetics.
frequently gives presentations to small groups and What are the pros and cons of each type of crown for this
would like to eliminate the dark restorations. She application? If an all-ceramic crown is done, what type of ce-
grinds her teeth in her sleep and clenches during the ramic material is best for this application? Should the crown
day. be bonded or just cemented? Why?

BIBLIOGRAPHY McLaren EA, Whiteman YY: Ceramics: rationale for material se-
lection, Inside Dentistry 38–50, 2012.
Al Dehailan L: Review of the Current Status of All-Ceramic Resto- Phillips RW, Moore KB: Dental Ceramics. Elements of Dental
rations. Indiana University School of Dentistry. Available at: Materi­als for Dental Hygienists and Dental Assistants, ed 5, Phil-
https://www.dentistry.iu.edu/files/3713/7597/9182/cera adelphia, 1994, Saunders.
mic_lit_review.pdf Poticny DJ, Klim J: CAD/CAM in-office technology: innova-
Anusavice KJ, Shen C, Rawls HR: Dental ceramics. In Phillips’ tions after 25 years of predictable, esthetic outcomes, JADA
Science of Dental Materials, ed 12, St. Louis, 2013, Saunders. 141(Suppl 6):5S–9S, 2010.
Baum L, Phillips R, Lund M: The Metal-Ceramic Restoration. Text­ Powers JM, Farah JW, O’Keefe KL, et al.: Guide to all-ceramic
book of Operative Dentistry, ed 3, Philadelphia, 1995, Saunders. bonding, The Dental Advisor, 29(4), 2012.
Ferracane JL: Materials for Inlays, Onlays, Crowns and Bridges. Ma- Powers JM, Wataha JC: Dental ceramics. In Dental Materials:
terials in Dentistry, ed 2, Baltimore, 2001, Lippincott Williams Foundations and Applications, ed 11, St. Louis, 2017, Elsevier.
& Wilkins. Rosenstiel SF, Land MF, Fujimoto J: All-ceramic restorations. In
Giordano R: Materials for chairside CAD/CAM-produced resto- Contemporary Fixed Prosthodontics, ed 4, St. Louis, 2006, Mosby.
rations, J Am Dent Assoc 137:14S–21S, 2006. Sakaguchi RL, Powers JM: Ceramics. In Craig’s Restorative Dental
Heyman HO, Swift EJ, Ritter AV: Additional conservative es- Materials, ed 13, St. Louis, 2012, Mosby.
thetic procedures. In Sturdevant’s Art and Science of Operative Santos MJ, Costa MD, Rubo JH, et. al.: Current all-ceramic
Dentistry, ed 6, St. Louis, 2013, Mosby. ­systems in dentistry: a review. Compend Contin Educ Dent.
Kois JC, Chaiyabutr Y: Intraoral occlusal adjustment and polish- 36(1):31–7, 2015.
ing for modern ceramic materials, Inside Dentistry 11(3), 2015. Sorensen JA: Finishing and polishing with modern ceramic sys-
McLean JW, Hughes TH: The reinforcement of dental porcelain tems, Inside Dentistry 9:10–16, 2013.
with ceramic oxides, Br Dent J 119:251–267, 1965. Trost L, Stines S, Burt L: Making informed decisions about incor-
McLaren EA: CAD/CAM dental technology: a perspective on its porating a CAD/CAM system into dental practice, J Am Dent
evolution and status, Compendium 32(4), 2011. Assoc 137:32S–36S, 2006.
10 Dental Amalgam

http://evolve.elsevier.com/Eakle/materials/

Chapter Objectives
Upon completion of this chapter, the student should be able to:
1. List the main components in dental amalgam. 8. D iscuss the advantages and disadvantages of amalgam
2. Describe the advantages of high-copper amalgams over as a restorative material.
low-copper amalgams. 9. Discuss the safety of amalgam as a restorative material.
3. Explain the role of the gamma-2 phase in corrosion of 10. Perform safe mercury hygiene practices in the dental
amalgam. office.
4. Describe the particle shapes in lathe-cut, admix, 11. Collect and process amalgam scrap for recycling.
and spherical alloys, and discuss their effects on the 12. Select an appropriate size of matrix band for a class II
condensation resistance of freshly mixed amalgam. amalgam preparation.
5. Define creep, corrosion, and tarnish. 13. Assemble a Tofflemire band in its retainer.
6. Compare the strength of amalgam with that of composite 14. Evaluate a class II amalgam matrix setup for meeting
resin or glass ionomer cement. proper placement criteria.
7. Discuss the effect of mixing time on the strength and 15. Assist with or place (as allowed by state law) amalgam in
manipulation of amalgam. a class II cavity preparation.

Key Terms
Alloy a mixture of two or more metals teeth and can cause amalgam to bulge out of the cavity
Amalgamation reaction that occurs when silver-based alloy preparation
is mixed with mercury to form an amalgam Tarnish oxidation affecting a thin layer of a metal at its
Dental Amalgam metallic restorative material composed of surface that does not change the metal’s mechanical
silver-based alloy mixed with mercury properties
Lathe-Cut Alloy irregularly shaped particles formed by shav- Corrosion breakdown of a metal by chemical or electro-
ing fine particles from an alloy ingot chemical reaction with substances in the environment
Spherical Alloy small spheres of alloy particles produced by such as water or air. It negatively impacts the properties of
spraying a fine mist of liquid alloy into an inert gas environment amalgam
Admixed Alloy mixture of lathe-cut and spherical alloys Triturator or Amalgamator mechanical device used to
Gamma-2 Phase a chemical reaction between tin in the mix silver-based alloy particles with mercury to produce
silver-based alloy and mercury that causes corrosion in the amalgam
amalgam Condensation the act of pressing amalgam mix into a cavity
Delayed Expansion expansion of amalgam containing zinc preparation with instruments to produce a dense mass
when it is contaminated with moisture (e.g., saliva) during Burnishing after the amalgam mix is placed an instrument
condensation. Inside the amalgam hydrogen gas develops is used to further condense and smooth the amalgam
from the interaction of water and zinc, and it creates an surface
outward pressure that causes creep to occur Amalgam separator a device that collects amalgam par-
Creep gradual change in the shape of a restoration usu- ticles and mercury from evacuation systems that might
ally caused by compression from occlusion or adjacent otherwise escape into the wastewater and therefore enter
the environment
  

Dental amalgam has been in use for more than 180 years and patients demand more esthetic materials such as composite
has been used for hundreds of millions of restorations. Den- resin and ceramic restorations which have continually im-
tal amalgam is an amalgamation or combination of metals, proved in their physical properties and handling character-
mostly silver alloy powders and mercury. It is easy to manip- istics. In addition, health and environmental concerns have
ulate, has good clinical durability, and is low-cost. However, been raised due to the mercury content of the amalgam caus-
its use has been gradually diminishing in many countries as ing some countries to move away from the use of amalgam.
192
 Dental Amalgam CHAPTER 10 193

It is essential that oral health practitioners have an under- SILVER-BASED AMALGAM ALLOY PARTICLES
standing of the characteristics of the various amalgam alloys, so Silver-based amalgam alloys are classified as irregular,
they can correctly select, mix, place, and carve them. In addi- spherical or admixed according to the shape of the par-
tion, knowledge of safe mercury hygiene measures is important ticles in the powder (Fig. 10.1). Each of these particle
for health and safety reasons. Dental assistants and hygienists shapes contributes certain handling characteristics to
will be asked questions by patients regarding the mercury con- the amalgam, and to some degree the amalgam type is
tent of amalgams and the health risks. Patients need to be pro- selected by the dentist according to these characteristics.
vided with accurate information about this issue. Some states
mandate patients be provided with a dental materials fact sheet Lathe-cut alloy
listing pros and cons of the materials. This chapter covers the Irregularly shaped particles are formed by shaving
properties and handling of amalgam and mercury hygiene. fine particles (10-70 μm in width and 60-120 μm in
length) off a heat-treated ingot of the alloy with a cut-
ting machine called a lathe (thus, lathe-cut alloy). The
DENTAL AMALGAM particles are sifted to separate them into fine and ultra-
Millions of amalgam restorations are placed each year. fine particles.
Amalgam has been studied and tested more than any
other restorative material. Although composite resins Spherical alloy
are being requested by patients with increasing frequen- Spherical particles are produced by spraying (atom-
cy for posterior restorations, amalgam is still a widely izing) a mist of molten alloy into an inert gas. Small
used direct-placement material for the posterior region spherical particles (2-43 μm) are formed as the atom-
of the mouth and accounts for about 30% of the direct ized droplets cool (thus producing spherical alloy). The
restorations placed in this region. No other direct restor- spherical particles are heat-treated and washed in acid
ative material has the durability, ease of handling, and to remove surface contaminants.
good physical characteristics of amalgam. Its wear re-
sistance and compressive strength are superior to com-
posite resin and glass ionomer cement. Clinical studies
indicate a typical life expectancy of about 15 years for
conservative class I and II amalgams. Many can last
much longer, with a few amalgams documented as last-
ing 40 to 50 years. The safety of amalgam has been called
into question in recent years, but a study conducted by
the National Institutes of Health (NIH) from 1991 to
1993 concluded that amalgam is safe for human use. In
addition, the U.S. Public Health Service, the U.S. Food
and Drug Administration (FDA), the American Dental
Association, the Centers for Disease Control and Pre-
vention, and the World Health Organization all consider
amalgam to be a safe material. Less than 0.01% of people
have an adverse reaction to the components of amal- A
gam. However, a combination of concerns by patients
about its safety and its lack of esthetics has prompted
many patients to request tooth-colored restorative mate-
rials. Insurance carriers have seen a reduction in the use
of amalgam for posterior restorations by approximately
45% in the past 20 years. Health and safety concerns will
be discussed in detail later in the chapter.

ALLOYS USED IN DENTAL AMALGAM

An alloy is a mixture of two or more metals. The al-
loy used to produce dental amalgam is composed pre-
dominantly of silver but also contains copper and tin.
A variety of other metals, such as palladium, indium,
or zinc, may be added in much smaller quantities to B
produce specific properties in the alloy. When the sil-
ver-based alloy particles are mixed with mercury the FIG. 10.1 A, Scanning electron micrograph (SEM) of admixed alloy
showing a mixture of irregularly shaped particles and spherical par-
reaction that occurs is called amalgamation and the ma- ticles. B, SEM of spherical alloy with spherical particles of various sizes.
terial that is produced is a strong, hard, durable mate- (Courtesy of Grayson W. Marshall, University of California School of
rial called dental amalgam. Dentistry [San Francisco, CA].)
194 CHAPTER 10 Dental Amalgam

Admixed alloy liquid mercury is used up. Not all of the alloy particles
Admixed particles consist of a mixture of lathe-cut and are dissolved before the mercury is used up, so they re-
spherical particles (admixed alloy). main in the core of the amalgam, held together by com-
pounds of mercury with silver and tin (acting as a ma-
Composition of Amalgam Alloys trix), and make up about half of the amalgam volume.
Dental alloys for amalgam are composed mainly of sil- These particles contribute to the strength and corrosion
ver and tin. Copper is added to replace some of the resistance of the amalgam. The freshly mixed amalgam
silver to lessen the brittleness. Alloys can be grouped has a putty-like consistency that can be packed into the
or classified by their copper content. Modern dental al- cavity preparation. Over the next several minutes, the
loys are considered to be high in copper content (13% free mercury is used up in the crystal formation and the
to 30%) compared with their predecessors, which had mix gradually becomes firmer. During the first part of
4% to 6% copper by weight (Table 10.1). They gener- this firming phase, the amalgam can be carved (during
ally contain 40% to 70% silver and 12% to 30% tin. the working time or time available to manipulate the
They are mixed with mercury 42% to 52% by weight amalgam) to the anatomic shape of the tooth. Once it
(wt. %). Spherical alloys require less mercury to wet reaches its initial set, it can no longer be carved and is
the particles, because the surface area of spheres is less firm but is not fully reacted. It is relatively brittle at this
than that of lathe-cut particles. Spherical alloys require point, and the patient is advised not to bite on it for
about 42 to 45 wt. % of mercury whereas lathe-cut and several hours. Many of the high-copper spherical amal-
admix alloys require 50 to 52 wt. %. Spherical amalgam gams gain approximately 50% of their compressive
generally sets faster than lathe-cut amalgam. Manu- strength in the first hour, but it takes up to 24 hours for
facturers may also add indium (1% to 4%), palladium most amalgams to gain their maximum strength. Once
(0.5%), and zinc (0.01% to 2%). Zinc may inhibit corro- fully set, they are hard, strong, durable restorations.
sion by reducing the oxidation of the other metals in
the amalgam. Setting Reactions
The manufacturer can affect how amalgam handles by The chemical reaction that occurs when the alloy and
varying the components of the alloy and by varying the mercury are mixed has three phases. The first phase,
shape, size, and distribution of the sizes of particles. The called the gamma phase (γ), is the silver alloy phase. It
manufacturer, too, can control how fast the amalgam sets is the strongest phase and has the least corrosion. The
by various treatments of the alloy particles, such as heat- second phase is the gamma-1 phase (γ1), consisting of
treating them or removing oxides from their surface. The mercury reacting with the silver. It is strong and corro-
dentist, then, can select alloys with slower or faster set- sion resistant, although not as resistant as the gamma
ting times depending on the intended application. phase. The third phase, the gamma-2 phase (γ2), con-
sists of the reaction of mercury with tin. Gamma-2 is
SETTING TRANSFORMATION (AMALGAMATION) weak and corrodes readily. Tin is used to control the
When the alloy in powder form is mixed with liquid rate of set of the amalgam. Both silver and tin dissolve
mercury, a chemical reaction occurs. The reaction starts into the liquid mercury until the solution becomes
at the surface of the alloy, so the size and shape of the saturated with them, and they also absorb mercury.
alloy particles will affect the setting process. The al- Newly formed particles begin to precipitate (crystal-
loy particles dissolve into the mercury. When no more lize) out of the mercury until there is no more mercury
metal can dissolve into the mercury, a mixture of me- left to react. This process may take up to 24 hours to go
tallic compounds begins to crystallize in the mercury to completion. Low-copper amalgams had much more
(a process called amalgamation) and continues until the corrosion because of the chemical reaction of tin and

Table 10.1    Main Components of Amalgam Alloy

HIGH-COPPER LOW-COPPER
COMPONENT FUNCTION OTHER EFFECTS ALLOY, % ALLOY, %
Silver (Ag) Increases strength Decreases setting time 40–70 68–72
Increases durability Tarnishes easily
Decreases creep
Tin (Sn) Improves physical properties when Reduces setting expansion 12–30 28–36
compounded with silver Increases setting time
Copper (Cu) Increases strength Increases setting expansion 13–30 4–6
Increases hardness Decreases creep
Reduces corrosion
Zinc (Zn) Reduces oxidation of other metals Causes delayed expansion with 0–1 0–2
moisture contamination
 Dental Amalgam CHAPTER 10 195

mercury (gamma-2 phase). Copper reacts with the tin Table 10.2    Properties of High-Copper Amalgam
to keep it from being available for the gamma-2 phase.
ADMIX SPHERICAL
High-copper amalgams do not have a gamma-2 phase
Compressive Strength (MPa)
and are superior in their clinical performance, display-
1 hour 110–220 260–315
ing reduced corrosion and tarnish, higher compressive 400–440 450–500
1 day
strength, less dimensional change, and better integrity
Tensile Strength (MPa)1 day 43–50 49–64
of margins than low-copper amalgams.
Dimensional Change −1.9 to −3 −5 to −8.8
PROPERTIES OF AMALGAM at 24 hours (μm/cm)
Strength Creep ( %) 0.25–0.45 0.05–0.15
Amalgam is among the strongest of the directly (approximate – values vary with each product)
placed restorative materials. Its compressive strength
is similar to tooth structure. It has the ability to resist Table 10.3    ANSI/ADA Standard No. 1 for Amalgam
the strong forces of the bite repeatedly over many PROPERTY VALUE
years when properly placed. Amalgams are stronger Dimensional change Maximum of 20 μm/cm
in compression (approximately 400 to 450 megapas-
Creep Maximum of 1%
cals [MPa]) than composites (300-350 MPa) or glass
Compressive strength Minimum at 1 hr: 80 MPa
ionomers (50-150 MPa). However, they are relatively
Minimum at 24 hr: 300 MPa
weak in tension (about 12% of compressive strength)
and shear. All amalgams are considered to be brittle. ANSI/ADA, American National Standards Institute/American Dental Association;
MPa (megapascals).
Therefore, they require adequate bulk to resist break-
ing. If the cavity preparation is too shallow or the compressive strength as a measure of amalgam qual-
occlusal morphology of the restoration is carved too ity. See Table 10.3.
deeply, the restoration is more likely to fracture. Thin
excesses of amalgam left over the cavosurface mar- Dimensional Change
gins lack strength and chip away over time, creating Ideally, the dimensions of a newly placed amalgam
an irregular margin that tends to collect plaque and should not change. If amalgam contracts excessively, it
contribute to recurrent caries. Additionally, cavosur- will open gaps at the margins, contributing to leakage of
face margins of the cavity preparation should be at 90 fluids and bacteria and causing sensitivity. If it expands
degrees to follow the direction of the enamel rods and excessively, it can put pressure on the cusps and cause
to prevent forming thin edges of amalgam that may pain with biting pressure or may result in fracture of
fracture. Excessive forces from bruxing, chewing on the cusps. Some expansion and contraction occur dur-
ice or biting on a popcorn kernel can cause fracture of ing the setting reaction of the amalgam. It is the net ef-
the amalgam. fect of these two processes that is important. The com-
The strength of the amalgam can be affected by the position of the alloy particles, the ratio of the mercury
speed and duration of trituration. Under or over tritu- to alloy powder by weight, and salivary/moisture con-
rating the amalgam mix amd a mix that is too wet or tamination are other factors that contribute to dimen-
dry can decrease the strength of the amalgam. Like- sional changes. Low-copper amalgams containing zinc
wise, the amount of mercury used in the mix can af- are prone to expansion over time if they are exposed
fect strength. A mix that is poorly condensed into the to moisture during placement. This gradual expansion
cavity preparation can result in voids that weaken the after placement is called delayed expansion (Fig. 10.2).
final restoration. In general, spherical alloys require It is caused by the formation of hydrogen gas resulting
less condensation pressure than admix alloys and they from a reaction of zinc and water that causes an out-
develop a degree of strength more quickly. ward pressure on the amalgam, causing it to creep. De-
In general, high-copper amalgams have a higher early layed expansion can cause the restoration to expand be-
compressive strength (1 hour) than low-copper amal- yond the cavity walls, causing cracking in the adjacent
gams. This is advantageous because it helps resist break- enamel. Most high-copper amalgams do not contain
age if the patient inadvertently bites on a newly placed zinc or have very small amounts, and therefore delayed
amalgam. Some high-copper amalgams gain approxi- expansion is less common. In fact, most present-day
mately 80% of their strength in the first 8 hours. Low- and amalgams have contracted slightly by the time they set
high-copper amalgams are comparable in compressive because of smaller alloy particle size and the use of less
strength once they have completely set at about 24 hours. mercury (see negative numbers for dimensional change
See Table 10.2 for some of the properties of high-copper in Table 10.2 indicating shrinkage).
amalgam.
The American National Standards Institute/Ameri- Creep
can Dental Association (ANSI/ADA) Standard No. Creep in dental amalgams refers to the gradual change
1 for Amalgam has set maximum values for dimen- in shape of the restoration from compression by the op-
sional change and creep and minimum values for posing dentition during chewing or by pressure from
196 CHAPTER 10 Dental Amalgam

FIG. 10.3 Low-copper amalgam restoration showing surface tarnish,

margin deterioration, and corrosion. Tooth has darkened as corrosion
products from the amalgam have penetrated the dentinal tubules.
(From Bird, DL, Robinson DS: Modern Dental Assisting, ed. 11, St.
FIG. 10.2 Delayed expansion of amalgam. Margins of the restoration Louis, 2015, Saunders.)
stand up from the tooth. (Courtesy of Dr. Steve Eakle, University of
California, San Francisco.) containing electrolytes (saliva is such a solution). An
electrical current is generated between the metals
adjacent teeth. It is a phenomenon associated with the (much like a battery) in a process called galvanism. The
gamma-2 phase seen with low-copper alloys (about result of the galvanic reaction is oxidation of one of
6%) and results in deterioration of the margins. High- the metals. This oxidation is responsible for corrosion
copper alloys exhibit far less creep (less than 0.5%) and of the amalgam. Corrosion also takes place within the
have superior marginal integrity. amalgam through interaction of its metal components.
It weakens the amalgam over time, can stain sur-
Tarnish rounding tooth structure as corrosion products enter
Tarnish is an oxidation that attacks the surface of the the dentinal tubules, and can lead to deterioration of
amalgam and extends slightly below the surface. the margins (see Fig. 10.3). The high copper content
It results from contact with oxygen, chlorides, and of newer alloys eliminates the formation of the gam-
sulfides in the mouth. It causes a dark, dull appear- ma-2 reaction product that caused weakening of the
ance, but it is not very destructive to the amalgam amalgam. High-copper alloys have virtually replaced
(Fig. 10.3). The rougher the surface, the more it tends low-copper alloys, because high-copper amalgams are
to tarnish. Metals such as palladium are sometimes more durable, with less deterioration at the margins
added to help reduce tarnish. Polishing of the restora- (better marginal integrity), less corrosion (with less
tion can also reduce tarnish. Polishing of amalgams is staining of surrounding tooth structure), and higher
best done after the restoration has set for a period of strength.
24 hours or longer. Some clinicians have advocated Clinically, a galvanic reaction may occur when a
polishing fast-set amalgams in as little as 20 minutes newly placed amalgam contacts another metal restora-
after placement. However, amalgams polished this tion such as a gold crown. The patient feels a mild elec-
soon after placement usually do not achieve a high trical shock and may experience a metallic taste. This
shine. High-copper amalgams have a smoother sur- problem may persist until the amalgam completes its
face after carving than low-copper amalgams and setting reactions, until enough oxides build up on one
tend to tarnish less. Polishing is not as critical to their of the metals to stop the electrical current, or until the
longevity as with low-copper amalgams. Because of offending restoration is replaced with a non-conduct-
this fact, controversy exists among dental educators ing restoration such as composite or with a restoration
and clinicians as to whether high-copper amalgams of a metal similar to the one next to it. Corrosion, how-
need polishing if they are well carved and contoured ever, can occur within an amalgam without the patient
at the time of placement. Generation of excessive heat ever being aware of the process.
during polishing can cause a release of mercury from
the silver-mercury phase resulting in a mercury-rich Thermal Conductivity
surface that will corrode more readily and deteriorate Amalgam, being a mix of metals, is a good conductor
at the margins. of heat and cold. In shallow cavity preparations the
thickness of the dentin remaining over the pulp is usu-
Corrosion ally adequate to dissipate the heat or cold. However, in
Corrosion can occur from a chemical reaction be- deeper cavity preparations or in teeth that were sensi-
tween the amalgam and substances in saliva or food, tive before the placement of the amalgam restoration,
resulting in oxidation of the amalgam. It can also oc- a base or liner should be used for the comfort of the
cur when two dissimilar metals interact in a solution patient. Hot coffee or ice cream can produce quite a
 Dental Amalgam CHAPTER 10 197

painful shock to the patient when thermal insulation is smooth convexity is formed on the outside of the band
not used in these deeper preparations. (Fig. 10.5).
This will form the contact area when the amalgam
APPLICATIONS FOR DENTAL AMALGAM is condensed into the box form of the Class II cavity
Amalgam is useful for small to moderate intracoronal preparation. Bands that are 0.002 inch in thickness are
restorations in posterior teeth where esthetics is not a easier to contour and hold their shape better when
concern. These cavity preparations include Class I, II, placed in the retainer. Bands are also available that are
V, and VI. Amalgams do well in stress-bearing areas. already contoured and need little or no adjustment
Amalgams are used in large cavity preparations and (Fig. 10.6).
to replace missing cusps when patients cannot afford
crowns and onlays. They are used for foundations Matrix Band Retainers
(build-ups) for crowns. They are sometimes used to Some bands require a retainer to hold the band in
seal a root apex after apical surgery. They are often the place around the tooth which enables the operator
material of choice when restoring a cavity where con- to tighten the band around the tooth. The Tofflemire-
trol of saliva and blood is difficult. Amalgams are the type retainer (developed by Ben Tofflemire, a gradu-
least technique sensitive of the direct placement restor- ate of UCSF School of Dentistry) is the most widely
ative materials. used (and has been used for about a century). It comes
in two designs, straight or contra-angled. A smaller
version is available for use on primary teeth. The
MATRIX SYSTEMS contra-angled retainer is useful when the retainer is
A matrix for amalgam restorations usually consists placed on the lingual side of the teeth instead of the
of three components: (1) a flexible metal band that typical buccal placement and on posterior teeth where
is placed around all or part of the tooth to tempo- the straight retainer does not fit well. The retainer has
rarily form a wall that helps contain and shape the four parts: a U-shaped head that has three slots for po-
amalgam during placement, (2) a device that helps to sitioning the band, a locking vise with a sliding com-
retain or hold the band in place, and (3) a wooden or ponent that holds the band, a long knurled knob that
plastic wedge that secures the band against the tooth is turned to tighten the diameter of the band, and a
and produces some separation of the two adjacent short knob that locks the band within the sliding com-
teeth. ponent (Fig. 10.7).

USE OF MATRIX BANDS Placing the Band in the Retainer

A matrix band is used to help contain the amalgam The band is slightly curved so that when it is folded to
during condensation in a class II preparation and form a loop, there will be a larger circumference on one
helps to form the proximal contours and contacts edge and a smaller circumference on the other edge.
of the restoration. Matrix bands are thin strips of (See Fig. 10.5) The edge with the smaller circumfer-
material that encompass all (circumferential bands) ence is placed toward the gingiva, because most teeth
or part (sectional bands) of the tooth. For amalgam constrict toward the cervical. The edge with the wider
the bands are typically composed of stainless steel.
Metal bands are available in thicknesses of 0.001,
0.0015, and 0.002 inch with 0.001 being the thinnest.
The bands are made in various heights occlusogin-
givally (narrow and wide) to accommodate shorter
or taller teeth (premolars, adult molars, and primary
molars). The universal matrix band will adapt to
most posterior teeth, but occasionally on taller teeth
or teeth with deep gingival box forms the univer-
sal band will be too short to cover the entire cavity
preparation. A band with extensions to cover deep
mesial and distal box forms (called an extension
band or a mesiooccluso-distal [MOD] band) is then
selected (Fig. 10.4).
If the metal band is flat as the conventional bands
often are, then it must be shaped to form the proper
contours of the final restoration. Using a flat band will
produce a contact area that does not have full contour.
To shape the band place it on a soft paper pad and at FIG. 10.4 Common types of posterior metal matrix bands for Tofflemire-
the location of the contact area begin rubbing a bur- type retainer. (From Bird DL, Robinson DS: Modern Dental Assisting,
nisher against the inner portion of the band until a ed 11, St. Louis, 2015, Elsevier.)
198 CHAPTER 10 Dental Amalgam

circumference is oriented toward the occlusal side and mm beyond the gingival floor of the preparation and
is placed into the retainer. The ends of the band are the occlusal edge extends approximately 1 mm above
placed into the slot of the locking vise, and then the the marginal ridge of the adjacent tooth (assuming
loop of the band is positioned into the slot of the re- both teeth had marginal ridges at the same height be-
tainer head that orients it toward the tooth with the fore the preparation).
retainer on the buccal side of the tooth. The small lock- If the universal band is short of the gingival floor
ing knob is turned clockwise to secure the band in the of the proximal box, then the MOD extension band
retainer. should be used. If the preparation involves only one
proximal surface or only one proximal box is deep,
Placing the Band on the Tooth then with scissors cut away the extension of the band
If the band loop has been constricted when putting that is not needed (i.e., if the distal box is deep but
the band in the retainer, use a mirror handle inside the not the mesial, then cut away the mesial extension
loop to open it and round it out (Fig. 10.8). level with the rest of the band), otherwise that un-
If the diameter of the loop is larger than needed needed extension may not let the band seat fully
to go around the tooth, then adjust the diameter by (Fig. 10.9).
tightening the inner knob. Slide the matrix band While holding the band from the occlusal sur-
around the tooth. If it cannot pass through a tight con- face with a finger, tighten the band to the tooth by
tact area, try placing a wedge to slightly separate the turning the long knob clockwise until the band is
teeth. The gingival edge of the band should be prop- snug to the tooth. Check with an explorer to see that
erly oriented and the open end of the retainer head there is no gap at the gingival margin with the band.
should be positioned toward the gingiva (to allow Next, use a plastic instrument or an interproximal
ease of removal in an occlusal direction). Fully seat burnisher to burnish the band against the adjacent
the band so that the gingival edge extends at least 0.5 tooth.

A B

C
FIG. 10.5 Burnishing the matrix band. A, A flat metal matrix band is burnished with a small burnisher on a paper pad to
provide proper contours for the contact area. B, A football burnisher forms the contours for mesial and distal contact
areas. C, The band is burnished and ready to use. (Courtesy Aldridge Wilder, DDS from Heymann H, Swift E, Ritter A:
Sturdevant’s Art & Science of Operative Dentistry, ed 6, St. Louis, 2013, Elsevier.)
 Dental Amalgam CHAPTER 10 199

gingival margin of the box form without distorting the

Criteria for Matrix Band Placement for Class
band (Fig. 10.10).
II Preparation
The wedge is usually inserted firmly into the gin-
CRITERIA REASON gival embrasure from the lingual side, because this
1. Band approximately 1. If band is higher, amalgam is typically the widest of the two embrasures. The
1 mm above level of packed too high at the ridge wedge must be placed firmly enough to make up
the marginal ridge is likely to fracture when
removing the band
3
2. Band should not be 2. Amalgam packed over the Outer knob
lower than marginal top of the band will fracture
1 Spindle pin 4
ridge level when removing the band. (stabilizes band in holder) Inner knob
Difficult to establish marginal
ridge contours. 5
Diagonal slot to receive ends
3. External surface of 3. Establishes proper proximal of band
band should be con- contours and contact
vex and establish 2 Outer slot to hold
contact with adja- A position of band

cent contact area.

4. Band firmly in con- 4. Prevents overhang at gingi-
tact with the gingival val margin
margin of box
5. Band well adapted 5. Reduces excess amalgam at
at buccal and lingual buccal and lingual margins
margings of box. and makes carving easier.

B
The Wedge
The function of the wedge is to adapt the matrix tight-
ly against the gingival margin of the proximal box and
to produce some separation of the teeth to compensate
for the thickness of the matrix band. Otherwise, when
the band is removed there would be a gap between the
restoration and the adjacent tooth (called an open con-
tact). Commercially made wedges are often triangu- C
lar-shaped pieces of wood or plastic. Some clinicians
prefer to use wedges made from round toothpicks.
Select a wedge that is large enough to fit the gingi-
val embrasure space and will hold the band against the

D
FIG. 10.7 Use of the Tofflemire-type retainer. A, Components of the
retainer. B, Metal band placed in guide slot and diagonal slot. The
closed end of the guide slots is oriented toward the occlusal surface of
the teeth, and the occlusal edge of the band is inserted first toward the
closed end. C, Tighten locking nut to secure band in the retainer. D,
Note that band has been angled through the left guide slot to be posi-
tioned on the buccal surface of the tooth. The band is tightened around
the tooth by turning the inner knob clockwise. A wedge is inserted
firmly into the lingual embrasure to create separation of the teeth and
hold the band against the tooth gingivally. (A, From Bird DL, Robinson
DS: Modern Dental Assisting, ed. 11, St. Louis, 2015, Elsevier. B, From
Darby ML, Walsh MM: Dental Hygiene: Theory and Practice, ed. 4, St.
FIG. 10.6 Pre-contoured matrix bands. (Getz Contour Bands, Louis, 2015, Elsevier. C, From Darby ML, Walsh MM: Dental Hygiene:
Waterpik.) Theory and Practice, ed. 3, St. Louis, 2010, Elsevier.)
200 CHAPTER 10 Dental Amalgam

for the thickness of the matrix band. If a circumfer- of the tooth (e.g., Wedge Wands or G-Wedges by
ential band (encircles the tooth) is used, there are Garrison Dental. See Chapter 6, Figure 6.14). If the
two thickness of matrix band (mesial and distal) to cavity preparation includes both mesial and distal
compensate for. So, the wedging pressure must be proximal boxes, then a wedge will be needed for
greater than when a sectional band (goes only on one each embrasure.
proximal surface) is used (see Chapter 6 for sectional Once the wedge is in place, loosen the retainer by
matrix systems). Some manufactured wedges are turning it counterclockwise one quarter turn. This
concave on their sides to accommodate the convexity

FIG. 10.9 Trimming the MOD band. When the matrix band extension is
needed only on one proximal surface, the other extension is removed
FIG. 10.8 Opening and rounding a constricted matrix band loop. (From to allow full seating of the band. (From Heymann H, Swift E, Ritter
Bird DL, Robinson DS: Modern Dental Assisting, ed 11, St. Louis, A: Sturdevant’s Art & Science of Operative Dentistry, ed 6, St. Louis,
2015, Elsevier.) 2013, Elsevier.)

A Incorrect B Correct

C Incorrect D Correct
FIG. 10.10 Indications for use of a round toothpick wedge versus a triangular (i.e., anatomic) wedge. A, Often the tri-
angular wedge does not firmly support the matrix band against the gingival margin in conservative Class II preparations
(arrowhead). B, The round toothpick wedge is preferred for these preparations because its wedging action is nearer the
gingival margin. C, In Class II preparations with deep gingival margins, the round toothpick wedge crimps the matrix
band contour if it is placed occlusal to the gingival margin. D, The triangular wedge is preferred with these preparations
because its greatest width is at its base. (From Heymann H, Swift E, Ritter A: Sturdevant’s Art & Science of Operative
Dentistry, ed 6, St. Louis, 2013, Elsevier.)
 Dental Amalgam CHAPTER 10 201

will loosen the band slightly so it can be adapted to

the adjacent contact area and will allow the condensed
amalgam to push the band against the adjacent con-
tact. Once the band is loosened, burnish it against the
adjacent tooth with an interproximal burnisher or the
back of a large spoon excavator.

Atypical Wedge Placement

The wedge may have to be placed in an unconvention-
al way depending on a number of factors:
1. On occasion, the shape of the wedge is not compat-
ible with the convex shape of the tooth. In this case, A
the wedge can be custom-shaped by carving it with
an amalgam knife or a scalpel.
2. If the wedge sits too high in the embrasure space,
it may distort the matrix band, fail to seal the gin-
gival margin, and cause concave proximal con-
tours in the gingival aspect of the restoration (Fig.
10.11).
3. If the embrasure space is very large because the gin-
gival tissue has receded, it will be difficult to secure
the band against the gingival margin of the proximal
box with a single wedge because it will be apical to
the gingival margin. It may be necessary to place a
second, smaller wedge on top of the first wedge.
B
4. If the cavity preparation has resulted in a very wide
proximal box (from facial to lingual), it may be nec- FIG. 10.11 Radiographs depicting poor proximal contours of the amal-
essary to place two wedges, one from the facial and gams: A, caused by a wedge place too far coronal to the gingival mar-
one from the lingual, in order to ensure that the two gin of the cavity preparation that distorted the matrix band; B, overhang
of amalgam caused by a wedge that was not firmly placed, was placed
gingival corners of the proximal box are sealed, slightly above the gingival margin, or the band did not cover the deep
The presence of a rubber dam may make wedge gingival margin. (Courtesy Dentaljuce CPD Providers Ltd, https://www.
insertion more difficult as it tends to push the wedge dentaljuce.com/direct-restorations-wedges.)
back out. To lessen this problem, stretch the interseptal
rubber dam in the opposite direction of wedge place-
ment while inserting the wedge. After the wedge is Pre-Wedging
fully seated, gently release the dam. Some clinicians prefer to place a wedge interproxi-
mally before starting to cut the proximal box of a
Criteria for Wedge Placement for Class II cavity preparation. The wedge separates the
Class II Preparation approximating teeth slightly to allow preparation of
the box form with less risk of damaging the adjacent
CRITERIA REASON proximal surface. It also provides some protection of
1. Wedge firmly seated 1. To separate teeth the interseptal gingiva. There is a commercially avail-
enough to make up for able product called the Fender Wedge (Garrison Den-
thickness of band tal Solutions) that has a protective metal sheet that
2. Wedge holds matrix 2. Prevents amalgam over- extends from the wedge occlusally to protect the ad-
band against gingival hang jacent tooth during preparation of the proximal box
margin of proximal box (Fig. 10.12).
3. Wedge is not located 3. Prevents amalgam from
coronal to the gingival escaping under the band Final Evaluation of the Matrix before
margin of proximal box to create an overhang Condensation
4. Wedge is not located 4. Prevents overhang
Once the matrix band has been placed around the pre-
too far apical to gingival
pared tooth, the retainer appropriately tightened and
margin of proximal box
5. Wedge does not deform 5. Allows proper anatomic the wedge snugly pressed into place, a final check is
the band contours proximal contours made of the matrix assembly before the preparation is
filled with amalgam. Check for the following features
(see Fig. 10.13):
1. The matrix band extends apical to the gingival mar-
gin of the proximal box by about 1 mm.
202 CHAPTER 10 Dental Amalgam

Fig. 10.12 Wedge with a metal shield attached that acts to protect
the proximal surface of the adjacent tooth during cavity preparation.
(Fender Wedge, courtesy of Garrison Dental Solutions.)

2. There is no gap between the band and the gingival

margin of the box form.
3. There is no gingival tissue or rubber dam caught be- FIG. 10.13 Properly placed and wedged matrix band for Class II cavity
tween the band and the tooth. preparation. The gingival margin is sealed with the band and wedge
4. The top edge of the band extends beyond the adja- and the band is adapted to the adjacent tooth. (From Heymann H,
cent marginal ridge by approximately 1 mm. Swift E, Ritter A: Sturdevant’s Art & Science of Operative Dentistry, ed
6, St. Louis, 2013, Elsevier.)
5. The wedge is firmly in place, so that it will produce
some separation of the teeth.
6. The band is well adapted to the buccal and lingual
walls of the proximal box. some separation of the teeth to make up for the thick-
7. The band is adapted to the adjacent tooth. ness of the matrix band to ensure a snug contact (see
8. The wedge has not distorted the convexity of the Figure 6.15, Chapter 6 [Composites, Glass Ionomers,
band in the cervical area. and Compomers]). When using a sectional band with
9. The band is stable so that it will not move around a pressure ring, be sure to check the contact with floss
during placement and condensation of the right after removing the matrix band. If the contact
amalgam. is too tight, insert a wedge snugly and pass floss
See Procedure 10.1 at chapter end for placement and through the contact several times to loosen the tight
carving of Class II amalgam. contact.

Retainerless Matrix Systems HANDLING CHARACTERISTICS OF ­

Some matrix systems do not require a retainer. The Au- HIGH-COPPER ALLOYS
toMatrix (Dentsply) and ReelMatrix (Garrison Dental) High-copper alloys are mostly admix or spherical types
have a band formed into a circle with a coil-like loop (see Table 10.4 for a comparison of admix and spherical
at the end. A special tool is used to wind the coil and alloys). Spherical particles have a smaller surface area
tighten the band (Fig. 10.14). Other bands include the with which the mercury can react. Therefore they need
copper T-band (Fig. 10.15) used in pediatric dentistry approximately 10% less mercury for the amalgamation
and custom spot welded bands that are formed to the process. Freshly mixed spherical amalgam has very little
teeth, then removed and spot welded to retain the loop. resistance to condensation into the cavity preparation
and feels soft compared with an admixed amalgam.
SECTIONAL MATRIX SYSTEMS Spherical amalgams do not displace a matrix band and
Some systems use bands that do not go entirely force it into contact with the adjacent tooth in class II
around the tooth. These are called sectional bands. preparations as well as admixed amalgams. Therefore
They are typically used with composite resin res- spherical amalgams may require a bit more physical sep-
torations but can be used for class II or III (distal of aration of the teeth with the wedge in order to establish
canines) amalgam preparations, particularly where a good proximal contact after the matrix band has been
only one proximal surface has been prepared (mesi- removed. Spherical amalgams have higher 1-hour and
occlusal or distocclusal ). A wedge is placed just as 24-hour compressive strengths than admixed amalgams.
with all of the other matrix systems. A pressure ring Newly placed spherical amalgams have slightly more
is applied that holds the band in place and produces shrinkage than admixed amalgams. At 24 hours, both
 Dental Amalgam CHAPTER 10 203

A
C

FIG. 10.15 Copper T-band used for primary molars. A, T-band B,

T-band prepared for placement. C, T-band positioned around the tooth
and tightened by folding the flaps. (Copyright Elsevier Collection.)

Table 10.4   High-Copper Amalgams: Admix

and Spherical
ADMIX SPHERICAL
Needs greater Needs less condensation
condensation pressure pressure
Adapts readily to cavity Requires both vertical and
preparation lateral condensation
Establishes contact Requires heavier wedging
readily to establish contact
B Medium early strength High early strength
FIG. 10.14 Retainerless matrix systems use a tool to tighten the matrix Needs more mercury Needs 10% less mercury
band into a coil. A, Automatrix Kit (Courtesy of Dentsply Caulk). B, Coil Longer working time Faster set
is tightened with tool to tighten it against the tooth (Automatrix band).
(B, Courtesy Dentaljuce CPD Providers Ltd, https://www.dentaljuce.
com/direct-restorations-wedges.)
doing a large multi-surface amalgam and needs more
time to place and carve the amalgam, an admix alloy
admixed and spherical high-copper amalgams shrink may be selected. Some alloys are specifically manufac-
slightly. tured to be fast setting, and these alloys may be selected
when the clinician needs early strength in the restoration.
MANIPULATION OF AMALGAM High-copper alloys are selected because they have supe-
(See Procedure 10.1.) rior properties.

Selection of Alloy DISPENSING OF ALLOY AND MERCURY

Because most of the modern dental alloys are high-cop- Amalgam must be handled properly from the start
per, the dentist selects the dental alloy based on personal through the entire placement process if a restoration
preference for its handling characteristics (see Table is to be successful. The preferred dispensing of alloy
10.5 for commercially available alloys and their particle powder and mercury is done in commercially pre-
types). There are variations among the commercially pared capsules that contain factory-measured amounts
available alloys in working and setting times, resistance of alloy and mercury separated from each other by a
to condensation pressures, and resistance to carving plastic membrane. The manufacturers determine the
pressures. Admix amalgam generally has a longer work- optimal ratio of alloy and mercury for their products
ing time than spherical amalgam. So, if the clinician is based on testing of materials for their best properties.
204 CHAPTER 10 Dental Amalgam

Table 10.5    Common High-Copper Amalgams A less frequently used form of alloy is a pellet that
is placed into a reusable capsule with a pestle and mer-
MANUFACTURER SET SPEEDS
cury is added from a dispenser. The pestle pulverizes
AND BRAND NAME TYPE OF ALLOY AVAILABLE
the pellet into a powder during mixing in the triturator.
Dentsply
This older method of mixing the amalgam has declined
Dispersalloy Admix Regular and Fast in use, because the capsules often leak mercury into
Megalloy EZ Spherical Regular the operatory during mixing, mixes are not as consis-
Ivoclar Vivadent tent, and the dispenser is a potential source of mercury
Valiant Spherical Regular spills.
Valiant Ph.D. Admix Regular
Kerr Dental Clinical Tip
Contour Admix Regular and Fast Do not activate the capsule before you are ready to
begin mixing it. Activating the capsule and placing it in
Tytin Spherical Slow and Regular
the triturator before completing the cavity preparation will
Tytin FC Spherical Regular and Fast allow the alloy powder to be partially wet by the mercury.
When the mix is actually triturated a few minutes later,
some of the reaction will have already started. The resulting
amalgam will not have optimal properties and may have
Usually capsules are available with different quantities reduced working time. Self-activating capsules avoid this
of materials depending on the size of the restoration. potential problem.
They are offered as single mix (also called one spill,
containing 400 mg of alloy), double mix (two spill, 600
mg), triple mix (three spill, 800 mg) or more, depend- Expansion, contraction, creep, and corrosion can be
ing on the manufacturer, and capsules are color-coded caused by improper manipulation, moisture contami-
to indicate the quantity. With large preparations, sev- nation, overtrituration, and undertrituration. Under-
eral capsules may be needed. triturated alloy has a dry, crumbly appearance, sets
too quickly, and does not condense well. It results in
MATRIX APPLICATION a weaker restoration, because the components have
Some cavity preparations will require the use of a ma- not totally mixed, leaving a higher level of unreacted
trix system to contain and shape the amalgam, partic- mercury and alloy particles. On the other hand, over-
ularly when all or a part of one or more walls of the triturated alloy is too wet and has low resistance to
tooth are missing. The operator will select a matrix sys- condensation. It also results in an amalgam that sets
tem (with retainer or retainerless) well suited for the too quickly because of the heat produced by prolonged
clinical situation. A sectional or circumferential matrix mixing. It results in a weaker restoration that will cor-
band will be adapted to the tooth and wedges will be rode more readily, because it forms too many reaction
placed as needed to seal the cervical area and create products (silver-mercury and copper-tin). Properly
separation of the teeth. If a matrix is needed, it should triturated alloy has a satin appearance (Fig. 10.16) and
be applied prior to triturating the amalgam. produces the desired physical properties and resis-
tance to condensation.
TRITURATION
(See Procedure 10.1). The powder and mercury are WORKING AND SETTING TIMES
mixed together in a mechanical device called a triturator After the amalgam has been mixed a certain amount
(or amalgamator). The triturator has settings that allow of time is needed to place, condense, and carve the
adjustment in the speed and time of the mixing process. amalgam before it begins to harden. This time is
The manufacturer’s recommendations for the selected called the working time. After the working time has
material should be followed. Some capsules require ac- been exceeded the amalgam cannot be condensed or
tivation before trituration to break the membrane and carved without causing problems in the material. Al-
allow the powder and mercury to mix. Other capsules loys are commercially available in fast, regular, and
are self-activating meaning the membrane ruptures slow set forms. The amount of working time selected
with the forces created by rapid movement of the tritu- is by operator preference. A slower set material may
rator. Some capsules have a small plastic or metal rod be desired if a very large restoration needs to be done
called a pestle inside to aid in the mixing. A capsule is and more time is needed to place and condense the
placed in the retaining arms of the triturator (see Pro- material.
cedure 10.1, Fig. 10.24), the proper settings of time and The setting time has two components: the initial set-
speed are made, and the device is activated. The retain- ting time and the final setting time. The initial setting
ing arms move back and forth rapidly to mix the pow- time is the time at which the amalgam reaches a pre-
der and mercury, much like an automatic paint mixer. defined firmness in the setting process. Usually, this is
 Dental Amalgam CHAPTER 10 205

Alloy
powder B D
C

Under- Properly Over-

triturated triturated triturated

Liquid
mercury

FIG. 10.16 A, Alloy powder and mercury. B, Undertriturated amalgam

is dry and crumbly. C, Properly triturated amalgam has a satin-like
appearance. D, Overtriturated amalgam appears too wet.

the time when the restoration can no longer be carved

and the occlusion can be checked and adjusted with- FIG. 10.17 Amalgam is condensed with overlapping steps of the con-
out damaging the amalgam. The final setting time is denser to avoid voids within the amalgam that might weaken it. (Cour-
the time when the setting reaction has been completed. tesy of David Graham, University of California School of Dentistry [San
The final set usually occurs 12 to 24 hours after tritura- Francisco, CA].)
tion depending on the type of alloy used.

PLACEMENT AND CONDENSATION Spherical amalgams have less resistance to con-

(See Procedure 10.1.) densation pressures and require the use of larger con-
densers, whereas admix amalgams require more pres-
Amalgam Placement sure to condense and typically condensation is started
After mixing, the amalgam is removed from the capsule with smaller condensers progressing to larger ones.
and placed into an amalgam well or the small end of a The cavity preparation is slightly overfilled to allow
Dappen dish. The pestle (if one is present) and the plastic enough material to carve to contours and to remove
membrane are removed from the mixed amalgam. The excess mercury that has been forced to the surface
amalgam is picked up in increments from the well by an during the condensation process. If excess mercury
amalgam carrier and is placed by the assistant into the is left, physical and mechanical properties will be
cavity preparation (see Procedure 10.1, Figs. 10.25 and poorer.
10.26).
Clinical Tip
Condensation When filling a large, complex cavity preparation or crown
The main objectives of condensation are to reduce the po- buildup with amalgam, the slower, novice operator should
rosity in the amalgam and to adapt the amalgam to the choose an amalgam alloy that will provide additional working
time (such as an admix alloy like Dispersalloy [Dentsply]).
walls of the cavity preparation. Amalgam condensers are
If the earlier increments of amalgam begin to set before
used to carefully work the amalgam into all of the cor-
the large restoration or buildup is completed, the later
ners and retentive areas of the preparation, using vertical increments may not adequately join to them and parts of
and lateral condensation. Condensers should be care- the amalgam may fall away as the matrix band is removed.
fully stepped around the preparation in vertical overlap-
ping steps to prevent voids in the material (Fig. 10.17),
and lateral condensation is used to adapt the material Caution
closely to the walls of the preparation. Voids in the amal- Ultrasonic condensation devices used on amalgam can
gam will produce a weaker restoration. Amalgam that is produce unsafe mercury vapor levels in the dental office.
poorly adapted to the walls of the preparation may allow
microleakage and cause post-placement sensitivity. When a large cavity preparation is restored, several
Condensation should occur in a well-isolated, clean, capsules of the mixed amalgam might be needed. If
dry preparation. A well placed rubber dam is the ideal placement of the newly mixed amalgam is too slow
method of isolation. Amalgam is the most forgiving of and the material placed in the cavity preparation starts
the direct restorative materials in the presence of sa- to get firm, then additional mixes of the material added
liva and blood, but will have its properties diminished on top might not join with the firm material. This could
none-the-less. result in a weak restoration that will separate under
206 CHAPTER 10 Dental Amalgam

chewing forces at that non-joined interface. Careful time the amalgam takes to harden can vary depending
coordination and timing of mixing and placement be- on the type of amalgam and its composition. In gen-
tween the dental assistant and the operator are crucial eral, admix amalgams set more slowly than spherical
to a successful restoration. amalgams, but some amalgams are formulated to be
fast-setting and can set in 2 to 3 minutes versus 5 to 10
Clinical Tip minutes for regular set amalgams.
Amalgam should be placed as soon as it is mixed. If allowed A variety of carving instruments can be used for
to stand for a couple of minutes, the amalgam will be various parts of the restoration—occlusal, proximal,
weaker because crystals that are forming will be disrupted and cervical—based on operator preference. In general,
during condensation. The amalgam will feel drier and more carving instruments are used so that part of the instru-
crumbly. Discard this mix and make a new one. ment rests on the adjacent tooth structure for support
and as a guide to follow tooth contours (see Procedure
Clinical Tip 10.1, Fig. 10.31). This helps to prevent over carving and
exposure of the cavosurface margin of the preparation.
When removing the matrix band from a newly placed class
II amalgam, hold the marginal ridge of the amalgam down
After carving the amalgam surface can be smoothed
with a large condenser to prevent the amalgam ridge from further by gently rubbing the surface with a damp cot-
breaking. If the wedge is left in place while removing the ton pellet.
band, some separation of the teeth will remain and there
will be less chance of breaking the marginal ridge of the new CHECKING THE OCCLUSION
amalgam when the band is removed. After the restoration is carved to restore tooth contours,
the occlusion should be checked. If the amalgam forming
the a marginal ridge is too high, then the patient could
BURNISHING AND CARVING bite too hard and break the amalgam. To avoid this mis-
(See Procedure 10.1.) hap, first check to see that the marginal ridge of the amal-
gam is about the same height as the marginal ridge of the
Burnishing adjacent tooth and then instruct the patient to close very
lightly at first on the articulating paper. After the amal-
Burnishing is a controversial procedure for amalgam. gam has been completed, the patient should be instructed
Some feel that burnishing brings excess to mercury to to avoid chewing on the newly placed amalgam until the
the surface where it can be carved away. Others do not next day (most amalgams will gain about 80% of their
burnish, because they feel that burnishing may dam- strength by 8 hours). The ADA Standard No. 1 requires a
age the amalgam at the margins. Of those clinicians minimum compressive strength of 80 MPa at 1 hour (see
who burnish their amalgams, some burnish just before Table 10.3).
carving and others burnish gently after carving to pro-
duce a smooth, dense surface. Caution
When clinicians burnish the amalgam before they In general, the height of the marginal ridge of the newly
begin carving, they use a large burnisher to further placed class II amalgam should be at the level of the
condense the amalgam with pressure in the faciolin- adjacent marginal ridge. If it is much higher, it should be
gual and mesiodistal directions (see Procedure 10.1, reduced before the occlusion is checked. Otherwise, the
Fig. 10.27). Burnishing before carving produces a much ridge might fracture when the patient bites down on the
smoother and denser surface. articulating paper. Remember, the patient might still be
numb and cannot tell how hard he/she is biting.
Carving
After the amalgam has been burnished, a carver (the
FINISHING AND POLISHING
cleoid end of a discoid/cleoid carver is useful) is
used with a light touch to remove the gross excess of Finishing and polishing (see Chapter 13 [Abrasion,
amalgam on the occlusal surface without touching Finishing, and Polishing]) is best done 24 hours or
the cavosurface margins. As the amalgam gradually more after the initial placement to allow crystallization
becomes firmer, begin carving the occlusal anatomy within the amalgam to go to completion. The purpose
and shaping the proximal surfaces. Remove all excess of finishing is to make the amalgam flush with the ca-
at the margins on the proximal surface with a suitable vosurface margins of the tooth, adjust the contours,
carver (such as a half-Hollenback) before completing and eliminate roughness. It is usually accomplished
the occlusal anatomy. Access to the proximal surfaces with multi-fluted finishing burs or fine abrasive disks.
is more difficult, so these areas should be completed Polishing further smoothes the surface and creates a
before the amalgam sets. Once the amalgam is hard, at- high shine (see Procedure 10.1, Fig. 10.32, tooth #29).
tempts at carving may damage the amalgam margins Many clinicians do not finish and polish their amal-
or cause fracture of portions of the amalgam mass. The gam restorations, because (1) it requires a second visit,
 Dental Amalgam CHAPTER 10 207

(2) modern amalgams are smoother after carving, and

(3) high-copper amalgams have low tarnish and cor-
rosion. Although not ideal, some clinicians choose to
finish and polish at the time of placement. With their
high early strength, spherical amalgams can be light-
ly polished after their initial set. Polishing should be
done using a water coolant and a light touch to avoid
generating heat that can potentially irritate the pulp
and bring mercury to the surface. Typically, polish-
ing agents such as silex or a slurry mix of fine pumice
or abrasive-impregnated rubber polishers are used.
When amalgam is polished early (after the initial set) a
smooth satin surface is produced but a high shine can-
not be achieved.
FIG. 10.18 Copal resin varnish for cavity sealing (Copalite, Temrex
Advantages and Disadvantages of Amalgam Corporation.)

ADVANTAGES DISADVANTAGES
Can withstand high Not an esthetic material
chewing forces interface of the amalgam and the preparation over
Biocompatible May require more tooth structure time greatly reduced the microleakage. With low-
removal to retain the restoration copper amalgams corrosion occurred relatively
Useful when isolation Cannot chew on it immediately quickly as the varnish began to disappear. However,
is difficult after placement with the introduction of high-copper amalgam, cor-
Easy to manipulate Possible temperature sensitivity rosion was greatly reduced and the amalgam shrank
after placement as it set. So, as the copal resin washed out, micro-
Very durable and wear Possible galvanic reaction with
leakage and resulting post-operative sensitivity was
resistant other metals in the mouth
often seen. Some clinicians lined the dentin with
Relatively inexpensive Requires mercury hygiene meas-
ures with scrap material calcium hydroxide (a popular commercial prepa-
Alternative for cusp Fills the cavity preparation but ration was Dycal by Dentsply Sirona) to cover ex-
replacement when does not support the surround- posed dentin and act as a thermal insulator under
patient cannot afford ing walls like a bonded com- the amalgam. Studies showed that calcium hydrox-
a crown posite or ceramic restoration ide also washed out over time (Fig. 10.19). Currently,
Strongest direct Cannot be used for buildup with many clinicians use bonding agents as sealers at the
placement material all-ceramic restorations (gray margins and over exposed dentin. These materials
for crown buildups color shows through) tend to hold up better over time than cavity varnish,
(cores) and they can actually seal the dentinal tubules while
cavity varnish merely placed a temporary cover over
the tubules.
Clinical Tip Bases and liners are used less frequently under
Care should be taken when polishing amalgam to avoid amalgam then in the past, because the need for their
generating heat. Heat greater than 60 °C (140 °F) causes use on a routine basis has not been established. They
mercury to come to the surface of the restoration, weakening are applied mostly in deeper cavity preparations for
the surface and margins; and pulpal irritation can occur. Do thermal insulation and pulpal protection.
not polish dry. Use low speed and a light touch, particularly
with abrasive rubber points and cups.
LONGEVITY OF AMALGAMS
High-copper amalgams in use today last longer than
USE OF A CAVITY SEALER low-copper amalgams due to their superior physical
and mechanical properties. High-copper amalgams
For many years a copal resin varnish (e.g., Copalite, are stronger, corrode less, creep less, and have better
Temrex Corporation) was routinely placed in the marginal integrity. Although there are many factors
cavity preparation before the amalgam was insert- that go into how long amalgams last, the typical sur-
ed (Fig. 10.18). The purpose of the varnish was to vival rate ranges from 7 to 15 years. However, some
prevent microleakage at the amalgam margins and amalgams have been documented to last as long as
thereby, reduce sensitivity. The copal resin tended 40 to 50 years, whereas some fail in just a few years.
to wash out with time. Corrosion products at the Amalgams in conservative cavity preparations last
208 CHAPTER 10 Dental Amalgam

Why Amalgams Fail

Reasons for Amalgam Failure
Poor Case Selection Not a good place to use amalgam
Improper Cavity Too deep, too shallow, inadequate
Design extensions of the preparation,
improper isthmus width, inad-
equate retention, cavosurface
margins not 90 degrees
Improper Manipula- Overtrituration or undertrituration
tion
Poor Placement Improper condensation leaving
voids or porosity, using a mix
that is too dry or wet
FIG. 10.19 Calcium hydroxide cavity liner for pulpal protection (Dycal, Improper Carving Too deep or too shallow, poor
Dentsply Sirona) (From Dentistry Today: New Options for Restoring a
carving or finishing of margins
Deep Carious Lesion. Category: Dental Materials Created: Monday, 18
March 2013 13:56 Written by Robert E. Rada, DDS, MBA.) leaving gross overhangs
Inadequate Isolation Contamination of the cavity prepa-
ration by blood and saliva
Improper Use of Poor matrix selection, careless
longer than those in larger preparations. Conservative Matrix matrix placement and removal,
Class I amalgams last about 15-18 years and conser- poor contouring and wedging
Other Factors Too much force placed on the new
vative Class II amalgams last about 12-15 years. The
restoration before it has gained
accompanying box lists some of the reasons that amal-
full strength causing fracture,
gams fail. a restoration that is too high in
Clinically, an amalgam restoration needs to be re- occlusion, poor oral hygiene
placed when it is no longer functional. Meaning, you leading to recurrent caries
can no longer chew on it, it is loose, part of it has
fallen out, or part of the tooth has fractured away
from the amalgam. Other reasons include defective
REPAIR OF AMALGAM
margins, recurrent caries, voids or cracks in the amal-
Using Amalgam
gam, gross overhangs causing damage to the peri-
odontium, or poor contours or contacts causing food At times part of a large amalgam may fracture or have
impaction. a relatively minor defect. A decision involving the pa-
Many of the reasons for failure of the amalgam tient’s informed consent may be made to repair the
are caused by operator error such as poor case selec- existing amalgam rather than replace it. To repair the
tion (not a good place to use amalgam), improper amalgam a retentive preparation (possibly using me-
cavity design (too deep, too shallow, inadequate chanical interlocks, undercuts, grooves, and troughs)
extensions of the preparation, improper isthmus needs to be made in the existing amalgam and possi-
width, inadequate retention) or improper manipu- bly the surrounding tooth structure. The prepared sur-
lation (over- or undertrituration), placement (im- faces need to be rough but free of any cutting debris,
proper condensation or using a mix that is too dry blood, or saliva. Fresh amalgam is then condensed into
or wet), and carving (too deep or too shallow) of the preparation against the roughened amalgam walls.
the amalgam. Contamination of the cavity prepa- The repair will not have the strength of unrepaired
ration by blood and saliva by inadequate isolation amalgam but if not under excessive occlusal loading
is another factor in failure of the restoration. Poor may serve the patient well for a number of years.
matrix selection, careless placement or removal,
poor contouring, and wedging can all contribute to Using Flowable Composite
amalgam failure. Other factors are too much force On occasion, a gap might form in an amalgam at an
placed on the new restoration before it has gained accessible margin but the amalgam is otherwise ser-
its full strength or a restoration that is too high in viceable. To close the gap and extend the life of the
the occlusion. amalgam the margin could be repaired by the use of
Occasionally after placement a new amalgam may bonded flowable composite. Any debris is removed
have post-operative sensitivity or pain. Some of the from the gap and the absence of decay is confirmed.
reasons for this are: inadequate cooling of the tooth Acid etchant is placed on the gap between the amal-
during preparation, leaking margins, incomplete gam and tooth for 10 to 20 seconds, rinsed, and dried.
caries removal, hyperocclusion, cracked tooth, or A bonding agent is applied and cured followed by
galvanism. the application of flowable composite to the gap. An
 Dental Amalgam CHAPTER 10 209

explorer or fine brush is used to work the composite

into the gap and displace entrapped air; then the com-
posite is light cured. This process reseals the margin
to prevent leakage and recurrent caries at that site. Al-
though repairing the amalgam is not ideal, it can of-
ten extend the life of the existing amalgam, conserving
tooth structure and reducing expense to the patient.

BONDING AMALGAM
Amalgam is retained in the cavity preparation by parallel
walls or undercut walls and by its adaptation to irregu-
larities in the tooth created during preparation. Amalgam FIG. 10.20 Inflammatory response of the buccal mucosa (lichen-
oid lesion) to contact with an amalgam restoration in a sensitive
placed in this manner simply occupies the space of the cav-
patient. (From https://www.proprofs.com/flashcards/cardshowall.
ity preparation; it is not bonded to and does not support php?title=oral-path-exam-3).
the surrounding walls. Low-copper amalgam expands
slightly as it sets and forms corrosion products at the tooth-
amalgam interface as it ages. The expansion and corrosion Mercury is the only metal that is in a liquid state
help to reduce microleakage at the tooth-amalgam inter- at room temperature. Elemental mercury can pass
face. High-copper amalgams shrink slightly during setting through the gastrointestinal tract without being ab-
and form corrosion products more slowly and to a lesser sorbed. It is mercury vapor that is of greatest health
degree. They tend to have more microleakage initially, concern as it is absorbed by the lungs. Exposure to
which in some cases can result in transient tooth sensitivity. mercury vapor occurs during placement or removal.
Bonding of amalgam was popular in the 1990s, but Low levels of mercury vapor are released from the set
mixed research results have cast a shadow on its use- amalgam under function (eating) or bruxing. Mercury
fulness. This technique uses bonding methods similar can accumulate over time in certain body tissues such
to those used with composite resin. After etching and as the brain and kidneys. Low level exposure creates
application of bonding agent, a dual-cure bonding resin no demonstrable problems. However, higher levels
is applied to the cavity preparation and while it is still such as those experienced by workers who are ex-
wet the amalgam is placed. The wet resin mechanically posed to the vapors at their jobs may experience signs
intermixes with the amalgam during condensation, and and symptoms. These include headaches, irritability,
when the resin sets, it mechanically locks the amalgam fatigue, memory loss, or neurological signs.
in place and the resin bonds to the tooth. The resin along Concerns about the safety of amalgam and the
the margins of the restoration creates a seal, reducing mercury it contains should be considered from three
microleakage. There is some concern that the resin bond aspects:
will hydrolyze over time and lose its effectiveness. a. Safety of the patient
b. Safety of the dental staff
ALLERGY TO AMALGAM c. Safety of the environment
Allergy to components of amalgam is very uncommon
occurring in less than 1% of patients. A local hypersen- ADA STANCE ON DENTAL AMALGAM SAFETY
sitivity reaction is most typically encountered; more se- The amount of mercury that is released from a set
vere reactions with swelling, difficulty breathing, and amalgam is very small and has not been shown to
anaphylaxis are extremely rare. Local contact dermatitis be dangerous to patients. The amount of mercury
is usually seen as red or combined red and white lesions released in vapor form from amalgam is about 1 to
(resembling lichen planus and thus called lichenoid le- 2 micrograms (μg)/day, but the total exposure to the
sions) of the buccal mucosa (Fig. 10.20) or lateral border patient will depend on a number of factors, includ-
of the tongue in close proximity to the amalgam. On oc- ing the number and type of amalgam restorations and
casion, the gingiva surrounding a cervical amalgam may their size, frequency of chewing, and whether or not
be affected as well. Usually, replacement of the amalgam the patient grinds their teeth. The ADA has addressed
restoration with an alternative material (such as compos- health concerns about mercury in amalgam (see the
ite, ceramic, or gold) will usually resolve the problem. ADA Council on Scientific Affairs [CSA] Statement on
Dental Amalgam and the CSA Amalgam Safety Up-
date, both of which can be accessed at the ADA web-
MERCURY SAFETY PROCEDURES site, www.ada.org), as has the FDA (see their Update/
Mercury is a toxic metal, but the elemental mercury Review of Potential Adverse Health Risks Associated
used in amalgam is less toxic than organic mercury with Exposure to Mercury in Dental Amalgam, which
(methylmercury) that can end up in the food chain, es- can be accessed at www.fda.gov).
pecially in seafood and can be absorbed through the di- In 2004 a review of the scientific literature was con-
gestive tract. ducted by the Life Sciences Research Office and funded
210 CHAPTER 10 Dental Amalgam

by the National Institute of Dental and Craniofacial Re- rooms must have adequate ventilation to disperse any
search (National Institutes of Health) and the Center for mercury vapor that may come from the sterilizer during
Devices and Radiological Health (a branch of the FDA). the sterilization process. Staff members should stand
Their report states that “The current data are insuffi- an arm’s length away from the sterilizer when opening
cient to support an association between mercury release the door to avoid inhaling any vapors that might be re-
from dental amalgam and the various complaints that leased. Operatory floors should have surfaces that are
have been attributed to this restoration material. These nonporous and easy to clean. Carpets and tiled floors
complaints are broad and nonspecific compared to the with seams tend to trap amalgam particles and mercury
well-defined set of effects that have been documented droplets and therefore are not recommended. Gloves,
for occupational and accidental elemental mercury ex- masks, and eye protection should be worn when work-
posures. Individuals with dental amalgam–attributed ing around amalgam and mercury. Use of factory en-
complaints had neither elevated urinary mercury nor capsulated alloy and mercury will minimize handling
increased prevalence of hypersensitivity to dental amal- of mercury and reduce the risk of mercury spills. Keep
gam or mercury when compared with controls.” a variety of capsules with various portions (spills) of
amalgam on hand to minimize amalgam waste. Amal-
CONCERNS ABOUT THE SAFETY OF AMALGAM gam scrap should be stored in airtight containers. Op-
Safety for patients eratories should be well ventilated. If staff members
Prudent oral health providers should limit the expo- have concerns about mercury exposure, offices can be
sure of patients to mercury. Mercury can enter the monitored for mercury vapor (available through private
body through ingestion, through direct contact with companies). Individual staff members could also wear
the skin, and by inhalation of the vapor. Care should monitors and have periodic blood and urine analyses.
be taken when placing or removing amalgam restora-
tions to prevent swallowing of amalgam particles or Safety for the Environment
inhalation of mercury vapor. However, the mercury Although dental offices do not contribute as much
in swallowed particles is not absorbed well and typi- mercury to the environment as large companies, their
cally excreted. Use of the rubber dam and high-volume contribution is not insignificant. In 2003 dental offices
evacuation will aid in minimizing both. were estimated to be responsible for 50% of the mer-
Mercury in the bloodstream of pregnant mothers cury contamination from waste water entering pub-
can pass through the placental barrier to reach the licly owned treatment works (POTWs). In 2008 the En-
developing fetus. It can also be passed in breast milk vironmental Protection Agency (EPA) estimated that
to nursing infants. The developing nervous system the approximately 162,000 dentists who use or remove
may be more sensitive to the mercury vapor. There is amalgam discharged 3.7 tons of mercury annually into
very little research or clinical data on the long-term POTWs. The POTWs typically remove about 90% of
effects of mercury exposure to developing fetuses or the amalgam, so the remaining 10% goes into streams,
young children. Therefore, in order to be prudent rivers, lakes, and oceans. Therefore, it is vitally impor-
many countries throughout the world have banned tant to our environment that the dental profession do
the use of amalgam in pregnant women or young all it can to manage amalgam waste.
children. Special collection devices called amalgam separators
are available to collect amalgam particles and mercury
Safety for office staff that might escape into the wastewater. The Environ-
In some dental offices, dentists and their staff have been mental Protection Agency mandated under the Clean
found to have higher levels of mercury than the popula- Water Act that in July 2017 dental practices must control
tion in general. Precautions should be taken in the dental amalgam waste through the use of amalgam separators
office to limit the exposure to the dental team. The Oc- certified by the International Organization for Stan-
cupational Safety and Health Administration (OSHA) dardization (ISO). The ISO standard 11143 for amalgam
has set an acceptable level of exposure to mercury at separators requires they collect at least 95% of the mer-
0.05 mg/m3 for a 40-hour workweek. Because exces- cury waste. Practices that place and remove amalgam
sive exposure to mercury can cause it to build up in the are also subject to two best practices: (1) they must col-
body faster than it is eliminated, it is essential to practice lect and recycle scrap amalgam and (2) they must clean
good mercury hygiene. Most dental offices comply with waterline traps with cleaners not containing bleach or
mercury hygiene standards, as demonstrated by studies chlorine so that mercury is not released. Amalgam scrap
that have shown mercury levels in most dental offices to that is collected from used capsules, remnants from the
be far below OSHA’s recommended minimum. amalgam well, and amalgam debris from high-volume
Several measures can be taken by the office staff to evacuation traps and vacuum pump filters should be
minimize mercury exposure. Free mercury vapor is re- appropriately recycled. Do not dispose of the waste
leased if amalgam is heated above 800° C (1472° F). In- in biohazard bags, infectious waste (red) bags, or dis-
struments contaminated with amalgam should never be card it in the trash that ends up in landfills. Some re-
heated to this temperature in the operatory. Sterilization cyclers want the amalgam scrap separated into contact
 Dental Amalgam CHAPTER 10 211

TABLE 10.6    Best Practices for Amalgam Waste mercury. Provisions of the treaty included a global ban on
the import and export of mercury-containing products by
DO THESE: DO NOT DO THESE:
2020. However, dental amalgam was exempted from an
Use factory encapsulated alloy Do not use bulk mercury outright ban. Instead, countries still using it were encour-
Store in air-tight containers Do not dispose of amal- aged to find alternatives to amalgam, phase out amalgam
and recycle amalgam scrap, gam scrap, capsules, over time, and promote best environmental practices.
capsules, and extracted or extracted teeth with
teeth with amalgam amalgam in biohazard
bags, infectious waste Sources of Office Staff Exposure to Mercury
bags, or regular trash
1. Placing or removing amalgam
Use chairside amalgam traps, Do not clean traps, filters, 2. Leaking amalgam capsules (less frequent with factory-
vacuum pump filters, and or separators over the sealed capsules)
amalgam separators. Re- sink 3. Mercury droplets collecting on triturator surfaces
cycle scrap 4. Sterilizing instruments contaminated with amalgam
Use line cleaners that do not Avoid cleaners that con- 5. Improper disposal of amalgam capsules and waste
dissolve amalgam tain bleach or chlorine 6. Improper storage of amalgam scrap
Train all staff in safe handling Avoid direct contact with 7. Amalgam particles in traps within high-volume evacua-
procedures and review state amalgam and its scrap tion system
regulations 8. Carpeted operatories or floors with tile or linoleum
seams that can collect spilled mercury

and noncontact containers. Noncontact amalgam scrap

Methods for Mercury Vapor Reduction
is that which is left over in the amalgam well or other
sources that have not touched the patient and, obvious- Use factory-sealed amalgam capsules, not bulk alloy and
ly, contact amalgam scrap is that collected after touching mercury that could spill.
Use an amalgamator with a completely enclosed mixing
the patient which includes extracted teeth (Table 10.6).
arm to prevent spread of mercury during mixing.
RESTRICTIONS ON AMALGAM USE Store amalgam scrap in a sealed container. Do not use
x-ray fixer for amalgam scrap storage because the fixer
The stance taken in the USA on amalgam safety has is another environmental hazard.
been largely retrospective, meaning that no studies so Recap used amalgam capsules and dispose of them in a
far have shown a harmful effect from the use of amal- sealed container.
gam in the general population or in specific groups Use copious water and high-volume evacuation when
such as pregnant women or children. So, amalgam can removing old amalgam to prevent release of mercury
be used until studies show a harmful effect. However, vapor into the air.
in Europe and some other countries a more precau- Use a rubber dam whenever possible to prevent patients
from swallowing scrap or breathing mercury vapors.
tionary approach is used. They conclude that because
Use facemask and shield to avoid splatter and vapors.
mercury is a known toxin, it is prudent to restrict the
Use traps or filters (or both) in evacuation systems. Check
use in pregnant women and young children unless it and clean regularly.
is proven safe. Avoid the use of mechanical or ultrasonic condensers.
In 1956 Japan experienced a public health disaster They increase mercury vapor release.
from mercury poisoning in the city of Minamata that Clean up spilled mercury promptly with a commercial spill
killed thousands and sickened many others. Seafood kit. Avoid handling with bare skin. Dispose of it in a
contaminated with mercury from industrial waste was sealed container (one comes with the kit).
the culprit. In the 1980s, primarily to reduce mercury Clean instruments of any adherent amalgam before steril-
in the environment, Japan became one of the first na- ization.
tions to restrict dental amalgam use. Since then, many Avoid carpeted operatories. Use floor coverings that are
nonabsorbent, seamless, and easy to clean.
countries have taken steps to reduce the use of amalgam
Remove professional protective clothing before leaving the
both for environmental reasons and patient safety, espe-
workplace.
cially in pregnant women and children under 6 years of
age. These countries include members of the European
Union (United Kingdom, Germany, Netherlands, Hun- Handling of Mercury Spills
gary, Switzerland, and Austria) as well as Finland, Can-
1. Do not use a vacuum cleaner to removed spilled mercury.
ada, New Zealand, and Singapore. The use of amalgam
2. Do not use cleaning products, especially those that
has been banned in Norway, Sweden, and Denmark. contain bleach, chlorine, or ammonia.
In October 2013 an international meeting called the 3. Do not use a broom or brush to collect the mercury.
Minamata Convention was held in Minamata, Japan, to 4. Do not dispose of the mercury in the drain.
address health and environmental concerns involving 5. If clothing or shoes have been contaminated with mer-
mercury pollution. By November of that year 93 coun- cury, remove them and leave them at the spill site.
tries had signed a treaty to reduce the risks to human 6. Use a commercially available clean-up kit to safely con-
health and to the environment from the use and release of tain and remove mercury.
212 CHAPTER 10 Dental Amalgam

SUMMARY Patient education is an essential role of the dental

auxiliary in the dental practice. The ability to describe
Dental amalgam is a widely used restorative mate- the pros and cons of the various materials used in prac-
rial. Amalgam is an economical, durable, and useful tice to the patient and the ability to aid in the treatment
restorative material, although composite resins have process depends on your knowledge of these materials.
surpassed amalgam in popularity. Dental auxiliaries As new materials are introduced into dental practice,
play an important role in the delivery of amalgam res- it is important to stay current about their indications,
torations to patients by assisting the dentist or, in some contraindications, and application techniques. Manu-
states when properly licensed, the placement, carving, facturers’ instructions for their care and use should also
and finishing and polishing of the amalgams. Knowl- be followed. Many manufacturers have websites on
edge of the physical properties, mixing and placement which they post information relative to their materials.
techniques, and finishing and polishing methods is
important for the proper handling of amalgam and
ultimately the longevity of restorations. Safe mercury
INSTRUCTIONAL VIDEOS
hygiene practices in the workplace are essential to the See the Evolve Resources site for a variety of educa-
health and well-being of patients, office staff, and to tional videos that reinforce the material covered in this
the environment in general. chapter.

Procedure 10.1 Placing and Carving Class II Amalgam

See Evolve site for Competency Sheet. NOTE: After placement, the band should be bur-
nished against the adjacent tooth with an interproxi-
EQUIPMENT/SUPPLIES (Fig. 10.21) mal burnisher or the blade of a plastic instrument to
create the proper contour of the contact area.
a. Local anesthesia setup
The band should:
b. Operative dentistry setup: Assorted burs,
(a) be sealed against the tooth at the gingival
excavators, hand-cutting instruments
margin by the wedge
c. Amalgam placement setup: Amalgam carrier and
(b) extend approximately 1 mm coronal to the level
well, large and small condensers, ball burnisher;
of the marginal ridge
coronal and interproximal carvers; matrix retainer,
(c) be in contact with the proximal surface of the
pre-burnished bands, wedges; articulating paper
adjacent tooth
and holder and dental floss
The wedge should:
d. Encapsulated amalgam alloy and mercury
(a) press the band against the tooth to seal the
e. Dental dam setup
gingival margin
f. Disposables: Gauze, cotton pellets, high-volume
(b) create a separation of the teeth to make up for the
evacuation (HVE) tip, air-water syringe tip
thickness of the matrix band so an open contact
PROCEDURE STEPS is not formed when the band is removed
2. Place a base, liner, or cavity varnish, as needed.
1. After the administration of local anesthetic,
NOTE: Copal resin is seldom used as a cavity var-
application of the dental dam, and preparation
nish, because it quickly washes out of the prepara-
of the cavity, place the preassembled Tofflemire
tion. Some offices have replaced it with dentin sealers
matrix band and retainer on the tooth and firmly
or bonding agents that occlude the dentinal tubules.
insert the wedge in the interproximal space from
At present, bases and liners are used less frequently
the lingual side (Fig. 10.22).
and are applied mostly in deeper cavity preparations,
 Dental Amalgam CHAPTER 10 213

Procedure 10.1 Placing and Carving Class II Amalgam—cont’d

FIG. 10.21

FIG. 10.22 FIG. 10.23

because the need for their use has not been established
on a routine basis. Deeper preparations may need a
base or liner for thermal insulation.
3. After the base or liner has set, activate the
amalgam capsule (unless it is self-activating), place
it into the arms of the triturator, and set for the
recommended time and speed (Fig. 10.23).
4. Mix the amalgam, open the capsule, and place the
mixed amalgam in the amalgam well (Fig. 10.24).
5. Fill both ends of the amalgam carrier and place the
amalgam in the proximal box from the small end
first (Fig. 10.25).
NOTE: Some clinicians who use spherical al-
loy prefer to place the amalgam in large increments
and quickly condense it into the cavity preparation. FIG. 10.24
Continued
214 CHAPTER 10 Dental Amalgam

Procedure 10.1 Placing and Carving Class II Amalgam—cont’d

Spherical amalgam requires much less condensation its surface and margins (Fig. 10.26). Some clinicians
pressure and displaces easily into the preparation as use an anatomic burnisher (e.g., acorn burnisher) to
compared with an admixed amalgam. begin the initial contour of the occlusal morphology.
6. Continue to fill the preparation with amalgam. NOTE: Burnishing creates a denser surface, adapts
Mix additional amalgam as needed to complete the the amalgam closely to the margins, and brings excess
restoration. mercury to the surface that is then carved away. Not all
NOTE:. Usually, the smaller end of the condenser is clinicians burnish their amalgams.
used first to condense amalgam onto the gingival floor 8. An explorer tip is used to carve excess amalgam
of the box and against the facial and lingual walls. Both away from the band and to begin shaping the
vertical and lateral condensation forces should be used marginal ridge (Fig. 10.27). A discoid carver is used to
to adapt the amalgam to the preparation. remove large excesses of amalgam from the occlusal
7. After the preparation has been slightly overfilled, the surface.
amalgam is burnished with the ball burnisher over

FIG. 10.25

FIG. 10.26
 Dental Amalgam CHAPTER 10 215

Procedure 10.1 Placing and Carving Class II Amalgam—cont’d

NOTE: Removing excess amalgam adjacent to the 10. An interproximal carver (e.g., 1/2 Hollenbeck)
band helps prevent fracture of the amalgam during re- is used to carve first the gingival margin, then
moval of the band. facial and lingual margins to remove any excess
9. Remove the matrix retainer. While holding the material (Fig. 10.29). Next, a discoid/cleoid
marginal ridge of the amalgam restoration down or similar carver is used to carve the occlusal
with a large condenser, remove the matrix band in surface (Fig. 10.30). The blade of the carver is held
an occlusal direction with a gentle rocking motion partially on the adjacent enamel to act as a guide
(Fig. 10.28). so that the amalgam margins are not overcarved.
NOTE: Some clinicians prefer to leave the wedge 11. After the amalgam is firm, pass dental floss
in place while removing the band to maintain some through the contact to clear the embrasure of
separation of the teeth. This helps to minimize risk of excess carving debris and to test the adequacy of
fracture of the marginal ridge. If the marginal ridge is the contact relationship (Fig. 10.31).
not held down during removal of the band, the unset NOTE: A weak, open, or poorly contoured contact
amalgam is at risk of fracture, requiring its removal relationship with the adjacent tooth can lead to food
and placement of fresh amalgam. impaction into the gingival tissues and periodontal
pocket formation.
12. Remove the dental dam and mark the occlusal
contacts with articulating paper (Fig. 10.32).
High spots as indicated by heavy marks from
the articulating paper are carefully carved
away. Repeat the process until contact is no
longer heavy and the patient indicates that the
restoration does not feel high. As a last step, some
clinicians smooth the surface of the amalgam with
a wet cotton pellet.
NOTE: Before checking the occlusal contacts make
sure the marginal ridges of the amalgam are at the
same level as the ridges of the adjacent teeth. The pa-
tient should be instructed to close very lightly and
then open again. If the patient closes too firmly and
the amalgam is high, especially at the marginal ridge,
it might fracture. When patients are still numb from
the local anesthetic, they often cannot judge how
hard they are biting. Some clinicians prefer to wait a
FIG. 10.27 couple of minutes after completing the carving before

FIG. 10.28
Continued
216 CHAPTER 10 Dental Amalgam

Procedure 10.1 Placing and Carving Class II Amalgam—cont’d

FIG. 10.29

FIG. 10.30

FIG. 10.31
 Dental Amalgam CHAPTER 10 217

Procedure 10.1 Placing and Carving Class II Amalgam—cont’d

In some states, dental hygienists and assistants li-

censed in expanded functions can place, condense,
and carve the amalgam.
13. Instruct the patient to avoid chewing on the new
amalgam restoration until the next day. Advise
the patient to take care while they are still numb
from the anesthetic when chewing or consuming
hot foods or beverages due to the risk of biting
the lip or tongue or burning the oral tissues or
throat.
NOTE: High-copper amalgams, especially spheri-
cal ones, have a high early strength and gain about
80% of their compressive strength in the first 8 hours.
FIG. 10.32
The set is usually complete within 24 hours.

checking the occlusal contacts to allow the amal-

gam to gain some firmness, especially for very large
amalgams.
218 CHAPTER 10 Dental Amalgam

Get Ready for Exams!

Review Questions c. It is easy to manipulate

d. All of the above
Select the one correct response for each of the following
10. For best mercury hygiene practices, which type of floor-
multiple-choice questions.
ing is preferred for the dental operatory?
1. In an amalgam restoration, which of the following ele- a. Hardwood plank flooring
ments has the greatest effect on reduction of corrosion? b. Ceramic tile
a. Silver (Ag) c. Seamless vinyl
b. Mercury (Hg) d. Tight-knit carpet
c. Copper (Cu)
11. How does tarnish differ from corrosion?
d. Indium
a. Tarnish occurs only on the surface.
2. In the amalgam restoration, the two main components b. Tarnish is more harmful to the restoration than is
are corrosion.
a. Silver and copper c. Tarnish contributes to the destructive effects seen in
b. Copper and tin the gamma-2 phase.
c. Silver and mercury d. Tarnish cannot be removed by polishing, whereas
d. Mercury and zinc corrosion can.
3. Why should all remnants of amalgam be removed from 12. Which one of the following amalgam mixes has the least
the placement instruments before they are autoclaved? resistance to condensation pressure?
a. The steam causes the amalgam to fuse to the stain- a. Lathe-cut low-copper
less steel. b. Spherical high-copper
b. Amalgam corrosion products produced by the steam c. Admix high-copper
are toxic. d. Lathe-cut high-copper
c. The heat causes mercury vapor to be released from
13. Delayed expansion of amalgam is caused by contact of
the amalgam.
water with which component of amalgam?
d. The heat melts the silver component, and it will clog
a. Mercury
the drain of the autoclave.
b. Copper
4. The strength of the amalgam restoration can be affected by c. Tin
a. Overtrituration d. Zinc
b. Undertrituration
14. Polishing of amalgam should be done
c. Corrosion
a. With light pressure, using water as a coolant
d. All of the above
b. With rubber abrasive points without water
5. A properly mixed amalgam should appear c. Immediately after carving
a. Dry and crumbly d. With heavy pressure, using pumice in a rubber cup
b. Soupy and shiny
15. Amalgam is strongest in which one of the following?
c. As a homogeneous mass with a slight shine
a. Tension
d. Liquid-like and should pour easily out of the capsule
b. Shear
6. Scrap amalgam should be c. Compression
a. Autoclaved before it is sent to the recycler d. Torsion
b. Thrown into the incinerator
16. All of the following features meet the criteria for a well
c. Stored in a sealed container
placed matrix assembly except one. Which one?
d. Put into the general nonmedical waste
a. The narrow portion of the band is oriented toward
7. With high-copper alloys, which metal reacts with copper the gingival margin.
to reduce gamma-2 phase corrosion? b. Matrix band extends apical to gingival margin of
a. Tin proximal box by at least 1 mm.
b. Zinc c. No gap is present between the band and the gingival
c. Silver margin of the proximal box.
d. Palladium d. Top edge of the band extends 3 mm above the adja-
8. The fact that mercury makes up almost half of amalgam cent marginal ridge.
has caused concerns about 17. Which one of the following statements does NOT fit
a. Its safety for patient use the criteria of a well placed wedge for a Class II cavity
b. Risks to the office staff preparation matrix assembly?
c. Environmental effects of improper disposal of amal- a. The wedge is located just coronal to the gingival
gam waste margin of the proximal box.
d. All of the above b. The wedge does not deform the contours of the
9. Amalgam has been popular for the restoration of cari- matrix band.
ous teeth because c. The wedge is seated firmly to produce separation of
a. It is economical the teeth.
b. It has excellent physical properties
 Dental Amalgam CHAPTER 10 219

d. T he wedge holds the band against the gingival mar- amalgams must be removed because they contain mer-
gin of the proximal box. cury. She asks you about the safety of amalgam fillings.
18. The dental staff is most at risk for mercury overexpo- Discuss the safety issues related to amalgam, its mercury
sure from which one of the following sources? content, and the risks involved in removing the restorations.
a. Inhaling mercury vapor 3. You have just triturated a double mix capsule of amal-
b. Handling amalgam with gloved hands gam, and mercury has leaked while the capsule was
c. Triturating commerically prepared capsules of being shaken and can be seen in small puddles on the
amalgam outer surface of the triturator.
d. Polishing amalgam under water spray Discuss appropriate ways to capture the spilled mercury and
For answers to Review Questions, see the Appendix. dispose of it. What risks does the spill present to the office
staff?
Case-Based Discussion Topics 4. While removing the matrix band from a newly placed
MOD amalgam on tooth #19, the mesial marginal ridge
1. A healthy 23-year-old college student reports to the den- of the amalgam fractured off.
tal office for a routine examination. It is discovered that Can this fracture be fixed by replacing the matrix band and
she has several class II carious lesions in her molars that adding more amalgam from a fresh mix? Why or why not?
require restoration. She does not have a lot of money What steps can be taken to avoid the marginal ridge fracture
and wants a durable restoration. She is not concerned when removing the band?
about whether the restorations show when she speaks. 5. A 36-year-old nurse had an MO amalgam placed on a
Discuss the advantages and disadvantages of amalgam and moderately deep cavity preparation in tooth #3. When
composite resin for her situation. Which would you choose she drinks hot coffee or eats ice cream she gets a sud-
for yourself? Why? den sharp pain in the tooth that lasts 2 to 3 seconds.
2. A 43-year-old housewife comes to the dental office and What is the likely cause of the pain? How could this problem
reports that another dentist has told her that all of her old have been prevented?

BIBLIOGRAPHY Marshall GW, Marshall SJ, Bayne SC: Restorative dental materi-
als: Scanning electron microscopy and x-ray microanalysis,
ADA Council on Scientific Affairs: Dental mercury hygiene rec- Scanning Microsc, 2:2007–2028, 1988.
ommendations, J Am Dent Assoc, 134:1498–1499, 2003. Office of Environmental Health Hazard Assessment: Mercury in
American Dental Association (ADA): Amalgam Waste Best Man- Dental Amalgam Fillings. State of California, March 2016. Oeh
agement, Available at ada.org/-/media/ADA/Member% ha.ca.gov/media/downloads/proposition-65/chemicals/
20Center/Files/topics_amalgamwaste_brochure.ashx, 2007. mercurydentalamalgamfactsheet.pdf.
Anusavice KJ, Shen C, Rawls HR: Dental amalgams. In Phillips’ Powers JM, Wataha JC: Dental amalgam. In Dental Materials: Foun-
Science of Dental Materials, ed 12, Philadelphia, 2013, Saun- dations and Applications, ed 11, St. Louis, 2017, Elsevier.
ders, p 2013. Sakaguchi RL, Powers JM: Restorative materials – metals. In Craig’s
Bird DL, Robinson DS: Restorative and esthetic dental materials. Restorative Dental Materials, ed 13, Philadelphia, 2012, Mosby.
In Modern Dental Assisting, ed 12, Philadelphia, 2018, Saunders. Stafford G: The Environmentally Responsible Dentist—Dental
DermNet NZ: Lichenoid Amalgam Reaction, Available at: Amalgam Recycling: Principles, Pathways and Practice, July
http://dermnetnz.org/reactions/amalgam-lichenoid.html, 2011. Available at: https://www.researchgate.net/publicatio
2010. n/263370547_The_Environmentally_Responsible_Dentist_-_
Eakle WS, Staninec M, Lacy AM: Effect of bonded amalgam on Dental_Amalgam_Recycling_Principles_Pathways_and_Pra
the fracture resistance of teeth, J Pros Dent, 69(2):257–260, 1992. ctice.
European Commission, Department of Health and Food Safety: Fi- U.S. Department of Health and Human Services: Public Health
nal Opinion on Dental Amalgam, https://ec.europa.eu/health/ Service (DHHS/PHS): Dental Amalgam: A Scientific Review
scientific_committees/consultations/public_consultations/ and Recommended Public Health Service Strategy for Research,
scenihr_consultation_24_en, 2014. Educa­tion and Regulation, Washington DC: DHHS/PHS, 1993.
Heyman HO, Swift EJ, Ritter AV: Class I, II and VI Amalgam Resto­ https://health.gov/environment/amalgam1/ct.htm
rations in Sturdevant’s Art and Science of Operative Dentistry, ed U.S. Department of Labor, Occupational Safety and Health Ad-
6, St. Louis, 2013, Mosby. ministration. Permissible Exposure Limits. Annotated OSHA Z-2
Life Sciences Research Office: Executive Summary: Review and Table, December 19, 2016. https://www.osha.gov/dsg/anno
Analysis of the Literature on the Health Effects of Dental Amal­ tated-pels/tablez-2.html
gam, Available at: http://www.lsro.org/presentation_files/ U.S. Food and Drug Administration. About Dental Amalgam Fill-
amalgam/amalgam_execsum.pdf. ings, Updated 1/27/2015. Fda.gov/MedicalDevices/­Product
Mackey TM, Contreras JT, Liang BA: The Minamata Convention sandMedicalProcedures/DentalProducts/DentalAmalgam/
on Mercury: attempting to address the global controversy of ucm171094.htm.
dental amalgam use and mercury waste disposal, Science of Xu HH, Eichmiller FC, Giuseppetti AA, et al.: Three-body wear
the Total Environment, 472:125–129, 2014. of a hand-consolidated silver alternative to amalgam, J Dent
Res, 78:1560–1567, 1999.
11 Metals and Alloys

http://evolve.elsevier.com/Eakle/materials/

Chapter Objectives
Upon completion of this chapter, the student should be able to:
1. Describe the differences among the types of gold alloy 6. E xplain how solders are used.
used for dental restorations. 7. List metals used for solders.
2. Differentiate between high-noble, noble, and base-metal 8. Describe how wrought metal alloys differ from casting
alloys. alloys.
3. Describe the properties needed for porcelain bonding 9. Describe the uses of wrought wire.
alloys. 10. Explain the use of the different types of metal for
4. Describe the properties of metals used for casting partial orthodontic arch wire.
denture frameworks. 11. Explain the purpose of an endodontic post.
5. Explain the biocompatibility issues associated with some 12. Describe the types of materials used for preformed
alloys. endodontic posts.

Key Terms
Alloy a solid compound made up of two or more elements of Glazing firing porcelain at high temperature to achieve a
which at least one is a metal smooth, shiny surface
High-Noble Alloy alloy containing at least 60% noble met- Sintering a process whereby particles are heated to the
als, 40% of which must be gold point that they fuse together at their borders but do not
Base-Metal Alloy alloy composed of non-noble metals clump into one solid mass
which corrode more readily Yield Strength amount of stress at which a substance
Noble Alloy alloy composed of metals that do not corrode deforms
readily; at least 25% must be noble metals Solder an alloy used to join two metals together or to repair
Precious Metal classification of metal based on its high cost cast metal restorations
Elastic Modulus a measure of the stiffness of a material. A Wrought Metal Alloy an alloy that has been mechanically
high modulus indicates a stiff material and a low modulus a changed into another form to improve its properties
more flexible one (including ductility and malleability)
Porcelain Bonding Alloys special casting alloys manufac- Anneal to modify physical properties of a metal by heating it
tured for their compatibility with porcelain that is bonded to Nitinol an alloy of nickel and titanium often used for orth-
them at high temperature odontic wires
Coping a thin covering like a thimble that serves as a sub- Gauge a measure of the thickness of a wire; the lower the
structure for a porcelain-bonded-to-metal crown (in this gauge, the thicker the wire (e.g., 8 gauge is thicker than 16
case, the coping is metal) gauge)
Firing a process of heating porcelain powders at high tem- Endodontic Post a metal or nonmetal dowel placed within
perature until they fuse the root canal to retain a core buildup
  

Historically, the most widely used material in restorative is malleable and ductile and the margins of gold restorations
and corrective dentistry has been metal. Because a pure can be burnished for better adaptation to the tooth prepa-
metal may not possess the physical and mechanical proper- ration margins. As esthetic nonmetal materials improve in
ties desired for a restoration, it may be combined with one their physical properties, they are gradually replacing metals
or more other elements to form an alloy with the properties in many applications.
desired. Metal alloys generally have high strength and con- The dental health care worker (clinical or laboratory) is
sequently make durable dental restorations. They melt at in contact with and involved in the manipulation of metal
high temperatures, conduct temperature and electricity, can dental materials in various ways every day. Grinding dust
be polished to a high shine (luster), and have varying degrees from certain metal alloys can present the dental health
of ductility (ability to be pulled or drawn into a wire). Gold care worker with health hazards, so personal protective
220
 Metals and Alloys CHAPTER 11 221

Electrons (negative ions)

Metallic lattice

Positive ions form the

crystal lattice, while
delocalized electrons
move freely throughout
the lattice, gluing the
whole lattice together. Protons (positive ions)
FIG. 11.1 Representation of a crystal lattice structure of a metal. A sea of free electrons in the outer shell are shared
among all of atoms. (Modified from HSC Physics, Dux College.)

equipment must be used. It is essential that the dental aux- the manner in which steel is heated and cooled can
iliary have an understanding of the properties of various increase its hardness but can also make it more brittle.
metal materials in order to correctly manipulate and care
for them and to be able to answer questions by patients All-Metal Casting Alloys
relative to a particular material that will be used for their In the early 1900s, W.H. Taggart developed a technique
treatment. for making dental restorations from metal that was
melted and cast into a mold, using the lost wax tech-
STRUCTURE OF METALS AND ALLOYS nique (see Chapter 16 Gypsum and Wax Products). A
variation of this technique with improved equipment
PURE METALS is still used today for casting metal dental restorations.
Pure metals are composed of multiple small inter- Pure metals are seldom used in dentistry, because
locking crystals (also called grains) arranged in a they lack properties that make them useful in the oral
highly ordered, three dimensional structure called cavity. Therefore, they are usually combined with other
a lattice (Fig. 11.1). There are fourteen types of lat- metals or nonmetal materials in portions that achieve
tice arrangements found in metals. Each crystal is desirable physical and mechanical properties. Alloys
composed of multiple, closely packed metal ions sur- used with the lost wax technique are called dental cast-
rounded by a sea of free electrons in the outer shell ing alloys. Unlike amalgam, restorations made from
that are shared among all of the atoms. The force of these alloys are not placed directly into the preparation
attraction between the metal ions and the electrons but are made outside the mouth by an indirect tech-
circulating among them forms the metallic bond. nique, and then are cemented in place (see Chapter 6
The metallic bond is very strong, helps the metal to Composites, Glass Ionomers, and Compomers and
maintain a regular shape, and is responsible for the Chapter 14 Dental Cement). Cast metal restorations
physical properties of the metal. These physical prop- can be classified as intracoronal (preparation is made
erties include high melting and boiling points, high within the crown of the tooth) or extracoronal (prepa-
strength, ductility, malleability, thermal and electri- ration is made primarily on the outside of the crown
cal conductivity, high density, hardness, opacity, and of the tooth). An inlay is an intracoronal restoration,
luster. whereas an onlay has both intracoronal and extra-
coronal components in that it has an inlay preparation
ALLOYS
and also covers the outer surface of one or more cusps
Since most pure metals lack the properties desired for (Fig. 11.2). Other extracoronal cast restorations include
dental uses, they are combined with other metals or partial coverage (¾ and ⅞ crowns) and full coverage
nonmetal elements to form an alloy. Alloys are formed crowns (Fig. 11.3). Cast metal alloys can also be used to
by melting the metal and added elements, mixing make fixed partial dentures (bridges) and removable
them together and then cooling them back into a solid. partial dentures for replacement of missing teeth.
Alloys typically have higher strength and hardness The International Organization for Standardization
than pure metals. Instead of a melting point like pure (ISO) sets specifications for casting alloys; these can be
metals, alloys have a melting range determined by its found at its website (www.iso.org). Dental casting al-
different components. loys can also be classified by their use:
Both pure metals and their alloys are crystalline sol- • All-metal alloys for crown and bridge
ids. The properties that are desired for dental uses can be • Ceramo-metal alloys (porcelain fused to metal) for
controlled by the changes to the crystalline structure that crown and bridge
occur when they are processed or heated, for example, • All-metal alloys for removable partial dentures
222 CHAPTER 11 Metals and Alloys

TABLE 11.1    Classification of Gold Alloys

CHARACTER­
ISTIC CLASS I CLASS II CLASS III CLASS IV
Hardness Soft Medium Hard Extra hard
Use Inlays Inlays, Inlays, Partial
(not in crowns crowns, denture
heavy bridges frame-
func- work,
tion) bridges
Yield strength Low Medium High High
(amount of
stress at
which alloy
deforms)
FIG. 11.2 Inlay (blue arrow) and onlay using high-noble metal (gold Wear resis- Low Medium High High
alloy). (Courtesy of Richard V. Tucker, Department of Restorative Den- tance
tistry, University of Washington [Seattle, WA].)

As an example, pure gold is 24 karat, 100%, or 1000

fine, and half gold is 12 karat, 50%, or 500 fine. The
term karat is used more to signify the gold content of
jewelry than dental alloys. Pure gold has limited use
in dentistry today but is used in the form of gold foil
by a small number of dentists for direct-placement
restorations. Pure gold is too soft to use for dental
castings; however, gold alloys have excellent proper-
ties and handling characteristics.
The American Dental Association classifies dental
casting alloys according to their noble metal content
and divides them into three categories: high-noble,
noble, and base-metal alloys. To be considered a high-
noble alloy, they must contain at least 60% noble ele-
ments (gold, palladium, and platinum), of which 40%
must be gold. Base metals (usually copper, silver, or
gallium) make up the remaining 40%. Noble alloys con-
tain at least 25% noble elements with no requirement
for gold, and the remaining 75% consists of base met-
als. Base-metal alloys have no requirement for gold
and require less than 25% by weight of noble metals.
Dental gold casting alloys can also be classified (Ta-
ble 11.1) by their
• Hardness (resistance to penetration)
• Malleability (ability to be shaped, as by tapping or
pounding)
FIG. 11.3 Partial and full coverage cast gold restorations. (Courtesy of • Ductility (ability to be elongated, as by stretching or
David Graham, University of California, San Francisco [San Francisco, pulling)
CA].)
The more ductile the alloy, the more the margins can
be burnished (pushing or pulling the metal at the mar-
Noble Metal Dental Casting Alloys gins to close small gaps between the restoration and
A noble alloy is one that does not tarnish or corrode the tooth). Dental casting alloys should possess the
very readily in the oral environment. Gold (chemi- following properties: strength, resistance to corrosion
cal symbol, Au) is the most corrosion resistant noble and tarnish, melting temperature compatible with in-
metal and has been used in dentistry for centuries. vestment materials (gypsum materials used in the lost
However, its use in dentistry is declining because wax technique of casting to encase the wax pattern, see
of its high cost, and it is not considered esthetic in Chapter 16), thermal expansion compatible with por-
Western cultures. Gold alloy is classified as karats, celains (for porcelain-fused-to-metal restorations), and
percentage, or fineness (obtained by multiplying per- biocompatibility.
centage of gold by 10) according to its gold content.
 Metals and Alloys CHAPTER 11 223

Other Noble Metals for Casting Alloys. Other noble TABLE 11.2    Function of Metals Added to Gold Alloys
metals include platinum (Pt) and palladium (Pd).
METAL MELTING
Platinum is not used much because of its expense,
(SYMBOL) FUNCTION POINT (°C) COLOR
high melting point, and difficulty mixing with gold.
Palladium Reduces corrosion and 1554 White
Palladium is used widely, because it has good corrosion
(Pd) tarnish
resistance, increases hardness of the alloy, and is less Improves mechanical
expensive than gold (however, palladium alloys properties
have greatly increased in price because of shortages
Platinum Raises melting tempera- 1772 Blue-
in the supply of palladium). These noble metals are (Pt) ture white
sometimes referred to as precious metals because of Improves hardness and
their high monetary value. Although silver (Ag) is elasticity
considered to be a precious metal, it is not considered Copper Hardens and strength- 1083.4 Reddish
noble because of its tarnish and corrosion in the oral (Cu) ens the alloy
cavity. Allows heat-treatment
Gold, palladium, and platinum are the noble metals properties
most widely used in dentistry. The remaining four of the Silver (Ag) Hardens gold alloy 961.9 Silver
seven noble metals (rhodium, iridium, ruthenium, and Counters copper’s red-
osmium) are used in very small amounts to enhance the ness
physical properties of a dental alloy. Other metals that Zinc (Zn) Acts as oxygen scav- 419.6 Blue-
may be added to noble metals to enhance their proper- enger during casting white
ties and handling characteristics include copper, silver, process
zinc, tin, indium, gallium, and nickel (Table 11.2). Indium (In) Used as a replacement 156.6 Gray-
for zinc white
Base-Metal Dental Casting Alloys Nickel (Ni) Seldom used. Increases 1453 White
Base-metal dental casting alloys consists of less than hardness and strength
25% noble metals. The most common base-metal alloys Tin (Sn) Acts with palladium and 232 White
are chrome-cobalt and nickel-chrome. It is the chro- platinum to harden the
mium content that gives these metals their corrosion alloy
resistance. Other base metals used in casting alloys are Gallium Forms oxides for bond- 29.8 Gray-
copper (Cu), nickel (Ni), silver (Ag), zinc (Zn), tin (Sn), (Ga) ing ceramic to metal white
and titanium (Ti). Copper and silver are often added to
Iridium (Ir) Improves yield strength 2410 Silver-
gold alloys to increase their hardness. Zinc is added to by creating smaller white
reduce oxidation when the alloy is cast. grains
Because of their low cost, base metals have also been
Ruthe- Improves yield strength 2310 White
called nonprecious metals. They are inexpensive alterna- nium by creating smaller
tives to noble metals for all-metal crowns and porce- (Ru) grains
lain-to-metal crowns. Base metal alloys have about
half the density of gold alloys, making them much
lighter. Although they are not considered to be as good silver-colored alloys. However, this may not be true. It
as the noble metals, the base metals are essential for is possible for a yellow casting alloy to have absolutely
many applications in dentistry. The stiffness (modulus no gold at all! On the other hand, a silver casting alloy
of elasticity) of base alloys is twice as great as that of may have a high gold content. Because beauty is in the
gold-based alloys which makes them useful for remov- eye of the beholder, some patients may prefer the yel-
able partial denture frameworks. low color, whereas others prefer the silver color, and
Drawbacks of base metals include their higher cast- others still prefer no metal showing at all.
ing temperatures that require different equipment and
investing materials than the gold-based alloys and their Melting Range
potential biocompatibility problems. They are much A dental casting alloy, being composed of more than
harder than noble metals, making them difficult to cut one metal, will have a temperature range at which it
and finish. Other base metals used for casting remov- melts rather than a single melting point. The tempera-
able prostheses are discussed later in this chapter (see ture at the start of the range is when the alloy shows
Removable Prosthetic Casting Alloys). an initial shift toward melting and the temperature at
the end of the range represents the point at which the
PROPERTIES OF CASTING ALLOYS entire alloy is liquid. So, an alloy with a range of 1100
Color of Casting Alloys °C to 1300 °C has the first signs of melting at 1100 °C
Most dental casting alloys are either yellow or silver and will be totally melted (called liquidus) at 1300 °C.
(“white”) in color. Often an assumption is made that When cooling a melted metal the temperature at which
yellow casting alloys have a higher gold content than it becomes a solid is called solidus.
224 CHAPTER 11 Metals and Alloys

Elastic Modulus
The elastic modulus is a measure of stiffness of the al-
loy. The higher the elastic modulus of the alloy, the
stiffer the alloy will be. Alloys used for fixed bridge
restorations need to be stiff to avoid bending or dis-
torting. If the crown or bridge has porcelain fused to it,
bending would cause the brittle porcelain to fracture.
Likewise, alloys used for removable partial dentures
need to be stiff so that the framework does not flex too
much and stress the abutment teeth when the patient
chews. Wires used for orthodontic purposes must have
a low elastic modulus to allow them to be bent without
breaking.

Thermal Expansion FIG. 11.4 Chronic gingival inflammation due to allergic reaction to a
metal substructure of the porcelain-fused–to-metal crown. (Courtesy
When a metal is heated, atoms within the metal in- of Dr. Nicole Vane, Encinitas, CA.)
crease in vibration. The result is a small increase in its
length, width, and volume known as thermal expan- resistant to denting or scratching and will be more
sion. How much expansion occurs depends on the difficult to polish. Gold restorations, being softer, will
particular metal. In the case where the metal will be also be kinder to the opposing enamel.
heated to high temperature in order to bake porcelain
on it for a porcelain-fused-to-metal crown, the expan- Crystal Formation (Grains)
sion of the metal must be compatible with the expan- After casting alloys have been melted and cast into the
sion of the porcelain when they are heated. Otherwise, mold, they cool and form crystals (also called grains).
the brittle porcelain will crack. Small crystals produce more desirable properties (es-
pecially improved yield strength) in the metal alloy
Thermal and Electrical Conductivity than large crystals. Some elements such as iridium or
Metals are good conductors of heat and electric- ruthenium are added to gold-based alloys to keep the
ity. Thermal and electrical conductivity is determined crystals from growing too large. Reheating gold-based
mainly by the movement of free electrons throughout alloys (called annealing) can improve some of the prop-
the lattice structure of the metal. Heat excites the tight- erties. After heating, slow cooling produces a harder
ly packed particles in the metal so that their vibrations metal and rapid cooling keeps the metal soft. Howev-
quickly pass from one to the next. Electricity causes er, with base-metal alloys, reheating will degrade the
electrically charged particles—the free electrons—to physical properties.
flow through the lattice structure of the metal.
Resistance to Tarnish and Corrosion
Density It is important that dental casting alloys be composed
Gold and platinum are among the densest (and heavi- of materials that resist tarnish and corrosion in the oral
est) of the metals used in dental casting alloys. On environment. The noble metal alloys naturally resist
the other hand, titanium is less dense and is lighter tarnish and corrosion. Base metal alloys are more likely
in weight. Gold alloys are easier to cast than chrome- to corrode in the mouth, so they are blended with other
cobalt alloys because their weight drives the molten metals such as chromium that make them more corro-
metal into the investment better under casting forces sion resistant.
than the lighter alloys.
BIOCOMPATIBILITY
Strength Noble metals are more biocompatible with the oral tis-
Dental casting alloys must be strong enough to resist sues, because they tend to corrode less than base met-
fracture or distortion. Typically, they are strong in both als. As metals corrode, they release metal corrosion
compression and tension. When the strength of alloys products into the oral cavity. Some of these products
is compared, it is their yield strength that is considered. are responsible for allergic responses (Fig. 11.4). Of the
The yield strength is the stress or force needed to cause base metals, nickel has the highest incidence of allergic
permanent distortion of the alloy. Typically, base-metal response. Women have a higher rate of allergy to nick-
alloys have greater yield strength than gold alloys. el than do men, by a ratio of 10 to 1. A prior exposure
to nickel in jewelry is thought to be the likely source
Hardness of the exposure that sensitizes women to nickel. The
Alloys that have low yield strength (like gold alloys) overall allergy rate to nickel for the general population
will be softer than those with higher yield strength is about 9% to 12%. The allergic response is sometimes
(like base-metal alloys). A hard alloy will be more seen around the free gingival tissues, especially at the
 Metals and Alloys CHAPTER 11 225

margins of base-metal crowns. This is less common for

removable partial dentures because the metal often
is not in direct contact with the tissues, and they are
not worn constantly as fixed partial dentures or single
crowns are worn. Some responses to nickel cause a
skin reaction rather than a response in the mouth, even
though the oral cavity is the source of the nickel.
Beryllium is a base metal added to nickel-chrome al-
loys to reduce the fusion temperature for easier casting
and to improve physical properties by creating smaller
metal crystals when the molten metal cools after cast-
ing. Beryllium is toxic and can cause chronic lung
scarring with difficulty breathing. It can also cause
allergic reactions with skin rashes. Once exposed the
individual is at risk for disease for her lifetime even
FIG. 11.5 Variety of metal alloys used to restore the teeth. Shown are
if exposure is stopped. Laboratory technicians are at gold and base metal alloys and alloys used for porcelain-fused-to-
risk for nickel and beryllium exposure when casting metal crowns. (Courtesy of Steve Eakle, University of California, San
(metal vapors), grinding, and polishing these metals. Francisco [San Francisco, CA].)
In the laboratory an exhaust hood should be used for
grinding procedures and the room should have good temperatures, and therefore they are usually avoided
ventilation. When grinding in the mouth, high-volume for use with ceramic materials. Most of the alloys are
evacuation should be used as well as isolation with a silver (“white”) in color, but alloys that are gold col-
rubber dam where applicable. In addition, dental per- ored (yellow) contain mostly gold with platinum and
sonnel should wear personal protective equipment palladium added to increase the melting temperature.
(PPE) when working with these materials.
PORCELAIN-BONDED-TO-METAL
RESTORATIONS
Caution Preparing the Metal
Inhalation of beryllium is known to contribute to a lung Porcelain-bonded-to-metal (also called porcelain-fused-
disease called berylliosis. All dental personnel should wear to-metal, or PFM) crowns have a metal substructure
PPE when grinding these alloys to prevent inhalation of small (typically 0.3 to 0.5 mm thick) that is covered with lay-
particles and to prevent fine particles from getting into the
ers of porcelain. The metal substructure (also called a
eyes. They should follow Occupational Safety and Health
coping) must be at least 0.3 mm thick to prevent distor-
Administration (OSHA) guidelines for occupational hazards.
tion at high temperatures and must be convex in shape
with no sharp angles. Sharp angles would create stress
areas in the overlying porcelain that would be subject
PORCELAIN BONDING ALLOYS
to fracture. To make room for a thin metal substructure
Porcelain bonding alloys were developed in the late and layers of porcelain that are at least 1.5 mm thick
1950s. They are similar to the other casting alloys with in areas under function, these crowns require a greater
similar physical properties. They are also classified as reduction of the tooth than all-metal crowns. For por-
high-noble, noble, and base-metal alloys (Fig. 11.5). celain to bond to the metal, after the substructure is
However, they have minor changes in their composi- cast it is heated at high temperature to form oxides on
tion that make them compatible with dental ceramic the surface of the metal, a process called degassing (oxi-
materials. The most common ceramic materials used dizing would be a more accurate term).
with these metals are conventional feldspar-based por-
celains (see Chapter 9 Dental Ceramics). The metals in Fusing Porcelain to Metal
porcelain bonding alloys are selected and blended so The first layer of porcelain applied to the metal is
that they have the ability to withstand the high tem- opaque porcelain that keeps the metal oxide color
peratures at which porcelain is fired without melting from showing through and is the main color used for
or distorting. They also have a lower thermal expan- the crown (see Chapter 9, Fig. 9.11). Base metals often
sion than gold alloys used for all-metal crowns, so they form darker oxides that are more difficult to hide with
will not expand too greatly and crack the brittle por- opaque porcelain. The oxidized metal and porcelain
celain that lies over top. In addition, small amounts of are heated (fired) at temperatures ranging from 870 °C
metals such as indium, iron, tin, or gallium are added to 1370 °C, depending on whether the porcelain fuses
to form oxides on the metal surface to which porce- at low, medium, or high temperature. The oxides and
lain will bond (or fuse) at high temperature. Alloys porcelain chemically fuse together and mechanically
that contain silver and copper may cause green stain- interlock. Then additional layers of porcelain called
ing (called greening) of the porcelain when fired at high body and incisal porcelains are built up or stacked to
226 CHAPTER 11 Metals and Alloys

simulate dentin and enamel colors and translucency. difficult to produce, and therefore the laboratories
After final contouring of the crown, another firing that charge more for this service. Another margin configu-
maintains the temperature at the fusing temperature ration is the disappearing metal margin. The metal
for a while will produce a surface glaze (a smooth, at this margin has been ground to a thin, knife-edge
shiny surface created by the glazing process). where it extends to the edge of the preparation mar-
gin. Porcelain is applied over the metal (most of the
Failure Modes metal disappears from view), but a thin dark line of
The metal and porcelain must have compatible rates metal may be visible. Therefore, to hide this metal
of thermal expansion or the porcelain will crack as it line, the preparation of the tooth usually extends be-
and the metal cool. Porcelain manufacturers will indi- low the crest of the marginal gingiva. Over time, the
cate the type of alloy needed for compatibility. Prob- gingiva may recede and expose the dark line of metal.
lems seen clinically with ceramic-alloy crowns are Patients do not like the appearance of this dark line
usually associated with fracture within the porcelain, and may mistake it for dental caries. The dental aux-
where a piece of porcelain breaks off (called debond- iliary may be asked by the patient what is causing
ing) at the metal-porcelain interface, leaving metal that dark line, so it is important to be able to provide
exposed (see Chapter 9, Fig. 9.10). Failure can also an accurate explanation. A third configuration of the
result from formation on the metal surface of an inad- margin of the crown is an all-metal margin or collar.
equate oxide layer, an oxide layer that is too thick, or The all-metal collar is used, because it usually pro-
contamination of the oxide layer. The American Na- vides the best marginal fit, but it is used only in a
tional Standards Institute/American Dental Associa- non-esthetic zone (Fig. 11.6).
tion (ANSI/ADA) Specification #38 sets the standard
for testing the porcelain-metal bond. On occasion, TITANIUM AND ITS ALLOYS
composite resin bonding techniques can repair por- Titanium and its alloys can be used for implant fix-
celain failures, but the repairs are prone to failure of tures, partial denture frameworks, and all-metal and
the bond to porcelain or metal if they are subjected to metal-ceramic crowns and bridges. Titanium and its
chewing pressures. Often the crown needs to be re- alloys have very high melting temperatures (approxi-
placed if the fracture causes an esthetic or functional mately 1670 °C) and require special equipment in or-
issue. In addition to potential fracture problems, PFM der to melt and cast them. They have low density and
crowns can cause accelerated wear of the opposing therefore, are very lightweight and harder to cast into
enamel, where it contacts the porcelain. Low-fusing the investment mold. Casting is done under pressure
porcelains are used more frequently, because they and vacuum or centrifuge and vacuum. Because of
produce less wear of opposing enamel than is pro- the difficulties in casting titanium, some crowns and
duced by medium- or high-fusing porcelains. Once partial denture frameworks are fabricated from metal
the glaze on the surface of the porcelain is disrupted blocks using CAD/CAM techniques.
(e.g., adjusting the bite and not adequately repolish- Titanium and its alloys have a low coefficient of
ing the porcelain) it is rough and very abrasive to the thermal expansion, so they need special low-expan-
opposing teeth. sion porcelains when being used for metal-ceramic
restorations. The most widely used titanium alloy is
Crown Design Ti-6Al-4V (6% aluminum and 4% vanadium). It has
Ceramic-metal crowns can have several different de- high hardness, high strength, and more fatigue resis-
signs based on the esthetic demands of the patient tance than other titanium alloys. However, there are
and the need for maximal strength. In highly esthetic potential health concerns, because it contains alumi-
zones, patients usually do not want any metal to show, num and vanadium that slowly leach from the alloy
so the metal must be covered with porcelain. In parts by way of electrochemical corrosion. The concentra-
of the mouth where esthetics is secondary to the need tion of the metal ions will affect how much toxicity
for maximal strength (as with a maxillary molar or pre- results. Small amounts may cause no discernible prob-
molar), the occlusal surface might be kept in metal and lems. Aluminum ions are known to be more toxic than
the buccal surface covered with porcelain to look like vanadium ions. Pure titanium is less toxic than alumi-
a tooth when the patient smiles. Patients who grind num and vanadium as well as nickel, chromium, and
their teeth are at greater risk of chipping or breaking cobalt.
the porcelain, so they are good candidates for metal oc- Although titanium alloys have good physical and
clusal surfaces when possible. mechanical properties to serve as partial denture
The margins of the crowns can also have different frameworks, their high melting temperature and dif-
configurations. The most esthetic margin is a porce- ficulty in casting them make them harder to work with
lain facial margin. This is achieved by not extending than chrome-cobalt alloys. Surface oxides resulting
the metal substructure all the way to the margin and from casting are more tedious to remove and internal
leaving room to place porcelain to complete the mar- porosities from casting can make the clasps more sus-
gin. These porcelain margins are technically more ceptible to fracture.
 Metals and Alloys CHAPTER 11 227

A B

C
FIG. 11.6 Margin configurations for porcelain-fused-to-metal crowns. A, Porcelain facial margin. B, Disappearing metal
margin seen as a dark line at the margin after gingival recession exposes it. C, All-metal margin (metal collar). (A, Cour-
tesy of Dr. George Freedman. B, Courtesy of Infodentis. C, Courtesy of Marotta Dental Studio.)

SINTERED COMPOSITE ALLOYS commercially available product is the Captek coping

Alloys in this class differ from the casting metal al- (Argen Corporation). It contains 88.2% gold, 9% plati-
loys, because they are formed under high temperature num-group metals, and 2.8% silver. The Captek coping
through a process called sintering. In this process, pow- can be as thin as 50 microns (μm) at the margins and
dered metal is heated and pressed into shapes with therefore requires less tooth reduction compared with
uniform content. Particles of metal alloy, in this case conventional metal-ceramic crowns. Combined coping
gold-palladium-platinum, are distributed in casting and porcelain thickness for anterior crowns can be as
wax. The mixture is placed in an oven and the wax is thin as 0.7 to 1.0 mm and 1.2 mm for posterior crowns.
burned off. The alloy particles are heated to the point
REMOVABLE PROSTHETIC CASTING ALLOYS
that they fuse or sinter together at their points of con-
tact but do not melt into one solid mass. This leaves At one time, type IV gold alloys were the predominate
a mass with lots of spaces between the particles—a metals used for partial denture frameworks. However,
meshwork. This material is hand-pressed onto a re- they became quite expensive as the price of gold in-
fractory die (a die made from special gypsum mate- creased after deregulation of gold prices in 1971. The
rial that can withstand high temperatures) to form the metals used today are mostly base metal alloys with or
first layer of a metal coping (the metal substructure to without minor amounts of noble elements (Fig. 11.8).
which porcelain is added) for a crown. Next, a wax Because the base metals are less dense than gold, they
containing gold-silver alloy particles is put on the first are lighter in weight. These base metals include nick-
sintered alloy mass and is heated to the point that the el, titanium, chromium, aluminum, cobalt, vanadium,
gold-silver alloy melts but the gold-palladium-plati- iron, beryllium, molybdenum, gallium, and carbon. In
num alloy does not (it has a higher melting point). The addition to corrosion resistance, hardness and resis-
second alloy melts, flows into, and fills by capillary ac- tance to deformation under function (yield strength) are
tion the spaces of the first meshwork. This produces a important properties for these metals. Hardness indi-
composite of the two alloys that serves as the coping or cates their resistance to scratching and denting and the
substructure for a porcelain-to-metal crown or bridge. increased effort needed to polish them. Their resistance
To get the porcelain to bond to the alloy, it is necessary to deformation is especially important for use in partial
to apply yet another alloy to the composite alloy to al- denture frameworks, where flexing of the framework
low the development of a ceramic-alloy fusion zone would put undue stress on abutment teeth. Base metal
rather than an oxide-porcelain fusion. The fusion zone alloys used for partial denture frameworks should also
allows porcelain to melt and mechanically bond to the be resistant to fatigue, so that repeated flexing of the
metal surface rather than undergo chemical fusion to clasp arms as the partial denture is seated and removed
an oxide layer as with traditional alloys (Fig. 11.7). A does not cause them to break off. Cobalt-chromium
228 CHAPTER 11 Metals and Alloys

B
FIG. 11.7 Sintered alloy composite. A, A traditional porcelain-fused-
to-metal crown on the left includes dark oxidized metal that must be
covered with opaque porcelain. The Captek crown on the right with
the sintered alloy has a gold color that does not require the opaquing
needed for the traditional crown. B, Fixed partial denture (bridge) made B
with a sintered alloy substructure. (Courtesy of Argen Corporation, San
Diego, CA.) FIG. 11.8 Chrome-cobalt metal framework for a removable partial den-
ture. A, Framework on the cast. B, The completed partial denture in
alloys are the most resistant to this type of fatigue and the mouth after processing of acrylic and teeth over the retentive area.
(Courtesy of Mark Dellinges, University of California School of Dentistry
most commonly used for partial denture frameworks.
[San Francisco, CA].)
Because these metals are among the hardest of the
alloys and are quite difficult to cast, they require spe-
cial casting machines and are cast by commercial den-
tal laboratories. Other metals may be used for attach-
ments for prostheses, such as attachment bars between
tooth abutments (see Chapter 12 Dental Implants, Fig.
12.15), overdenture attachments, and precision and
nonprecision attachments for partial dentures. These
attachments are made from high-noble, noble, or base
metals. Attachments are used more frequently with the
increasing use of combinations of implants and remov-
able partial or complete denture combinations.

Cautiion
Patients should be advised not to soak their appliances with
metal components in household bleach. It will attack and FIG. 11.9 IdentAlloy certificate that indicates the components of the
metals used. (Courtesy of the IdentAlloy/IdentCeram Council.)
corrode the metal.

laboratory and the dentist can have a copy. Benefits of

IDENTALLOY PROGRAM this program include the following: assurance the al-
Manufacturers of dental alloys have developed a pro- loy meets the ADA classification criteria; provision of
gram that certifies the content of the alloys they pro- a record for the laboratory in case the U.S. Food and
duce. A certificate (IdentAlloy) is provided for each Drug Administration (FDA) has a recall, the dentist
alloy (Fig. 11.9). It lists the manufacturer, name of the has questions, or future repairs are needed; insurance
alloy, composition, and the ADA classification and is claims documentation and documentation in the pa-
color-coded based on the noble metal content. The cer- tient’s record concerning what was used in case the
tificate is provided with a duplicate, so that both the patient has an allergic reaction to the alloy.
 Metals and Alloys CHAPTER 11 229

SOLDERS
Metals are joined by three processes:
1. Soldering
2. Brazing
3. Welding
Soldering and brazing are similar and use a molten
filler metal to join two other metals together. The differ-
ence between soldering and brazing is the temperature
at which the procedure is completed. Soldering is per-
formed at temperatures below 450 °C and brazing is done
at temperatures above 450 °C. Because the term soldering
is the one most commonly used, we use it here to dis-
cuss both soldering and brazing. Welding, on the other
hand, is a process that uses high heat to fuse two metals
together where they contact each other without the use
of a filler metal. At one time custom matrix bands were
made by spot welding two ends of a strip of matrix band
material together by a device using electrical resistance.
FIG. 11.10 An arch expander unit is attached to a metal orthodontic
GOLD SOLDERS band with silver solder. (Courtesy of Royal Dent.)

Solders are used to join metals together or repair cast

restorations. Solders used for crown and bridgework Soldering of units of porcelain-fused-to-metal is much
are generally gold-based alloys, because they are more challenging, because the ceramic and the metal alloy
used with gold alloys that make up the crowns. They have different melting temperatures, and uneven heating
generally contain gold, silver, and copper with small of the unit can cause the porcelain to crack. Often solder-
portions of zinc and tin. Gold-based solders are used ing of PFM units is done in a special furnace where the
to join together units of a bridge, add contacts, close temperature can be better controlled than with a torch.
holes ground in the occlusal surface by adjusting the
bite, or correct small marginal deficiencies on onlays SILVER SOLDERS
and crowns when they are found to be deficient at the Silver-based solders are used more often in ortho-
try-in appointment. Gold-based solder is often catego- dontics and pediatric dentistry to solder fixed-space
rized according to its fineness. The higher the fineness maintainer components (e.g., wire loop soldered to
number, the higher the gold content and the lower the an orthodontic band) and to solder wire components
melting point of the solder. to removable and fixed orthodontic appliances (Fig.
Gold solders are available with different melting 11.10). These solders contain varying amounts of sil-
ranges (690 °C to 870 °C), depending on their composi- ver, copper, and zinc and small amounts of tin which
tion, to accommodate the melting ranges of the gold lowers the melting temperature and improves the flow
alloys to which they will be soldered. This is impor- of the molten metal. Silver solder is selected because
tant when two gold castings are soldered together or it melts at a lower temperature (620 °C to 700 °C) than
when a contact is added to a gold crown, because the gold solder. The higher heat required to melt gold sol-
solder must melt before the casting. Tin is often add- der, which is greater than that for silver solder, some-
ed to the solders to lower the melting range. To sol- times will degrade the wire adjacent to the solder joint
der two units of a bridge together, they first must be and weaken it. Flux for nongold alloys usually is a po-
invested in a special gypsum soldering investment in tassium fluoride flux.
the proper relationship to each other (see Chapter 16).
A flux is applied to the alloy surfaces to be soldered.
The flux removes surface oxides so that the solder will WROUGHT METAL ALLOYS
flow freely and will wet the alloy surfaces as it melts. Wrought metal alloys are different from casting alloys
Flux for gold alloys usually contains borax. The alloys in that they are formed after the metal is cast. Usually
are heated with a torch until they turn red. The solder the metal is drawn or extruded through a die or formed
is added and heated until it melts and flows over the in a press to the desired shape, such as a flat plate or a
exposed surfaces of the bridge units. Often a contact wire or a knife or other instrument shape (Fig. 11.11).
can be added to a single crown without investing it by So, wrought alloys are alloys that have been mechani-
holding it over a Bunsen burner. Graphite from a pen- cally changed into another form. The result is an alloy
cil “lead” can be used to outline the limits of the con- that is harder and has greater yield strength (the point
tact area to be soldered. It acts as an antiflux to prevent at which a force can create permanent deformation of
the solder from flowing too far over the surface. the metal). Wrought metal has the characteristic of being
230 CHAPTER 11 Metals and Alloys

Wrought
wire

Hard tungsten
carbide rollers Metal slab

FIG. 11.11 Wrought wire is formed from a slab or thick rod of metal (A) by pulling it through a hard metal die or (B) forcing
it through rollers.

able to be heat-modified, or annealed, to create differ- more esthetic alternatives are available, they are no
ing resistance to deformity. However, overheating can longer used much for anterior teeth. These crowns are
degrade the properties of the metal. thin and flexible to fit over minimally prepared teeth.
They have applications in pediatric dentistry when
Wire trying to protect a primary tooth until it exfoliates or
Wire is a wrought metal that may be soft and easily on an abutment for a fixed space maintainer. Applica-
shaped or may resist bending as does a spring. Vari- tions for these durable stainless steel crowns also in-
ous degrees of resistance to bending can be created clude primary teeth following pulpotomy or pulpecto-
by annealing. Wrought metal is used in removable my, caries involving multiple surfaces where amalgam
prosthetic appliances, primarily for clasps. It can be would not hold up, or fractured teeth. They are also
a base metal such as stainless steel or a high-noble used for adults to protect a tooth when the patient can-
alloy composed of platinum-gold-palladium (called not afford a cast metal crown.
PGP wire). Additional examples of wrought wire used
in dentistry include archwires and ligature (tie) wires METALS USED IN ORTHODONTICS
used in orthodontics and arch bars and ligature wires
used in oral surgery for stabilization of a jaw fracture. WIRES
Orthodontic wires are composed mostly of base met-
Stainless Alloys als. They are also wrought metal alloys commonly
Steel is made from iron to which a small amount of made of stainless steel, cobalt-chrome-nickel, titanium,
carbon has been added. Stainless steel is steel to which or an alloy of nickel and titanium. Of these metal al-
chromium (12% or more) has been added to reduce loys, stainless steel is the most commonly used in or-
tarnish and corrosion. Chromium acts by forming a thodontics and is easily bent by the dentist.
very thin and transparent protective layer of oxides Special characteristics are manufactured into these
on the steel when it is in contact with oxygen. If this archwires to create the desired amount of resistance to
protective layer is scraped off inadvertently, corrosion deformity. Resistance to deformity creates “memory” in
can occur. In the oral cavity, this usually is not an is- the wire so that it tries to reassume its original shape. It is
sue, because the applications for stainless steel are of- the “memory” that exerts the forces that move the teeth.
ten limited in the length of time they are used (e.g., Nickel-titanium (NiTi) alloy was developed in
use of endodontic files or archwires for orthodontics). 1963 by Buehler who was a space program metallur-
Other metals such as molybdenum and nickel may gist. It is called nitinol as an acronym for nickel tita-
also be added to stainless steel to improve its physical nium Naval Ordinance Laboratory where it was de-
and mechanical properties. Because of their low cost, veloped. It was introduced to orthodontics around
good mechanical properties, and corrosion resistance, 1970 and has become very popular. Nitinol now en-
stainless steel alloys have the following applications in compasses a group of alloys with variations in the
dentistry: endodontic files; wires, brackets, and bands ratios of nickel to titanium. Nitinol wires are resil-
used in orthodontics; and fixed-space maintainers and ient and springy and maintain their shape. Nitinol
stainless steel crowns used in pediatric dentistry. wire has the most springback or memory to return
to its original shape compared with the other alloy
PREFORMED PROVISIONAL CROWNS wires, so it more readily facilitates tooth movement
Wrought alloys of stainless steel are used for the fabri- with lower force. Because they cannot be bent eas-
cation of preformed provisional crowns. They are the ily at chairside, they are usually used as preformed
most durable of the preformed crowns and can last for archwires. If bent sharply, they are prone to frac-
months or even years. They come in a variety of sizes ture. Another limitation of nitinol is that it cannot
that fit most molars and premolars (see Chapter 18 be soldered or welded because heating changes its
Provisional Restorations, Figs. 18.4 and 18.5). Because microstructure.
 Metals and Alloys CHAPTER 11 231

The orthodontist will order wires either preformed

or straight wires in various lengths and diameters.
The diameter of wire is sometimes referred to as its
gauge. The thicker the wire, the smaller its gauge; thus
8-gauge wire is thicker than 16-gauge wire. The diame-
ter of wire is more commonly described in hundredths
of an inch (e.g., 0.36 inch). Most orthodontic wires are
supplied using the inch diameter classification, al-
though some manufacturers, particularly in Europe,
use millimeters as the unit of measure. Wire is strong
but can be made to fracture by repeatedly bending it
back and forth. Repeated bending reduces the wire’s
ductility and strain hardens it, eventually causing it to
break. Some archwires are preformed to the approxi-
mate shape of a dental arch.

BRACKETS AND BANDS FIG. 11.12 Orthodontic bands with tubes and hooks, edgewise brack-
ets, archwires, and elastics used for tooth movement. (Courtesy of
Orthodontic brackets and bands are bonded or cemented North Coast Orthodontics.)
on the teeth, and they retain the archwire that the ortho-
dontist has shaped. The archwire is shaped into a form
that will guide the teeth into their new position. When
the wire is tied to the brackets of the teeth, the wire tries to
assume its ideal form, and as a result, exerts a force on the
teeth that gradually moves them in the desired direction.
The archwire is held to the bracket or band by ligature
wire or elastics. Metal orthodontic brackets are cut and
shaped from stainless steel alloy and are attached to a
stainless mesh backing (see Chapter 5 Principles of Bond-
ing, Fig. 5.33). They are bonded to the tooth with bond-
ing resin or other appropriate luting cement that locks
into the mesh backing (see Chapter 5, Procedure 5.3).
The edgewise bracket, which is the most common, has
a horizontal slot between four wings. The slot is where FIG. 11.13 Orthodontic bonded wire lingual retainer. (Courtesy of Steve
the archwire is placed, and the wings are used to hold Eakle, University of California, San Francisco [San Francisco, CA].)
the elastics or ligature wire that secures the archwire.
Orthodontic bands are formed from a stainless steel alloy position. Some removable appliances used for minor
and are preformed or formed at chairside by the dentist. tooth movement also use a wire embedded in acrylic.
Stainless steel brackets, tubes, and hooks are welded onto In this case, the wire is activated to put pressure on
the bands or brackets for the purpose of attaching intra- the teeth to be moved (Fig. 11.14). After the teeth have
oral wires, elastics, or extraoral headgear (Fig. 11.12). moved into their desired position, the appliance can be
used as a retainer by keeping the wire resting passively
RETAINERS AND REMOVABLE ORTHODONTIC against the facial surfaces of the teeth.
APPLIANCES
A retainer is often placed to help maintain the position SPACE MAINTAINERS
of the teeth after orthodontic treatment. It provides When teeth are lost prematurely, it is desirable to pre-
long-term stabilization of the anterior teeth. Retain- vent adjacent teeth from drifting into the space. If the
ers can be fixed or removable and often use a round space of a primary tooth is lost, the permanent tooth
wire to help hold the teeth in position. A fixed lingual may not have room to erupt into its proper position.
retainer is simply a wire adapted to the lingual sur- If a drifting neighbor takes up the space of a lost per-
faces of the mandibular anterior teeth and bonded in manent tooth, there may not be adequate room for a
place with composite resin (Fig. 11.13). On occasion, a bridge or implant and the drifting tooth may tip into
similar fixed retainer is used on the lingual surfaces of the space, altering its proper alignment. Fixed and re-
the maxillary anterior teeth. It may be shortened to in- movable space maintainers are often used temporar-
clude only the maxillary central incisors if its purpose ily to hold the space. Common fixed space maintain-
is merely to prevent a midline diastema from reform- ers consist of a wire loop that is attached to a stainless
ing after orthodontic closure. A removable retainer steel crown or an orthodontic band. The loop rests
often uses a wire embedded in acrylic. The wire en- against the adjacent tooth and holds it in position
gages the facial surfaces of the teeth and holds them in (Fig. 11.15).
232 CHAPTER 11 Metals and Alloys

A FIG. 11.15 Fixed band and loop space maintainer. (Courtesy of Brent
Lin, Pediatric Dentistry, University of California, San Francisco.)

the point of the curvature. Nickel-titanium (nitinol) files

are far more flexible than stainless steel files. They have an
enhanced elastic characteristic that allows them to return
to their original shape after they have had a load or force
put on them. When used for instrumenting curved canals,
they will regain their shape, unlike stainless steel files.
Some files are used to instrument root canals by hand,
and some are used in slow-speed dental handpieces at
low speeds and are called rotary instruments. Rotary in-
struments are usually composed of nickel and titanium al-
B loys. Rotary instruments are very popular and allow root
canal therapy to proceed much faster and more efficiently.
Their flexibility is highly desirable in a curved canal, be-
cause they can follow the curvature of the canal more eas-
ily and remove less dentin than stainless steel files.
Both hand files and rotary files are subject to metal
fatigue that can cause fracture of the file after repeated
use. If the file fractures within the root canal, it might
not be able to be removed. This could result in failure of
the root canal treatment. The dentist and the assistant
should determine how many times a file can be used,
and then should discard the file when it has reached
that limit. A tracking system must be developed to
document how many times each file has been used.
C Reamers are similar to files except that they have
fewer twists in the metal and cut faster. Reamers are
FIG. 11.14 Removable orthodontic appliance to retract tooth #8. It can
serve as a retainer after tooth movement has been accomplished. A,
made by twisting a tapered triangular or square rod
Protruding maxillary central incisor. B, Hawley appliance with adjust- so that its cutting edge is parallel to its long axis. It
able labial wire bow to move tooth lingually. C, Tooth has been reposi- is used for cutting canal walls to enlarge and shape
tioned. (Courtesy of Dr. Scott Rooker, Bend, OR.) them. A reamer will remove debris more efficiently
than a file.
METALS USED IN ENDODONTICS
ENDODONTIC POSTS
ENDODONTIC FILES AND REAMERS Teeth in which the pulpal tissues are infected or die
Endodontic files and reamers are other examples of often receive root canal therapy (endodontic treat-
wrought metal used in dentistry. They are made of ment). Conventional root canal therapy generally en-
wrought wire that has been twisted to produce multiple tails making an access preparation through the crown
cutting edges (Fig. 11.16). Files are made of stainless steel of the tooth to the pulp chamber, removing the dis-
or nickel-titanium and are used within the root canal eased pulpal tissue from within the root canal with
to clean and shape it for final filling. Stainless steel files a series of fine files, and sealing the root canal space
become stiffer as the diameter of the file increases. This with a special sealing material (gutta percha) and a
stiffness is not desirable when curved canals are instru- sealing cement so that bacteria cannot grow in the
mented, because the files tend to remove more dentin at space.
 Metals and Alloys CHAPTER 11 233

B
FIG. 11.16 A variety of endodontic files. A, Types of hand files. B, Rotary files. (A, From Robinson DS, Bird DL: Endodon-
tics. In Essentials of Dental Assisting, ed 6. St. Louis, 2017, Elsevier. B, Courtesy of Dentsply Sirona.)
234 CHAPTER 11 Metals and Alloys

Purpose of the Post Custom Posts

Endodontic posts are metal or nonmetal dowels or rods Custom posts are made from a wax or resin pattern
placed within the root canal space after a root canal made directly on the tooth or in the laboratory on a rep-
treatment. It once was believed that posts reinforced lica of the preparation (a die) poured from an impres-
endodontically treated teeth against fracture, and sion of the tooth. Custom posts are cast into metal or
many posts were placed for this purpose. However, it ceramic using the lost wax technique, or can be milled
is now clear that the purpose of a post is to retain the using CAD/CAM techniques (see Computer-Aided
core buildup over which the final restoration (crown) Machining in Chapter 9). Noble or base-metal alloys or
is placed. If there is adequate tooth structure remaining ceramic-fired materials are used. Cast posts generally
to hold the core buildup without a post, a post should are made as one unit with the core already attached.
not be used. While the choice of using posts or other
retaining designs is up to the dentist, it is important for Preformed Posts
all clinicians to be familiar with the various types of Preformed posts are available from many commercial
posts that might be used. Dental auxiliaries are often sources and are by far the most commonly used posts
asked questions by patients about the materials they (Fig. 11.17). They can be used in most clinical situations,
see in their teeth on the radiographs mounted on the are inexpensive, and can be placed in one appointment
view box or seen on the monitor. Some patients may (Fig. 11.18). They are much more time efficient than cast
confuse the post with an implant and need to be edu- posts, which take two appointments. The designs of these
cated as to the differences. preformed posts are active or passive, parallel or tapered,
and metal or nonmetal. They rely on retention by their
Classification of Posts length, diameter, and shape and by the use of a cementing
It is beyond the purpose of this section to discuss re-
tention and post design, but basically posts can be
TABLE 11.3    Composition of Posts
classified as active or passive. Active posts engage the
root canal surface with threads like a screw, and pas- CUSTOM CAST POSTS
sive posts are simply cemented into the canal space Nickel-chromium alloy (Ni-Cr)
without actively engaging the canal walls. Posts can Cobalt-chromium alloy (Co-Cr)
also be classified by their shape: parallel or tapered. Gold alloy (ADA type IV)
Parallel posts have been shown by in vitro studies Palladium-silver alloy
(meaning they were not conducted in living crea- PREFORMED POSTS
tures but were done in the laboratory) to transmit less A. Metal
stress to the root than tapered posts. Tapered posts Titanium (99% pure)
when loaded place a wedging force on the root, with Stainless steel (Fe-Ni-Cr)
a higher risk of root fracture. Posts can be made of Titanium-aluminum-vanadium alloy (Ti-Al-V)
metal or can be nonmetal such as resin-fiber posts (Ta- B. Nonmetal
ble 11.3). Posts can be custom-made in the laboratory
Ceramic (zirconia)
(cast posts) or can be purchased preformed in various
Fiber-reinforced resin
sizes and materials.

Nonmetal posts

Metal posts

FIG. 11.17 A variety of preformed metal and nonmetal posts.

 Metals and Alloys CHAPTER 11 235

A B
FIG. 11.18 Clinical photographs of preformed metal posts. A and B show two views of preformed metal posts that
will be used to retain a composite resin core. Supplemental retention boxes have been cut to lock in the core material.
(Courtesy Dr. Dennis J. Weir, Novato, California.)

FIG. 11.19 Radiograph of lower first molar with endodontic gutta percha filling and metal preformed post in the distal
canal. A composite core has been added. The post retains the core. (Courtesy of Dr. Steve Eakle.)

or bonding medium (see Chapters 5 and 14 for discus- nonmetal posts are made of fiber-reinforced resin or ce-
sions of bonding and cementing materials). Preformed ramic materials. Preformed posts generally do not have a
posts come in kits with drills specific to the size and style core attached by the manufacturer, so one must be added
of the post. Preformed metal posts (Fig. 11.17) are made (Fig. 11.19). The core can be made of amalgam, composite
of stainless steel, titanium, or titanium alloy. Preformed resin, or resin-modified glass ionomer cement.
236 CHAPTER 11 Metals and Alloys

Endodontic treatment has moved into the modern era

SUMMARY
with the use of rotary files and the controlled speed
Metals play a major role in restorative and corrective of the electrical handpiece. Likewise, the restoration of
dentistry. Gold and alloys of gold are some of the most endodontically treated teeth and the use of post and
biologically compatible materials and have many uses, core materials have changed dramatically. Now, both
even with the shift toward cosmetic dentistry. Noble metal and nonmetal posts are available for the dentist
and non-noble metals have a significant role in modern to select for the process of restoring endodontically
prosthetic dentistry. They are the main support for re- treated teeth. The indications for each are important
movable partial dentures, fixed bridges, and prosthe- for the clinician to understand.
ses used in combination with implants. Orthodontic Patient education is an important aspect of the role
treatment relies heavily on the use of metal. Brackets of the dental auxiliary in dental practice. Your ability to
are predominantly metal, although some are ceramic. describe to the patient the pros and cons of the various
Wrought wire, with its “memory,” exerts predictable materials used in practice and to aid in the treatment
forces and has made the job of the orthodontic clinician process depends on your knowledge of these materi-
easier, improved comfort for the patient, and reduced als. As new metal-based materials are introduced into
the time needed for treatment. Titanium is a light- dental practice, it is important to stay current on their
weight metal and has good characteristics of strength properties, indications, contraindications, and applica-
and elasticity. Titanium alloy is the main alloy used tion techniques. Manufacturers’ instructions for their
for dental implant fixtures (see Chapter 12). It is used care and use should be followed. Many manufacturers
as an alloy with nickel for archwires in orthodontics have websites on which they post information relative
and for endodontic hand files and rotary instruments. to their materials.

Get Ready for Exams!

Review Questions d. low thermal expansion

6. M etal that is formed by casting into an ingot or bar and
Select the one correct response for each of the following
then is altered in its form by extruding or pressing it is
multiple-choice questions.
known as
1. The ADA recognizes which three major categories of a. Stainless steel
alloys? b. Wrought metal
a. High noble, noble, and low noble c. Milled metal
b. High noble, noble, and base metal d. Brazed metal
c. Precious, semiprecious, and nonprecious
7. High-noble alloys usually have which metals added to
d. Class I, II, and III
increase their hardness?
2. High-noble metal classification must contain what per- a. Silver or copper
cent by weight of gold? b. Nickel or beryllium
a. 40% c. Iron or aluminum
b. 60% d. Chromium or cobalt
c. 75%
8. Which type of orthodontic wire has the most springiness
d. 90%
and tendency to maintain its original shape?
3. Noble metal elements include all of the following except a. Stainless steel
a. Silver b. Cobalt-chrome nickel
b. Gold c. Gold
c. Palladium d. Nickel-titanium (nitinol)
d. Platinum
9. Allergy to nickel
4. How does porcelain bond to metal alloys? a. Occurs in less than 3% of the population
a. By fusing to oxides formed on the surface of the b. Is seen only in the oral cavity
metal c. Occurs 10 times more often in women than in men
b. By sandblasting the metal surface to roughen it d. Is associated more often with orthodontic wire than
c. By the use of metal bonding adhesive systems with crowns
d. By melting the surface of the metal and embedding
10. Solder has all of the following uses except one. Which
the porcelain in it
one?
5. When bonding porcelain to metal for a crown, the metal a. Adding a contact to a crown
must have which one of the following properties to pre- b. Joining a pontic to a bridge retainer
vent cracking of the porcelain? c. Repairing a hole in the occlusal surface of a crown
a. high hardness discovered in a patient’s mouth
b. high density d. Joining a wire loop to a band to make a space
c. low melting range retainer
 Metals and Alloys CHAPTER 11 237

Get Ready for Exams!—cont’d

11. T he purpose of a flux used during soldering is to 2. A 65-year-old retired accountant comes to the dental
a. Lower the melting point of the solder office with a gold crown for tooth #19 in his hand. It
b. Make the solder harden quickly came off last night while he was eating sticky candy.
c. Prevent the solder from flowing to areas where the The patient complains that since the crown was placed
solder is not needed last year, he has been packing food between the crown
d. Remove oxides from the surfaces of the metals so and tooth #20, which has a disto-occlusal amalgam. The
the solder can flow and wet the surfaces better crown has an acceptable fit to the tooth and no dental
12. Preformed metal posts are available in all of the follow- caries are present. The amalgam is also acceptable.
ing materials except one. Which one? What procedures can you suggest to solve the food impac-
a. Pure gold tion problem without remaking the crown or the amalgam?
b. Stainless steel What materials should be used? Describe the correct se-
c. Titanium quence for the procedure(s).
d. Titanium alloy 3. A 46-year-old businesswoman at her annual oral
13. The purpose of a post is to examination complains that as her gum has receded
a. Strengthen the root on tooth #12, a dark line can be seen at the margin of
b. Put a permanent seal over the root canal filling a porcelain-bonded-to-metal crown that was placed 5
material years ago. She is unhappy with the appearance and is
c. Strengthen the core material concerned that it might be “decay.”
d. Retain the core material What is the likely cause of the dark line she is referring to?
14. An all-metal crown that is yellow in color has which one How might the dentist have prevented this from occurring?
of the following? 4. A 34-year-old female schoolteacher presents to your
a. A high gold content dental office complaining that she broke off a cusp on
b. A high copper content her lower left first molar. Visual inspection reveals that
c. A high palladium content tooth #19 is missing the distolingual cusp down to the
d. Can’t tell the composition from the color gingival crest, and a large MOD amalgam is present. The
15. All of the following statements about cast posts are true patient is a heavy bruxer and she admits that she wakes
except one. Which one? up sometimes grinding her teeth. The dentist recom-
a. They may be formed from a wax or acrylic resin mends a crown to restore the tooth.
pattern. From a strictly functional perspective, what type of crown
b. They can be cast using high-noble, noble, or base- would be the most trouble free and durable? If the patient
metal alloys. selects a porcelain-fused-to-metal (PFM) crown with porce-
c. They usually have the core already attached to the lain on the occlusal surface, what should the patient be told
post. regarding the risks and benefits of this type of crown?
d. They are used in practice far more often than pre- 5. As you are preparing for a cementation appointment for
formed posts. a porcelain-bonded-to-metal crown for tooth #12, you
16. The alloy most used for partial denture frameworks and notice several small cracks in the porcelain. The crown
most resistant to fatigue failure of the clasps is which has just come from the lab and has not been in the
one of the following? patient’s mouth.
a. cobalt-chromium alloy If the crown was not dropped or otherwise mishandled, why
b. stainless steel did these cracks appear? Discuss compatibility problems as
c. gold alloy they relate to the physical properties of the porcelain and the
d. titanium alloy porcelain-bonded alloy. Should the dentist proceed with the
For answers to Review Questions, see the Appendix. cementation of the crown?
6. A 58-year-old female mail carrier presents for her annual
periodic examination. She says she has noticed some
Case-Based Discussion Topics inflammation in the gum around tooth #14 that started
1. A
 33-year-old schoolteacher comes to the dental office 2 weeks after a base-metal crown was placed last year.
to have a crown placed on tooth #18. The dentist has She says she has been brushing and flossing carefully
told the patient that she should have a gold crown. After but the inflammation does not go away.
the dentist has left the room, the patient asks you if What are some possible causes for the inflammation? If a
there are any cheaper metals that could be used. She prophylaxis and application of antibiotics to the sulcus have
says that she has no insurance and is short of money at no effect, what now becomes a greater suspect for the
this time. cause? If the dental laboratory uses IdentAlloy labels, what
What can you tell her about the general types of metals used information can you glean that might help in determining the
for cast crowns and what the pros and cons are for each? likely cause?
238 CHAPTER 11 Metals and Alloys

BIBLIOGRAPHY Roach M: Base metal alloys used for dental restorations and im-
plants, Dent Clin N Am, 51:(3):603–627, 2007.
American Dental Association (ADA): Council on Scientific Affairs: Robinson DS, Bird DL: Endodontics. In Essentials of Dental Assist­
Products of Excellence: ADA Seal Program, Chicago, 1999, ADA. ing, ed 6, St. Louis, 2017, Elsevier.
Anusavice KJ, Shen C, Rawls HR (eds): Dental casting alloys Rosenstiel SF, Land MF, Fujimoto J (eds): Laboratory Procedures.
and metal joining, wrought metals. In Phillips’ Science of Den- Con­temporary Fixed Prosthodontics, ed 5, St. Louis, 2016, Else-
tal Materi­als, ed 12, Philadelphia, 2013, Saunders. vier.
Department of Health and Human Services, Agency for Toxic Sakaguchi RL, Powers JM (eds): Restorative materials—metals.
Substances and Disease Registry: Beryllium Toxicity: Patient In Craig’s Restorative Dental Materials, ed 13, Philadelphia,
Education Care Instruction Sheet. Updated May 2008. Ac- 2012, Mosby.
cessible at https://www.atsdr.cdc.gov/csem/csem.asp? Sansone V, Pagani D, Melato M: The effects on bone cells of met-
csem=5&po=15. al ions released from orthopaedic implants. A review, Clin
Leinfelder KF: An evaluation of casting alloys used for restora- Cases Miner Bone Metab, 10(1):34–40, 2013.
tive procedures, J Am Dent Assoc 128:37–45, 1997. Van Noort R: Structure of metals and alloys. In Michele Barbour,
Powers JM, Wataha JC: Casting alloys, wrought alloys and sol- editor: Introduction to Dental Materials, ed 4, St. Louis, 2013,
ders. In Yen-Wei Chen, editor: Dental Materials: Foundations Mosby.
and Applications, ed 11, St. Louis, 2017, Elsevier.
Dental Implants 12
http://evolve.elsevier.com/Eakle/materials/

Chapter Objectives
Upon completion of this chapter, the student should be able to:
1. Describe the components of an implant used for a 13. M ake an impression for an implant, using the open- or
crown. closed-tray procedure (as permitted by state law).
2. Describe the most common materials used for dental 14. Identify the uses for mini-implants.
implants. 15. Define the types of bone grafting.
3. Explain osseointegration of an implant. 16. Describe the purpose of the sinus lift procedure.
4. Discuss the indications and contraindications for dental 17. Identify when sutures would be utilized in a dental
implants. procedure.
5. Explain the advantages of image-guided implant surgery. 18. List the different types of sutures.
6. Identify risks to the patient for implant surgery. 19. Describe the types of needles used to place sutures.
7. Describe the sequence of the one-stage surgical 20 Demonstrate the removal of sutures.
procedure. 21. Describe the assessments that should be done for dental
8. Present postsurgical instructions to a patient. implants at the hygiene visit.
9. Compare the one-stage, two-stage, and immediate 22. Demonstrate to a patient the use of home care aids for
surgical procedures. dental implants.
10. Discuss the pros and cons of immediate loading of an 23. Explain the rationale for the selection of instruments for
implant. cleaning titanium implants.
11. Explain the process of taking an implant impression. 24. Perform periodontal maintenance around an implant
12. Compare the open-tray and closed-tray impression (hygienists) using appropriate probes, scalers, curettes,
procedures. and ultrasonic tips.

Key Terms
Endosseous Implant implant placed into the bone when the fixture is covered with the flap in a two-stage
Implant Fixture metal or ceramic component placed into surgical procedure
bone to support a crown or prosthesis Impression Abutment component used in the implant
Implant Abutment metal or ceramic component that impression to align the implant analog in the same way as
connects the implant crown to the implant fixture the implant fixture was in the mouth
Healing Abutment a component placed temporarily on the Implant Analog a substitute for the implant fixture used
implant fixture during the healing phase to allow the gingiva during the laboratory fabrication of the implant crown
to adapt to it and form a cuff that will function around the Open-Tray Impression impression for implants that uses a
implant tray with a hole over the impression abutments to be able
Osseointegration bone growing into intimate contact with to remove the abutments with the impression
an implant fixture after placement (a microscopic space Closed-Tray Impression impression for implant that
exists between the bone and the implant surface) removes the impression with the impression abutment still
Biointegration a total integration of the implant fixture with attached to the implant fixture; the abutment is later
the bone (without a microscopic space) that occurs with removed and placed in the impression
ceramic implant materials Temporary Anchor Devices (TADs) small, tack-like
Mini-Implant a very small–diameter implant that can be mini-implants used on a temporary basis as anchors for
placed with minimal surgery involved orthodontic tooth movement
Cone Beam Computed Tomography (CBCT) type of Autograft graft tissue harvested from the patient’s own body
digital tomographic radiography used to produce three- Allograft tissue taken from a donor (usually deceased) for
dimensional images of the jaws; useful for analyzing the grafting in another human
structures before surgery Xenograft graft tissue taken from an animal (usually bovine)
Cover Screw component placed in the top of the implant for use in a human
fixture to prevent tissue from growing into the screw hole Alloplast synthetic graft material

239
240 CHAPTER 12 Dental Implants

Barrier Membrane protective membrane that prevents the Sutures natural or synthetic material with the appearance of
in-growth of fibrous connective tissue into a graft site and thread used to hold tissues together or to reposition
also holds the graft material in place tissues after trauma or surgical procedures
Sinus Lift a surgical procedure that lifts up the floor of the Absorbable Sutures sutures broken down naturally by the
maxillary sinus to allow placement of a bone graft. It is body’s enzymes and absorbed
used to provide adequate bone for an implant when there Non-Absorbable Sutures sutures made of materials that
was not enough available over the maxillary sinus are not broken down by the body and require removal by a
Peri-Implantitis an infection around an implant that can dental professional
cause gingival inflammation and loss of bone around the
implant
  

For centuries people have attempted to replace missing teeth

with some form of implant. The first evidence of attempted im-
plants was bamboo pegs placed in a jawbone in ancient China
4000 years ago. Then 3000 years ago in ancient Egypt, a cop-
per stud had been nailed into a jawbone. The Mayans, in about
600 c.e., tried implanting carved shells into the anterior man- A
dible. Centuries later, in 1905, C.R. Scholl introduced a porce-
lain root-form implant to the modern world. Over the next
60+ years many materials and implant designs were used with
limited success. The major breakthrough came in 1969 when
P.-I. Brånemark and co-workers using medical implants re-
ported their finding of integration of bone with an implant sur-
face. The Brånemark dental implant system was introduced B
into the United States in 1982. The development of endosseous
root-form implant treatment has rapidly progressed over the
last 40+ years with high success rates. Advances in technology
with cone beam computed tomography (CBCT) and computer-
aided design software have helped dentists more accurately
plan for and place dental implants. Bone grafting and guided
tissue regeneration have helped to improve bone in sites for C
implant placement where previously the patient would have
not been considered a candidate for implants. The introduction FIG. 12.1 Older implant types. A, Subperiosteal. B, Transosteal. C,
of narrow-diameter implants has also broadened the applica- Older variety of endosseous implants. (From Phillips RW, Moore BK:
tions of dental implants. The use of implants in modern den- Elements of Dental Materials for Dental Hygienists and Dental Assis-
tistry has accelerated rapidly, with sales of implant compo- tants. Philadelphia, 1994, WB Saunders.)
nents exceeding 3.5 billion dollars worldwide.
This chapter emphasizes endosseous implants, because subperiosteal implants a surgical excision exposes the
they are the most widely used. The materials used for implants bony ridge and an impression is made. A metal frame-
and the indications, contraindications, placement, restora- work is fabricated and placed over the bony ridge (and
tion, integration with bone, components, and maintenance are beneath the periosteum) with metal struts protruding
discussed. It is essential that the dental hygienist have an un- through the soft tissues to support a prosthesis. The
derstanding of the characteristics of the various implant mate- transosteal implant (also called a mandibular staple) is
rials to correctly manipulate and care for them. The dental placed from under the chin and has a flat plate from
assistant and hygienist must be able to answer questions by which two to four threaded posts projected through
patients relative to the material and techniques that will be the anterior mandible into the oral cavity. The posts are
used for their treatment. In addition, they must have an un- used to support a complete denture. Subperiosteal and
derstanding of the process of restoring implant fixtures so transosteal implants are rarely done because of the
they can ably assist the dentist. Where allowed by state law, high success rate of endosseous implants. Endosseous
hygienists and assistants trained in expanded functions can implants are the most commonly used implants in
make impressions for implant restorations and play an impor- dentistry today and are the focus of this chapter.
tant role in implant maintenance.
ENDOSSEOUS IMPLANTS
Endosseous implants are surgically placed into the
DENTAL IMPLANTS
bone and act like a root substitute for missing teeth to
Dental implants are of three main types: subperios- support a crown or prosthesis (Fig. 12.2). Implants can
teal, transosteal, and endosseous (Fig. 12.1). With be used to replace one or more single units as
 Dental Implants CHAPTER 12 241

implant site are not candidates for implants because of

the risk of delayed bone healing and bone infection
(osteonecrosis). Patients with compromised immune
systems are also not candidates for implants. Smokers
are not good candidates because their healing may be
compromised. In addition, patients who are mentally
or physically not able to maintain good oral hygiene or
those with unrealistic expectations are not candidates
for implants.

BENEFITS OF IMPLANTS
Dental implants have several benefits that make them
a desirable means for restoring the dentition. When
implants are used in place of a fixed bridge, tooth
structure is preserved because abutments do not have
to be prepared. The individual implant units are easier
to keep clean than a fixed bridge, so the gingiva stays
FIG. 12.2 Contemporary endosseous dental implant. (From Rosenstiel healthier and the caries incidence of adjacent teeth is
SF, Land MF, Fujimoto J: Contemporary Fixed Prosthodontics, ed 4, lowered. When teeth are extracted the bone at the site
St. Louis, 2006, Mosby.) begins to resorb fairly rapidly soon afterward and then
continues more slowly over time. When an implant is
individual crowns or as fixed bridges, or they can sup- placed it helps to preserve the bone both in ridge height
port a partial or full denture. Their use is expanding as and width.
implant materials and techniques continue to improve, Patients with complete dentures can bite and chew
and their success rate remains high with careful case with only a small fraction of the force they could with
selection. Clinical studies have shown these implants their natural teeth. The muscles of mastication weaken
to be very successful, with long-term survival (greater and show signs of atrophy and the ridges resorb. With
than 10 years) of approximately 90% in the maxilla and an implant-supported denture, biting, chewing, and
95% in the mandible. The difference in success rates speaking are improved. Muscle tone is regained and
between the two jaws is related to the quality of the the implants help preserve bone. The patient is more
bone in each jaw. The bone in the mandible is generally comfortable, especially when chewing hard foods, and
much denser. does not have the discomfort associated with shifting
of the denture and pressure on the soft tissues. The es-
INDICATIONS FOR IMPLANTS thetic result often is improved because the teeth can be
Implants are indicated for a variety of clinical situa- set where most attractive rather than being limited to
tions. Because of the excellent survival rate of implants, placement over the center of a ridge that has resorbed.
they are often the treatment of choice in place of a par-
tial denture or a fixed bridge when a single tooth has IMPLANT COMPONENTS
been lost, particularly when the potential abutment Numerous components are used for restoration with
teeth are unrestored. When most of the posterior teeth an implant. Some components are permanent parts of
have been lost in an arch, implants are often preferred the implant, and others are used temporarily for heal-
to a distal extension partial denture. When a patient ing phases, impression making, or crown construction.
has a problem stabilizing a denture because of extreme Different terms may be used to describe them, depend-
ridge resorption, implants can be used to anchor the ing on the manufacturer. Conventional dental implants
denture. Implants may also be indicated to improve used to support crowns and bridges have three basic
function and esthetics. components: the implant fixture, abutment, and crown
(or bridge) (Fig. 12.3).
CONTRAINDICATIONS FOR IMPLANTS Implant fixture: The implant fixture is that portion of the
Implants are contraindicated in patients who have implant that is placed in the bone and remains there
medical conditions (such as advanced cardiovascular to support the crown (or other prosthesis).
or respiratory disease) that make them poor candi- Implant abutment: The implant abutment is an attachment
dates for surgery. Patients with conditions that can af- to the implant fixture that protrudes through the gin-
fect their ability to fight infections or heal properly giva and acts like a tooth preparation on which the
(such as diabetes) are not good candidates for implants. crown attaches or the prosthesis rests. The abutment
Patients who have recently taken bisphosphonates is usually attached to the fixture with a screw. An-
(such as Boniva and Zometa) to prevent osteoporosis other type of abutment is the healing abutment. The
or that have had radiation therapy affecting the healing abutment is attached to the fixture and is
242 CHAPTER 12 Dental Implants

B C

D E
FIG. 12.3 Implant components. A, Healing abutment placed after the surgeon uncovers the top of the implant fixture
to allow the soft tissue to adapt. B, Impression abutment facilitates orientation of an implant analog to the cast in the
same way the implant fixture was oriented in the mouth. C, Implant analog is used in the laboratory as a substitute for
the implant fixture, so the implant crown can be made. D, Screw-retained implant crown with occlusal screw-access
hole. E, Implant crown in the mouth with the access hole filled. (Courtesy of Fritz Finzen, University of California School
of Dentistry [San Francisco, CA].)

placed temporarily to allow the gingiva to heal growth into the top of the implant while it is covered
around it and form a gingival cuff and sulcus. Both with the surgical flap during the healing phase. The
the abutment for a crown and the healing abutment healing abutment replaces the cover screw after the top
may be prefabricated or custom made. Prefabricated of the implant is uncovered during the second stage of
abutments are generally round, so the gingiva con- the two-stage surgery procedure (see Fig. 12.3, A). A
forms to the round shape. However, teeth are rarely torque wrench is used to tighten various components
round in shape. Custom abutments are shaped more of the implant to very specific amounts of force (ex-
like the root form of the teeth they are replacing. The pressed in newtons [N]). Impression and laboratory
custom abutment may be made by a laboratory tech- components are discussed in the section “Implant Im-
nician or milled by a CAD/CAM (computer-aided pression and Laboratory Components.”
design/computer-aided machining) unit.
Implant crown or prosthesis: When a single tooth is being IMPLANT MATERIALS
replaced, a crown is made to fit to the abutment Various materials have been used for implant fixtures
much like a crown is made to fit to a prepared tooth. over the years, but metal and ceramics are the materi-
When multiple teeth are being replaced, an implant als currently used. The metals of choice are titanium
supported fixed bridge, removable complete den- and titanium alloy.
ture, or partial denture is used.
Titanium
Other Components Titanium (Ti) and titanium alloys are the metals most
Additional components are needed in the implant pro- commonly used because of their favorable biocompati-
cedure. Titanium alloy screws are used to attach the bility with the oral tissues. Their elastic modulus is the
abutment to the implant fixture and in some cases will closest to bone of the materials used for implants. As a
attach the crown to the abutment. Of course, a screw- result, forces placed on the implant will be more evenly
driver is also needed. The cover screw is the compo- distributed between the implant and the bone. Those
nent that is placed in the top of the implant fixture in implant materials with an elastic modulus much greater
the two-stage surgery; it prevents bone and tissue than bone will concentrate stress within the implant.
 Dental Implants CHAPTER 12 243

A B C D E
FIG. 12.5 Implant designs. From left to right: A, Cylinder. B, Tapered.
C, Textured. D, Vented. E, Ceramic cylinder.

space as seen with osseointegration); this is called

FIG. 12.4 Osseointegration - bone cells growing in contact with a tita-
biointegration.
nium implant (Courtesy Professor Per-Ingvar Branemark, Institute for
Applied Biotechnology, Gothenburg, Sweden.) Ceramics are also used for implant abutments in the
esthetic zone, particularly where all-ceramic crowns
Titanium is a lightweight, corrosion-resistant, bio- are used to restore the implants. Metal abutments tend
compatible material that is 99% titanium with oxygen to show through and cause a gray coloration in the cer-
and trace elements. Bone will grow around and closely vical area of the crowns, due to the partial translucency
adapt to titanium and titanium alloy implants (a pro- of the ceramic crowns. Zirconia and titanium are
cess called osseointegration) when they are placed in- equally biocompatible implant fixtures.
timately in contact with the bone (Fig. 12.4). There
should be no fibrous connective tissue formed at the IMPLANT FIXTURE DESIGNS
interface, but there will be a microscopic space present Over the years, various endosseous implant designs
between the fixture surface and the bone. There will be have been used. Today, the most commonly used im-
no mobility of the implant. plant fixtures are the threaded type with a cylindrical
Titanium is not as rigid or strong as titanium alloy, or tapered shape. The threads vary in their spacing
and this property can occasionally lead to failure of an and angulation. Some designs include the use of very
implant if it is placed under heavy loading forces (such small threads at the coronal aspect of the implant to
as with patients who grind their teeth frequently). Tita- aid in directing forces away from the implant top.
nium quickly forms a thin surface layer of oxides that This helps to prevent loss of bone at the crest with
will integrate with the bone. Titanium alloys contain resultant gingival recession and compromised
small amounts of vanadium (decreases corrosion) and esthetics.
aluminum (increases strength, decreases density) to Some threads are sharp and will cut into the bone.
improve their mechanical properties, particularly their An initial pilot hole is made slightly smaller than the
tensile strength. Ti-6Al-4V is a commonly used titani- implant, which is screwed into place, making for a
um alloy containing 6% aluminum and 4% vanadium. very close adaptation to the bone. Nobel Biocare makes
Because of the favorable mechanical properties of tita- an implant with self-cutting threads. Other manufac-
nium alloys, they are also used for the screws that hold turers produce implants with non-cutting threads
the implant components together. (Straumann, for example). Some designs have a hol-
low core with or without holes in the apical portion.
Ceramics and Other Implant Materials The holes were placed to allow bone to grow into them
Other materials that have been used for dental implant and mechanically lock the implant in place. The expec-
fixtures are ceramics, composites, vitreous carbon, tation is that these surface designs will help the inte-
polymers, and a variety of metals including gold. gration of bone with the implant (Fig. 12.5).
These materials have been used with limited success. Early implant fixtures were flat on top, allowing
Composite, vitreous carbon, and polymer implant fix- bacterial contamination of the internal portion of the
tures did not integrate with the bone. Negative aspects implant with an ensuing inflammatory response from
of the early ceramic materials were their brittleness the tissue. Current implants use a conical connection
and lack of flexibility, causing them to transmit greater that provides a seal against bacteria and as a result a
stress to the implant site; these implant fixtures were at healthier periodontium.
greater risk of fracture from functional forces.
Newer ceramics such as zirconia (see Chapter 9 Implant Dimensions
Dental Ceramics) are much stronger and hold up bet- The dimensions of implant fixtures can vary in diameter
ter than older ceramics that were brittle and ran the and length to fit the implant site and amount of avail-
risk of fracture. Ceramic implants will integrate with able bone. The size of the tooth being replaced is a factor
the bone more intimately than titanium implants. It is in determining the diameter and length of the implant
thought that they integrate chemically with the bone fixture used. A wider diameter implant fixture provides
so that that there is continuity between the ceramic more surface area for support of the crown or prosthe-
surface and the bone (with no microscopic sis. When an implant is placed between two adjacent
244 CHAPTER 12 Dental Implants

teeth, approximately 1.5 mm of bone should remain be- (ADA) Seal of Acceptance. The ADA requires compa-
tween the implant and the adjacent tooth root to prevent nies to submit information about the materials used,
compromising the bone. Likewise, there should be 1.5 research, and 5 years of clinical testing. The U.S. Food
mm of bone on the facial and lingual surfaces to prevent and Drug Administration (FDA) does not require clini-
bone remodeling and gingival recession. When the pa- cal testing. Although the ADA seal is not required to
tient is partially or totally edentulous, implant size in sell implants, it demonstrates a commitment by the
the mandibular anterior may be 3 mm or smaller, 4 mm companies to produce a reliable product.
in the premolar area, and 6 mm in the molar area. Wide-
bodied implants have diameters ranging from 8 to 10
IMAGE-GUIDED IMPLANT PLANNING AND SURGERY
mm. They are often used when a shorter length of im-
plant is needed; their larger diameter provides addition- Before the introduction of cone beam computed to-
al surface area for support to make up for the lack of mography (CBCT), most surgeons relied on their clini-
length. Very small–diameter implants (mini-implants) cal examination and two-dimensional radiographs.
are growing in popularity for mandibular complete Panoramic radiographs magnify dental structures by
denture support (they are discussed in the section “Re- about 25%, and thus the risk of introducing errors is
tention of the Removable Prosthesis”). increased. The use of CBCT provides the dentist with
very accurate three-dimensional images of the dental
Surface Treatment structures. With CBCT the density of the bone, the
Titanium and its alloys are very reactive and will read- thickness and height of the ridge at the planned im-
ily form oxides on their surfaces. Manufacturers will plant site, the location of nerves and major blood ves-
create these oxides in a controlled environment to pre- sels, and the size and configuration of the maxillary
vent contamination of the oxide layer. To further pro- sinuses can all be assessed. Therefore, the surgeon can
tect from contaminants, after their manufacture the have an image of the anatomy of the patient’s jaw with
implant fixtures are sealed in containers and are pro- all of its concavities and irregularities prior to the
tected until they are ready to be placed in bone. The surgery.
oxide layer is very thin but is essential to integration
with bone. Special care must be used when cleaning IMPLANT PLANNING SOFTWARE
implants in the mouth to prevent scratching the im- Treatment planning software can import CBCT imag-
plant surface. Scratching will disrupt the oxide layer es, allowing the surgeon and restorative dentist to plan
and allow contaminants to form on the damaged for the implant placement surgery. They can virtually
surface. extract teeth and determine precisely where the im-
Manufacturers may roughen the surfaces of the im- plant should be placed. They can plan for the type of
plant fixtures to increase the surface area available for implant; the proper diameter and length of the im-
integration with bone. Roughening has been accom- plant; and the proper position in the buccolingual, me-
plished by sandblasting, etching with acid, or coating siodistal, and apicocoronal dimensions. Bone density
with titanium plasma spray. Some studies show faster can be determined, and the surgeon can simulate
healing and greater integration with the bone with placement of the implant. The CAD simulation can de-
rough-surface implants. Bone apposition of 80% or termine the angulation and position of the implant for
more occurs when surface roughening is used as op- ideal esthetics and gingival contours. Once the proper
posed to only 40% bone-to-implant contact with im- placement is determined, then CAD/CAM technology
plants that were not roughened. can be used to create accurate acrylic models of the pa-
Ceramic coatings have been used on titanium alloys tient’s jaws, if needed, and make precision surgical
to promote more rapid integration with the bone. The guides for placement of the implants (Fig. 12.6). Three-
ceramic materials are applied in thin layers by a plas- dimensional (3D) design software creates a digital im-
ma spraying process. The bond of the ceramic coating age of the surgical guide. The guide can be fabricated
may break down with time, and therefore use of this by milling or 3D printing. If printing the guide, the de-
process is controversial. sign information is fed to a 3D printer. Instead of cut-
ting away material as milling does, 3D printing builds
Epithelial Seal up the surgical guide as it sprays the material in suc-
Epithelial cells will adapt to and adhere to the surface cessive layers to make the desired form.
of the implant to provide a seal to prevent the ingress
of bacteria along the implant interface with the bone. ADVANTAGES OF GUIDED IMPLANT SURGERY
This seal is important to the longevity of the implant. Implant surgery that is precision guided by this tech-
nology affords several distinct advantages. Among
ADA Seal of Acceptance these advantages are the following:
Of the many companies that manufacture implants, • The option to place the implant without laying a
only a few (including Nobel Biocare, Astra, and Strau- flap; this leads to less postoperative discomfort and
mann) have obtained the American Dental Association faster healing
 Dental Implants CHAPTER 12 245

A B E

D F G

H I J
FIG. 12.6 Image-guided implant planning and surgery combines cone beam computed tomography (CBCT) and implant
planning computer software. A, Plastic guide with barium-filled teeth marks positions in the CBCT scan. B, Scan guide
in the mouth. C, Barium-filled teeth show up in the scan (white opaque). D, Scan lines (orange) orient position of trans-
verse cross-section of the mandible. E, Software allows simulation of implant placement. F, Software designed surgical
guide for correct position of implants. G, Surgical guide positioned in the mouth. H, Implant fixtures seen in panoramic
radiograph. I, Implant fixture heads seen in the mouth. J, Restored implants in the mouth (From Rosenstiel SF, Land MF,
Fujimoto J: Contemporary Fixed Prosthodontics, ed 4, St. Louis, 2006, Elsevier.)

• F ewer perforations of bone by a misaligned drill

• Improved prosthetic outcomes of treatment and en-
IMPLANT PLACEMENT AND RESTORATION
hanced esthetics because of better implant placement Variations are seen in the surgical approaches to implant
• Increased survival rates for the implants placement and in healing times before the crown or other
Minimally invasive surgical techniques are greatly prosthesis is placed. Decisions underlying these varia-
facilitated by image-guided surgery. tions depend on whether there is already a healed eden-
tulous space with adequate bone or whether a tooth needs
CAD/CAM TECHNOLOGY to be extracted first. The surgery for implant placement is
In Chapter 9, Ceramics, CAD/CAM technology was often done by an oral surgeon or a periodontist. However,
discussed regarding fabrication of ceramic restora- many well-trained general dentists are now placing im-
tions. The same technology can be applied to fabrica- plants in the more straightforward cases—those patients
tion of custom implant abutments and crowns. Addi- who are healthy and have adequate bone. Implants are
tionally, when implants are placed in the socket restored by general practitioners and prosthodontists.
immediately after extraction of the tooth, a provisional
restoration can be fabricated to support the gingival INFORMED CONSENT
tissues and help maintain their contours during heal- Before the surgical procedure the patient must be fully
ing. A digital impression could be made prior to the informed of the risks, benefits, and alternatives to im-
extraction to fabricate a provisional restoration shell plants. The patient must be given the opportunity to
that can be relined with acrylic to fit the newly placed ask questions and have things explained in terms they
implant and support the gingival tissues. Otherwise, can understand. Many times the patient will ask the
the provisional restoration can be made immediately dental assistant or hygienist questions about implants
after the extraction and placement of the implant. Mill- or the surgery, so it is important to be knowledgeable
ing or 3D printing can be used to fabricate the provi- about the entire implant process.
sional restoration to fit the implant. After the soft tis-
sues and bone have healed, a custom abutment and SURGICAL RISKS
crown can be made from a new digital scan. A new Risks from the implant surgery include the usual sur-
scan is made because the gingival tissues will likely gical risks of excessive bleeding and swelling, infec-
have shrunk some during healing and the contours of tion, and necrosis of the gingival flap. In addition,
the crown will be made to accommodate for that there are risks of perforation of the bone or the maxil-
change. lary sinus, puncture of major blood vessels, and
246 CHAPTER 12 Dental Implants

damage to nerves. Also, bone grafting material may designated as the surgical assistant and a second as-
not develop a blood supply and new bone, and the im- sistant should be a roving assistant to retrieve supplies.
plant fixture may not integrate with the bone. The responsibility of the surgical assistant is to set up
the operatory; transfer instruments; retract cheeks,
PREPARATION OF THE PATIENT FOR SURGERY tongue, or the flap; evacuate saliva from the mouth
Several steps can be taken to enhance the success of the and blood from the surgical site; and carefully monitor
surgery. An oral hygiene appointment should be the patient during the procedure.
scheduled a week or so before the surgery to improve The operatory needs to be properly disinfected and
gingival health and remove any calculus that could clean zones with barriers established for placement of
break off and fall into a surgical site. Prior to the sur- sterile instruments and supplies. A sterile field must be
gery, postoperative instructions should be reviewed maintained during the surgery. Implant kits are avail-
with the patient while they are still capable of listening able that are prepackaged and sterile. The kits contain
to and understanding the instructions. The patient many small parts and drills. A system should be estab-
should also be given written instructions as many pa- lished to keep all of the parts organized. Many kits
tients will forget or misunderstand portions of the in- contain labeled holders for the drills and components.
structions given verbally. Just before the surgery all The sequence for using the components of the kit
removable prostheses should be removed and the should be rehearsed. Members of the surgical team
mouth rinsed with an antibacterial rinse such as should know the terminology of the parts so that com-
chlorhexidine (e.g., Peridex or PerioGard) to reduce munication during the surgery is clear. In addition, a
bacterial levels in the mouth. Some clinicians like to throat drape or barrier should be used to prevent aspi-
administer an antibiotic and an anti-inflammatory ration or the swallowing of small parts if they are
medication (e.g., ibuprofen) to minimize the risk of in- dropped in the mouth. A common safeguard is to tie a
fection and reduce swelling. The surgery can be done long piece of floss around the handle of small screw-
under a local anesthetic, but some patients prefer oral drivers to quickly retrieve them. Sterile saline is used
or intravenous sedation. Sedated patients may be kept for irrigation and as a coolant because city water sup-
in recovery for an hour or more and should have some- plies will have bacterial contaminants.
one drive them home after the surgery.
IMPLANT PLACEMENT SURGERIES
POSTSURGICAL INSTRUCTIONS Presently there are three modes of implant placement
First, provide the patient with a cold pack to place on surgery:
the face in the area of the surgery to help minimize • two-stage
swelling. The patient can apply an ice pack at home— • one-stage
10 minutes on, 10 minutes off—for a couple of hours. • immediate placement
Postsurgical instructions should be reviewed again or
reviewed with a companion who will be with the pa- TWO-STAGE SURGICAL PROCEDURE
tient at home. A pack of sterile gauze should be pro- The surgical procedures are done in two stages.
vided to use with pressure for an hour or two on the
surgical site to control bleeding. The patient should First Stage
rest and limit physical activity, eat soft foods, drink The first stage involves exposing the bone at the cho-
plenty of fluids but not through a straw (to avoid dis- sen placement site with a surgical flap. Next, a hole
rupting any clots), avoid smoking, and avoid vigorous (called an osteotomy) is drilled in the bone at low speed
rinsing. All medications should be taken as prescribed. and with sterile saline irrigation to prevent overheat-
Warm salt water rinses three or four times a day can be ing the bone. A series of burs will be used, starting
started the day after the surgery and continued for with a small-diameter bur and increasing to the size of
about 4 days (unless the patient has high or uncon- the implant fixture being used. The hole is the shape
trolled blood pressure which would limit sodium in- and length of the implant fixture and a size that is just
take). The surgical site should not be brushed but can slightly smaller than the fixture. Depending on the im-
be cleaned gently with a cotton swab or gently wiped plant fixture design, the implant is either lightly tapped
with a piece of gauze during the first week. Heavy or into place to have a frictional fit with the bone, or it is
prolonged bleeding, abnormal swelling, intense pain, screwed into place. Often an acrylic resin surgical
and allergic reactions should be reported to the sur- guide (called a stent) is made ahead of time with holes
geon at once. For any adverse reactions perceived to be drilled through it at the same angulation at which the
life-threatening, the patient or companion should call implant should be positioned. The surgeon places it
911. over the ridge at the time of surgery and inserts a bone-
cutting bur through the predetermined holes to cut the
PREPARING THE OPERATORY FOR SURGERY hole for the implant at the correct angulation. The stent
A team approach is important for implant surgery. is particularly helpful when the surgeon must place
Team members should know the role they will play several implants that need to be parallel to each other
and their responsibilities. One assistant should be for purposes of the restoration that will be placed on
 Dental Implants CHAPTER 12 247

the implants. It is important that excessive heat not be flap. Instead, the healing abutment is placed and the
generated during drilling of the bone. The bone can be gingiva is positioned around the healing abutment and
damaged easily and then will not integrate with the sutured (Fig. 12.8). The one-stage procedure is increas-
implant fixture. ing in popularity, because it saves the patient from
After the implant fixture is placed in the bone, a cov- having to go through a second surgery. It is best used
er screw is placed into the opening at the top of the when the patient’s restorative needs are not compli-
fixture (Fig. 12.7). The cover screw prevents tissue from cated. Occasionally, a provisional crown is placed that
growing into the screw hole to which the future abut- is out of occlusion while healing takes place.
ment will be attached. The surgical flap is repositioned The two-stage surgery was popular when osseointe-
and sutured closed over the implant. gration was first introduced to dentistry in the 1980s,
because it was thought that covering the implant dur-
Second Stage ing healing was needed to ensure success. Research
Approximately 3 months later, the surgeon uncovers has shown that there is no difference in survival of the
the top of the implant fixture, removes the cover screw, implant between the one-stage and the two-stage
and places a smooth, prefabricated or custom healing surgery.
abutment (Fig. 12.3, A) that screws onto the top of the
fixture. Next, the soft tissue (gingiva) is positioned IMMEDIATE-PLACEMENT SURGICAL
around the healing abutment, leaving it exposed to the PROCEDURE
oral cavity while the gingiva heals around it. This pro- When the implant procedure involves the extraction of
cess allows the gingiva to form a cuff around the im- a tooth, some clinicians place the implant fixture at the
plant, which will adapt to the crown when it is placed. time of extraction directly into the new socket. This is
After a few weeks, the crown impression procedure called an immediate-placement implant, and this proce-
can begin. dure is growing in popularity. A soft tissue flap is used
to cover the extraction site until bone fills in and inte-
ONE-STAGE SURGICAL PROCEDURE grates with the fixture. Often an artificial bone material
With the one-stage procedure, surgery for placement is also placed in the socket to aid the growth of new
of the implant fixture is performed just as with the bone into the socket and to help stabilize the fixture.
two-stage procedure. The difference is that with the
one-stage procedure, a cover screw is not placed at the
top of the fixture and it is not covered with the gingival

FIG. 12.7 Cover screw (also called healing screw) used in a two-stage FIG. 12.8 Healing abutment used immediately in a one-stage surgical
surgical procedure. It prevents tissue from growing into the screw hole procedure or in a two-stage procedure after initial healing of 2 to 3
after the implant fixture is covered with the surgical flap. (From Rosen- months. The healing abutment is placed to allow the gingiva to form a
stiel SF, Land MF, Fujimoto J: Contemporary Fixed Prosthodontics, ed cuff around it. (From Rosenstiel SF, Land MF, Fujimoto J: Contempo-
4, St. Louis, 2006, Mosby.) rary Fixed Prosthodontics, ed 4, St. Louis, 2006, Mosby.)
248 CHAPTER 12 Dental Implants

There is a slightly higher rate of failure of the implant Fig. 12.3, B), and an imprint of it is captured in the im-
after initial placement with this procedure compared pression. The abutment is transferred from the mouth
with the one- or two-stage surgical approaches. to the impression, and when the impression is poured,
it becomes part of the cast. The implant analog is the
IMMEDIATE LOADING component used during laboratory construction of the
Initially, it was thought that 3 to 6 months of healing implant crown. It attaches to the impression abutment
was needed so that osseointegration could occur be- and is used to replicate the implant fixture for the labo-
fore the implant could be loaded. Loading, it was ratory cast (see Fig. 12.3, C); the impression abutment
thought, would cause movement of the fixture that orients the analog in the cast in the same way that the
would result in failure to integrate with the bone and implant fixture is oriented in the mouth.
loss of the implant. However, more recent findings
suggest that it is the stability of the implant in bone IMPRESSION PROCEDURES
that is important for loading rather than osseointegra- There are two conventional impression techniques
tion. Therefore, many clinicians are placing the abut- used for dental implants:
ment and a provisional crown at the same visit as the • open-tray impression
placement of the implant fixture. Usually, this is done • closed-tray impression
when the implant is long and wide enough to engage
sufficient bone in the socket and beyond to have a sta- Open-tray impression. The open-tray impression (also
ble fixture. If needed, bone grafting material is packed called a pick-up impression because it picks up the abut-
around the fixture to provide additional stability. ments in the impression) is the easiest for the inexperi-
Loading of the implant under chewing forces, then, oc- enced clinician (Fig. 12.9). With this procedure a plastic
curs before integration of the fixture with the sur- impression tray is tried in for fit to the arch. Then, the
rounding bone. However, forces still need to be con- impression abutments are attached to the implant fix-
trolled, distributed, and directed along the long axis of tures. The plastic tray is reinserted into the mouth, and
the implant. the location of the abutments is marked on the tray. An
If the surgical procedure is performed in accordance acrylic bur in the straight handpiece is used to cut a
with a careful protocol and the fixture is very stable, window in the tray over the abutments, so the ends of
then the success rate for implants with immediate the abutments can be accessed when the tray is in
loading is equivalent to that of implants with conven- place. Next, the impression is made. Usually, polyether
tional loading (after healing), according to a meta-anal- or polyvinyl siloxane impression materials are used. A
ysis (i.e., a review of many similar but independently rigid heavy-body material is used in the tray and a
conducted experiments). This finding applies to rough- light-body material is syringed around the impression
surface implants for single-unit crowns or short-span abutments. After the tray is seated, a gloved finger is
fixed bridges. However, conventional loading is still used to wipe impression material away from the ends
recommended for mandibular overdentures support- of the abutments that are accessed through the hole in
ed by two implants. the tray. The tray is stabilized until the impression ma-
terial has fully set. A screwdriver (hex driver) is used
to disengage the abutments from the fixtures, and the
RESTORATIVE PHASE tray is removed. The abutments will come out in the
Restoration of a single-tooth implant is usually impression. The impression is inspected to determine
achieved with a prosthetic crown. With one- or two- that the abutments are properly seated and that the im-
stage procedures, once the soft tissue has healed pression has captured all of the structures needed. Be-
around the top of the implant, the impression for the fore the impression is poured in die stone, implant an-
crown can begin. Dental assistants/hygienists may alogs will be attached to the abutments. The analogs
need to become familiar with the implant impression will be locked in the cast in the same position as the
techniques and the impression and laboratory compo- implant fixtures are in the mouth. The laboratory tech-
nents, because they may be called on to assist the den- nician can then fabricate the implant abutments and
tist with the impressions and pour the impressions, or, crowns.
if allowed by state dental practice acts, may be asked to The open-tray procedure cannot be used if there is a
make the impressions. lack of interarch space to allow access to unscrew the
abutments.
IMPLANT IMPRESSION AND LABORATORY
COMPONENTS Clinical Tip
Some components are used during the impression- When making an open-tray impression, be sure to wipe
making process to facilitate the correct alignment of away impression material from the ends of the abutments
after the tray is fully seated. Otherwise, you will be frantically
the implant to the cast. An impression abutment (also
searching for the abutments in set material! Don’t forget to
referred to as the impression post, transfer post, or im-
fully loosen the abutments fully before removing the tray!
pression coping) is attached to the implant fixture (see
 A B

C D

E F

G H
FIG. 12.9 Open-tray impression procedure. A, Screw impression abutment into the implant fixture. B, Select a plastic impression tray to fit the arch.
C, Cut a hole in the tray over the top of the impression abutment to allow access to it after the impression material is placed. D, Monophase or light-
bodied impression is syringed around the abutment and heavy-bodied impression material is placed in the tray, and then the tray is seated. E, Impres-
sion material is wiped away from the abutment through the hole in the tray. F, After the impression material has set, unscrew the impression abutment
before removing the impression. G, Impression with impression abutment in place. H, Carefully attach the implant analog to the end of the impression
abutment, making sure it does not shift position within the impression. When poured in stone, the analog will represent the implant fixture
(see Fig. 12.3, C). (Courtesy of Arun Sharma, University of California San Francisco School of Dentistry.)
250 CHAPTER 12 Dental Implants

Closed-tray impression. With the closed-tray impres- out. If they are tightened too much, the metal of the
sion (also called a transfer impression), there is no hole screw might be strained to the point of breaking. Spe-
cut in the impression tray. The impression abutments cial wrenches called torque wrenches are set to deliver
are screwed to the fixtures and the impression is made the recommended amount of force to tighten the
using the same types of materials as with the open-tray screws (typically about 35 N).
procedure (Fig. 12.10). When the set impression is re- Screw-retained crowns require an access hole in the
moved from the mouth, the abutments remain in the crown (see Fig. 12.3, D and Fig. 12.12, A) for placement or
mouth, attached to the fixtures. The abutments are re- removal of the screw. After the screw is tightened, a soft
moved from the fixtures, and then the implant analogs material such as cotton, gutta percha, or Teflon tape is
are attached to them. The abutments are reinserted placed over the screw head (to make retrieval easier), and
into the impression in their proper orientation. Some then a restorative material, usually composite, is placed
clinicians like to syringe some soft tissue-simulating into the hole (see Fig. 12.3, E). The composite may wear or
material around the neck of the analog before pouring stain with time and may need replacement.
the impression (Fig. 12.10, panels E-H). (This material
will act as gingiva around the analog and is more eas- Cement-retained implant crowns. Cementing the im-
ily trimmed for laboratory procedures than stone.) The plant crown (Fig. 12.13) is a much more popular tech-
impression is poured in stone and the cast will look the nique, particularly for anterior crowns. If the crown is
same as with the open-tray procedure. cemented with permanent cement, it will not likely be
The biggest drawback of the closed-tray procedure retrievable. But if it is cemented with provisional ce-
is the potential source of error if the abutments are not ment, then retrievability is possible. The downside is
placed back into the impression fully or in their proper that the crowns may come off unexpectedly. It is very
orientation. important to ensure that no cement remains under the
tissue. Cement remnants could cause peri-implantitis
Digital impressions. Digital impression techniques will and loss of the implant (Fig. 12.14).
be discussed in detail in Chapter 15, Impression Materi- If an implant is not aligned properly, it is easier to
als. Intraoral scanners that can take digital images of the use a cemented crown to correct the misalignment
oral structures have been available for over a quarter of a than a screw-retained crown. With the screw-retained
century. This technology can be applied to capturing im- crown the access hole may end up in an undesirable
ages of implant components for purposes of fabricating location such as on the facial surface in order to make
custom implant abutments and crowns. The precise lo- up for the misalignment.
cation of the implant can be captured as well as the inter-
Caution
nal details of the head of the fixture that has anti-rotation
and seating orientation features for the abutment. After cementing an implant crown, it is critically important to
For the digital impression, a scannable impression ensure that all cement has been removed from the gingival
sulcus. Cement retained under the gingiva can lead to
coping is placed into the implant fixture and its seating
infection and loss of the implant!
verified with a radiograph. The scan is made and
checked to see that all necessary components have
been captured: opposing teeth, bite registration, con-
tact areas of adjacent teeth, and gingival contours (Fig. RETENTION OF THE REMOVABLE PROSTHESIS
12.11). The laboratory prescription is completed con- Implants can be used to support a partial or full den-
taining the tooth shade and abutment and crown mate- ture. In the mandible, atrophy (loss of bone through
rials. The scan and prescription can be transmitted by resorption) of the alveolar ridge is common in patients
way of the internet allowing the laboratory to start who have lost teeth at a relatively young age. A com-
work immediately without having to produce models plete denture often has very little retention in this cir-
for the abutment or crown. cumstance. Implants are a viable option for support
and stability of the prosthesis (Fig. 12.15). They can
RETENTION OF THE IMPLANT CROWN. also be used to anchor a prosthesis used to replace
Implant crowns can be retained by screws or by ce- missing facial parts, such as a nose, eye, or ear lost to
menting. There are pros and cons with each type of trauma or cancer surgery (see Chapter 17 Polymers for
retention. Prosthetic Dentistry, Fig. 17.22).

Screw-retained implant crowns. The implant crown

MINI-IMPLANTS
can be attached to the implant fixture core by a small
screw often made of titanium alloy or gold alloy (Fig. Mini-implants (also called narrow-body implants) are
12.12). Screw-retained crowns are retrievable so that smaller in diameter than conventional implants and
the implant fixture or abutment can be evaluated or the typically range in diameter from 1.8 to 2.9 mm. They
crown replaced or repaired. However, if screws are can be placed in sites where the available bone would
used and are not tightened properly, they may come be inadequate for conventional implants. They are
 Dental Implants CHAPTER 12 251

A B C

D E F

G H I

J K L

M
FIG. 12.10 Closed-tray impression technique for a single implant crown. A, Impression abutment in place in the implant
fixture. B, Closed-tray impression showing imprint of the impression abutment. C, Impression abutment (on left) has
been removed from the mouth and is next to the implant analog. D, Impression abutment is attached to the implant
analog. E, Impression abutment is seated into its imprint in the impression. F, Soft tissue simulation material is placed
around the top of the implant analog before casting in dental stone. G, Poured cast with the impression abutment show-
ing. H, Implant analog can be seen after the impression abutment has been removed. Impression abutment positions the
analog the same way the implant fixture is in the mouth. I, Soft tissue material can be shaped to develop the emergence
profile of the crown. J, Ceramic abutment selected. K, Zirconia abutment seated on the cast for crown fabrication. L,
Zirconia abutment seated in the mouth. M, Ceramic crown cemented on the abutment. (From Rosenstiel SF, Land MF:
Contemporary Fixed Prosthodontics, ed 5, St. Louis, 2016, Elsevier.)
252 CHAPTER 12 Dental Implants

A B
FIG. 12.11 Digital impression for fabrication of implant abutments and cantilevered bridge #7-10. A, impression abutments on implant fixtures #8 and 9.
B, digital impression scan captured the impression abutments, gingival contours, opposing teeth, bite relationship and proximal contact areas of adjacent
teeth. (Courtesy Sang J. Lee, DMD, MMSc.)

retention from the mini-implant and O-ring (Fig.

12.16). Another system (Locator Overdenture Implant
System; Zest Anchors) uses a replaceable retentive
head on the implant that engages a retentive cap placed
A in the denture base instead of an O-ring.
Mini-implants are also used in sites with minimal
bone that could not accommodate a conventional im-
plant unless grafting was done. They are used to replace
teeth with narrow roots such as lower incisors or upper
lateral incisors, and then they are restored with a crown.
Conventional implants are often too wide for these sites.
B A growing use for mini-implants is as temporary anchor
devices (TADs) in orthodontic treatment when adequate
FIG. 12.12 Assembly of implant components. A, Screw-retained implant anchorage is not naturally present (Fig. 12.17). They are
crown with implant fixture and retaining screw. The screw-access hole
can be seen on the lingual surface of the crown, and the implant abut- even smaller than the typical mini-implant, with diam-
ment can be seen at the apical end of the crown. B, Crown retained eters ranging from 1.2 to 2.0 mm. They can be useful to
on implant fixture by the screw. (Courtesy of Fritz Finzen, University of move molars distally, intrude them, or to help close
California School of Dentistry [San Francisco, CA].) open bites. The TADs are used short-term (about 6 to 12
months), and then are easily removed.

minimally invasive in that a soft tissue flap is usually

not needed and the hole made by the implant is much BONE GRAFTING
smaller than conventional implants. Healing is faster
with less discomfort. The survival rates for mini-im- PURPOSE OF BONE GRAFTING
plants are similar to conventional implants, ranging In order for a dental implant to be successful it must
from 91% to 96%. They are less costly than conven- be anchored in an adequate amount of bone to with-
tional implants, because they require less of a surgical stand the forces placed on it. Bone grafting is needed
procedure and can be placed in one visit. Two to four when the proposed implant site lacks an adequate
mini-implants can be placed by an experienced oper- amount and quality of bone. Common bone graft
ator in under 2 hours, using local anesthesia. Com- procedures are done to increase the width or height
monly, they are loaded immediately after placement. of bone at the implant site.
One type of bone grafting is done before placement of
USES FOR MINI-IMPLANTS the implant. The alveolar ridge may be deficient in bone,
One of the main uses for mini-implants is to stabilize a in width or height, or both. Grafting can help to replace
denture. One system (MDI; 3M ESPE) has a ball on the the lost bone. The use of three-dimensional imaging, such
head of the implant that engages an assembly placed as cone beam CT, can help the dentist determine which
in the denture base with a rubber O-ring that snaps sites are deficient in bone. In addition, in the upper poste-
over the ball when the denture is fully seated. The den- rior arch the maxillary sinus may be positioned too close
ture rests gently on the ridge and gains support and to the alveolar ridge so that there is not enough bone to
 Dental Implants CHAPTER 12 253

A C
FIG. 12.13 Single-tooth implant with a cemented crown. A, Radiograph of fixture in bone and the attached implant abut-
ment. B, Abutment is attached to the fixture by a screw. C, Crown is cemented onto the abutment. (Courtesy of Mark
Dellinges, University of California School of Dentistry, San Francisco, CA.)

TYPES OF BONE GRAFTS

Bone graft materials can come from the patient’s own
body, from a tissue bank with freeze-dried bone
from another person, from animal bone components
(usually bovine), or from synthetic bone materials. The
most effective graft material comes from the patient’s
own body. Freeze-dried human bone is next in effec-
tiveness followed by animal bone, and then synthetic
bone materials. These basic types of bone grafts can be
put into four general categories:
• autografts
• allografts
FIG. 12.14 Peri-implantitis resulting in bone loss around the dental
implant. (Courtesy of Toronto Implant Institute.) • xenografts
• alloplasts

place an implant. Bone grafting is done to develop ade- Autografts. Autografts are those harvested from the pa-
quate bone for placement of the implant. tient’s own body. Typical sites for harvesting this bone
Another type of bone graft is done at the time of im- are the back of the lower jaw (ramus), chin, hip (iliac
plant placement. It is done when there is generally suf- crest), or shin (tibia). This grafting material is very ef-
ficient bone for implant placement, but some portion fective, because it contains the patient’s own bone mar-
of the implant may not be completely covered with row with cells that can promote bone growth and heal-
bone. Graft material is placed to cover the exposed ing. The negative aspect is that it requires another
parts of the implant. Still another use for bone grafting surgery with a certain amount of discomfort, healing
is when an implant is placed in the socket immediately time, and expense.
after a tooth is extracted. Bone graft material is placed
in the socket around the newly placed implant to help Allografts. Allografts are human bone taken from do-
stabilize it and to stimulate new bone to fill in the sock- nors who have donated body parts at the time of their
et and integrate with the implant. death (cadaver bone). The bone is rigorously washed
254 CHAPTER 12 Dental Implants

A B

C D
FIG. 12.15 Implant-supported denture. Implants were used because the ridge had resorbed and was inadequate to retain
the denture. A, Implants supporting a connector bar onto which a lower denture will attach. B, A metal clip inside the den-
ture slides over the bar (A) to retain the denture. C, Lower denture supported by the implants. D, The implants and the bar
are cleaned with a brush. (Courtesy of Fritz Finzen, University of California School of Dentistry, San Francisco, CA.)

A B
FIG. 12.16 Mini-implants. A, MDI mini-implant (3M ESPE) with housing that is secured to the inside of the denture.
The rubber O-ring resides in the housing and snaps over the ball on the head of the implant for retention. B, Complete
denture is retained by the mini-implants. (Images Courtesy of 3MTM ESPETM MDI Mini Dental Implants, 2010. All rights
reserved.)

and sterilized. It is freeze-dried and stored in a tissue (Nobel Biocare), MinerOss (BioHorizons), and DFDB
bank. The rigorous processing protocol eliminates con- (Biomet).
cerns of transmitting disease from the donor to the re-
cipient. Allograft materials that are commercially avail- Xenografts. Xenograft material is obtained from ani-
able include Puros (Zimmer Dental) (Fig. 12.18), CreoS mals, usually cows (bovine bone), but occasionally
 Dental Implants CHAPTER 12 255

A B
FIG. 12.17 Temporary anchor devices (TADs) are used when there is not enough anchorage in the natural dentition to
orthodontically move teeth. They are removed after tooth movement is complete. A, TADs for additional anchorage for retrac-
tion of teeth. B, TAD anchor for molar uprighting. (Courtesy of Jesse Patino, University of California, San Francisco, CA.)

Table 12.1    Bone Graft Materials

TYPE MATERIAL SOURCE
Autograft Human bone (host) Iliac crest (hip)
Ramus (posterior
mandible)
Tibia (shin)
Mandibular tori
Allograft Cadaver bone CreroS (Nobel BioCare)
(Fresh, freeze MinerOss (BioHorizons)
dried, demineral- Puros (Zimmer Dental)
ized freeze dried)
Xenograft Mainly bovine bone BioOss (Geistlich)
or porcine Zcore (Osteogenics)
MinerOssX (BioHori-
zons)
FIG. 12.18 Allograft cadaver bone in granules and large and small Alloplast Hydroxyapatite Novabone (Novabone
pieces. (Puros, Zimmer Dental.) Bioactive glass Products)
Calcium phosphate PerioGlass (Novabone
pigs (porcine bone). The bovine bone is very similar in Calcium sulfate Products)
structure to human bone, so it works well for grafting. SynOss (Collagen Matrix)
The bovine graft material is processed to make it sterile
and biocompatible. Only the mineral components are Potential risks with bone grafting
used, and it acts as a matrix or filler around which new
bone grows (Fig. 12.19). Xenograft materials include •  leeding
B
Bio-Oss (Geistlich), PepGen P-15 (Dentsply Sirona), • Infection
• Postoperative pain
and Endobon Xenograft Granules (Biomet 3i).
• Nerve damage causing numbness in lips, gums, and
cheek
Alloplasts. Alloplasts are inert, synthetic materials that • Sinus problems with sinus lift or implant encroaching on
stimulate new bone growth. They are commonly com- sinus
posed of calcium phosphate or hydroxyapatite, com- • Swelling and bruising
ponents found in human bone (Fig. 12.20). Often the • Inadvertant damage to adjacent teeth or tissues
material is mixed with the patient’s bone marrow or
with growth factors to stimulate bone activity. It also
acts as a matrix or scaffold on which new bone is laid. Newer Additions to Grafting
Some types of alloplastic graft material are resorbed by Bone grafting has been enhanced by the use of human
the body and some types are not resorbed. growth factors, such as bone morphogenetic proteins or
Common synthetic graft materials include Bioplant platelet-derived human growth factor, which can stimu-
(Kerr Dental), Gem 21S (Osteohealth), and IngeniOs late new bone growth. Bone morphogenetic protein (BMP)
(Zimmer Dental). can induce rapid bone growth from the body’s own
256 CHAPTER 12 Dental Implants

A B

FIG. 12.19 Xenograft mineral granules used for bone graft. A, Granular xenograft bone substitute material (also available in
blocks). B, Edentulous site with inadequate bone for implant. C, Xenograft granular bone substitute material packed around
newly placed implant fixtures. (A, Image used with the courtesy of Geistlich Pharma AG [Wolhusen, Switzerland]. B and
C, Image used with the courtesy of Prof. Dr. M. Chiapasco [Milan, Italy] and Geistlich Pharma AG [Wolhusen, Switzerland].)

Studies are showing that autogenous bone grafts with

growth factors are producing the best results compared
with other graft materials. The other graft materials lack
the live cellular material possessed by autografts.

BARRIER MEMBRANES
At times it is beneficial to cover a bone graft with a
protective barrier. The barrier membrane is in the form
of a thin membrane that prevents fibrous tissue from
growing into the site where bone is needed, and it pre-
vents the graft material from being lost from the graft
site (Fig. 12.21). The barrier membrane can be made of
resorbable or nonresorbable materials. Both types are
well tolerated by the tissues.
Resorbable membranes are composed of materials
derived from collagen. The ideal situation is to be able
to cover the membrane with a soft tissue flap (primary
closure), but this is not always possible. Even when not
FIG. 12.20 Alloplast synthetic bone made from hydroxyapatite (HA).
covered by a flap, the collagen-type membrane will
(Courtesy of Zimmer Dental.)
stick to and integrate with the surrounding soft tissue.
mesenchymal cells (a process called osteoinduction). Some Nonresorbable membranes (such as polytetrafluoro-
commercial products containing BMP include Regenafil ethylene, also known as Teflon) are often chosen when
(Exactech), OP-1 (Stryker Biotech), and Infuse (Medtron- the graft site will be exposed to the mouth. They are
ics). Also, stem cells can be saved in human allograft mate- removed in approximately 3 weeks.
rials, and they can accelerate the formation of new bone.
For years orthopedic surgeons have used the pa- SINUS LIFT
tient’s own blood components, called platelet-rich fibrin, A sinus lift is a surgical procedure that adds bone in
to promote bone growth and healing. Some oral sur- the molar and premolar region when the maxillary si-
geons like to use it in their grafting procedures for the nus has extended into that area, bone has resorbed
same purposes. from the alveolar ridge after teeth were lost, or both.
 Dental Implants CHAPTER 12 257

A B

C D

E F
FIG. 12.21 Barrier membrane placed to protect bone graft. A, Presurgical edentulous site. B, Gingival flap reflected. C, Bovine
collagen barrier membrane trimmed, hydrated, and placed over graft material. D, Gingival flap sutured over bone graft and barrier
membrane. E, Surgical site 4 months postoperative. F, Provisional restoration placed on dental implant. (From Jaypee Journals,
Copyright 2013 Jaypee Bros Medical Publishers Article: Comparison of Guided Bone Regeneration using a Bovine Collagen
Membrane vs a Calcium Sulfate Barrier, Ghaly M, Kerns DG, Hallman WW, et. al. Jaypee Journals, 2013; 3(3), 138-143.)

Expanded
sinus

Sinus Bone graft Granules fill New Implant

A membrane granules the space bone fixture

B C D E F G
FIG. 12.22 Sinus lift procedure and implant placement. A, Maxillary sinus expanded into edentulous space reducing the
amount of bone at the ridge. B, frontal section through the sinus and ridge. C, Entry is made through the lateral sinus
wall and an instrument is used to lift the sinus membrane off the sinus floor. D, Bone grafting granules are placed on the
sinus floor. E, Graft material fills the space that was created. F, New bone formed around the graft material. G, Adequate
bone is present and an implant fixture is placed.

An oral surgeon or a periodontist usually does the sur- could be perforated or torn and ­require closure with su-
gery. For the procedure, a soft tissue flap is raised to ex- tures or a barrier membrane. The patient’s bone may fail
pose the bone. The bone is cut to create a window to the to integrate with the graft material and the graft may fail
floor of the maxillary sinus. An instrument is used to to develop a blood supply. These complications may ne-
separate the sinus membrane from the bone and lift it up. cessitate additional surgery or may preclude placement
Bone graft material is placed into the space created by lift- of an implant in that site.
ing the sinus membrane. The soft tissue flap is reposi-
tioned and sutured. New bone will form around the graft
SUTURES
material. The area is allowed to heal (typically 4 to 6
months) before an implant is placed in the site (Fig. 12.22). Extraction of teeth, placement of implant fixtures,
As with any surgery, there can be complications, and the bone grafting, and sinus lift procedures often require
patient needs to be informed of these and give informed sutures. The dental assistant or hygienist frequently
consent before the surgery. There can be problems with will assist in placement of sutures and may be asked
infection, bleeding, and swelling. The sinus membrane to remove them (as permitted by state dental practice
258 CHAPTER 12 Dental Implants

FIG. 12.24 Synthetic polyglycolic acid sutures, size 3-0 (Vicryl, Ethicon
Inc.) are made from a biodegradable thermoplastic polymer. (Courtesy
of Matt Crimaldi.)

FIG. 12.23 Chromic gut sutures, size 4-0 derived from animal collagen.

acts) after initial healing has occurred. It is important

for these dental auxiliaries to know why sutures were
needed, which suture materials were used, how long
they should remain in place, what to do if sutures
come out prematurely, and which suture materials
need to be removed or will absorb on their own.
Sutures, also known as stitches, are used to hold tis- FIG. 12.25 Non-absorbable suture made of braided silk, size 3-0.
sues together so they can grow together or to reposition
tissues after trauma or surgical procedures. Initial healing include surgical silk (Fig. 12.25), polyester fiber and
is considered the point at which sutures are no longer nylon.
needed, typically 7 to 10 days. Until initial healing has
occurred sutures aid in bleeding control and prevent Characteristics of Sutures
blood clots from being dislodged after tooth extraction. Sutures may be a single filament or multifilament in a
braid or twist. The diameter (size) of sutures is identi-
TYPES OF SUTURES fied by a number of zeros. The sizes range from 0 (ought)
Sutures can be made from a variety of materials con- to 8-0 (eight ought). The size of the suture declines as the
sisting of those that are naturally occurring and those number increases such that 8-0 is smaller than 2-0.
manufactured from man-made materials. The two cat-
egories of sutures are absorbable and non-absorbable. Needles
In order to place sutures the filament is pulled through
Absorbable Sutures the tissue with a needle (Fig. 12.26).
Absorbable sutures do as the name indicates; they are Needles come in a variety of shapes and sizes. The ma-
broken down by the body’s proteolytic enzymes and jority of needles used in dentistry are curved in an arc.
absorbed, thereby eliminating the need for a second Needles are tapered with a round cross-section or cutting
removal appointment. Absorbable sutures include with a triangular cross-section. Cutting needles have a
synthetic polyglycolic acid and surgical gut in plain or sharp triangular apex. Those with the cutting surface on
chromic. Surgical gut sutures are composed of purified the bottom of the triangle are called reverse cutting.
collagen taken from the serosal or submucosal layer of Needles are predominately composed of stainless
intestines from cattle, sheep, or goats. With chromic steel. Needles can have an opening (eye) that the su-
gut sutures the collagen has been treated with chromic ture material passes through and a knot is tied to hold
acid which almost doubles the length of time over the suture to the needle.
plain gut before they absorb (Fig. 12.23). Synthetic The second needle option does not have an eye and is
polyglycolic acid (Vicryl) (Fig. 12.24) sutures are made called a swaged needle. The end opposite the sharp tip is
from a biodegradable thermoplastic polymer. a tube that the suture material is inserted and the tube
crushed (swaged) onto the suture binding it to the needle.
Non-Absorbable Sutures Due to the absence of a knot, swaged needles pass through
Non-absorbable sutures are not absorbed by the body’s en- the tissue more easily and cause less tissue damage.
zymes and must be removed at a later appointment. See
Procedure 12.1 for suture removal technique. If not re- Suturing Techniques
moved the body will see the sutures as a foreign body and Interrupted sutures are those placed where each stitch
initiate the inflammatory process. Non-absorbable sutures is tied and knotted separately. Examples include
 Dental Implants CHAPTER 12 259

A B

FIG. 12.26 Suture needle attached to suture. (From Hupp JR, Ellis E III,
Tucker M: Contemporary oral and maxillofacial surgery, ed 6, St Louis,
2014, Mosby.)

C
single interrupted suture and mattress interrupted
suture. The continuous suture is a series of sutures
made with one thread that is tied at the beginning
and end of the series. Examples include the continu-
ous blanket suture and the simple continuous suture.
(Fig. 12.27)

IMPLANT LONGEVITY
IMPLANT FAILURE D E
Early failure of an implant is usually due to failure of FIG. 12.27 Types of suturing techniques. A, Interrupted sutures. B,
the bone to integrate with the implant. Lack of integra- Continuous suture. C, Vertical mattress suture. D, Horizontal mat-
tion can be due to poor surgical technique, lack of tress suture. E, Continuous box suture. (From Singh PP, Cranin AN:
proper infection control, excessive generation of heat Atlas of Oral Implantology, ed 3, St. Louis, 2010, Mosby. In Bird
DL, Robinson DS: Modern Dental Assisting, ed 11, St. Louis, 2015,
when the implant hole is drilled in the bone; infection Elsevier.)
of the implant site; poor quality of bone; or placement
of loading forces too soon on the implant. Failure of the
implant that occurs after the initial integration is often
caused by bacterial infection extending from the peri- LONG-TERM SUCCESS
implant tissues into the bone, or overloading of the im- Long-term success is found with implants that have
plant during function, leading to loss of the supporting i­ntegrated with the bone, and when the implant com-
bone. ponents are kept clean, the surrounding gingiva is
maintained in a healthy state, and forces on the im-
Potential Adverse Outcomes from Implant plant are not excessive and are aligned with the im-
Placement plant. Forces on the implant must be properly man-
aged. Because the implant has no periodontal ligament,
•  ailure of implant to integrate with bone
F
patients cannot sense how much pressure they are ap-
• Loss of integration
• Infection around the implant
plying to the implants. Therefore, forces must be dis-
• Systemic infection tributed across the arch to other teeth or prostheses.
• Perforation of maxillary sinus, nasal cavity, inferior alveo- Excessive force can result in loss of bone around the
lar canal, buccal or lingual cortical plate of bone implant as well as fracture of ceramic crowns, denture
• Inadequate sterility of implant fixture, leading to infection bases, denture teeth, and implant components. Bruxers
and implant loss can stress the implant components to the point of frac-
• Heat damage to bone during drilling for implant site ture, resulting in implant failure. Occlusal guards are
• Improper angulation of implant that compromises es- often indicated for bruxers.
thetics or function When the negative factors are well controlled, implants
• Damage to adjacent teeth during implant placement have success rates of 95% or more and the implant crowns
• Nerve damage
may last 10 to 20 years or more. Complete and partial den-
• Lingering numbness or pain
tures may need replacement as teeth wear or bases break.
260 CHAPTER 12 Dental Implants

IMPLANT MAINTENANCE and work with the dentist and dental hygienist to im-
plement an effective tissue management program. The
In addition to its interface with the bone, the implant dental hygienist plays an integral role in helping the pa-
has an interface with the soft tissue, where it protrudes tient maintain the health of the implants and in reinforc-
through the gingiva or mucosa. Although no connective ing home care techniques. Likewise, the dental assistant
tissue fibers (i.e., periodontal ligament or junctional epi- can reinforce oral hygiene techniques when the patient
thelium) are connected to the implant surface, as they comes in for periodic examinations or treatment.
are to the cementum on the root surface of a natural
tooth, close adaptation and attachment of the sulcular HOME CARE
epithelium to the implant surface are noted (Fig. 12.28). Patients should thoroughly clean the implant surfaces
This close adaptation helps to develop a biological seal no less than once a day. If the patient has an implant-
that prevents microorganisms from invading the tis- supported complete or partial denture, the prosthesis
sues. The implant surface can accumulate bacterial should be removed to facilitate cleaning of the implant
plaque and calculus, just as teeth do. If this occurs, the and the prosthesis. The number and type of implants
tissues surrounding the implant (peri-implant tissues) and the prostheses used for restoration will vary from
will become inflamed, much like the gingiva around the patient to patient. Therefore it is important to custom-
teeth. If not controlled, this inflammation and bacterial ize the home care regimen for each patient. Home care
invasion can progress into the bone (peri-implantitis) aids that are beneficial to patients with implants in-
surrounding the implant and can contribute to its loss. It clude a variety of each of the following:
is critically important to the success of the implant that • Disclosing agents
the patient employ meticulous oral hygiene techniques • Brushes

FIG. 12.28 Gingival adaptation to titanium dental implant compared to that with a natural tooth. (Courtesy Dear Doctor,
Inc., Hopewell Junction, New York.)
 Dental Implants CHAPTER 12 261

• F losses interproximal cleaning (Fig. 12.31). It can be soaked in

• W  ooden plaque removers chemotherapeutic agents to deliver them to specific
• Antibacterial agents sites.

Disclosing Agents Flosses. Several types of flosses are available. Regular-

Plaque-disclosing agents can help patients visualize thickness floss, dental tape, flossing cord, knitting
the location of plaque in difficult-to-reach areas. yarn, twill tape (from fabric stores), gauze strips, and
These agents should be used daily for the first few fuzzy-type floss with threader (Oral-B Superfloss;
weeks until the patient becomes more proficient in Procter & Gamble) all have applications for plaque re-
keeping the implants clean, and then periodically to moval, depending on the nature of the implants and
check on the effectiveness of hygiene techniques. The the overlying prosthesis (Fig. 12.32). Floss threaders
patient should be given a disposable mouth mirror to are helpful for carrying floss under prostheses such as
help visualize all areas of the mouth. Adequate light- implant-supported complete dentures or fixed bridg-
ing is important also. es, particularly where access is difficult.

Brushes. Gentle sulcular brushing is recommended to Wooden plaque removers. Balsa wood triangular sticks
help maintain peri-implant tissue health. Brushes also (e.g., Stim-U-Dents [Revive Personal Products]) and
need to be positioned at a variety of angles to clean toothpicks can be used with care to aid in plaque re-
around and under the prosthesis. In many cases con- moval. These items will not scratch implants.
ventional toothbrushes can be used, but selection of
brushes will depend in part on the number and spac- Antibacterial agents. Chlorhexidine gluconate solution
ing of the implants. For single-tooth implants, as well (0.12%) (such as Peridex [3M ESPE]) is an effective anti-
as for implant-supported fixed bridges, interproximal bacterial agent. It may be used as a rinse for about a week
brushes are helpful for reaching between the implant after implant placement or during the second surgical
and the adjacent tooth or pontic (artificial replacement
tooth that is part of a fixed bridge). Interproximal
brushes that have a plastic coating on the wire holding
the bristles together are recommended to avoid scratch-
ing the implant (Fig. 12.29). End-tuft brushes can be
helpful when the space between implants is greater
than is practical for interproximal brushes (Fig. 12.30).
For most brushes with plastic handles, the angulation
of the brush head can be altered by heating the handle
in hot water and bending it to the desired angle. Pa-
tients who have problems with manual dexterity be-
cause of arthritis, stroke, or other medical problems
can use power brushes. Rotary brushes with bristles
forming a point are useful for reaching between im-
plants that are spaced far apart. If a dentifrice is used,
one should be selected that is not abrasive. A foam tip FIG. 12.30 End-tuft brush to clean implant. (Reprinted by permission from
(Oral B, Procter & Gamble) is also useful for Endosteal Dental Implants, St. Louis, 1991, Mosby, Figure 31-6, p. 404.)

A B
FIG. 12.29 A, Interproximal brush used to clean implant. B, Nylon-coated proxy brush to clean between individual
implants. (A, Reprinted by permission from Endosteal Dental Implants, St. Louis, 1991, Mosby, Figure 31-6, p. 404 B,
From Darby ML, Walsh MM: Dental Hygiene: Theory and Practice, ed 4, St. Louis, 2015, Elsevier.)
262 CHAPTER 12 Dental Implants

the sulcus around the implant to help ­manage bacteria.

Orally administered doxycycline hyclate (Periostat, 20-
mg tablets; Galderma Laboratories) t­aken twice a day
may help to manage the inflammation.

Home Care Aids for Implant Patients

Brushes
Regular soft-bristled toothbrush
FIG. 12.31 Use of foam tip for cleaning interproximal surfaces of an Interproximal brush with plastic-coated wire
implant. (Courtesy Procter & Gamble.) End-tuft brush
Power brushes: Standard or rotary with pointed brush tip
Flosses
Regular floss or tape
Yarn or Superfloss
Cord
Twill tape
Gauze strips
Wooden sticks
A Balsa wood sticks (Stim-U-Dents [Revive Personal Prod-
ucts])
Toothpicks
Antibacterial agents
Chlorhexidine solution
Phenolic compound rinse (Listerine; Johnson & Johnson)

HYGIENE VISIT
The patient should return to the dental office 3 to 4
months after implant placement for assessment and
B maintenance. The interval between subsequent visits
FIG. 12.32 Floss threader used to pass floss under a bridge. A, Use of should be based on how well the patient is doing with
floss threader to go under a bridge pontic B, Superfloss used to clean oral hygiene measures, the health of the peri-implant tis-
under implant-supported bridge. A, Floss passed under the connector sues, and how rapidly calculus accumulates. At the main-
between the implant and the pontic B, Superfloss used to clean the
tenance visit, review of the health history and vital signs
proximal surfaces of the implant and pontic. (A. From Babbush CA:
Dental implants: the art and science, Philadelphia, 2001, Saunders. B. and examination of extraoral and intraoral structures are
Courtesy Procter & Gamble.) conducted in the same manner as for patients without
implants. However, questions specific to implants should
stage when the implant is uncovered. It is also useful be asked, such as those involving the presence of implant
when inflammation is found in peri-implant tissues after mobility, soreness, bleeding of peri-implant tissues, pain
placement of the prosthesis. It is often used as a 30-­second with chewing, and looseness of the prosthesis.
daily rinse for 1 to 2 weeks. It can also be applied directly
to the problem site on an interproximal brush, end-tuft Radiographic assessment. The dentist may request pe-
brush, foam tip, or cotton swab. Frequent use of chlorhex- riodic radiographs to check the bone level surrounding
idine will cause brown staining of the prosthesis and the implants. It is common in the first year for about 1
natural teeth. An alternative antibacterial agent that is mm of crestal alveolar bone to be lost around the top of
beneficial in controlling gingivitis but is not as effective the implant. Conventional bitewings may not extend
as chlorhexidine is a phenolic compound (e.g., Listerine; far enough apically to capture the bone around the
Johnson & Johnson) (see Chapter 7 Preventive and De- crest of the implant, and therefore vertical bitewings
sensitizing Materials). Oral irrigation may be used to de- should be used. Periapical radiographs alone usually
liver antibacterial solutions, but it should be used at low are angled, so the true level of the bone around the top
pressure and not directed into the sulcus. If the pressure of the implant cannot be determined.
used is too high, damage to the biological seal between
the epithelium and the implant may occur. Visual assessment. The hygienist should perform a vi-
When a patient has inflammation around the im- sual inspection of the peri-implant soft tissues to
plant that is not responding to good oral hygiene mea- e­valuate for edema (swelling), erythema (redness),
sures and hygiene visits, then prescription antibacterial ­bleeding with gentle probing, recession, and other in-
agents may be needed. Arestin (OraPharma) is a pow- dications of a developing problem. Exudate (pus) may
der of slow-releasing minocycline that can be placed in be discovered upon probing or palpation of the area
 Dental Implants CHAPTER 12 263

A B
FIG. 12.33 Use of plastic probe around implant. A, Plastic probe for measuring sulcus around implant. B, Probe measur-
ing sulcus without scratching implant (Sensor Probe, Pro-Dentec, courtesy of J. Kleinman). (From Darby ML, Walsh MM,
Dental Hygiene: Theory and Practice, ed 4, St. Louis, 2015, Elsevier.)

with a cotton-tip applicator. Usually, when these signs

are limited to the tissue around the top of the implant,
it is caused by bacterial plaque on the implant. Prob-
lem areas can be pointed out to the patient, and a re-
view of oral hygiene techniques should be done. If the
patient has a particular problem area, alternative clean-
ing aids and techniques can be recommended.

Probing. At one time probing was not recommended for

fear of damaging the epithelial cuff around the implant
and introducing bacteria into these tissues. However,
the current consensus is to perform gentle probing at
maintenance visits. When probing of the peri-implant FIG. 12.34 Titanium scalers for titanium implants. (Courtesy of Hu-
Friedy Manufacturing Company, Inc., Chicago.)
sulcus is done to check the status of an implant, it should
be done with a light touch and a plastic probe (e.g., Col-
orvue Probe [Hu-Friedy] or Sensor Probe [DenMat]) so avoid damage to the surface of the implant. Titanium
as not to disturb the biological seal and scratch the im- scalers are preferred because they will not scratch the ti-
plant surface (Fig. 12.33). The plastic probe will also al- tanium implant components and the blades are narrower
low for proper adaptation to the surface of the implant allowing greater access to tight spots (Fig. 12.34). Titani-
as some flexibility is needed and the plastic probe pro- um-coated, gold-coated, or Teflon-coated instruments
vides the appropriate amount of flexibility without may lose their coating with time and the underlying met-
damaging the biological seal. Sites with increased prob- al could scratch the implant. Plastic (e.g., Implacare Im-
ing depths, exudate, and bleeding should be recorded. plant Scalers; Hu-Friedy) curettes and scalers (Fig. 12.35)
or ultrasonic implant tips with plastic or rubber coating
Mobility. Implants should be checked for mobility. An or sleeve (e.g., Cavitron SofTip Implant Ultrasonic Insert,
implant that has integrated with the bone should not be Dentsply Sirona; Piezon Implant Cleaner, EMS and TIS-P
mobile. Mobility can be tested by using the handles of Implant Scaler, Tony Riso) (Fig. 12.36) should not be used
two dental instruments to try to push the implant back when rough ­surfaces or implant fixture threads are ex-
and forth buccolingually. Do not use your fingers be- posed. Research has shown that tiny bits of the plastic or
cause the soft pads of tissue on the finger tips will com- rubber can become lodged on these rough surfaces, re-
press when trying to move the implant. This can be mis- main subgingival, and act as soft tissue irritants and
taken for mobility of the implant. On occasion, the plaque traps. Some clinicians still use plastic instruments
patient may complain that the implant is loose, but care- but limit their use to biofilm/plaque removal on smooth
ful examination may determine that a component of the surfaces. Implant and abutment-safe tips must be used if
implant such as a retention screw has loosened or bro- an ultrasonic scaler is needed.
ken. If the implant is loose, there should be some radio- Prophylaxis pastes with coarse or medium grit
graphic finding of bone loss. should not be used on titanium. Even very fine paste
can produce some surface scratches on the implant. If
Cleaning the implant surface. The clinically accessible polishing is deemed necessary, tin oxide or other non-
surfaces of the implant should be thoroughly cleaned of abrasive polishing paste in a rubber cup applied with
plaque and calculus at each maintenance visit. Stainless light pressure may be used.
steel scalers and curettes should not be used on titanium Air-polishing. Air-polishing devices (also called air-
implants because they will scratch them. When titanium powder polishing devices) were derived from technol-
is exposed, special scaling instruments should be used to ogy developed by Dr. Robert Black in the 1940s. These
264 CHAPTER 12 Dental Implants

FIG. 12.35 Scaling instruments for implants with replaceable high-grade resin tips. (From Implacare Maintenance Instru-
ments, courtesy of Hu-Friedy Manufacturing Company, Inc., Chicago.)

FIG. 12.37 Air-polisher with subgingival nozzle (Air-Flow 3.0 Premium,

Hu-Friedy EMS). (Courtesy of Hu-Friedy Manufacturing Company, Inc.,
Chicago.)

powder particles is kept small, 60-80 μm. Sodium bicarbo-

nate is less than half as abrasive as pumice, which is used
in prophylaxis paste. However, some studies have shown
sodium bicarbonate to cause some changes to the implant
B
surface. It has also caused some soft tissue abrasions.
FIG. 12.36 Plastic tips for ultrasonic scalers. A, Disposable polysulfone Glycine (an amino acid) powder is an alternative to
plastic tip (Cavitron SofTip, courtesy of Dentsply International, York, sodium bicarbonate and is a very mild abrasive with a
PA.) B, Plastic ultrasonic scaler insert for titanium implants. (Courtesy particle size of 20-30 μm. One air-polisher (Air-Flow Pe-
of Tom Riso Company, North Miami Beach, FL.)
rio, Hu-Friedy EMS) uses glycine and with its nozzles
designed for subgingival use has been found to be high-
devices spray a stream of compressed air and water ly effective at removing subgingival biofilm (Fig. 12.37).
containing an abrasive powder through a nozzle onto In one study comparing glycine to sodium bicarbonate,
the implant surface to remove plaque and stain. They glycine was found to be 80% less abrasive.
are not meant to remove calculus. High volume evacu- Contraindications for air-polishing. Contraindications for
ation should be used with air-polishing to capture as air-polishing include patients with respiratory p ­ roblems
much of the aerosol as possible to minimize the amount such as chronic asthma or pulmonary disease that may
the patient inhales and swallows. Air-powder polish- be aggravated by inhaling the powder spray. Patients
ers are generally considered safe to use on implants ac- with transmissible diseases that could be spread by the
cording to in vitro studies. However, these systems aerosol created and those with compromised immune
must be used with caution. The use of incorrect pow- systems are also not good candidates for air-polishing.
ders can scratch titanium implant surfaces and can in-
jure surrounding soft tissues. Incorrect use or too much
SUMMARY
air pressure can result in air being forced into tissue
spaces (called tissue emphysema). The risk is greatest Dental implants are increasing in use, with more than 2
if the stream is aimed directly into the gingival sulcus million placed annually. Screw-type titanium alloy im-
rather than angled toward the implant. plants are the most commonly used and have a success
Abrasive particles. Sodium bicarbonate to which flavor- rate of approximately 95% with proper case selection and
ing agents have been added is the most common powder careful surgical technique. Image-guided i­mplant plan-
used with supragingival air-polishing. The size of the ning and surgical procedures have minimized surgical
 Dental Implants CHAPTER 12 265

complications. Two-stage surgical procedures were once detailed assessment of the implants should be done at
the norm but are being replaced by the more popular each hygiene visit. Care must be taken when providing
one-stage and immediate-placement procedures. Dental periodontal preventive care around titanium fixtures to
assistants and hygienists can play an integral role in mak- prevent scratching their surfaces. Hygienists must know
ing the impressions for the implant restorations. which hand instruments and ultrasonic tips can be used
When implants were introduced, it was thought that with implants to avoid damaging them.
immediate loading should be avoided at all costs. More Patient education is an important aspect of the role of
recent findings indicate that as long as the implant is the dental assistant and the dental hygienist in dental
firmly embedded in bone and is stable, immediate load- practice. The ability to describe to the patient the pros and
ing can be successful if occlusal forces are properly con- cons of the various materials used in practice and to aid
trolled. Mini-implants have been introduced that are in the treatment process depends on your knowledge of
minimally invasive and can be used in sites where con- these materials. As new materials are introduced into
ventional implants could not. They are very useful for dental practice, it is important to stay current on their in-
supporting dentures where there is little remaining al- dications, contraindications, and application techniques.
veolar ridge, and variants of them, called TADs, are Manufacturers’ instructions for their care and use should
used as temporary anchorage for orthodontic tooth be followed. Many manufacturers have websites on
movement. Bone grafting can improve sites for implants which they post information relative to their materials.
by building bone both in width and height. Bone graft-
ing is also used in sinus lift procedures.
INSTRUCTIONAL VIDEOS
It is not enough to just place and restore implants;
they must be routinely maintained to ensure the success See the Evolve Resources site for a variety of educa-
of the implants. Patients must be shown how to use the tional videos that reinforce the material covered in this
various aids for cleaning implants. In addition, a chapter.

Procedure 12.1 Suture Removal

See Evolve Site for Competency Sheet or diluted disinfectant mouthwash) to remove
bacteria and debris (Fig. 12.39).
EQUIPMENT/SUPPLIES (FIG. 12.38) NOTE: Inspect surgical site for closure of the
• Mouth mirror wound, absence of drainage and inflammation.
• Explorer 2. With cotton pliers grasp suture knot.
• Hydrogen peroxide or diluted mouthwash NOTE: Be sure not to pinch tissues.
• Cotton tip applicator
• Suture scissors
• Cotton pliers
• Gauze squares

PROCEDURE STEPS
1. Using a cotton tip applicator swab teeth and
tissues with antiseptic agent (hydrogen peroxide

FIG. 12.38 (From Bird DL, Robinson DS: Modern Dental Assisting, ed
12, St. Louis, 2018, Elsevier.) FIG. 12.39

Continued
266 CHAPTER 12 Dental Implants

Procedure 12.1 Suture Removal—cont’d

3. Lift knot gently away from tissues creating a

space to insert scissor blade (Fig. 12.40). Suture removal
NOTE: This will expose a portion of suture
that has been under tissue and thought to be free of
bacteria.
4. Insert one cutting tip of suture scissors into the
space between suture and tissue (Fig. 12.41).
NOTE: If suture scissors have a half moon cut out
in one of the blades, this blade should be inserted un-
der the suture.
5. Snip one thread close to tissue taking care not to
cut tissue (Fig. 12. 42).

FIG. 12.42 (From Robinson JK et al: Surgery of the Skin, ed 1, St.

Louis, 2005, Mosby.)

NOTE: Cutting suture material close to knot will

FIG. 12.40 allow suture previously exposed in the oral cavity to
pass through tissue. This will contaminate sub-epithe-
lial tissues with bacteria.
Suture removal
NOTE: Cutting both ends of suture may result in
suture material being left in the tissue.
NOTE: If cutting scissors are used, the blade is in-
serted in the space with the tip curved away from tis-
sue to prevent laceration/cutting of tissue.
6. Using a smooth continuous action to pull the
suture out of the tissue in one piece.
NOTE: Do not pass the knot through the tissue, as
this would cause the patient discomfort.
7. Place suture on gauze square.
8. Remove all visible sutures and place them on
gauze square.
NOTE: To control bleeding, apply pressure to area
with gauze square.
9. When all sutures have been removed, count
the number of sutures on the gauze square to
confirm the number is equal to the number
recorded in the patient chart during the surgical
appointment.
10. Record the number of sutures removed in the
patient chart and any significant observations
about the wound healing.
FIG. 12.41 (From Robinson JK et al: Surgery of the Skin, ed 1, St.
Louis, 2005, Mosby.)
 Dental Implants CHAPTER 12 267

Get Ready for Exams!

Review Questions c. Held in place by screws only

d. Welded on
Select the one correct response for each of the following
9. The instruments used to remove calculus from implants
multiple-choice questions.
where titanium is exposed include
1. The metal most commonly used for dental implants is a. Carbon steel curettes
a. Gold b. Air polishers
b. Silver c. Metal ultrasonic tips
c. Stainless steel d. Titanium curettes and scalers
d. Titanium
10. The closed-tray impression procedure requires that
2. An implant inserted into a hole drilled into bone is which one of the following components be repositioned
of the following types? in its proper alignment into the set impression
a. Subperiosteal after it is removed from the mouth; which one is it?
b. Endosseous a. Impression abutment
c. Transosteal b. Implant analog
d. Exosteal c. Fixture
3. Why is the surface of a titanium implant fixture d. Healing abutment
roughened? 11. The purpose of the cover screw is to
a. To remove oxides a. Cover the screw hole on top of the fixture to prevent
b. To provide a larger surface area for osseointegration tissue from growing into it
c. To remove adherent bacteria b. Allow a cuff of gingiva to heal around it after the
d. To prevent the implant from rotating under function surgical flap has been repositioned
4. With a two-stage implant, after the fixture is placed, c. Hold the abutment to the fixture
which one of the following occurs? d. Cover the screw hole in the implant crown used to
a. The implant crown is placed. place the retention screw
b. The fixture is covered with bone. 12. Mini-implants can be used for which of the following
c. A cover screw is placed and the fixture is covered by purposes?
the soft tissue flap. a. To support complete dentures
d. The healing abutment is placed and the soft tissue is b. To support crowns for narrow-rooted teeth such as
allowed to heal around it. mandibular incisors
5. Potential adverse outcomes when an implant fixture is c. To serve as anchors for orthodontic tooth
surgically placed include movement
a. Infection around the implant d. All of the above
b. Perforation of one of the cortical plates of bone 13. Which type of bone graft is derived from animal tissue?
c. Improper angulation of the implant a. Allograft
d. Damage to a nerve or a large blood vessel b. Autograft
e. All of the above c. Xenograft
6. Immediate-placement implants are done d. Alloplast
a. About 3 weeks after the extraction of a tooth 14. Which one of the following statements regarding the
b. At the time of extraction of the tooth that will be gingiva around an implant is false?
replaced a. The gingiva has connective tissue fibers that
c. Only when a bone graft is needed connect or integrate with the surface of the implant.
d. To plug the hole made when the maxillary sinus is b. When healthy, the gingiva produces a biological seal
accidentally perforated against the implant that prevents microorganisms
7. Implants can be used to support which of the following from invading the deeper tissues.
prostheses? c. The gingiva is closely adapted to the implant but is
a. Single crowns not attached to the surface.
b. Fixed bridges d. Chronic inflammation of the gingiva around the
c. Partial or complete dentures implant could lead to peri-implantitis.
d. All of the above 15. The consequences of not maintaining good oral hygiene
8. Implant crowns are fixed to the implant abutment by around an implant include all of the following except one.
which method? Which one?
a. Cemented only a. Inflammation and swelling of the gingiva
b. Cemented or held by screws b. Loss of the biological seal

Continued
268 CHAPTER 12 Dental Implants

Get Ready for Exams!—cont’d

c. B acterial invasion and potential loosening of the to the patient both conventional endosseous implants
implant and mini-implants. After the dentist leaves the operatory,
d. Increased bone growth due to chronic irritation the patient is somewhat confused and asks you to
16. Biointegration where the bone totally integrates with the explain the difference.
implant is seen with which implant material? In laymen’s terms, describe the difference to the patient. If
a. ceramics the patient asks you specific details about why the dentist is
b. stainless steel recommending one type of implant over another, what
c. gold should you do?
d. titanium 2. A 74-year-old retired grocer comes to the dental office
for a maintenance visit. He has several implants sup-
17. W hich part of the implant is placed in bone? porting two fixed bridges in the posterior part of the
a. healing abutment maxilla.
b. fixture When the patient has his implants cleaned, describe the
c. analog types of instruments the hygienist will likely use and the in-
d. impression coping struments that should be avoided if titanium will be scraped.
Explain the selection of these instruments.
18. This type of suture will be absorbed naturally by the
body’s enzymes 3. The patient described in the preceding discussion topic
a. Silk is found to have inflammation in the peri-implant tissues
b. Nylon around three implants and moderate amounts of
c. Vicryl calculus and plaque on the proximal surfaces of the
d. Polyester fiber implants. He tells you that he had missed his previously
scheduled maintenance appointment and that he is just
19. When removing sutures, the suture material should be
using a regular toothbrush with hard bristles to clean his
cut close to the knot to prevent contamination of the
implants.
sub-epithelial tissues with________________ as the
What can you do to reinforce regular maintenance visits?
suture is pulled through the tissue.
What home care aids can you recommend to help him keep
a. viruses
his implants clean? Should an antibacterial agent be sug-
b. bacteria
gested? If yes, which one?
c. mucus
For answers to Review Questions, see the Appendix. 4. You are in the room when the dentist reviews the
informed consent for implants with a patient. The patient
is 78 years old and seems to be confused about what
Case-Based Discussion Topics was just said to her. You question whether she has the
mental capacity to give informed consent.
1. T
 he dentist has discussed a treatment plan with a
What should you do? What topics should be covered in an
patient who is a candidate for implants to support a
informed consent discussion?
mandibular complete denture. The dentist has described

BIBLIOGRAPHY McKinney RV: Oral hygiene protocol for implant patients. In

McKinney RV, editor: Endosteal Dental Implants, St. Louis,
American Dental Association (ADA): Council on Scientific Affairs. 1991, Mosby.
Products of Excellence: ADA Seal Program, Chicago, 1999, ADA. Moldovan S: Dental implants: a comprehensive review. Continuing
Bird DL, Robinson DS: Dental implants. In Modern Dental Education Course. Available at http://www.dentalcare.com/en-
­Assist­ing, ed 12, St. Louis, 2018, Elsevier. US/dental-education/continuing-education/ce420/ce420.as
Bird DL, Robinson DS: Oral and maxillofacial surgery. In Modern px.
Dental Assist­ing, ed 12, St. Louis, 2018, Elsevier. Perry DA, Beemsterboer PL, Taggart EJ: Dental implants. In Clin-
Darby ML, Walsh MM: Dental implant maintenance. In Dental ical Periodontics for the Dental Hygienist, ed 2, Philadelphia,
Hygiene Theory and Practice, Darby and Walshed 4, St. Louis, 2001, Saunders.
2015, Elsevier/Saunders. Powers JM, Wataha JC: Dental implants. In Dental Materials:
Edel A: Air Polishing for Implant Maintenance, CDE World, 2017. Properties and Manipulation, Yen-Wei Chened 11, St. Louis,
Available at https://cdeworld.com/courses/20704-Air_Poli 2017.
shing_for_Implant_Maintenance. Rethman MP: Introduction and Historical Perspectives on Dental Elsevi-
Grisdale J: The clinical applications of synthetic bone alloplast, J er Im­plants. White paper commissioned by Hu-Friedy. Available
Can Dent Assoc, 65:559–562, 1999. at http://www.friendsofhu-friedy.com/userfiles/file/Implant
Kotick PG, Blumenkopf B: Abutment selection for implant resto- Maintenance White Paper/Implant Maintenance White Paper
rations, Inside Dentistry 7(7), 2011. Final.pdf
 Dental Implants CHAPTER 12 269

Robinson DS, Bird DL: Oral and maxillofacial surgery. In Es- Wilk BL: Intraoral digital impressioning for dental implant res-
sentials of Dental Assist­ing, Bird and Robinsoned 6, St. Louis, torations versus traditional implant impression techniques,
2017, Elsevier. Compend Contin Educ Dent, 36(7):529–533, 2015.
Sakaguchi RL, Powers JM: Dental and orofacial implants. In Wilkins E: Sutures and dressings. In Clinical Practice of the Dental
Craig’s Restorative Dental Materials, Sakaguchi and Powersed Hygienist, ed 12, Philadephia, 2017, Wolters Kluwer.
13, St. Louis, 2012, Mosby.
Competency 12.1  Suture Removal
Competency Form
PERFORMANCE OBJECTIVE: THE STUDENT
WILL DEMONSTRATE THE PROCEDURE FOR
REMOVING A SUTURE.
PROCEDURE SELF-EVALUATION INSTRUCTOR EVALUATION
1. Set up instruments and supplies
2. Used appropriate patient and clinician protection
3. Properly cleansed the area around
the suture with
antiseptic agent
4. Properly cut the suture to prevent contamination of
tissue
5. Properly removed suture in one continuous motion
6. Placed removed suture on 2x2 gauze square
7. Properly recorded suture removal
procedure in
patient progress notes
8. Maintained infection control throughout procedure

Time allowed: Time started: Time finished:

Instructor comments:

Instructor signature:

269.e1
13 Abrasion, Finishing, Polishing, and Cleaning

http://evolve.elsevier.com/Eakle/materials/

Chapter Objectives
Upon completion of this chapter, the student should be able to:
1. Define abrasion, finishing, polishing, and cleaning. 8. D escribe the abrasives and the procedures used for
2. Discuss the purpose of finishing, polishing, and cleaning finishing and polishing metals, composite, and porcelain.
of dental restorations and tooth surfaces. 9. Describe the abrasives and the procedures used for
3. Identify and discuss the factors that affect the rate and polishing and cleaning metals, composite, ceramic, and
efficiency of abrasion. gold alloys as part of oral prophylaxis.
4. Compare the relative ranking of abrasives on restorations 10. Describe the safety and infection control precautions
and tooth structures. taken by the operator when using abrasives.
5. Describe methods by which dental abrasives are applied. 11. Relate the instructions given to patients to prevent and
6. Discuss the contraindications to the use of abrasives on remove stain from tooth surfaces and restorations.
tooth structure and restorations. 12. Finish and polish a preexisting amalgam restoration.
7. Describe the clinical decisions made to determine which 13. Polish a preexisting composite restoration.
abrasive to use when finishing, polishing, or cleaning
dental restorations or tooth structures.

Key Terms
Finishing a procedure used to remove excess restorative Grit the size of the abrasive particles, typically classified as
material to develop appropriate occlusion, contour, and coarse, medium, fine, and superfine
functional form; usually done with rotary cutting instru- Margination a procedure for removal of excessive restor-
ments. Finishing removes surface blemishes and produces ative material from the margins of restorations
a smooth surface Flash feather-like excesses of material present at the margins
Polishing a procedure that produces a smooth, shiny of a restoration typically on occlusal and proximal surfaces
surface by eliminating minor surface imperfections, fine Overhang excessive material present at the cervical cavo-
scratches, and surface stains using mild abrasives fre- surface margin
quently found in the form of pastes or compounds. Polish- Supragingival Air Polishing the process of polishing or
ing produces little change in the surface. finishing the clinical crown using fine, soft particles under
Mohs Hardness a measure of hardness on a scale of 1 to air pressure to remove biofilm and stain from enamel
10 where 1 is a very soft material such as talc and 10 is surfaces and in pits and fissures; an alternative to prophy
the hardest material such as diamond pastes
Cleaning a procedure that is primarily meant to remove Subgingival Air Polishing the process of polishing the
soft deposits from the surface of restorations and tooth anatomical crown and clinical root surface using fine, soft
structures. Polishing and cleaning are done to remove particles under air pressure to remove biofilm subgingivally
surface stains and soft deposits from the clinical crowns Air Abrasion or Microabrasion like air polishing, but using
and exposed root surfaces of teeth after all hard deposits greater air pressure and harder particles. Used to cleanse
are removed cast appliances before cementation, repair porcelain
Abrasive a material composed of particles of sufficient and composite restorations, prepare tooth surfaces
hardness and sharpness to cut or scratch a softer material before bonding, and cut tooth structure for restorative
when drawn across its surface preparations
Hardness is the ability of a material to resist abrasion
  

Proper finishing, polishing, and cleaning of tooth struc- grown dramatically causing a multitude of clinical and
tures and restorative materials is clinically relevant because over-the-counter products available to provide this ben-
this improves esthetic and tissue health, while increasing efit to grow. The allied dental professional must carefully
the longevity of the restorative material. The demands for evaluate the clinical procedures used for the removal of
improved esthetics through whiter and brighter teeth have stains and soft deposits with the use of abrasives. These

270
 Abrasion, Finishing, Polishing, and Cleaning CHAPTER 13 271

procedures should be selective procedures, performed after

the needs of the individual patient are considered, and the
types of stains and restorative materials present are prop-
erly identified. The routine polishing of teeth with abrasive
prophylactic (prophy) paste after scaling and root planing
is not recommended. The clinician must critically evaluate
the potential negative effects of the coronal polish proce-
dure against the benefits.
The goal of finishing and polishing restorations, intra-
oral appliances, and tooth structure is to remove excess ma-
terial, smooth roughened surfaces, and produce an estheti-
cally pleasing appearance with minimal trauma to hard
and soft tissues. The finishing and polishing of a surface in-
volves removing marginal irregularities, defining anatom-
ic contours and occlusion, removing the surface roughness
of the restoration, and producing a mirror-like surface lus-
ter. Many benefits are derived from smooth tooth surfaces,
restorations, or appliances in the intraoral environment.
A smooth surface resists accumulation of soft deposits and
stains, is less irritating to the gingival or mucosal tissue, FIG. 13.1 A finished and polished amalgam restoration.
and is esthetically pleasing because it reflects light better.
A smooth and polished tooth surface can help to motivate
the patient to maintain these positive results with better of restorative material using coarse or medium grit
self-care procedures. A smooth, highly polished restorative diamond burs, carbide finishing burs, and abrasive
surface is more resistant to the effects of corrosion and sur- discs and strips. Fine finishing refines the anatomic
face breakdown. A properly finished and polished surface morphology, that is, occlusal surfaces and occlu-
will contribute to the appearance and longevity of the res- sion, embrasure spaces, and marginal ridge form us-
toration or appliance and the health of the surrounding oral ing medium to fine versions of the gross finishing
tissues (Fig. 13.1). instruments. Fine finishing prepares the surface for
Clinicians who perform finishing and polishing pro- polishing.
cedures must have a clear understanding of the factors Polishing is the process of removing scratches from
that cause and control abrasion. Improper use of abra- the surface of a restoration with a series of particles,
sives can lead to roughening and over-reduction of tooth coarse to fine, to produce a smooth, glossy surface that
and restorative surfaces. The clinician must be able to is esthetically pleasing, tolerated well by soft tissues,
recognize that different types of tooth structures and and resistant to biofilm adhesion. Polishing produces
restorative surfaces abrade differently and must use the little change in the surface. It may have to be repeated
proper protocol for finishing, polishing, or cleaning each periodically during the life of the restoration if tarnish
surface. It is also the clinician’s responsibility to teach or stains develop. Polishing requires materials with a
the patient how to properly care for the surfaces with Mohs’ hardness of only 1 to 2 units above the substrate
home care devices and how to prevent the staining habits being polished. Finishing and polishing are intended
that diminish their appearance (see Chapter 2 Oral Envi- to produce selective and controlled wear of the surface
ronment and Patient Considerations for identification of being manipulated.
restorative materials). Cleaning does not produce scratches or wear and
is primarily used for the removal of biofilm. Polish-
ing and cleaning are done to remove surface stains
FINISHING, POLISHING, CLEANING and soft deposits from the clinical crowns and ex-
The process of finishing and polishing involves using posed root surfaces of teeth after all hard deposits
sequentially coarser to finer abrasives on a surface to are removed. Aside from abrasives, there are also
first contour, then smooth, and finally bring a luster to chemical cleaning products that are primarily used
the surface. Contouring to cut or grind away excessive for removable appliances. Cleaning requires materi-
materials with rotary instruments may be required als with Mohs’ hardness no greater than equal to the
first to produce the desired anatomic form. substrate.
Finishing removes excess material to develop the There is no single type of abrasive that can be used
surface morphology and functional form. Contour- safely and effectively on all types of dental materials
ing of the restoration is most often done with rota- and tooth structures. The effect of abrasion is directly
ry instruments in high-and low-speed handpieces. related to the properties of the abrasive and the mate-
Gross finishing is done first to remove large excesses rial (substrate) it is abrading.
272 CHAPTER 13 Abrasion, Finishing, Polishing, and Cleaning

FACTORS AFFECTING ABRASION Table 13.1    Mohs and Knoop Hardness Scales
An understanding of the properties of abrasives and MOHS KNOOP
the factors that control the rate or efficiency of abra-
Diamond 10 7,000-10,000
sion will help the clinician make appropriate clinical
Silicon carbide 9-10 2,500
decisions. The rate of abrasion is determined by the
­(carborundum)
abrasive being used and the surface being abraded
(the substrate). The abrasiveness of particles is deter- Tungsten carbide 9 1,900
mined by size, irregularity, and hardness; the num- Aluminum oxide 7-9 2,100
ber of particles contacting the surface; and the pres- ­(corundum), emery
sure and speed at which they are applied. The rate Sand (quartz) 7 820
of abrasion is also dependent on the surface being Zirconium silicate 6.5-7.5
abraded; a hard substrate such as enamel is much Silicon dioxide (Silex) 6-7
more resistant to abrasion than softer cementum.
Flour of pumice 6-7 460-560
An understanding of these factors will assist the cli-
*CAD/CAM ceramic 6-7
nician in making appropriate clinical decisions for
the indications, contraindications, and control of Porcelain (ceramic) 6-7 560
abrasion. Tin oxide 6
Perlite 5.5-7
Size, Irregularity, and Hardness of Abrasive Enamel 5.5-6 340-431
Particles Composite 5-7 30-55
The size, irregularity, and hardness of the abrasive
Rouge 5-6
particle determine the depth of the scratches in the
material being abraded and therefore the amount of Amalgam 5-6 90
material being removed. An example is the effect of Gold Type IV alloy 3-4 220
pumice, which comes in several grades of coarseness, Dentin 3-4 70
on cementum and amalgam. Coarse pumice, consist- Cementum 2-3 40
ing of larger and irregular particles, will remove more Denture base resin 2-3 20
surface from the softer cementum than from the hard- (acrylic)
er amalgam. If superfine pumice (also called flour of
Calcium carbonate 3
pumice), consisting of much smaller and more regular
Aluminum trihydroxide 2.5-4
particles is used, the effect will be to polish the cemen-
tum as well as the amalgam. Diamonds are the most Sodium bicarbonate 2.5-3
abrasive materials used in dentistry. Coarse diamond Glycine 2
abrasives, often used for contouring restorations as Potassium and sodium 0.04-0.05
part of gross finishing, can remove large amounts of Tooth structure in shaded rows
tooth structure and restorative material. They can also *CAD/CAM, computer-assisted design/computer-assisted machining.
be used for fine finishing and polishing of restorations,
all according to diamond particle size and regularity.
Their rate of abrasion will also depend on the material has the highest resistance to abrasion and is therefore
being abraded, the pressure applied, and the speed of considered the hardest; flour of pumice rates a 6 to 7
the rotating device. on the Mohs scale and 460 to 560 on the Knoop scale,
If the surface being abraded is harder than the which is similar to tooth enamel but harder than
abrasive, there is little or no effect. If the clinician is amalgam and dentin. Therefore, pumice may be used
using prophy paste with appropriate technique on to polish enamel, whereas contact with exposed den-
enamel, it will polish the surface; if the same paste tin would be too abrasive. It is important to note that
and technique is used on demineralized enamel it porcelain is harder than enamel and dentin. Abrasive
will result in enamel loss. It is important that the cli- wear of tooth structures in contact with porcelain res-
nician have an appreciation for the relative hardness torations is a problem for many patients. The greater
of various intraoral natural and restorative materials the difference in hardness between the abrasive and
and abrasives used on these materials. Hardness is the the surface it is abrading, the faster and more effec-
ability of a material to resist abrasion. The Mohs scale tive the abrasive action. To effectively polish, a par-
of hardness ranks materials by their relative abra- ticle must be harder by 1 to 2 Mohs units than the
sion resistance. The Knoop hardness test is based on surface it is polishing. Cleaning, when no abrasion is
the ability of materials to resist indentation. In both indicated, requires a substance 1 Mohs unit less than
of these tests the farther apart the substrate and the or equal to the surface on which it is directed. Com-
abrasive are in hardness number, the more effective is pare Mohs and Knoop hardness rankings for enamel
the abrasive process. As seen in Table 13.1, diamond and dentin. You can surmise that exposed dentin is
 Abrasion, Finishing, Polishing, and Cleaning CHAPTER 13 273

If too hard an abrasive is used the result will be deep

scratches that cannot be finished or polished out. The
clinician must make decisions as to the coarseness of
the abrasive and the application method needed for
each procedure.

Number of Particles That Contact the Surface

The more concentrated the particles that contact the
surface, the more quickly the surface will be abrad-
ed. If a lubricant is used to dilute the concentration
of the particles, the abrasiveness of the material is
reduced. Water and saliva are lubricants commonly
used to dilute the effect of abrasion. When using an
abrasive, the clinician has control of how much lu-
bricant to add to the material, whether this is done
before it is placed in the mouth or while it is being
FIG. 13.2 The grit in prophy paste (available as single-dose units in used intraorally as it picks up saliva. Pumice (Fig.
holders) comes in various sizes. (Courtesy of Proctor & Gamble.) 13.3) is manufactured as a powder or paste which
allows the clinician the opportunity to further di-
lute this abrasive. Rotary cutting instruments such
abraded at a much greater rate than enamel during as abrasive disks and stones will lose effectiveness
dental polishing procedures. Compare the Mohs and as particles break away from their surface or debris
Knoop rankings of composite and gold. If the same clogs the surface. Many rotary cutting stones and di-
polishing agent were used on these as on enamel, the amonds use the water from the handpiece or three-
result would be greater loss of the restorative mate- way syringe to assist in the movement of debris from
rial. As you can also see, denture base materials are the cutting edge and act as a surface coolant, thus
very susceptible to abrasion. allowing the surface to maintain its abrasive action
much longer.
Clinical Tip
It is important that patients be given instructions to use Speed and Pressure
only approved denture cleaners for their home care; Increasing the speed and pressure at which an abra-
even toothpaste may be too abrasive for acrylic intraoral sive is applied will increase the rate of abrasion. In-
appliances such as dentures. creased speed alone can produce undesired effects
if it results in lack of control. Increased pressure will
produce deeper scratches, as well as several other pos-
The size and shape of the particles must be con- sible results:
sidered in manipulating an abrasive. Particles that •  Less control of the amount of material being
are large and irregular, with jagged edges, will cut removed
more efficiently. The sharpness, or efficiency, of the •  Decreased clinician’s tactile sensitivity, possibly
particles is usually lost with use as the jagged edges leading to an undesired over-abraded surface
break down and become rounder and the particles • Reduced cutting efficiency of the abrasive, the result
no longer “grab” the surface. Unlike the shape of of decreased instrumental torque
the particles, the size of the particles does not al- Increased speed and pressure also result in frictional
ways change significantly with use. Abrasive parti- heat, which may have a detrimental effect on the tooth
cles are classified from coarse to fine, based on their structure, the pulp, and on patient comfort. Heat gen-
size measured in micrometers (also called microns erated from rotary instruments can bring mercury to
[symbol, μm]). One micrometer is equal to one-thou- the surface of an amalgam restoration and degrade its
sandth of a millimeter (1 mm = 1000 μm). Abrasives properties. Polishing that is done dry with continuous
are classified as coarse (particles 100 μm and above), application produces the highest temperature increase
medium (20 to 100 μm), and fine (20 μm to submi- on the surface of the restoration. If polishing needs to
cron particle sizes). Manufacturers use the term grit be done dry, then intermittent application with light
to refer to the size of abrasive particles. Particles are pressure should be used.
passed through a standardized sieve that allows a
specific size of particles to pass, categorizing them
from coarse through superfine. Prophylactic polish- Caution
ing pastes are commonly manufactured in various Care must be taken to control the amount of pressure
degrees of coarseness, as are abrasive disks and ro- and speed with which abrasives are applied. For most
tary diamonds (Fig. 13.2). applications a light intermittent touch is recommended.
274 CHAPTER 13 Abrasion, Finishing, Polishing, and Cleaning

FIG. 13.4 Various delivery designs for abrasives: Paste, bonded, and
coated.

• M icroparticle (or hard-particle) abrasives, delivered

by air pressure
Two-body abrasives, also known as direct contact
FIG. 13.3 Pumice delivered in a single dose of premixed paste.
(Copied from smartpractice.com.) abrasives, include abrasive agents that are fixed on
an abrasive instrument such as on sandpaper disks,
strips, or burs. Tooth-to-tooth contact, known as attri-
tion, is an example of two-body abrasion. Three-body
When is polishing accomplished? Patients can abrasives are those that are free to rotate between the
detect surface roughness on restorations with their delivery device and the surface being polished. Prophy
tongue: the tongue can sense a surface roughness of paste in a rubber cup is an example of a three-body
less than 1 μm, and roughness greater than 1 μm may abrasive. Toothpaste is a three-body abrasive, as are
lead to breakdown of the restoration surface due to abrasive foods or materials that might be introduced
biofilm accumulation and corrosion. Gloss and/or during mastication. Microparticle abrasives are those
luster are produced when the scratches on the restora- that are forced against the substrate by air pressure.
tion surface are smaller than the wavelength of visible This technique, called air polishing (with a ProphyJet,
light (<0.5 μm) resulting in a shiny surface that reflects Dentsply) or air abrasion depending on the particles
light. and air pressure used, is an example of the use of hard-
The clinician must be able to determine if the sur- particle abrasives.
face of the restoration is smooth in order to properly
determine the amount and rate of abrasion needed to Bonded Abrasives (Two-Body, Direct Contact
polish the surface. When the surface of a restoration Abrasives)
is rough, polishing should be completed in order to Bonded abrasives are attached to rotary instruments;
smooth the surface. The clinician will select the appro- the abrasive particles are uniformly incorporated in a
priate type of material to polish the surface without binder and bonded to the device. The devices vary in
causing excessive damage; this is known as selective the available shape, such as points, disks, cups, brush-
polishing. Determining the amount and rate of abra- es, and wheels. These devices are frequently used for
sion is an important consideration when clinical deci- intermediate finishing and initial polishing of restora-
sions are made regarding what type of material to be tions (Fig. 13.5).
abraded, how much material is to be removed, and the
desired outcome. Coated Abrasives (Two-Body, Direct Contact
Abrasives)
MODE OF DELIVERY OF ABRASIVES Coated abrasives are supplied on rotary disks and
Dental abrasives are supplied in a number of forms handheld finishing strips. The abrasive particles are
(Fig. 13.4): secured to one side of a flexible backing with an ad-
• Two-body abrasives, including: hesive. Devices with coating on only one side protect
• Bonded abrasives the adjacent tooth from the abrasive and are referred
• Coated abrasives to as safe-sided. Flexible backing such as paper or
• Three-body abrasives, including: plastic gives such devices the advantage of flexibil-
• Paste abrasives ity but eliminates their ability to be sterilized. Abra-
• Loose abrasives sive coated rotary devices are typically attached to a
 Abrasion, Finishing, Polishing, and Cleaning CHAPTER 13 275

FIG. 13.6 Coated abrasives: Various designs of sandpaper disk and

mandrels and sandpaper strip.
FIG. 13.5 Bonded abrasives: Reusable point on mandrel, and dispos-
able cup, point, and disk with sterilizable mandrel.
Spiral finishing wheel Spiral polishing wheel
autoclavable shaft or mandrel, for convenience and
cost-effectiveness (Fig. 13.6). Sof-Lex spiral finishing
and polishing wheels (3M ESPE) (Fig. 13.7).

Paste Abrasives (Three-Body Abrasives)

Paste abrasives are found in the form of prophy paste
and toothpaste. A more complete discussion of both
follows in the section “Preparations Used for Abra-
sion” (below).

Loose Abrasives (Three-Body Abrasives)

FIG. 13.7 A Sof-Lex spiral finishing and polishing wheel. Its shape adapts
Loose abrasives are manufactured as powders and to all tooth surfaces, making it an alternative to traditional points, cups,
pastes and are classified by their grit or particle size. disks, and brushes. (Courtesy of 3M ESPE [St. Paul, MN].)
Grits of coarse, medium, fine, and superfine are avail-
able for finishing, polishing, and cleaning surfaces.
These may be applied with wheels, brushes, cups, or usually are not disposable, so they are found most
soft pads. The concentration of particles that contact often bonded in varying degrees of coarseness to ro-
the surface is clinically controlled. If the clinician tary cutting shanks or disks (Fig. 13.8). They are ster-
uses a coarse, thick paste, rapid removal of surface ilizable and can be reused several times before they
material will result, along with possible pulpal dam- wear out. Coarse and medium grit diamond burs are
age due to excessive frictional heat. However, if a used cut crown and bridge preparations and fine and
superfine, highly diluted paste is used, little or no ultrafine diamond burs are used to finish and polish
material may be removed. The proper grit and di- composite restorations. Fine particle diamonds come
lution of the loose abrasive must be considered to in a paste for polishing composite and porcelain
obtain the best results in finishing and polishing a restorations.
given surface.
Abrasives are manufactured for use at chairside and Silicon Carbide
in the laboratory. Some may be used for either pur- Rare in nature, silicon carbide is typically synthesized
pose. Regardless of how the abrasive material is sup- as an extremely hard and efficient abrasive material (9
plied, the clinician must control the rate of abrasion. to 10 on the Mohs scale). Silicon carbide–coated disks
and bonded rotary devices are used primarily in the
MATERIALS USED IN ABRASION beginning steps of finishing procedures for composites
Many types of natural and synthetic (human-made) and ceramics.
materials are available for use in dentistry. The follow-
ing materials are listed from most to least abrasive. Tungsten Carbide Finishing Burs
Tungsten carbide is a very hard material (harder than
Diamond steel) material used to fabricate carbide tools with cut-
Diamond is the hardest known substance rating a 10 ting that do not dull quickly. Tungsten carbide finish-
on the Mohs hardness scale. It will efficiently abrade ing burs come in several shapes, with designs ranging
any substance. Rotary diamonds are expensive and from 7 to 30 cutting flutes (Fig. 13.9).
276 CHAPTER 13 Abrasion, Finishing, Polishing, and Cleaning

FIG. 13.9 (Courtesy of AXIS Dental Sàrl.)

removal and on rubberized cups and points used for

finishing and polishing composite restorations.

Pumice
Pumice is volcanic silica manufactured as a loose abra-
sive. Superfine, flour of pumice (Mohs hardness scale,
6) is extremely fine and a major component of many
prophylaxis pastes used to polish tooth structure, den-
A C tal amalgam, and acrylic bases. Fine, medium, and
coarse pumice are primarily used in dental laboratory
FIG. 13.8 (From Heymann H, Swift E, Ritter A: Sturdevant’s Art & Sci- procedures and should not be used on natural tooth
ence of Operative Dentistry (ed 6). St. Louis, 2013, Elsevier.) structures.

The higher the number of flutes the bur has, the fin- Tin Oxide
er is the ultimate finish. A bur that contains only seven Tin oxide (6 on the Mohs harness scale) is an extremely
flutes will have a very aggressive cutting action. These fine abrasive that is used extensively as a final polish-
burs rank up to 9 on the Mohs scale and are used pri- ing agent for enamel and restorations. This abrasive is
marily for finishing. They are used to cut preparations usually found as a powder that is mixed with water or
or to finish composite restorations. glycerin (Fig. 13.10).

Aluminum Oxide (Corundum), Emery Rouge

Aluminum oxide (corundum; 9 on the Mohs scale) Rouge is iron oxide with a Mohs hardness value of 5
is a synthetic abrasive that is often manufactured as to 6. It is frequently found in block form, which then is
a white or tan powder. The powder form is used in run onto a rag wheel to polish precious and semipre-
sandblasting restorations in preparation for cementa- cious metal alloys in the laboratory. Rouge is not used
tion and air abrasion. It is used in bonded and coated intra-orally (Fig. 13.11).
rotary devices. Aluminum oxide–impregnated rubber
wheels are called Burlew wheels. This popular abrasive Calcium Carbonate
comes in several grit sizes and has largely replaced Calcium carbonate, also called chalk or whiting, is
emery. It is used to smooth enamel or to finish metal a mild abrasive with a low Mohs ranking of 3. It
alloys and ceramic materials, and to polish highly is found in prophylaxis paste and dentifrice. It is
filled and hybrid composite restorations and porce- used to polish teeth, metal restorations, and plastic
lain restorations. materials.

Sand Sodium Bicarbonate

Sand is a natural abrasive composed of quartz and Sodium bicarbonate has a very low Mohs ranking of
silica. This abrasive rates a 7 on the Mohs scale and 2.5 to 3 and is used as a cleaning agent in toothpaste
is manufactured as coated disks and handheld strips and in supragingival air polishing (Fig. 13.12).
used in the finishing process.
Glycine
Silicon Dioxide Glycine is an amino acid with a Mohs ranking of 2 and
Silicon dioxide has a Mohs ranking of 6 to 7 and is is used as a cleaning agent in supra-gingival and sub-
commonly found in prophylaxis paste for heavy stain gingival air polishing (Fig. 13.13).
 Abrasion, Finishing, Polishing, and Cleaning CHAPTER 13 277

A B
FIG. 13.10 (A, Courtesy of American Dental Supply, Inc. B, Courtesy of How to Clean Marble.)

FIG. 13.11 Stick rouge to be utilized on a rag wheel in the dental labo-
ratory to polish precious and semi-precious metal alloys. (Courtesy
Buffalo Dental Manufacturing Co. Inc.)

Potassium and Sodium

Potassium and sodium have very low Mohs rankings
of 0.4 and 0.5. These agents are nonabrasive and are
used in toothpaste and desensitizing agents.
FIG. 13.12 Sodium bicarbonate utilized for supra-gingival air abrasion.
(Courtesy Dentsply Sirona.)
PREPARATIONS USED FOR ABRASION
Prophylaxis (Prophy) Paste preparation in a paste form by preventing hardening on
Prophylaxis (prophy) paste is a mixture of 50% to 60% exposure to air. Preservatives are included to prolong
abrasive materials such as pumice and tin oxide and lu- shelf life, and coloring and flavoring agents are added to
bricants. Prophy paste may be 20 times more abrasive increase patient acceptance. Fluoride is added to many
to dentin and 10 times more abrasive to enamel than preparations and is claimed to be a therapeutic agent in
commercially prepared dentifrice. Preservatives, flavor- the prevention of caries, but studies have shown it not
ing agents, coloring agents, and therapeutic agents are to be effective in the amount and concentration used.
added. The abrasive powder is diluted with a lubricant Prophylaxis pastes are supplied as coarse grit (5 μm) to
to reduce the rate of abrasion and the amount of fric- superfine grit (2 μm) commercially prepared pastes for pol-
tional heat produced. The lubricant also helps keep the ishing and cleaning of tooth structures. Coarse prophylaxis
278 CHAPTER 13 Abrasion, Finishing, Polishing, and Cleaning

When considering prophy pastes, select the least

abrasive paste possible, or a nonabrasive paste, to re-
move existing stains and soft deposits. These abrasives
should be applied as wet as possible with a light, in-
termittent touch and at low speed. Whenever coarse
or medium paste is selected, it should be followed by
the use of fine paste in a new or cleaned prophy cup.
Unstained teeth should not be polished with abrasive
agents but rather a nonabrasive cleaning paste.
Various prophy pastes have been developed with
additives to assist in remineralization and to reduce
tooth sensitivity. MI Paste (GC America) contains Recal-
dent (casein phosphopeptide-amorphous calcium phos-
phate) (See Fig. 7.14), which allows teeth to remineralize
and repair the very early stages of decay. NuCare (Sun-
star Butler) with NovaMin (Sultan Healthcare) contains
bioactive glass particles that release calcium, sodium,
phosphate, and silica ions in the presence of water/
saliva. These ions combine to form a hard and strong
hydroxycarbonate apatite layer to occlude, and thereby
FIG. 13.13 Glycine powder utilized for supra-gingival and subgingival desensitize, dentinal tubules. Use of these pastes before
air polishing. (The photograph is reproduced herein with permission. © nonsurgical periodontal therapy may be indicated for
3M 2020. All rights reserved.) those patients whose sensitivity to scaling is not pro-
found enough to warrant the use of local anesthetics.
paste can produce scratches on polished surfaces of resto- Specialty products are recommended for today’s
rations such as gold, amalgam, and composite. cosmetic restoration when the use of traditional paste
Caution will damage the surface, resulting in a less than ideal
appearance. NUPRO Shimmer (Dentsply Sirona) is not
Remember: Polishing materials should be harder (but by
only one to two Mohs hardness rankings) than the surface designed for stain removal due to the particle size in
to which they are applied. Cleaning materials should be the paste being so fine they are not course enough to
equal to or less hard than the surface to which they are remove stain; however, they do produce a high shine on
applied. the already polished restoration. Clinpro Prophy Paste
(3M ESPE) uses abrasive variability in its formulation;
Polishing of tooth surfaces should remove soft de- this abrasive begins as a coarse material to remove stain
posits (biofilm) and polishable stains without damage and then quickly breaks down to a fine paste to provide
to hard or soft tissues. Studies of the amount of tooth luster. Soft Shine (Waterpik Technologies) is made from
structure removed with prophy paste and rubber cup micron-fine particles that effectively polish all types of
polish have been questioned due to the variables as- composite and ceramic restorations. Traditional prophy
sociated with the studies. No scientific proof shows paste is not recommended for use on esthetic restorative
how much enamel is removed during polishing or if materials; use agents that have been specially formulat-
it is removed at all due to the polishing process. These ed for esthetic restorative surfaces.
results led to the philosophy of “essential selective pol-
ishing,” which is now regarded as the most appropri- Dentifrice (Toothpaste)
ate approach in selecting the suitable polishing agent Similar to prophylaxis paste, toothpaste contains a mix-
for the clinical situation and determining which teeth ture of abrasive materials to clean tooth structures and
and surfaces should be polished with said agent. All restorations, and enhance resistance to discoloration
teeth stained or unstained may be polished; it is just a and plaque accumulation. These commercial prepa-
matter of selecting the appropriate agent to complete rations contain 20% to 40% abrasive agents, coloring
the polishing procedure. It is essential to first evalu- agents, flavoring agents, and therapeutic agents. The
ate the type of tooth structure (enamel, dentin, cemen- abrasive agents improve the efficiency of the tooth-
tum), the state of demineralization, and/or the type of brush in the removal of stains, food debris, and bio-
restorative material (metal, porcelain, composite) pres- film. They also increase light reflected by the enamel.
ent before a polishing or cleaning agent is selected. The lowest possible abrasive rankings are desirable to
prevent removal of softer tooth structures and restora-
Caution tions (Fig. 13.14). Sodium bicarbonate and calcium car-
A significant amount of roughening of composite, porcelain, bonate are the most common abrasives used in com-
and gold restorations is produced even by fine prophy mercial preparations of dentifrice. Therapeutic agents
pastes. that benefit the tooth structures such as fluorides,
 Abrasion, Finishing, Polishing, and Cleaning CHAPTER 13 279

FIG. 13.14 Toothbrush abrasion; notice that the effects of abrasion are
also seen on the amalgam restoration. (Courtesy of Dr. Steve Eakle.)

tartar control agents, desensitizing and remineralizing

agents, and agents that remoisturize dry mouths are
also delivered through dentifrices.
The American Dental Association (ADA) Seal of Ac-
ceptance on toothpaste products indicates that the abra-
FIG. 13.16 In-office tartar and stain remover. (Courtesy of Patterson
sive particles in the dentifrice do not exceed the maximal Dental.)
acceptable abrasiveness, and that scientific data verify
claims made by the manufacturer (Table 13.2). The U.S. Caution
Food and Drug Administration (FDA) regulates the
A well-thought-out infection control protocol must be in
amount and type of abrasive that is placed in dentifrice.
place to prevent contamination of a removable prosthesis
and ultrasonic cleaner.
Benefits of Dentifrices
•  ssist in the reduction of biofilm
A
• Assist in the reduction of stains Procedure for Cleaning a Removable Pros-
• Assist in the reduction of dental caries thesis in the Dental Office with an Ultrasonic
• Assist in the reduction of dentin hypersensitivity Cleaner and Immersion Agent
• Assist in the remineralization of tooth structures
• Assist in the remoisturizing of dry mouth 1. Completely submerge the prosthesis in a sealed bag such
• Assist in the reduction of calculus formation as a ziplock bag or use an autoclavable beaker filled with
an immersion agent (tarter and stain remover) (Fig. 13.16).
2. Follow the manufacturer’s directions for correct dilution
Factors Contributing to Dentifrice Abrasion of the immersion, amount of time for immersion, and
agitation in the ultrasonic, typically 10 to 15 minutes.
•  ype of abrasive in the dentifrice
T 3. Remove the prosthesis and rinse thoroughly with water.
• Amount of abrasive used Be careful to avoid contamination of the prosthesis and
• Stiffness of the toothbrush bristle the liquid in the ultrasonic basin.
• Toothbrushing method used by the patient 4. Remove loosened debris with a denture brush.
• Frequency and duration of toothbrushing
• Amount of saliva present
• Type of restorations present Commercial denture cleansers should be nontoxic,
• Amount and location of exposed root surfaces present nonabrasive, and harmless to the components of the
prosthesis. Full acrylic prostheses can be soaked in
dilute alkaline or acid commercial preparations. Pros-
Denture Cleansers theses with metal components should not be placed in
The use of a toothbrush with water and a mild cleaning dilute acid solutions or hypochlorites (bleach) because
agent (Fig. 13.15) is sufficient to remove most plaque, of the resultant corrosion of these components.
surface stains, and food debris from removable pros-
Clinical Tip
thetic appliances. Immersion of the prosthesis into
commercially prepared denture cleansers that loosen Patients should always be reminded to use products
stains and deposits then can be rinsed or brushed specifically developed for home care of these removable
prostheses and never to use regular toothpaste, powdered
away is also appropriate. A dental ultrasonic agitating
household cleansers, or bleach when cleaning their
device may be used to improve the efficiency of a com-
removable appliances at home, including dentures, partial
mercially prepared immersion agent. Commercially dentures, orthodontic appliances, mouth guards, and
prepared stain and tartar agents are beneficial in the whitening trays.
removal of calculus from the prosthesis.
280 CHAPTER 13 Abrasion, Finishing, Polishing, and Cleaning

the choice of abrasive agents, the properties of the

Table 13.2   Components of Prophy Paste and surface, and the order in which the abrasives are ap-
Toothpaste
plied, and that attention be given to thorough remov-
PROPHY PASTE COMPONENT TOOTHPASTE
al of each abrasive agent before a finer one is used. If
50%-60% Abrasive 20%-40% abrasive agents are left on structures or on delivery
20%-25% Humectant 20%-40% equipment, they continue to abrade even though a
10%-20% Water 20%-40% finer abrasive is currently being applied. Some abra-
— Foaming agent—sodium 1%-2% sive agents are designed for both finishing and pol-
lauryl sulfate (SLS); ishing because of the presence of components with
removed from many abrasive variability. One-step diamond micropolisher
dentifrices because of cups and points are appropriate for both finishing and
patient sensitivity polishing. The clinician must be careful of heat gener-
2%-3% Flavoring/coloring agents 2%-3% ated by the use of rotary instruments, controlling this
1%-2% Therapeutic (fluoride) 1%-2% by applying pressure and speed intermittently, and
using water or air for cooling purposes.
In addition, care must be taken to consider the ana-
tomic form of the tooth. The finished and polished res-
toration should have a smooth, continuous line flush
with the tooth surface. When restorative margins end
at or near the root, instrumentation near or on this ca-
vosurface margin may result in ditching or gouging of
the softer cementum surfaces. Contours of teeth must
be re-created and should not be flattened or overly
rounded. The contact area need not be polished. Pol-
ishing this area may remove material, resulting in an
open contact that can lead to impaction of food, caus-
ing damage to the periodontium, or may contribute to
caries formation.
The provision of finishing and polishing procedures
for tooth structures and restorative materials by the
oral health care auxiliary is dependent on the scope of
practice regulations established by each state.

Caution
Some intraoral finishing and polishing procedures are not
allowed by auxiliary under certain circumstances or with
specific types of equipment according to state dental
practice acts.
FIG. 13.15 Polident denture cleansing agent. (Courtesy of GlaxoSmithKline.)

MARGINATION AND REMOVAL OF FLASH

FINISHING AND POLISHING PROCEDURES Before finishing or polishing an amalgam or com-
posite restoration, the clinician should check the in-
Finishing and polishing procedures follow a similar tegrity of the cavosurface margins for prematurities
sequence. Sufficient amounts of material are removed (overhanging margins) and deficiencies (Fig. 13.17).
to reproduce the anatomic contours of the restoration/ The detrimental effects of overhanging margins on
prosthesis, and finer and finer cuts are then made into hard and soft tissues are well documented. The over-
the material with diminishing abrasive agents until hanging margin acts as a niche for microorganisms
it takes on a smooth, shiny, mirror-like surface. The that contribute to periodontal disease and caries, pre-
benefits of a properly finished and polished restora- vents the efficient use of dental floss, and increases
tion/prosthesis include decreased biofilm retention, inflammation. The process of removing restoration
resistance to tarnish/corrosion, increased longevity prematurities to bring the restoration flush with the
of the restoration, decreased attrition of natural tooth cavosurface tooth structure is called margination. This
surfaces during chewing, improved esthetics, and im- process may vary from removal of feathered flash to
proved health of surrounding tissues. It is important removal of overhang (ledges created by overhanging
that the appropriate clinical decision be made as to cervical margins). The decision to remove excessive
 Abrasion, Finishing, Polishing, and Cleaning CHAPTER 13 281

Excessive margin (flash) Deficient margin

Indications for Margination with Hand Instru-
ments or a Slow-Speed Handpiece
•  verhang or flash is not extensive in size.
O
• Tooth anatomy and contour can be improved.
• Proximal contact is present.
• Restoration is intact; no fractures, open margins, or
caries is present.
Excessive margin (overhang) • The margin is accessible without damage to tissue or
A B C adjacent tooth structures.
FIG. 13.17 Line drawing of (A) excessive occlusal margin (flash); (B)
excessive proximal margin (overhang); and (C) deficient occlusal
margin.
Hand cutting instruments, such as an amalgam
knife, scalers and files, or rotary cutting diamonds
burs and carbide burs, are used. When using hand
instruments for margination, use very sharp instru-
Table 13.3   Indications and Contraindications for Air ments and work apically to the margin of the restora-
Polishing tion, using a shaving motion in diagonal overlapping
INDICATIONS FOR CONTRAINDICATIONS FOR AIR strokes and keeping the instrument in contact with the
AIR POLISHING POLISHING tooth surface. Avoid trying to remove too much of the
Patient with supra- Patient with respiratory disease overhang, in a single stroke. An ultrasonic scaler, or
gingival extrinsic slow-speed rotary handpiece with abrasive points and
stain cups, may be used to remove overhanging margins.
Patients with biofilm Patient with sodium restriction Follow this with hand cutting instruments and finish
accumulation diets when sodium bicarbon- with abrasive strips, and then check the results with
ate is powder of choice for floss and an explorer.
stain removal
Patients with biofilm Patient with limited swallowing Caution
induced Patient with difficulty breathing
If it is determined that the overhanging margin or flash is
inflammation Patient with communicable
too large for safe and effective removal by the auxiliary,
infections
the patient should be scheduled for an appointment with
Immunocompromised patients
the dentist, who will perform this procedure or replace the
Patient taking potassium, antidi-
restoration.
uretics, or steroid therapy.

AMALGAM
material from a restoration is based on clinical and ra- It is generally recommended that amalgam restora-
diographic findings. Careful evaluation of the resto- tions be polished no sooner than 24 hours after place-
ration is necessary to determine whether margination ment. The slow final setting of traditional amalgams
is indicated or the restoration needs to be replaced and potential for chipping the margins of even the new
(see the accompanying box “Indications for Margin- high-copper amalgams prevent immediate polishing
ation”). Margination may be indicated if the overhang (see Chapter 10). In addition, as many older types of
is small, the contact is intact, and there is no indica- amalgams age, the results of creep and corrosion pro-
tion of caries. Margination is not generally within duce surfaces that may benefit from periodic polishing
the scope of practice for the dental assistant, and al- procedures. This does not seem to be a problem for the
though it is within the scope of practice for the dental newer high-copper amalgams. The amount of finish-
hygienist in many states it should not be considered ing and polishing required depends on the care taken
a routine procedure. Careful consideration as to the in carving and burnishing the amalgam at the time of
type and amount of restorative material present must placement and the effects of the oral environment on
be made before undertaking this procedure. Margin- older restorations (Fig. 13.18).
ation by the dental hygienist may be performed with
hand cutting instruments, with a slow-speed rotary FINISHING AND POLISHING AMALGAM
device, or with ultrasonic instruments although in- RESTORATIONS
struments may not effectively or safely remove large Polishing of amalgam should begin by evaluating
overhanging margins. Extreme care must be used cavosurface margins for excess material, and remove
to preserve the integrity of the existing restoration as indicated (Procedure 13.1). Finishing is next, us-
and to prevent damage to adjacent tooth and tissue ing abrasive devices to remove severe scratches and
structures. surface defects. Bonded and coated abrasives greater
282 CHAPTER 13 Abrasion, Finishing, Polishing, and Cleaning

B FIG. 13.19 (From Heymann H, Swift E, Ritter A: Sturdevant’s Art & Sci-
ence of Operative Dentistry (ed 6). St. Louis, 2013, Elsevier.)

FIG. 13.18 A, Polished amalgam restoration. B, Unpolished amalgam

Traditional prophy paste, air polishing, and the use
restoration. of ultrasonic scalers are not recommended for most
esthetic restorations. If the composite has developed
extrinsic staining, it may need to be polished after
than 25 μm in particle size or special multifluted fin- placement. Fine abrasives are used in progression
ishing burs are used. Polishing that is accomplished from fine to finest, with care taken to change the de-
with bonded, coated, or loose abrasives ranging in livery device and rinse thoroughly between each pol-
particle diameter from 20 μm to submicron-sized ishing. The procedure should remove only the outer-
gives the amalgam restoration a mirror-like luster. most stained surface and should produce a lustrous
Care must be taken whenever rotary instruments finish.
are used to avoid the generation of excessive heat
and aerosols. The use of water through an air-water GOLD ALLOY
syringe or from the handpiece and proper evacua- Precious and nonprecious crowns, inlays, and on-
tion are recommended. lays are finished and polished in the dental labora-
tory before they are delivered to the dental office
COMPOSITE for final fitting and cementation. In the process of
Composite restorations are finished and polished in final fitting, minor adjustments made with abrasive
three steps as part of the restorative procedure (Pro- stones and diamonds may be necessary. It is impor-
cedure 13.2). Marginal and occlusal excesses are first tant that the resultant scratches are removed before
removed in initial finishing with diamonds or mul- final cementation. Burlew wheels on a slow-speed
tifluted carbide burs. Intermediate finishing is ac- handpiece are used, followed by rouge on a rag
complished with flexible disks (Fig. 13.19), cups, and wheel (Fig. 13.11).
strips, beginning with coarse and sequentially pro-
ceeding to superfine. Final polishing is accomplished CERAMICS (PORCELAIN)
with a submicron aluminum oxide–based polishing Ceramic restorations (including porcelain) achieve a
paste applied with soft cups or felt pads (see the ac- glassy smooth surface from the glazing procedure at
companying box, “Finishing and Polishing Compos- high temperatures (see Chapter 9). Occasionally, they
ite Restorations”). need some adjustment and are finished and polished
in the dental laboratory. Adjustments made chairside
during the fitting of these restorations are done with
Finishing and Polishing Composite
diamonds. The resultant roughened ceramic surface
Restorations
after clinical adjustment has been shown to increase
Initial finishing: Bonded and coated rotary abrasives, 100 wear of opposing tooth structure. Clinicians must
μm or larger, or multifluted carbide or diamond finishing properly finish and polish ceramic restorations after
burs making adjustments. Rubber polishing points and
Intermediate finishing: Bonded and coated rotary abrasives wheels designed for ceramics are used for finishing,
<100 μm but >20 μm and diamond polishing paste (Fig. 13.20) is used for
Final polishing: Bonded and coated abrasives or polishing
the final polish of the restoration to an enamel-like
paste from 20 to 0.3 μm to produce a final luster.
luster.
 Abrasion, Finishing, Polishing, and Cleaning CHAPTER 13 283

FIG. 13.20 Diamond polishing paste utilized for the final polish of
ceramic restorations. (Courtesy Abrasive Technology, Inc.)

Caution
Heat generated during adjustment may also result in
cracking of ceramic—always use low speed and low
pressure to minimize heat generation and cracking.

Characteristics of a Properly Finished and

Polished Restoration
•  mooth anatomic contours
S
• Contact areas intact with normal form FIG. 13.21 Acrylic finishing and polishing kit utilized for chairside pol-
• Embrasures spaced correctly ishing of a partial or complete denture. (Courtesy of Matt Crimaldi.)
• Refined margins
• Smooth surfaces correctly identify and remove calculus. If a restoration
• Restored function is incorrectly identified as calculus and is aggressively
• Eliminate biofilm retention irregularities scaled, the restoration may be removed or altered to the
• Restored gingival health point of needing replacement. In addition, all restor-
ative materials must be identified to prevent undesired
removal, damaging of margins, or scratching of the sur-
Chairside Adjusting and Polishing of Acrylic face by traditional, commercially prepared prophy paste
Denture Bases (see Chapter 2 for identification of restorative materials).
After the placement of a new denture or partial, a reline Adverse effects on the tooth surface with the use of pro-
of the prosthesis or when weight loss occurs, a patient phy paste and the philosophy of selective polish are dis-
may need to have a denture or partial adjusted due to cussed earlier in this chapter [see the Caution box in the
sore spots or over-extensions of the acrylic flanges into section “Prophylaxis (Prophy) Paste”]; polishing must be
the vestibule or posterior of the mouth that makes the a carefully considered part of the oral prophylaxis. The
appliance hard to wear. The dentist will evaluate the clinician must consider the tooth structure as well as re-
denture for any necessary adjustments and make those storative surface when choosing the most appropriate
adjustment at chairside. The first step is to trim any polishing or cleaning agent.
excess material with an acrylic bur (Fig. 13.21, far left).
(See Chapter 17 for detection of sore spots with Pres-
sure Indicator Paste or Colored Transfer Applicators.) AMALGAM
Once the appropriate amount of material has been re- Low-copper amalgam restorations will tarnish and
moved the dentist will polish the denture by using a series corrode over the years (see Chapter 10). Polishing dur-
of abrasives and rubber points to eliminate the roughness ing oral prophylaxis may greatly benefit these resto-
caused by the burs and more abrasive points (see Fig. rations. Rubber cups or bristle brushes with commer-
13.21, points are in order by abrasivity, blue most abra- cially prepared prophy paste are used on occlusal and
sive to yellow least abrasive). In order to ensure scratches smooth surfaces and dental tape on proximal surfaces.
are not left in the surface of the appliance which could The contact area should not be polished, as contact
harbor bacteria, the dentist will incrementally move from with the adjacent tooth may be lost.
the most abrasive material to the least abrasive material.
This will leave a smooth surface on the appliance. COMPOSITE
Composite restorations, which become stained after
placement, may be polished as part of a regular main-
POLISHING DURING ORAL PROPHYLAXIS tenance appointment. The use of ultrasonic and sonic
(CORONAL POLISH) scalers and air-polishing devices should be avoided
Before the coronal polishing procedure is begun, a care- on or around these restorations because these instru-
ful tactile evaluation of tooth surfaces must be done to ments may damage the surface of the restoration. The
284 CHAPTER 13 Abrasion, Finishing, Polishing, and Cleaning

use of traditional prophy pastes may cause excessive

wear; typically these restorations should be polished
with aluminum oxide polishing paste. It is important
that composite restorations be polished only if stain
is present, and that appropriate manufacture’s rec-
ommended materials are selected and used to avoid
scratching or altering the surface of the softer com-
posite materials. Begin stain removal with the least
abrasive products. If the stain is not easily removed
with fine paste, proceed to more aggressive grits or
rubber polishing points and finishing disks. Pay
close attention to the restoration’s contour and mar-
ginal integrity, always keeping the rotary instrument
moving using a light, sweeping intermittent motion.
Complete the polishing procedure using light pres-
sure with a very wet, specialized polishing paste on a
soft felt pad. Total polishing time should not exceed
30 seconds on any stained surface.
Remember to proceed sequentially from most abra-
sive to least abrasive polishing material, using a clean
or new prophy cup at each step, to polish the restora-
tion. Staining at the margins may also represent micro-
leakage (see Chapter 6, Fig. 6.3) that penetrates under
the restoration. These stains cannot be polished away
(Procedure 13.2).

GOLD ALLOYS AND CERAMICS

FIG. 13.22 Proxyt polishing paste. (Courtesy of Ivoclar Vivadent.)
Ceramics and gold alloys are extremely resistant to
staining (see Chapter 9). If scratches or irregularities
are present, they are usually due to instrumentation be as successful as originally expected and is seldom
that has scratched the outer glaze of the ceramic or used in modern practices. Air polishing, however, is
high polish of the gold. Regular prophy paste is not very successful and widely used to remove extrinsic
recommended for polishing ceramic restorations be- stains and biofilm. If used, clinicians should follow
cause of possible removal of the glaze layer. Specialty manufacturers’ recommendations for precautions in
pastes (such as Proxyt) are available that contain mi- safety and contraindications in individual clinical
crofine particles that are not harmful for polishing por- applications.
celain veneers and crowns (Fig. 13.22).
Supragingival Air Polishing
RESIN/CEMENT INTERFACE Supragingival air polishing uses several forms of pow-
Margins on resin-bonded ceramic restorations are der (sodium bicarbonate, aluminum trihydroxide,
more susceptible to staining because of the properties glycine, erythritol, calcium sodium phosphosilicate,
of resin cements. Stains accumulating at the ceramic/ or calcium carbonate) plus flavoring agents, air, and
cement interface must be evaluated carefully for actual water at a pressure of approximately 40 to 60 pounds
staining or microleakage. per square inch (psi) as a fast, effective, and efficient
means of removing stains and soft deposits from
IMPLANTS enamel surfaces and in pits and fissures. Glycine and
The clinician must be careful not to abrade the sur- erythritol powders have been found to produce less
face integrity of titanium implants (see Chapter 12). surface damage on restoratives than sodium bicar-
Biofilm may be removed with special titanium hand bonate powders; however glycine does not remove
instruments, plastic sheaths for ultrasonic scalers, and stain and is only effective in biofilm removal. Calci-
nonabrasive cleaning paste (such as Proxyt) or tin ox- um sodium phosphosilicate powder has been found
ide. Air polishing with glycine is also appropriate for to have desensitizing results in cases of dentinal hy-
removal of soft deposits on implants. persensitivity, and aluminum trihydroxide powders
contain harder particles that should not be used on
AIR POLISHING AND AIR ABRASION most esthetic restorations.
The use of air to propel very small particles (mic- Proper technique is essential to remove stain and
roparticles) as a replacement for rotary cutting instru- biofilm while controlling contaminated aerosols and
ments (a process called air abrasion) has not proven to preventing soft tissue damage. The closer the tip of
 Abrasion, Finishing, Polishing, and Cleaning CHAPTER 13 285

FIG. 13.23 Supra-gingival air polishing unit. (Courtesy of Dentsply International [York, PA].)

the air-polishing unit is to the tooth surface the great-

er the amount of aerosols produced. The nozzle of the
air-polishing unit should be kept in a constant circu-
lar motion 3 to 4 mm from the tooth surface, at an
angle of 60 to 80 degrees on smooth surfaces and a
90 degree angle on occlusal surfaces. Most research
continues to recommend caution near restorations,
particularly composite, resin cement, and porcelain
surfaces (Fig. 13.23).
Air polishing is less abrasive than traditional pro-
phy paste, as the particles used in air polishing have
a Mohs hardness ranking of 3 versus the ranking of 6
found in some traditional prophy pastes. Air polishing
is not contraindicated for use on enamel and may be
less damaging to cementum or dentin than traditional
polishing. In addition, air polishing can be safely used FIG. 13.24 Subgingival air polishing unit. (Courtesy of Acteon Group.)
on titanium implants and orthodontically banded/
bracketed teeth.
damage to the tooth structure and the junctional epi-
Subgingival Air Polishing thelium (Fig. 13.24).
Subgingival air polishing is the process of polishing As with supragingival air polishing, proper tech-
the anatomical crown and clinical root surface using nique is essential with Subgingival air polishing to
fine particles under air pressure of approximately 40 prevent the spread of dental aerosols and air-polish-
pounds per square inch to remove biofilm subgingi- ing powders. Glycine powder can be used in most air
vally. Subgingival air polishing improves periodon- polishing devices; however, a subgingival nozzle is
tal health by detoxifying root surfaces in shallow to required to reach the depth of the sulcus. The nozzle
moderate or deep periodontal pockets. The powder is inserted into the pocket at a 90-degree angle to the
approved in the United States for use in the in the long axis of the root until resistance is met, then moved
subgingival air polishing unit is glycine (Mohs rank- back from the base of the pocket about a 3 mm dis-
ing of 2). Other forms of powder (sodium bicarbonate, tance. At this time the tip is activated, dispensing gly-
aluminum trihydroxide, calcium sodium phosphosili- cine and water under pressure to remove biofilm. The
cate, or calcium carbonate) should not be used as they tip should not be activated for longer than 5 seconds
are more abrasive than the glycine, which can cause per root surface.
286 CHAPTER 13 Abrasion, Finishing, Polishing, and Cleaning

FIG. 13.25 Air abrasion tip. (Courtesy of KaVo Dental [Charlotte, NC].)

Clinical Tip
Air polishing has been shown to be very effective in the
removal of stains and debris from pits and fissures. Debris
in the fissures prevents adequate etching and penetration of
sealant into the fissures. Air polishing eliminates this cause FIG. 13.26 (Courtesy of T. Rand Collins MD.)
for many pit and fissure sealant failures.

Air Abrasion
Air abrasion, also known as microabrasion, uses greater
compressed air pressure and a 27- or 50-μm alumi-
num oxide powder particle size with a Mohs hard-
ness ranking of 9. This process is used for chairside
cleaning of cast appliances before cementation, in-
traoral repair of ceramic and composite restorations,
and preparation of tooth surfaces before bonding. Air
pressure of 40 to 160 psi and a controlled adjustable-
tip orifice allow aluminum oxide particles to strike
a tooth or restoration with enough force to effec-
tively abrade the surface. Cutting can be controlled FIG. 13.27 Polishing acrylic on partial denture. (Courtesy of Masanari
to remove minimal amounts of tooth and restorative Oshima.)
structure (Fig. 13.25).
Caution
The use of appropriate clinician and patient safety equipment
and control of aerosols with high-volume evacuation are
critical for both air polishing and air abrasion.

LABORATORY FINISHING AND POLISHING

Some appliances and restorations such as complete
and partial dentures and gold crowns must be pol-
ished after adjustments have been made to them.
The adjustments can be made at chairside and some
polishing devices are available for chairside use (see
Fig. 13.21). However, many clinicians utilize rag
wheels and/or felt tips or wheels in the dental office
laboratory to complete the final polishing of these
appliances and restorations (prior to cementation) FIG. 13.28 Polished acrylic. (Courtesy of Masanari Oshima.)
(Fig. 13.26).
wheel. They come in a variety of sizes that can be used
with a laboratory handpiece or dental lathe. A polish-
RAG WHEEL ing agent is added to the rag wheel and used for buff-
The rag wheel is a polishing device made of muslin ing or polishing acrylic appliances such as denture and
or cloth clamped or sewn together in the shape of a partial denture bases (Figs. 13.27 and 13.28).
 Abrasion, Finishing, Polishing, and Cleaning CHAPTER 13 287

PATIENT EDUCATION
Composite restorations and resin-bonded ceramic
restorations are particularly susceptible to staining.
Effective oral hygiene techniques and awareness
of dietary staining and stain-producing habits can
prevent a certain amount of surface discoloration.
Thorough removal of biofilm from restorative sur-
faces will prevent staining associated with bacterial
accumulation.
Patient education on the effects of staining foods,
particularly colored beverages such as coffee, tea,
soft drinks, and wine, and on the result of tobacco
stain on composite restorations and tooth surfaces,
FIG. 13.29 U.S. Air Force Senior Airman Justin Rhodes, 20th Dental should be part of the original restorative procedure,
Squadron dental lab technician, polishes a gold crown at Shaw Air as should regular recall appointments. Patients with
Force Base, S.C., May 15, 2012. Rhodes is a native of Owensboro, exposed cementum and dentin are particularly sus-
KY. (U.S. Air Force photo by Airman Nicole Sikorski/Released.)
ceptible to staining and the effects of abrasives. In
an attempt to improve the color of their teeth, pa-
FELT CONES AND WHEELS tients may use home remedies or excessively abra-
Felt cones and wheels are polishing devices made of sive commercial products. The consequences often
felt in the shape of cones and wheels that can be used are toothbrush abrasion and wear of restorations
with a laboratory handpiece or dental lathe. The abra- and tooth surfaces. Patient education should include
sive agent is added to the felt polishing device and used the use of approved abrasive agents. The mainte-
to smooth restorations and appliances (Fig. 13.29). nance of esthetic restorations and tooth structure is a
collaborative effort between the patient and the cli-
nician. Good patient education and the evaluation
SAFETY/INFECTION CONTROL of teeth and restorations for appropriate polishing
Aerosols are created whenever a rotary device and and finishing will increase oral esthetics and patient
moisture are used. These aerosols can provide a means satisfaction.
for disease transmission. The use of rotary devices
may produce particulate matter and vapors from the
SUMMARY
substrate being abraded. Silica particles from restora-
tions and mercury vapors pose potential health risks. The decision to abrade a surface to contour, finish, pol-
In addition, splatter from abrasives can produce seri- ish, or cleanse a structure requires careful consider-
ous eye damage. These particles are released into the ation. The clinician must have knowledge of the prop-
air and are hazards to dental personnel and their pa- erties of the material being abraded, the abrasive, and
tients. The use of precautionary personal protective the factors that affect abrasion. The process of abrasion
equipment, including a mask and eye protection, is can produce undesirable effects if not carefully con-
essential for the dental team. Protective eyewear is trolled. Appropriate use of abrasion can also produce
highly recommended for the patient as well. The use a surface that will contribute to the esthetics and lon-
of pre-procedure antimicrobial rinses has been shown gevity of the restoration and the health of surrounding
to reduce microbial aerosols, and high-speed evacua- oral tissues.
tion is recommended instead of a saliva ejector.
Caution INSTRUCTIONAL VIDEOS
• M aintain dental laboratory asepsis by sterilizing or disin- See the Evolve Resources site for a variety of educa-
fecting all wheels and rotary cutting devices tional videos that reinforce the material covered in this
• Use fresh, dry powders for each procedure, and chapter.
remove contaminated portions of stick or block
abrasives
• Maintain adequate ventilation to efficiently remove par-
ticulates from the air
288 CHAPTER 13 Abrasion, Finishing, Polishing, and Cleaning

Procedure 13.1 Finishing and Polishing a Preexisting Amalgam Restoration

See Evolve site for Competency Sheet for equal intensity of the articulating paper
markings.
Consider the following with this procedure: safety glasses are
NOTE: Premature occlusal contact can cause sensi-
recommended for the patient, PPE is required for the operator,
tivity and excessive wear on the restoration or opposing
ensure appropriate safety protocols are followed, and check your
teeth; the dentist will need to adjust the occlusion.
local state guidelines before performing this procedure.
2. Remove proximal cavosurface excesses with an
amalgam knife or a similar sharp instrument,
EQUIPMENT/SUPPLIES (FIG. 13.30) using short, overlapping strokes (Fig. 13.31).
1. Mirror and explorer 3. Isolate the restoration with cotton rolls and saliva
2. Air-water syringe ejector.
3. Articulating paper 4. Use pointed stones for the occlusal surface and
4. Isolation materials a disk or cup for smooth surfaces, beginning
5. Slow-speed handpiece and attachment with the coarsest abrasive (i.e., a brown cup
6. Finishing burs, stones, disks, and cups or “brownie”) and then with finer abrasives
7. Dappen dish (“greenies” and finally “super greenies”) (Fig.
8. Pumice or polishing paste 13.32 and 13.33). Adapt the side of the stone to the
9. Disposable rubber cup and brush restoration and tooth.
10. Tin oxide 5. Use slow to low-moderate speed, always moving
NOTE: Polish amalgam no sooner than 24 hours the stone from tooth to amalgam to prevent
after insertion to allow the amalgam to develop its ditching the cavosurface margin.
maximal strength. 6. Use a light sweeping intermittent motion
while keeping the finishing instrument moving
PROCEDURE STEPS to avoid excessive heat and mercury vapor
Examine the cavosurface margins of the entire restora- production. Maintain a wet environment to
tion for excess material. reduce heat.
NOTE: Remove excess material to prevent plaque 7. Rinse the area thoroughly when changing
accumulation or gingival irritation. abrasives to prevent the more abrasive particles
1. Check occlusion with articulating paper and from abrading the surface.
clinically for premature occlusal contact; look

FIG. 13.30 FIG. 13.31

 Abrasion, Finishing, Polishing, and Cleaning CHAPTER 13 289

Procedure 13.1 Finishing and Polishing a Preexisting Amalgam Restoration—cont’d

8. Use the rubber cup and brush with a slurry of 9. Keep the cup or brush in motion at all times,
pumice and then tin oxide (Fig. 13.34). using light intermittent strokes and moderate
speed.
10. Rinse thoroughly between the use of pumice and
tin oxide.
11. Polish the proximal surfaces with a handheld
finishing strip or pumice and dental tape.
12. Wrap the strip around the tooth contours to avoid
flattening of proximal contours (Fig. 13.35).
13. Do not polish through the contact area. Polishing
through the contact area can create a weak or
open contact.
14. NOTE: The final product is shown in Fig. 13.36.

FIG. 13.32

FIG. 13.35

FIG. 13.33

FIG. 13.34 FIG. 13.36

290 CHAPTER 13 Abrasion, Finishing, Polishing, and Cleaning

Procedure 13.2 Polishing a Preexisting Composite Restoration

See Evolve site for Competency Sheet. NOTE: This pattern of movement prevents ditch-
ing of restorations at the margins.
Consider the following with this procedure: safety glasses are
7. Keep the rotary device in motion at all times.
recommended for the patient, PPE is required for the operator,
NOTE: Smooth surfaces can be polished using
ensure appropriate safety protocols are followed, and check your
cups and disks; occlusal surfaces are better reached
local state guidelines before performing this procedure.
with points (Fig. 13.41).
8. Complete the polish with sequentially applied
EQUIPMENT/SUPPLIES (FIG. 13.37) abrasive paste on a rubber cup.
1. Mirror and explorer NOTE: This must be an abrasive paste designed
2. Air-water syringe for polishing composites; begin with coarse and pro-
3. Isolation materials ceed through superfine.
4. Slow-speed handpiece and attachment
5. Abrasive finishing disks
6. Sterilizable mandrel
7. Abrasive flexible wheels and points
8. Polishing paste
9. Rubber cup
NOTE: Initial contouring, finishing, and polishing
are done immediately after insertion.

PROCEDURE STEPS
1. Examine the restoration for staining.
NOTE: Do not polish if stain is not present.
2. Isolate the area with cotton rolls and saliva ejector.
3. Remove cavosurface flash with a sharp scaler, a
FIG. 13.38
#12 scalpel blade, or a gold knife.
4. NOTE: A gold knife, also called a finishing
knife or amalgam knife, has a small, thin blade
designed to carve restorative materials.
NOTE: Avoid deeply scratching the restorative
material. A shaving motion is used rather than bulk re-
moval, as bulk removal may result in voids at the mar-
gins if excess composite is removed.
5. Use, in order, coarse to fine abrasive disks on a
sterilizable mandrel or flexible wheels and rubber
points, rinsing after each application (Fig. 13.38
and 13.39).
NOTE: Rinse thoroughly to completely eliminate
coarser particles before polishing with finer abrasive
disks, to prevent overabrasion.
6. Use a light sweeping intermittent motion from FIG. 13.39
enamel to restoration (Fig. 13.40).

FIG. 13.40
FIG. 13.37
 Abrasion, Finishing, Polishing, and Cleaning CHAPTER 13 291

Procedure 13.2 Polishing a Preexisting Composite Restoration

9. Polish proximal surfaces with handheld polishing NOTE: Keep the rotary polishing device or abra-
strips or polishing paste and dental tape (Fig. 13.42). sive strip contoured to the shape of the tooth.
NOTE: These strips must be very thin to prevent 11. Rinse thoroughly and evaluate for smoothness
loss of the proximal contact. and luster.
10. Avoid flattening of proximal contours.

FIG. 13.41 FIG. 13.42

Get Ready for Exams!

Review Questions 6. W hich powder is best for subgingival air polishing

practices?
Select the one correct response for each of the following
a. Sodium bicarbonate
multiple-choice questions.
b. Aluminum trihydroxide
1. The goal of finishing and polishing of restorations c. Glycine
includes: d. Calcium carbonate
a. The removal of excess material
7. To control the numbers of abrasive particles that con-
b. The smoothing of roughened surfaces
tact the surface:
c. The production of better esthetics
a. The operator should increase the speed
d. All of the above
b. The operator should decrease the pressure
2. Cleaning of teeth is primarily meant to: c. The operator should use a lubricant
a. Remove excess material d. The operator should not use rotary instruments
b. Smooth roughened surfaces
8. Loose abrasives:
c. Remove soft deposits
a. Are safe-sided
d. Recontour surfaces
b. Are used on cups and brushes
3. The depth and space between cuts made by an abra- c. Come in various shapes
sive are determined by: d. Use sterilizable mandrels
a. The properties of the abrasive
9. A substance used to prevent a dentifrice from drying is
b. The properties of the substrate being abraded
called a(n):
c. The contour of the restoration
a. Humectant
d. Both a and b
b. Binder
4. Which of the following represents the correct hardness c. Detergent
ranking, from hardest to softest? d. Alkaline peroxide
a. Gold, amalgam, composite, enamel
10. After polishing a patient’s teeth you notice scratches on
b. Enamel, amalgam, gold, composite
a gold crown; the following most likely contributed to
c. Composite, enamel, gold, amalgam
these scratches:
d. Amalgam, enamel, composite, gold
a. Use of an inappropriate polishing agent
5. All of the following will increase the rate of abrasion b. Corrosion of the crown
except: c. Improper toothbrushing
a. Increased pressure d. None of the above would contribute to scratches on
b. Decreased speed the crown
c. Use of larger abrasive particles
d. Use of more abrasive particles than substrate

Continued
292 CHAPTER 13 Abrasion, Finishing, Polishing, and Cleaning

11. Y
 our patient has older amalgam restorations present, an amalgam restoration, a composite restoration, and a
and you have determined that these restorations could gold restoration.
benefit from amalgam polish. Give the correct sequence 2. List two materials used to polish stains from the coronal
in the use of rubber abrasive points: surfaces of teeth, and discuss the contraindications to
a. Brownies, super greenies, greenies using various abrasives on tooth surfaces.
b. Brownies, greenies, super greenies 3. Case Study Question
c. Supper greenies, greenies, brownies A 30-year-old computer programmer comes to the dental
d. Greenies, super greenies, brownies office complaining of catching dental floss on a new class
For answers to Review Questions, see the Appendix. II distal occlusal (DO) composite restoration on tooth #29.
Examination reveals excess composite at the gingival
Case-Based Discussion Topics margin and an overcontoured distofacial surface of this
restoration.
1. D
 iscuss how the operator uses knowledge of the factors Discuss instruments, materials, and techniques for correct-
that affect abrasion to control the polishing sequence of ing the problem.

BIBLIOGRAPHY Davis K: Biofilm Removal with Air Polishing and Subgingival Air
Polish­ing, ADA Continuing Education Recognition Programpen-
American Dental Hygienists’ Association (ADHA): Association Po- nwell publications, 2013. Available at https://fliphtml5.com/
sition Paper on the Oral Prophylaxis. Available at https://www. jarv/ijwq/basic.
adha.org/resources-docs/7115_Prophylaxis_Postion_Paper.pdf. Davis K: Do You Know About Air-Flow Perio? RDH Magazine
Anusavice KJ, Shen C, Rawls HR: Phillips’ Science of Dental Mate- 2013. Available at https://www.rdhmag.com/articles/p-
rials (ed 12). Philadelphia, 2013, Saunders. rint/volume-33/issue-1/coumns/glycine-powder-aids-in-
Barnes CM: Polishing esthetic restorative materials. Dimensions periodontal-biofilm-removal.html.
of Dental Hygiene, 8(24):26–28, 2010. Felix L, Mossman S: Dental hygienists play key roles in advising
Barmes CM: Shining a new light on selective polishing. Dimen- patients on restorative options and helping them maintain
sions of Dental Hygiene, 10(3):42–44, 2012. them. Dimensions in Dental Hygiene, 15(3):30–31, 2017.
Barnes CM: Air Polishing: A Mainstay for Dental Hygiene, ADA Con- Gutkowski S: The trek to positive polishing, mastering the chal-
tinuing Education Recognition Program. PennWell Publications, lenge to actually use air polishers. RDH Magazine, 6:68–70, 2013.
St. Louis, July 2013. Available at https://www.yumpu.com/ Mopper K: Contouring, finishing, and polishing anterior com-
en/document/read/22671110/air-polishing-a-mainstay-for- posites, Inside Dentistry, 7(3):62–70, 2011.
dental-hygiene-ineedcecom. Mossman SL: Material selection and maintenance. Dimensions of
Bird D, Robinson D: Modern Dental Assist­ing (ed 12). Missouri, Dental Hygiene, 12:63–67, 2014.
St. Louis, 2018, Elsevier. Pence S: Polishing basics. Dimensions of Dental Hygiene, 11(26):28,
Calley K: Maintaining the beauty and longevity of esthetic resto- 2013.
rations. Dimens Dental Hygiene, 7:38–41, 2009. Pence S: Polishing particulars. Dimensions of Dental Hygiene,
Darby M: An Evidence-Based Approach to Cleansing and Polishing 11(26):28, 2013.
Teeth. The American Academy for Oral Systemic Health, 2012. Robinson D, Bird D: Essentials of Dental Assist­ing, (ed 6). Mis-
Available at https://aaosh.org/evidence-based-approach- souri, 2017, St. Louis, Elsevier.
cleansing-polishing-teeth/. Sorensen JA: Finishing and polishing with modern ceramic sys-
Darby M, Walsh M: Dental Hygiene Theory and Practice (ed 4). tems. Inside Dentistry, 2:10–16, 2013.
Missouri, 2015, Elsevier Saunders. Wilkins E: Clinical Practice of the Dental Hygienist (ed 12). Phila-
Daubert D: Subgingival air polishing. Dimensions of Dental Hy- delphia, 2017, Lippincott, Williams & Wilkins.
giene, 11(12):69–73, 2013.
Dental Cement 14
http://evolve.elsevier.com/Eakle/materials/

Chapter Objectives
Upon completion of this chapter, the student should be able to:
1. Compare the various types of cements for: 5. C ompare the advantages and disadvantages of each
• Pulpal protection cement.
• Luting 6. Describe the manipulation considerations for mixing
• Restorations cements.
• Surgical dressing 7. Describe the procedure for filling a crown with luting
2. Describe the properties of cement, and explain how cement.
these properties affect selection of cement for a dental 8. Describe the procedure for removing excess cement after
procedure. cementation.
3. Identify the components of the various dental cements. 9. Apply the mixing technique for each type of cement.
4. Describe how the components of various dental cements
affect the properties of the cement.

Key Terms
Cavity Varnish a thin layer of resinous material placed on Luting cementing two components together such as an
the floor and walls of the preparation to seal the tubules indirect restoration cemented on or in a tooth, including
and minimize microleakage inlays, crowns, bridges, veneers, orthodontic brackets and
Liner a thin layer of material placed to protect the pulp from bands, and posts and pins
the chemical components of dental materials, from oral Permanent lasting indefinitely
fluids and microorganisms associated with microleakage, Temporary/Provisional referring to materials expected to
to stimulate reparative dentin, or to act as a pulp capping last from a few days to a few weeks
Base a thick layer of cement used to protect the tooth from Intermediate referring to materials expected to last from a
chemical and thermal irritation and to support restorations few weeks to a year
in deep cavity preparations Sedative soothing; acting to relieve pain
Secondary Consistency thick, putty-like, condensable Primary Consistency less viscous, easily flowing state of a
physical state of a material which can be rolled into a ball material which can be can be drawn out to a 1-inch string
or rope, suitable for use as a base with a spatula lifted from the center of the mass, suitable
Buildup a thick layer of cement or restorative material used for luting
to replace missing tooth structure in a badly broken-down Adhesion the attractive forces of atoms or molecules that
tooth and to act as support for a restoration such as a join two surfaces together
crown

Few materials in dentistry are used as frequently or with with other restorative materials and, with the exception of
as many applications as dental cements. There are an im- resin and glass ionomer cements, have little or no adhesive
pressive number of dental cements available, and each may properties. Even with these limitations,cements are used in
have specific or multiple uses. No single cement is univer- a wide variety of dental procedures. The clinical demands
sally acceptable for all applications; rather, various cements of different types of prosthetic restorations, ranging from
are available whose properties and manipulation make gold crowns, PFM (porcelain-fused-to-metal) crowns, all-
them an appropriate choice for a given application. There ceramic crowns, indirect composite resins, and CAD/CAM
are cements specifically targeted for use in orthodontics, (computer-­ assisted design/computer-assisted machining)
endodontics, surgery, and implants. Many dental cements products, have made the selection of cements more challeng-
have inferior strength and high solubility when compared ing. With the multitude of cements available, it is easy to

293
294 CHAPTER 14 Dental Cement

become confused as to which cement should be selected for tooth or cement or bond orthodontic bands or brackets
a given situation. In most cases, the dentist will select the in place. These cements can be permanent (long-term)
cement for a procedure on the basis of mechanical as well as or provisional (temporary).
biological factors. It becomes the dental assistant’s respon- Type II Cements. These cements are used for provi-
sibility to manipulate the cement to the proper consisten- sional or intermediate restorations or long-term in the
cy within the recommended mixing time. Many expanded case of glass ionomer cements. Cements used as dental
function auxiliaries are also placing the cement, seating the sealants are also in this group.
crown and removing the excess at the end of a procedure. The Type III Cements. These cements are used for bases
dental hygienist may be placing and removing cements and or liners for cavity preparations.
instrumenting against the cement surface during periodon-
tal procedures. It is important that the oral health practitio- USES OF DENTAL CEMENTS
ner have a thorough understanding of cement uses, prop- Dental cements have a variety of uses. These include
erties, limitations, and manipulation to effectively use and ­pulpal protection and sedation, luting of indirect restora-
work around these materials. tions, provisional restorations, intermediate intracoronal
restorations, root canal sealers and surgical dressings
(Table 14.1).
DENTAL CEMENTS
Cement can be defined as a substance that binds two Pulpal Protection
surfaces together rigidly. In dentistry cement, when The bacterial effects of caries, the biological response to
set, is a hard, brittle material with a wide range of chemicals contained in restorative materials, and even
applications such as lining a cavity preparation, as a the cutting of tooth structure may cause pulpal irritation.
temporary or permanent filling or securing a crown Pulpal irritation can also occur as the result of thermal
in place. Typically, cement is formed by mixing two conductivity of metal restorations placed near the pulp,
components together, often a powder and liquid or and when the dentin remaining over the pulp is too thin
two pastes that becomes a viscous liquid or mass that to withstand compressive, tensile, and shearing stresses.
hardens. Luting agents are cements used as adhesives Many of the chemicals contained within the materials
to secure indirect restorations to the tooth. used to restore teeth have the potential to cause irrita-
tion. Older amalgam formulations were prone to more
CLASSIFICATION corrosive products leaking into the tubules of the tooth
Dental cements have been classified by their uses and structure, causing discoloration. Cavity varnishes, liners,
properties into three categories by the International and bases act as protective layers between the dentin and
Standards Organization and the American Dental the restorative material (Fig. 14.1). There has been a dra-
Association. matic reduction in the use of pulpal protection materials
Type I Cements. These cements are luting agents as resin bonding technologies and high-copper amal-
that glue crowns, bridges, onlays and inlays to the gams have replaced these older types of restorations.

TABLE 14.1    Uses of Dental Cements

USES OF CEMENTS CEMENT
Cavity liner/pulpal cap Calcium hydroxide
Pulpal medicament/low-strength base Zinc oxide eugenol
High-strength bases Reinforced zinc oxide eugenol, zinc phosphate, zinc polycarboxylate, GIC,
RMGIC, resin-based cements
Crown buildups RMGIC, composite resins
Permanent cementation
Cast crowns, inlays/onlays, and bridges Zinc phosphate, zinc polycarboxylate, GIC, RMGIC, resin-based
Porcelain, ceramic or composite veneers, Resin cements, self-adhesive resin cements
inlays, onlays, and all-ceramic crowns RMGIC, adhesive resin, self-adhesive resin
High-strength ceramics
Endodontic posts Zinc phosphate, GIC, RMGIC, adhesive resin, and self-adhesive resin
Orthodontic bands Fluoride-added zinc phosphate, polycarboxylate, GIC, RMGIC
Orthodontic brackets GIC, RMGIC, Resin
Provisional cementation Zinc oxide eugenol or noneugenol, zinc polycarboxylate, resin provisional cement
Provisional restorations Reinforced zinc oxide eugenol, polycarboxylate, zinc phosphate, GIC, RMGIC
Surgical dressing Zinc oxide noneugenol
GIC, glass ionomer cement; RMGIC, resin-modified glass ionomer cement.
 Dental Cement CHAPTER 14 295

Cavity varnish. Cavity varnish is not cement, but it acts an aqueous suspension is another form of the material
as a protective barrier between the tooth preparation used for pulp capping or vital pulpotomies.
and restoration (see also Cavity Varnish in Chapter
10 Amalgam), varnish formulations are solutions of Mixing Calcium Hydroxide (Dycal) for
natural resins (copal) or synthetic resins dissolved in Cavity Liner
a solvent such as alcohol, ether, or chloroform. The
varnish is applied in two or three layers over the sur- Mix: Equal lengths of base and catalyst pastes on paper
face of the preparation. The solution is placed in a thin pad for 10 seconds to a uniform color
film, allowing evaporation of the solvent to occur in 5 Working time: 2 minutes 30 seconds
Setting time: 3 minutes 30 seconds
to 15 seconds before application of the second layer.
An air stream can speed up the evaporation of the sol-
vent. The resin layer protects the pulp by sealing the Calcium hydroxide has an alkaline pH about 11 and
tubules from the penetration of irritating chemicals can neutralize some acids. This alkali stimulates sec-
found in some restorative materials and/or acidic lut- ondary dentin when in direct contact with the pulp,
ing agents such as zinc phosphate cement. This resin providing a barrier between pulp and restoration. It
varnish is thought to reduce the amount of microle- has some antimicrobial activity, meager thermal in-
akage and staining at the restoration/tooth interface. sulating properties, and provides minimal strength to
Copal varnishes, although popular for many years, support the forces of condensation. Under amalgam
are no longer widely used today. They were used restorations calcium hydroxide paste slowly leaches
extensively under amalgam restorations, but studies out over time as it is water-soluble.
showed that they washed out, leaving a microscopic
gap between the amalgam and the cavity preparation. Bases. A base is cement that is applied in a layer about
Today’s resin bonding agents, which also seal enamel 1-2 mm thick over the dentin to provide thermal and
and dentinal tubules, have largely replaced the use of chemical insulation to the pulp and provide support to
varnish. restorations in deep cavity preparations. Some bases
may act as a pulpal medication as well. Bases may be
Liners. A liner is a thin layer of protective material that classified as low strength or high strength.
is placed over the dentin to seal the tubules from chem- Zinc oxide – eugenol (ZOE) is considered to be
ical or bacterial irritants. a low-strength base material. Unless it is reinforced
Calcium hydroxide is used as a liner in cavity prep- with other materials such as polymethylmethacrylate
arations in which the remaining dentin over the pulp (PMMA) fibers to make it stronger, it typically will
is minimal. When close to the pulp or very small expo- not be used to support a restoration. The eugenol in
sures are suspected, this material is used as an indirect ZOE does have some soothing effects on the pulp. An
or direct pulp-capping agent or as a dressing after vital unreinforced ZOE base is often used more like a liner
pulpotomy procedures on primary teeth. Components and is placed in a thin layer which as a consequence
of a popular two-paste system include calcium hy- will provide little thermal insulation. It is supplied as a
droxide, zinc oxide, and glycol salicylate (e.g., Dycal, powder (zinc oxide) and liquid (eugenol) or in a paste-
Dentsply). A light-cured form of the paste-paste sys- paste formulation (e.g., Cavitec, Kerr Corporation).
tem is also available, and because of its resin content it Equal lengths of the two pastes are extruded from
is a bit stronger than the other liners. With paste-paste tubes, mixed to a uniform consistency, and applied in a
systems, equal amounts of catalyst and base are mixed thin layer over the desired area. ZOE will be discussed
to a creamy consistency. Calcium hydroxide powder in in detail later in the chapter.
High-strength bases have approximately four times
Cement Restoration the compressive strength of low-strength bases and lin-
ers. They have the strength needed to support restora-
Enamel tions in deep preparations. Cements used as bases are
Base
mixed to secondary consistency—a thick putty-like
consistency that is condensable and can be rolled into
a ball or rope. Bases placed at a thickness of 0.75 mm or
greater provide protection from the thermal conduction
Liner of metallic restorations and galvanic shock. When the
cavity preparation is so deep that there is 2 mm or less
Dentin of remaining dentin over the pulp, many clinicians will
choose to provide mechanical support for the restora-
tion by first placing a cement base. The restorative mate-
rial is placed after the initial set of the base has occurred.
FIG. 14.1 Line drawing of layers of cement, base and liner, under a Some high-strength bases are provided as hand-mixed
restoration. powder and liquid or premeasured capsules of powder
296 CHAPTER 14 Dental Cement

and liquid that are mixed by trituration. Others are pro-

vided as paste-paste systems in tubes with automixing
tips. Examples of cements used for high-strength bases
include reinforced ZOE (IRM, Dentsply), zinc phosphate
(Fleck’s Cement, Keystone Industries), zinc polycarbox-
ylate (Durelon Maxicap, 3M ESPE), glass ionomer (Fuji
II, GC America), resin-modified glass ionomer (Fuji II
LC, GC America), and resin (a dentin bonding agent and
usually a flowable composite). Zinc phosphate cement
is acidic, so a liner or varnish may be needed under it
to protect the pulp in deep preparations. Resin-modified
glass ionomer cement is one of the most popular mate-
rials used as a base material, because it is not irritating
to the pulp, bonds to tooth structure, releases fluoride,
and is strong. When placed in a thin layer resin-modified
glass ionomer cement can also be used as a liner.

Clinical Tip
Because of their fluoride release and low solubility, light- FIG. 14.2 Radiograph of a cement buildup over endodontically treated
tooth #30, to reinforce the remains of the tooth in preparation for crown
cured resin-modified glass ionomer cements are a popular
placement. (Courtesy of Steve Eakle, University of California, San
choice as general cavity liners or bases. Some of the new Francisco [San Francisco, CA].)
bioactive formulations release calcium ions to promote hy-
droxyapatite and secondary dentin growth.

Prosthesis
Mixing Reinforced ZOE (IRM, Dentsply) for
Cement
a Base
Mix: Dispense a ratio of 1 level scoop to 1 drop of liquid on
a paper pad or glass slab. Use a stiff spatula to mix ½ the Tooth structure
powder into the liquid, then add the remaining powder in 1
or 2 increments. Spatulate thoroughly to produce a thick mix.
Wipe the mix with the spatula vigorously 5 to 10 seconds to
produce a smooth, stiff mix. Total mixing time about 1 minute.
Working time: 3.5 to 4 minutes
Setting time: 5 minutes from the start of mix
Setting time is accelerated by increased temperature,
humidity, and powder/liquid ratio.
Cement layer

Buildup
A buildup, much like a high-strength base, provides
mechanical support for a restorative material when an
excessive amount of tooth structure is missing. The re- FIG. 14.3 Line drawing of a seated crown and the cement filling the
maining tooth structure first needs to be rebuilt to bet- restoration/tooth interface.
ter support the restorative material or to act as a foun-
dation before crown preparation. With placement of a Luting of Indirect Restorations
cement buildup, the compromised tooth is reinforced A luting agent is a material with low viscosity, which
(Fig. 14.2). Resin-modified glass ionomer and resin ce- placed between the prepared tooth and restoration, sets,
ments are the strongest of the cements. Typically, resin and firmly attaches the restoration to the tooth (Fig. 14.3).
cement is not used in thick layers as a buildup, but
composite resin restorative material serves well for Orthodontic Bands and Brackets
this purpose. Resin-modified glass ionomer cement is Orthodontic bands and brackets are retained on teeth
frequently used as a buildup material when only a por- for several months or even years. Brackets are usually
tion of the coronal tooth structure is missing so that bonded directly to the enamel with resin cements (see
there is still remaining sound tooth structure to sup- Fig. 14.4 and Chapter 5 Principles of Bonding, Procedure
port the crown. Its desirable features are its strength 5.3), whereas bands are cemented without bonding.
(compared to the conventional cements), chemical The cement must adhere tenaciously to the enam-
bond to the mineral component of enamel and dentin, el and the orthodontic band to provide leverage for
good seal to the tooth, and fluoride release. tooth movement and when the band is removed have
 Dental Cement CHAPTER 14 297

of cement for this type of restoration is largely based

on the particular clinical situation. Provisional resto-
rations are used for emergency situations when ap-
pointment scheduling does not allow sufficient time
to place a permanent restoration. Provisional restora-
tions are placed when a tooth is symptomatic or when
deep caries removal is required. By placing a sedative
provisional restoration, the dentist is able to evaluate
the response of the pulp before reappointing for a per-
manent restoration. Provisional and intermediate res-
torations are used to restore teeth awaiting treatment
such as inlays, between endodontic appointments,
or when extensive treatment plans require several
FIG. 14.4 Orthodontic brackets bonded directly to enamel with resin
weeks or months of coverage before treatment can be
cement. (From Powers JM, Wataha JC: Dental Materials: Properties completed.
and Manipulation, ed 10, St. Louis, 2013, Mosby, p. 87.) See Chapter 18 Provisional Restorations for a dis-
cussion of provisional luting and intracoronal cement
minimal effect on the tooth surface. Demineralization provisionals.
of the tooth surface due to solubility of cements and
resultant leakage of bacteria between the bands and Root Canal Sealers
the tooth surface has often led to white spots on the There are many types of cement that can be used along
enamel or caries. This concern has been minimized with gutta percha or without it to seal the canal space
to some extent with fluoride-releasing, anticariogenic when doing root canal therapy. The sealers are avail-
glass ionomer (e.g., Ketac Cem, 3M ESPE) and resin- able as two pastes that can be packaged in syringes or
modified glass ionomer cements (e.g., GC Fuji Ortho, premeasured capsules or powder and liquid which are
GC America). hand mixed on a pad or glass slab. The sealer materi-
Metal, plastic, and ceramic brackets can be bonded als may encompass a wide range of components such as
to the enamel with resin cements. The enamel is treated calcium hydroxide, zinc oxide with eugenol or non-eu-
with phosphoric acid, rinsed, and dried before appli- genol substitute, resins, glass ionomer, calcium silicate,
cation of bonding agent. Then, resin cement is applied or mineral trioxide aggregate. Some of the materials are
to the bracket and seated on the primed enamel. Self- also used for vital pulpal therapy. They all have different
etching primers could be used as well, but some of them properties, handling characteristics, working and setting
do not etch the enamel as well as phosphoric acid. Self-, times. Manufacturers’ specifications must be followed
light- and dual-cured cements are available. It is pos- carefully.
sible to use light-cured cement under metal brackets by
positioning the curing light at 45 degrees to the bracket Surgical Dressings
from all angles on the facial, then curing from the lin- As surgical dressings, cements are used to provide
gual as well. protection and support for the surgical site, to pro-
vide patient comfort, and to help control bleeding.
Restorative Material The periodontal surgical dressing was developed in
Permanent, Intermediate, and Provisional (Temporary). 1923 by Dr. A W Ward. His product was called Ward’s
Because of their lower strength and wear resistance Wonder Pac and it consisted of zinc oxide, eugenol
and higher solubility, cements are not frequently cho- with added alcohol, pine oil, and asbestos fibers (to-
sen as permanent restorations. The exceptions are day’s product no longer contains asbestos). Over time
glass ionomer cement (GIC) and resin-modified glass it became apparent that eugenol acted as an irritant
ionomer cement (RMGIC), which, because of their re- to the tissues and was damaging to exposed bone.
lease of fluoride and chemical bond to tooth structure, Current products have shifted away from the use of
are used for class V restorations of root caries in adults eugenol.
and for restoration of primary teeth (see Chapter 6 The most widely used product in the USA is Coe
Composites, Glass Ionomers, and Compomers). The Pak (GC America). It is a two-paste system—base and
formulations of glass ionomer cement and resin-mod- catalyst. The base contains zinc oxide as the main com-
ified glass ionomer cement as restorative materials are ponent with oils as plasticizers (make it flexible), gums
different and much thicker than the GIC or RMGIC lut- to give it body for handling, and lorothidol as a fun-
ing cements. The luting cements must have a low film gicide. The catalyst paste contains coconut fatty acids
thickness to allow the restoration to seat fully. that are thickened with rosin and chlorothymol as an
As provisional (also called temporary) and inter- antibacterial agent. It is available in regular and fast set
mediate restorations, dental cements are mixed to and hard set formulations. It also comes as manual mix
secondary consistency (Procedure 14.1). The choice or automix delivery (Fig. 14.5).
298 CHAPTER 14 Dental Cement

Preparing the Surgical Dressing

For the hand-mixed dressing, equal lengths of base
and catalyst pastes are dispensed onto a non-porous
paper pad. They are mixed with a tongue blade (dis-
posable) or spatula to a soft putty-like consistency of
uniform color. The setting time can be accelerated by
immersing the mixed putty-like material in warm wa-
ter. When the mix is no longer tacky, it can be shaped
into two ropes about the width of a little finger. These
materials tend to stick to gloves, so a lubricant such as
KY Jelly (Reckitt Benckiser), petroleum jelly, or water
should be applied to the gloves before handling. Start-
ing at the distal of the surgical site a rope is spread over
A the tissues on the facial and lingual and pressed into
the interproximal areas. The dressing is mechanically
retained by gently forcing the material into the embra-
sure spaces and under the contacts (Fig. 14.6). The ma-
terial should not extend more than 2 mm b ­ eyond the
surgical site. If needed, the patient (or the operator if
the patient is too numb) should move the cheeks, lips,
and tongue in a range of motions to shape the edges
of the dressing (a process called muscle trimming or
molding). This helps to prevent the hardened material
from irritating tissues and dislodging the dressing af-
ter it has set. The occlusion should be checked to assure
that the dressing is not interfering. Use a plastic instru-
ment or other suitable instrument to keep the dress-
B ing from extending above the height of contour of the
FIG. 14.5 Surgical dressing in 2-paste systems. A, Tubes of hand-mixed teeth. Some materials become hard and others remain
material. B, Pastes in automix system. (Courtesy Coe Pak, GC America.) somewhat flexible depending on their formulation.

A B

D C
FIG. 14.6 Mix and application of surgical dressing (Coe Pak, GC America). Clockwise: A, Tubes of material, mixing slab,
and disposable spatula. B, Base and catalyst pastes dispensed on a slab. C, Mixed pastes. D, Dressing applied to the
surgical site. (From Kathariya R, Jain H, Jadhav T: To pack or not to pack: the current status of periodontal dressing. J
Appl Biomater Funct Mater, 13(2):e73–e86, 2015.)
 Dental Cement CHAPTER 14 299

Clinical Tip Luting restorations with traditional cements using

When mixing surgical dressing material use a wooden mechanical retention was the only means of cementa-
tongue blade. It can be discarded when done. The material tion until the mid-1960s when dentin bonding with
is sticky and difficult to remove from a spatula. acid-etch systems was developed, leading to today’s
adhesive dentistry. Zinc polycarboxylate and glass
ionomer cements with some degree of chemical ad-
Removing the Dressing hesion to tooth structure were also introduced about
After the tissues have healed it is time to remove the that time.
dressing. A blunt instrument is used under the edge
of the dressing with gentle lateral pressure to loosen PROPERTIES OF LUTING CEMENTS
the pack. The clinician must be aware of the location of Properties of luting cements differ from one type of
sutures and avoid breaking the sutures away with the cement to another. No cement is ideal for every clini-
dressing. Large pieces of the dressing are lifted with cal situation. Although one type of cement may be ap-
cotton forceps and the surgical site is cleaned with a propriate for a single crown, it may not be ideal for
dilute solution of hydrogen peroxide or sterile water a multiple-unit bridge; some cements work well on
(Fig. 14.7). Occasionally, all or part of a dressing will metal surfaces, but others are more appropriate for ce-
come off prematurely and need to be reapplied. ramic or porcelain surfaces. Ideally, the cement should
adhere to the tooth structure as well as the restorative
material. The clinician must consider both physical
Criteria for a Well-Placed Dressing
and biological properties when selecting cement for a
• D oes not dislodge or disturb the placement of any specific dental procedure. The most important prop-
surgical sutures
erties are as follows: strength, solubility, viscosity (af-
• Smooth, with as little bulk as possible
fecting film thickness), biocompatibility, anticariogenic
• Covers the surgical site with minimal overextension
• Interlocked interdentally to provide stability properties, retention, esthetics, radiopacity, and ease of
manipulation (Table 14.2).

TYPE I CEMENTS: LUTING AGENTS Ideal Properties of a Luting Agent

Luting cements can be placed into two broad catego- •  dhesion to tooth structure
A
ries: non-adhesive and adhesive cements. • Adhesion to restorative material
Non-adhesive cements: Retention of the restoration is • Adequate strength to resist functional forces
enhanced by filling the interface between the restora- • Not soluble in oral fluids
• Ability to achieve low film thickness
tion and the prepared tooth with a hard setting cement,
• Biocompatibility with oral tissue
much like hard-setting household cements. • Anticariogenic properties
Adhesive cements: Stronger than non-adhesive ce- • Radiopacity
ments, adhesive cements fill the interface and provide • Ease of manipulation
micromechanical and/or chemical retention between • Esthetics and color stability
the tooth substrate and restorative materials.

A B
FIG. 14.7 Removal of surgical dressing. A, Instrument under the edge of the dressing to loosen it. B, Use an instrument
to remove pieces of the dressing from the interproximal spaces. (From Robinson DS, Bird DL: Essentials of Dental Assist-
ing, ed 6, St. Louis, 2017, Elsevier.)
300 CHAPTER 14 Dental Cement

TABLE 14.2    Properties of Luting Cements

ZINC
PROPERTY GIC RMGIC RESIN ZINC PHOSPHATE POLYCARBOXYLATE ZOE
Strength Moderate Moderate High Low Low Low
Solubility Moderate Low Very low High High High
Film thickness Low Low Low Low Low, medium Low, medium
Postoperative Moderate Low Low Moderate Low Low
sensitivity
Fluoride release High High None None None None
Adhesion Moderate Moderate High None Moderate None
Esthetics Good Good Good None None None
Manipulation* Moderately easy Easy Moderate Difficult Moderately easy Easy
GIC, Glass ionomer cement; RMGIC, resin-modified glass ionomer cement; ZOE, zinc oxide eugenol cement.
*Encapsulated and automix forms are easy to manipulate.

Strength thickness. High resistance to oral solubility helps to

The cement’s resistance to deformation or fracture maintain the marginal seal. Bonded, resin-containing
under an applied force is a measure of its mechanical cements are nearly insoluble.
properties. Cements must be strong enough to resist
the forces of mastication and the dynamics of the pa- Viscosity and Film Thickness
tient’s mouth and occlusion. Compressive, tensile, and The consistency, or viscosity, of mixed cement refers
flexural strengths are important considerations for dif- to its thickness and ability to flow. Cements used for
fering cement applications. Bond strength is important permanent or temporary luting of fixed prostheses,
in high-stress areas. other indirect restorations, and endodontic posts
must be able to flow to a thin film thickness to allow
Caution the restoration to seat properly and completely. On
the inside of a crown a small space is created in the
Cements are brittle materials with good compressive but laboratory to allow room for the cement. Without this
more limited tensile and flexural strength.
space the crown would not seat fully. Also, if the film
thickness is too thick, the restoration will not seat ful-
The strongest cements are resin cements, and the ly, leaving cement exposed at the margins. This will
weakest is zinc oxide eugenol. Cements used for perma- result in the need for excessive occlusal adjustment
nent luting and high-strength bases need good compres- and the increased likelihood of cement washing away
sive, tensile and flexural strength. As can be seen in Table at the margins leading to tooth sensitivity, recurrent
14.2, resin-based cement is high in mechanical strength decay, and staining.
and fracture toughness, and polycarboxylate cement is For primary consistency, also known as luting con-
low in both. Many cements consist of a combination of sistency, cements should be able to be mixed thin—to
powder and liquid; their ratio determines many of their about the consistency of honey with a film thickness of
properties. The strength of cement is controlled primar- 25 μm or less (see Procedure 14.2).
ily by the amount of powder used in the prepared mix.
In general, an increase in the powder-to-liquid ratio in-
creases the strength of the cement. However, excessive Clinical Tip
powder or liquid can weaken the cement. Low film thickness is critical to fully seating and retaining
indirect restorations.
Solubility
One of the greatest challenges for dental cements is the The cement must be able to flow easily and com-
tendency to dissolve in oral fluids, leading to marginal pletely throughout the interface between the restora-
ditching, microleakage, recurrent caries, and failure of tion and preparation. To be considered an effective
the restoration. Solubility is important whenever the luting cement, American Dental Association (ADA)
cement is expected to remain exposed to mouth flu- specifications require the cement to be able to flow
ids for prolonged periods. Many cements will disin- to a film thickness of 25 μm or less. As a comparison,
tegrate in the oral environment over time. Increasing a human hair is about 20 to 50 μm. Resin-based ce-
the amount of powder incorporated into the liquid can ments and resin-modified glass ionomer cements
reduce the solubility of the cement. However, there are thixotropic, meaning they will flow under pres-
are limits since it may increase the viscosity and film sure. When cementing with any of these cements the
 Dental Cement CHAPTER 14 301

patient should be instructed to bite down on a stick Retention and Adhesion

during initial set to force the material into all intra- Good adhesion is a critical component of restorative
coronal areas. dentistry, as good adhesion helps to increase retention
Mixing cement to secondary consistency requires of the restoration and minimize microleakage.
the addition of powder to increase strength and bring Adhesion is the bonding of dissimilar materials by
the cement to a thick, putty-like consistency (see the attractive forces of atoms or molecules and includes
­Procedure 14.1). Cements mixed to secondary consis- two types of adhesion: mechanical and chemical.
tency are used as bases and restorations, provisional Mechanical adhesion: Mechanical adhesion is based
or permanent. on the interlocking of one material with another; an
Several factors influence the consistency of mixed excellent example is Velcro.
cement. Temperature has a great effect; a lower tem- Chemical adhesion: Chemical adhesion occurs at the
perature will slow the setting reaction, giving the clini- molecular level, when atoms of the two materials swap
cian more working time and allowing incorporation of electrons (ionic bonding) or share outer electrons (co-
more powder into the liquid. valent bonding).
In many dental applications, chemical adhesion and
mechanical adhesion occur together. We now have a
Caution much better understanding of the surface characteristics
Although the amount of powder incorporated into the mix of enamel and dentin and the requirements needed to
has a direct relationship to strength and solubility, it may obtain good adhesion to them. The most recently devel-
substantially increase the viscosity of the mixed cement, oped dental cements, using resin adhesive technologies,
making it unsuitable for cementation of a restoration. strive to achieve a micromechanical and chemical bond
between the tooth and the restoration. Several things
may weaken the strength of the adhesion between two
materials, including differences in the coefficient of
Biocompatibility and Anticariogenic Properties thermal expansion of the two materials, dimensional
Cements must be safe to use on patients. Where a spe- changes that occur during setting of the adhesive agent,
cific type of cement may be appropriate in one circum- and contamination of the substrates by water and saliva
stance, it may be inappropriate in another. Cement and/or by residual enamel and dentin cutting debris
may be suitable for use in a conservative preparation, from tooth preparation, known as the “smear layer.”
but then cause sensitivity and even pulpal necrosis
in a deep preparation. Some cements are composed
Clinical Tip
of a combination of zinc oxide powder or powdered
glass mixed with an acid. The pH of the acid both at Good adhesion will not occur unless there is a good fit be-
placement and after complete setting is a matter of tween the restoration and the tooth preparation.
concern due to postoperative pulpal sensitivity asso-
ciated with the acid exposure. Other causes of pulpal There are three possible reasons for failure of an
sensitivity include unsealed dentinal tubules, trauma adhesive: structural, adhesive, and cohesive failure.
to the pulp during preparation, and bacterial leakage Structural failure occurs as a result of internal failure
under the provisional restoration. Careful attention within the tooth structure; the tooth itself breaks away
to powder-to-liquid ratios, dispensing technique, and from the restoration, leaving the restoration intact.
mixing recommendations can minimize sensitivity Adhesive failure is a failure of the bond, and it oc-
from cements. Cement with low risk for postopera- curs when the adhesive layer separates from the tooth
tive sensitivity should be selected when susceptibil- structure causing the restoration to dislodge from the
ity to sensitivity is a concern. Eugenol, found in the tooth. Cohesive failure is a measure of the strength of
liquid of zinc oxide eugenol cements, has an obtun- the bonding material itself, and it occurs when there is
dent (i.e., soothing, sedative) effect on the pulp due to failure within the adhesive layer; this may also result
its good sealing ability, antibacterial properties, and in dislodging of the restoration with the cement layer
neutral pH. still present in the restoration and on the tooth prepa-
ration (Fig. 14.8). Failure of the adhesive can result in
Clinical Tip failure of the restoration, leakage occurring between
Many products include fluoride in their formulations; it is the tooth structure and restoration, and the formation
important to distinguish between fluoride release and fluo- of secondary caries.
ride-containing products. Fluoride released from powdered The acid-etch bonding system is the basis of to-
glass formulations found in glass ionomer cements has
day’s adhesive dentistry. In this process, the main
an anticariogenic property for reducing secondary caries.
Products that do not release fluoride do not have an anti-
mineral component of enamel and dentin, hydroxy-
cariogenic effect. apatite, is removed from the surface of the tooth
structure with an acid etchant to create roughness
302 CHAPTER 14 Dental Cement

porcelain veneers, ceramic or composite inlays and on-

lays, and ceramic full crowns.

Radiopacity
Radiopacity is an important property in the measure
of the success of a cement. High radiopacity will al-
low the cement to show when examined with x-rays
so that it will not be mistaken for caries or a void.
Good radiopacity will also make excess cement easi-
er to see; this is particularly important in the case of
A. Structural failure B. Adhesive failure C. Cohesive failure implants and in restorations with deep subgingival
FIG. 14.8 Failure mechanisms of adhesive bonding. The blue line is margins.
the adhesive, to the left is tooth structure and to the right is the res-
toration. A, Structural failure occurs within the tooth structure (or the Selecting a Luting Cement
restoration). B, Adhesive failure occurs between the adhesive and the
tooth structure (or the adhesive and the restoration). C, Cohesive fail-
When choosing a luting cement, the clinician must
ure occurs within the adhesive itself. consider which of the following indirect restorations
are being used:
• Metal and metal-based restorations—crowns, bridg-
es, inlays, or onlays
• Glass-ceramic restorations
• High-strength ceramic restorations
• Indirect composite restorations
The restorative material itself may be the primary
determinant for the cement selection. For example,
some glass-ceramic restorations need to be bonded to
the tooth in order to enhance their strength, but a high-
strength ceramic such as zirconia can be cemented with
non-adhesive cement. Other considerations include the
amount of mechanical retention from the form of the
preparation and whether the patient has parafunction-
al habits (i.e., bruxing). In order for the cement to be
successful, the tooth preparation must have adequate
retention and resistance form. While adhesive cements
FIG. 14.9 Scanning electron micrograph of tooth-restoration interface
can enhance retention of the restoration, they cannot
bonded with dental adhesive. A, adhesive layer. H, hybrid layer with T, overcome the negative influence of an over-tapered,
resin tags. RC, resin composite restoration. (From Frankenberger R, non-retentive preparation and extreme bruxing forces.
Perdigão J, Rosa BT, et al: “No-bottle” vs “multi-bottle” dentin adhe-
sives—a microtensile bond strength and morphological study. Dent
Mater, 17:373–380, 2001.)
CLASSIFICATION OF LUTING CEMENTS
Luting cements not only serve to retain a restoration
and micropores. When resin bonding agents or self- to the tooth but also help to prevent microleakage
adhesive cements are applied to the etched surfaces by sealing the interface between the tooth and the
resin monomers of the bonding agent or cement fill restoration. Retention of the restoration to the tooth
the micropores and roughness to create resin tags can be by mechanical means, chemical interaction
that micromechanically lock the substrate to the res- with the tooth, or a combination of the two. Luting
toration (Fig. 14.9). cements may be chosen as permanent cements or
provisional (temporary) cements depending on the
clinical need.
Caution
Luting cements can be classified according to their
A bond will not occur if the surfaces being bonded are not composition. That is, they are water-based, resin-
completely clean and dry. Enamel should be dry and den- based, or oil-based.
tin free of excessive moisture or saliva. Over-drying of the
dentin can cause sensitivity and a weaker bond in some
techniques. Functions of Luting Cements
The two main functions of luting cements are:
1. to seal the interface between the tooth preparation and
Esthetics
the restoration
Cements are available in a variety of shades and opaci- 2. to augment the retention of the restoration
ties. Typically, resin cements are used for bonding
 Dental Cement CHAPTER 14 303

WATER-BASED LUTING CEMENTS Strength, solubility, and film thickness are impor-
Water-based cements undergo an acid–base setting re- tant properties. The internal surface of indirect resto-
action. The cements are typically a liquid (the acid) and rations such as PFM or gold crowns, inlays, and on-
a powder (the base). When they are mixed together lays are sandblasted to enhance retention. The cement
they undergo a chemical reaction that neutralizes the flows into irregularities in the roughened surface of
acid and base. The cation (H+) of the acid and the an- the restoration and onto the prepared tooth surface,
ion (OH−) of the base combine to form water and the locking the two together. The low film thickness of
remaining components form a salt. It may take several properly mixed cements allows for the intimate con-
hours for the setting reaction to reach completion and tact necessary for good retention. Zinc phosphate ce-
the acidity to become neutral. ment has adequate strength and rigidity for cemen-
tation of single-unit and long-span bridges, but it is
Zinc Phosphate Cement weaker than resin or hybrid ionomer cements. Ceram-
Zinc phosphate, the oldest of the cements, was in- ic restorations are not cemented with zinc phosphate
troduced in 1879. Zinc phosphate cements because cement, because it does not bond the ceramic to the
of their acidic nature have produced problems with tooth and thus puts the brittle ceramic restoration at
post-cementation hypersensitivity. These cements are risk of fracture. Zinc phosphate cement’s solubility
also soluble and among the cements in use today are is clinically acceptable but greater than that of most
weaker cements. For these reasons, zinc phosphate ce- other cements. This greater solubility has made it less
ments are not widely used. If used, they are applied favorable with clinicians for the cementation of orth-
as permanent luting agents under metal-based indirect odontic bands.
restorations and for cementation of orthodontic bands.
The incorporation of additional powder into the mix
Zinc Phosphate
makes them strong enough for high-strength bases,
and they provide thermal insulation for the pulp. A ADVANTAGES
popular brand of zinc phosphate cement is Fleck’s Ce- • Over a century of clinical use
ment (Keystone Industries). • Low film thickness
• Inexpensive
Composition. The powder of zinc phosphate cement • High rigidity
is principally zinc oxide (90%) and magnesium oxide DISADVANTAGES
(10%); fluoride is added by some manufacturers to aid • Initial pulpal irritation and postoperative sensitivity
in the prevention of caries under orthodontically band- • Mechanical bond only
ed teeth. The liquid is made from phosphoric acid and • Technique-sensitive proportioning and mixing
water. When the cement powder is incorporated into the • Relatively high solubility
liquid, an exothermic chemical reaction occurs, that is, • Weaker than most other cements
heat is produced. Attention to proper mixing technique
is required to minimize this reaction. The setting and Manipulation. Zinc phosphate cements are dispensed
exothermic reactions of zinc phosphate cement are con- in a powder/liquid system and are mixed on a cooled
trolled by time and temperature. Incremental incorpora- glass slab with a metal cement spatula. The powder is
tion of the powder into the liquid allows for controlled shaken before it is dispensed into four to six portions
dissipation of heat. Mixing over a large area of a cooled on one end of the slab, and the liquid is dispensed
glass slab also dissipates the heat. The glass slab should in drops at the other end of the slab. The powder is
be cooled to be effective in dissipating heat, but not to added slowly in small increments to the liquid. With
below the dew point (approximately 18 °C [65 °F]), at smaller initial increments the acidity is reduced and
which water condensation would shorten the setting the reaction is retarded. Each increment is mixed for
time. Use of a frozen slab can greatly increase the incor- 10 to 15 seconds, for a total of 60 to 90 seconds of mix-
poration of powder and can increase the working time, ing. The cement is mixed in a figure-eight motion over
helpful when several orthodontic bands are cemented. a large area of the cooled slab to absorb the heat of
the exothermic reaction, neutralize the acid, and allow
Properties. Initially, the acidity (pH about 2.5) of zinc more powder to be incorporated. Proper luting con-
phosphate cement is low and becomes neutral within sistency is achieved when the mixed cement strings
24 to 48 hours. The initially low acidity may irritate 1 inch above the slab from the mixing spatula. (See
the pulp in deep preparations (usually those with less Procedure 14.2.)
than 1 mm of remaining dentin over the pulp) result- Excess cement should be removed from inter-
ing in post-cementation hypersensitivity or in rare proximal areas before the cement sets. A knotted
occasions, even pulpal necrosis.. Pulpal protection in strand of dental floss is a helpful tool when dragged
deep cavity preparations is recommended with cavity back and forth across the margins several times. The
varnish, liners, bases, or dentin bonding systems. excess at accessible margins should be allowed to
304 CHAPTER 14 Dental Cement

set before removing it. Ideally, varnish or another retention of indirect restorations. The chemical ad-
surface sealer should be applied to the margins after hesion to the tooth is created by free carboxylic acid
the excess is removed to allow maturation of the set groups interacting (chelating) with calcium ions in the
and decrease solubility. tooth structure. The bond is achieved only if the ce-
ment still exhibits a glossy appearance when the res-
toration is seated. The bond is not as strong as that
Clinical Tip
obtained with resin cements combined with bonding
Zinc phosphate cements are difficult to remove from mixing agents. The working time can be extended with the use
surfaces; glass slabs and spatulas should be wiped clean of a cooled glass slab.
before the cement sets. Set cement may be removed with
the use of ultrasonic cleaners or a solution of baking soda
and water. Zinc Polycarboxylate

ADVANTAGES
Mixing Zinc Phosphate Cement for Luting • Adheres to tooth structures
Mix: On cool glass slab mix 4 to 6 small increments of pow- • Nonirritating to the pulp
der into liquid for 10 to15 seconds each increment over a • Inexpensive
large area to dissipate heat. Mix for a total of 60 to 90 sec- DISADVANTAGES
onds until smooth and creamy. It should string 1 inch from • Higher solubility
the spatula. • Lower strength
Working Time: 2 minutes • Shorter working time
Setting Time: 5.5 minutes • Early increase in film thickness can inhibit seating of the
restoration

Zinc Polycarboxylate Cement

Zinc polycarboxylate cements (introduced in 1968) were Manipulation. Polycarboxylate cements are dispensed
the first cements developed with an adhesive bond to in a powder/liquid system and are mixed on a glass
tooth structures. These cements have been used for fi- slab or a nonabsorbent paper pad with a metal ce-
nal cementation of indirect restorations; today they are ment spatula. The powder is dispensed with the
used primarily as long-term temporary cements. manufacturer-supplied scoop, and the viscous liquid
is dispensed with a dropper or a unit-marked syringe.
Composition. Zinc polycarboxylate cements are sup- Never increase the amount of liquid, as this will dra-
plied as a powder/liquid system and set through an matically reduce the strength of the cement. Add the
acid–base reaction. The powder is similar to that of powder to the liquid, and mix for 30 seconds until the
zinc phosphate cement and is mostly zinc oxide with mix is creamy. The cement must be used immediate-
magnesium oxide, bismuth, and aluminum oxide. The ly because of the short working time. The cement is
liquid is an aqueous solution of polyacrylic acid. The no longer usable when it loses its gloss and becomes
polyacrylic acid produces minimal irritation to the stringy. (See Procedure 14.3.) Two common brands
pulp. Some manufacturers are supplying premeasured are Durelon (3M ESPE) and HyBond Polycarboxylate
capsules for mixing in a triturator. (Shofu Dental Corporation).

Properties. The viscosity of zinc polycarboxylate cement

Mixing Polycarboxylate Cement for Luting
is higher than that of most other cements. However, on
vibratory action on the restoration during seating the ce- Mixing: Mix all powder into liquid at once for 30 seconds
ment flows to an appropriate film thickness. The liquid until creamy
Working Time: 2.5 minutes. Do not use when it loses its
of this cement should not be dispensed before mixing
gloss and becomes stringy
time, as the loss of water by evaporation can make it Setting Time: Regular set—10 minutes; Fast set—5
more viscous. minutes
These cements have lower compressive strength
(55 MPa) and higher solubility when compared with
glass ionomer and resin cements. Zinc polycarbox- Clinical Tip
ylate cements cause little irritation to the pulp even As with other cements, cleanup of mixing surfaces and
when the remaining dentin layer is as thin as 0.2 mm. spatula should be done while zinc polycarboxylate cement
They are useful for cementing indirect restorations, is still soft.
for bases, liners, and temporary fillings. They are ra-
diopaque, so excess interproximal cement can be seen
on an x-ray. Glass Ionomer Cements
Retention of polycarboxylate cements is both chem- Glass ionomer cements (introduced in 1972) were
ical and mechanical, making this cement useful for derived from silicate cements and polycarboxylate
 Dental Cement CHAPTER 14 305

cements. Originally developed as an alternative to sili- static, may have an anticariogenic effect, and may
cate cements for esthetic restoration of anterior teeth, act to remineralize tooth structure attacked by bacte-
glass ionomer cements have become one of the most rial acids. GIC acts as a fluoride reservoir. It can re-
versatile cements used today. Similar to the polycar- lease fluoride but can also absorb fluoride from oral
boxylate cements, these cements chemically bond with sources such as fluoride-containing toothpaste or
tooth structures through chelation with calcium ions, mouthrinse and release it at another time. Strength,
although retention is primarily through micromechan- solubility, and film thickness are comparable with
ical retention. Glass ionomer cements also contain alu- other permanent ­cements. Its compressive strength
minum fluorosilicate glass, giving them the ability to is over 100 MPa but its brittle nature causes it to be
release and replenish fluoride. Glass ionomer cements weak in tension, about 6 MPa.
are used as permanent luting agents for indirect res- An increase in solubility has been demonstrated
torations, luting of orthodontic bands, restorative ma- with moisture contamination during the first 24
terials (see Chapter 6), high-strength bases, and core hours. Teeth restored with glass ionomer restorations,
buildups. Although the cement is able to chemically bases, and core buildups must be properly isolated
bond to metals such as noble, non-noble, and stain- for the 6- to 8-minute setting time. The margins of
less steel and tooth substrate, it is not able to bond to the cemented crown must be coated with the sup-
glazed porcelain. In many instances, the same prod- plied coating agent or varnish until the initial set is
uct can be mixed to different viscosities for different achieved. Faster setting materials are less sensitive
uses. This simplifies product selection and inventory to the solubility issue. The best bond to enamel and
control. Glass ionomer cements include both tradi- dentin can be achieved for GIC and RMGIC by first
tional GICs and resin-modified glass ionomer cements removing the smear layer created by cavity prepara-
(RMGICs). tion debris. To remove the smear layer, mild acid such
as 10% polyacrylic acid is applied to the preparation
Traditional Glass Ionomer Cements for 5 to 10 seconds and rinsed off. Leaving the acid on
Composition. The cement is supplied as a powder and longer will begin to remove mineral from the tooth
liquid system. The powder is aluminum fluorosilicate surface and weaken the bond since the glass ionomer
glass with barium glass added for radiopacity (Fig. cement bonds to mineral.
14.10). The liquid is polyacrylic acid copolymer in wa-
ter. When the powder and liquid are mixed, the poly-
Traditional Glass Ionomer Cements
acrylic acid attacks the glass to release fluoride ions.
Fluoride improves the translucency of the otherwise ADVANTAGES
opaque material and improves the material's strength. • Chemical adhesion to tooth and metal
• Fluoride release
Properties. Glass ionomer cements are biologi- • Easy to mix
cally compatible with the pulp when manipulated • Moderate strength
properly. Mild to severe postoperative sensitivity DISADVANTAGES
has been reported. Overdrying of the preparation, • History of postoperative sensitivity
moisture contamination during the first 24 hours • Sensitive to moisture or drying during setting
of setting, and hydrostatic pressure on fluid in the • Does not bond to glazed porcelain
dentinal tubules when seating a crown have all been • Marginal solubility
indicated as possible sources of this sensitivity. Fluo-
ride release during the life of the cement is bacterio-
Manipulation. These cements are dispensed in a
powder/liquid system or in premeasured capsules.
Hand mixing of the powder and liquid is similar to
that of polycarboxylate cement. Premeasured cap-
sules are very popular because of their ease of use
and consistency of mix (e.g., Ketac Cem Aplicap, 3M
ESPE or GC Fuji I Capsule, GC America) (Fig. 14.11).
When using the premeasured capsules, follow the
manufacturer’s directions on activating the capsule
and mixing in the triturator. After mixing the cap-
sule is mounted in a gun-type applicator and has a
delivery tip for dispensing of the mixed cement. The
mix should be used right away and mixes that be-
come thick or lose their glossy appearance should be
FIG. 14.10 Radiograph of the interface between restorations and teeth discarded. For GC Fuji I Capsule the mixing time is
filled with radiopaque cement in upper right molars. 20 seconds with a working time of 2.5 minutes and
306 CHAPTER 14 Dental Cement

and can be initiated by exposure to a curing light, or in

darkness occurs by self-cure of the resin. The acid–base
reaction is slower and continues for some hours after
the material has hardened.

Properties. The added resin helps to improve the

compressive and tensile strength and to decrease
solubility. These cements do not have the suscep-
tibility to early moisture contamination that tradi-
tional glass ionomers have because of the resin com-
ponent. They have excellent film thickness. Fluoride
release is the same as that of traditional glass iono-
FIG. 14.11 Glass ionomer cement kit with premeasured capsules, acti- mer cements. RMGIC expands as it absorbs mois-
vator and delivery gun. (Ketac Cem Aplicaps, Courtesy 3M ESPE.)
ture after setting. The expansion is greater in some
RMGICs than others, and some non–high-strength
a setting time of 2 minutes and 50 seconds. Glass all-ceramic restorations fractured after they were
ionomer luting cements are self-curing (see Proce- cemented with RMGIC because of excessive expan-
dure 14.4). sion. (See Chapter 9 Ceramics.) The most problem-
atic of those RMGIC have been removed from the
market.
Mixing Glass Ionomer Cement for Luting
Mix: Resin-Modified (Hybrid) Ionomer Cements
1. Premeasured capsules: mix in triturator according to
manufacturer’s instructions ADVANTAGES
2. Powder-liquid: mix level scoop to 1 or 2 drops (varies • Good strength
by manufacturer) incorporating all of the powder into • Fluoride release
the liquid until smooth mix is achieved. • Insoluble
Working Time: About 3 minutes depending on product • Chemical adhesion to tooth
Setting Time: 5-7 minutes depending on product • Less postoperative sensitivity
Note: If the mix loses its glossy appearance, do not • Excellent film thickness
use it
DISADVANTAGES
• Recommended for luting only high-strength all-ceramic
restorations or metal-based restorations
Resin-Modified Glass Ionomer Cements
Resin-modified glass ionomer cements (also called
hybrid glass ionomer cements) were introduced in Manipulation. The powder and liquid can be hand
1995. Resin was added to traditional glass ionomer mixed, but the most popular version is the premea-
cement to help improve its properties. For luting sured capsule. The capsule is activated to allow
they can be used for metal-based restorations, end- powder and liquid to join and is mixed in a tritura-
odontic metal posts, orthodontic bands and brack- tor as specified by the manufacturer (see Procedure
ets, or stronger ceramics such as zirconia or lithium 14.4). The capsule has a dispensing tip so the mixed
disilicate. cement can be placed directly into a crown (or cav-
ity preparation in the case of the restorative mate-
Composition. The composition of resin-modified glass rial). An example of encapsulated luting RMGIC is
ionomer cement (RMGIC) is similar to that of tradi- GC Fuji Plus (GC America). When handling the glass
tional glass ionomer cement, but it is modified by the ionomer cement a no-touch technique is mandatory
addition of resin. The cement is supplied as a paste- since the liquid contains HEMA, a known contact
paste formulation or powder and liquid. The powder ­allergen.
is similar to traditional GIC but has chemicals added Resin-modified glass ionomer luting cements are
to catalyze the light-cure or chemical-cure reaction of also available in two-paste systems: one system has a
the resin component. The liquid contains water-solu- cartridge that delivers each paste separately to be hand
ble methacrylate monomers, tartaric acid, water, and mixed (e.g., RelyX Luting Cement, 3M ESPE) and the
2-hydroxyethyl methacrylate (HEMA) as well as initia- other system has a cartridge with an automixing tip
tors for light-curing. making mixing and dispensing easy and convenient
The set of the material occurs by two mechanisms: (RelyX Luting Plus, 3M ESPE; FujiCEM 2, GC Amer-
an acid–base reaction and a resin polymerization re- ica). For FujiCEM 2 the working time is 2 minutes 15
action that can be light-cured, chemical-cured, or both seconds and setting time in the mouth is 4 minutes 30
(dual-cured). The polymerization reaction occurs first seconds.
 Dental Cement CHAPTER 14 307

Clinical Tip Light-Cured. Light-cured resin cements require a light

of a certain wavelength to activate photo-initiators that
To avoid postoperative dentin hypersensitivity when using
start the polymerization process (see Chapter 6, section
a RMGIC, it is important not to overdry and desiccate the
on Light Curing). Light-cured materials allow the op-
preparation before cementation.
erator to have extended working time and decide when
to initiate curing. When removing excess cement some
clinicians use a “wave” technique (also called tack
RESIN-BASED LUTING CEMENTS cure) whereby they wave the curing light over the resin
Resin cements were introduced in the mid-1980s and margins for a few seconds to cause the resin to gel but
are basically composite resins modified to have lower not reach its final set. This “tacks” the restoration in
viscosity. They are used for bonding of ceramic res- place and allows for easier clean up of the excess ce-
torations, conventional crowns and bridges, and for ment. Light-cured cements are popular for thin porce-
direct or indirect bonding of orthodontic brackets. lain veneers or in easily accessible parts of the mouth.
Low-strength ceramic restorations (especially por- Light-curing will not work well when the restoration
celain-based materials) must be bonded to the tooth is too opaque or too thick to allow the light to transmit
with resin cements to reduce their risk of fracturing to all of the cement. Light-cured resin cements are the
under functional stresses. However, high-strength most color stable compared to chemical- or dual-cured
(zirconia and some lithium disilicate, e.g., e-Max, Ivo- cements.
clar Vivadent) crowns are very strong and can be ce-
mented with RMGIC (see Chapter 9). Resin cements Dual-Cured. Because of the afore-mentioned limita-
help increase retention of crowns placed onto clini- tions with light curing, materials are available that have
cally short teeth or teeth with less than ideal prepara- a combined chemical-cure and light-cure. Usually the
tion taper. chemical-cure is slow to allow for adequate working
time and the light initiates the cure. In areas where the
Composition light cannot reach, the chemical-cure will take the set to
Resin-based cements are similar in composition to completion. Dual-cured resin cements are very popular
composite restorative materials. Filler particle size but have the drawback of potentially discoloring over
is kept very small, similar to microfills, microhy- time because of chemicals called aromatic amines that
brids, or nanohybrids (see Chapter 6). Initiators help in the setting process. The highest degree of polym-
of polymerization are added to change the setting erization occurs when light-curing is used to initiate the
mechanism. Pigments are added to aid in tooth color setting process.
matching.
Categories of Resin Cements
Properties Resin cements can be categorized into four main
Resin cements are virtually insoluble in the oral cav- groups:
ity. They have superior bond strength to enamel and • Esthetic resin cements
dentin, wear resistance at exposed margins, and high • Adhesive resin cements
compressive strength. • Self-adhesive resin cements
• Provisional resin cements
Methods of Cure
Polymerization (curing) of resin cements occurs by Esthetic Resin Cements. Esthetic resin cements are low
three possible mechanisms: chemical-cure (self-cure), viscosity resins derived from composite resin. They are only
light-cure, or dual-cure. Some materials are cured by lightly filled with very small particle fillers and are mostly
only one of these methods, while others may use both low viscosity resin to maintain a low film thickness. They
light-curing and self-curing methods; that is, they are are strong, radiopaque, and have good bond strength to
dual-cured. tooth and restoration when proper surface preparation is
performed.
Chemical-Cured. With chemical-cured resins the set is Some of these esthetic cements are manufactured
initiated when the components are mixed together. No as a single paste that is light-cured. They are used ex-
light or heat is needed. They are useful where light-curing tensively for cementation of porcelain veneers and for
is not possible as with thick or opaque ceramic restora- ceramic and indirect composite resin restorations that
tions, metal restorations, or endodontic posts. Limited are somewhat translucent. Because of their translucen-
number of shades and translucencies are available with cy, the final color of the restoration can be impacted by
chemical-cured resins. Chemical-cured resin cements are the color of the underlying cement. These light-cured
more radiolucent than the other types of resin cements cements provide the operator with almost unlimited
making it difficult to detect excess cement on radiographs. working time to seat and position multiple veneers
Careful removal of excess cement should be done before at one time. They are, however, rather light sensitive
the cement reaches its final set. so the overhead operatory light should be positioned
308 CHAPTER 14 Dental Cement

away from the mouth once the veneers have been seat-
ed. Head lamps used with loupes should be turned off.
Esthetic resin cements can also be used for bonding of
orthodontic brackets.
Other esthetic resin cements are manufactured as
two-paste systems (base and catalyst) that come in du-
al-barrel syringes with automixing tips. These cements
are dual-cured and that assures a final cure in all as-
pects of the restoration, especially in those restorations
with thicker or opaque parts that the curing light can-
not penetrate.
Esthetic resins are not adhesive in nature. Hence,
they require the use of enamel and dentin bonding
agents on the tooth and silane coupling agents or spe-
cial primers on the ceramic or composite restoration in
order to bond the restoration to the tooth. The enamel
and dentin is usually prepared by the etch-and-rinse
technique before bonding agents are applied. Internal
surfaces of ceramic restorations are etched with hydro-
fluoric acid or sandblasted before the application of FIG. 14.12 Esthetic resin kit for luting ceramics such as porcelain
silane or primers. veneers. Kit contains etchant, bonding agent, and several colors of try-
in paste and resin cement. (Calibra Esthetic Resin Cement, Courtesy
When esthetic cements are used to cement porcelain Dentsply Sirona.)
veneers, the surface to which they are being bonded is
mostly enamel and the etch-and-rinse technique is pre-
ferred. Acidic (self-etching) primers are easier to use with low film thickness and strong bonds to properly
by eliminating etch and rinse steps, but they do not prepared tooth and restoration surfaces. Adhesive res-
etch enamel as well as the etch-and-rinse technique. in cements when used with bonding agents have the
(See Chapter 5 Principles of Bonding.) capability of bonding to metal as well as ceramic res-
Esthetic resins are made in a variety of tooth colors torations. Ceramic restorations are prepared for bond-
and translucencies to aid in achieving a desirable es- ing by either sandblasting or etching with hydrofluoric
thetic outcome. Usually, a shade is chosen to approxi- acid, and then silane is applied. Internal surfaces of
mate the shade of the restoration, so that the appear- metal restorations are sandblasted. A special primer is
ance of the restoration is not altered by the underlying used on the metal or ceramic. The adhesive cement is
cement as light passes through the restoration and typically a dimethacrylate resin (with glass filler par-
reflects off the cement. On occasion, it is necessary to ticles) which bonds to the primer. It is formulated in
mask the color of the dentin, especially if it is discol- self-cure or dual-cure modes.
ored. In this situation, an opaque cement of the appro- Other resin systems may be used. C&B Metabond
priate shade is selected. (Parkell) uses a 4-META (methyl methacrylate) resin
Many manufacturers provide try-in paste. This wa- and contains adhesive monomers that can bond to
ter-soluble, non-setting paste is matched to the base metal. Panavia 21 (Kuraray Co.) uses a phosphorylated
shade of the cement and is used to temporarily hold methacrylate monomer (MDP) that aids bonding. Pana-
the restoration in place while the operator confirms via requires the use of a protective gel on the margins of
the shade of the final product. Commercially available the restoration to exclude oxygen so the cement can set
esthetic resin cement kits include Nexus (Kerr Den- completely. The resins used in these two products are
tal), RelyX ARC (3M/ESPE), and Calibra (Dentsply) attracted to metal oxides on the surface of base metal
(Fig. 14.12). alloys.
Adhesive resin cements are available in universal,
translucent, or opaque colors and are formulated in
Clinical Tip paste-paste automix systems.
Try-in paste is used to confirm the final shade of the resto- While the use of self-etching primers greatly sim-
ration and to hold the restoration in place while the dentist plify the bonding process by reducing the number of
and the patient inspect its form and esthetics. steps and potential operator errors compared to the
etch-and-rinse technique, it is still vitally important to
Adhesive Resin Cements. Adhesive resin cements carefully follow manufacturer’s instructions. Do not
have wide applications for luting metal, ceramo-metal, mix and match primers and adhesive resins from dif-
and all-ceramic restorations but are not used for por- ferent manufacturers, because there may be incompat-
celain veneers. They are strong, radiopaque cements ibility that will weaken the bond or inhibit full setting.
 Dental Cement CHAPTER 14 309

Caution
Carefully follow manufacturer instructions for use of resin
cements and bonding agents. Do not use bonding agents
from one manufacturer with resin cement from another
manufacturer. There may be incompatibility of materials that
prevent full setting of materials or weaken the bond.

Self-Adhesive Resin Cements. While adhesive resin

cements require separate bonding agents to bonding
to tooth or restoration surfaces, self-adhesive resin
cements eliminate the need for separate etching and
priming for bonding. This is achieved by combining
acidic monomers with the adhesive diacrylate resin. FIG. 14.13 Self-adhesive resin cement with a dual-barrel syringe to
which an auto-mixing tip can be attached. (MaxCem Elite Chroma,
The acidic monomers have a low pH and etch the
Courtesy Kerr Dental.)
tooth. The negatively charged acidic monomers form
ionic bonds with positively charged calcium ions in the
tooth. During setting of the self-adhesive resin the acid-
ic monomers undergo a change in pH from very acidic Types of Restorations and Methods of Curing
(pH 2) to less acidic (pH 5 to 6) as glass filler particles LIGHT-CURED
react with the acidic monomer and fluoride is released. • Porcelain veneers less than 1.5 mm thick
The smear layer is incorporated into the cement rather • Orthodontic retainers not containing metal
than being dissolved and rinsed away as with the etch- • Periodontal splints not containing metal
and-rinse technique. The cement must be completely DUAL-CURED (LIGHT ACTIVATED AND CHEMICALLY ACTIVATED)
cured, because uncured resin will be acidic and irritate • Ceramic or indirect resin inlays, onlays, crowns, and
the pulp. The advantage for the clinician is a reduction bridges
in the number of clinical steps required. There is no
CHEMICAL-CURED (SELF-CURED)
need for etching, rinsing, or drying the tooth structure. • Metal-based inlays, onlays, crowns, and bridges
This also reduces the risk of over- or under-drying the • Full metal crowns and bridges
dentin and reduces post-cementation sensitivity. • Endodontic posts
The disadvantage of self-adhesive resin cements is • Ceramic or indirect resin inlays, onlays, crowns, and
that they do not achieve bond strengths as great as es- bridges
thetic or adhesive resin cements. The bond to dentin is
of moderate strength, but the bond to enamel is not as
good. Self-adhesive resin cements should not be used Caution
where a strong enamel bond is needed as with cemen- Light-cured and dual-cured resin cements should be pro-
tation of orthodontic brackets or porcelain veneers un- tected from ambient light in the operatory as it may initiate
less a separate selective acid etching of enamel is also the curing process.
used. With selective enamel etching, phosphoric acid
is applied to enamel only for 10-20 seconds before the
self-adhesive resin is applied. Phosphoric acid should Cementation of Ceramic Restorations with
be kept off the dentin because etching it lowers the Resin Cement
bond strength of self-etching resins to dentin. Try-In of Ceramic Restoration. Before cementation the
The application of the mixed cement is very simple. restoration is tried on the crown preparation or in a
It takes only a single step much like the application cavity preparation (inlay/onlay) to confirm esthetics
of zinc phosphate cement – mix and apply. Exam- and adjust the fit as needed. The internal surface of
ples of self-adhesive resin cements include MaxCem the restoration will be contaminated after try-in and
Elite Chroma (Kerr Dental) (Fig. 14.13), Smart-Cem 2 must be cleaned. Additionally, the surface of the ce-
(Dentsply), and Rely-X Unicem (3M/ESPE). These ma- ramic must be prepared for bonding. Some clinicians
terials are supplied as dual-cured formulas. They are use a solution of acid (typically hydrofluoric acid) for
packaged in auto-mix syringes with two pastes or cap- ceramics or sandblasting depending on which ceram-
sules with dispensing tips. A new self-adhesive resin ic system is used. Some ceramics should not be acid
cement has been introduced that is called a universal treated but require special primers. (See Chapter 9 for
cement (Panavia SA Cement Universal, Kuraray Nori- a discussion of the preparation of the internal surfaces
take), because it has incorporated two monomer tech- of ceramic restorations for cementation.) If the labora-
nologies that allow it to bond to glass-based ceramics tory has pre-etched the ceramic restoration, do not re-
without etching and applying silane and to non-glass etch it after try-in. Use alcohol or a commercial ceramic
ceramics without the need for a separate special primer. cleaner such as Ivoclean (Ivoclar Vivadent).
310 CHAPTER 14 Dental Cement

Removal of Excess Resin Cement. Dental auxiliaries Clinical Tip

may be asked to remove excess cement from crown
It is important to pay attention to the manufacturer’s direc-
margins after seating. It is important to be familiar
tions regarding bonding of the tooth surface and prepara-
with the proper consistency recommended for each tion of the restoration surface to achieve a strong bond and
type of cement intended for removal. Check the manu- to eliminate postoperative sensitivity.
facturer’s recommendations.
When cementing permanent ceramic restora-
tions, excess resin cement should be removed as Caution
soon as seating is completed and before the chemi-
Removal of excess resin cement is difficult if the material is
cal set or light cure is complete. (See Procedures allowed to set completely; follow the manufacturer’s direc-
14.5 and 14.6.) Excess cement is removed by going tions for removal. Excess cement is easy to remove after
from restoration to tooth or parallel to the margins. a few seconds of exposure to a curing light, but difficult to
Avoid moving from tooth to restoration as cement clean up if cured too long.
may be pulled away from the margins leaving an
opening.
Some clinicians prefer to “tack-cure” the resin ce- Resin-Based Cements
ment to aid in removal. The tack-cure is best used for
translucent restorations, because the light can pen- ADVANTAGES
etrate the restoration and the gel set will be the same • High strength
inside and outside the restoration. That way cement • Insoluble
• Low wear
won’t be pulled from under the margins when re-
• Excellent adherence to tooth structure
moving the excess. Once the excess cement has been
• Can bond all-ceramic restorations
removed, light-curing is completed. • Esthetic shades available
Self-cured resin cements are best used for metal or • Low chance of postoperative sensitivity
opaque ceramic restorations. Remove the excess ce-
ment when it just begins to stiffen. The resin under DISADVANTAGES
• The introduction of water or oral fluids at any point during
the margins will be partly set to the same degree as
the bonding procedure can lead to lowered bond strength
the excess outside the restoration. Removal of the ex- • Self-adhesive resin cements should not be applied on
cess at this stage will avoid pulling cement from un- exposed pulp or dentin that is close to the pulp
der the margins. • Requires additional steps in preparation of internal
The set of some resin cements (Panavia 21, for ex- restoration surfaces
ample) is more strongly inhibited by oxygen, so the • Removal of excess cement may be difficult
manufacturer recommends coating the margins with
glycerin or other gel to exclude oxygen during the
set. Knotted floss can be used interproximally to re- Provisional Resin Cements
move excess cement before it sets. It is possible that Provisional resin cements are used to temporarily retain
all excess cement will not be removed before it sets. provisional crowns, bridges, or other indirect provision-
Having a good knowledge of the tooth morphology al restorations. They are formulated to have low com-
is helpful in knowing where to look for residual ce- pressive and tensile strengths, so the provisionals can
ment, because concavities on the crown/root or root readily be removed. Some provisional resin cements are
furcations can tend to retain excess cement. Explor- formulated to have higher compressive strength for cas-
ers, scalers, curettes, and scalpels are helpful in re- es where longer term provisionals are needed (e.g., Ul-
moving excess cement. A good, solid finger rest and traTemp REZ, Ultradent Products). They are not bond-
short strokes are a must when using a scalpel for ce- ed so clean up of the prepared tooth is simple. Because
ment removal to avoid slippage and soft tissue trau- they shrink on setting, microleakage is slightly greater
ma. Residual excess cement will act as a plaque trap than with other provisional cements. They eliminate the
with risks of recurrent caries, gingival inflammation, problem associated with eugenol from ZOE provisional
or periodontal infection with bone loss. Some clini- cements. Residual eugenol from provisional crowns ce-
cians prefer to take a radiograph after cementation mented with zinc-oxide/eugenol can adversely affect
if excess cement is suspected. Many resin cements the set of resin cements used for the final restoration.
are radiopaque and can be seen on the radiograph. Provisional resin cements are composed mostly of
Cement on the proximal surfaces is easier to detect dimethacrylate resin with glass filler particles. They are
on the radiograph than buccal and lingual surfaces, compatible with other resin systems such as bonding
because the bulk of the tooth structure can hide the agents, composites, and resin build-up materials. They
­cement from view. are available in paste-paste systems in cartridges or sy-
ringes with auto-mixing tips, so mixing and dispensing
 Dental Cement CHAPTER 14 311

smell of cloves, because it is a derivative of oil of cloves.

It is a weak acid and up to 2% acetic acid may be added
as an accelerator. Zinc oxide and eugenol when mixed
together undergo an acid–base reaction. If acetic acid
has not been added, then water is needed to initiate
the reaction.
In systems using two pastes, as for provisional ce-
ments, vegetable or mineral oil is added to the zinc ox-
ide powder to create one paste and fillers are added to
eugenol to create the other paste. The paste with zinc
oxide will be white and the eugenol paste will be am-
ber in color.
Because eugenol can interfere with the set of resins,
ZOE should not be used as a base or provisional cement
if composite resin or resin bonding agents will be used.
FIG. 14.14 Provisional resin cement kit containing cartridge of res-
ins (base and catalyst), automixing tips, and mixing/dispensing gun. However, if the surface of the enamel or dentin is cleaned
(SensiTemp Resin, Courtesy Sultan Healthcare.) thoroughly before bonding, the effect of the eugenol is
removed. After the provisional crown is removed and ex-
is easy. They come with self-, light-, or dual-cure capabil- cess cement removed, cleaning the preparation with flour
ity. Some of the self-cure cements are available in regu- of pumice and a prophy cup or brush is an effective way
lar or fast set modes. Examples of commercial available of removing the small bits of residual ZOE cement.
products include TempBond Clear (Kerr Dental), Pre- Formulations are made without eugenol and are
mier Implant Cement (Premier Dental Products), and called non-eugenol zinc oxide cements. They are used
SensiTemp Resin (Sultan Healthcare) (Fig. 14.14). as provisional cements (e.g., TempBond NE by Kerr
Dental) for provisional crowns when resin cement is
Compomer Cements planned for the permanent restoration.
Compomer cements are considered to be a subset of resin
cements. Compomer cement are somewhere between Properties. Eugenol has long been known for its seda-
resin cements and glass ionomer cements in their com- tive effect on the pulp, largely caused by its antibacte-
position since they contain some of the components from rial effects and its good marginal seal. It can be irritat-
each type. Compomer is a composite modified by poly- ing when in direct contact with oral mucosa or pulp.
acid, so that it releases fluoride like GIC (but to a lesser The mixed ZOE has a neutral pH of 7, which makes it
extent) and is strong and wear resistant like composite. It very biocompatible with tooth structure.
has both the slow acid–base reaction similar to GIC and ZOE cements are not as strong as other permanent
the polymerization reaction of resin. It can be self-cured, luting agents and are rarely used for this purpose. Thus,
light-cured, or dual-cured. The self-cure occurs in about they are ideally suited for provisional cementation. Their
3 minutes in the mouth. The luting compomer comes in weaker tensile strength allows them to be easily removed
a powder-liquid formulation. Some versions are not ad- at a second appointment, when a permanent restoration
hesive to tooth structure like glass ionomer. So, to gain is to be placed. ZOE cement has a compressive strength
adhesion a bonding agent is needed. However, Dyract of 26 MPa which falls below the ISO 3107 standard of 35
Cem Plus (Dentsply) is a product that is self-adhesive. MPa for permanent luting cements. When EBA (2-eth-
Compomer luting cements are not widely used. oxybenzoic acid) is added to the eugenol in a 2:1 ratio
and 30% alumina is added to the powder to reinforce it,
OIL-BASED LUTING CEMENTS much more powder can be incorporated into the liquid
Zinc Oxide Eugenol and the resultant mix is much stronger (72 MPa com-
Zinc oxide eugenol cements, commonly referred to as pressive strength). Resin fibers (20% polymethyl meth-
ZOE cements, have been widely used for many years. acrylate) are also added to increase strength and wear
Generally, ZOE cements do not have the strength needed resistance making them suitable for intermediate resto-
to serve as permanent cements or high-strength bases. So, rations (e.g., IRM, Dentsply Sirona) and high-strength
they are mainly used for provisional cementation, provi- bases.
sional and intermediate restorations, low-strength bases, The film thickness of ZOE cements is between 16
and as root canal sealers and periodontal dressings. and 28 μm and when alumina is present it approaches
57 μm (25 μm and below are more ideal for luting).
Composition. Various ZOE cements are available in ZOE cements are susceptible to hydrolysis and a sig-
powder/liquid and paste/paste systems. In the two- nificant amount of its volume can be lost in a 6 month
paste system, one is labeled a base and the other a cata- period. So, they do not serve well for long-term provi-
lyst. The principal ingredient of the powder is zinc ox- sional restorations. Glass ionomer and resin-modified
ide and it can contain up to 8% other zinc salts which glass ionomer cements perform much better as long-
act as accelerators. The liquid, eugenol, has the distinct term provisional restorations.
312 CHAPTER 14 Dental Cement

Caution BIOACTIVE CEMENTS

Cements that contain eugenol should not be used under Bioactive cements are a relatively new category of ce-
composites or as provisional cements before final cementa- ments. They are called bioactive because they stimulate
tion with resin-modified glass ionomer or resin cements, be- living tissues. In dentistry the test for bioactivity is for
cause eugenol may inhibit the set of the resin. Non-eugenol them to form an apatite-like substance on their surface
zinc oxide cements are preferred in these clinical situations.
when left in a simulated body fluid for a specified length
of time. The bioactive cements used in dentistry can stimu-
Powder/liquid and paste/paste systems are easily late the pulp to produce a reparative dentin bridge or they
manipulated. The set, strength, and viscosity are con- can stimulate the process of remineralization of deminer-
trolled by the incorporation of powder into the liquid alized dentin. The bioactive materials can be divided into
or, in the paste/paste system, by a change in the ratio two groups: calcium silicates and calcium aluminates.
of base to catalyst. They both have acid–base setting reactions and produce
an alkaline byproduct that raises the pH significantly.
Zinc Oxide Eugenol Calcium silicates have been useful in pulp capping
and vital pulpotomies. The first of these materials to be
ADVANTAGES
widely used in endodontics is mineral trioxide aggregate
• A wide variety of uses
• Sedative to the pulp (MTA). Introduced in the 1990s as ProRoot MTA (Dentsp-
• Easily manipulated ly), MTA is chemically similar to Portland cement. It has
• Low cost a number of properties that contribute to wound healing:
1. it is alkaline in nature because it forms calcium hydrox-
DISADVANTAGES
ide as it sets creating an antibacterial environment, 2. it
• Low strength
• High solubility
releases calcium ions that help repair dentin, 3. it bonds
• Unable to be used under composite restorations and and seals the area, and 4. it stimulates formation of sec-
indirect restorations cemented with resin or resin-modi- ondary dentin and hydroxyapatite. The shortcomings
fied glass ionomer cements (RMGICs) of MTA are that it is difficult to handle, has a very long
setting time, and a low compressive strength (about 50
MPa). Newer improved materials have emerged with
Manipulation. When two-paste ZOE are used, equal
new applications. TheraCal LC (BISCO Dental Products)
lengths of accelerator and base pastes are placed on
is a light-cured resin-modified calcium silicate used as a
a paper mixing pad or glass slab and are mixed un-
liner and Biodentine (Septodont) is used as a base under
til a uniform color is achieved. If the powder/liquid
direct restorations to stimulate dentin repair.
system is used, the powder bottle is shaken and the
Calcium aluminate cements are usually hybrid ma-
powder is measured with the manufacturer-supplied
terials containing calcium aluminate and glass ionomer.
scoop. The liquid is dispensed in the corresponding
The calcium aluminate portion is responsible for the de-
number of drops. The powder is incorporated into
velopment of a high pH during setting, strength, reduced
the liquid until the desired consistency is achieved.
microleakage, and stability. The glass ionomer portion is
Heavy spatulation with a metal spatula allows for
responsible for its viscosity, early setting time, and early
the incorporation of more powder; this additional
strength. Due to their strength (compressive and shear
powder will greatly enhance the strength of the ce-
bond), retention, low solubility, and low film thickness
ment. (See Procedure 14.1.)
(about 15 μm), they make excellent permanent luting
agents for all metal, ceramo-metal, or high-strength ce-
ramic crowns and bridges (e.g., C ­ eramir C&B, Doxa Den-
Clinical Tip tal). They do not require surface treatment of the tooth
ZOE cements are difficult to remove from mixing surfaces; such as etching, priming, or conditioning. They are avail-
glass slabs and spatulas should be wiped clean before the able in premeasured capsules with delivery tips.
cement sets. Set cement may be removed with alcohol or
orange solvent.
HANDLING OF CEMENTS
STORAGE
Timeline of the Introduction of Dental Cements should not be stored in warm or humid areas
Cements of the dental office. If you are refrigerating your ce-
1850s: Zinc oxide eugenol ment, it should be taken out of the refrigerator at least
1870s: Zinc phosphate 1 hour prior to use so it can reach room temperature.
1950s: Methylmethacrylate resin (poor performance)
1960s: Zinc polycarboxylate, Bis GMA resin, and glass ionomer PRECEMENTATION CHECK
Early 1990s: Resin-modified glass ionomer, compomer, Prior to mixing the cement the crown or other indi-
and adhesive resin
rect restoration should be tried in/on the prepared
Early 2000s: Self-adhesive resin
tooth. In many states dental assistants and hygienists
 Dental Cement CHAPTER 14 313

licensed in expanded functions can prepare the resto-

ration for cementation by performing many of the fol-
lowing procedures:
1. If the crown is not immediately seating all the way, the
first thing to check and adjust is the proximal contacts.
2. If it is still not seating completely, the inside of the
crown should be checked (using a variety of materi-
als and techniques for marking spots that bind on
the preparation) and adjusted.
3. Next, the margins should be checked with a fine-
tipped explorer to see that they are flush with the pre-
pared margins of the tooth. If they are not flush, then
re-check the contacts and interior of the crown. If no
problems are found with the fit, the discrepancies may FIG. 14.15 Zinc oxide eugenol hand-mixed powder/liquid (IRM Inter-
be caused by a poor impression or a lab error (which mediate Restorative Material). It has resin fibers added to increase
strength and wear resistance and is used as an intermediate restora-
would necessitate starting with a new impression). tion. (Courtesy Dentsply Sirona.)
4. Then, check and adjust the occlusion.
5. Confirm that the patient is happy with the appear-
ance of the crown and the bite feels comfortable. Advantages and disadvantages of each delivery
6. Re-polish as needed and clean the interior of the system are listed in Table 14.3.
crown in preparation for cementation.
WORKING AND SETTING TIMES
MIXING
Working time and setting time are considerations in
It is important that cements be mixed to their appro- the choice of cement and mixing mechanism. A longer
priate consistency in accordance with manufactur- working time is needed for cementation of longer span
ers’ recommendations, with meticulous attention to bridges versus single crowns and a shorter setting
detail. Cements that are mishandled may lead to dif- time is desirable for difficult-to-isolate areas. Patient
ficulties in seating, retaining the restoration, or even considerations and the dental team’s mixing and de-
pulpal sensitivity. Cements may be hand mixed or may livery skills play a part in the selection of appropriate
come in premeasured capsules mixed in a triturator or cement. The dental auxiliary is responsible for deliver-
mixed as material is extruded through automixing tips ing the cement at the proper consistency within very
attached to dual-barrel syringes. definite time frames. A skilled auxiliary must be able
Even skilled hand mixing may incorporate air that to routinely mix a variety of cements rapidly to their
is thought to lead to the reduction of bond strength be- proper consistency.
tween the restoration and the tooth substrate. Also, in-
accurate ratios of powder and liquid can be dispensed
from scoops and liquid droppers. If hand mixing is
chosen, the amount of time taken to mix the cement Cement Manipulation Considerations for
must be carefully monitored as too much mixing time ­Cements in Powder and Liquid Form
may make the cement too viscous while too little time
may cause the cement not to be mixed thoroughly 1. Keep powder and liquid separated when dispensing.
2. Fluff powder before dispensing by gently rolling the
(Fig. 14.15). Cements mixed in capsules or via automix
container in your hand to aerate.
systems provide the following advantages: consistent 3. Use scoop provided by the manufacturer and ensure
mix, reduced clean-up, reduced cross contamination, scoop of powder is level, not heaping.
and avoids incorporating air in the mix. 4. Section the powder into increments according to the
manufacturer’s directions; when increment size varies,
the smallest increments are mixed first.
Clinical Tip
5. Dispense the liquid by holding the dispenser vertically
There are many types of cement available and each one has before squeezing to obtain uniform drops.
multiple uses and differences in mixing techniques so that 6. Close caps of powder and liquid containers im-
it is very important to ALWAYS follow the manufacturer’s mediately after dispensing to avoid evaporation and
instructions for storage, mixing, and handling. contamination.
7. Incorporate powder and liquid thoroughly when mixing.
If incremental mixing is used, each increment must be
Caution completely incorporated before the next is added.
Light-cured cements may not be appropriate for deep prep- 8. Use moderate pressure on the spatula when mixing.
arations: the ultraviolet (UV) light may fail to activate some of 9. Use both sides of the spatula blade.
the material, leaving part of the cement unset. Dual-cured 10. Mix cement in a “stropping” motion.
products help to eliminate this problem. 11. Gather all the material together to test the viscosity.
314 CHAPTER 14 Dental Cement

TABLE 14.3    Advantages and Disadvantages of Delivery Systems

HAND MIXING AUTOMIXING PREDOSED CAPSULES
Advantages
Vary viscosity Consistent mix Consistent mix
Vary volume of material mixed Vary volume of material used Convenience
No extra equipment Convenience Disposable, less asepsis
Less expensive Less cleanup required
Can mix shades if needed No air voids incorporated in the mix No air voids incorporated in the mix
Disadvantages
Inconsistent mix Unable to vary viscosity Unable to vary viscosity
Air voids incorporated in the mix
Less convenient Additional equipment needed Volume of capsule is fixed
More cleanup required Cannot blend shades, more expensive Cannot blend shades, requires extra equipment,
more expensive

Fig. 14.16 Loading a crown—wipe the blade of the spatula against the Fig. 14.17 Loading a crown—using a flat-bladed instrument, cover all
margin of the crown. the walls with a thin, even coating of the cement.

Caution
Light-cured cements should not be used if there is a poten- Reasons Cement May Keep a Crown from
tial for incomplete set of the cement under a dental pros- Seating Fully
thesis because the curing light cannot reach the cement to 1. Too much cement is present in the crown and hydraulic
activate curing. pressure does not allow excess cement to flow out.
2. The cement mix is too thick (viscous) and the cement
does not flow readily.
LOADING THE RESTORATION
3. The cement is starting to set and will not flow.
The dental assistant may be responsible for filling the 4. Cement was selected with a film thickness that is too
crown with a luting cement before transferring it to the great for luting.
dentist. The techniques described in the accompanying
box (“Loading a Custom-Made Crown for Cementa-
Caution
tion”) will ensure that the cement is evenly loaded in the
crown, and that the margins are coated internally. Crowns that have long walls and a narrow diameter, such as
crowns for lower incisors or for premolars, should not be filled
with too much cement. Just a thin layer of cement should be
Loading a Custom-Made Crown for Cementation applied to the walls of the restoration’s interior (intaglio) to al-
1. Gather cement from the mixing surface with the blade low cement to flow out when the crowns are seated. With too
of the spatula or a plastic instrument. much cement, hydraulic pressure may prevent the cement
2. Wipe the blade against the margin of the crown (Fig. 14.16). from flowing out and the crown from seating completely.
3. Cover all the interior walls of the crown with a thin, even
coating of cement, making sure it is free of air bubbles
(Fig. 14.17). REMOVAL OF EXCESS CEMENT
4. Do not fill the prosthesis to more than one-quarter the
inner volume; overfilling the prosthesis may prevent Some cements should not be removed until completely
complete seating. set, such as zinc phosphate cement; others may be best
5. Transfer the crown cement-side down on the palm of removed when the cement reaches a rubbery or gel con-
your hand for the dentist to pick up and seat. sistency, such as resin-modified glass ionomer cement;
 Dental Cement CHAPTER 14 315

and others when the cement is tack-cured, that is, light-

cured resin cement. (Removal of excess resin cement
was previously discussed.) Follow the manufacturer’s
directions for appropriate consistency at removal. Ce-
ment consistencies vary from rock hard to rubbery.
1. Remove cement in bulk when possible.
2. Use a piece of knotted floss to remove cement from
interproximal areas before it sets. Draw the floss
out under the contacts rather than coming back up
through the contact, which might dislodge the crown.
3. Use a scaler or curette followed by an explorer to re-
move excess cement from subgingival surfaces, taking
care to not scratch the surface of the restoration or gouge
the margins where the tooth and restoration meet.
FIG. 14.18 Excess cement remaining subgingivally has become a
Timing of Excess Cement Removal after chronic bacterial plaque trap causing bone loss around the dental
implant. See cement on the distal surface wrapping around to the facial
Luting a Crown
surface. (Courtesy Drs. Nick Shumaker and Leslie Paris. From Slim
(Follow the manufacturer’s directions for appropriate consist- L: Cement-associated peri-implantitis, RDH Magazine, 33(12), 2013.)
ency at removal). Remove interproximal cement before set
In general: dental hygienist should evaluate each implant carefully
Zinc phosphate—let cement set completely to monitor probe depths, clinical and radiographic signs
Zinc polycarboxylate—let cement set completely. Do not of inflammation, and/or the presence of cement residue.
try to remove when rubbery
Zinc oxide eugenol—let cement set completely Caution
Glass ionomer cement—some versions can be removed at
the gel stage Complete removal of excess cement is essential to maintain
Resin-modified glass ionomer cement—Expose excess to gingival health.
curing light for 1 second, then remove at gel stage or let
it self-cure and remove at gel stage CLEANUP, DISINFECTION, AND STERILIZATION
Resin cements—remove excess before they set complete-
ly, often after 1 second tack cure. The removal of cement before it is set provides for easier
cleanup of mixing slabs, spatulas and delivery instru-
ments. Instruments and equipment that come in contact
Clinical Tip with cement should be cleaned as soon as is reasonably
When removing excess cement before it is fully set, be sure possible, using alcohol-saturated gauze squares. If im-
to secure the crown against the tooth so your manipulation mediate cleanup is not possible, use an ultrasonic cleaner
does not lift the crown. with cement removal solution. If barriers have not been
used, equipment such as triturators, cement activators,
the outside of cement bottles, and dispensing scoops and
CEMENT-ASSOCIATED PERI-IMPLANT DISEASE syringes must be properly disinfected. Sterilization of
Excess cement remaining after placement of an implant is mixing and delivery instruments is necessary. Glass and
positively associated with peri-implant disease. Biofilm- plastic mixing slabs are recommended because they can
related infections can result in the removal of the implant be sterilized in heat sterilizers. Paper pads, although con-
in severe cases. The American Academy of Periodontol- venient, are a source of contamination; there is no reliable
ogy (2013) has reported a prevalence of peri-implantitis way to combat this other than using only one sheet at a
in three studies ranging from 6.61% to 36.6%. There are time (very difficult to mix on this). Porous paper pads ab-
several factors associated with these infections, including sorb some of the cement liquid and alter the powder to
cement residue. Radiographs do not always reveal this liquid ratio.
residual cement, especially on buccal/lingual surfaces.
Margins that are subgingival exhibit a greater amount of CARE AROUND MARGINS
undetected cement. Cement-related bone loss may occur Proper instrumentation during prophylactic procedures
quickly or be delayed for several years (Fig. 14.18). and appropriate delivery of some therapeutic agents
At the time of the cementation of the implant resto- such as fluoride are important considerations for the
ration, a titanium scaler or curette should be used for continuing care of the fine line of cement at margins of
removal of excess cement. Titanium instruments are indirect restorations. Care must be taken to avoid goug-
strong enough to remove the set cement but are soft ing or ditching the cement during hand instrumenta-
enough to avoid scratching the implant surface. Plas- tion. Although the cement margin may be very small (25
tic or graphite instruments may leave tiny bits of their μm), even minute breaks are a place for biofilm to form
material embedded in rough surfaces of the implant and initiate microleakage and secondary caries. Ultra-
that may themselves contribute to peri-implantitis. The sonic and sonic scalers should be avoided on margins of
316 CHAPTER 14 Dental Cement

cemented restorations whenever possible, because they situation. The allied oral health practitioner is responsible
may cause fracturing of the cement. Air polishers may for handling, mixing, and delivering the cement to the
abrade cement at restoration margins. Fluoride applica- dentist. Proper cement manipulation is important in de-
tion on glass ionomer and resin-based cement margins termining the quality of a cement’s physical properties.
should be limited to neutral sodium fluoride, because In addition, the use of instruments on a cement margin
acidulated fluoride products may attack the cement. can directly affect a restoration’s longevity. Procedures
for placement of provisional restorations are important to
SUMMARY the success of future permanent restorations. It is essen-
tial the auxiliary is knowledgeable in the uses, properties,
A restoration may be esthetically pleasing and functional handling characteristics, and precautions for all cements
at the time of cementation, but if problems occur with used in the dentist’s office.
retention, postoperative sensitivity, and recurrent car-
ies, patients will most likely ask questions as to why the
INSTRUCTIONAL VIDEOS
treatment failed and how good the dentist’s skills are. No
single cement satisfies all dental purposes. Cements are See the Evolve Resources site for a variety of educa-
chosen to match the physical properties of the restorative tional videos that reinforce the material covered in
material being used, and the requirements of each clinical this chapter.

Procedure 14.1 Zinc Oxide Eugenol Cement (ZOE): Primary and Secondary Consistency

See Evolve site for Competency Sheet.

Consider the following with this procedure: safety glasses

are recommended for the patient, PPE is required for the operator,
ensure appropriate safety protocols are followed, and check your
local state guidelines before performing this procedure.

EQUIPMENT/SUPPLIES (FIG. 14.19)

• Cement paste/paste or cement powder/liquid and
dispensers
• Paper mixing pad or glass slab
• Flexible cement spatula

PROCEDURE STEPS: PRIMARY CONSISTENCY

1. Dispense the recommended amount of base paste FIG. 14.20
and accelerator paste onto a mixing pad. PROCEDURE STEPS: SECONDARY
NOTE: One-half inch of each is usually enough for CONSISTENCY (FIG. 14.21)
a single crown restoration. 1. Fluff the powder, and measure onto one end of the
2. Mix the materials, using both sides of the flat blade mixing surface.
in a “stropping, pushing” motion. NOTE: Aerated powder provides for a more accu-
3. The mix is in primary consistency when it is rate measurement.
smooth and creamy and after gathering together 2. Shake the liquid, and dispense at the opposite end
lifts 1 inch off the mixing surface (Fig. 14.20). of the mixing surface.
4. Whenever possible, immediately clean the spatula
with gauze.

FIG. 14.19 FIG. 14.21

 Dental Cement CHAPTER 14 317

Procedure 14.1 Zinc Oxide Eugenol Cement (ZOE): Primary and Secondary

Consistency—cont’d

NOTE: Hold the dispenser vertical while dispens-

ing to obtain uniform drops.
3. Incorporate the powder into the liquid in
two increments or all at once according to the
manufacturer’s directions (Figure 14.22).
NOTE: Incorporate as much powder as possible
into the liquid (Figure 14.23).
4. Mix the materials, using both sides of the flat blade
in a “stropping, pushing” motion.
5. The cement will be in secondary consistency when
it can be rolled into a ball and is no longer tacky
(Fig. 14.24).
6. Whenever possible, immediately clean the spatula
FIG. 14.23
with moist gauze.

FIG. 14.22 FIG. 14.24

Procedure 14.2 Zinc Phosphate Cement: Primary Consistency

See Evolve site for Competency Sheet. NOTE: Smaller increments are incorporated first.
4. Shake the liquid, and dispense the recommended
Consider the following with this procedure: safety glasses are
amount at the opposite end of the slab.v
recommended for the patient, PPE is required for the operator,
NOTE: Hold the dispenser vertical while dispens-
ensure appropriate safety protocols are followed, and check your
ing to obtain uniform drops (Fig. 14.26).
local state guidelines before performing this procedure.
5. Incorporate the first increment into the liquid.

EQUIPMENT/SUPPLIES (FIG. 14.25)

• Cement powder
• Cement liquid and dispenser
• Cool glass slab
• Flexible cement spatula

PROCEDURE STEPS
1. Obtain a cooled glass slab.
NOTE: The frozen slab method may be used for
multiple orthodontic bands or long-span bridges.
2. Fluff the powder, and dispense the recommended
amount onto one end of the slab.
3. Divide the powder into four to six increments to
include smaller and larger increment sizes. FIG. 14.25
Continued
318 CHAPTER 14 Dental Cement

Procedure 14.2 Zinc Phosphate Cement: Primary Consistency—cont’d

NOTE: Hold the spatula blade flat against the mix- 7. Place the spatula blade at a 45-degree angle to
ing surface. Use both sides of the spatula in a sweep- the slab, and gather the mass together to test the
ing “figure-eight” motion over a large area of the slab consistency.
(Fig. 14.27). NOTE: For primary consistency, the material should
6. Each increment is completely incorporated and be smooth and creamy. Draw the spatula up from the
is mixed for 20 to 30 seconds, beginning with the mix; the cement should follow the spatula, breaking
smallest and progressing through the largest. ­after 1 inch (Fig. 14.29).
NOTE: Adding increments of powder and com- 8. Clean the spatula and slab with moistened gauze
pletely incorporating each into the mix will help to and disinfect or sterilize.
neutralize the acid, control the setting time, and allow NOTE: If the cement is allowed to harden on the
for completion of the exothermic reaction before use slab or spatula, it may be removed in an ultrasonic
(Fig. 14.28). cleaner or by soaking in a solution of baking powder.

FIG. 14.26 FIG. 14.28

FIG. 14.27 FIG. 14.29

Procedure 14.3 Zinc Polycarboxylate Cement: Primary Consistency

See Evolve site for Competency Sheet. EQUIPMENT/SUPPLIES (FIG. 14.30)

Cement powder and dispenser
Consider the following with this procedure: safety glasses are Cement liquid and dispenser
recommended for the patient, PPE is required for the operator, Paper mixing pad or glass slab
ensure appropriate safety protocols are followed, and check your Flexible cement spatula
local state guidelines before performing this procedure.
 Dental Cement CHAPTER 14 319

Procedure 14.3 Zinc Polycarboxylate Cement: Primary Consistency—cont’d

PROCEDURE STEPS NOTE: The consistency is somewhat thicker than that

1. Fluff the powder, and measure onto one end of the of other cements and appears glossy (Fig. 14.31). The ce-
mixing surface. ment is too thick and starting to set if it produces thin
NOTE: Aerated powder provides for a more accu- stringy “cobwebs” when lifted off the mixing surface (Fig.
rate measurement. 14.32). Do not use that mix if it loses its glossy appearance.
2. Shake the liquid, and dispense at the opposite end 6. Whenever possible, immediately clean the spatula
of the mixing surface. with moist gauze.
NOTE: Hold the dispenser vertical while dispens-
ing to obtain uniform drops, or, if using a syringe
­dispenser, be careful to note the number of lined incre-
ments to dispense.
3. Incorporate the powder into the liquid in
two increments or all at once according to the
manufacturer’s directions.
4. Mix the materials, using both sides of the flat blade
in a “stropping, pushing” motion.
5. The mix is in primary consistency when it is
smooth and creamy and after gathering together
lifts 1 inch off the mixing surface.
FIG. 14.31

FIG. 14.30 FIG. 14.32

Procedure 14.4 Glass Ionomer Cement: Predosed Capsule

See Evolve site for Competency Sheet.

Consider the following with this procedure: safety glasses

are recommended for the patient, PPE is required for the operator,
ensure appropriate safety protocols are followed, and check your
local state guidelines before performing this procedure.

EQUIPMENT/SUPPLIES (FIG. 14.33)

• Premeasured capsule of cement
• Cement activator
• Triturator
• Cement dispenser
FIG. 14.33
Continued
320 CHAPTER 14 Dental Cement

Procedure 14.4 Glass Ionomer Cement: Predosed Capsule—cont’d

PROCEDURE STEPS 3. Remove the capsule from the triturator and

1. Place the premeasured capsule into the cement immediately place into the cement dispenser;
activator and press down on the handle. advance the mixed cement to the end of the
NOTE: The activator breaks the seal between the dispensing tip (Fig. 14.36).
powder and the liquid in the capsule, allowing the ma- 4. Load the crown directly from the dispenser
terials to meet. Make sure you use sufficient pressure (Fig. 14.37).
to feel the seal break (Fig. 14.34). 5. Discard the capsule and disinfect the activator and
2. Place the capsule into the triturator and set for the triturator. The dispenser may be sterilized.
recommended amount of time, usually 10 to 15
seconds.
NOTE: The capsule is similar to an amalgam cap-
sule and needs to be secured in the arms of the tritura-
tor before mixing (Fig. 14.35).

FIG. 14.36

FIG. 14.34

FIG. 14.35 FIG. 14.37

 Dental Cement CHAPTER 14 321

Procedure 14.5 Resin-Based Cement for Indirect Restorations: Ceramic, Porcelain,

Composite

See Evolve site for Competency Sheet. 5. Apply tooth conditioner according to the
manufacturer’s directions.
Consider the following with this procedure: safety glasses NOTE: The use of a fine needle tip attached to the
are recommended for the patient, PPE is required for the operator, syringe of the conditioner will allow control of the con-
ensure appropriate safety protocols are followed, and check your ditioner to prevent etching of areas prone to postop-
local state guidelines before performing this procedure. erative sensitivity.
6. Rinse and blot dry, leaving a moist glistening
EQUIPMENT/SUPPLIES surface.
NOTE: Blot drying provides the correct amount
• Tooth conditioner (etchant)
of “wetness” on the tooth surface while avoiding
• Primer/bond (universal) adhesive
desiccating the tooth surface.
• Disposable applicator
7. Isolate the area to prevent saliva contamination.
• Dispensing dish
NOTE: If saliva contamination occurs, repeat steps
• Cement/adhesive
5 and 6.
• Blunt instrument
8. Apply primer/bond adhesive agent to the tooth
PROCEDURE STEPS and internal surface of the restoration according to
the manufacturer’s directions (Fig. 14.38). shows
1. Clean preparation of all provisional material.
the etch-and-rinse procedure to maximize bond
NOTE: Eugenol-containing materials should not be
strength with a significant amount of enamel
used in provisional coverage.
remaining in the preparations for these veneers.
2. Clean the dentin with a rubber cup and
9. The universal adhesive is applied to the teeth
nonfluoride cleaning paste.
and scrubbed for 20 seconds with a microtip
NOTE: Fluoride should not be used before bonding.
(Fig. 14.39).
3. Rinse thoroughly and lightly air dry.
10. Dispense the desired shade of cement base paste
4. Clean and dry and prepare the internal surface of
into the restoration and seat the restoration.
the restoration.
11. Initiate the set with a curing light until the cement
NOTE: Organic debris accumulated during try-in
reaches the gel phase and then remove the excess
must be removed; this can be done by several means,
cement (Fig. 14.40).
including the use of an ultrasonic cleaner and phos-
12. Review the final results, showing the veneers in
phoric acid etchant. Microetching is recommended for
place (Fig. 14.41).
preparation of the internal surface of the restoration.

FIG. 14.38 FIG. 14.39

Continued
322 CHAPTER 14 Dental Cement

Procedure 14.5 Resin-Based Cement for Indirect Restorations: Ceramic, Porcelain,

Composite—cont’d

FIG. 14.40 FIG. 14.41

Figures 14.38 - 14.41 from Blank JT: 3M ESPE’s RelyX Ultimate Adhesive Resin Cement: A cement for nearly any indirect indication, www.dental-
productsreport.com.

Procedure 14.6 Self-Adhesive Technique for Indirect Restorations: Ceramic,

Porcelain, Composite

See Evolve site for Competency Sheet. PROCEDURE STEPS

1. Follow steps 1-3 in Procedure 14.5.
Consider the following with this procedure: safety glasses are NOTE: When using self-adhesive cements the etch-
recommended for the patient, PPE is required for the operator, ing and bonding steps are not done (Fig. 14.43).
ensure appropriate safety protocols are followed, and check your 2. Try in the crown and confirm fit at margins, contact
local state guidelines before performing this procedure. areas and bite. (Fig. 14.44).
Shown is the cementation of a ceramic crown with a 3. Prepare the internal surface (intaglio) of the crown
self-adhesive resin cement. by sandblasting (Fig. 14.44).
4. Rinse thoroughly and dry the crown (Fig. 14.45).
EQUIPMENT/SUPPLIES 5. Place the mixing and delivery tips on the cement
• Matrix cartridge. Express cement and coat the walls of the
• Self-adhesive resin cement (Fig. 14.42). crown with a thin layer of cement and fully seat the
• Light-cure delivery system crown with finger pressure or have patient bite on
• Floss; explorer or scaler a cotton roll (Fig. 14.46).
NOTE: Do not overfill the crown with cement. Hy-
draulic pressure may prevent the crown from seating fully.
6. The cement is dual-cured, so wave the curing light
over the margins of the crown for 2 seconds to gel
the cement. Remove the excess cement with a scaler

FIG. 14.42

FIG. 14.43
 Dental Cement CHAPTER 14 323

Procedure 14.6 Self-Adhesive Technique for Indirect Restorations: Ceramic,

Porcelain, Composite—cont’d

FIG. 14.44 FIG. 14.46

FIG. 14.47

FIG. 14.45
or explorer. Used knotted floss to remove excess
cement from the interproximal area (Fig. 14.47).
NOTE: The removal of excess cement before curing
is necessary; a short light-cure to cause the cement to
gel allows for easier removal. Pay special attention to
interproximal areas, using knotted floss to remove
excess cement. Once the cement has fully set it is very
difficult to remove, especially from interproximal areas.
7. Check the cure marginal fit, contact areas and FIG. 14.48
adjust occlusion as necessary (Fig. 14.48).
NOTE: Try-in paste is matched to the cement base
8. Check the radiograph to confirm seating and
material and is used to obtain the correct shade of ce-
cement removal
ment. Restoration “try-in” particularly for anterior
9. Finish and polish any areas that have been adjusted.
crowns is recommended before final cementation to
TRY-IN OPTION: BEFORE PREPARATION OF ensure acceptance of restoration esthetics.
THE TOOTH FOR BONDING 2. Once the restoration fit and esthetics are verified,
the try-in paste is removed from the preparation
1. Dispense the appropriate shade of try-in paste
and the restoration is cemented, using one of the
onto a mixing pad. Load the restoration and seat
techniques already described.
onto the preparation.
Figures 14.42 - 14.48 courtesy of DMG America, Englewood, NJ.
324 CHAPTER 14 Dental Cement

Get Ready for Exams!

Review Questions a. Zinc oxide eugenol

b. Polycarboxylate
Select the one correct response for each of the following c. Calcium hydroxide
multiple-choice questions. d. Glass ionomer
1. Cements mixed to primary consistency are used for 10. Zinc phosphate cement is mixed over a large area of the
a. High-strength bases glass slab to
b. Luting a. Help lengthen the working time
c. Core buildups b. Help neutralize the chemicals
d. Surgical dressings c. Help dissipate the exothermic reaction
2. It may be necessary to place an insulating base under d. All of the above
restorations to 11. Proper instrumentation at cement margins includes
a. Encourage sclerotic dentin formation a. Avoiding gouging or ditching cement margins
b. Protect the pulp from sudden temperature changes b. Using ultrasonic scalers to remove deposits on
c. Reduce acidity resin-based cement margins
d. Calcify the dentinal tubules c. Use of air polishing on resin-based cement margins
3. The test for a properly mixed zinc phosphate luting d. All are correct
cement is 12. Light-cured cements may be used for luting
a. Putty consistency a. Non-metal orthodontic retainers
b. Granular consistency b. Porcelain veneers less than 1.5 mm thick
c. Checking whether cement will break and form a drop c. Porcelain or gold inlays
at the end of the spatula d. A and B
d. Checking whether cement will hold a thin string,
13. Which cement should not be used under a com-
breaking when the spatula is raised an inch
posite restoration because of the oil content of the
4. Which cement should not be used for temporary liquid?
cementation of crowns to be permanently cemented a. Zinc phosphate
with resin cements? b. Glass ionomer
a. Zinc polycarboxylate c. Calcium hydroxide
b. Zinc phosphate d. Zinc oxide eugenol
c. Zinc oxide eugenol
14. Adhesion is molecular attraction between materials
d. Any cement is appropriate
with
5. Which cement exhibits an exothermic reaction during a. Similar molecules
mixing? b. Dissimilar molecules
a. Glass ionomer c. Irregular surfaces
b. Zinc phosphate d. None of the above
c. Resin cement
15. The latest generation of adhesive systems
d. Calcium hydroxide
incorporates a
6. Which dental cements use the bonding procedure a. 1-step system
before placement of the dental cement? b. 2-step system
a. Zinc phosphate and polycarboxylate c. 3-step system
b. Zinc oxide eugenol and glass ionomer d. 4-step system
c. Resin
16. Newly mixed polycarboxylate cement should no longer
d. Calcium hydroxide and zinc oxide eugenol
be used for luting when
7. When luting a crown, it is important to a. the mix is shiny
a. Have a film thickness that allows for complete b. the mix flows readily
seating c. the mix is creamy
b. Have a film thickness that provides proper insulation d. the mix is stringy or web-like
c. Have a film thickness for complete filling of the
17. Adding resin to glass ionomer cement does all of the
crown
following except one. Which one?
d. None of the above
a. increases the fluoride release
8. Many cements should not be dispensed until ready to b. increased compressive strength
mix because of c. decreases solubility
a. Dehydration from exposure to air d. increases tensile strength
b. Contamination from moisture in the air
18. Failure to remove all excess cement from subgingival
c. Materials coming in contact with each other
margins may cause all of the following except one.
d. All of the above
Which one?
9. Which dental cement bonds to dentin, is “kind” to the a. aphthous ulcers
pulp, and resists recurrent decay? b. periodontal infection
 Dental Cement CHAPTER 14 325

Get Ready for Exams!—cont'd

c. bone loss Why was this cement chosen for the provisional coverage,
d. recurrent caries and which cement would be the best choice for the perma-
For answers to Review Questions, see the Appendix. nent crown?
3. A 9-year-old is scheduled for cementation of orthodontic
Case-Based Discussion Topics bands.
Which cement would be the best choice, and why?
1. A 22-year-old administrative assistant is scheduled for 4. You are asked to mix a final luting cement and fill a
a gold crown preparation. She has been seen in your crown with it in preparation for seating. Although the
office previously for a crown and experienced some dif- crown seated completely on try-in, when the dentist
ficulty with sensitivity while the provisional crown was in attempts to seat the cement-filled crown, the margins
place. remain open and the crown is high.
Which cement would be the best choice for luting the tem- What might be the explanation for this situation?
porary crown, and why? 5. Your office is considering going to a premeasured
2. A 40-year-old accountant is scheduled for cementation of cement system.
an all-ceramic crown on tooth #5. The provisional crown What situations can you foresee in which this system may be
has been cemented with a noneugenol zinc oxide cement. problematic?

BIBLIOGRAPHY Kaufman L: Proper clean-up: removing excess/residual resin-

based dental cement. Dental Learning, August 3, 2017. Available
American Academy of Periodontology: Academy report: peri- at http://www.dentallearning.net/proper-clean-removing-
implant mucositis and peri-implantitis: a current under- excessresidual-resin-based-dental-cement
standing of their diagnoses and clinical implication. J Peri- Leinfelder KF: Should I change the type of cement I use? J Am
odontol, 84:436–443, 2013. Dent Assoc 130:1492, 1999.
Anusavice KJ, Shen C, Rawls HR, editors: Phillips’ Science of Den- Miller M: Resin Cements and Resin Ionomers, (vol. 13). Houston,
tal Materials (ed 12)., Philadelphia, 2013, Saunders. 1999, REALITY Publishing. 505 to 544.
Baghani Z, Kadkhodazedeh M: Periodontal dressing: a review Notarantonio A: How to bond all-ceramic crowns [video]. Dental
article. J Dent Res Clin Dent Prospects Autum, 7(4):183–191, Products Report, May 2013. Available at http://www.dental-
2013. productsreport.com/dental/article/how-bond-all-ceramic-c
(No authors listed) Periodontal dressing. J Integrated Dent Au- rowns-video.
gust, 1(1):1–12, 2012. Pameijer CH: A review of luting agents. Int J Dent, 2012:752861,
Cao Y, Bogen GB, Lim J, et al.: Bioceramic materials and the 2012.
changing concepts in vital pulp therapy. J Cal Dent Assoc, Powers JM, Sakaguchi RL, editors: Craig’s Restorative Dental Ma-
44(5):279–289, 2016. terials, (ed 13)., St. Louis, 2012, Mosby.
Christensen G: Success with cements, self-etching primers. Den- Schmidt SJ: Temporary cements revisited. Inside Dental Assisting,
tal Products Report, 64–68, 2001. 11(2), 2014. https://www.aegisdentalnetwork.com/ida/201
Fruits T, Coury T, Miranda F, et al.: Uses and properties of current 4/04/Temporary-Cements-Revisited.
glass ionomer cements: a review. Gen Dent, 44:410–415, 1996. Slim L: Cement-associated peri-implantitis. RDH Magazine, 33(12),
Gutkowski S: Minimal intervention: making it stick: cements in 2013. http://www.rdhmag.com/articles/print/volume-33/is
dental hygiene. RDH Magazine, 28:36–37, 2008. sue-12/columns/cement-associated-peri-implantitis.html.
Helpin M, Rosenberg H: Resin-modified glass ionomers in pedi- Strassler HE, Morgan RJ: Cements for PFM and all-metal res-
atric dentistry. Practical Dental Hygiene, 33–35, 1996. torations, Inside Dentistry 9(11), 2013. https://www.aegis-
Jeffries SR: Bioactive dental materials. Inside Dentistry, 12(2), dentalnetwork.com/id/2013/11/cements-for-pfm-and-all-
2016. https://www.aegisdentalnetwork.com/id/2016/02/b metal-restorations?page_id=297.
ioactive-dental-materials. Strassler HE, Morgan RJ: Cements for today’s all-ceramic mate-
Jivraj SA, Reshad M, Donovan T: Selecting luting agents. Inside rials, Inside Dentistry 9(12), 2013. https://www.aegisdental-
Dentistry, 9(2), 2013. network.com/id/2013/12/cements-for-all-ceramic-materials.
Kathariya R, Jain H, Jadhav T: To pack or not to pack: the current Strassler HE, Morgan RJ: Provisional–temporary cements: tech-
status of periodontal dressing. J Appl Biomater Funct Mater, niques to facilitate placement of provisional restorations. In-
13(2):e73–e86, 2015. side Dental Assisting, 8(4), 2012. https://www.aegisdentalne-
twork.com/ida/2012/08/provisional-temporary-cements.
15 Impression Materials

http://evolve.elsevier.com/Eakle/materials/

Chapter Objectives
Upon completion of this chapter, the student should be able to:
1. Describe the purpose of an impression. 12. D iscuss the advantages and disadvantages of using
2. Describe the three basic types of impressions. polyether impression material for a crown impression.
3. Explain the importance of the key properties of 13. Explain the difference between a hydrophobic and a
impression materials. hydrophilic impression material.
4. Explain why alginate is an irreversible hydrocolloid. 14. Evaluate cord placement and gingival retraction for
5. List the supplies needed to make an alginate impression acceptability.
and explain how they are used. 15. Use ferric sulfate astringent to control gingival bleeding
6. Select trays for alginate impressions for a patient. before making an impression.
7. Mix alginate, load and seat the tray, and remove the set 16. Make a registration of a patient’s bite in centric occlusion.
impression. 17. Assemble the cartridge of impression material with mixing
8. Evaluate upper and lower alginate impressions, in tip and load into the dispenser.
accordance with the criteria for acceptability. 18. Explain what a digital impression is and how it is used.
9. Disinfect alginate impressions and prepare them for 19. Describe the advantages and disadvantages of digital
transport to the office laboratory. impressions.
10. Troubleshoot problems experienced with alginate 20. Disinfect PVS and polyether impressions and prepare
impressions. them for transport to the dental laboratory.
11. Compare similarities and differences among the physical
and mechanical properties of polyvinyl siloxane (PVS) and
polyether impression materials.

Key Terms
Diagnostic Casts positive replicas of the teeth and sur- Colloid glue-like material composed of two or more sub-
rounding oral tissues and structures produced from stances in which one substance does not go into solution
impressions that create a negative representation of the but is suspended within another substance; it has at least
teeth; commonly called study models and used for diag- two phases: a liquid phase called a sol and a semisolid
nostic purposes and numerous chairside and laboratory phase called a gel
procedures Hydrocolloid a water-based colloid used as an elastic im-
Preliminary Impression an impression of the dentition pression material
or edentulous arch and surrounding tissues taken as a Reversible Hydrocolloid an agar impression material that
precursor to other treatment; often used to make casts can be heated to change a gel into a fluid sol state that
(models) of oral structures for planning, and to construct can flow around the teeth, and then cooled to gel again to
custom trays or provisional restorations make an impression of the shapes of the oral structures
Final Impression a detailed impression of oral structures Irreversible Hydrocolloid an alginate impression material
used to make an accurate cast from which restorations or that is mixed to a sol state and as it sets converts to a gel
prostheses are made by a chemical reaction that irreversibly changes its nature
Bite Registration an impression of the upper and lower Agar a powder derived from seaweed that is a major compo-
teeth in the patient’s normal bite relation nent of reversible hydrocolloid
Dimensional Stability ability of a material to maintain its size Sol liquid state in which colloidal particles are suspended; by
and shape over a period of time cooling or a chemical reaction, it can change into a gel
Accuracy ability of a material to adapt to and flow over the Gel a semisolid state in which colloidal particles form a
surfaces of the oral structures to record fine detail framework that traps liquid (e.g., Jell-O)
Tear Resistance ability to avoid tearing when the material is Alginate a versatile irreversible hydrocolloid that is the most
in thin sections used impression material in the dental office; it lacks the

326
 Impression Materials CHAPTER 15 327

accuracy and fine surface detail needed for impressions for Polyvinyl Siloxane (PVS) (Also Referred to as Vinyl
crown and bridge procedures Polysiloxane) very accurate addition silicone elastomer
Elastomers highly accurate elastic impression materials that impression material; it is used extensively for crown and
have qualities similar to rubber; they are used extensively in bridge procedures because of its accuracy, dimensional
indirect restorative techniques, such as crown and bridge stability, and ease of use
procedures Polyether a rubber impression material with ether functional
Imbibition the act of absorbing moisture groups; it has high accuracy and is popular for crown and
Surfactant a chemical that lowers the surface tension of a bridge procedures
substance so that it is more readily wetted; for example, oil Astringent a chemical used in tissue management during
beads on the surface of water, but soap acts as a surfac- gingival retraction to control bleeding and constrict tissues
tant to allow the oil to spread over the surface Flash a common term for the cuff of impression material
Polysulfide an elastic impression material that has sulfur- that extends apical to the margin of a crown preparation
containing (mercaptan) functional groups; it has also been and represents an impression of the root or unprepared
referred to as rubber base impression material tooth
Condensation Silicone a silicone rubber impression Digital Impression detailed digital images of the prepara-
material that sets by linking molecules in long chains but tion, surrounding and opposing teeth, and tissues taken by
produces a liquid by-product by condensation a digital scanner for the purpose of making a restoration
Addition Silicone a silicone rubber impression that also sets Intraoral Scanner a type of camera that takes digital images
by linking molecules in long chains but produces no by- (typically in continuous video form) of oral structures for
product; the most commonly used addition silicones are CAD/CAM procedures, such as crown preparations.
the polyvinyl siloxanes
  

In dentistry, an impression material is used primarily to impression materials are used more extensively than
reproduce the form of teeth, including existing restorations rigid materials, because elastic materials flex from tis-
and preparations made for restorative treatments, as well as sue undercuts when removed from the mouth, where-
the form of the arches and other oral hard and soft tissues for as rigid materials cannot. The completed impression
removable prostheses. Impression materials are also used by forms a negative reproduction of the teeth and tissues.
maxillofacial prosthodontists to make molds of facial defects When plaster or stone is poured into the impression
resulting from cancer and trauma, so that they can construct and hardened, the replica that is formed is a positive
facial prostheses to restore facial form. Many different types reproduction of the teeth and tissues (see Chapter 16
of impression materials have been developed over the years, Gypsum and Wax Products). The replica is called a cast
allowing the dentist to select materials according to the de- or model. In the initial diagnosis and treatment plan-
mands of the treatment and the oral environment. Participa- ning phase, the dentist may request that the dental
tion in the making of impressions is one of the most frequent- assistant or hygienist make impressions of the teeth
ly performed patient contact functions of the dental assistant and surrounding structures, so that diagnostic casts,
and is performed increasingly by the dental hygienist. It is commonly called study models, can be made for further
important that both have an understanding of the clinical ap- study when the patient is no longer present. When an
plications, handling characteristics, physical properties, and impression is made of a tooth that has been prepared
limitations of these materials. They must also know proper for a restoration, the replica of the prepared tooth is
techniques and materials for disinfecting the impressions. In called a die and is used for fabrication of the restoration
some states, dental auxiliaries can be licensed in expanded in the dental laboratory. Fig. 15.1 shows an impression
functions that include making final impressions for crowns
and bridges, implants, and partial denture procedures.

OVERVIEW OF IMPRESSIONS
Making impressions of oral structures is almost an ev-
eryday occurrence in a busy dental practice. Selection
of the impression material will be influenced by what
the impression will be used for. To replicate oral struc-
tures, the impression materials must be in a moldable
or plastic state that can adapt to the teeth and tissues.
Usually, the impression material in its plastic state is
loaded into a tray for carrying it to the mouth and sup-
porting it so that it does not slump and distort. Within FIG. 15.1 A double-bite impression and the cast from the impression
a specified period of time, the impression material with a die of the crown preparation that can be removed by the techni-
must set to a semisolid, elastic, or rigid state. Elastic cian to facilitate the creation of a wax pattern.
328 CHAPTER 15 Impression Materials

and the mold and die made from that impression. Use laboratory where the restoration will be fabricated.
of the die allows the dentist or laboratory technician Bite registrations are also used to help mount diagnos-
to perform the procedure by the indirect technique. tic casts in their proper relationship on an articulator.
With the indirect technique, the restoration is not made Although wax has been used for bite registration for
directly on the tooth, as with the direct placement of decades (see Procedure 15.5), polyvinyl siloxane is cur-
amalgam, but is constructed in the laboratory (indi- rently more popular for this purpose. A wax bite regis-
rectly) and later is cemented on the tooth. tration is easily distorted.

TYPES OF IMPRESSIONS TYPES OF IMPRESSION MATERIALS

Dental impressions can be categorized into three basic Impression materials can be categorized into two ma-
types based on how they will be used. These types in- jor groups:
clude the following: 1. Elastic materials
1. Preliminary impressions 2. Inelastic materials
2. Final impressions Elastic impression materials include the hydrocol-
3. Bite registration (occlusal) impressions loids (agar and alginate), polysulfides, silicone rubber
While the dentist has a wide variety of materials to materials (condensation and addition; e.g., polyvinyl
choose from to make these impressions, in the modern siloxane), polyethers, and a hybrid of polyether and
practice the choice will likely be alginate, silicone rub- polyvinyl siloxane. Of the elastic materials agar hydro-
ber (polyvinyl siloxane), or polyether. It is possible that colloids, polysulfides, and condensation silicone rub-
no impression material will be used; instead, a digi- bers are not used much anymore. Alginate, polyvinyl
tal image of the oral structures may be used. Digital siloxane (PVS), and polyether are the most commonly
impressions are discussed separately (see “Digital Im- used elastic impression materials. Alginate is used ex-
pressions,” below). tensively for preliminary impression whereas PVS and
polyether are used primarily for final impressions.
Preliminary Impressions Inelastic materials are the older impression mate-
Preliminary impressions, as the name implies, are made rials and include dental compound, impression plas-
as a precursor to another treatment. Casts made from ter, zinc oxide eugenol, and impression wax. Because
them are often used for planning purposes such as for of the superior properties of the elastic materials, in-
diagnostic casts (study models). Preliminary impres- elastic materials are seldom used in dentistry today
sions may be used to make working casts from which (although some dentists still use stick compound for
custom trays or provisional (temporary) restorations can border molding custom trays for denture impressions).
be made or to create casts for pre- and post-treatment
records. On occasion, what starts out to be a preliminary Key Properties
impression can also be used as the final impression. For Although impression materials must have a degree of
example, a cast made from an alginate impression to de- strength, their key properties are as follows:
sign a removable orthodontic appliance may be accurate Accuracy: When the impression is made the impres-
enough to send to the laboratory for fabrication of the sion material must closely adapt to and flow over
appliance. Alginate is a useful, inexpensive material that the surface of the tooth preparation and tissues to
is excellent for preliminary impressions but lacks the de- record the minute details in order to be accurate.
tail and accuracy to be used for a crown impression. The material will tend to flow if it has low viscosity
and there is pressure on the material as the tray is
Final impressions seated.
Final impressions are impressions that are more accurate Tear resistance: After the impression material sets, it
in their replication of the oral structures. To provide must have good tear resistance to prevent tearing
a good fit and marginal integrity for a crown, bridge, during removal from the mouth. With a crown im-
or implant a very detailed and accurate impression of pression the material in the gingival sulcus is very
the preparation and surrounding structures is needed. thin and would tear if the tear resistance was poor.
A detailed replication of the oral tissues is needed to Dimensional stability: After the impression is re-
fabricate well-fitting partial and complete dentures moved, the set material must remain dimension-
as well. Polyvinyl siloxane and polyether are the two ally stable; otherwise, casts and dies poured from it
most commonly used materials for final impressions. would be inaccurate.

Bite registration
IMPRESSION TRAYS
A replication of the patient’s bite is needed to estab-
lish the proper relation between a restoration or pros- Impression trays are used to carry the impression ma-
thesis and the opposing teeth. An impression is made terial to the mouth and to support it until it sets, is re-
that captures this relationship (see Procedure 15.4), so moved from the mouth, and is poured into dental plas-
that it can be used in the office or sent to the dental ter or stone. Trays should be rigid to prevent distortion
 Impression Materials CHAPTER 15 329

of the impression. They can be made for arches with and children (Fig. 15.2). Stock trays can be metal or plas-
teeth or for edentulous ridges. tic, and each of these can be solid or perforated. Perfo-
rated trays have holes in their sides and bottom to help
STOCK TRAYS retain impression material as it extrudes through the
Impression trays can be pre-manufactured trays, called holes and locks into place. Solid trays often have raised
stock trays, which are purchased in a variety of sizes borders on the internal surfaces that help lock in the im-
(small, medium, large, and extra large) for both adults pression material. These are called “rim-lock” trays.

A D

F
C
FIG. 15.2 Variety of metal and plastic stock impression trays. A, Full arch metal perforated trays. B, Rim-lock metal tray with
option for water cooling (tray on the right has water hose attached). C, Disposable plastic perforated trays. D, Bite registration
trays. E, Triple trays take impression of prepared teeth, opposing teeth, and bite. F, Quadrant (left), anterior section (middle),
and full arch (right) trays. (From Bird DL, Robinson DS: Modern Dental Assisting (ed 11). Philadelphia, 2015, Elsevier.)
330 CHAPTER 15 Impression Materials

Impression materials used in solid trays require the

application of an adhesive to further retain them and
prevent distortion of the impression if they should par-
tially pull out of the tray. Plastic trays are inexpensive
and disposable, whereas metal trays are more expen-
sive and must be cleaned and sterilized between uses.

Stock Sectional Trays

In addition to trays used for full arch impressions,
metal and plastic stock trays can be used for sectional
impressions as well. Sectional trays can be shaped for
quadrants, anterior segments or half-mouth. They are
also used for bite registration impressions.
FIG 15.3 Custom acrylic trays that were fabricated on edentulous
casts.
Triple Trays (Closed-Bite Trays)
The triple tray (also called closed-bite, double-bite, dual-
arch, or check-bite tray) is a stock sectional tray that is
used to make an impression of the teeth being treated
and the opposing teeth at the same time and, if used
properly, will capture the correct centric occlusion
(bite) of the patient. Quadrant trays will fit a quadrant
of the mouth or one-half of an arch.

Bite Registration Trays

Bite registration trays are typically U-shaped plastic
frames with a thin fiber mesh stretched between the
sides of the frame. The mesh retains the impression
material (called bite registration material) and is thin
enough so as not to interfere with closure of the upper
and lower teeth in proper bite relationship. Bite reg-
istration material is placed on both sides of the mesh,
the frame is positioned over the teeth to be recorded,
and the patient closes into the normal bite relationship
until the material sets (see Figs. 15.67 through 15.70 in FIG. 15.4 Triad VLC tray material. (Courtesy of Dentsply Sirona.)
Procedure 15.4). They can encompass a full arch or be
limited to a quadrant or anterior section. Procedure 17-1. An example of thermoplastic mold-
able, full arch tray material is HeatWave (Clinician’s
CUSTOM TRAYS Choice Dental Products), which can be molded to
Because of the wide variation in size and shape of pa- fit the patient’s arch. The trays come in four upper
tients’ arches, stock trays may not fit some patients and lower anatomical shapes. The tray material
well. Ideally, the tray should conform to the length, softens after 1 minute in a water bath that is 71 °C
size, and height of the arch, depth of the palatal vault, (160 °F) and can be adapted to an existing cast or
and position of the teeth. To get the best fit it may be shaped by hand to fit the patient’s arch. Molding the
necessary to custom make the tray to fit the patient’s tray will adapt better, providing many of the ben-
mouth (Fig. 15.3). efits of a chemical- and light-cured custom tray; use
Custom trays used with elastomeric impression ma- less impression material; and provide more accurate
terials provide a uniform thickness of the impression impressions.
material producing dimensional stability and reduc- Custom trays can be made for full arch or sectional
ing inaccuracies. The result is highly accurate working impressions. A stock tray can be customized by lining
models and ultimately, well-fitting restorations. it with a putty impression material that is adapted to
Custom trays are usually constructed in the labo- the dental arch of the individual, and then an impres-
ratory with chemical-cured, light-cured, or thermo- sion is made in this customized stock tray.
plastic resins (see Procedure 15.1 for information on
fabricating full arch light-cured resin custom trays).
HYDROCOLLOIDS
A popular material for light-cured resin custom trays
is Triad VLC Tray Material, Dentsply Sirona (Fig. A colloid is a glue-like material composed of two or
15.4). The technique for fabricating custom chem- more substances in which one substance does not
ical-cured acrylic trays is presented in Chapter 17, go into solution but is suspended within another
 Impression Materials CHAPTER 15 331

substance. Hydrocolloids are water-based colloids that prepared teeth from which precisely fitting restora-
function as elastic impression materials. The two hy- tions will be made.
drocolloids used in dentistry are agar hydrocolloid
(or reversible hydrocolloid) and alginate hydrocolloid Common Uses of Alginate Impressions
(or irreversible hydrocolloid). Much like gelatin, when •  iagnostic casts (study models)
D
agar powder is mixed with water, it forms a glue-like • Preliminary impressions for complete dentures
suspension that entraps the water, making a colloidal • Partial denture frameworks
suspension called a sol. Heating it will disperse the • Opposing casts for crown and bridge treatments
agar in the water faster. When the agar sol is chilled, it • Repairs of partial and complete dentures
will gel, becoming semisolid or jelly-like (like Jell-O). • Provisional (temporary) restorations
When the agar gel is heated, it will reverse its state • Custom trays for home-use fluoride or bleaching
back into a liquid suspension (sol). Therefore it is a re- • Sports protectors and night guards
• Removable orthodontic appliances
versible hydrocolloid. Alginate powder will also form
a sol that gels. However, with alginate, a chemical
reaction occurs that prevents it from reversing back Composition and setting reaction. The main active in-
to a gel when heated. Therefore it is an irreversible gredient in alginate is potassium or sodium alginate,
hydrocolloid. which makes up 15% to 20% of the powder. Propor-
tions of ingredients vary from manufacturer to manu-
REVERSIBLE HYDROCOLLOID (AGAR) facturer and with fast-, regular-, and slow-set materi-
Reversible hydrocolloid was introduced into den- als. It is produced from derivatives of seaweed. See
tistry in 1925 and was the first elastic material to Table 15.1 for the components of alginate and their
gain popularity. It overcame many of the problems functions. The “dustless” alginate powders have or-
with inelastic materials (see the section “Inelastic ganic glycols or glycerin added to keep powder from
Impression Materials,”) in that it could take accurate becoming airborne when it is dispensed. The dust con-
impressions of teeth and arches with tissue under- tains silica particles, and they are a potential health
cuts and could be removed from the mouth without hazard if inhaled.
injuring the patient or breaking. Its main clinical use When alginate powder is mixed with water, cal-
is for impressions of operative and crown and bridge cium sulfate dihydrate reacts with sodium alginate to
procedures. It also has uses in the laboratory for the form calcium alginate. Calcium alginate is insoluble
duplication of casts (models). Its use has declined and causes the sol of mixed powder and water to gel.
over the years as elastic (rubber) impression mate- Because this occurs by a chemical reaction, it cannot
rials have been introduced. Detailed information be reversed back to the sol state as can agar hydrocol-
about reversible (agar) hydrocolloid can be found loid. It is a fairly rapid chemical reaction, so trisodium
on the Evolve website at www.evolve.elsevier.com/ phosphate is added as a retarder to delay the reaction.
Hatrick/materials. The amount of retarder that is added will control the
time of the set and will differentiate between fast- and
IRREVERSIBLE HYDROCOLLOID (ALGINATE) regular-set alginates. Diatomaceous earth is added as
Alginate, also called alginate hydrocolloid or irreversible a filler to increase stiffness and strength and to pre-
hydrocolloid, is by far the most widely used impression vent the surface from being sticky. Potassium sulfate
material. It is inexpensive, easy to manipulate, requires is added to keep the alginate from interfering with the
no special equipment, and is reasonably accurate for set of the gypsum products used to pour the impres-
many dental procedures. Alginate is used for mak- sion. Some manufacturers have added chemicals to
ing impressions for diagnostic casts, partial denture the alginate that change color as the chemical reaction
frameworks, and repairs of broken partial or complete progresses to indicate when it is time to insert the im-
dentures, as well as for fabrication of provisional res- pression, and the color changes again when it is time to
torations, fluoride and bleaching trays, sports protec- remove the impression.
tors, preliminary impressions for edentulous arches,
removable orthodontic appliances, and a multitude of Working time. Regular-set alginates have a working
other uses. However, it is not accurate enough for the time (from start of mix to seating in the mouth) of 2 to
final impressions for inlay, onlay, crown, and bridge 3 minutes, and fast-set alginate has a working time of
preparations. It does not capture the fine detail of the 1.25 to 2 minutes (American Dental Association [ADA]
preparation needed for a precise fit of such restora- specification no. 18 sets the minimum at 1.25 minutes).
tions. Also, it is thick and does not flow well into em- The longer the time used to mix the alginate, the faster
brasures or occlusal surfaces. Final impressions are it must be loaded into the tray and seated in the mouth.
made with more accurate materials such as one of the
elastomers (polyvinyl siloxane or polyether). Final Setting time. Regular-set alginates set in 2 to 5 minutes,
impressions are used to make detailed replicas of the and fast-set alginates set in 1 to 2 minutes. Setting time
332 CHAPTER 15 Impression Materials

TABLE 15.1    Composition of Alginate Impression Material

MATERIAL PERCENTAGE (APPROXIMATE) PURPOSE
Sodium or potassium alginate 15%-20% Colloidal particles as basis of the gel
Calcium sulfate dihydrate 14%-20% Creates irreversible gel with alginate
Potassium sulfate 10% Ensures set of gypsum materials
Trisodium phosphate 2% Retarder to control setting time
Diatomaceous earth 55%-60% Filler to increase thickness and strength
Other additives: Very small quantities
•  rganic glycols
O To reduce dust when powder is handled
• Flavoring agents To improve taste of material
• Coloring agents To provide pleasant colors
• Disinfectants To cause antibacterial action

can be lengthened by using cold water or shortened disinfected (Procedure 15.6), wrapped in a damp (not
by using warm water. Adjusting the powder-to-water dripping wet) paper towel, and sealed in a zippered
ratio can affect the set but also adversely affects the plastic bag. (An alternative to wrapping in a damp pa-
physical and mechanical properties and therefore is per towel would be to put a few drops of water in the
not recommended. It is advisable to leave the impres- plastic bag. Alginate could imbibe water from a towel
sion in the mouth for an additional minute after it ap- that is very wet and swell.) Enclosing the impression this
pears set, because the tear strength and the ability to way will create an environment with 100% humidity to
rebound from undercuts without permanent deforma- minimize water loss from the alginate. Some moisture
tion increase during this time. will be lost from the impression even in 100% humid-
ity from syneresis. Syneresis occurs with many gels that
Clinical Tip
are left standing, whereby they contract and some of the
For patients with sensitive teeth, alginate mixed with cool liquid is squeezed out of the gel, forming a wet film on
water can be painful. Use regular-set alginate with warm the surface. This loss of water changes the properties of
water. The working and setting times will be shortened, but
the material. Ideally, the impression is poured after it
the patient will be more comfortable.
is disinfected. If the impression must be stored until it
can be poured a few hours later, then it must be kept at
100% humidity (as with the zippered plastic bag and a
Important Properties of Alginate few drops of water). The longer that pouring is delayed,
Permanent deformation. Alginate will be compressed the more likely that some distortion will occur in the
when it is removed from undercuts in the mouth. The alginate.
greater the compression, the more likely it is that the al-
ginate will be permanently deformed to some degree. Tear strength. The tear strength of alginate is more
A certain thickness of alginate (2 to 4 mm) is needed important than its compressive strength because most
between the impression tray and the teeth or tissue un- commercial alginates far exceed the minimal allowable
dercut; alginate that is too thin will deform more and value for compressive strength. Alginate mixed with
will tear more easily. As with reversible hydrocolloid, too much water will be weaker and more likely to tear
when an alginate impression is removed it should be on removal from the mouth. Thin sections of alginate
done with a rapid “snap” to prevent the deformation of are also prone to tearing. In addition, slow removal of
critical surfaces. If 8 to 10 minutes are allowed to elapse the alginate from the mouth will contribute to tear-
from the time an alginate impression is removed from ing. If the impression can be left in the mouth for an
the mouth until pouring the model, some recovery or additional minute beyond the point when it is set, it
rebound will occur from the deformation. That defor- will increase in tear strength. When properly handled,
mation which does not recover is the permanent deforma- alginate has adequate tear strength for most purposes
tion, and it will be recorded in the poured gypsum cast for which it is used. Some alginates have silicone poly-
as a distortion. As long as the distortion is small, it may mers added to increase the strength.
not be clinically significant. Usually, the time needed for
disinfecting the impression is at least 10 minutes, and MAKING ALGINATE IMPRESSIONS
most of the rebound will have occurred by then. Objective
The objective of impression making is to reproduce the
Dimensional stability. Alginate is very sensitive to mois- oral structures with acceptable accuracy while prac-
ture loss and will shrink as a result. Once the impres- ticing good infection control and maintaining patient
sion is removed from the mouth, it should be rinsed and comfort. The dental assistant and the dental hygienist
 Impression Materials CHAPTER 15 333

can make alginate impressions. They will need to pre-

pare the patient for the impressions and to dispense,
mix, and load alginate into trays. After removal of the
impression, the assistant or the hygienist disinfects
and properly handles the impression until it is poured
with the appropriate gypsum material. She also may
be responsible for clearing residual alginate from the
mouth and face of the patient.

Tray Selection
Stock trays work well with alginate because they pro-
vide plenty of room for an adequate thickness of algi-
nate. Alginate must be tightly adapted to the tray to
be accurate. If the alginate pulls loose from the tray, a
distortion will occur. If a tray is set on the bench top,
unsupported alginate extending from the back of the
tray may lift a portion of the impression and dislodge
it from the tray. A perforated tray can be used because
the alginate oozes through the perforations and locks
into place. A solid tray can also be used if an adhesive
made for alginate (e.g., TAC, Bosworth) is applied to FIG. 15.5 Alginate packaged in bulk in a plastic drum or premeasured
packets equivalent to two scoops with many manufacturers. (Courtesy
the inside of the tray before the alginate is loaded. Solid
of Dentsply Sirona.)
rim-lock trays should also have adhesive applied be-
cause alginate will occasionally pull free from the rim-
lock on removal of the impression. If disposable plastic
trays are used, they should be rigid. Flexible plastic of the alginate. Powder measures (also called scoops)
trays have the potential to distort under the weight of will vary among manufacturers, so do not interchange
the wet gypsum during pouring or when used in areas them with other manufacturers’ scoops. The same
of undercuts in the mouth. principle applies to water measures.
A properly selected full arch tray will cover all of
the teeth and will extend into the facial and lingual
vestibules without impinging on the tissues. It will Clinical Tip
extend posteriorly to include the retromolar area for Water and powder measures can vary in size among
a mandibular tray and the hamular notch area for a manufacturers. If your office uses more than one brand
maxillary tray. It will be deep enough to provide at of alginate, color-code the measures so they are not
intermixed.
least 2 mm of space for alginate beyond the incisal
and occlusal surfaces of the teeth and wide enough
to allow approximately 5 mm of alginate between During shipping or prolonged periods of sitting,
the sides of the tray and the tissues. On occasion, the powder may pack tightly and some of the in-
standard stock trays will not cover all of the desired gredients may settle out, so that they are not evenly
areas for the impression and must be modified with distributed throughout the powder. Because of the
utility wax to create appropriate extensions of the compacting of powder particles, the amount of pow-
tray and support the alginate. A common area for der scooped will be greater than the manufacturer
this to occur is the third molar area of an individual intended when developing the measuring scoop.
with large jaws. Wax may also be added to the mid- When the compacted powder is incorporated into
palatal area of the tray to support the alginate when the recommended volume of water, the resulting
the patient has a very deep palatal vault (see Fig. mix will be too thick and will often set too rapidly. To
15.52, Procedure 15.2). Usually, the patient is asked prevent this from happening, containers of alginate
to rinse the mouth to remove loose debris and thick such as cans or plastic containers should be turned
saliva before the impression is made. An antimicro- end-over-end a few times to decompress (fluff) the
bial rinse may be used to reduce the number of oral powder and mix the ingredients. Some alginates
pathogens. are supplied in premeasured, watertight packages
with a quantity suitable for a medium-sized arch
Dispensing (equivalent to two scoops with most manufactur-
Manufacturers supply measures for powder and wa- ers) (Fig. 15.5). This packaging is more expensive,
ter for their alginates. Use the appropriate ones and but some practitioners find it to be convenient, to
adhere to the recommended proportions of powder provide a more consistent mix, and to minimize
and water to maintain the desired physical properties cross-contamination.
334 CHAPTER 15 Impression Materials

Caution mixing with the other. Some offices use mechani-

cal mixing machines for rapid mixing, ease of use,
Be sure to wear a mask while dispensing and mixing
and a consistent mix (Fig. 15.6). The rubber bowl
alginate. Alginate dust is potentially hazardous to inhale
because it contains silicon dioxide in the diatomaceous is attached to the mechanical mixer that spins the
earth fillers, as well as other chemicals. Using dustless bowl. With both mechanical and hand-mixing, the
alginate will minimize but not eliminate this risk. water-powder mixture is forced against the sides of
the bowl to further incorporate the powder into the
water and to force out entrapped air. Mixing should
Mixing. For a moderate to large upper adult arch, be completed within 45 seconds for regular-set algi-
three scoops of alginate powder are usually required; nate and within 30 seconds for fast-set alginate. The
a small upper arch requires two scoops. Most adult completed mix should have a creamy consistency
lower arches require two scoops. One unit of water (see Fig. 15.6, C). If it appears grainy, it has not been
is required per scoop. Typical water measures are mixed thoroughly.
marked to indicate up to three units. Room tempera-
ture tap water is placed in the rubber bowl, and the Loading the tray. Mixed alginate is picked up on the
powder is added to it. Cold water retards the set, and spatula and pushed into the depth of the tray. This
warm water accelerates it. The powder is stirred into action forces out air, thus preventing large voids
the water so that the powder becomes wet. Next, the in the impression. The alginate should be loaded
wet powder is aggressively mixed against the sides in large increments as quickly as possible. Using
of the bowl with a wide-bladed spatula. Some op- a small number of large increments reduces the
erators prefer to rotate the bowl in one hand while chance for entrapped air. The tray should be loaded

C
FIG. 15.6 Mechanical mixer used to mix alginate for an impression A. Mechanical mixer with water measure and spatula
B. After water is added to the powder in the bowl, a spatula is used to wet all of the powder C. Spatula presses the
wet powder against the rotating bowl until a smooth, creamy mixture is achieved (From Powers JM, Wataha JC: Dental
Materials: Properties and Manipulation (ed 11). St. Louis, 2017, Elsevier.)
 Impression Materials CHAPTER 15 335

FIG. 15.7 Mandibular tray seated and patient has lifted the tongue to
allow alginate to flow into the lingual vestibule and to shape the lingual
FIG. 15.8 To place the maxillary impression the right-handed operator
frenum attachment. (Courtesy of Gwen Essex.)
stands in the 11o’clock position (1 o’clock position for left-hander) and
retracts the right corner of the mouth with the side of the tray while
until the alginate is even with the top of the sides retracting the left corner of the mouth with the mirror or index finger
of the tray. A wet, gloved finger is used to smooth of the other hand. (From Robinson DS, Bird DL: Essentials of Dental
Assisting (ed 6). St. Louis, 2017, Elsevier.)
the surface of the alginate and to create a shallow
trough over the ridge area of the alginate (see Fig. the positions and stand at the 1 o’clock position, re-
15.54 in Procedure 15.2) that reduces the chance for tract the left corner of the mouth with the side of the
entrapped air and helps to orient the tray over the tray and retract the right corner of the mouth with a
teeth when it is seated. mirror or index finger of the other hand. The tray is
rotated into position, aligned over the teeth, centered
Seating the tray. Once the tray is loaded, the operator with the midline, seated in the posterior first, and gen-
should take some alginate from the bowl on the gloved tly seated toward the anterior to allow alginate to flow
index finger and wipe it on the occlusal surfaces and forward and not back into the palate. Trays can also
embrasures of the teeth to force air out from the oc- be placed while the patient is in the supine position. A
clusal grooves and embrasure spaces. If regular-set al- right-handed operator can seat the lower tray from the
ginate has a 2-minute working time and the alginate 8 o’clock position and the upper tray from the 11 or 12
was mixed for 45 seconds, the operator has 75 seconds o’clock position, and left-handed operators from com-
to load the tray, wipe the alginate on the teeth, and seat parable positions on the opposite side (4 o’clock for
the tray. For fast-set alginate, the operator has about 45 lower and 12 or 1 o’clock for upper). The patient should
seconds for the same process after mixing for 30 sec- be seated upright after the tray is placed to minimize
onds. On warm days, the tap water may be warmer the collection of saliva and alginate at the back of the
than usual and may accelerate the set. Conversely, on throat. For both upper and lower impressions, the pos-
cold days, cooler tap water may retard the set. terior aspect of the tray should be inspected for proper
For the lower impression, the operator is usually seating and for excess alginate. Excess alginate should
standing in front of the patient to one side at approxi- be swept away quickly with the mouth mirror or a cot-
mately the 7 o’clock position for right-handers and ton swab to prevent a gagging or breathing problem
5 o’clock for left-handers. The right side of the tray for the patient.
is used to retract the left corner of the mouth, and a
finger or mouth mirror retracts the right corner (op-
posite sides for left-handers) (see Fig. 15.55 in Proce- Clinical Tip
dure 15.2). The tray is rotated into the mouth, aligned Controlling the gag reflex:
over the teeth with the tray handle in the midline, and 1. Place topical anesthetic on a cotton swab, and put it on
seated in the posterior first. The tray is then seated in the back of the tongue for 1 to 2 minutes, or spray the
the anterior, and as it is being seated over the incisors, back of the mouth with topical anesthetic spray.
the lower lip is pulled out of the way to allow alginate 2. Place utility wax on the posterior extent of the upper
tray to help contain the material.
to flow into the anterior vestibule. The patient is asked
3. Use fast-set alginate. Accelerate the set with warm wa-
to lift the tongue to the roof of the mouth momentari- ter, if you can work fast enough to load and seat the tray.
ly and then to relax it (Fig. 15.7). This tongue motion 4. Properly proportion the water and powder so that the
allows alginate to flow into the lingual vestibule and mix is not too runny.
defines the lingual frenum attachment. The tray is sta- 5. Do not overfill the tray.
bilized by the index and middle fingers of the right (or 6. Seat the tray in the posterior first, then anterior. Look at
left) hand over the right and left sides of the arch. the palatal area and clear excess material with a quick
The procedure is similar for the upper arch with sweep of the mouth mirror.
the following modifications. A right-handed operator 7. Position the patient’s head forward slightly so that saliva
stands just behind the patient at the 11 o’clock posi- will not pool in the back of the throat, and use a saliva
tion and retracts the right corner of the mouth with ejector to keep the mouth clear.
8. Use distraction (e.g., have the patient lift one leg during
the side of the tray while retracting the left corner of
the impression and hold it up, and breathe slowly and
the mouth with the mirror or index finger of the other deeply through the nose).
hand (Fig. 15.8). Left-handed operators should reverse
336 CHAPTER 15 Impression Materials

Removing the tray. Alginate left in the mixing bowl

can be checked for completeness of set. The impression
should be left in the mouth for approximately 1 minute
after the set, because it gains in tear strength during this
time. This may not be possible with patients who gag
easily. When you are ready to remove the tray, use a fin-
ger at the top of the side of the tray to apply pressure to
break the seal while pulling the tray quickly away from
the teeth with a snap. Protect the teeth in the opposing
arch with fingers placed on top of the tray.

Handling the impression. The impression should be

rinsed thoroughly under running water to remove ad-
herent saliva. Next, it should be evaluated to determine
whether the impression is acceptable for its anticipated
use. If determined to be acceptable, the impression is
held inside a plastic bag (to prevent the inhalation of dis-
infectant spray) and sprayed with a suitable disinfecting
solution. An alternative to spraying the impression is to
immerse it for 10 minutes in a suitable disinfectant. Im-
mersion for up to 30 minutes in 1% sodium hypochlorite
or 2% glutaraldehyde has been shown not to significant-
ly affect the dimensions (by swelling) or surface detail of
alginate.
A laboratory knife is used to remove excess, unsup- FIG. 15.9 Acceptable upper and lower alginate impressions that have
ported alginate from the back of the tray. Any pooled met the established criteria. (Courtesy Dr. Steve Eakle.)
fluid is drained or shaken off because the alginate can im-
bibe moisture and swell. It is placed into a zippered plas- TWO-CONSISTENCY ALGINATE SYSTEM
tic bag labeled with the patient’s name with a few drops A relatively new development with alginate is a two-
of water or a damp paper towel until ready to pour (Fig. consistency system (AccuDent XD, Ivoclar Vivadent).
15.59, Procedure 15.2). Ideally, the impression should be Compatible alginates with two different viscosities
poured within an hour, because it is not dimensionally are used together to make impressions with improved
stable. accuracy and surface detail. This combination is par-
ticularly useful for complete and partial denture im-
CRITERIA FOR CLINICALLY ACCEPTABLE
pressions. The light-bodied gel flows well from the
ALGINATE IMPRESSIONS
large diameter tip of the delivery syringe but does
Alginate impressions should be evaluated immediate- not slump. It is placed into the peripheral vestibule of
ly after they are removed from the mouth and rinsed. the upper or lower arch and acts as a border molding
The determination should be made at this point as to material. The thick tray gel completes the impression
whether or not the impression should be repeated, so of the remainder of the arch while supporting the sy-
it can be done while the patient is still seated and the ringe gel (Fig. 15.10). The two materials meld together
operatory is set up for it. An acceptable impression without seams. The tray material resists flowing and is
will cover all areas of interest (teeth, ridge form, mus- more likely to stay in the tray and out of the patient’s
cle attachments, palate, etc.). The structures should be throat avoiding the gag reflex in many patients.
recorded with sufficient detail to be clearly identified The two materials come in premeasured packaging
and should not have a grainy surface, which is usu- and they are fast setting. However, the syringe ma-
ally the result of inadequate mixing. There should be terial has a slightly longer setting time to allow it to
minimal voids caused by entrapped air, especially in be mixed first, loaded into the syringe and put aside
areas critical to the use of the impression (e.g., occlu- while the tray materials is mixed and loaded into the
sal surfaces if a night guard will be made). The al- tray. The tray material undergoes a color change to in-
ginate should be fully seated in the tray and should dicate when setting has started.
not have pulled free or distorted (Fig. 15.9). The im-
pression should be free of debris. Table 15.2 lists cri-
teria used to assess an alginate impression for clini- ELASTOMERS
cal acceptability. When problems are found with an Elastomers are highly accurate elastic impression ma-
impression, refer to Table 15.3 for a troubleshooting terials that have qualities similar to rubber and hence
guide that suggests possible causes and solutions for are often called rubber materials. They are used exten-
a variety of problems. sively in restorative dentistry for fabrication of metal
 Impression Materials CHAPTER 15 337

  Criteria for an Acceptable Alginate castings, ceramic restorations, bridges, implant res-
TABLE 15.2 torations, partial denture frameworks, and complete
Impression
dentures. The four types of elastomers are as follows:
Both Maxillary and Mandibular Impressions
• Polysulfides
All teeth and alveolar processes recorded • Condensation silicones
Peripheral roll and frenums included
• Addition silicones (polyvinyl siloxane)
No large voids and few small bubbles present
• Polyethers
Good reproduction of detail
Free of debris The two most widely used elastomers are polyvinyl
No distortion siloxane (PVS) and polyether. More recently a hybrid ma-
Alginate firmly attached to tray terial, vinyl polyether, has been introduced that combines
Maxillary Impression the best properties of polyethers and polyvinyl siloxane.
The elastomers share a general formulation that in-
Palatal vault recorded
cludes a flexible matrix which contains filler to re-
Hamular notch area included
duce the effects during setting that polymerization
Mandibular Impression
shrinkage has on dimensional stability and accuracy.
Retromolar areas included They also have in common a polymerization reaction
Lingual extensions recorded that involves formation of long-chain polymers and

TABLE 15.3    Troubleshooting Alginate Impressions

PROBLEM CAUSE SOLUTION
Premature set Too much powder in mix Fluff powder in container; use correct
Prolonged mixing/loading time measures for powder and water
Water or room too warm Use timer to gauge working time
Use cool water to slow the set
Slow set Water too cold Use warmer water
Too much water Use correct water/powder measures
Grainy, lack of surface detail Incomplete mix of powder and water Wet all of powder, and mix to creamy
consistency
Incomplete coverage of teeth or tissues Tray too small or too short for arch Select larger tray or extend borders with
Tray incompletely seated rope wax
Use a mouth mirror to check for com-
plete seating of the tray
Voids on occlusal surfaces Trapped air when tray is seated Wipe alginate on occlusal surfaces
before seating tray
Large voids at vestibule or midpalate Trapped air Place alginate in vestibule or palate
Not enough alginate in tray before seating tray
Improper seating of tray Use adequate amount of alginate
Lip in the way Seat tray in posterior first, allow alginate
to flow forward into vestibule, seat tray
in anterior
Pull lip out to create room for alginate
Small voids throughout Air trapped in mix during spatulation Press alginate against sides of bowl
when mixing with wide-blade spatula
to force out air
Distortion or double imprint Impression removed too soon Check residual alginate in bowl for set;
Tray moved while alginate was setting let stand an additional 1 minute
Hold the tray steady until set; do not
have patient hold the tray
Torn alginate Impression removed too slowly Remove impression quickly with a snap
Thin mix Use proper proportions of water and
powder
Excess alginate at back of tray Tray seated in anterior first, then poste- Seat tray in posterior first, forcing algi-
rior, forcing alginate out the back nate anteriorly
Tray overfilled with alginate Load tray level with sides
Create shallow trough for teeth
Remove excess alginate from the back
of the tray
338 CHAPTER 15 Impression Materials

FIG. 15.11 Adhesive is applied to the interior of the tray to aid in retain-
ing the elastomeric impression material. (From Rosenstiel SF, Land MF,
Fujimoto J: Contemporary Fixed Prosthodontics (ed 4). St Louis, 2006,
FIG. 15.10 Maxillary impression with the two consistency alginate system Elsevier.)
for a partial denture framework. The syringe material (orange) has been
used to establish the peripheral borders and to capture an imprint of the
rest seats for the framework. (AccuDent XD, Courtesy of Ivoclar Vivadent.)
when impression materials are able to capture the detail
of a tooth preparation when the surface is moist (but not
cross-linking of chains. Because they are not water submerged in water or saliva). It also means that wet
based, they are not as sensitive as the hydrocolloids to gypsum materials will flow better into the fine details of
water loss or imbibition (water uptake). The shelf life is the preparation when the impression is poured.
typically 12 to 18 months. Storage of these materials in Clinical Tip
a refrigerator will lengthen the shelf life. Stored mate-
Each type of impression material has its own specific tray
rials should be allowed to return to room temperature
adhesive. Do not use an alginate tray adhesive for an
before use unless an extended working time is needed.
elastomer. Likewise, do not interchange polysulfide adhesive
with an adhesive for polyvinyl siloxane or polyether material.
USE OF ADHESIVE
The rubbery nature of elastomers means that they do
not adhere well to solid metal or custom acrylic impres-
POLYSULFIDES
sion trays. An adhesive is placed in the tray to prevent
the set material from separating from the tray and caus- Polysulfides are the oldest of the elastomers and are
ing distortion (Fig. 15.11). Each type of elastomer has commonly referred to as “rubber base.” They are more
its own adhesive with which it is compatible; therefore dimensionally stable and have greater tear strength
adhesives should not be interchanged among different than alginate or agar hydrocolloids. They are more ac-
types of materials. The tray adhesive should be applied curate than alginate but not as accurate as the other
in a thin layer and allowed to dry. If the adhesive is not elastomers. Polysulfides have been used successfully
applied well in advance of use of the tray, then a stream for crown and bridge impressions and for partial and
of air can be used to accelerate the drying process. complete denture impressions. They cannot be used in
automixing cartridges and must be hand mixed. They
ELASTIC RECOVERY are messy and have an unpleasant sulfur odor. When
Because of their rubbery nature, elastomers have a cer- polyethers and polyvinyl siloxanes came on the mar-
tain amount of elastic recovery, or “rebound,” from de- ket, most practitioners abandoned the polysulfides for
formation. Rebound reduces distortion in the cast that these more accurate, dimensionally stable, and pleasant
is poured from the impression. PVS impression mate- materials. Polysulfides are still used by some for im-
rial has the best elastic recovery of the elastomers. pressions for complete dentures. Detailed information
for the polysulfides can be found at the Evolve website
WETTABILITY at www.evolve.elsevier.com/Hatrick/materials.
Elastomers generally are not wet well by water (and Clinical Tip
are therefore called hydrophobic), because water forms a
Alginate can be used in a moist field, because it is hydrophilic.
high contact angle with them (see Fig. 5.2 in Chapter For the most part, elastomers are hydrophobic. Polyethers
5 Principles of Bonding). In other words, water beads are the most hydrophilic of the elastomers and are more
on their surface much like raindrops on a newly waxed forgiving of a little moisture, but not to the degree of the
car. Of the elastomers, the polyethers are the most hy- hydrocolloids. A well-isolated field for elastomers is essential.
drophilic, or wettable. Wettability can be seen clinically
 Impression Materials CHAPTER 15 339

SILICONE RUBBER IMPRESSION MATERIALS (deformation when subjected to a load after setting).
Two types of silicone impression materials have been This accounts for their accuracy even after repouring.
developed and are named according to the type of
polymerization reaction they undergo during setting: Hydrophobic Nature
condensation reaction or addition reaction. PVS impression materials are hydrophobic by nature and
must be used in a dry field. A little moisture on the pre-
Condensation Silicone pared tooth will result in loss of surface detail in the im-
Condensation silicone was developed in the 1960s as pression, because the impression material cannot displace
an alternative to the messy, smelly polysulfide and was the moisture and establish close contact with the surface
first used in the 1960s is useful for crown and bridge (it has a high contact angle and low wetting of the surface).
procedures. It has more desirable characteristics than Some PVS materials are called hydrophilic by their
polysulfide, such as ease of mixing, pleasant taste, no manufacturers, but in actuality they are hydrophobic
odor, and shorter working and setting times. The mate- materials to which a wetting agent (a soaplike surfac-
rial sets through a condensation reaction that produces tant) has been added, so that they can tolerate the pres-
ethyl alcohol as a by-product. The ethyl alcohol is rap- ence of a small amount of moisture. In a newly placed
idly lost by evaporation, leading to a relatively high impression it takes several seconds for the surfactant
dimensional instability from shrinkage. Condensation to move to the surface. Initially, the material is not hy-
silicones have been replaced by the more accurate and drophilic when it first contacts the teeth and tissues
stable addition silicones. but becomes more moisture tolerant as the surfactant
rises to the surface. This delay in the emergence of the
Addition Silicone surfactant means that the preparation needs to be dry
The addition silicone impression materials were intro- when the wash material is placed. However, the set
duced in the 1970s and are an improvement over the impression will be more receptive to pouring with die
condensation silicone materials. Their properties pro- stone.
vide greater dimensional stability and accuracy. They
are clean and easy to use, with no foul odor or taste. As Viscosities of the Material
a result of these improvements, they have become the PVS is manufactured in light, extra light, regular (or mono-
most popular materials for crown and bridge proce- phase), and heavy viscosities. A monophase viscosity is
dures. They are also among the most expensive of the available from most manufacturers that is used as both a
impression materials. tray material and a syringe material. It is not as viscous as
the tray material but is thicker than the light body mate-
POLYVINYL SILOXANE (VINYL POLYSILOXANE) rial, yet it flows well enough to be used in a syringe to be
Polyvinyl siloxane (PVS) or vinyl polysiloxane (VPS) is injected around a tooth preparation. Some PVS materials
an additional silicone impression material that under- are also available in a two-part putty form, consisting of
goes a polymerization reaction of chain lengthening base and catalyst putty. Powdered silica is added as a filler
(called an addition reaction) and cross-linking with reac- to give thickness to the base or catalyst pastes or putties.
tive vinyl groups that produces a stable silicone rub-
ber. The addition reaction does not produce a liquid Surface Detail
by-product that can evaporate and cause shrinkage as The accuracy of an impression material is measured
with the condensation silicones. PVS has the smallest by how well it captures the surface detail of a struc-
dimensional change (0.05%) on setting of the elasto- ture. To capture the surface detail the material must
mers and hydrocolloids. PVS materials have high elas- wet (have a low contact angle) and flow over the sur-
tic recovery after removal from undercuts, and they face well. Low-viscosity materials (wash/syringe ma-
resist tearing (high tear strength). terials) wet and flow better than high-viscosity (tray/
Some PVS materials produce hydrogen gas through heavy body) materials and, therefore capture more
a secondary reaction. If the impression is poured dur- detail.
ing the first 2 hours when the hydrogen is being re-
leased, the cast that results will have a very porous Dispensing System
surface and will be unsuitable for most procedures. To The most popular dispensing system for the light, extra
counter the release of hydrogen, manufacturers have light, regular, monophase, and heavy materials involves
incorporated scavengers such as palladium powder, to a cartridge with two chambers—one with base and one
absorb the hydrogen before it gets to the surface. with catalyst. A mixing tip fits on the end of the car-
PVS impressions can be poured in stone several tridge (Fig. 15.12). A hand-operated gun-type dispenser
times and are dimensionally stable for a least a week or a motor-driven dispenser (see Fig. 15.16) pushes both
without distortion. For this reason, many practitioners the base and the catalyst through the mixing tip at the
will send the impression with a prescription to the den- same time. They pass through an intertwined spiral
tal laboratory, where the impression may be poured that mixes appropriate amounts of each material to-
several days later. The PVS materials exhibit little flow gether thoroughly by the time they exit the end of the
340 CHAPTER 15 Impression Materials

tip. These mixing devices ensure the proper ratio of the approximately 2 minutes (fast set) to 6 minutes (reg-
two materials without the creation of bubbles or voids, ular set). The working and setting times are affected
which are common with hand-mixing. It is important by temperature. On a warm day the materials may set
for the operator to make certain that the orifices of the faster. Working and setting times can be increased by
cartridges are cleaned of any residual set material that refrigerating the material before use.
might block the flow of base or catalyst before applying Some newer materials (e.g., Imprint 4 VPS Super
the mixing tip. Otherwise, proper proportions of base Quick; 3M ESPE) have been introduced with a setting
and catalyst may not be mixed. time of 75 seconds. To achieve this fast set a chemi-
One manufacturer (Dentsply Sirona) packages cal reaction occurs after the working time has passed
the wash material in a small unit dose called a digit that warms the material quickly to body temperature,
(see Fig. 15.12). The digit has enough material for which accelerates the set.
a single unit restoration and has a shorter, smaller
mixing tip to minimize waste. The digit is mounted
in a palm-sized syringe and the material is delivered Putty/Wash Techniques
directly to the preparation. There is also a larger Some clinicians like to use putty for the tray material and
digit available with enough material for about three a light body wash material to syringe around the pre-
preparations. pared teeth. They feel that with subgingival margins on
the preparations, the stiff putty causes hydraulic pressure
Clinical Tip
that forces the wash material into the gingival sulcus to
Before placing the automixing tip on the impression better capture the margins in the impression. These mate-
cartridge, express a small amount of the material to make rials can be used with two different techniques.
sure the openings for the two chambers are not blocked by
set material.
One-step technique. With the one-step technique, the
putty is mixed and loaded into a tray by the assistant
while the operator injects the syringe material around
Working and Setting Time the prepared teeth. An indentation (about the size of
Because of the popularity of the PVS materials, manu- the prepared tooth) should be made in the putty in the
facturers have put much effort into improving their area of the preparation to allow wash material to cover
properties to make their products more appealing than the preparation without being displaced by the putty.
those of their competitors. The working time of PVS The tray is seated while the putty and syringe material
(from start of mix until it can no longer flow) is ap- are still unset, allowing them to bond together.
proximately 2 minutes. The setting time is the time
Clinical Tip
measured from the start of mix to the time the material
is hard and can be removed from the mouth. Setting With the one-step putty/wash impression technique, be
times have been adjusted so that the practitioner has sure to make an indentation into the putty in the area of the
preparation. Otherwise, the stiff putty will displace much of
an assortment of materials with fast or regular set. Set-
the wash material from the prepared tooth.
ting times vary among manufacturers and range from

FIG. 15.12 Polyvinyl siloxane impression material in a variety of viscosities (light, regular, heavy body) in cartridges with
mixing tip and mixing gun (top left) with unit-dose impression material (digit; Dentsply Caulk/Dentsply International) in a
delivery syringe (bottom left) and putty (base and catalyst) in plastic jars (right).
 Impression Materials CHAPTER 15 341

Two-step technique. With the two-step technique, the Removing the set impression. First, determine that
putty in essence is used to create a custom tray within the impression materials are fully set. Removing the
a stock tray. In the first step, the putty is mixed and impression prematurely can cause distortion. Read
placed in a stock tray. It is seated over the teeth with a the manufacturer’s instructions on setting time. Im-
plastic sheet placed between the putty and the teeth to mediately after seating the impression, place a small
create room for light body material. Some practitioners portion of the tray and wash materials on the bracket
prefer to cut away some of the putty after it has set to table. When they have set, the materials in the mouth
create space for the light body material rather than us- should also be set because the heat of the patient’s
ing the plastic sheet. In the second step, light body ma- mouth should accelerate the set.
terial is syringed around the prepared teeth, and some Remove the impression quickly to minimize the
is injected into the space in the putty created by the potential for plastic deformation (permanent defor-
teeth. The tray with the putty is seated over the teeth. mation) of the impression. Removing the impression
causes it to be stretched and compressed. The gingival
Caution
sulcus, interproximal areas, and areas of undercuts will
With the two-step putty/wash technique, putty should not produce the most stretching and compression. Elas-
show through the wash material in the impression of the tomers handle this stress best if applied quickly and
preparation. Show-through areas are pressure spots where
released. So, quick removal of the tray applies stress
the preparation hit the putty. The putty will compress while
quickly and allows it to release without deforming.
the tray is in the mouth, and then rebound after the tray is
removed. This will cause distortion in the impression. However, it takes a few minutes for complete recov-
ery to occur. For PVS materials it is best to wait 20 to
30 minutes before pouring the impression. Prolonged
Potential putty/wash distortions. Both one-step and stretching or compression will produce permanent dis-
two-step putty techniques can result in distortions tortion and result in an inaccurate cast or die.
in the impression if care is not taken. Because putty
does not flow well, the one-step technique may result Bite registration. A registration of the patient’s bite is
in voids or a pulled appearance of the wash material typically made using elastomers (PVS or polyether) or
when wash and putty do not flow and join together wax.
completely. With the two-step technique, because the PVS bite registration. PVS is used for bite registration
putty is set before the wash is added, any areas where because of its accuracy, dimensional stability, and ease
the putty shows through the wash material potentially of use. It offers no resistance to biting down; therefore
have distortion. The flexible set putty may have been it does not risk shifting the direction of the patient’s
compressed by contact with tooth structure and then bite as a hard material might. It can be used for this
rebounded to its original shape when the impression purpose in two ways:
was removed from the mouth. This is particularly crit- 1. Most practitioners prefer to use automatic mixing
ical if it occurs in the area of the prepared tooth. To cartridge systems and to inject material from the
avoid these problems with putty, some clinicians use mixing tip directly onto the occlusal surfaces of the
a one-step technique in which putty has been replaced mandibular teeth. They then have the patient close
with a heavy body tray material that flows better. into centric occlusion (Fig. 15.13). Bite registration
materials are viscous materials that stay in place
Clinical Tip when applied to the occlusal surfaces of teeth. This
property makes it easier to register the bite and re-
PVS putty should not be mixed while latex gloves are worn. move the material from the mouth, because it has
Sulfur products from the gloves can interfere with the set
not slumped and flowed all over the teeth.
of the material. Washed hands covered with vinyl gloves
should be used.
2. Some practitioners use a bite tray (Fig. 15.2, D) that
is usually a disposable plastic frame with a gauze-
like material stretched between the arms of the
Putty used for a matrix. Putty also has many uses at frame. Material is dispensed on both sides of the
chairside and in the laboratory. Putty is used in many gauze, the frame is seated over the teeth, and the
offices to capture an imprint of a tooth before it is patient closes into centric occlusion until the mate-
prepared for a crown. After preparation, the imprint rial sets (see Procedure 15.4). The tray supports the
is used as a matrix to form a provisional (temporary) bite registration better than without it. These mate-
crown with tooth-colored acrylic resin. Many practi- rials are formulated with a rapid setting time of 1 to
tioners use the heavy body material in the tray instead 2 minutes. When set they are relatively stiff materi-
of putty; others select a monophase material to place als that exhibit very little flow under loading forces
in the tray and to syringe around the teeth. The mono- and remain dimensionally stable for at least a week,
phase material is formulated to have enough body to unlike wax bite registrations, which can warp after
stay in the tray, yet is fluid enough to inject around the removal from the mouth with temperature changes
teeth. It does not flow as well as the light or extra light or applied loads.
materials, however. Polyether can be used in the same manner.
342 CHAPTER 15 Impression Materials

be a mismatch between the PVS bite registration and a

cast made from an alginate impression. The differences
are particularly acute in the occlusal, buccal, and lin-
gual embrasure areas of the teeth. With PVS the embra-
sures will be sharply detailed and the PVS material will
flow deeper into the embrasures in the bite registration,
whereas with alginate the impression of the embrasures
will be more rounded and shallower because alginate
does not flow as well, and the cast will be lacking in
detail in those areas. When the PVS bite registration is
placed on the cast, it will not seat fully (Fig. 15.15). If
the opposing cast is mounted against the preparation
cast with that registration, then the bite will be propped
open and the crown will be high in the mouth.
A To prevent this mismatch problem, trim the bite reg-
istration with a scalpel to leave just an imprint of the
occlusal surfaces and about 1 mm beyond and remove
any sharp extensions of PVS into the occlusal embra-
sures. Also be sure to remove from the casts any blebs
(beads of stone) created by trapped air in the impres-
sion. Making these adjustments should allow the bite
registration to seat fully on the cast.

PVS alginate substitutes. Relatively inexpensive PVS

materials (e.g., AlgiNot [Kerr Dental], Algin-X [Dentsp-
B ly Sirona], and Counter-Fit [Clinician’s Choice Dental
Products]) have been developed as substitutes for al-
FIG. 15.13 Bite registration. A, Applying bite registration material to the ginates. They are much more dimensionally stable for
teeth. B, Patient closed into centric occlusion.
long periods and do not need to be poured right away.
Therefore, an impression of the opposing arch could
be sent to the laboratory with the final crown impres-
sion without worrying about it drying and distorting,
as with alginate. The PVS materials do not have to be
wrapped in wet paper towels to avoid moisture loss
and can be repoured several times. They have applica-
tions for diagnostic casts (study models) and as a ma-
trix for a provisional crown or bridge. Because they are
dimensionally stable, the matrix can be disinfected and
stored, in case the patient breaks the provisional crown
FIG. 15.14 Wax bite wafers. On the left is a wafer made by the heating or bridge and a new one needs to be made.
and folding baseplate wax and on the right is a preformed commer-
cially available wax wafer. Silicone die technique. Some practitioners use a spe-
cially formulated addition silicone material in an
Wax bite. Wax is a less expensive material used by automatic mixing cartridge system to make dies for
some clinicians to register the bite (see Procedure 15.5). indirect composite inlays. A tooth is prepared for a
Baseplate wax or utility wax can be softened by heat- composite inlay, and an alginate impression is made
ing and then folded several times into a wipe rope of the preparation. The silicone die material is injected
about 4 or 5 mm thick that is bent into the shape of an into the alginate impression, and it sets within 2 min-
arch (horseshoe-shaped). Premade horseshoe-shaped utes. That die can be used to prepare the composite
bite wafers are commercially available (e.g., Coprwax, inlay at chairside. The completed inlay is cemented
Kulzer and Bite Wafers, Hygienic) and come with or into the preparation with resin cement (see Fig. 6.20
without a thin aluminum foil between two layers of in Chapter 6 Composites, Glass Ionomers, and Com-
wax (Fig. 15.14). The foil prevents biting all the way pomers). This procedure is relatively quick. It saves
through the wax. the dentist a laboratory bill, the need to clean, disin-
fect and prepare an operatory for a second visit, the
Mismatch between PVS Bite and Cast from Alginate need to place and remove a temporary filling, and it
Impression. Because PVS material captures so much saves an additional trip and local anesthetic injection
more detail and flows better than alginate, there will for the patient.
 Impression Materials CHAPTER 15 343

A B
FIG. 15.15 Mismatch between cast made from an alginate impression and bite registration made with PVS. A, Casts not
fully seated in the bite registration in the molar area. B, Casts seated after trimming cast and bite registration.

Polyethers
Polyethers are elastic impression materials that came
to the European market in 1965 and gradually became
popular in the United States. They are very accurate
materials with good flow and tear strength and are ex-
cellent for use in crown and bridge procedures. They
are more hydrophilic than PVS. The hydrophilicity
gives polyethers good wetting properties for making
detailed impressions in the presence of a small amount
of moisture, making them particularly useful for im-
pressions of preparations with subgingival margins.
They do not release hydrogen gas and can be poured
immediately with gypsum products without the for-
mation of bubbles on the surface of the cast. They have
excellent mechanical properties with good elastic re-
covery, and they do not shrink. FIG. 15.16 Polyether impression material mixed and dispensed from
the mixing machine (Pentamix; 3M ESPE) directly into a tray.
Consistency and setting reaction. Polyethers are sup-
plied as light, medium, and heavy body viscosities. cartridges used in the automatic mixing guns and is
Equal lengths of material are dispensed from two un- more economical.
equal-sized tubes of base and catalyst onto a mixing
pad, or the materials are provided in cartridges with Properties. The original polyethers were the stiffest
auto-mixing tips, similar to the PVS materials. The of all of the rubber impression materials; as a conse-
base is a moderately low molecular weight polyether quence, they were difficult to remove from the mouth
with a cation reactive group. The catalyst contains aro- in the presence of undercuts. In 2000 newer formu-
matic sulfonic acid that reacts with ethylene terminal lations of polyether (e.g., Impregum Penta Soft; 3M
groups, which polymerize by a reaction that causes ESPE) were introduced that are much more flexible
rings of polyether copolymer to open and link together and have a more pleasant taste (Fig. 15.17). They are
in long chains. When they go through their final reac- easier to remove from the mouth, and it is easier to
tion, they set very quickly. The catalyst can cause skin separate the cast from the impression without break-
and tissue irritation. Therefore thorough mixing of the ing teeth.
base and catalyst is necessary to avoid any irritation of
the oral tissues. Block out undercuts. With all of the elastomers, un-
dercuts around bridge pontics, open embrasures
Mechanical mixing. In addition to tubes or cartridges, around periodontally involved teeth, large bony
both polyethers and PVS impression materials come in tori and fixed implant fixtures should be blocked
large pouches of base and catalyst that are placed into out with utility wax. This will prevent the impres-
a mechanical mixer (Pentamix; 3M ESPE) and deliv- sion material from flowing under them and locking
ered directly into the impression tray (Fig. 15.16). The the impression tray in the mouth (Fig. 15.18). It is
mixer handles a much larger volume of material than a very unpleasant experience for both the patient
344 CHAPTER 15 Impression Materials

and the practitioner to have locked-in impression Hydrophilic nature. Permanent deformation is low
trays cut apart with burs to remove them from the compared with the polysulfides but not as low as
mouth. that of the silicones. This material is somewhat hy-
drophilic, so it is more forgiving of a little moisture
Working and setting times. Polyethers have working on the preparation than polysulfides or polyvinyl
and setting times comparable to those of PVS materi- siloxanes. Also because of this hydrophilic nature,
als. Regular set materials have a working time of 2 to they must not be stored in water or disinfecting so-
3 minutes and a setting time (total time from start of lution, because they will swell from the uptake of
mix) of 5 to 6 minutes. In 2005, 3M ESPE introduced moisture.
fast setting polyethers (Impregum Penta Soft Quick Impressions from this material can be poured up
[monophase or medium body], Impregum Penta H repeatedly for up to a week and can be shipped to a
and Impregum Soft Quick Step Tray [heavy body], dental laboratory and remain dimensionally stable for
and Impregum Penta L DuoSoft Quick [light body]) up to 14 days if properly stored. Because polyethers
that can be dispensed from either cartridges or a mix- are hydrophilic, they do not need to be sprayed with
ing machine. For these fast set materials the working surfactant before they are poured with stone. The fact
time is 1 minute and the setting time is 4 minutes. Poly- that their polymerization does not produce volatile
ethers have a “snap” set, meaning that the initial vis- by-products contributes to their dimensional stabil-
cosity remains the same throughout the working time ity. Table 15.4 compares features of elastic impression
but changes rapidly during the remainder of the set- materials.
ting process.
VINYL POLYETHER SILICONE HYBRID
In the early part of the 2000s, a new class of elasto-
mers was introduced. The new material is a hybrid
of PVS and polyether. The purpose of the hybrid is
to obtain the best features of each type of material.
The material is composed of polyether and silox-
ane groups combined in a polymer. The polyether
component makes the material hydrophilic, so it can
tolerate a little moisture around the preparation and
can be poured easily without the need to spray the
impression with a surfactant. The siloxane compo-
nent provides dimensional stability and recovery
from deformation (caused by removal of the im-
pression from the mouth). The material flows well
and has high tear strength. It is available in regular
FIG. 15.17 Softer formulation of polyether impression material. Kit and fast sets and in five viscosities, including light
contains 3 cartridges of tray (heavy-body) material and a cartridge of
syringe (light-body) material, bottle of tray adhesive, mixing tips and and extra light, monophase, heavy, and rigid heavy
delivery tips that snap on to the end of the mixing tips. (Impregum Soft body. An example of this hybrid is EXA’lence (GC
Quick Step, Courtesy of 3M ESPE.) America).

A B
FIG. 15.18 Wax to block out undercuts. A, Teeth with gingival recession that has created large embrasure spaces where
impression material may lock in place. B, Soft, red utility wax placed in spaces to prevent impression material from entering.
 Impression Materials CHAPTER 15 345

TABLE 15.4    Features of Elastic Impression Materials

IMPRESSION SURFACE DIMENSIONAL TEAR ABILITY TO
MATERIAL COST DETAIL STABILITY STRENGTH EASE OF USE POUR WITHIN RE-POUR
Alginate Low Lowest Low Low High 1 hr No
Addition High High Highest Medium High 1 wk Yes
silicone
(polyvinyl
siloxanes)
Polyether High High High Low to me- High 1 wk Yes
dium

FIG. 15.19 A series of sizes of knitted gingival retraction cord (Ultrapak, Courtesy of Ultradent Products.)

COMPONENTS OF IMPRESSION MAKING FOR Retraction Cord

CROWN AND BRIDGE PROCEDURES Placement of gingival retraction cords is among the
most common methods of displacing the gingival tissue
Both dental assistants and hygienists frequently are away from the tooth preparation to create space for the
involved in the impression-making process. Those impression material. Cord placement should not cause
that are licensed in extended functions may actually damage to the gingival tissue or tear the epithelial at-
pack retraction cord, use astringents, and make the tachment of the gingiva to the root. It should produce
impressions for crowns and bridges. All of those in- mild lateral displacement of the free gingival tissue.
volved in assisting with the impression or with mak- Retraction cords come in a variety of forms and thick-
ing it need to be knowledgeable about the materials nesses. The cords can consist of twisted strands of cord
and the process. material, braided strands, or woven or knitted strands.
GINGIVAL RETRACTION The various thicknesses of the cord are numbered to aid
selection. Typically, the smaller the number, the smaller
Retraction of the marginal gingiva is often needed for the diameter of the cord. For example, 000 cord is very
impressions of teeth prepared for restorations such small and number 3 is very large (Fig. 15.19). Cords can
as crowns and bridges, especially when the prepara- also be plain or impregnated with an astringent.
tion extends subgingivally. The objective of gingival Bleeding should be controlled before attempting
retraction is to provide a space in the gingival sulcus to place retraction cords. Bleeding control can be ac-
of adequate dimensions to receive the wash (syringe) complished in several ways: (1) a local anesthetic con-
material so that the entire margin can be captured in taining epinephrine can be injected into each gingival
detail and at least 0.5 mm of the tooth (usually the root) papilla to constrict the blood vessels; (2) an astringent
beyond the margin. can be applied to the sulcus to stop the bleeding; or
(3) coagulation can be obtained with a laser or by
Methods of Retraction electrocautery.
There are several ways to achieve the desired space
in the sulcus for the impression material. Methods in- Prepacking the Sulcus
clude use of cord, retraction paste, or a minor surgical Bleeding caused by trauma to the gingiva from the bur
procedure with a laser or electrosurgery to produce a during preparation of the tooth can be minimized by
small trough in the sulcus. packing a cord of medium diameter before finalizing
346 CHAPTER 15 Impression Materials

FIG. 15.21 Cord packers with different degrees of offset of the blade
to the handle. (From Rosenstiel SF, Land MF: Contemporary Fixed
Prosthodontics (ed 5). St Louis, 2016, Elsevier.)

A
Clinical Tip
Bleeding of the gingival tissue is the number one reason
for an inadequate impression. It must be controlled before
attempting to make the impression.

Astringents/Hemostatic Agents
Astringents are topically applied chemicals that con-
strict tissues and are useful in gingival retraction.
Because they also constrict small blood vessels and
produce mild coagulation of blood, they are also he-
mostatic agents. They are commonly applied to the tis-
sues on a cotton pledget or on retraction cord, or are
scrubbed into the tissues with a cotton-tipped cannula
attached to a syringe (Fig. 15.22).
The two most common astringents/hemostatic
agents are aluminum chloride (Hemodent [Premier
B
Dental Products], Gingi-Aid [Belport], and ViscoStat
FIG. 15.20 Prepacking the gingival sulcus. A. Cord is being packed Clear [Ultradent]) and ferric sulfate (Astringedent or
into the gingival sulcus B. Cord is placed prior to an operative proce- ViscoStat; Ultradent). Racemic epinephrine (Orostat;
dure to place a restoration in the sensitive root abrasion lesion. It keeps Belport) is an effective astringent and vasoconstrictor
the gingival tissue away from the rotating bur and helps prevent bleed-
ing. (From Heymann H, Swift E, Ritter A: Sturdevant’s Art & Science of
but is used less frequently, because it can spike blood
Operative Dentistry (ed 6). St. Louis, 2013, Elsevier.) pressure and increase the heart rate. This can be po-
tentially dangerous for patients with hypertension or
the margins. The cord displaces the gingiva away from cardiac problems.
the tooth and provides some protection for it (Fig. Astringents and hemostatic agents used to control
15.20). It also begins the retraction process, making it bleeding in the gingival sulcus will adversely impact
easier to pack the cords for the impression. the surface detail of a PVS impression. Ferric sulfate
may also interfere with the set of the material. Astrin-
Cord Packing Instruments gents should be washed off the tooth before applying
There are many instruments designed for packing re- wash material.
traction cord. Cord packers are two-ended with each
end at a different angle to the other to allow placement Caution
of the cord all the way around the tooth. The degree of Racemic epinephrine should be used with caution for
offset of the angle of the blade to the handle can vary patients with hypertension or cardiac problems. Cord
among manufacturers (Fig. 15.21). Cord packers can soaked in racemic epinephrine and applied to the gingival
be smooth on the end or serrated. The packing blade sulcus can spike the blood pressure and increase the
should be thin enough to fit into the sulcus without heart rate!
damaging the tissue but not so thin that it cuts the tis-
sue. The type of cord packer selected is based mostly Two-Cord Retraction Technique
on operator preference. The tooth preparation should A gingival retraction technique using two cords has be-
have adequate separation from the adjacent tooth to come popular. A small cord is placed first in the sulcus.
allow the packer to access the sulcus. The function of this cord is to help control bleeding and
 Impression Materials CHAPTER 15 347

FIG. 15.23 Retraction cord improperly placed: Gingiva rests against

the tooth in one portion (lower right).

B
FIG. 15.22 Astringent is used to control bleeding gingival tissues prior
to making the impression (ViscoStat, Ultradent Products). A. Large
syringe of astringent is used to fill individual smaller syringes. B. Ferric
sulfate astringent is scrubbed into the bleeding tissue with a cotton-
tipped cannula to form blood clots over the capillaries.

minimize the flow of gingival fluid from the sulcus.

Often the first cord is dampened with an astringent be-
FIG. 15.24 Retraction cord has come partly out of the sulcus and rests
fore it is placed. Once it is in the sulcus any overlapping on the margin (upper left). The cord should be tucked back in the sul-
edges are cut so it fits end-to-end. The second (top) cord cus to ensure adequate retraction.
is larger in diameter and does the bulk of the retraction.
The largest cord that fits into the sulcus should be used. It they tend to float out of the sulcus and retraction will
should be placed so that it is at the level of the margin or be lost. Next, an inspection is made of the top cord. It
slightly apical to it. The top cord should have some over- should be at the level of the margin (unless the mar-
lap so that a “tail” of cord sticks out of the sulcus. This gin is supragingival) and should be visible 360 degrees
provides something easily grasped when the cord is to be around the tooth. If gingival tissue is leaning over the
removed. If the sulcus is very shallow, it may not be pos- cord, it should be retracted by placement of an addi-
sible to use two cords. In this case, an appropriately sized tional piece of cord or a cotton pledget in that area. The
single cord should be used to achieve retraction. cord should remain in place for approximately 5 to 8
minutes to achieve good retraction. Time is needed for
Evaluation of Cord Placement the cord to stretch the gingival fibers to relax the gingi-
Once the top cord is in place, cord placement should be va away from the preparation, and any astringent/he-
evaluated. First, the working field should be well iso- mostatic agent used needs time to produce hemostasis.
lated, and isolation should be maintained throughout Cord Retraction Checklist: Before proceeding to
the impression-making process. If the prepared tooth making the impression your checklist should include
is wet and the cords become wet, they will be slippery (1) good isolation, (2) no bleeding, and (3) cord at the
and very difficult to place in the sulcus. In addition, if level of the margin and visible entirely around the
isolation is not maintained after the cords are placed, tooth (Figs. 15.23 and 15.24).
348 CHAPTER 15 Impression Materials

Deeper cord 1st “Stop sign”

2nd “Stop sign” B

FIG. 15.25 Evaluation points (stop signs) for cord placement and gingi-
val retraction. Top: Prepared tooth before cord placement. Left: Small
cord placed to help control gingival fluids and bleeding. Right: Top cord
is placed to displace gingival crest away from the margins of the pre-
pared tooth. At this point cord placement is evaluated (1st “stop sign”).
Bottom: Top cord has been removed. At this point the retraction is
evaluated (2nd “stop sign”). If evaluation at either “stop sign” indicates
a problem, it should be corrected before proceeding to the next step.
(Courtesy of Dr. John Ino, University of California, San Francisco, CA.)

Evaluation of Retraction
While waiting for the cord to retract the gingiva, use C
this time to reorganize the working surface for making FIG. 15.26 Clay retraction material (Expasyl; Courtesy of Kerr Corporation,
the impression. Move aside any instruments and ma- Orange, CA) contains aluminum chloride astringent. A, Isolate, dry thor-
terials that are not needed for removing the cord and oughly, and inject material slowly into sulcus. B, Leave material in sulcus for
2 minutes. C, Wash material away and dry. Retraction has been obtained.
making the impression. Think about which part of the
preparation may be most difficult to access with the
wash material. Usually, this is the site to start syring- margin. If any of these criteria are not met, do not pro-
ing the wash material first. However, when working ceed! The odds are small that your impression will be
on maxillary posterior teeth with the patient supine, successful. Do not waste time and materials by trying to
start syringing on the distal surface. If you start on the force an impression in a site that is not ready. If there is in-
mesial surface, the wash material may flow by gravity adequate space, repack the cords and determine whether
over the rest of the preparation and obscure your view a larger cord is needed. If there is bleeding, pick up a sy-
of the distal surface and may also entrap air. ringe of astringent (ferric sulfate is a good one for this)
When you are ready to remove the top cord, damp- and scrub the tissues with the cotton-tipped applicator.
en the cord slightly so it does not stick to tissues and Rinse and dry the tooth, and look to see whether bleed-
cause bleeding when it is removed. Grasp the “tail” of ing has stopped. If not, you may need to inject (where
the cord with cotton forceps and gently peel the cord allowed by State Law) a local anesthetic with epineph-
out of the sulcus to minimize the risk of bleeding. rine into the papillae. If the bottom cord has lifted, pack
Now, evaluate whether or not the gingiva is adequate- it back down. Once these criteria have been met you are
ly retracted. You should be able to see a space between ready to start the impression process.
the gingiva and the margin. There should be no bleed- The width of the space created in the gingival sulcus
ing. The bottom cord should have remained apical to the after the cord is removed should be at least 0.3 to 0.4 mm.
 Impression Materials CHAPTER 15 349

A B

E
FIG. 15.27 Critical errors in an impression. A, A large void is present in the wall of the molar. The adjacent premolar impres-
sion has shiny rounded margins lacking detail from contamination with blood. B, A portion of the margin is missing. C, The
bottom cord from a two-cord technique was not packed apical to the margin and is caught in the impression of the mar-
gins. D, The set impression material has separated from the tray likely from inadequate tray adhesive. E, Facial (left molars)
and lingual (right molar and premolar) pulls of material. Syringe material was starting to set before the tray was seated.

A sulcus width less than 0.2 mm can cause distortion or See Fig. 15.25 for an illustration of “stop signs” or
tearing of wash material at the margin. Other reasons for evaluation points for cord placement and gingival re-
tearing of the wash material include the following: a very traction. The first “stop sign” is after placement of the
deep sulcus, bleeding that causes flaws in the impression cord. Evaluate its placement. The second “stop sign” is
material, sharp edges of the preparation, and roughness after removal of the top cord. Evaluate whether retrac-
of the preparation that increases the force needed to re- tion is adequate. Do not proceed with the impression
lease the impression material from the surface. until each step is adequately performed!
350 CHAPTER 15 Impression Materials

A B
FIG. 15.28 Examples of good impressions. A, Clear margins with “flash,” no voids, and fine detail. Adjacent structures are captured well. B, Bottom
cord has been retained in the impression but is not sitting on the margins. Good detail, no voids, and “flash” is present at the margins. (Courtesy of
Steve Eakle, University of California School of Dentistry [San Francisco, CA].)

Retraction Paste, Silicone, or Gel

Criteria for a Good Impression for
Alternatives to cord for gingival retraction are retraction
a Restoration
paste, silicone (PVS), or gel. The first of these materials
to be introduced was Expasyl (Kerr Dental); it is a clay- •  igid tray selected and tried in for fit and coverage
R
like material with aluminum chloride as an astringent. • Adhesive applied to tray
Other retraction pastes include Traxodent (Premier Den- • Material mixed well
tal Products), Retraction Capsule (3M ESPE), Access • Tray adequately filled with material
Edge (Centrix), and Dryz (Parkell). GingiTrac (Centrix) is • Impression free of voids, tears, pulls—no critical errors
• Fine detail of preparation, margins with “flash” (impres-
a PVS material that is placed in the sulcus, after which
sion beyond the margin)
the patient bites on a compression cap and the pressure • Accurate representation of other teeth and tissues in
causes retraction. Racegel is a gel produced by Septo- the impression site
dont. The materials are delivered to the gingival sulcus • Teeth do not contact tray
by way of a blunt needle cannula or a fine delivery tip
on a capsule, much like a composite resin delivery cap-
sule. The material displaces the gingiva laterally, and the Evaluating the Impression
astringent produces some tissue shrinkage and helps to Before attempting to evaluate an impression, it must be
control bleeding. The material remains in place a mini- rinsed to remove blood, saliva, and debris. The impres-
mum of 2 minutes, and then is rinsed out thoroughly and sion should then be thoroughly dried. Continue to wear
dried before placing the wash material (Fig. 15.26). gloves when handling the impression, because it has not
been disinfected yet. If magnifying loops are available,
MAKING THE IMPRESSION they should be used. Bring the operatory light over the
(See Procedure 15.3 for detailed instructions.) impression at about a 70-degree angle to the plane of the
teeth to cast a slight shadow on portions of the impres-
Criteria for a Successful Impression sion. These shadows will help you read the impression
A final impression made for a restoration such as a better than a bright light brought directly overhead. Ro-
full crown must meet certain criteria in order to be tate the impression to read all aspects of it. Ask your-
considered useable. First, the impression must cap- self the following: (1) Did the impression capture all of
ture the fine detail of the prepared tooth, especially at the teeth and tissues needed for the restoration? (2) Can
the margins. This is important so that the restoration I see the preparation clearly? (3) Is the margin visible
is sealed at its interface with the tooth. A lack of detail clearly all the way around the tooth? and (4) Has the
at the margins may result in an ill-fitting restoration impression captured at least 0.5 mm of the unprepared
with recurrent caries or continued tooth sensitivity. tooth just apical to the margins (producing a cuff of sy-
The impression should be free of voids, folds, pulls, ringe material that is often referred to as the “flash” ).
and tears. The impression should capture an accurate Some flaws may be present in the impression. Most
representation of the other teeth and tissues in the impressions are not perfect. It is important to know
impression site. If the impression is a double-bite im- which of the flaws represent critical errors (must re-
pression (using a triple tray), it should capture the op- make the impression) and which ones are minor errors
posing teeth and a representation of the patient’s ac- that will still allow the impression to be used for the
quired bite (where their teeth ordinarily fit together). fabrication of the restoration.
 Impression Materials CHAPTER 15 351

Critical errors include the following:

Factors That Limit Obtaining an Accurate
• A portion of the margins is missing or torn.
Impression
• The margins look shiny and rounded rather than
clearly demarcated. This is usually caused by moisture • S electing a poorly fitting tray
(blood, saliva, or fluid from the sulcus) on the margin. • Not using enough tray adhesive or not letting it dry
• A fold or crease is present in the margin or wall of adequately before loading the tray
the preparation. A fold occurs at the junction of two • Inadequate control of bleeding
portions of materials that do not flow together, for ex- • Incomplete retraction of the gingiva
• Selecting impression material for syringing that is too
ample, when syringing around the preparation with
thick to flow around the preparation or into the gingival
wash material, the material at the start and that at the sulcus
end of the circling process do not flow together. Surface • Using mixed impression material that is starting to set
tension along the two walls of material may not allow • Tearing of impression material on removal because
them to join. When syringing around the tooth, push the material is too weak or the sulcus was not opened
through the material first laid down with new material adequately and the material flowing into it was too thin
rather than stopping when the two ends meet.
• A pull (or drag) is present in the area of the preparation.
A pull occurs when the wash material starts to set before DIGITAL IMPRESSIONS
the tray is placed. When the tray is seated, the partially
set wash material is pulled or dragged by the heavy- You have learned in this chapter that traditional im-
bodied tray material. This represents a distortion. pression materials for crown and bridge procedures
• A large void is present in the preparation or the teeth are required to be dimensionally stable, accurate in
needed to articulate with the opposing cast to estab- reproducing fine detail, strong in tear resistance, suf-
lish the proper bite relationship. Any void, large or ficiently flowable, easy to remove, able to rebound
small, on the margin is a critical error. Voids on the rapidly from distortion, pleasing in taste and smell,
margins are often caused when the syringe tip los- and easy to disinfect and store. The impression pro-
es contact with the tooth surface. As the syringe tip cess is technique sensitive and often unpleasant for the
bounces away and comes back to the tooth, some air patient. Computer-assisted design/computer-assisted
is trapped in the wash material. A good resting point machining (CAD/CAM) dentistry (see Chapter 9 Den-
for the hand is needed to stabilize it while placing the tal Ceramics) introduced the capture of digital images
syringe material (such as a finger rest). of the preparation, adjacent structures, and oppos-
• Set impression material has separated from the tray. ing dentition and structures, and this process became
This will cause a distortion. known as the digital impression. The digital impression
• Lack of a good union between the heavy-body or removes many of the requirements and pitfalls of tra-
putty material used in the tray and the light-body/ ditional impressions.
syringe material placed around the teeth (often
caused by one material starting to set before the LEARNING CURVE
other material is placed) As with any new technology introduced into the dental
See Fig. 15.27 for clinical images of critical errors in practice, the use of digital impressions requires some
impression making thought as to how it will be incorporated into the prac-
Minor errors include the following: tice, who will use the intraoral scanner (the image cap-
• Small voids (<1 mm) not on the margin ture device), who will maintain it and how training and
• Small folds not on the walls or margins of the practice will occur. Team members will need time away
preparation from daily activities to receive training, and there is a
• A pull on buccal or lingual surfaces of teeth that are learning curve, so some accommodation must be made
away from the preparation to allow team members to practice the new techniques
• A slight separation of the material from the tray at before they can become proficient. Some manufacturers
a site not involving the preparation or teeth critical of the intraoral scanners provide training in the dental
to establishing the occlusal relationship with the op- office and others provide it at their headquarters. With
posing teeth. proper training, the dental auxiliary can perform image
Fig. 15.28 shows examples of acceptable impressions. capture and transmission of the images to the laboratory.
Most state dental boards have not yet regulated the use
Clinical Tip of intraoral scanners by dental auxiliaries. Check to see
When using the two-cord technique, the bottom cord if any regulations have been implemented in your state.
often will come out and be embedded in the impression Intraoral Scanning: Originally, intraoral scanning
(Fig. 15.30, B). Do not try to remove it! That may tear the cameras were part of a complete in-office CAD/CAM
impression into the margins. Simply cut off any loose ends. system. The digital images captured by the scanner
The remaining cord will end up in the cast and can be easily were used with computer software to design the res-
removed when a removable die is made. toration and the design file was sent to an in-office
352 CHAPTER 15 Impression Materials

milling unit to cut out the ceramic restoration. Later,

stand-alone scanners were developed that could cap-
ture the desired images and send the file to a labora-
tory for processing. Stand-alone scanners do not have
the capability to design the restoration, but some scan-
ning systems let the clinician mark the location of the
margins. Captured images can be transmitted through
a secure Internet portal to a commercial laboratory and
copies of the file stored on the computer as a part of the
dental record. Not all dental laboratories are equipped
for CAD/CAM processing, so there may be designat-
ed laboratories to which the images are transmitted.
Another variation is to send the images to a central A
processing center that makes the models from those
images and sends the models to a standard laboratory
where the restoration is made.

SCANNING DEVICES
Complete in-office CAD/CAM systems with digi-
tal scanners, computer with design software, milling
device and firing/glazing oven are available (e.g.,
CEREC AC [Sirona Dental Systems] and E4D Dentist B
[E4D Technologies]). Stand-alone intraoral scanners
are also available for those offices that are not inter- FIG. 15.29 Intraoral digital scanner used by the auxiliaries A. Obtained
ested in or not ready to embrace in-office fabrication of a digital impression and opposing arch. B. Virtual bite registration (A,
from Rosenstiel SF, Land MF: Contemporary Fixed Prosthodontics,
restorations. These scanning systems include CEREC ed 5, St Louis, 2016, Elsevier. B, from Powers JM, Wataha JC: Den-
AC Bluecam and Omnicam (Dentsply Sirona), Plan- tal Materials: Properties and Manipulation (ed 11). St. Louis, 2017,
meca Emerald (E4D Technologies), Lava Chairside Elsevier.)
Oral Scanner (3M ESPE), iTero Element (Align Technol-
ogy), CS 3500 and 3600 Intraoral Scanner (Carestream steadiness for a clear image (Fig. 15.29). Scanning times
Dental) and TRIOS 3 (3Shape).Most of the scanners are vary a little from system to system and range from
connected to the computing unit by a cord, but some about 3 to 8 minutes, depending on operator skills,
new scanners are cordless (e.g., Trios 3 Wireless Scan- the number of teeth being scanned, whether powder
ner, 3Shape). is needed, and the demands of the scanning unit.
Image Capture: Intraoral scanners all are handheld Correcting the Scan: Some units have an erase soft-
but their methods of capturing images differ. Older ware tool that allows the operator to erase a portion
scanners captured images by taking multiple still im- of a scan and rescan only that portion. Some clinicians
ages and stitching them together by software. Newer have their assistant scan the arch before the prepara-
scanners use streaming video to capture images of the tion and scan the opposing arch. (It could be done
teeth and surrounding structures. while the patient is getting numb.) The assistant erases
For most single restorations images are needed of the portion of the scan that has the unprepared tooth
the prepared tooth, adjacent teeth and opposing teeth. and then just scans the prepared tooth. The software
A buccal bite registration image is used by many scan- fills in the prepared tooth in the correct location. There
ners to establish the proper occlusal relationship, but is no need to redo the entire scan.
the type of bite registration may vary from scanner to Open or Closed Software Platform: Some manufac-
scanner. All scanning systems are capable of scanning turers have a closed software platform meaning
full arches, not just quadrants. that the scanned images can only be used with that
Use of Powder: Some systems require that the teeth manufacturer’s CAD/CAM products (design soft-
be coated lightly with an opaque powder (usually ti- ware and milling). The trend is for manufacturers
tanium oxide) to provide contrast for the best image to use open software platforms that allow images to
reproduction. The powder provides uniform reflective be transferred and milled on platforms produced by
surfaces so the camera can accurately record the many different manufacturers.
contours present in the preparations or teeth. Other From Table 15.5 with scanners from major manu-
systems do not need to use the powder because their facturers, the trend with the newest versions of in-
imaging mechanisms are different. traoral scanners is that they use continuous video to
Scanner Positioning: Some systems require that the in- capture images in full color without the use of pow-
traoral portion of the scanner with the camera portal be der and the captured images can be used with other
held just off the teeth when capturing the images where- manufacturers CAD/CAM chairside or laboratory
as others allow the scanner to rest on the teeth to increase equipment.
 Impression Materials CHAPTER 15 353

TABLE 15.5    Digital Impression Systems

USE WITH ANY
DIRECT IMAGE MANUFACTURERS’
TRANSMISSION TO PRODUCTS (OPEN
SYSTEM IMAGING CAPTURE COLOR IMAGE LABORATORY POWDER NEEDED PLATFORM)
CS 3600 Continuous video Yes Yes No Yes
(CareStream
Dental)
CEREC Omnicam Continuous video Yes Yes No Yes
(Sirona Dental
Systems)
Planmeca Emerald Continuous video Yes Yes No Yes
(E4D Technolo-
gies)
Lava Chairside Continuous video Yes Yes No Yes
Oral Scanner
(3M ESPE)
iTero Element (Align Continuous video Yes Yes No Yes
Technology)
TRIOS 3 (3Shape) Continuous video Yes Yes No Yes

Shade Taking: At least one scanning system incorpo- to a properly trained hygienist or assistant, allowing
rates shade taking with its ability to take digital intra- the dentist to perform other functions. When digital
oral photographs. The scanner takes the shades of the impressions are used in conjunction with an in-office
adjacent teeth during the scan of the prepared teeth milling device, the restoration can be completed in
eliminating the potential human error in interpret- one visit instead of two (see Fig. 9.3, Chapter 9, Den-
ing shades. The shades are mapped out on the images tal Ceramics).
at several locations and can be seen on the computer For the patient the impression process is easier,
monitor. This is a time saving feature since it elimi- particularly for those patients with a strong gag re-
nates separate steps for shade taking and writing a flex or severe tissue undercuts or tori. In addition,
shade description for the laboratory. the time needed for the completed restoration to re-
turn from the laboratory is shortened. The images
can be transmitted instantly, so the time needed for
ADVANTAGES AND DISADVANTAGES OF DIGITAL the laboratory to pick up the impression, pour it, cut
IMPRESSIONS out dies, and mount the casts in the proper occlusion
Advantages is eliminated. A few studies have been done compar-
In addition to not needing impression materials, there ing the accuracy of digital impressions to traditional
is no need for trays, adhesive, disinfectants, pouring impressions. The studies concluded that digital im-
impressions, and packaging impressions for trans- pressions were as accurate as or better than tradi-
port to the laboratory. A significant advantage is the tional impressions.
ability of the clinician to view the preparation mag-
nified on a computer monitor and see it from mul-
tiple angles by rotating the image. Undercuts, uneven Disadvantages
or rough margins, and areas of under-reduction can There are significant costs (between $15,000 and
be detected and corrected before the image is trans- $35,000 for stand-alone systems) involved in purchas-
ferred to the laboratory. The evaluation of the prep- ing a digital scanner and some training and practice
aration before sending the images to the laboratory that are needed to efficiently operate it. Laboratories
eliminates many potential errors that would result in charge a fee for processing digital images. The size of
remakes of the restorations. The images themselves the scanner may present a problem for patients with
can be reviewed and retaken if judged inadequate. In limited opening, but they would have problems with
many states this important function can be delegated traditional impressions as well.
354 CHAPTER 15 Impression Materials

Digital Impressions: Advantages and

Disadvantages
Advantages
• Creates permanent 3-D color pre- and post-
operative models which can be stored and reused
indefinitely and do not take up space in the office
• Digital images can be used to point out problems to
the patient and better communicate treatment needs
A
• At least as accurate as traditional impressions, pos-
sible better
• Does not need impression materials, adhesive, trays,
pouring impressions and packaging them for the lab
• The prepared tooth/teeth can be viewed on the
computer monitor and corrections can be made
before sending images to the lab or in-office milling
• Images can be sent to the lab instantly
• Scanning can be stopped and restarted at will (e.g.,
to control moisture) B
• Images can easily be re-made if necessary
FIG. 15.30 Model and die created from a digital scan that was sent to
• Images can be made by properly train dental auxilia-
a 3-D printer A. Digital scan of the quadrant with the crown preparation
ries in most states and opposing quadrant articulated by a digital bite registration B. CAD/
• Eliminates messy clean-up CAM ceramic crown is seated on the die (From Powers JM, Wataha
• More comfortable for the patient JC: Dental Materials: Properties and Manipulation (ed 11). St. Louis,
• Fewer adjustments needed on the restoration and 2017, Elsevier.)
fewer remakes
Disadvantages
• Cost of the scanner is significant of digital impressions, their applications have ex-
• Training and practice is needed panded beyond uses for traditional crown and
• There may be a fee for processing digital images bridge procedures. Many clinicians are applying
• Some scanners may be too large to fit in the most the technology to implant impressions for surgical
posterior regions of small mouths or patients with guides, custom abutments and crowns and for com-
limited opening plete denture impressions to produce digital models
• A very few manufacturers have closed-system soft- of the ridges and design software to fabricate den-
ware so that the scanner only works with their CAD/
tures. Applications for orthodontic impressions have
CAM systems
also being developed such as for orthodontic align-
ers and appliances. The models needed for these ap-
SOFT TISSUE MANAGEMENT plications can be milled from large blocks of acrylic
Although many of the components of traditional im- or generated from digital impression using software-
pressions are not needed, there is still a need for man- directed 3-D printers that spray fine acrylic particles
agement of the gingival tissues. If the margins of the in layers to build up the models to the desired form
preparation are all supragingival, there may be no (Fig. 15.30).
need for gingival retraction and likely there will be no
bleeding. However, most crown preparations involve Offices without Scanners
the replacement of old restorations where at least some For clinicians that do not have scanners in their of-
of the margins are at or below the gingival crest. The fices, there are still options to have CAD/CAM res-
digital image of the preparation needs to capture the torations fabricated. They can make a traditional
margins and approximately 0.5 mm of tooth apical impression and the laboratory can scan it to create
to the margin (comparable to the desired “flash” in a a digital impression or they can pour up the tradi-
traditional impression). So, some form of gingival re- tional impression to produce a gypsum model that
traction and use of astringents/hemostatic agents (as the laboratory can scan and use to design and mill
previously discussed) may be needed. As with any a restoration.
restorative impression good isolation is also required.
The preparation must be kept free of blood clots, saliva INELASTIC IMPRESSION MATERIALS
and debris, as the scanner cannot distinguish between
extraneous material and the prepared tooth. This could Inelastic impression materials in the form of dental
result in a restoration with faulty margins. impression compound, impression plaster, zinc oxide
eugenol, and impression wax are among the oldest im-
EXPANDED USE OF DIGITAL IMPRESSIONS pression materials used in dentistry. For the most part,
As the technology has improved and more clinicians the elastic impression materials have replaced them in
and manufacturers have discovered the capabilities modern dentistry.
 Impression Materials CHAPTER 15 355

ZINC OXIDE EUGENOL IMPRESSION MATERIAL

Zinc oxide eugenol (ZOE) impression material, like im-
pression plaster, is seldom used today. In its day, ZOE was
favored as an impression material for mucostatic (does
not displace the tissues) impressions. When a patient had
loose tissue over an edentulous ridge and the operator did
not want to displace these tissues with a stiff or heavy vis-
cosity impression material, ZOE was often chosen.

IMPRESSION WAX
Wax is another inelastic material that was used early in
dentistry for impressions. Waxes are often stiff at room
FIG. 15.31 Types of impression compound: cake and sticks. temperature and become moldable when heated. They
lack accuracy for final impressions for restorative treat-
ments and distort easily on removal from tissue under-
cuts or when affected by temperature fluctuations after
removal from the mouth.
Some waxes with low melting temperatures remain
moldable at mouth temperatures and are used to correct
minor voids in impressions for complete dentures or to
build a posterior seal (post dam) for the maxillary denture
by adding wax to the impression in the area of the junc-
ture of hard and soft palates, and then reseating the im-
pression in the mouth (see more on waxes in Chapter 16).

INFECTION CONTROL PROCEDURES

DISINFECTING IMPRESSIONS
FIG. 15.32 Stick compound used for border molding of a custom
impression tray. (Courtesy of Mark Dellinges, University of California Dental impressions should always be considered con-
School of Dentistry [San Francisco, CA].) taminated. They are usually contaminated with saliva or
blood, which may contain viral and bacterial pathogens.
DENTAL IMPRESSION COMPOUND Although most infectious agents, such as human immu-
Uses nodeficiency virus (HIV), do not survive for long peri-
Impression compound is a rigid thermoplastic mate- ods of time outside of the body, many pathogens, such as
rial that softens when heated and becomes firm again the hepatitis viruses, can survive for several days. When
at mouth temperatures. Impression compound is most impressions are not disinfected before they are poured,
commonly used as thick sheets (sometimes called microorganisms can get into the gypsum and survive for
cakes) or sticks (Fig. 15.31). At one time, compound a week or longer. Spores can survive much longer.
cakes were used in denture impression making, but
Caution
they are no longer popular for this use.
Some dentists use and some dental schools still Impressions are potentially infectious. They must be
teach the use of compound sticks to mold the peripher- disinfected before being handled in the office laboratory or
sent to a commercial laboratory.
al borders of a custom tray and to form the palatal seal
in impressions for complete dentures (Fig. 15.32). After
the peripheral borders have been established, an im- Ideally, disinfection of impressions should begin in
pression is taken in the tray with one of the elastomers. the operatory through chairside measures once the im-
pression is removed from the mouth. Dental person-
IMPRESSION PLASTER nel should wear personal protective equipment while
Impression plaster is seldom used today but was used handling and disinfecting the impressions. The dental
mainly for complete denture impressions. When used as office has the primary responsibility for disinfection.
the primary impression material, a wet mix (high water- Although the Occupational Safety and Health Admin-
to-powder ratio) was used to make it more fluid. After istration (OSHA) allows transportation of contami-
it set in the mouth, it was scored with a knife or bur, nated items, regulations require proper packaging and
fractured along the score lines, and removed. The piec- labeling of these contaminated items. Dental offices
es were reassembled in the laboratory, and poured into should discuss with the dental laboratory the protocol
dental stone to form the cast. Because of the complexity they will use to disinfect items sent to the laboratory
of its technique, impression plaster has been replaced by and how restorations returning from the laboratory
elastic materials that are easier to use and more accurate. should be handled.
356 CHAPTER 15 Impression Materials

TABLE 15.6    Disinfection of Impressions

IMPRESSION MATERIAL COMPATIBLE DISINFECTANTS IMMERSION TIME
Alginate Iodophors or chlorine compounds (1:10 10 (up to 30) minutes or spray
dilution of household bleach)
Polyvinyl siloxane Iodophors, glutaraldehydes, complex 10-30 minutes or spray
phenolics, chlorine compounds
Polyether Iodophors, glutaraldehydes, chlorine <10 minutes or spray
compounds

The material that is to be disinfected must be particular material may be adversely affected by some
compatible with the disinfectant used and the pro- disinfectants. For example, phenols with high alcohol
cedure employed. Incompatible disinfection materi- content can dehydrate some of the impression materi-
als and procedures can cause significant distortion als. Some solutions may also dissolve the tray adhesive
of the impression and failure of the restoration to fit that retains the impression material and cause it to come
correctly. loose from the tray. The silicone (PVS), polysulfide, and
After removal from the mouth, impressions should polyether elastomers can be disinfected with 1:213 io-
be rinsed thoroughly with water to remove saliva, dophor (i.e., 1 part iodophor to 213 parts distilled wa-
blood, debris, and other loosely attached contami- ter), 1:10 sodium hypochlorite, or complex phenolics.
nants. Excess water should be shaken off before the Silicones and polyethers can also be disinfected with
disinfectant is used, so as not to dilute it. Disinfectants glutaraldehydes. It is important to follow the manu-
can be applied by immersion of the impression or by facturer’s recommendations as to the use and length of
spraying its surfaces. Spraying may be preferred for time to apply the disinfectant.
impression materials that tend to distort with immer- Wax bite registrations, PVS bite registrations, and casts
sion, such as the polyethers and alginate. However, all present different problems for disinfection. Wax may
spraying has two main disadvantages. First, it creates distort when it is immersed. The recommended disin-
airborne particles of the disinfecting chemicals that fecting procedure is to rinse, spray, rinse, spray, and rinse
could be inhaled by the staff or patients. Second, it again, and then to place it in a container for transport.
may not adequately reach all surfaces if severe tissue Most elastomeric bite registration materials can be safely
undercuts are present. Immersion can cause distor- disinfected with the same solutions as their impression
tion of some impression materials, because they are material counterparts. See Table 15.6 for disinfecting
prone to imbibe water and they swell. Alginate can times and materials for impressions. Procedure 15.6 de-
be immersed in appropriate disinfectants for up to scribes processing methods for impression materials.
30 minutes. The length of time these sensitive materi-
als are immersed must be monitored carefully, some- DISINFECTING CASTS
times a difficult task in a busy office. Impressions On rare occasions, it may be necessary to disinfect the
should be rinsed after the recommended contact time cast produced from an impression that could not be
with the disinfectant to remove residual chemicals properly disinfected because of the nature of the con-
that can affect the surface of the poured cast. If im- taminants or an impression material that could not be
pressions are to be transported to the dental labora- immersed in the proper disinfectant. Casts should be
tory, they should be placed in a closed container or a completely set and stored for at least 24 hours before
sealed plastic bag. disinfection to prevent attack by the chemicals on the
surface of the cast. Casts seem to be minimally affected
Clinical Tip by the use of 1:10 sodium hypochlorite, iodophors, or
chlorine dioxide. Casts should be sprayed rather than
Spraying an impression should be done inside a plastic
immersed in disinfecting solutions, because some stud-
bag or headrest cover to contain the spray and protect the
handler from inhaling droplets. ies have shown damage to the surface in only a few
minutes in water-based solutions. Manufacturers have
added antimicrobial agents to some gypsum materials,
Selecting Disinfecting Solution but studies are not conclusive as to their effectiveness.
Impression materials differ from each other in their com-
position. Thus each type of impression material may re- STERILIZING IMPRESSION TRAYS
quire its own disinfecting solution and procedure. Man- Impression trays must be sterilized properly after their
ufacturer recommendations for disinfection should be use and after a tray is tried in the patient’s mouth for fit.
followed. Alginate impressions can be disinfected safely Disposable plastic trays are recommended when they can
with an iodophor or 1% sodium hypochlorite solution meet the demands of the impression material being used.
for 10 minutes. Elastomeric impressions can be disin- Flexible materials require a rigid tray to prevent flexing
fected with a wide range of solutions. However, each of the tray and distortion of the material. Because of their
 Impression Materials CHAPTER 15 357

thickness and rigidity, some putties can better tolerate deformation, and rebound are among the many physical
flexible plastic trays. Inelastic impression materials also and mechanical properties that must also be considered
may require rigid trays to prevent them from cracking. when impression materials are handled and disinfected,
Plastic trays that are more rigid have been developed and if the clinician is to meet the objective of producing as ac-
are commercially available. Custom acrylic trays should curate a replica of the oral structures as possible.
be discarded when the procedure has been completed or Dental auxiliaries who have been properly trained
should be immersed in an acceptable disinfectant if they and licensed in their states can pack cord and make
will be reused at the patient’s next appointment. Alumi- final impressions using elastic materials or digital im-
num, chrome-plated, and stainless steel trays can be ster- ages for crowns, bridges, implants, and removable
ilized by heated steam or chemical vapors, dry heat, or prosthetics. It is imperative that clinicians have a reli-
ethylene oxide after they have been thoroughly cleaned. able approach to making impressions, including soft
tissue management. They must use definitive criteria
to evaluate the cord retraction process and the final
SUMMARY impression. They must apply their knowledge about
In almost all phases of dentistry, impressions are an in- the characteristics and manipulation of the impres-
tegral part of the procedures needed for delivering com- sion materials to troubleshoot problems with an im-
prehensive care to patients. In many offices, impressions pression so they do not repeat their mistakes.
are made daily, and the various impression materials With the growing use of CAD/CAM technology,
must be understood by the clinician for correct selection, digital impressions are being used more and more
manipulation, and disinfection of the materials and for as an alternative to impression materials. Digital im-
pouring of casts. Alginate is still the material of choice for pressions are much easier for the patients, and they
preliminary impressions. With the improvements made eliminate many of the requirements needed in the
in the impression materials over the past several decades, impression materials, such as dimensionally stability,
many of the older materials such as agar hydrocolloid, strength in tear resistance, flowability, ease of removal,
polysulfide, condensation silicone, and the inelastic ma- rapid rebound from distortion, disinfection, and stor-
terials have been replaced by more accurate, dimension- age. Digital impressions can be transmitted to the den-
ally stable elastic materials. Polyvinyl siloxanes and poly- tal laboratory within minutes of capturing the images
ethers are the most popular impression materials for final or may be used to design and mill restorations in the
impressions for restorations and removable prostheses. dental office.
Each category of the impression materials has its own
handling characteristics, which must be considered.
INSTRUCTIONAL VIDEOS
Changes in temperature and humidity will influence the
materials in different ways, so operators must take these See the Evolve Resources site for a variety of educa-
factors into consideration when making impressions. tional videos that reinforce the material covered in this
Dimensional changes over time, water loss and gain, chapter.
358 CHAPTER 15 Impression Materials

Procedure 15.1 Fabrication of Custom Impression Tray Using Light-Cured Resin

See Evolve site for Competency Sheet. 4. Use a scalpel or lab knife to cut the wax back to the
marked tray borders.
EQUIPMENT AND SUPPLIES Place holes in the wax at the location of the marked
tray stops at the 2nd molars and central incisor (Figs.
• Maxillary or mandibular cast
15.37 and 15.38).
• Sheet of baseplate wax, Bunsen burner, scalpel or
lab knife, sheet of aluminum foil
• Triad TruTray kit with resin sheets, Model Release
Agent, Air Barrier Coating, disposable brush
• Lab handpiece and acrylic bur or lab lathe with
arbor band, acrylic polishing point
• Triad curing unit (Fig. 15.33).

PROCEDURE STEPS
1. Use a trimmed cast (study model) made from a
preliminary impression. Use a pencil to scribe a
line around the cast that is approximately 3 mm
short of the depth of the vestibule (Fig. 15.34). This
will be the border of the tray.
NOTE: The cast has marks for location of tray stops
on the 2nd molars and central incisor. FIG. 15.34 (From Rosenstiel SF, Land MF: Contemporary Fixed Prosth-
2. Assemble baseplate wax, cast and aluminum foil to odontics (ed 5). St Louis, 2016, Elsevier.)
use for wax spacer in the tray (Fig. 15.35).
3. Soften baseplate wax and adapt it over the teeth to
act as a spacer (Fig. 15.36).
NOTE: for an edentulous cast one layer of baseplate
wax is usually adequate. (See Procedure 17-1 in Chap-
ter 17 for placement of wax spacers and tray stops on
edentulous casts.) When taking an impression for a
crown or bridge, some clinicians prefer two layers of
wax. The spacer provides for a uniform thickness of
impression material within the tray.

FIG. 15.35 (From Rosenstiel SF, Land MF: Contemporary Fixed Prosth-
odontics (ed 5). St Louis, 2016, Elsevier.)

FIG. 15.36 (From Rosenstiel SF, Land MF: Contemporary Fixed Prosth-
FIG. 15.33 odontics (ed 5). St Louis, 2016, Elsevier.)
 Impression Materials CHAPTER 15 359

Procedure 15.1 Fabrication of Custom Impression Tray Using Light-Cured Resin—cont’d

NOTE: Tray stops ensure an even thickness of im- NOTE: If the foil was not used, the cast and wax
pression material within the tray. should be coated with a thin layer of Model Release
5. Cover the wax with a sheet of aluminum foil (Fig. Agent. This makes it easier to separate the tray from
15.39). Remove the excess and smooth the foil the cast and remove the wax.
(Fig. 15.40). 6. Remove the tray material from its light-proof
NOTE: Polymerizing the tray material often pro- packaging (Fig. 15.41). Insert a small bit of the resin
duces heat that melts the wax causing it to stick to the material into the holes created for tray stops and
tray. The foil makes it easier to remove the wax from fill the edentulous spaces with resin (Fig. 15.42).
the tray after the tray has been light-cured. 7. Adapt the tray material to the cast using gloved
hands spreading it evenly; do not create thin areas
(Fig. 15.43).
7. Use a sharp knife or scalpel to remove the excess
tray material extending beyond the marked
borders. Use a finger to gently rub the tray border
to remove wrinkles or sharp edges (Fig. 15.44).
NOTE: Creating smooth borders at this stage save a
lot of time later grinding and polishing.
8. From the remaining excess material, shape a
handle and place it on the anterior area at the
midline. Blend the base of the handle into the tray
to get a smooth union of the two (Fig. 15.45).

FIG. 15.37 (From Rosenstiel SF, Land MF: Contemporary Fixed Prosth-
odontics (ed 5). St Louis, 2016, Elsevier.)

FIG. 15.38 (From Rosenstiel SF, Land MF: Contemporary Fixed Prosth- FIG. 15.40 (From Rosenstiel SF, Land MF: Contemporary Fixed Prosth-
odontics (ed 5). St Louis, 2016, Elsevier.) odontics (ed 5). St Louis, 2016, Elsevier.)

FIG. 15.39 (From Rosenstiel SF, Land MF: Contemporary Fixed Prosth- FIG. 15.41 (From Rosenstiel SF, Land MF: Contemporary Fixed Prosth-
odontics (ed 5). St Louis, 2016, Elsevier.) odontics (ed 5). St Louis, 2016, Elsevier.)
Continued
360 CHAPTER 15 Impression Materials

Procedure 15.1 Fabrication of Custom Impression Tray Using Light-Cured Resin—cont’d

8. Insert the cast with the tray material into the Triad NOTE: Curing time depends on the type of tray
curing unit and set the timer for manufacturer’s material being used.
recommended curing time (Fig. 15.46). 9. After initial curing, remove the tray from the cast
and remove the softened wax spacer (Fig. 15.47).
NOTE: Heat from the curing lights will soften the
wax.
10. Coat the tray with Air Barrier Coating and
return it to the curing unit with the tissue side of
the tray positioned up. Follow manufacturer’s
recommended curing times (Fig. 15.48).
NOTE: Resins when cured will have a thin layer
of uncured resin on the surface caused by exposure
to oxygen in the air. This is the same thing seen with
sealants or composites. The air barrier eliminates the
oxygen and allows the resin on the surface to cure.
As an alternative to using the air barrier coating, the
tray can be scrubbed with a gauze soaked in isopropyl
FIG. 15.42 (From Rosenstiel SF, Land MF: Contemporary Fixed Prosth- alcohol (rubbing alcohol), and then cleaned with soap
odontics (ed 5). St Louis, 2016, Elsevier.) and warm water to remove the film of unset resin.

FIG. 15.43 (From Rosenstiel SF, Land MF: Contemporary Fixed Prosth-
odontics (ed 5). St Louis, 2016, Elsevier.) FIG. 15.45 (From Rosenstiel SF, Land MF: Contemporary Fixed Prosth-
odontics (ed 5). St Louis, 2016, Elsevier.)

FIG. 15.44 (From Rosenstiel SF, Land MF: Contemporary Fixed Prosth- FIG. 15.46 (From Rosenstiel SF, Land MF: Contemporary Fixed Prosth-
odontics (ed 5). St Louis, 2016, Elsevier.) odontics (ed 5). St Louis, 2016, Elsevier.)
 Impression Materials CHAPTER 15 361

Procedure 15.1 Fabrication of Custom Impression Tray Using Light-Cured Resin—cont’d

11. Clean the cured tray with a brush and warm (not
hot) water and soap to remove residual air barrier.
12. Use an arbor band on a lathe or an acrylic bur
in a lab handpiece to adjust the tray borders
and remove any sharp edges (Fig. 15.49). Use
an acrylic polishing point to smooth the tray
borders. Check with your fingers to make
sure there are no sharp edges that might be
uncomfortable to the patient. Clean trimming
debris from the tray.
NOTE: If additional retention of the impression ma-
terial is desired beyond that provided by tray adhe-
sive, holes can be cut in the tray.
13. Disinfect the tray in a suitable disinfectant for the
recommended time. Rinse and dry the tray and
store it in a zippered plastic bag with the patient’s FIG. 15.48 (From Rosenstiel SF, Land MF: Contemporary Fixed Prosth-
name and/or chart number. odontics (ed 5). St Louis, 2016, Elsevier.)

FIG. 15.47 (From Rosenstiel SF, Land MF: Contemporary Fixed Prosth- FIG. 15.49 (From Rosenstiel SF, Land MF: Contemporary Fixed Prosth-
odontics (ed 5). St Louis, 2016, Elsevier.) odontics (ed 5). St Louis, 2016, Elsevier.)

Procedure 15.2 Making an Alginate Impression

See Evolve site for Competency Sheet. including rim-locks require alginate adhesive
• Utility wax ropes
Consider the following with this procedure: safety glasses are
• Saliva ejector, disinfecting solution, zippered
recommended for the patient, PPE is required for the operator,
plastic bag, paper towels
ensure appropriate safety protocols are followed, and check your
local state guidelines before performing this procedure. PROCEDURE STEPS
1. Patient preparation: Seat the patient. Cover the
EQUIPMENT/SUPPLIES (FIG. 15.50) patient’s clothes with a plastic-backed bib. Explain
• Basic setup the procedure. Inquire about the gag response and
• Alginate, powder scoop, and water-measuring ability to breathe through the nose. Remove dental
cylinder prostheses unless needed in the impression. Have
• Rubber bowl, wide-bladed spatula the patient rinse his or her mouth.
• Impression trays (perforated) or solid trays
Continued
362 CHAPTER 15 Impression Materials

Procedure 15.2 Making an Alginate Impression—cont’d

FIG. 15.50

FIG. 15.52

for a large upper arch or two scoops for a smaller

arch. Two scoops are adequate for the average
lower arch. Place in a rubber bowl one measure of
room temperature water for each scoop of powder.
Add powder to water and stir to wet the powder.
Vigorously mix and press the wet powder against
the sides of the bowl with a spatula while rotating
the bowl with the other hand. The final mix should
appear smooth and not grainy (Fig. 15.52).
FIG. 15.51 NOTE: Prepackaged alginate does not require fluffing,
because it is already present in the correct proportions.
NOTE: If the patient has bridges or fixed implant pros- Mix by wiping vigorously against the sides of the bowl
theses, block out with utility wax around pontic spaces to remove entrapped air, and thoroughly mix the pow-
likely to lock alginate in place and make removal of the der and water. Water that is cooler than room tempera-
impression difficult. Orthodontic bands, brackets, and ture lengthens working and setting times, whereas warm
arch wires may also need to be blocked out. If the patient water shortens these times. Complete the mix within 45
has very loose teeth, block out embrasures around these seconds for regular-set or within 30 seconds for fast-set
teeth to prevent removing them with the impression. alginate, to allow enough time to load the tray, paint oc-
Take precautions for gagging (as highlighted in the clini- clusal surfaces, and seat the impression before initial set.
cal tip on controlling the gag reflex). Patients who cannot 4. Loading the tray: Load the tray in large increments,
breathe through the nose may feel threatened if alginate pressing each into the tray until level with the sides.
runs out the back of the tray and blocks the airway; there- Use a wet, gloved finger to smooth the surface and
fore seat the tray in the posterior first to force material create a shallow indentation where the teeth will go
forward. On occasion, the dentist may want the prosthe- (Fig. 15.53). Remove excess alginate.
sis left in during the impression to examine the occlusion NOTE: Fewer increments will trap less air. Force out
later on. Check with the dentist. Rinsing before making entrapped air by pressing alginate into the depth of the
the impression removes debris and ropy saliva. An anti- tray. Indentation for the teeth helps to orient the tray
bacterial rinse will reduce the number of pathogens. when seating. Extra material added to the anterior part
2. Tray selection: Quickly examine the patient’s mouth, of the tray helps to fill the vestibule and get a good pe-
arch size and shape, and palatal depth. Select a tray ripheral roll.
of the appropriate size. Try it in for fit. Add utility 5. Seating the tray: Take alginate from the bowl on a finger,
wax as needed for comfort and extension of the tray. and wipe it over the occlusal surfaces and into the
NOTE: If the tray border is short or the palate deep, embrasures. For upper impression: From behind and
add wax to extend the tray and support the alginate to the side of the patient (right-handed—11 o’clock
(Fig. 15.51). position; left-handed—1 o’clock), retract the right
3. Mixing alginate: Tumble the container of alginate to cheek with the posterior corner of the tray and the left
fluff powder. Measure three level scoops of powder cheek with the index finger (reverse for left-handed).
 Impression Materials CHAPTER 15 363

Procedure 15.2 Making an Alginate Impression—cont’d

FIG. 15.55

FIG. 15.53

FIG. 15.56

minimizes the gag response. Employ distraction tech-

niques for gaggers. Have them position the head for-
FIG. 15.54
ward, breathe through the nose deeply and slowly, and
use the saliva ejector to prevent pooling of saliva.
For lower impression: From in front and to the side 6. Stabilize the tray until the alginate is fully set. Allow
of the patient (right-handed—8 o’clock position; an additional minute before removing the tray.
left-handed—4 o’clock), retract the left cheek with NOTE: Check alginate remaining in the bowl to
the side of the tray and the right cheek with the left confirm set. Tray movement during setting will cause
index finger (reverse for left-handed) (Fig. 15.54). Both distortion in the impression. Allowing 1 minute after
impressions can be made with the operator seated and set helps to increase tear strength.
the patient reclined, or with the operator standing with 7. Removing the tray: Break the seal by pressing down
the patient upright. If the patient is reclined, seat the (or up for a lower impression) on the side of the
patient upright after the tray is placed. For both upper tray with a finger, or have the patient close his
and lower impressions: Rotate the tray into the mouth, or her lips around the tray handle and blow to
and align the tray over the teeth with the handle in the puff out the cheeks. Hold the handle in the hand,
midline. Seat the back of the tray first and complete grasping with the index finger and thumb, and
seating to the anterior as the lip is gently pulled out of remove the tray with a snap.
the way. Inspect the back of the tray for excess alginate NOTE: Protect the patient’s teeth in the opposing
and remove with a quick sweep of the mouth mirror. arch with fingers of the other hand. Rapid removal
For lower impression: Have the patient lift the tongue minimizes distortion and tearing of alginate.
once the tray is seated, and relax it again once alginate 8. Handling the impression: Rinse under running water
has flowed into the lingual areas. to remove saliva and debris. Shake out pooled
NOTE: Seating the posterior of the tray first allows water. Inspect the impression, using criteria for
alginate to flow forward rather than back into the pa- acceptability (see Table 15.3) (Figs. 15.55 and 15.56).
tient’s throat. Lifting the lip allows alginate to flow 9. Disinfecting the impression: Spray thoroughly with
into the vestibule. Quickly removing excess alginate disinfectant. Drain off the pooled liquid.
Continued
364 CHAPTER 15 Impression Materials

Procedure 15.2 Making an Alginate Impression—cont’d

NOTE: When the impression is sprayed inside a the air, water will evaporate, causing distortion. Ideally,
bag or headrest cover, the aerosol is better contained the impression should be poured within 30 minutes, be-
(Fig. 15.57). Alginate will imbibe liquid and swell, so cause it is not dimensionally stable for long periods. It
pooled liquid should be removed. will lose water (by syneresis) even in 100% humidity.
10. Cut off unsupported alginate at the back of the Allow 10 minutes before pouring to allow the disinfec-
tray. Wrap the impression in a damp paper towel tant to be effective and to allow rebound to occur.
or place a few drops of water in a zippered plastic 11. Help the patient remove alginate from the face
bag marked with the patient’s name (Fig. 15.58) with a damp towel. Have the patient rinse his
and seal it. or her mouth. Inspect the patient’s mouth and
NOTE: If the tray is laid on the bench top, unsup- remove trapped alginate from the embrasures
ported alginate at the back of the tray may lift a portion with an explorer and floss.
of the impression and dislodge it from the tray. This will
cause a distortion in the impression. If alginate is left in

FIG. 15.57 FIG. 15.58

Procedure 15.3 Making a Double-Bite Impression for a Crown

See Evolve site for Competency Sheet. • Impression syringe

Consider the following with this procedure: safety glasses are PROCEDURE STEPS
recommended for the patient, PPE is required for the operator,
1. Assemble the cartridge in the gun and extrude a
ensure appropriate safety protocols are followed, and check your
small amount of impression material onto a paper
local state guidelines before performing this procedure.
towel to ensure that the orifices are not clogged.
NOTE: In some states, the dental assistant or hy-
gienist may be licensed to place a retraction cord and
make the impression. In states where these functions
are not permitted, it is assumed that the dental assis-
tant or the hygienist will assist the dentist.

EQUIPMENT/SUPPLIES (Fig. 15.59)

• Basic crown and bridge setup\
• Double-bite tray (paper insert for metal trays), tray
adhesive
• Elastomeric impression material in cartridges:
Heavy body tray material and light body syringe
material
• Dispenser gun and mixing tips FIG. 15.59
 Impression Materials CHAPTER 15 365

Procedure 15.3 Making a Double-Bite Impression for a Crown—cont’d

Place the mixing tip. that the tissue is adequately retracted in all areas
NOTE: Clogged or partially clogged orifices will re- around the preparation, that it is not bleeding,
sult in an improper mix of the material, with alteration and that the margins of the preparation are free of
of setting time and physical properties. debris, blood, and astringent. (This is the second
2. Inform the patient of the procedure and have the “stop sign.”)
patient practice closing into centric occlusion (patient’s NOTE: The tissues will stay retracted long enough
“normal” bite) with the tray in place (Fig. 15.60). to control the field. The impression syringe should not
NOTE: Choose opposing teeth that are easily seen, be loaded until the field is dry, bleeding is controlled,
such as the canines on the opposite sides of the mouth, and retraction is adequate. If a two-cord retraction tech-
and note their position when they occlude. This rela- nique is used in which a smaller cord is left in the sul-
tionship will be checked when the impression is made cus during the impression, check to see that the smaller
to ensure proper closure. cord has stayed in place and has not lifted over the
3. Maintain isolation in the quadrant in which the margins. If it has lifted, pack it back into place. If blood
impression will be made. is oozing from the sulcus, control bleeding by scrub-
NOTE: Saliva can saturate the retraction cord and bing the sulcus with ferric sulfate astringent (such as
may cause it to displace from the gingival sulcus. Astringedent; Ultradent) on a small cotton pellet or ap-
4. Confirm that cord retraction around the crown plicator. Then, rinse residual astringent away, because
preparation is adequate (Fig. 15.61). compounds that contain sulfur can interfere with the
NOTE: This is the first “stop sign.” The clinician set of polyvinyl siloxane impression materials.
should be able to see the preparation, the cord, and 7. With the preassembled dispenser gun and mixing
the gingiva displaced from the preparation. In other tip, load the impression syringe with the light body
words, the cord should not be placed so deeply into material. Change cartridges and mixing tips. Load
the gingival sulcus that the gingival crest has collapsed both the preparation and opposing arch sides of
over it and is resting on or near the preparation or the the double-bite tray with the heavy body material.
cord should not be placed so shallowly that it is resting NOTE: The gun-type mixing system ensures a
on top of the margin. thorough mix with minimal waste of material. For ef-
5. Carefully remove the retraction cord after it has ficiency of time and motion, two guns could be used
been in place for about 5 minutes (8 minutes if the and preassembled rather than having to unload the
tissue had been bleeding prior to cord placement). light body and load the heavy body with a single gun.
Rinse and dry the tooth. Impression putty could be used in place of the heavy
NOTE: If the retraction cord is dry, lightly wet it be- starting with the tip just apical to the margin. With the
fore removing it. A dry cord may stick to tissues and
cause bleeding when removed. To prevent bleeding,
the cord should be gently lifted from the sulcus rather
than ripped out quickly.
6. Inspect the gingiva, sulcus, and preparation before
proceeding with the impression. Check to see

FIG. 15.60 FIG. 15.61

Continued
366 CHAPTER 15 Impression Materials

Procedure 15.3 Making a Double-Bite Impression for a Crown—cont’d

material continually flowing, keep the tip in contact Inspect it for completeness of the preparation
with the tooth while slowly tracing the margin and fill- detail. There should be a slight excess of impression
ing the gingival sulcus. Circle the entire tooth to com- material extending beyond the margins and no
pletely cover the margins, and then continue circling folds or voids (Fig. 15.64). Minor air bubbles in
while covering the axial walls and finally the occlusal noncritical areas such as the occlusal surface might
surface (Fig. 15.62). be acceptable. Check with the dentist.
NOTE: Establishing a good finger rest will help sta- NOTE: Folds on axial walls are often the result of
bilize the impression syringe. Some manufacturers pro- material that did not join together at the start and end
vide a delivery tip that can be attached to the mixing tip of the circling process around the tooth, because the
to deliver the light body material directly to the prepa- material had started to set or because the circle was not
ration from the cartridge. This method can be awkward completed with new material flowing into first-placed
in the posterior part of the mouth because the end of the material. Air entrapment resulting in small or large
long mixing tip is far away from the operator’s hand, voids is often the result of loss of contact of the syringe
making fine control of the tip difficult. Without good tip with the tooth during syringing of the material. If
hand control, the tip frequently bounces out of contact a two-cord retraction technique was used and the cord
with the preparation during injection of light body ma- left in place during the impression comes out attached
terial around the tooth, creating air voids in critical parts to the impression, do not attempt to remove it. The
of the impression. For retention grooves, the syringe tip impression could tear. Cut off with scissors any loose
should be placed at the bottom of the groove and the ends of cord hanging from the impression and leave
groove filled from the bottom to the top. the cord that is embedded in the impression material.
9. Place the impression tray over the teeth and instruct
the patient to close into the rehearsed bite. Check the
reference teeth to ensure that the patient has closed
into the proper position (Fig. 15.63). Instruct the patient
not to shift the bite or open until instructed to do so.
NOTE: A missed bite relation will result in a crown
that is grossly high.
10. When the two viscosities of impression material
have set, remove the impression. Rinse and dry
the impression to remove saliva, blood, and debris.

FIG. 15.63

FIG. 15.62 FIG. 15.64

 Impression Materials CHAPTER 15 367

Procedure 15.3 Making a Double-Bite Impression for a Crown—cont’d

11. Hold the impression up to the operatory light 12. Spray the impression with a suitable disinfectant
and inspect for proper occlusal contacts. The while it is contained within a plastic bag, seal it in a
impression material will be very thin where there zippered plastic bag that has been labeled with the
is contact between opposing teeth, and light can patient’s name, and transport it to the laboratory
be seen through the material. If contacts are not in (see Figs. 15.59 and 15.60 in Procedure 15.2).
the proper locations, a separate bite registration
may need to be made.

Procedure 15.4 Bite Registration with Elastomeric Material

See Evolve site for Competency Sheet. NOTE: Choose opposing teeth that are easily seen,
such as the canines, and note their position when they
Consider the following with this procedure: safety glasses are
occlude. This relationship will be checked when the
recommended for the patient, PPE is required for the operator,
bite registration is taken.
ensure appropriate safety protocols are followed, and check
1. Dry the teeth to be included in the bite registration.
your local state guidelines before performing this procedure.
2. Extrude mixed material onto each side of the bite
registration tray until the gauze is evenly covered
EQUIPMENT/SUPPLIES with material about 2 mm thick (Fig. 15.66).
• Basic setup 3. Center the tray over the mandibular teeth to
• Plastic bite tray be included and have the patient close into the
• Elastomeric bite registration material in dual cartridge practiced bite (Figs. 15.67 and 15.68).
• Automatic mixing extruder (gun-type) and mixing NOTE: Now is the time to check the relationship
tips (Fig. 15.65) of the opposing teeth (i.e., canines) to see if they are
properly occluded.
PROCEDURE STEPS 4. Instruct the patient to hold the teeth together until
1. Assemble the cartridge in the gun and extrude a the material is set (in 3 minutes or less).
small amount of bite registration material onto NOTE: If the patient moves the teeth during the set-
a paper towel to ensure that the orifices are not ting stage, a distortion will likely occur and will often
clogged. be seen as imprints wider than the teeth.
NOTE: Clogged or partially clogged orifices will 5. Remove the bite tray when the material is set.
result in an improper mix of the materials, with altera- Inspect it to see that all of the teeth needed for
tion of setting time and physical properties. the registration are included and that there are no
2. Place the mixing tip on the cartridge. major voids (Fig. 15.69).
3. Inform the patient of the procedure and have the NOTE: When set, the material should not indent
patient practice closing into centric occlusion (the and should feel firm.
patient’s “normal” bite) with the tray in place.

FIG. 15.65 FIG. 15.66

Continued
Procedure 15.4 Bite Registration with Elastomeric Material—cont’d

FIG. 15.67

FIG. 15.69

teeth. The gauze with a thin layer of material

should be present in these areas.
NOTE: If the material is thick in areas where there
should be contact of opposing teeth, the patient may
not have closed properly. Inspect the patient’s occlu-
sion and compare it with the bite registration. If there
is an error, rehearse bite closure and repeat the proce-
dure. If the tray is not inserted far enough posteriorly,
the patient may bite on the back edge of tray rather
than biting together completely.
7. Rinse the material under running water to remove
saliva and debris.
8. Spray the bite registration material with a suitable
FIG. 15.68 disinfectant while it is contained within a plastic
6. Check for correct occlusion. Hold the bite bag. Seal it in a zippered plastic bag labeled with the
registration material to the operatory light and patient’s name, and transport it to the laboratory.
see that light shines through in areas of contacting

Procedure 15.5 Wax Bite Registration

See Evolve site for Competency Sheet. PROCEDURE STEPS

Consider the following with this procedure: safety glasses are 1. Heat utility wax sheets until pliable, and fold
recommended for the patient, PPE is required for the operator, several times to get 3 to 4 layers of wax.
ensure appropriate safety protocols are followed, and check your NOTE: You will need a thickness of 3 to 4 mm to
local state guidelines before performing this procedure. avoid distortion when removing.
2. Form the wax into a horseshoe shape.
NOTE: You may need to reheat the wax to keep it
EQUIPMENT/SUPPLIES (Fig. 15.70) pliable (Fig. 15.71).
• Bite registration wax or utility wax 3. Try the wax into the mouth, cutting the ends to fit
• Heat source only to the middle of the last tooth in the arch.
• Laboratory knife
Procedure 15.5 Wax Bite Registration—cont’d

NOTE: If you are using preformed wax bite regis- 6. Place the wax horseshoe onto the occlusal
tration blocks, then you will need to trim them only for surfaces of the maxillary teeth (Fig. 15.74).
length (Fig. 15.72). 7. Instruct the patient to bite gently, yet firmly, into
4. Seat the patient in the upright position and give the wax.
him or her instructions on closing. NOTE: If the patient bites too firmly, the wax may
NOTE: Concerning patients in the supine position: be distorted and torn. If not firmly enough, the teeth
if the patient’s mouth has been open for a long time or may not make adequate indentations in the wax
is numb, the patient may close in an abnormal position. (Fig. 15.75).
5. Heat the wax again until softened. 8. Allow the wax to cool in the patient’s mouth for 1
NOTE: If using a flame source, assure the patient to 2 minutes.
that the wax will not burn their tissues (Fig. 15.73). NOTE: Use an air syringe to hasten cooling by gen-
tly spraying the area around the wax.
9. Have the patient open with a straight snap to
avoid distortion of the wax.

FIG. 15.70
FIG. 15.73

FIG. 15.71
FIG. 15.74

FIG. 15.72 FIG. 15.75

Continued
370 CHAPTER 15 Impression Materials

Procedure 15.5 Wax Bite Registration—cont’d

10. Remove the wax bite registration carefully, being 12. Store the wax in a cool area (ideally at slightly less
sure not to break or distort the wax (Fig. 15.76). than room temperature).
11. Disinfect the wax bite and store it in a bag labeled NOTE: You should try to use the wax as soon as
with the patient’s name. possible to articulate models and to avoid distortion
NOTE: Follow the manufacturer’s recommenda- due to relaxation of residual stress (Fig. 15.77).
tions for use of this material. Some disinfecting agents
may break down the wax.

FIG. 15.76 FIG. 15.77

Procedure 15.6 Disinfection of Impression Material or Bite Registration

See Evolve site for Competency Sheet. (see Fig. 15.59 in Procedure 15.2).
NOTE: Polyethers can be sensitive to immersion.
Consider the following with this procedure: safety glasses are
ZOE should not be disinfected with chlorine-contain-
recommended for the patient, PPE is required for the operator,
ing solutions, because it breaks down the material.
ensure appropriate safety protocols are followed, and check your
3. Leave the solution on the sprayed impression or
local state guidelines before performing this procedure.
leave the immersed impression in solution for the
recommended time period.
EQUIPMENT/SUPPLIES NOTE: Polyethers should not be immersed for lon-
• Impressions/bite registration ger than 10 minutes because they imbibe water and
• Various disinfecting solutions in appropriate swell. Spraying is preferred.
containers 4. Rinse with water and gently shake off the excess to
• Zippered plastic bags remove any residual chemicals.
NOTE: Residual chemicals can adversely affect the
PROCEDURE STEPS surface of the cast when the impression is poured.
1. Rinse the impression under running tap water and 5. Package properly for transport (see Fig. 15.60 in
shake off the excess. Procedure 15.2). A zippered plastic bag is usually
NOTE: Rinsing removes much of the saliva, blood, satisfactory. Label with the patient’s name.
and other biological debris that can interfere with NOTE: Alginate and agar hydrocolloid should be
disinfection. wrapped in a damp paper towel (or place a few drops
2. Immerse or spray the impression with an of water in the plastic zipper bag) to keep them from
acceptable disinfectant prepared according to the losing moisture and distorting. It is not necessary to
manufacturer’s instructions. If spraying, hold the wrap elastomers. They should be dried after the disin-
impression within a plastic bag to contain the spray fectant is rinsed off.
 Impression Materials CHAPTER 15 371

Get Ready for Exams!

Review Questions 9. P reliminary impressions are useful for all of the following
except one. Which one?
Select the one correct response for each of the following a. Diagnostic casts (study models)
multiple-choice questions. b. All-ceramic inlays
1. A dental impression material c. Custom trays
a. Forms a positive imprint of the oral structures d. Provisional restorations
involved 10. Three of the following impression materials are the most
b. Allows the creation of a replica of the structures commonly used. Which one is not commonly used?
involved a. Polysulfide
c. Is always flexible for easy removal from the mouth b. Polyether
d. Is used only for crown and bridge procedures and for c. Polyvinyl siloxane
diagnostic casts (study models) d. Alginate
2. Which one of the following impression materials is 11. The three key properties that materials used for final
transformed from a sol to a gel state when set? impressions must possess include all of the following
a. Alginate except one. Which one?
b. Polysulfide a. Accuracy
c. Polyether b. Dimensional stability
d. Polyvinyl siloxane c. Wettability
3. All of the following are elastic impression materials d. Tear resistance
except one. Which one? 12. Which one of the following impression materials has the
a. Alginate lowest tear strength?
b. Polyether impression material a. Polyvinyl siloxane
c. Dental compound b. Polyether
d. Polyvinyl siloxane (PVS) impression material c. Vinyl polyether hybrid
4. The types of impression materials that are considered d. Alginate
hydrophilic are those that 13. It is important for an accurate impression that the tray
a. Have a lot of water in them not be
b. Can be immersed in water without absorbing it a. Too smooth
c. Cause water to bead on their surface b. Too flexible
d. Have good surface-wetting characteristics c. Too rigid
5. Hydrophobic impression materials d. Perforated
a. Absorb moisture only after their final set 14. Which one of the elastomers has the highest natural (no
b. Are the best type of material to use in the mouth chemicals added) wettability?
because they repel saliva and blood a. Polyvinyl siloxane
c. Need a dry field to get the best results b. Polysulfide
d. Provide the best surfaces on gypsum casts, because c. Polyether
they resist the uptake of water during curing of the
15. As the viscosity of the impression material increases,
gypsum
which one of the following properties decreases?
6. Alginate impression material a. Accuracy
a. Is accurate enough to be used for crown and bridge b. Tear strength
procedures c. Dimensional stability
b. Has very few uses in the modern dental practice d. Setting time
c. Is dimensionally stable during the first 24 hours
16. Which of the following elastomers will imbibe water
d. Can be immersed in an appropriate disinfectant for
when stored in it and change dimensions?
up to 30 minutes without distorting
a. Polysulfides
7. An irreversible hydrocolloid b. Polyethers
a. Is one that goes from a gel to a sol when it is heated c. Addition silicones
b. Is no longer in common use
17. Which one of the following statements is true about the
c. Is hydrophobic
addition silicones?
d. Cannot reverse from a gel to a sol because a chemi-
a. They are good materials for complete denture
cal reaction prevents it
impressions but are not accurate for crown and
8. The elastic recovery (or rebound) of alginate impres- bridge procedures.
sion material can be increased by which one of the b. They are very dimensionally stable.
following? c. They cost about the same as alginate.
a. Leaving the impression in the mouth for 1 minute d. They require the use of custom acrylic trays.
beyond its set.
18. The least accurate of the elastic impression materials is
b. Using a thicker mix of material
a. Polyvinyl siloxane
c. Using cold water in the mix
b. Polyether
d. Removing the impression slowly from the mouth
Continued
372 CHAPTER 15 Impression Materials

c. Vinyl polyether silicone hybrid 26. W

 hich one of the following impression materials is least
d. Alginate affected by soaking it in a disinfectant solution for 2
19. After removing a PVS impression form the mouth it is hours?
found that the surface has unset material on it. What can a. Alginate
cause this to happen? b. Polyether
a. Incomplete mixing of the material c. Polyvinyl siloxane
b. Residual ferric sulfate astringent on the teeth 27. Disinfecting of impressions
c. Contamination from latex gloves a. Is done to protect the patient from surface bacteria
d. All of the above b. Must be done for all impressions
20. PVS substitutes for alginate have all of the following c. Is done only with impressions for patients with known
advantages except one. Which one? infectious diseases
a. Dimensionally stable for long periods d. Does not need to be done for the new alginates that
b. Less expensive than alginate have bactericidal chemicals incorporated into them
c. Can be re-poured several times For answers to Review Questions, see the Appendix.
d. Do not have to be poured right away
21. At present, the most common conservative method of Case-Based Discussion Topics
creating space in the gingival sulcus of a prepared tooth
for wash (syringe) material is which one of the following? 1. A 30-year-old retail store manager comes to the dental
a. Retraction paste office to have impressions made for home whitening
b. Retraction cord trays. She indicates that she has a moderate gag reflex.
c. Laser troughing What impression material is well suited for making whitening
d. Electrosurgical troughing trays? What steps can be taken to minimize gagging and to
22. Which one of the following astringents has the poten- shorten the length of time the impression material remains in
tial to be dangerous to patients with cardiovascular the mouth? How should the impression material be handled
disease? from the time it is removed from the mouth until it is poured
a. Racemic epinephrine with dental plaster or stone?
b. Ferric sulfate 2. A dentist practicing in California decides to use the
c. Aluminum chloride services of a dental laboratory located in New York City.
d. ViscoStat He plans to mail all of his impressions to the laboratory
23. Reasons the wash material may tear when removing the rather than pour them in his office.
set impression from the mouth include all of the follow- What types of impression materials can be used under these
ing except one. Which one? circumstances that will still produce accurate casts and dies?
a. Narrow sulcus width (<0.2 mm) Which materials definitely cannot be used? What properties of
b. Very deep sulcus the materials are most important? How should the impressions
c. Sharp edges on the preparation be handled before they are shipped to the laboratory?
d. Removing the impression with a snap 3. A 53-year-old mail carrier comes to the dental office
24. A successful double-bite impression for a crown on with a broken facial cusp on tooth #31. Adjacent to #31,
tooth #30 includes all of the following except one. Which the patient has a fixed bridge from #28 to #30 that has
one? a hygienic pontic replacing tooth #29. The dentist will
a. The margins of the preparation are shiny and prepare #31 for a porcelain-bonded-to-metal crown, and
rounded. the dental hygienist or assistant with extended functions
b. The margins and a little of the tooth beyond are cap- will make an impression. Isolation is difficult because
tured in the impression. the patient salivates profusely, and the gingiva is bleed-
c. No large voids are present in the walls of the ing because the patient is taking blood thinners. The
preparation. clinician will be able to control most of the saliva. The
d. Opposing teeth are captured in the proper bite relation. bleeding will be greatly reduced when a local anesthetic
with a vasoconstrictor is injected into the gingival papil-
25. Digital impressions have several advantages over tradi-
lae around the tooth. However, the preparation will not be
tional impressions. Which one of the following is not an
completely dry.
advantage?
Which elastomer, by its nature, is somewhat hydrophilic and
a. Impression material and associated supplies are not
could be used? Which materials are not naturally hydrophilic but
needed.
may have surfactants added to make them more hydrophilic?
b. Digital impressions can be electronically transferred
What precautions should be taken before the impression is made
to the laboratory.
to ensure that it can be easily removed from the mouth?
c. Images of the preparation can be viewed from mul-
tiple angles before being sent to the laboratory. 4. The dentist in your office will replace an existing crown
d. Gingival retraction is not needed for preparations with on tooth #5 for a young female college student because
subgingival margins. of recurrent caries under the distal margin. The dentist
likes to use a two-step polyvinyl siloxane (PVS) putty/
wash technique. You will be asked to prepare an acrylic
custom provisional crown for the patient.
 Impression Materials CHAPTER 15 373

How should you prepare for this before the dentist removes by proper disinfection. In addition, the accuracy of the
the crown, using the materials at hand? What types of im- impressions might be adversely affected by improper
pression trays can the dentist use with this technique? Can disinfection techniques.
a polysulfide tray adhesive be used with the PVS putty? How Describe the procedures for disinfecting alginate, polyvinyl
soon does the PVS impression have to be poured? What siloxane, and polyether impression materials.
disinfectants are safe to use with PVS materials? 7. A dental hygienist licensed with extended functions is
5. The dentist uses polyether in the office for crown and preparing to make a PVS impression of tooth #19 for
bridge impressions. This afternoon, a call came in from a gold crown. The hygienist has packed cord accord-
the dental laboratory indicating that the laboratory’s ing to the two-cord technique. The hygienist needed to
delivery person had been in an automobile accident yes- scrub the gingival sulcus with ferric sulfate astringent to
terday; the dies picked up from the dentist’s office were control bleeding.
broken. Before making the impression, what criteria should the hy-
Can the dentist repour the impression and send new dies? gienist use to determine whether the top cord is properly
Why or why not? Which of the impression materials are good placed? Once the top cord is removed, what criteria should
for this purpose? Which elastomer has the greatest accuracy be used to determine whether the next steps for making the
for the longest time? impression can be taken? What should be done to the pre-
6. A variety of impression materials may be used in the pared tooth surfaces once the bleeding has been controlled
dental office on a daily basis. It is important to protect with ferric sulfate? When the impression has been complet-
all dental personnel who might handle the impressions ed, what criteria will the hygienist use to determine whether
the impression can be used for the crown?

BIBLIOGRAPHY Farah JW, Powers JM, editors: Bite registration materials. Dental
Advisor, 15:2, 1998.
Bayne SC: Impression Materials [PowerPoint presentation]. Merchant VA: Infection control in the dental laboratory environ-
Available at Open. Michigan website Ann Arbor, MI: Univer- ment. In Cottone JA, Terezhalmy GT, editors: Molinari GT)
sity of Michigan. http://open.umich.edu/education/dent/ Practical Infection Control in Dentistry (ed 2). Philadelphia,
dental-materials/2008/materials or http://www-personal. 1996, Williams & Wilkins.
umich.edu/∼sbayne/dental-materials/117-Impression-Mate Organization for Safety and Asepsis Procedures: Impression dis-
rials/Handouts/117-IM-PPT-Handout-CL.pdf. infection. OSAP Monthly Focus, 7:1, 1998.
Bird DL, Robinson DS: Impression materials. In Torres and Ehr­ Powers JM, Wataha JC: Impression materials. In Dental Materials:
lich’s Modern Dental Assisting (ed. 12). Philadelphia, 2018, El- Foundations and Applications (ed 11). St. Louis, 2017, Elsevier.
sevier/Saunders. Sakaguchi RL, Powers JM: Replicating materials—impression
Boksman L, Cowie RR: Making polyvinyl impressions: success and casting. In Craig’s Restorative Dental Materials (ed 13). St.
lies in the details. Contemporary Dental Assisting, 28–32, 2007. Louis, 2012, Elsevier/Mosby.
Burgess JO: Impression material basics. Inside Dentistry, 1(1), Shull GF: An update on CAD/CAM dentistry. Dental Learning
2005. February, 4(2):2–8, 2015.
Burgess JO, Lawson NC, Robles A: Comparing digital and con- Skramstad M: The clinical application of CAD/CAM technology
ventional impressions. Inside Dentistry, 68–74, 2013. and materials. Dental Learning, 1(6), 2012.
Burgess JO, Lawson NC, Robles A: Digital impression system
considerations. Inside Dentistry, 72–76, 2015.
16 Gypsum and Wax Products

http://evolve.elsevier.com/Eakle/materials/

Chapter Objectives
Upon completion of this chapter, the student should be able to:
1. Differentiate between negative and positive reproduction. 9. Identify the common components of dental waxes.
2. Differentiate among diagnostic cast, working cast, and dies. 10. Compare the properties of waxes.
3. Describe the chemical and physical nature of gypsum 11. Describe the clinical/laboratory significance of each of the
products. properties of waxes.
4. Explain the manufacturing process for gypsum products 12. Discuss the three classifications of waxes.
and how this affects their physical characteristics. 13. Differentiate between direct and indirect waxings and
5. Compare the following properties and behaviors of identify which property of dental waxes is most important
gypsum products: strength, dimensional accuracy, in their difference.
solubility, and reproduction of detail. 14. Describe the usual color, form, and use of inlay, casting,
6. List the American Dental Association–recognized gypsum baseplate, boxing, utility, and sticky waxes.
products and their most appropriate uses. 15. Prepare model plaster or stone for pouring.
7. Explain initial and final set of gypsum and the factors that 16. Pour the anatomic and base portions of maxillary and
affect the setting time, setting expansion, and strength. mandibular diagnostic casts.
8. Explain the procedure for mixing and handling gypsum 17. Trim maxillary and mandibular diagnostic casts.
products to create diagnostic casts. 18. Obtain a bite registration, using bite registration or utility wax.

Key Terms
Casts hard replicas of hard and soft tissue of the patient’s Pouring pouring the cast refers to the process of vibrat-
oral cavity, made from gypsum products; also referred to ing the flowable gypsum product into an impression; this
as models process must produce a cast that is an exact replica of the
Diagnostic Casts casts generally made from dental structures captured in the impression
plaster or stone and used for patient education, treatment Trimming the process of removing excess hardened gyp-
planning, and tracking the progress of treatment, as with sum from the cast for ease in working with the cast and
orthodontic models; these casts are also known as study appearance in presentation
models Melting Range a range of melting points of the individual
Working Casts casts generally made from one of the components of wax
dental stones that are strong enough to resist the stresses Flow the movement of wax as it approaches the melting
of fabricating an indirect restoration or prosthesis; these range
casts are also known as master casts or working models Excess Residue a wax film that remains on an object
Dies replicas of the prepared teeth that are generally remov- after the wax is removed
able from the working cast Wax Pattern a duplicate of a restoration carved in wax
Model Plaster the weakest, most porous form of gypsum Lost Wax Technique a technique for fabricating a metal
product used in dentistry restoration by encasing the wax pattern in stone and then
Dental Stone a stronger, less porous form of gypsum vaporizing the wax under high temperatures to leave an
product used in dentistry empty impression space once occupied by the wax; mol-
Die Stone the densest form of gypsum product used in ten metal is then cast into the space and takes the shape
dentistry of the pattern
  

Gypsum is a mineral widely found in nature that has been used impression is filled with a gypsum material made from a fine
for making dental casts since 1756. Dental casts and dies are powder that is mixed with water to form a flowable mass. Once
used as replicas of the hard and soft tissues of the patient’s oral hardened, this material will be a hard, stable positive reproduc-
cavity. First, an impression, the negative reproduction of the tion, or cast, of the hard and soft tissues (Fig. 16.1). These hard
patient’s mouth, is taken using a soft, elastic material. This replicas are used to plan and track the progress of treatment.
374
 Gypsum and Wax Products CHAPTER 16 375

FIG. 16.1 Impressions (negative reproductions) are poured into gyp- FIG. 16.2 Diagnostic casts made from plaster. (From Bird DL, Robin-
sum to form casts (positive reproductions). son DS: Modern Dental Assisting (ed 12). St. Louis, 2018, Elsevier.)

They are also used in laboratory procedures, where they serve models extensively as they plan and treat the align-
as the replicas on which dental procedures, either unsafe or too ment of the teeth. (Fig. 16.2)
difficult to do directly in the mouth, are performed. The dental Working casts: Also called working models, working
auxiliary is frequently called upon to produce these replicas. In casts are used to fabricate appliances such as an orth-
some states, the assistant or the hygienist may fabricate intra- odontic retainer or bleaching tray or a removable pros-
oral prostheses on these replicas. Both auxiliaries may also find thesis such as a partial or full denture. (Fig. 16.3)
the resultant model useful in presenting information for patient Dies: Dies are replicas of individual teeth or groups
education. The production of gypsum casts requires meticulous of teeth and are used to fabricate crowns and bridges.
attention to detail, a well-thought-out process in their produc- (Fig. 16.4)
tion, and knowledge of the advantages and limitations of each Diagnostic casts, working casts, and dies are not re-
gypsum material for appropriate selection. Inaccurate, incom- quired to meet the same use stresses; therefore they do
plete, or weak casts are of little use and are likely to produce not have the same physical property requirements. The
costly mistakes in patient treatment procedures. accuracy of each of these replicas is dependent on the
Dental waxes are used in a wide variety of clinical and accuracy of the impression from which they are poured.
laboratory dental procedures. Clinically, they may be used to The accuracy and use of the replica also depend on the
fabricate direct waxing patterns for cast restorations; altera- gypsum material used and the properties of this material.
tions and adaptations for impression trays; and wax bite reg-
istrations. In the laboratory, they may be used to box an im-
pression before pouring a gypsum product, as baseplates for
DESIRABLE QUALITIES OF GYPSUM PRODUCTS
full and partial dentures, to hold components together before There are several desirable qualities for gypsum
articulation, and to provide indirect patterns for casting. products used in the making of diagnostic and work-
The dental assistant and hygienist typically will not fab- ing casts or dies. These qualities have differing sig-
ricate the actual direct or indirect wax pattern for a dental nificance depending on the use stresses applied to the
casting, but they do need an appreciation for the many steps product. The importance of qualities such as accura-
in the procedure known as the lost wax technique (described cy, reproduction of fine detail, dimensional stability,
later in this chapter). The assistant and the hygienist will hardness, strength, and resistance to abrasion, solu-
frequently manipulate waxes in making alginate impres- bility, ease of use, cost, color, and safety depend on
sions, pouring impressions, and making a wax bite registra- the application of the product. All casts and dies must
tion for articulation of models. be accurate, hard, and dimensionally stable under
normal conditions of use and storage. Because work-
ing casts and dies are used to fabricate intraoral pros-
USES AND DESIRABLE QUALITIES OF GYPSUM
theses and restorations they must also have excellent
Gypsum products are most frequently used to make reproduction of fine detail, strength and resistance to
replicas of the patient’s mouth. These replicas are abrasion, and minimal solubility. Color is important
called diagnostic casts, working casts, and dies. Each of in the identification of the material and to provide
these has a specific purpose in the treatment planning contrast between the die material and the waxed in-
or fabrication of intraoral appliances, prostheses, or lay pattern. The amount of expansion of the gypsum
restorations. material during its set is important to the overall ac-
Diagnostic casts: Also called study models, diagnos- curacy of the cast. The cost, ease of use, and safety are
tic casts are used to plan treatment and observe the practical considerations in the manipulation of the
oral structures of the mouth. Orthodontists use study product and frequency of its use.
376 CHAPTER 16 Gypsum and Wax Products

resistance to abrasion of the final product. The compo-

nents of all gypsum products are chemically the same;
the physical differences in the materials are due to the
differences in calcination and the resulting amount of
water that is drawn off the dihydrate.

Calcination:

Mineralsgypsum (dihydrate of calcicum sulfate)

heat and/or pressure
calcium sulfate hemihydrate + water

Reverse reaction:
Calcium sulfate hemihydrate + water
→ dihydrate of calcium sulfate (exothermic)

Clinical Tip
Plaster contains the most excess water of the various
FIG. 16.3 Working cast made of dental stone used to fabricate appli- gypsum mixes and therefore produces bigger and more
ances. (Courtesy of Steve Eakle.) numerous air voids; die stone contains the least excess
water and therefore produces fewer, smaller air voids.

PRODUCTION OF GYPSUM PRODUCTS

Production of the various forms of gypsum is basically
the same. With some modifications, they are used for
several different purposes. Ground gypsum (i.e., calcium
sulfate dihydrate) is heated during the manufacturing
process until it loses water and becomes calcium sulfate
hemihydrate. If the heating process occurs in open vats
FIG. 16.4 Dies which are replicas of individual teeth used to fabricate
crowns and bridges. (Courtesy of Pocket Dentistry.)
at a temperature of approximately 115 °C (239 °F), the
resulting hemihydrate is porous and irregular in shape.
This process will form model plaster or β-hemihydrate
PROPERTIES AND BEHAVIORS OF GYPSUM commonly used for diagnostic casts (study models). If the
PRODUCTS heating process is done under pressure, in the presence
of steam, and at a higher temperature (125 °C [257 °F]),
CHEMICAL PROPERTIES a more uniformly shaped and less porous form of hemi-
Chemically, the mineral gypsum is a dihydrate of calci- hydrate, referred to as dental stone, is produced. Dental
um sulfate (CaSO4·2H2O), which is mined as solid mass. stone is used for working casts (master casts). By first boil-
To form it into a powder, the manufacturer heats this di- ing the gypsum rock in a 30% calcium chloride solution a
hydrate, which causes it to lose water. It is then ground high-density raw material called densite is produced. This
to produce a powdered hemihydrate, CaSO4·½H2O. densite material is then washed and heated with a greater
This process is referred to as calcination. When the hemi- increase in pressure, and then even more refining of the
hydrate is again mixed with water, a viscous product powder by grinding results in the densest stone known as
capable of flowing is produced. Once this chemical re- high-strength or die stone. This additional refining makes
action is complete, the hemihydrate is converted back even more regular particles with better packing ability,
to a dihydrate and becomes again a solid mass. The by- thus reducing the amount of water required for mixing
product of the chemical reaction is heat, so it is called an and increasing the final density of the product. When
exothermic reaction. The amount of water required to mix high-strength stone is mixed with silica, it forms dental in-
with the calcium sulfate hemihydrate is greater than the vestment, a material able to withstand the high heat and
amount required for the chemical reaction. This excess stress produced when molten metal is forced into molds
water produces a mix that can flow into the details of to form indirect restorations by the lost wax technique
dental impressions. The excess water evaporates on set- (described later in this chapter).
ting, and a mass of interlocking gypsum crystals is pro-
duced. Between the gypsum crystals are small voids of
Clinical Tip
air that were once occupied by the water that has evapo- The increase in water necessary to mix a gypsum product
rated. The amount and size of the air voids remaining also increases the setting time and reduces the strength
are directly related to the final hardness, strength, and and hardness of the set gypsum.
 Gypsum and Wax Products CHAPTER 16 377

PHYSICAL PROPERTIES affect their hardness. Because gypsum products require

Physically, gypsum products are manufactured as varying amounts of water to wet and incorporate the
plaster, stone, high-strength stone, and gypsum-bond- powder into a workable mixture, it follows that the more
ed investment. The main differences in the physical water that is used, the weaker the cast will be. Increased
forms are dependent on the variations in size, shape, porosity of the particles makes it necessary to use more
and porosity of the powders produced by the different water to convert the hemihydrate particles back to dihy-
manufacturing processes. The larger, more irregular drate particles. A product with less water has a higher
and porous the particles of powder, the weaker and density of crystals and is therefore a denser and stron-
less resistant to abrasion the final product becomes ger product. The larger, more irregularly shaped particles
(Fig. 16.5). are prevented from fitting together densely. For instance,
Its properties and behavior determine the specific plaster particles are both porous and irregular, requiring
use of the gypsum product. Properties of strength, more water to mix. The resulting product has more air
abrasion resistance, and solubility and behaviors of set- space because of the less densely packed particles, mak-
ting time and expansion vary in importance, depend- ing plaster considerably weaker than the less porous and
ing on the application. Diagnostic casts, for example, more densely packed stone products.
are placed under little stress and are usually produced The strength of the gypsum product is an indicator of
from less expensive materials such as plaster or stone, its ability to resist fracture. Compressive strength of plas-
both of which have lower properties of strength and ter is four times less than that of densite and three times
abrasion resistance. Working casts and dies require less than that of stone. The tensile strength of plaster is
materials resistant to greater stresses and thus require half that of stone. American Dental Association (ADA)
higher properties of strength and abrasion resistance specifications require that the material reach minimal
and precise accuracy; therefore setting expansion must compression strength (i.e., wet strength) 1 hour after
be carefully controlled. setting.
Clinical Tip
Strength, Hardness, and Resistance to Abrasion
To reach maximal strength (i.e., dry strength), the cast
The morphology of the gypsum particles determines the
may need to set in a dry environment for several hours or
properties and behavior of the gypsum product. Factors overnight.
that affect the strength of gypsum products also affect
their hardness. Two factors contribute to the strength and
abrasion resistance of the final product: the shape of the
particles and their porosity; how much water is needed Dimensional Accuracy
to mix the product. The strength of gypsum products is Setting expansion occurs with all gypsum products.
related to the amount of water, and more critically, ex- Plaster expands the most, at 0.30%, and high-strength
cess water, used in producing the study or working cast. stone products the least, at 0.10%. Setting expansion is
Factors that affect the strength of gypsum products also a result of the growth of crystals as the particles join.
Controlling setting expansion is critical for the produc-
tion of accurate models and dies. It is important that
expansion be held to a minimum, particularly when
the material is being used to fabricate restorations
and dental prostheses. If expansion were excessive,
any die fabricated from the gypsum material would
eventually result in an oversized restoration. Although
some expansion is acceptable for models fabricated
from plaster, expansion of die materials would be a
source of costly errors. Strict proportioning of water
and powder, and of the chemical additives provided
by the manufacturer, is required to produce dies with
the required level of accuracy. Power-driven, vacuum-
mixed, high-strength stone, as produced by dental lab-
oratory technicians, will expand less than if the stone
20 m is hand mixed. Setting expansion occurs only during
hardening of the gypsum product. No changes occur
under normal conditions of use and storage once the
FIG. 16.5 Scanning electron micrograph of the surface of set high- product has reached its final set.
strength dental stone (die stone). The surface is porous with many
interlocking crystals of calcium sulfate dihydrate. To the naked eye this
surface would appear smooth. (From Powers JM, Wataha JC: Dental
Reproduction of Detail
Materials: Properties and Manipulation (ed 10). St. Louis, 2013, Else- The greater the porosity of the final gypsum product,
vier, p. 115.) the less surface detail is produced. Even products that
378 CHAPTER 16 Gypsum and Wax Products

have the least amount of porosity have surface irregu-

larities visible at the microscopic level.
Contamination of an impression with blood, food
debris, or saliva will affect the surface detail. The im-
pression should be rinsed with water and closely in-
spected for extraneous materials, and all water used
in this rinsing should be thoroughly removed before
pouring the impression. Compressed air via the air/
water syringe is the best method of removing all the
water from the impression prior to pouring.
Compatibility of impression material and gypsum
material can influence the quality of surface reproduc-
tion. Gypsum materials flow best when there is com-
patible wetting with the surface of the impression.
Wetting describes the ability of a material to flow and
not bead up, like water on a waxed surface. A decrease
in wetting may prevent the gypsum material from
flowing into all the details of the impression, leaving FIG. 16.6 Surfactant which can be added to gypsum to prevent
air voids from bubbles. Impression materials that are bubbles from occurring. (Courtesy WonderAdmix.)
water based work better with water-based gypsum
materials: for example, agar and alginate impression
materials are water based and generally form the best Clinical Tip
surface detail with gypsum products. It is always im- CAD/CAM technology (see Chapter 9) uses a digital image
portant to follow the manufacturer’s directions in se- of the preparation and can avoid the use of stone dies
lecting gypsum products that are compatible with im- when the restoration is made in one visit without the use of
pression materials. models. Therefore many of the problems mentioned above
Silicone, polyvinylsiloxane and polyether impres- regarding strength, abrasion, dimensional accuracy, and
sion materials, which are not water based, may ben- solubility can be avoided.
efit from the addition of a surfactant sprayed into the
impression before pouring to aid the gypsum in wet-
ting the impression material. The surfactant helps in
CLASSIFICATION OF GYPSUM PRODUCTS
the wetting of the impression, thus allowing the gyp-
sum material to flow more easily on the impression The desired physical properties and behavior neces-
surface. Spray surfactants should be used sparingly as sary for a particular use determine the criteria for
pooling of the surfactant in the impression will result selection of a gypsum product. If strength is desired,
in chalky areas on the model. A new material on the the choice of a stone or high-strength stone material
market distributes surfactant throughout the gypsum is important. If a diagnostic cast is being fabricat-
product to ensure an equal distribution of surfactant ed, plaster or stone is adequate. ADA specification
to the entire impression. The product (Wonderadmix; number 25 identifies the following five gypsum
Dental Creations) (Fig. 16.6) helps to eliminate pouring products.
bubbles by breaking the surface tension and allowing
the gypsum to glide over the surface of the impression.
Wonderadmix is added to the water before the gyp- IMPRESSION PLASTER (TYPE I)
sum powder is introduced. Impression plaster is rarely used by today’s dentists,
having been replaced with the less rigid, elastic im-
pression materials. If selected, it would be used as a
Solubility final impression wash for edentulous arches. Impres-
Set gypsum products are not highly soluble in wa- sion plaster may also be used to mount casts on an
ter. Solubility is directly related to the porosity of the articulator. A dental articulator is a mechanical device
material; therefore plaster is much more soluble than used to place maxillary and mandibular casts in occlu-
stone. Exposing models to water for prolonged periods sion and in a fixed position (Fig. 16.7). This device is
should be avoided (Table 16.1) as they will lose much used in the fabrication of removable and fixed prosth-
surface detail as they begin to dissolve. odontic appliances.
Clinical Tip
If gypsum needs to be soaked in water, the soaking should MODEL PLASTER (TYPE II)
be done in slurry water, that is, water saturated with plaster
Model plaster is frequently used for diagnostic casts
particles to prevent the loss of surface detail.
and articulation of stone casts. It has a water-to-powder
 Gypsum and Wax Products CHAPTER 16 379

Table 16.1    Properties of Gypsum Products

COMPRESSIVE
TYPE* POROSITY STRENGTH (MPa) ABRASION RESISTANCE SETTING EXPANSION
Type II: Model plaster High 8.8 Low High
Type III: Dental stone Moderate 20.6 Moderate Moderate
Type IV: High-strength/ Low 34.3 High Low
low-expansion stone
Type V: High-strength/ Low 48.0 High High
high-expansion stone
MPa, megapascal (1 MPa equals approximately 145 lb/in2); W/P ratio, water-to-powder ratio (milliliters of water per gram of powder).
*Type I (impression plaster) is rarely used by today’s dentists.

Uses of Diagnostic Casts

• P rovide a three-dimensional record of the patient’s hard
and soft tissues
• Facilitate study of the occlusal relationship of the dental
arches
• Facilitate study of tooth size, position, and shape and
arch relations
• Facilitate study of hard and soft tissues from the lingual
view while teeth are in occlusion
• Provide a record of present conditions for comparison
as treatment progresses
• Provide a visual aid for patient education
• Provide a legal record of the patient’s arches for insur-
ance, legal suits, and forensics

DENTAL STONE (TYPE III)

Dental stone (e.g., Hydrocal, USG Corporation), is ideal
for making full or partial denture models, orthodontic
models, and casts requiring higher strength and abra-
sive resistance. Dental stone has uniformly shaped, rela-
tively nonporous crystals. Because of the particle char-
acteristics, dental stone requires less water (W/P ratio =
0.30); its particles therefore pack together more tightly
(i.e., the material is denser) and approximately 2.5 times
FIG. 16.7 Articulated working casts with full upper and lower remov-
able prosthodontics. (Courtesy of Keystone Industries.) stronger than plaster. Stone is easy to use, moderately
expensive, and traditionally colored yellow or white.

(W/P) ratio of approximately 0.45 (i.e., 0.45 ml of wa- DENTAL STONE, HIGH-STRENGTH/
ter per 100 grams of powder), which produces a du- LOW-EXPANSION (TYPE IV)
rable but relatively weak cast when compared with the Type IV materials are often referred to as die stones or
stone categories. The irregular shapes of the particles densite because they are especially suited for fabricating
prevent them from fitting together tightly. These study wax patterns for cast restorations. A hard, abrasive-resis-
casts do not require a significant amount of strength tant surface is necessary to resist the abrasion of sharp
or abrasion resistance. Model plaster is available in instruments used to carve wax on these stone dies. Their
fast and regular sets and is easy to manipulate. This crystals are slightly larger and more dense than stone.
product is traditionally produced in a white color to These products require very strict and detailed handling,
distinguish it from dental stones. Because of its simple are often colored pink or green, have a W/P ratio of 0.23,
manufacturing processes, plaster is the least costly of and are almost two times stronger than type III stones.
all the gypsum products.
DENTAL STONE HIGH-STRENGTH/
Clinical Tip
HIGH-EXPANSION (TYPE V)
Model plaster is different from orthodontic plaster, which is
a mixture of plaster and stone.
Type 5, a recent addition to the list of ADA gypsum
products, has been developed in response to the need
380 CHAPTER 16 Gypsum and Wax Products

for even higher strength, high-expansion dental stones

and materials that can withstand the high temperatures
(1500 °C [2732 °F]) required by the casting process. The
addition of silica, a refractory material, improves the
material’s resistance to heat and is the reason the ma-
terial has increased thermal expansion. Higher expan-
sion may seem to be an undesirable property, but it is
needed to compensate for the greater casting shrink-
age of the newer base metals used for dental castings.
These materials are also referred to as gypsum-based
investment. The increased strength is obtained from a
W/P ratio of 0.20. This material, colored blue or green,
is the most costly of all the gypsum products.
FIG. 16.8 A working cast with a stone base and high-strength stone ana-
METAL-PLATED AND EPOXY DIES AND RESIN- tomic portion, and a die made from high-strength stone with metal plating.
REINFORCED DIE STONE
Type IV and V gypsum products are commonly used plaster is the appropriate choice because of the low
die materials. These materials are very hard, but they physical property requirements and because of its low
are susceptible to abrasion during carving of wax pat- cost and ease of manipulation. A working cast would
terns. Dies are occasionally electroplated with metal to require higher strength, accuracy, hardness, and abra-
produce better surface detail and make them less sus- sion resistance and therefore would probably be made
ceptible to abrasion. Silver or copper plating can create from dental stone. The dimensional accuracy, strength,
metal-plated dies that are highly resistant to abrasion. and abrasion resistance required for a die would make
The electroplating process forms a thin shell of metal high-strength stone the best choice. In some instances, a
on the outside of the die. combination of one or more gypsum products is appro-
Epoxy dies use a resin and hardener to produce a die priate to curtail cost and increase ease of manipulation.
that is harder and has greater abrasion resistance than When working models for cast restorations are being
high-strength stone. These epoxy materials set slowly and made, the die (the replica of the tooth on which, e.g.,
may require 16 to 24 hours for setting. Newer fast-set ep- a crown is being fabricated) is poured of high-strength
oxy materials are supplied in an automix system similar stone and the remaining teeth and base are poured with
to automix impression materials (see Chapter 15 Impres- type III stone (Fig. 16.8). The entire working model is
sion Materials). The epoxy resin and catalyst are forced attached to a dental articulator with plaster.
through the mixing tip directly into the final impression.
These fast-set products harden within 30 minutes. PROPORTIONING (WATER-TO-POWDER RATIO)
Some gypsum product die stones have resin par- The properties of gypsum products are directly related to
ticles added to reinforce the high-strength stone and their W/P ratio. It is important that the mixed material
make them more abrasion resistant. have sufficient flow to reproduce accurate and minute
surface detail; it should be remembered that an increase in
INVESTMENT MATERIALS
the recommended water will result in a thinner mix that
Investment materials are used to form metal cast- takes longer to set but because more water was used, the
ings through the lost wax technique. These materials, final product will be considerably weaker, and less accu-
which combine gypsum and silica, can be used to pro- rate. If water is decreased, the mixture will be thicker and
duce models sufficiently strong to allow molten metal may become difficult to manipulate, because it does not
to be poured into them. Investment materials have in- produce a flowable mix. Strict adherence to the manufac-
creased expansion on setting; this expansion is neces- turer’s suggested W/P ratio is recommended (Table 16.2).
sary to compensate for the shrinkage of metal castings.
New controlled expansion liquid is available to replace Caution
the use of water for mixing of investment materials. The W/P ratio has a direct effect on the properties of the
This liquid formulation is used to achieve greater ex- resultant product and must be carefully controlled.
pansion, allowing the dental laboratory technician to
achieve optimal fit for a variety of materials. Water should be measured with a graduated cylinder
and powder weighed on a scale. The use of scoops to
MANIPULATION OF GYPSUM PRODUCTS measure powder is not recommended because the pow-
der tends to pack down over time as it sits in a container.
MATERIAL SELECTION The use of inappropriate measuring devices and mea-
As previously mentioned, the selection of a gypsum suring technique will likely lead to one of two results:
product should be based on the desired properties of the • Stone cast with a too-low W/P ratio: The stone will
material. If a diagnostic cast is being fabricated, dental be too thick and detail will be lost.
 Gypsum and Wax Products CHAPTER 16 381

Table 16.2    Recommended Water/Powder (W/P) Ratios

Manufacturer Recommended W/P Ratios
Gypsum Product Water (in Milliliters) Powder
(in Grams)
Plaster (type II) 45-50 ml (0.45-0.50) 100 g
Stone (type III) 30-32 ml (0.30-0.32) 100 g
High-strength stone 19-24 ml (0.19-0.24) 100 g
(type IV)

FIG. 16.9 Broad metal gypsum spatula. (From Powers JM, Wataha JC:
Dental Materials: Properties and Manipulation (ed 11). St. Louis, 2017,
Elsevier.)

• S
 tone cast with a too-high W/P ratio: The stone will
be too thin, and its strength may be no greater than
FIG. 16.10 Programmable, power-driven, vacuum-mixing unit, pro-
that of model plaster. grammed for various types of gypsum products. The powerful vacuum
To avoid either of these scenarios, manufacturers quickly removes air and reduces the risk of bubbles. (Courtesy of Whip
produce pre-weighed envelopes of powder for critical Mix Corporation [Louisville, KY].)
measurements. This method enhances accuracy and
saves time but also increases the cost of the material.
impression with the help of a mechanical vibrator (Fig.
MIXING: SPATULATION 16.11) . As the viscosity of the mixture increases, the flow
Most commonly, plaster and stone are mixed in a flex- characteristics are decreased and the product loses its
ible rubber bowl with a broad metal plaster spatula (Fig. glossy appearance. This loss of gloss indicates that the
16.9); this mixing process is called spatulation. Mechanical gypsum has reached its initial set. At the time of initial
vacuum mix devices are used when the control of spatu- set, the material has no measurable compressive or ten-
lation is critical. The measured amount of water is placed sile strength and should not be removed from the mold.
into the mixing bowl and the measured powder slowly For regular-set products, the initial set occurs within 8 to
sifted into the water within 30 seconds. By sifting powder 16 minutes from the beginning of the mix. With a mixing
into water, an even wetting of the powder particles takes time of 1 minute, this leaves ample working time to pour
place and clumps are avoided. This is the reason for plac- the impression.
ing the powder in water rather than water into powder.
This technique will also minimize the amount of air incor- FINAL SETTING TIME
porated into the mix during hand spatulation. The ma- The final set is reached when the material can be handled
terials are spatulated by first incorporating the powder safely, but it has minimal hardness and resistance to abra-
and water slightly and then vigorously wiping the mix sion. At this time, the chemical reaction is complete and
against the sides of the bowl to force out air and ensure the model is cool to the touch, having completed the
wetting of all the powder particles. Spatulation should exothermic reaction. Most manufacturers recommend 45
continue for 1 minute at two revolutions per second un- minutes to 1 hour before the material may be safely sepa-
til a smooth, homogeneous mix with a glossy surface is rated from the impression. Gypsum products continue to
produced. An increase in the time and rate of spatulation harden and are two to three times harder after 24 hours.
has a definite effect on setting time and expansion: it will
Clinical Tip
shorten the setting time and increase the rate of setting
expansion. Many dental laboratories use mechanical Before separating the impression from the cast, ensure that
spatulation with a vacuum device to reduce air bubbles no part of the impression tray is connected to the gypsum.
Do not pry or rock in one direction too far, or the cast will
and enhance the consistency and accuracy of mixing (Fig.
likely break because of its lack of tensile strength.
16.10). Hand spatulation is the most common means of
mixing gypsum materials in private dental offices (Pro-
cedure 16.1). Allowing the impression and cast to remain togeth-
er for more than 1 hour before separation may have a
INITIAL SETTING TIME AND WORKING TIME detrimental effect on the surface characteristics of the
After mixing for 1 minute, the working time begins. Dur- cast. Alginate will absorb water from the surface of
ing this time, the semifluid mixture is poured into the the cast producing a weaker, more porous surface. The
382 CHAPTER 16 Gypsum and Wax Products

Temperature
Within limits, an increase in the temperature of the mix-
ing water will accelerate the setting time. Gypsum is ide-
ally mixed with room temperature water. Increasing the
temperature of the water, not to exceed 38 °C (100 °F), will
accelerate the set. Any increase in temperature to above 38
°C (100 °F) will have a retarding effect, and at 100 °C (212
°F) no reaction takes place and the gypsum will not set.

Accelerators and Retarders

The most practical way to control setting time is through
the manufacturer’s addition of chemical accelerators or
retarders. Manufacturers add accelerators and retarders
to change the solubility of the hemihydrate in water. By
FIG. 16.11 Small increments of plaster flowing slowly from the posterior
increasing the solubility of the hemihydrates, the added
of an alginate impression on the dental vibrator to ensure air does not accelerator decreases the setting time, and by decreasing
get trapped. (From Robinson DS, Bird DL: Essentials of Dental Assist- the solubility, the added retarder increases the setting
ing (ed 6). St. Louis, 2017, Elsevier.) time. When accelerators are placed into the gypsum, the
manufacturer can cut the time between the initial and
directions provided by the manufacturer of the impres- final set by 50%. These materials are labeled “fast set.”
sion material will indicate how long a gypsum product If no accelerators or retarders are placed in the product,
may remain in contact with the impression material. the product is labeled “regular set.”
The clinician may also add accelerators. Potassium
Clinical Tip
sulfate (K2SO4) and set gypsum (CaSO4) particles are
If an alginate impression has dried out before the cast has examples. The water and crystals from ground set
been separated, soak the impression and cast in water for 15 gypsum, commonly retrieved from the runoff water of
minutes. The alginate will soften, allowing removal of the cast
model trimmers, is called slurry water. The dihydrate
without breaking of the teeth or other anatomic structures.
Do not leave gypsum products soaking in water longer than
crystals in the slurry water accelerate the chemical re-
absolutely necessary as they will begin to dissolve. action by acting as established sites for crystallization.

Using Clean Equipment and Impressions

CONTROL OF SETTING TIMES When set materials are left in mixing bowls, on spatu-
It is important to keep in mind that it is impossi- las, or on other mixing equipment these materials may
ble to accelerate the final set of a mixture without inadvertently become part of the fresh mix. The result
also accelerating the initial set, thereby reducing the may be the same as the addition of an accelerator; how-
working time. If it is necessary to alter the setting ever, this uncontrolled error will likely also result in an
time, this can be accomplished by altering the W/P uneven setting of the material. All equipment should
ratio, spatulation, temperature or amount of accel- be meticulously cleaned after pouring an impression
erators or retarders. to avoid this mistake.
Blood, saliva, and alginate are organic substances
Altering the W/P Ratio that can retard the set of gypsum. If these organic com-
As previously mentioned, an increase in the propor- ponents are left in an impression, the surface detail of
tion of water will retard the setting times. However, the resulting model may be easily abraded. All impres-
because an increase by even 1 part water can reduce sions must be rinsed free of any organic matter before
the strength by as much as 50%, this is not a recom- the impression is poured. Alginate remains in contact
mended control. Decreasing the proportion of water with the gypsum product, so it must be noted that
will accelerate the setting time, but it also makes the even though the outside surface of a cast poured from
mixture more difficult to manipulate, causing air bub- an alginate impression may seem set, the area adjacent
bles and leading to an inaccurate model. Decreasing to the teeth needs more time to fully harden.
the amount of water (i.e., decreasing the W/P ratio) Remember that when a change is made in the final
is recommended only when the mixture is not being setting time, a sacrifice is usually made in the working
poured into an impression, such as when it is being time, strength, or setting expansion of the final product
used as a base to secure models on an articulator. (Table 16.3).

Spatulation FABRICATING AND TRIMMING DIAGNOSTIC/

A longer and more rapid spatulation of gypsum results WORKING CASTS
in an accelerated setting time. This rapid spatulation Diagnostic and working casts have two parts:
will also result in increased setting expansion. (see Fig. 16.12)
 Gypsum and Wax Products CHAPTER 16 383

Table 16.3    Manipulation Factors

FACTOR WORKING TIME VISCOSITY STRENGTH
Increase W/P ratio Increase Decrease Decrease
Decrease W/P ratio Decrease Increase Increase
Increase rate of spatulation Decrease Increase No effect
Increase temperature of H2O Decrease Increase No effect
Decrease temperature of H2O Increase Decrease No effect
W/P ratio, water-to-powder ratio (milliliters of water per gram of powder).

• A natomic portion: The anatomic portion replicates Maxillary model

the hard and soft structures.
• Art portion or base: The art portion aids in handling Back
and articulating the casts.
Heel
The anatomic portion is poured by vibrating small Art portion Top
increments of flowable gypsum into the impression.
The mixture should be poured slowly in small incre-
ments under vibration and allowed to flow from the Anatomic
one tooth imprint to the next, pushing out air ahead of portion
itself as it fills the entire impression, thus eliminating
air voids. To conserve costs and make the cast easier Wax bite
to trim, the anatomic portion may be poured with a
higher-strength gypsum product and the base poured Mandibular model
with a lower-strength product. The art or base portion
can be poured by any of three methods (Fig. 16.13) (see Anatomic
Procedures 16.2 and 16.3). portion
Art portion
Double-Pour Method FIG. 16.12 Line drawing of parts and proportions of diagnostic casts.
The double-pour technique involves two separate (From Bird DL, Robinson DS: Modern Dental Assisting (ed 11). Phila-
mixes and two separate setting times. The anatomic delphia, 2014, Elsevier.)
portion of one or both arches is poured and left in the
upright position. Make sure you have slightly over-
filled the entire impression, including the palate and
borders of the impression. Add a couple of additional stone and the base portion is poured with plaster.
small mounds of gypsum to the surface to make a bet- This gives the anatomic portion sufficient densi-
ter lock with the base. Approximately 10 minutes after ty while allowing for easier trimming of the base
the loss of gloss, a second mix is produced for the art portion.
portion(s). This mixture is approximately 1 inch thick
and placed on a glass tile in the shape of the impres- Single-Step Method (Inverted Pour Method)
sion tray or into a base former. The filled impression In the single-step method, one mix of gypsum is pro-
is inverted onto the base, with the handle of the tray duced to pour both the anatomic and art portions
parallel to the base, and the peripheries of the two por- of the cast. After the impression is poured, the re-
tions are joined. Care must be taken to ensure that the maining material is used for the base. This material
base material is thick enough to support the weight of is placed on a glass tile or into a base former (Fig.
the filled impression so that it does not sink into the 16.13, lower image), the impression is inverted onto
base. Avoid manipulating the filled impression once it, and the peripheries of the two portions are joined.
you place it on the base; over manipulation will sink This method requires better skill and timing. If the
the filled impression into the base. After inverting the mixture is too wet when you finish pouring the im-
impression, excess material may be carefully removed pression, the base may flow excessively when the
from the base to form a model requiring less time to impression is inverted, causing the tray to become
trim on the model trimmer. Be careful not to allow the locked into the set gypsum. Also, the material in the
base material to contact the impression tray as this will inverted impression may slump away from the im-
produce a mechanical lock between the tray and set pression, causing distortion of the cast or trapping
gypsum, making it difficult to separate the tray from of air voids. If the mixture in the anatomic portion
the model. has reached its initial set when it is inverted onto
If the cast is being used as a working cast, the the art portion, the union between art and anatomic
anatomic portion is frequently poured with dental portions will be incomplete.
384 CHAPTER 16 Gypsum and Wax Products

Clinical Tip
Avoid reaching into the plaster bin with wet hands or
spatula. It will affect the set of the material that has been
contaminated.
Products offered in pre-weighed envelopes are com-
monly used in offices where the turnover of gypsum is low.

CLEANUP
Gypsum mixing and handling equipment must be
kept meticulously clean. As previously mentioned, set
gypsum particles inadvertently included with freshly
mixed gypsum will accelerate the setting time. Bowls,
spatulas, mechanical vibrators, and mixing devices
should be cleaned of all traces of gypsum as soon as
possible after manipulation.
FIG. 16.13 Pouring the art portion of a cast by boxing; model former Caution
and inversion on patty base.
Remember that all excess material should be placed in the
trash and not rinsed down drains, where it will likely clog
pipes. Equipment should then be thoroughly rinsed under
Criteria for Evaluation of Poured Diagnostic running water. Sinks in gypsum-handling areas should be
Casts fitted with plaster traps.
• T he anatomic portion is free of all air voids.
• The art portion is free of all air voids greater than 2 mm.
• The union between art and anatomic portions forms a INFECTION CONTROL AND SAFETY ISSUES
continuous surface.
• The occlusal plane, at the premolar area, is parallel to
The need for infection control measures to extend into
the bottom of the base. the dental laboratory has been clearly documented.
• The base is of adequate thickness but not so thick as Routine disinfection of impressions should be done in
to require excessive trimming. the dental office. (A discussion of disinfecting agents
• There is sufficient material extending past the muco- and procedures for disinfecting impressions are present-
buccal fold and posterior to the casts to replicate all ed in Chapter 15 Impression Materials.) Disinfection of
anatomic structures. impressions is the best way to prevent the introduction
• Excess material in the tongue area has been of contaminants into the laboratory area. If this has not
smoothed., been done, the impression and all equipment, such as
plaster spatulas and dental vibrators, must be handled
with proper personal protective equipment or barriers.
Boxing Method Casts should be completely set and stored for at
In the boxing method, a strip of boxing wax is used to least 24 hours before disinfecting to prevent attack by
surround the impression, forming a wall into which the the chemicals on the surface of the cast. Casts should
gypsum is poured (Fig. 16.13, upper left image). The wax be sprayed rather than immersed in disinfecting solu-
should not distort the impression. It should extend at tions, because some studies have shown damage to the
least 0.5 inch higher than the highest point of the impres- surface in only a few minutes in water-based solutions.
sion and create a base that is parallel to the occlusal plane. Solutions such as 1:10 sodium hypochlorite, iodophors,
or chlorine dioxide have been shown to have minimal
STORAGE effect on cast surfaces when used in this manner. When-
Gypsum products can absorb water from the environ- ever working with powdered gypsum products a mask
ment. Humidity and close proximity to water sources should be worn to prevent inhaling the fine powders. A
will adversely affect the powder. Initially this expo- mask should also be worn during trimming of casts as
sure will accelerate the setting reaction by producing aerosols are produced by the model trimmer that can
established sites of crystallization. After prolonged ex- be inhaled. Protective glasses must always be worn for
posure, the setting reaction is retarded because of de- both the pouring and trimming of casts.
creased solubility of the crystals by the formation of a
dihydrate layer on the hemihydrate particles. SEPARATING THE IMPRESSION FROM THE CAST
Gypsum should be stored in airtight, moisture- On setting of the gypsum, the impression, tray, and
proof containers. To avoid prolonged exposure to cast must be separated (Procedure 16.4). When the im-
moisture, open plaster bins are recommended only if pression is poured, care should be taken to make sure
there is rapid turnover of the products. the gypsum does not flow onto the tray, locking it into
 Gypsum and Wax Products CHAPTER 16 385

the set gypsum. To separate the cast, begin by cutting 30 Canine

the excess gypsum away from the periphery of the eminence
tray. Gently ease a laboratory knife under the tray and
lift the tray slightly in several areas. Use the impres-
sion material as a cushion to avoid gouging the ana-
tomic portion of the cast. Remember, gypsum products 65 65
have very low tensile strength. Do not rock the tray

/2 ”
back and forth too much; this may result in breaking 115 115 Heel

1
A
the teeth of the cast. Mid-sagittal Tuberosity
raphe
Criteria for Evaluation of Trimmed Diagnostic Cut to depth
Casts of buccal
sulcus
• A natomic portion accounts for one-half of the total B
depth, and the base portion for one-half of the total
depth.
• Bases of the maxillary and mandibular casts should be
parallel with the occlusal planes and with each other. Rounded
• Posterior borders of both casts are at right angles to the
base and will stand together when articulated on end.
• Posterior portions include retromolar pads and
tuberosities.
• Side borders are perpendicular to the base, symmetric,
and trimmed to the depth of the vestibule. 55 55
• Anterior borders are perpendicular to the base and are
115 115

/2 ”
trimmed to the depth of the vestibule. C

1
• Anterior borders of the maxillary cast form a point at
FIG. 16.14 Line drawing of landmarks, angles, and cuts of art portion
the midline and are rounded from cuspid to cuspid of diagnostic casts. A, Maxillary cast. B, Cut to depth of the vestibule.
for the mandibular cast. C, Mandibular cast. (From Bird DL, Robinson DS: Torres and Ehrlich
• Mandibular casts have a smoothed tongue space. Modern Dental Assisting (ed 9). Philadelphia, 2009, Elsevier.)
• Maxillary and mandibular casts are labeled with the
patient’s name and date.
Caution
Exercise care when using the model trimmer. Always wear
protective eyewear and mask, establish a flat surface from
TRIMMING
which to trim, and pay attention to your hand positions.
Trimming of models with a model trimmer is done to pro- The abrasive wheel can rapidly abrade skin and fingernails!
duce an attractive, symmetric model with easy access to Use even, steady pressure with both hands while trimming.
all anatomic portions of the model and a base of sufficient To maintain the abrasive surface of the trimming wheel,
bulk for stability. Bases made from dental stone should be maintain an adequate flow of water on the trimming wheel
soaked in water for 5 to 10 minutes before trimming to sat- when in use, so that it does not clog with gypsum. Clean the
urate the stone, making it easier to trim. Anatomic portions wheel and work surface of all gypsum products immediately
should never be soaked. Saturation of the teeth may lead after finishing.
to a change in surface texture and, in the case of plaster,
may make the teeth more susceptible to chipping.
The cast should be trimmed so that, proportionally, the
base makes up one third and the anatomic portion two
COMPOSITION AND PROPERTIES OF DENTAL
thirds of the total depth. The occlusal plane should be
WAXES
parallel with the base. The periphery of the largest arch is Dental waxes are composed of a mixture of components
trimmed first, and then the smaller arch is articulated with from natural and synthetic sources. Natural waxes are
a wax bite and trimmed to match (see Procedure 15.5 for produced from plants, used in carnauba wax; insects,
a description of wax bite registration). The outer borders used in beeswax; and minerals, used in paraffin and
should be cut to the depth of the vestibule and should in- ceresin wax. These natural waxes contribute properties
clude all muscle attachments, retromolar pads, and tuber- to the wax but are rarely used in their pure form. They
osities. If there are facially inclined or rotated teeth, the out- are combined or mixed with synthetic waxes, gums,
side borders should be extended symmetrically to include fats, oils, resins, and coloring agents. Each component
these anatomic structures. The anterior portion of the max- is added to attain the physical properties desirable for
illary arch is cut to a point at the midline, and the anterior the wax application. The components of waxes allow
portion of the mandibular arch is rounded from canine to them to be sticky, solid, or liquid depending on the
canine (Fig. 16.14) (see Procedure 16.5 for detailed instruc- temperature of the wax. Use of the wax will determine
tion on trimming models). properties that are desirable for its application.
386 CHAPTER 16 Gypsum and Wax Products

Important properties of waxes in general, and of

dental waxes in particular, include the following:
• Melting range
• Flow
• Excess residue
• Thermal expansion
The operator must consider these properties when se-
lecting a wax, as well as during manipulation of the wax.

MELTING RANGE
Dental waxes have a melting range, a range of tempera-
tures at which each component of the wax will start
to soften and then flow. The components with lower FIG. 16.15 Various forms of wax: Sheets, ropes, and sticks. Impres-
melting points will soften first; then, as the tempera- sion wax (top row left), baseplate wax (top row middle left), casting
ture is increased, more components will soften and the wax (top row middle center), inlay wax (top row middle right), utility wax
(middle), and boxing wax (bottom).
wax will eventually flow and eventually become a liq-
uid or vaporize. Because wax is unstable, the operator
must be careful to prevent its distortion. Controlling THERMAL EXPANSION
the temperature of the wax allows operator control of Waxes expand when heated and contract when cooled;
the viscosity and flow of the wax. In many cases, the the thermal expansion and contraction of waxes is
operator does not want the wax to flow but only to greater than that of any other dental material. This
soften. A flame source is needed if a flowable state is property is especially important for pattern waxes. If
desired. To prevent distortion, the melting range must a wax is heated too far above the melting range or is
be higher than the temperature of the environment. heated unevenly, expansion above acceptable stan-
This is especially important in hot climates. dards will result. Manufacturers provide temperature
and handling guidelines for pattern waxes to prevent
FLOW inaccuracies in the final casting. In addition, if waxes
Flow is the movement of wax as molecules slip over are allowed to stand, dimensional changes occur from
each other. As the temperature of the wax increases, the the release of residual stress. Wax patterns should be
viscosity of the wax decreases until the wax becomes a invested within minutes of carving.
liquid. Control of the flow and the melting range is im-
portant in manipulating wax. If a wax were capable of
CLASSIFICATION OF WAXES
flowing at room temperature, it would be very difficult
to control. However, even at mouth temperature, there Waxes are grouped as follows:
is a point at which flow is undesirable. If you were us- • Pattern waxes: Pattern waxes include inlay wax, cast-
ing a wax for a wax bite registration, you would not ing wax, and baseplate wax
want it to flow at mouth temperature, causing distor- • Processing waxes: Processing waxes include boxing
tion of the wax. It is important that the wax not require wax, utility wax, and sticky wax
temperatures much greater than mouth temperature to • Impression waxes: Impression waxes include correc-
soften, or it would be uncomfortable when placed in tive impression wax and bite registration wax
the mouth of the patient. A melting range that is only Manufacturers produce these waxes in several
slightly higher than mouth temperature is desirable for forms. Sticks, sheets, blocks, and tins are used. Waxes
this wax application. For laboratory purposes, waxes have unique coloring to distinguish them in use (Fig.
may have a much higher melting range. However, even 16.15).
for laboratory purposes, high melting ranges may be
undesirable. If you want to use a wax in the boxing of PATTERN WAXES
an impression, for example, it is much more desirable Pattern waxes are used in the construction of metal cast-
to mold the wax, using the heat of your hands or warm ings and bases for dentures. The three types of pattern
water, rather than having to use a flame. waxes are inlay wax, casting wax, and baseplate wax.

EXCESS RESIDUE Inlay Wax

It is important that all wax be removed from the ob- Inlay waxes are used to produce patterns for metal
ject onto which it is melted. If excess residue remains casting through the lost wax technique. There are
after the wax is removed, this may result in inaccura- three ADA specifications for Inlay wax: Type A that
cies in the object being produced. This is especially can be used directly in the mouth, Type B (type I) and
important in the lost wax technique, which requires Type C (type II), which are both melted onto a die out-
that the wax pattern be completely melted out of the side the mouth in the indirect technique. (Table 16.4)
investment mold. (Fig. 16.16). Type A wax, when used directly in the
 Gypsum and Wax Products CHAPTER 16 387

Table 16.4   Classification of Pattern Waxes, ADA Specification, and General Application.
CLASSIFICATION OF DENTAL PATTERN WAXES
NAME OF WAX ADA SPECIFICATION USES
Inlay wax Type A Direct patterns in mouth
Type B (type I) Indirect patterns on dies
Type C (type II)
Casting wax Construct metal framework of partial
and complete denture
Baseplate wax Type I Impression in cool climates
Type II Impression in warm climates
Type III
This Table Identifies the Different Types of Pattern Waxes, the American Dental Association Specification, and Uses of the Wax in Dentistry

mouth, has a much lower melting range to prevent

damage to the pulp of the tooth, for the comfort of
the patient and the accuracy of the wax on removal.
Because direct waxing is performed in the patient’s
mouth, all the limitations of working in the mouth
and patient safety measures must be considered. Be-
cause of these limitations, most dentists prefer to use
the indirect waxing technique and call on the exper-
tise of a dental laboratory technician to produce the
wax pattern and casting. Inlay waxes are supplied
in sticks, pellets, and tins, generally in dark colors of
red, blue, or green. They are labeled hard, medium,
and soft, which refers to their melting ranges. ADA
specification number 4 sets standards for pattern
waxes: low thermal expansion, complete removal of
excess residue, and appropriate melting ranges are
important properties.

Casting Wax
Casting waxes are used to construct the metal FIG. 16.16 An inlay waxing on a die.
framework of partial and complete dentures. These
waxes come in sheets and preformed pieces for
components of partial dentures. The physical prop-
erties of casting waxes are similar to those of inlay
waxes, with the exception of melting range. Be-
cause these waxes are not softened in the mouth,
the melting range is important only for laboratory
procedures.

Baseplate Wax
Baseplate waxes are sheets (7.5 cm wide by 15 cm
long) of wax that generally are pink in color. These
sheets are usually layered to produce the contours
of the denture and hold the position on which den- FIG. 16.17 A denture setup on baseplates.
ture teeth are set (Fig. 16.17). There are three ADA
specifications for baseplate wax. Type I is softer
and utilized in cool climates; Type II has a medium set, the form is then tried into the mouth to estab-
hardness and utilized in warm climates; and Type lish denture dimensions. The wax must not distort
III is harder and is also utilized in warm climates at mouth temperatures. Baseplate wax may also be
(Table 16.4). When the sheets of baseplate wax have used for occlusal rims (see Chapter 17 Polymers in
been layered on resin denture bases to produce the Prosthetic Dentistry) and bite registration (see Chap-
contours of the denture and the denture teeth are ter 15 Impression Materials).
388 CHAPTER 16 Gypsum and Wax Products

Utility wax ropes clear or ivory in colors may be

given to orthodontic patients to cover sharp brackets
and wires that irritate lips, cheeks and tongue. Util-
ity wax sheets may also be layered to form a horse-
shoe shape and used for wax bite registrations; how-
ever, because they are pliable they can distort easily.
These waxes come in various colors of pink, white,
and red.

Sticky Wax
Sticky wax comes in orange and red sticks that at
room temperature are hard and brittle, but when
heated under flame become soft and sticky. Sticky
wax is used to adhere components of metal, gyp-
sum, or resin together temporarily during fabrica-
tion and repair. Because of its brittle nature at room
FIG. 16.18 Utility wax used on the posterior of the impression tray temperature, even the slightest torque will fracture
to extend the tray and make the fit more comfortable for the patient. the wax. This is an important characteristic because
(From Bird DL, Robinson DS: Modern Dental Assisting (ed 12). St.
it alerts the operator that distortion has occurred
Louis, 2018, Elsevier.)
during manipulation.

PROCESSING WAXES
IMPRESSION WAXES
Processing waxes are used primarily to aid in dental
Impression wax and impression wax compounds are
procedures both clinically and in the laboratory. The
thermoplastic materials used to obtain impressions
three types of processing waxes are boxing wax, utility
of the oral structures. When heated, they become
wax, and sticky wax.
soft and able to take on a new form in the mouth;
and when cooled, they harden and can be removed.
Boxing Wax
These waxes and techniques for using them to take
Boxing wax is used to form the base portion of a
impressions are described further in Chapter 15
gypsum model. A 1.5-inch-wide red , green, or
Impression Materials. The two types of impression
black strip of boxing wax is wrapped around an
waxes are corrective impression wax and bite regis-
impression to produce a form into which gypsum
tration wax.
is poured. This wax is easily manipulated at room
temperature; it is also slightly tacky at room tem-
Corrective Impression Wax
perature, allowing it to adhere to itself to secure the
Corrective impression wax is used in conjunction
boxed form.
with other impression materials in the process of
taking edentulous impressions. This wax flows at
Utility Wax
mouth temperature and is used within another im-
Also called periphery wax, this wax comes in sticks,
pression material to correct undercut areas, to fill
long square ropes, and round strips that are easily
in small voids or to help develop a functional pos-
manipulated at room temperature. They may be used
terior palatal seal for maxillary complete denture
with boxing wax to aid in the pouring of an impres-
impressions.
sion. Utility wax rope is used to adapt the periphery
of the impression tray to customize the tray and aid in
Bite Registration Wax
patient comfort (Fig. 16.18). The wax provides a better
Bite registration wax is used to produce wax bite
fit into the vestibule and control of movement of the
registrations for articulation of models. The pre-
impression material.
formed U-shaped horseshoe shaped wax is often
The pliable wax can also be used to block out under-
reinforced with metal particles to provide stabil-
cuts around teeth or tissues prior to impression mak-
ity. However, similar to corrective impression wax,
ing to prevent the impression from locking in place
this wax is susceptible to distortion at tempera-
(see Chapter 15, Fig. 15.20). However, there is a block
tures only slightly higher than mouth temperature
out wax on the market that is soft and pliable allowing
and must be carefully monitored. Because of this
for easy placement into undercuts on an impression
limitation, silicone and other more stable impres-
before pouring a model, making baseplates, splints, or
sion materials have largely replaced wax for bite
injection molding.
 Gypsum and Wax Products CHAPTER 16 389

registrations. For fabrication of a wax bite registra-

tion, see Procedure 15.5. Wax pattern

OTHER WAXES UTILIZED IN THE DENTAL OFFICE A

There are other waxes available on the market for spe-
cial uses in the dental practice or laboratory setting.
Wax pattern
They are not included in the categories listed above as
they have specialized uses.
Sprue

Orthodontic Wax
This wax is utilized for patients experiencing pain and
irritation while wearing braces. As the teeth are being B
moved, the orthodontic appliances in the mouth may
irritate the soft tissues of the gums and buccal mucosa. Casting ring
The orthodontic wax is applied to the brackets, bands, Wax pattern
or wires to prevent poking and scratching of the tis-
sues. The product is clear which will not be readily vis- Sprue
ible in the mouth. The wax may be provided in a por-
table container so the patient has access to the material Investment
regularly. A small chunk is taken out of the container
C
and flattened out, and then the piece of wax is stuck to
the area causing the patient discomfort. The product
is safe to ingest as there is a chance a small piece can
become dislodged and swallowed. Burnout pattern
This wax is a composite material containing pow-
dered aluminum to increase the heat retention, integ-
rity of the compound and provide the properties nec-
essary for efficient modeling. This material is utilized
when a dentist is making a new removable denture for D
a patient. During the jaw-registration stage, the wax is
softened over an open flame and place between the re-
cord blocks. It will keep the two record blocks together.
Casting
(See Chapter 17 Polymers for Prosthetic Dentistry, Pro-
cedure 17.2). Some clinicians use it in the laboratory as
a block put wax.

MANIPULATION OF WAXES E
Wax should be softened evenly in dry heat, with FIG. 16.19 Line drawing series on the lost wax technique. A, Wax pat-
warm hands, a warm water bath or by flame. If a wax tern on a die. B, Wax pattern with sprue on a die. C, Wax and sprue
is softened by flame, it should be rotated above the on sprue base and in investment ring. D, Wax pattern vaporized from
investment. E, Metal casting of wax pattern.
flame so that it evenly softens or flows. Melted wax
should be added in layers onto an object. As previ-
ously mentioned, because of changes caused by re-
laxation of residual stress, wax patterns should be with medical practitioners, invented a method for cast-
invested within 30 minutes of carving. Waxes such ing gold for dental restorations in molds; today’s tech-
as boxing and utility wax are slightly tacky at room niques are much the same (Fig. 16.19). The process of
temperature to help them adhere to themselves. They creating a detailed wax pattern and converting it into a
must remain dry if one is to take advantage of this final restoration is known as casting. The primary steps
characteristic. in the lost wax and casting procedure are as follows:
To avoid distortion of waxes, they should be stored 1. Pouring the die: An exact impression of the prepara-
at or slightly below room temperature. tion is first obtained and poured into a high-strength
die stone forming the die.
LOST WAX TECHNIQUE 2. Waxing the die: A detailed wax pattern of the resto-
Artisans have used the lost wax technique for several ration is carved on the die including all anatomy,
hundred years. In the 1500s, artisans, in conjunction contours, occlusion, and proximal contacts.
390 CHAPTER 16 Gypsum and Wax Products

FIG. 16.21 Cleaned and polished metal castings of inlays and crowns.

FIG. 16.20 Waxing of inlays and crown. investment material, and casting must be controlled
to achieve a final restoration that will have intimate
contact with the tooth preparation. This accuracy
3. Spruing the die: A wax or plastic sprue is attached will produce a cement interface of as little as 20 μm,
to the pattern to form the channel into which the ensuring a precise fit with space for a very fine film
molten metal will be forced. Multiple sprues may be of luting cement.
used for a more complex wax pattern.
4. Attaching the sprue base: The sprue is attached to a
SUMMARY
sprue base; this forms the funnel to help guide the
flow of molten metal into the wax pattern. Gypsum products are used to produce diagnostic
5. Investing the wax pattern: The pattern and attached and working models of the patient’s hard and soft
sprue are encased in an investment ring into which tissues. The properties of strength and hardness, set-
gypsum-based investment is poured. ting expansion, and solubility are directly related
6. Burning out the wax: Once hardened, the sprue to the amounts of water used in their construction.
base is removed and the investment-enclosed The density of the final product is related to these
pattern and sprue are heated in a burnout oven water amounts and to the size and shape of the par-
at high temperatures (500 to 700 °C), causing the ticles that are manufactured. Manipulation factors
wax and the sprue to vaporize (lost wax), leav- such as the W/P ratio, rate of spatulation, and water
ing an impression of the wax pattern in the now- temperature used in the mix have a great effect as
empty space. well. The clinician must have a clear understanding
7. Casting the restoration: The molten metal is moved of how these variables can be manipulated appro-
by centrifugal force through the empty channel priately. Pouring of models requires meticulous at-
formed by the sprue and into the empty wax pat- tention to detail to produce a replica that accurately
tern space. reflects the hard and soft tissues of the patient’s oral
8. Final steps: The metal cools, the sprue is removed, cavity.
and the casting is cleaned and polished using a The dental assistant and dental hygienist may have
series of polishing steps to form a smooth and occasion to use dental waxes in a variety of clinical and
glossy surface. The polishing procedure must be laboratory procedures. Although waxes have inherent
accomplished without altering the margins, con- disadvantages in dimensional stability and control of
tacts, or occlusion of the restoration. It is now flow, they are used successfully. The operator must
ready to be cemented onto the tooth (Figs. 16.20 keep in mind the limitations of each wax in order to
and 16.21). use it to its best advantage.
The accuracy of the entire casting process must be
carefully executed to produce a clinically acceptable
final restoration The lost wax procedure takes sev-
INSTRUCTIONAL VIDEOS
eral steps, each of which can cause inaccuracies in See the Evolve Resources site for a variety of educa-
the final product. Properties of expansion and con- tional videos that reinforce the material covered in this
traction in the impression material, die stone, wax, chapter.
 Gypsum and Wax Products CHAPTER 16 391

Procedure 16.1 Mixing Gypsum Products

See Evolve site for Competency Sheet. 3. Sift the powder gradually into the water, allowing
the particles to become wet—about 30 seconds.
Consider the following with this procedure: safety glasses are
NOTE: This minimizes the amount of air trapped
recommended for the patient, PPE is required for the operator,
in the mix.
and ensure appropriate safety protocols are followed.
4. Vigorously mix for about 60 seconds by wiping the
spatula against the sides of the bowl to incorporate
EQUIPMENT/SUPPLIES (FIG. 16.22) all the powder, removing excess air, until a smooth
• Gypsum product homogeneous mixture is obtained (Fig. 16.23).
• Scale NOTE: The viscosity of the mix should be sufficient
• Water (room temperature) to allow the material to flow only under mechanical
• Water-measuring device vibration.
• Flexible mixing bowl 5. Turn the vibrator on low/medium and place the
• Broad-blade metal spatula bowl onto the work surface.
• Mechanical vibrator 6. Press the sides of the bowl inward with the palms
of your hands, at the same time pressing the bowl
PROCEDURE STEPS downward on the work surface of the vibrator
1. Measure the recommended amount of room to remove all air incorporated during the mixing
temperature water into a clean, flexible, rubber procedure. The air bubbles will rise to the surface
mixing bowl. of the mix
NOTE: Increasing or decreasing the water tempera- NOTE: This helps to remove air trapped during
ture is the preferred way to control the working time. mixing.
2. Weigh the recommended amount of gypsum powder 7. Complete the preparation of the gypsum material
onto the scale; use another bowl or weigh onto a paper within 2 minutes.
towel. Make sure to account for the weight of the bowl NOTE: This includes mixing and initial vibrating
if you are using this method to transfer powder. and allows for sufficient working time in pouring.

FIG. 16.22 FIG. 16.23

Procedure 16.2 Pouring the Cast: Anatomic Portion

See Evolve site for Competency Sheet. • Gypsum mixture

• Broad-blade metal spatula
Consider the following with this procedure: safety glasses are
• Small wax spatula
recommended for the patient, PPE is required for the operator,
• Disinfected impression
and ensure appropriate safety protocols are followed.
PROCEDURE STEPS
EQUIPMENT/SUPPLIES (FIG. 16.24) 1. Rinse the impression of all traces of disinfecting
• Mask and safety glasses solution and tap it over the sink until no more
• Mechanical vibrator water can be shaken out.

Continued
392 CHAPTER 16 Gypsum and Wax Products

Procedure 16.2 Pouring the Cast: Anatomic Portion—cont’d

2. Holding the handle of the impression tray, place in the impression, or when the mixture will not flow
the impression tray onto the working surface of sufficiently to fill the indentations. Use small enough
the mechanical vibrator. Rest the tray handle at an increments to control the flow and tilt the impression
angle to the surface of the vibrator. as needed to aid the speed of the flow.
NOTE: To facilitate cleanup, cover the working sur- 6. Continue adding small increments of mixture in
face of the mechanical vibrator with a disposable cover, the same area while watching the material flow
such as a plastic bag. Hold the tray at a slight angle to toward the anterior portion of the impression (Fig.
the working table of the vibrator to aid in the flow of 16.26).
the material. The speed of the vibrator should be ad- 7. Tilt the impression forward and continue adding
justed only high enough to make the stone flow easily. increments across the anterior portion of the
Too much speed can incorporate bubbles into the mix. impression, making sure to control the flow so
3. Pick up a small increment of gypsum mixture, no that air is not trapped.
bigger than a large pea, on the end of the small 8. Tilt the impression toward the opposite posterior
wax spatula. portion and continue the addition of increments
NOTE: This allows for control of the amount of until the flow reaches the other end of the
material flowing into the tooth indentations. impression (Fig. 16.27).
4. Place the increment of mixture at one of the most 9. When all of the tooth indentations are filled
posterior corners of the impression (Fig. 16.25). with the gypsum mixture, begin adding larger
5. Allow the mixture to flow into the tooth increments until the impression is slightly
indentations from one side to the next of each overfilled (Fig. 16.28).
indentation while controlling the flow of the NOTE: Lift the impression from the vibrator to
mixture under vibration to force air out of each prevent the material from flowing over the impression
indentation. tray.
NOTE: Air bubbles are formed when the mixture
moves too fast over the tooth indentations, trapping air

FIG. 16.26
FIG. 16.24

FIG. 16.27
FIG. 16.25
 Gypsum and Wax Products CHAPTER 16 393

Procedure 16.2 Pouring the Cast: Anatomic Portion—cont’d

10. Vibrate the entire tray for 2 to 3 seconds to settle

all increments. Do not smooth the surface of the
material.
NOTE: A roughened surface will allow for better
attachment with the base; you may add an additional
two or three small mounds of material to the top of the
gypsum to help facilitate attachment to the base.
11. Cleanup: Wipe all excess gypsum from the bowl
and place it in the trash. Rinse and thoroughly
clean the bowl and spatula under running water
in a sink fitted with a plaster trap. Remove the
plastic bag from the mechanical vibrator and
clean the vibrator with a wet paper towel. FIG. 16.28

Procedure 16.3 Pouring the Cast: Art (or Base) Portion

See Evolve site for Competency Sheet. NOTE: This will produce a thicker mix, which is
necessary to accommodate the weight of the poured
Consider the following with this procedure: safety glasses are
impression when it is inverted. You may use plaster
recommended for the patient, PPE is required for the operator,
to pour the art portion of a model even if the anatomic
and ensure appropriate safety protocols are followed.
portion is poured with a different product. By using
plaster, you will save on the cost of the more expen-
EQUIPMENT/SUPPLIES sive stone products and if model trimming is neces-
• Mask and safety glasses sary, you will save time as plaster trims much more
• Glass tile or base former easily than stone.
• Broad-blade spatula 3. Place the mixture onto the glass tile or into a base
• Gypsum mixture former. You should have a mass at least 0.5 inch
• Poured impression thick and slightly larger than the dimension of
the filled impression and tray (Fig. 16.29).
PROCEDURE STEPS: DOUBLE-POUR METHOD NOTE: If using a base former, make sure you
1. Allow the poured impression to set for at least 10 choose one large enough for the impression and select
minutes. the correct arch shape for your impression: pointed for
NOTE: This prevents the gypsum material from maxillary and rounded for mandibular.
“slumping” away from the impression when it is in- 4. Invert the poured impression onto the base,
verted, causing distortion in the cast. making sure the occlusal plane remains parallel
2. Prepare a mixture of gypsum, using less water for with the base. Use the tray handle and the top of
the W/P ratio. the impression tray as your guide.
NOTE: If using a base former, you will also need to
make sure you keep the midline centered.
5. Very gently move the impression back and forth
to bring the anatomic and art portions together.
Be careful to prevent the filled tray from sinking
into the base.
6. Bring the base material up with a spatula to fill
the heels and sides of the impression and along
the tray periphery, taking care not to lock the tray
in with excess material (Figs. 16.30 and 16.31).
NOTE: Make sure there are no large air pockets
trapped between the art and base portions.
7. Smooth the tongue area of the mandibular
FIG. 16.29 impression level with the tray periphery.

Continued
394 CHAPTER 16 Gypsum and Wax Products

Procedure 16.3 Pouring the Cast: Art (or Base) Portion—cont’d

FIG. 16.30 FIG. 16.31

8. You may choose to carefully remove some of the 9. Allow the gypsum to set completely before
base material to begin to replicate the angle of the separating the model for the impression—45 to 60
trimmed model. This will cut down the amount minutes.
of time spent trimming the model on the model 10. When the final set has been reached, the gypsum,
trimmer. Make sure the model has reached its impression, and cast are separated.
initial set (loss of gloss) before attempting this.

Procedure 16.4 Separating the Impression from the Cast

See Evolve site for Competency Sheet.

Consider the following with this procedure: safety glasses are
recommended for the patient, PPE is required for the operator,
and ensure appropriate safety protocols are followed.

EQUIPMENT/SUPPLIES
• Safety glasses
• Laboratory knife
• Plaster nippers

PROCEDURE STEPS
1. Remove the model from the glass tile or base former.
NOTE: Do not allow agar-type impressions to re- FIG. 16.32
main longer than 1 hour without separating, as surface
detail will be diminished.
2. Trim all excess gypsum from the tray at the tray
edge with a laboratory knife (Fig. 16.32).
NOTE: Ensure that no part of the tray is connected
to the gypsum.
3. Loosen the tray from the impression material by
placing the laboratory knife between the tray and
the impression material in several areas and gently
prying the two apart.
4. Attempt to lift the tray in a upward motion; if the
tray does not lift, determine the location of the
locked area and remove it with the laboratory knife
or plaster nippers (Fig. 16.33).
NOTE: Remember that gypsum products have very
poor tensile strength; too much rocking of the tray will FIG. 16.33
likely result in broken teeth.
 Gypsum and Wax Products CHAPTER 16 395

Procedure 16.5 Trimming Diagnostic Casts

See Evolve site for Competency Sheet.

Consider the following with this procedure: safety glasses are
recommended for the patient, PPE is required for the operator,
and ensure appropriate safety protocols are followed.

EQUIPMENT/SUPPLIES (Fig. 16.34)

• Safety glasses and mask
• Maxillary and mandibular diagnostic casts
• Wax bite registration
• Measuring devices; millimeter ruler and compass
• Pencil
• Laboratory knife
• Plaster nippers
• Model trimmer
FIG. 16.35
PROCEDURE STEPS
1. Soak the art portion of casts for 5 to 10 minutes in
water.
NOTE: Do not allow teeth to soak in water, as this
may cause chipping of plaster or surface roughness of
plaster or stone. The art portion of the cast should soak
for a minimum of 5 minutes.
2. Cut excess gypsum distal to the retromolar pads
and tuberosities with plaster nippers (Fig. 16.35).
NOTE: Excess gypsum in this area may prevent
models from being articulated.
3. Remove small bubbles (blebs) of gypsum on the
occlusal surfaces with a laboratory knife.
NOTE: This allows for complete articulation with
the wax bite.
4. Check the working table of the model trimmer to FIG. 16.36
make sure it is secure and at a 90-degree angle to
the trimming wheel. bench and rock forward so that the anterior teeth
5. Adjust water flow over the trimming wheel to touch the laboratory bench. The cast should be
allow for sufficient water to clean the wheel. parallel to the bench top. Measure from the teeth
to the base of the cast; the anatomic portion of the
Base Cut cast should be two thirds of the total height, with
6. Place the maxillary cast teeth side down on a the art portion accounting for one half of the total
cushion of layers of paper towels on the laboratory height. Mark the models with a compass to this
line (Fig. 16.36).
NOTE: The occlusal surfaces are parallel to the
laboratory bench, with the anterior teeth touching the
surface.
7. Trim the base to the marked line, periodically
stopping to evaluate your progress. Remember:
You can always continue to cut; if you cut away
too much you may need to retake and repour the
impression.
NOTE: You may first need to make a flat back cut to
secure casts on the working table of the trimmer.
8. Repeat steps 6 and 7 with the mandibular cast.
When occluded the casts should be between 2 and
FIG. 16.34 2.5 inches.
Continued
396 CHAPTER 16 Gypsum and Wax Products

Procedure 16.5 Trimming Diagnostic Casts—cont’d

Side and Back Cuts vestibule or the most facially inclined tooth. Mark
9. Measure the back by making a straight line 3 mm the casts with a straight edge to connect this point
behind the retromolar pads of the mandibular and the point 3 mm from the canine eminence.
cast or tuberosities of the maxillary cast. 14. Trim the anterior cuts symmetrically to form a
10. Trim back to this line (Fig. 16.37). The maxillary midline point.
and mandibular cast’s back cuts should be NOTE: The maxillary cast forms a point between
parallel with one another. the central incisors.
NOTE: Trim the longest cast first, and then articu-
late casts with the wax bite, and match the opposite Anterior Cut: Mandibular Cast
cast’s back cut with the models articulated (Fig. 16.38). 15. Measure as previously described, 3 mm from
Do not trim away any anatomy on either cast. several places in the anterior region of the
11. Measure the sides 3 mm from the buccal bone at mandibular arch; connect these points with the
the widest portion of the arch (usually the molar point of the canine eminence to form a curved
area) and 3 mm at the canine eminence. Mark the line. Trim the anterior cut of the mandible to this
cast with a straight edge to connect these points. curved line.
12. With the models articulated trim the side cuts
symmetrical to these lines (Fig. 16.39). Again the Heel Cuts
maxillary and mandibular cast’s side cuts should 16. Trim the heel cuts at a 90-degree angle to a line
be parallel with one another. formed by connecting the canine eminence point
NOTE: Do not trim past the depth of the vestibule. to the side/back cut of the opposite side. The
maxillary and mandibular cast’s heel cuts should
Anterior Cut: Maxillary Cast be parallel to one another.
13. Measure 3 mm labial to the midline between NOTE: This line is approximately 0.5 inch and sym-
central incisors. Measure from the depth of the metric on each side.

FIG. 16.37 FIG. 16.39

FIG. 16.38 FIG. 16.40

 Gypsum and Wax Products CHAPTER 16 397

Procedure 16.5 Trimming Diagnostic Casts—cont’d

Optional Steps 19. Using model polish and a soft buffing cloth,
Finishing/Polishing polish the cast to a shine (Fig. 16.40).
17. Inspect the models for small air voids; small voids
may be filled in with a paint brush and a fresh Labeling/Storage
mix of gypsum. 20. Using an indelible ink marker, label the base or
NOTE: Unless requested by the dentist, do not fill in the back cut of the cast with the patient’s name
air voids in areas critical to the case. and date.
18. Trim the contours of the peripheral borders of the 21. Place the cast in a model box labeled with the
model above the mucobuccal fold to form soft patient’s name, the date of the impression, and the
scalloped shapes. case number.

Get Ready for Exams!

Review Questions 7. A study model is a positive reproduction. An impression

is a negative reproduction:
Select the one correct response for each of the following a. both statements are true
multiple-choice questions. b. both statements are false
1. Carefully controlled calcination under steam pressure in c. the first statement is true and the second statement
a closed container produces: is false
a. Plaster d. the first statement is false and the second statement
b. Dental stone is true
c. High strength stone 8. Material that will act as retarders for the set of gypsum
d. High strength, high expansion stone products include:
2. To decrease the working time of a gypsum product, a. saliva
without changing any physical properties, it is best to: b. set gypsum products
a. Decrease the water-to-powder ratio c. slurry water from the model trimmer
b. Increase the rate of spatulation d. none of the above are considered retarders
c. Increase the water temperature 9. It is important to consider the following statements
d. Decrease the water temperature when pouring an impression:
3. The main difference between model plaster and dental a. Alginate impressions should remain unseparated
stone is: from the model for only 1 hour.
a. Chemical formula b. When the single-step method is used, the material
b. Solubility in water poured into the impression must reach the initial set
c. Particle size and shape before the base is poured.
d. Accelerators and retarders c. Gypsum should be mixed as wet as possible to allow
4. The most appropriate type of gypsum product to use for for sufficient working time
orthodontic casts is: d. A and B
a. Type I e. A and C
b. Type II 10. Diagnostic casts are used for:
c. Type III a. patient education
d. Type IV b. fabricating dentures
5. Initial setting can be detected clinically by: c. fabricating crowns
a. Loss of gloss d. fabricating orthodontic appliances
b. The end of the exothermic reaction 11. CAD/CAM fabrication of indirect restorations eliminates
c. A change in color the need for:
d. Testing to see whether the material is hard enough to a. investing
separate from the impression b. cutting the preparation
6. The area of the diagnostic cast that records the hard c. impression taking
and soft tissues is called the: d. A and B
a. Art portion e. A and C
b. Base 12. The melting range can best be described as:
c. Anatomic portion a. The point at which the wax flows
d. Impression b. The point at which the wax softens
c. The required temperature of the heat source
d. A combination of melting points

Continued
398 CHAPTER 16 Gypsum and Wax Products

Get Ready for Exams!—cont’d

13. A direct wax pattern is fabricated in the mouth. Which • T  he dentist has taken an impression for a space
property of the inlay wax is the most important? maintainer.
a. Flow • The hygienist has taken an impression for a custom
b. Residual stress bleaching tray.
c. Melting range • The expanded-function assistant has taken an
d. Excess residue impression for a full gold crown.
14. A wax pattern is invested and burned out by the lost 2. How would each of the following situations be best
wax procedure. Which property of the inlay wax is the handled?
most important? • You need to make a custom tray for an appointment
a. Melting range in progress and have just taken the alginate impres-
b. Flow sion. How would you accelerate the setting time of
c. Residual stress the gypsum product you select?
d. Removal of excess residue • You have fast-set plaster in your office and wish to
15. The wax used to form a base into which to pour a gyp- mix enough material to pour two arches. How would
sum model is: you increase the working time?
a. Boxing wax • Several air voids are present on the surfaces of the
b. Sticky wax teeth. What factors may have caused this?
c. Pattern wax • When you are working on a cast, the teeth chip and
d. Baseplate wax crumble easily. What factors may have caused this?
16. Utility wax ropes are used to: 3. A gypsum model is articulated with a wax bite registra-
a. Hold components together for repair tion and is left in the dental laboratory over a hot week-
b. Make forms for wax bite registrations end. The assistant, on coming in on Monday, discovers
c. Make corrections in undercut areas of impressions that the model is no longer in the correct occlusion.
d. Adapt the periphery of impression trays • What property of the dental wax most likely caused
17. The sprue is used in the lost wax procedure to: the problem?
a. Make the channel into which molten metal is • What could have been done to avoid this problem?
forced 4. A gypsum model is being poured, using boxing wax.
b. Account for delayed expansion and contraction in The wax is formed around the impression but will not
the final casting hold in place.
c. Hold the wax pattern in the investment What can the assistant do to the wax to help it adhere to
d. Aid in lowering the melting range of the wax itself and the tray?
For answers to Review Questions, see the Appendix. 5. After the preceding problem is corrected, the impression
is poured. The hygienist, on separating the boxed model,
finds that there is a thin layer of wax on the base portion.
Case-Based Discussion Topics What property of the wax most likely caused this and what
property of the gypsum product contributed to this problem?
1. F
 or each of the following situations, which gypsum
material would be the best choice? 6. A final impression for an edentulous case is corrected
• The assistant has taken an impression for an with corrective impression wax; the impression is then
­orthodontic case study. sent to the dental laboratory.
What precautions must be considered when sending the
impression?

BIBLIOGRAPHY King BB, Norling BK, Seals R: Gypsum compatibility of anti-

microbial alginates after spray disinfection. J Prosthodont,
American Dental Association (ADA): Council on dental materi- 1994.
als: instruments, and equipment: American Dental Associa- Kotsiomite E, McCabe JF: Experimental wax mixtures for dental
tion Specification No. 25. J Am Dent Assoc, 102:351, 1981. use. J Oral Rehabil, 24:517–521, 1997.
American Dental Association (ADA): Council on scientific af- Kotsiomite E, McCabe JF: Waxes for functional impressions. J
fairs and ada council on dental practice: infection control rec- Oral Rehabil, 23:114, 1996.
ommendations for the dental office and dental laboratory. J McCrorie JW: Some physical properties of dental modeling wax-
Am Dent Assoc, 1996. es and of their main constituents. J Oral Rehabil, 1:29, 1974.
Bird DL, Robinson DS: Modern Dental Assisting (ed 12). Missouri, Robinson DS, Bird DL: Essentials of Dental Assisting, (ed 6). Mis-
2018, Elsevier. souri, 2016, Elsevier.
Brukl CE, McConnell RM, Norling BK, et al.: Influence of gaug- Sakaguchi RL, Powers JM: Craig’s Restorative Dental Materials (ed
ing water composition on dental stone expansion and setting 13). St. Louis, 2012, Mosby.
time. J Prosthet Dent, 1984. von Fraunhofer JA, Spiers RR: Accelerated setting of dental
Darby ML, Walsh MW: Dental Hygiene Theory and Practice (ed 4). stone. J Prosthet Dent, 49:859–869, 1983.
Missouri, 2015, Elsevier. van Noort R: Introduction to Dental Materials (ed 4). 2013, Elsevier.
Polymers for Prosthetic Dentistry 17
http://evolve.elsevier.com/Eakle/materials/

Chapter Objectives
Upon completion of this chapter, the student should be able to:
1. Describe the formation of long-chain polymers from 11. A djust a denture to relieve a sore spot as permitted by
monomers. state law.
2. Explain the effect that cross-linking has on the physical 12. Repair a broken acrylic denture.
and mechanical properties of polymers. 13. Use an ultrasonic cleaner for cleaning complete and
3. Describe the stages of addition polymerization. partial dentures in the office.
4. Explain the function of a free radical. 14. Educate patients regarding the home care regimen they
5. List the important properties of acrylic resins. should follow for complete and partial dentures.
6. Describe the procedure for heat processing a denture. 15. Inform patients of the precautions they should take when
7. Compare the properties of hard and soft lining materials. cleaning their dentures.
8. List the indications for long- and short-term soft liners. 16. Fabricate custom impression trays for upper and lower
9. Compare the advantages and disadvantages of chairside arches.
and laboratory-processed hard liners. 17. Fabricate record bases for complete dentures, using
10. List the indications for the use of acrylic denture teeth light-cured material.
versus porcelain teeth.

Key Terms
Polymers long-chain, high molecular weight molecules Poly(Methyl Methacrylate) (PMMA) a polymer composed
produced by chemically linking many low molecular weight of numerous methyl methacrylate monomers linked to-
monomer molecules gether into a long chain. Methyl methacrylate is commonly
Monomers low molecular weight molecules that are joined used in denture fabrication
to form polymers; as used in dentistry, monomers are usu- Plasticizer liquid added to acrylic resin to soften it and make
ally liquids it more pliable
Polymerization the act of forming polymers by chemically Porosity numerous microscopic holes or voids within a ma-
linking monomers into long chains; the process can be terial; often caused during polymerization of resins when
activated by chemicals, heat, or light monomer vaporizes and is lost; can also be caused by
Cross-Linked Polymers adjacent long-chain polymers entrapping of air during mixing of powder and liquid
joined by the bonding of short chains along their sides to Prosthesis a device used for the replacement of missing
enhance the properties of the polymer teeth and/or soft tissues. It can serve both cosmetic and
Addition Polymerization common form of polymerization functional roles
for dental materials; monomer molecules are added one to Long-Term Soft Liner a soft liner that is used in patients
another sequentially as the reactive group on one molecule who have problems with hard acrylic denture bases; it is
initiates bonding with an adjacent monomer molecule and expected to last for 1 to 3 years
frees another reactive group (free radical) to repeat the Short-Term Soft Liner a soft provisional (temporary) liner
process used to improve tissue health; also called a tissue condi-
Free Radical a reactive group on one end of a monomer tioner; typically, it lasts from a few days to a few weeks
that initiates the joining of adjacent monomer molecules to Hard Liner a rigid reline material used inside a denture to
form a polymer improve the fit and stability
  

The steady increase in the numbers of older Americans as maxillofacial prostheses (used to replace missing oral or
will assure a demand for removable complete and partial facial structures). They can be used to simulate the oral mu-
dentures. Acrylic resins are polymers that play an impor- cosa, gingiva, and teeth. They are also used to reline these
tant role in removable prosthetics. Acrylic resins are used prostheses to improve their fit and to repair them when
in the fabrication of complete and partial dentures, as well they break. CAD/CAM technology has also been applied to
399
400 CHAPTER 17 Polymers for Prosthetic Dentistry

fabrication of complete and partial dentures. Once appropri- the monomer will vaporize and produce porosity in
ate records have been attained, prostheses can be fabricated the material. Porosity weakens the material, causes it
by milling or three dimensional (3D) printing. to discolor as stains are absorbed into the pores, and
Even though a commercial dental laboratory fabricates can lead to retention and growth of oral microorgan-
most of the removable prostheses, the allied oral health isms and development of an unpleasant odor (“den-
practitioner needs to be familiar with the materials and ture breath”).
their uses, care, and repair. She or he must understand
the materials used in prosthetic dentistry to better care for CROSS-LINKED POLYMERS
the patient and to assist the dentist. Patients who wear Polymer chains often have short chains of atoms at-
removable prostheses will often ask the dental assistant or tached to their sides. When the side chains of adjacent
hygienist questions that relate to the fit or home care of polymers bond together, the polymers are termed
their prosthesis. This chapter covers the uses of acrylics for cross-linked polymers (see Fig. 6-4 in Chapter 6 Com-
fabrication of complete and partial dentures and for relin- posites, Glass Ionomers, and Compomers). When side
ing, tissue conditioning, and repairing these prostheses. It chains of adjacent polymers are joined by weak bonds,
also covers the use of acrylic denture teeth, porcelain den- the polymers are easily manipulated, bent, or stretched.
ture teeth, and acrylic repair techniques. The instructions When adjacent polymers are joined by highly charged
to be given to the patient for the care of these prostheses side chains, the bond is stronger, and the cross-linked
are presented. polymers are stronger and stiffer. They also are more
wear resistant and, consequently, can be used in den-
REVIEW OF POLYMER FORMATION ture teeth. They polish more easily and are less affected
by solvents such as alcohol.
POLYMERS
Polymers are large, long-chain molecules formed by POLYMERIZATION REACTIONS
chemically joining together smaller molecules, called There are two types of polymerization:
monomers. The polymer chains will vary in length as • Addition polymerization
the monomer is being consumed and may contain • Condensation polymerization
from 10,000 to 100,000 monomer units. The chains will The reactions are the same as for the impression
lengthen until no more monomer is available. Most of polymers, addition silicones, and condensation sili-
the polymers shrink as they form, and this creates un- cones (see Chapter 15 Impression Materials).
desirable features in the final product.
Addition Polymerization
COPOLYMERS Addition polymerization is the most common form of
When two or more different types of monomers join polymerization for dental materials. It occurs in three
together, the polymer formed from them is called a stages:
copolymer. Copolymers are produced to enhance the Stage 1: Initiation (or induction)
physical and mechanical properties of the material. Stage 2: Propagation
They are used in dentures to make them more resis- Stage 3: Termination
tant to fracture, in soft reline materials to make them Unlike condensation polymerization, the reaction does
soft and pliable, and in mouth guards to improve their not produce any by-products. Monomers have a core
shock-absorbing capacity. unit of two carbon atoms joined by a double bond. One
carbon atom has two hydrogen atoms attached, and
POLYMERIZATION the other carbon atom has attached to it one hydrogen
The act of forming polymers is called polymerization. atom and one reactive group called a free radical. The
In general, less than 100% of the monomer is used up. free radical is made reactive by the chemical reaction
The remaining unused monomer is called the residual of organic peroxide, such as benzoyl peroxide, with an
monomer. The best clinical results occur when there is activator or accelerator, such as a tertiary amine, or by
little residual monomer. heating.

Polymerization (Curing) Methods Initiation. The free radical initiates the reaction by
The materials that react by chemical means are called opening the bond between the two carbon atoms of the
chemical-curing, self-curing, or autopolymerizing. Ma- monomer. The broken carbon bond causes the mono-
terials that use heat to initiate the reaction are called mer molecule to bond to another monomer. Each link-
heat-curing polymers. Materials in which the reaction age leaves a free radical available for further reaction.
is activated by light are called photo- or light-curing.
Whether initiated by chemical means, light, or heat, Propagation. The process of linking monomer units is
the polymerization process releases heat (i.e., it is an termed propagation, and it continues until the mono-
exothermic reaction). The heat must be controlled dur- mer units are used up, or until a substance reacts with
ing the process. If the temperature becomes too great, the free radical to tie it up.
 Polymers for Prosthetic Dentistry CHAPTER 17 401

Termination. When the free radical is tied up or de-

stroyed, the process is terminated.

Condensation Polymerization
Materials formed by a condensation reaction do not
have many uses in dentistry. The condensation silicone
impression materials are the most commonly known,
and even they are not used much today. Typically, more
than one type of monomer is used. The reaction itself
produces by-products such as water, hydrogen gas, or
alcohol that may compromise the physical properties
or handling characteristics.
FIG. 17.1 Removable acrylic orthodontic tooth movement device.
ACRYLIC RESINS (PLASTICS)
Synthetic polymers used in prosthetic dentistry are PROPERTIES
called acrylic resins, because they are derived from Polymerization Shrinkage
acrylic acid. Acrylic resin forms when a liquid mono- Polymers undergo shrinkage as a result of the polym-
mer (commonly methyl methacrylate) is mixed with erization process. Heat-cured acrylic resins shrink
a powder of small polymer beads, and the mixture about 6% by volume and about 0.2% to 0.5% linearly
undergoes polymerization. The polymerized resin (from one point on the denture to another).
is poly(methyl methacrylate) (PMMA). It is composed
of numerous methyl methacrylate (MMA) monomer Dimensional Change
units linked together to form a long-chain polymer. Sources of dimensional change in addition to polymer-
ization shrinkage include water sorption and thermal
USES OF ACRYLICS expansion. A denture base will increase slightly in its
The resins are used for denture bases, denture teeth, overall size when it absorbs water. This expansion may
relining and repair of prostheses, provisional acrylic help offset some of the shrinkage that occurs during
partial dentures (flippers or stayplates), tissue condi- polymerization. The coefficient of thermal expansion is
tioners, and custom impression trays. They also have more than twice that of composite resins.
uses as orthodontic retainers and removable tooth
movement devices (Fig. 17.1), bruxism mouth guards Strength
and provisional restorations (see Chapter 18 Provi- The strength of the acrylic resins is fairly low, with a
sional Restorations). Specialized acrylic resins are compressive strength of approximately 11,000 pounds
used in esthetic tissue replacement for severe gingival per square inch (psi; or 75.8 megapascals [MPa]) and a
recession and for facial reconstruction due to trauma, tensile strength of 8000 psi (55.2 MPa). By comparison,
surgery, or birth defects. Acrylic resins are especially amalgam has a compressive strength of about 60,000
useful because they can be shaped to any contour and psi (413.7 MPa). Acrylics are not very hard materi-
custom-colored to match the shade of the teeth, gin- als (Knoop hardness number, 16 to 18) and as a con-
giva, or skin. sequence are not very wear resistant. Although they
have fairly good resistance to fatigue failure (can be
MODIFIERS flexed repeatedly before they break), they will break if
Acrylic resins used in dentistry are often modified dropped on the floor or in an empty sink during clean-
by the addition of plasticizers, rubbers, and fillers to ing. To combat the brittleness and breakage problem,
change their physical and mechanical properties. Plas- some manufacturers add butadiene-styrene rubber
ticizers are liquids added to soften the acrylic plastics to the MMA to create a high-impact acrylic resin. An
and make them more pliable. Oily liquids called aromat- example of a high-impact acrylic resin is Lucitone 199
ic esters are often used as plasticizers. Rubbers may be (Dentsply International), which comes in four gingival
added to increase the impact fracture resistance of the shades.
acrylic resin. Fillers are added to strengthen the resin or
change its optical properties. Chemical coupling agents Thermal Conductivity
may be used to bond the filler to the acrylic resin. This Denture bases do not conduct temperature well. Pa-
coupling prevents the filler particles from being plucked tients wearing dentures will notice a marked differ-
out of the resin by abrasion, the result of chewing on ence when they eat foods such as ice cream or drink
food, and makes the resin more wear resistant (similar hot beverages. Because the denture partially insulates
to the use of silane to couple fillers in composite resins). against the temperature of the food or beverage, pa-
These bonded fillers can be found in light-cured denture tients may burn themselves when they attempt to
repair or impression tray materials. swallow foods that are too hot.
402 CHAPTER 17 Polymers for Prosthetic Dentistry

Table 17.1   Properties of Heat-Cured Acrylic Resins

(PMMA)
PROPERTY VALUE
Polymerization shrinkage (by 6%
volume)
Polymerization shrinkage (linear) 0.2%-0.5%
Coefficient of thermal expansion More than twice that of
composite
Compressive strength 75.8 MPa (11,000 psi)
Tensile strength 55.2 MPa (8000 psi)
Hardness (Knoop) 15-18 kg/mm2
Biocompatibility Good FIG. 17.2 Pressure pot used to provide a denser chemical-cured
Thermal conductivity Poor acrylic.

Wear resistance Fair

Fatigue resistance (to flexing) Good the monomer from evaporating during polymeriza-
Impact resistance (to breakage Poor tion and creates a denser acrylic. When chemical-cured
when dropped) acrylic is cured in room temperature water and 15 to 20
PMMA, poly(methyl methacrylate). pounds of air pressure in a pressure pot (Fig. 17.2), the
resulting acrylic is stronger and has less porosity and
shrinkage. A pressure pot is a laboratory device that re-
Chemical-Cured versus Heat-Cured Acrylics sembles a pressure cooker. It is a thick-sided metal pot
The type of processing has some effect on the prop- that seals well and can be pressurized by the addition
erties. Polymerization is never 100% complete, and of air through a one-way valve in its lid. Porosity can
varying amounts of free monomer may be present in also occur by the entrapment of air during mixing of
the polymerized material. In general, chemical-cured the powder and liquid acrylic resin components.
acrylic resins are weaker, softer, more porous, and less
color stable than the heat-cured acrylic resins. After
polymerization, there is more residual monomer in Caution
the chemical-cured acrylic (up to 5%), and it initially When using a pressure pot, it is not necessary to pressurize
adversely affects many of the physical and mechani- it with air to more than 20 psi. Although the pressure pot is
cal properties until the monomer leaches out in min- constructed of heavy materials and can usually withstand
ute amounts over several days or weeks. Some dimen- high pressure and has a pressure release valve, excessive
pressure—more than 30 psi—increases the risk of a mishap
sional change can occur during the first 24 hours in
should the release valve malfunction.
chemical-cured acrylic. For this reason, custom acrylic
trays should not be used immediately, but should sit
for 12 to 24 hours to allow most of the dimensional
change to occur, so the impression will not be dis- ALLERGIC REACTION
torted. Heat-cured acrylics are harder, stronger, and Sensitive patients can react to the components of the
less porous and have less than 1% residual monomer denture materials. If excessive free monomer is present
that leaches out of the surface relatively quickly. Prop- in the denture base, some people’s tissues may be irri-
erties of heat-cured acrylic resins are summarized in tated and inflamed by the methacrylate monomer. Other
Table 17.1. components such as hydroquinone, benzoyl peroxide,
and pigments can also cause irritation. Dental personnel
Porosity who work with the materials can develop contact der-
Porosity in polymerized acrylic resin is characterized matitis through repeated exposure of unprotected skin
by the presence of many small or microscopic voids or to the materials. Personal protective equipment (PPE)
pores. Porosity in the acrylic weakens it and makes it should be used when handling these materials. Dental
prone to collect debris and microorganisms. Denture resins are not known to cause systemic toxic reactions.
odor and stains develop more readily. Porosity is a re-
sult of loss of monomer or inadequate pressure during
Caution
processing. The monomer is highly volatile and can
evaporate rapidly at room temperature during han- To prevent contact dermatitis, avoid contact with methyl
dling of the mixed powder and liquid. Monomer can methacrylate even with gloved hands. Most resin monomers
easily pass through gloves. Remove gloves and wash hands
vaporize during heat-curing of the resin if the tempera-
thoroughly if contact occurs.
ture rises too much. Curing under pressure helps keep
 Polymers for Prosthetic Dentistry CHAPTER 17 403

A B

C
FIG. 17.3 Complete dentures. A, Edentulous ridges. B, Denture teeth set in wax for try-in. C, Dentures processed in
acrylic, polished, and delivered to patient.

ACRYLIC RESINS FOR DENTURE BASES

The functions of the acrylic resin denture base are to
• Retain the artificial teeth in the prosthesis
• Adapt to the supporting structures for stability
• Distribute forces of mastication over a wide area to
reduce pressure on the ridges that might contribute
to resorption of the underlying bone
• Replace missing tissues or rebuild the contours of
tissues lost when the underlying bone resorbs
• Establish a seal along the periphery of a complete
denture that aids in retention (Fig. 17.3)

POLYMERIZATION REACTION
FIG. 17.4 Acrylic shade guides for matching the color of the gingiva.
Acrylic resins polymerize by an addition reaction. (Courtesy of Mark Dellinges, School of Dentistry, University of Califor-
Acrylic resins are supplied as a powder and a liquid. nia, San Francisco [San Francisco, CA].)
The powder is composed mostly of small beads of
PMMA and benzoyl peroxide (the initiator). Inor-
ganic pigments are added to give the acrylic resin dimethacrylate as a cross-linking agent. Cross-link-
colors resembling those of the oral mucosa, and tita- ing of the acrylic polymer chains helps prevent sur-
nium dioxide is added to keep the acrylic from being face cracks, and it improves resistance to structural
too transparent. Small, colored fibers may be added fatigue that can lead to fracture. The liquid is sup-
to simulate small blood vessels. Several shades of plied in dark brown bottles to prevent ultraviolet
acrylic are available, so that the clinician can at- light from initiating polymerization during storage.
tempt to match the variations of racial pigmentation When the powder and the liquid are mixed, chemi-
that can occur in the gingiva and mucosa of patients cal- and heat-cured materials go through a similar
(Fig. 17.4). The liquid contains MMA, hydroquinone reaction, except that chemical-cured materials have
as an inhibitor or preservative to prevent polym- a tertiary amine in the liquid as an activator, where-
erization of the MMA during storage, and glycol as heat-cured materials do not (Table 17.2).
404 CHAPTER 17 Polymers for Prosthetic Dentistry

Steps in Complete Denture Fabrication Table 17.2   Ingredients of Acrylic Resin and Their
1. Make preliminary alginate impressions of edentulous Function
ridges (by dental assistant/hygienist). COMPONENT FUNCTION
2. Pour impressions into stone for preliminary casts (by Liquid
dental assistant/hygienist). Methyl methacrylate Monomer
3. Fabricate custom impression trays from preliminary
casts (by dental assistant/hygienist or laboratory Hydroquinone Inhibitor to prevent
technician). polymerization of monomer
4. Border mold trays with compound (or other ther- during storage
moplastic material) and make final impressions with Glycol dimethacrylate Cross-linking agent
elastomer (by dentist or extended-function dental Tertiary amine Activator for chemical-cured
assistant/hygienist). resin
5. Box impressions with utility wax and pour into die
Powder
stone for master cast (by dental assistant/hygienist or
sent to lab). Poly(methyl methacrylate) Polymer beads
6. Fabricate record bases (used to capture relations Benzoyl peroxide Initiator
between upper and lower jaws; also called wax rims) Titanium dioxide Reduces translucency
(by dental assistant/hygienist or laboratory technician).
Pigments Simulate tissue colors
7. With record bases, record jaw relations, midline and lip
line. Make facebow transfer—not used by all dentists (by Colored fibers Simulate small blood vessels
dentist or extended functions dental assistant/hygienist).
8. Select shade and mold of teeth (by dentist with help
from assistant/hygienist and patient). Chemical-Cured Resins
9. Mount casts on articulator and set teeth in wax of Polymerization of chemical-cured acrylic resins is set into
record bases (by dentist or laboratory technician). action when the tertiary amine in the liquid activates the
10. Try teeth in wax in the patient’s mouth to check ap- benzoyl peroxide in the powder to produce free radicals.
pearance and occlusion (by dentist).
The hydroquinone initially inhibits the reaction from
11. Return wax try-in to laboratory for final processing in
acrylic resin.
progressing by destroying free radicals. This inhibition
increases the working time so that the materials can be
manipulated for a reasonable period of time, usually
while the material progresses from the stringy stage to the
Caution dough stage. As the hydroquinone is depleted, the reac-
Liquid monomer should be considered a hazardous tion proceeds more rapidly and advances from the dough
material. It is flammable and vaporizes easily when the lid stage to the rubber stage. The reaction is exothermic (re-
is off of the container. Use in a well-ventilated area, ideally leases heat) and ultimately becomes quite hot. When the
under a vapor hood. Avoid prolonged direct breathing of the reaction is complete, the material is hard and stiff.
vapor. Because all of its potential hazards have not been
defined, it is advisable for pregnant workers and patients to Pour technique. Some chemical-cured materials can be
avoid breathing the fumes. It can irritate eyes, nose, skin,
mixed to a thin, fluid consistency and poured into a
and lungs and may affect the nervous system.
mold and cured under pressure.

Heat-Cured Resins
Physical Stages of Polymerization The most common method for processing denture
Sandy stage. The first stage seen when the powder bases uses heat and pressure during polymerization of
(polymer) and the liquid (monomer) are mixed is the acrylic resin. Heat-cured acrylic resins go through
called the sandy stage, because the mixture looks grainy, initial stages of polymerization that are similar to those
similar to sand and water, and has a runny consistency. of chemical-cured resins.

Stringy stage. The second stage occurs when the pow- Processing the Complete Denture
der particles absorb the liquid into their surface. It is After the dentist has tried in the denture teeth set in
called the stringy stage, because the mixture is stringy wax and the patient approves the appearance, the den-
when handled and is thicker in consistency. ture is returned to the laboratory, where the technician
places the cast of the edentulous arch, along with the
Dough stage. In the next stage, called the dough stage, more denture setup (teeth mounted in wax on a record base),
of the powder goes into solution and the mixture changes in a specially designed processing flask. The flask sepa-
from stringy to doughy and is more easily manipulated. rates in the middle into two sections. The denture setup
mounted on the cast is invested in a plaster investing
Rubber stage. In the final stage, called the rubber stage, material in the flask in such a manner that the flask can
the mixture has a rubbery consistency that can no lon- be opened in the middle to allow removal of the wax and
ger be manipulated for forming the denture base. record base after heating in a water bath. The teeth are
 Polymers for Prosthetic Dentistry CHAPTER 17 405

held in place by the plaster. All remnants of the wax are

removed. A liquid, called a separating medium, is placed
and air-dried on the plaster and the cast to prevent the
acrylic resin from sticking to or absorbing moisture from
the gypsum materials. Mixed acrylic resin in the dough
stage is placed in the space created by removal of the
wax and record base. (It has a longer dough stage than
chemical-cured acrylic, because it does not have the ter-
tiary amine activator.) This space is where the denture
base will be formed. A sheet of polyethylene material is
placed over the resin and the flask is reassembled and
closed under pressure. The flask is reopened to remove
excess material that exudes out of the sides of the flask.
This process is repeated until no excess material appears
and the polyethylene sheet is removed. The flask is put
into a device called a pneumatic press that maintains pres- FIG. 17.5 Components of a removable partial denture framework. (From
sure on it, and it is placed into a temperature-controlled Carr AB, Brown DT: McCracken’s removable partial prosthodontics,
water bath for at least 8 hours. Heat activates the benzoyl (ed 13). St Louis, 2016, Mosby.)
peroxide, causing the formation of free radicals and al-
lowing polymerization to occur. Applying pressure and for framework components) invested in the mold, as
controlling the heat minimize porosity by preventing the well as the teeth set in wax. Because the acrylic resin
monomer from vaporizing. More of the monomer is con- does not adhere well to the metal, a retentive mesh or
sumed during the polymerization, so less free monomer lattice is made as part of the partial denture framework
is present in the cured denture base with heat-processed to lock the acrylic in place (Fig. 17.6).
dentures. Similar to the chemical-cured resins, the ma-
terial is hard and stiff when the polymerization is com- Components of a Removable Partial Denture
plete. It also shrinks when it is polymerized. Shrinkage (RPD) Framework
is seen most readily in the palatal area and can cause the The framework is the structure that supports the denture
acrylic to lift from the cast as much as 0.25 mm. If a room base and the teeth and provides stability and retention of
temperature processing technique is used, shrinkage is the prosthesis. Its components include:
less, but the properties of the denture are poorer initially, • Major Connector—joins the components of the frame-
because of the presence of much more free monomer. work on one side of the arch to the other side. In Fig.
The properties improve as the free monomer leaches out. 17.4 it is the lingual bar. A maxillary RPD would have a
palatal connector. The major connector provides cross-
arch stability and aids in resisting displacement of the
Components of a Complete Denture RPD by functional forces.
• D enture Base—acrylic resin component that rests on • Minor connectors—join the major connector to the other
the edentulous ridge and adjacent oral mucosa and components of the framework such as the retentive clasp
contains the denture teeth. In the maxillary denture it assembly, occlusal or cingulum rests and indirect retainers
also covers and rests on the hard palate. • Direct retainer—the clasp assembly that has a retentive
• Flange—that portion of the denture that extends verti- clasp arm (that engage undercuts on the crown of the
cally from the base of the denture into the facial or lin- support tooth), a reciprocal arm opposite the reten-
gual vestibule. In Fig. 17.3, panel B, it is the pink acrylic tive arm (that braces against lateral stresses) and rests
that extends on the facial from the base of the denture (metal stops on the occlusal of posterior teeth or cin-
teeth to the depth of the vestibule. gulum of anterior teeth that prevent the partial denture
• Peripheral seal—a seal created around the outer edge from seating too far and putting too much pressure on
of the denture by its intimate contact with the oral soft the gingiva and bony ridge and directs occlusal forces
tissues. It is needed to provide retention of the denture. along the long axis of the support teeth)
• Posterior Palatal Seal (also called Postdam)—a seal • Indirect Retainer—when an RPD has no support teeth
formed in the posterior extent of the maxillary denture at the distal extent of the arch on one or both sides,
base at the junction of the hard and soft palates. It is the the indirect retainer aids the direct retainer in preventing
part of the peripheral seal of the denture that resists tip- displacement of the distal extension denture base. In
ping of the denture when biting with the anterior teeth. Fig. 17.6 the upper right quadrant has a distal exten-
• Denture Teeth—acrylic, composite resin or porcelain sion denture base replacing teeth #2 to #5.
teeth used to replace missing natural teeth • Retentive meshwork—a metal grid overlying the eden-
tulous ridge into which the denture acrylic will be forced
during processing for retention of the denture base
Processing of a Removable Partial Denture (RPD) • Denture Base—acrylic resin component that rests on
the edentulous ridge and adjacent oral mucosa and
A similar process is performed for applying a denture
contains the denture teeth
base to a removable partial denture, except that the par- • Denture Teeth—acrylic, composite resin or porcelain
tial denture will have a metal framework (see Fig. 17.5 teeth used to replace missing natural teeth
406 CHAPTER 17 Polymers for Prosthetic Dentistry

Microwave Processing from reaching it and causing premature polymeriza-

The same denture resins used for the heat processing tion. The light-cured materials are fast and easy to use
technique can be used for processing in a microwave but require the purchase of an expensive light-curing
oven. If a special monomer liquid is used in place of unit (see Fig. 17.33 in Procedure 17.2). The material is
regular monomer, less porosity is found. Processing available in limited acrylic colors. It is used for denture
time is greatly speeded up, and processing is com- bases, record bases (see Procedure 17.2), custom trays,
pleted in about 5 minutes instead of the several hours and denture repairs. It also has applications for remov-
needed for heat processing. able orthodontic appliances.

Injection Molding
Some vinyl acrylic resins can be processed by injecting
DIGITAL DENTURES
the material into a mold when it is in a doughy form. With The use of CAD/CAM technology in dentistry has
some materials, shrinkage and porosity are reduced by expanded beyond crown and bridge applications to
injection molding. Some laboratories use this technique many other clinical facets of dentistry including re-
because it is faster than the traditional heat processing. movable partial and complete dentures. In Chapter 15
digital scanners were discussed and they can scan the
Light-Cured Resins edentulous ridges for complete dentures. However,
In addition to heat- and chemical-curing, dental resins the scanners are not able to determine with accuracy
can be light-cured. The light-polymerized resins have where the flange of the denture should end in the vesti-
photoinitiators such as camphorquinone and amine bule. Therefore, they cannot be used for complete den-
activators. These react to form free radicals when ex- ture final impressions since the peripheral seal needed
posed to blue light and initiate the polymerization for retention cannot be established from the scan. A
reaction (see Chapter 6). One of the commercially mix of traditional denture construction techniques and
available light-cured materials (Triad VLC; Dentsply CAD/CAM techniques are needed.
International) contains urethane dimethacrylate resin The clinician that wants to provide digital dentures
and silica fillers for thickening the material and rein- has two options in order to participate. First, the cli-
forcing it. It comes in flat sheets or ropes depending nician can use traditional denture methods up to the
on the application. Each sheet is individually pack- point of processing the denture and then can have the
aged in a thick black plastic bag to prevent room light records entered into a CAD/CAM system for design

A B

C
FIG. 17.6 A, Metal frameworks for upper removable partial denture with retentive areas to hold acrylic. B, Acrylic pro-
cessed over retentive structure with denture teeth added. C, Maxillary partial denture in the mouth.
 Polymers for Prosthetic Dentistry CHAPTER 17 407

and fabrication by milling or 3-D printing. The second designs the denture based upon the records (Fig. 17.7).
option is to use methods and devices developed by The dentist can receive this image and view it with the
companies for digital denture systems. These systems patient in the dental office and make adjustments on
allow final impressions and records of the bite and oth- the arrangement, size and shade of the teeth before the
er jaw relations, occlusal plane orientation, tooth shade denture is processed. If desired, a try-in denture can be
and mold and maxillary anterior tooth position all to made and sent to the dentist for the patient to evaluate.
be gathered in the first appointment and sent to the The AvaDent system mills the denture base from
company to be scanned and entered into their CAD/ large, thick preformed disks of acrylic that has been
CAM software. Then, denture can be designed and polymerized under heat and much more pressure
processed. than conventionally processed denture bases (Fig.
There are two main systems presently: AvaDent 17.8). As a consequence, when the denture base is
Digital Denture Solutions (Global Dental Science) and milled there will be no polymerization shrinkage be-
Pala Digital Dentures (Heraeus Kulzer). The two sys- cause it occurred when the disk was made and poros-
tems differ in their records collections methods, design ity will be greatly reduced. The acrylic disk is highly
software and method of fabricating the dentures. The cross-linked producing a stronger acrylic. The Ava-
two systems use trays that can be customized to take Dent system bonds artificial teeth to the denture base
final impressions at the first visit and use their own de- (Fig. 17.9).
vices for capturing jaw records and the other features The Pala Digital Denture system also designs the
(mentioned above) needed to design the denture. The denture and allows the clinician to review it with the
impression and other records are sent to the company. patient. Processing of the denture is by 3-D printing.
A technician scans the records into the software and The denture base and teeth are printed as one unit.
It produces a denture with similar improvements in
physical properties.

Advantages of Digital Dentures

• R educed number of appointments—usually 2 instead of
5 for conventional denture techniques
• Time savings for dentist and patient
• Dentures can be ready in a matter of days rather than
weeks with conventional dentures
• Better fit of the denture because polymerization shrink-
age is eliminated
• Porosity is reduced or eliminated reducing staining and
development of odor
• Records can be stored for futures needs
• Duplicate or replacement dentures can be made with-
out additional appointments
FIG. 17.7 Technician scans the clinical records and designs the den-
ture. (Courtesy of AvaDent.)

A B
FIG. 17.8 Denture base is being milled from a preformed, thick acrylic disk. A, Milling of the denture base. B, Completed
denture base with spaces created for the denture teeth. (A, courtesy Loma Linda University Dentistry Summer/Autumn
2012, CAD/CAM technology: application to complete dentures by Mathew Kattadiyil, DDS, MSD and Charles J. Good-
acre, DDS, MSD. B, Courtesy of AvaDent.)
408 CHAPTER 17 Polymers for Prosthetic Dentistry

sores have formed. Soft liners may also be used for

long-term treatment for patients who have chronic
soreness with hard denture bases because of sharp
bony spicules or thin mucosa over the ridges. Pa-
tients feel more comfortable with a lining that has a
cushioning effect, especially if the denture is oppos-
ing natural teeth. Long-term soft liners are also used
for patients with bony tissue undercuts that cannot
be surgically corrected. A hard denture base rubs the
mucosa in the area of the undercut, whereas a soft lin-
er cushions the tissues and will flex in and out of the
undercut when the denture is placed and removed.
Soft liners are used with palatal defects such as cleft
palate or tissue loss from cancer surgery or trauma.
On average, long-term soft liner materials last about
1 to 3 years.

Long-Term Soft Liners

FIG. 17.9 Completed dentures after teeth have been bonded to the Long-term soft liners are made from silicone rubber
denture base. (Courtesy of AvaDent.) or acrylics such as ethyl or methyl methacrylate that
have been made pliable by the addition of plasticiz-
ers such as aromatic esters and alcohol (Fig. 17.10).
DENTURE RELINE MATERIALS (LINERS)
Long-term liners may be processed at room tempera-
Relining a denture is done for several reasons. A re- ture or with the application of heat. Although some
line will fix looseness that occurs as the bony ridges long-term silicone and acrylic liners can be placed at
resorb and the gums shrink. An upper denture will chairside, others are placed at the commercial labora-
occasionally crack lengthwise through the palatal tory. Heat-cured silicone liners are processed in the
area as the ridges resorb. The reline readapts the laboratory, because they release acetic acid that can
denture to the ridges and repairs the fracture. A soft cause tissue burns. Laboratory-processed relines are
temporary reline material may act as a tissue con- denser and last longer (1 to 3 years). Chairside soft
ditioner to improve the health of the tissues before relines are more porous and stain more easily. Long-
a hard reline is done. Some soft temporary reline term liners composed of acrylic will harden over time
materials will flow gradually to adapt to the tis- as the plasticizers leach out and will need replace-
sues when worn for a day or two and will serve as a ment. The silicone liners are more stable over the long
functional impression for a hard reline. A reline may term, because they do not have softeners to leach out.
serve to prolong the life of the denture as an alterna- However, they can be difficult to adjust. Special burs
tive to making a new one. and stones are needed to make these adjustments.
Long-term denture relines can be made with ei- Another problem with long-term soft liners is that
ther a hard setting material or a soft, flexible one. they often do not form a good bond to old acrylic.
Both types of materials can be applied to the denture Therefore, they may separate from the denture base
at chairside or may be sent to the dental laboratory at the edges and leak between the liner and the den-
for processing. In general, the laboratory processed ture base.
reline gives a better result and will last longer. The Silicone liners support the growth of yeasts such as
chairside relines are more porous, more likely to Candida albicans and may cause tissue irritation that
break down sooner, and will stain more readily. The requires antifungal therapy. Cleaning soft liners on a
laboratory processed reline requires that the patient daily basis in benzalkonium chloride will reduce the
leave the denture out for 12 to 24 hours to allow the growth of yeasts.
tissues to return to an uncompressed state before
taking the impression for the reline: Pressure from Short-term soft liners (tissue conditioners). Short-term
wearing and eating with the denture will compress soft liners are referred to as tissue conditioners or treat-
the tissues. ment liners and are usually placed at chairside. They
are supplied as a powder composed of poly(ethyl
SOFT RELINING MATERIALS methacrylate) and softeners or plasticizers of aromatic
Complete and partial dentures sometimes have a soft oils and ethanol (Fig. 17.11).
lining material placed on the tissue-bearing surface Application of short-term liner. The powder and liquid
of the denture base. Soft liners may be used as short- are mixed thoroughly according to the manufacturer’s
term treatment for a few days up to a few weeks to directions and are flowed onto the tissue-bearing sur-
allow tissues to heal after surgery, or when denture face of the denture, which was previously cleaned with
 Polymers for Prosthetic Dentistry CHAPTER 17 409

A B

C
FIG. 17.10 Long-term soft liners. A, Heat-cured, silicone-based soft lining material. B, Soft liner processed in lower den-
ture. C, Chairside, chemical-cured, silicone-based soft liner in cartridges dispensed with a mixing gun and tip. (Courtesy of
Mark Dellinges, School of Dentistry, University of California, San Francisco [San Francisco, CA].)

term liners and therefore need frequent replacement.

Some short-term liners last for only 1 week; others last
for 2 to 4 weeks.
Use of appropriate denture soaks can prolong the
useful life of soft liners, and therefore the manufac-
turer’s recommendations are important. The dental as-
sistant and hygienist must be familiar with materials
and procedures for the placement of liners at chairside
and for the home care of both chairside and laboratory-
processed liners.

DETECTION AND MANAGEMENT OF DENTURE

SORES
Denture sores are common with new dentures as the
FIG. 17.11 Two tissue conditioners (short-term soft liners) (Visco-gel, tissues adapt to the new prosthesis. Older dentures
Courtesy of Dentsply International, York, PA; Coe-Soft, Courtesy of GC may also produce sore spots as the bony ridges slowly
America, Alsip, IL). They come with two components—powder and
liquid.)
resorb and the denture becomes loose. Sore spots can
also occur after a denture reline since a whole new tis-
sue-bearing surface has been created.
soap and water. The denture is reseated in the patient’s
mouth, and the patient is instructed to gently close into Signs and Symptoms
normal occlusion until the material cures (see sequence Typically, the patient first senses some mild soreness
in Fig. 17.12). These liners are capable of readapting to under the denture when eating or placing and remov-
the patient’s tissues as they heal, because they have a ing the denture. After a few days mild soreness may
high degree of flow. Because this flow property is great- become outright pain. Initially, the affected area may
est the first day, hard foods should be avoided to pre- be slightly red as inflammation begins, and then can
vent distortion of the material. As the plasticizers leach become a larger, bright red area in a couple days (Fig.
out, the resin becomes stiffer. The plasticizers leach out 17.13). If not treated right away, the tissue can ulcerate
more quickly in the short-term liners than in the long- leaving a painful raw area that will take longer to heal.
410 CHAPTER 17 Polymers for Prosthetic Dentistry

A B C

D E F

G H
FIG. 17.12 Application of a tissue conditioner. It flows and adapts to the tissues as they heal. A, Tissue conditioner. B,
Separating material to keep conditioner from sticking to outer surfaces of denture. C, Liquid added to powder. D, Mixed
conditioner material. E, Conditioner added to tissue-bearing surfaces. F, Denture inserted into patient’s mouth, seated
evenly, and left until it gels. G, Excess material around denture border. H, Scalpel blade used to trim excess from border.
(From Powers JM, Wataha JC: Dental Materials: Properties and Manipulation (ed 10). St. Louis, 2013, Elsevier. Courtesy
of Richard Lee, Sr., and Bradley Jones, University of Washington Department of Restorative Dentistry, Seattle, WA.)

Causes of Denture Sores is fit with the dentures some of the resin that went
Elastomeric impression materials used for complete into the undercut is removed, but often not all of it.
dentures by their rubbery nature are flexible when The soft tissues under the denture will compress to a
set and will flex out of tissue undercuts and return to limited degree allowing the denture to seat even with
their original shape (elastic recovery). The cast made mild undercuts. When the patient wears the dentures
from these impressions will exhibit the undercuts the for a few days and takes them in and out of the mouth,
way they were in the mouth. When the denture is pro- the acrylic will rub the soft tissues and create a sore
cessed on these casts, the acrylic resin will flow into spot. Another way a sore spot develops is when the
the undercuts and harden as it sets. When the patient occlusion is too heavy in one area and puts excessive
 Polymers for Prosthetic Dentistry CHAPTER 17 411

A B
FIG. 17.13 Denture sore. A, Denture flange impinged upon maxillary frenum. B, Denture sore resulted. (Courtesy of Dr.
Mark Dellinges.)

pressure on the ridge. A denture sore can develop

when the borders are overextended. Still another way
is when the denture presses on sharp edges of bone
that were part of the sockets left when teeth were re-
moved. The tissues overlying the sharp bone become
irritated (These sharp bony edges may take months to
remodel and become rounded. Sometimes they need
to be surgically corrected). Dentures that have become
loose and slide around under function can also cause
sore spots.

FIG. 17.14 Pressure Indicator Paste (Pressure Indicator Paste [PIP],

Common Causes of Denture Sores Keystone Industries) Available in bulk jar, pump, tube or single-use
•  ony or soft tissue undercuts
B packets with brush. Spray bottles of PIP removal agent and wetting
• Sharp bony edges to sockets of extracted teeth agent (to keep PIP from sticking to the tissues).
• Overextended denture borders
• Loose dentures
• Uneven occlusion on the denture causing pressure multiple sore areas or limited to one area if there is
areas only one sore. The brush supplied with the paste (PIP)
will produce fine lines in the paste. Try to make the
lines all go in the same direction. When the denture
Treatment is seated, the operator or the patient can apply mild
The denture requires some adjustment to eliminate the pressure to the denture by pressing evenly on the
source of the irritation. The source needs to be detected. first molar/second premolar region with the thumbs
Sometimes there is an obvious projection on the inside (upper denture) or index and middle fingers (lower
of the denture that can readily be removed with rotary denture). An alternative to holding the denture with
instruments such as an acrylic bur (a metal bur made the fingers is to place cotton rolls over the occlusal
for grinding acrylic) or abrasive stone. Other times it surfaces of the posterior teeth and have the patient
is necessary to discover precisely where the offending close with mild pressure. Carefully remove the den-
acrylic is located. There are two common methods for ture after about 20 seconds. Ideally, there should be
finding the acrylic that rubs the tissues: even contact throughout the denture surface. A thin
• use of a paste painted inside the denture that shows layer of the paste will be evenly spread out where
the area of pressure the denture contacted the tissues (Fig. 17.15). Lines
• colored dye that is applied to the denture sore and in the paste from the brush will still be present in
transferred to the inside of the denture areas where the denture failed to touch the soft tis-
Use of Pressure Indicating Paste (PIP). Paste used sues. The PIP will be displaced in areas of excessive
to show pressure areas inside the denture (Pressure pressure exposing the denture base. This is the area
Indicating Paste (PIP) | Keystone Industries) is an to be adjusted (see sequence of figures below).
opaque white silicone paste (Fig. 17.14) that is paint- Use of Dye Transfer Method A small wooden ap-
ed inside the denture with a brush. A thin layer of plicator with dry purple dye on one end (Dr. Thomp-
the paste should be evenly distributed across the en- son’s Sanitary Color Transfer Applicators, Great
tire tissue-bearing surface of the denture if there are Plains Dental Products) is used to mark the denture
412 CHAPTER 17 Polymers for Prosthetic Dentistry

A B

C D

E F
FIG. 17.15 Use of Pressure Indicating Paste (PIP) at delivery of a new denture or after a hard reline. A, A tongue blade
is used to remove enough PIP to coat the denture a couple times. B, PIP is picked up on a disposable brush. C, PIP is
spread on the tissue-bearing portion of the denture. D, PIP is spread in a even coating leaving brush marks that all course
in the same direction. This pattern helps in reading tissue contact with the denture. E, Denture with PIP is seated in the
mouth with light pressure for about 20 seconds. F, When the denture is removed, the brush marks are gone and an even
distribution of PIP has occurred. No pressure spots are evident. Pressure spots would show as areas where PIP was
displaced and the denture base exposed. Areas where the denture did not have contact with the tissues would show as
PIP with remaining brush marks. (Courtesy of Dr. Mark Dellinges, University of California, SF.)

sore (Fig. 17.16). Excess moisture is wiped away from will have been picked up by the denture in the area of
the denture sore with gauze. Next, the tip of the ap- the sore. This marks the spot to be adjusted (Fig. 17.18).
plicator with dye is wet with a drop of water and Occasionally, the mouth is so sore that the patient
touched to the sore depositing the dye (Fig. 17.17). cannot eat with the dentures. In this case, a tissue con-
The inside of the denture should be dry. The denture is ditioner (temporary, soft denture liner) may be placed
seated over the ridge and gently held in place for 10 to for a few days to a few weeks depending on the sever-
20 seconds. The denture is removed and the purple dye ity of the mouth soreness. An alternative is to have the
 Polymers for Prosthetic Dentistry CHAPTER 17 413

HARD RELINING MATERIALS

Immediate dentures are those placed immediately af-
ter extraction of the teeth. They become loose rapidly
(usually within 6 to 12 months) as the extraction sites
heal and the bone resorbs. These loose dentures can
often be made to fit well again by placement of a hard
liner to fill in the spaces. Conventionally placed den-
tures will loosen as well but over a longer period of
time. The most common material used for this purpose
is an acrylic resin similar to the original denture base
material. This hard liner is placed directly into the pa-
tient’s mouth at chairside or indirectly in the dental
laboratory.

When to Use a Reline Material

• Inadequate seal of denture borders
• Lack of retention of the denture
• Looseness and poor denture stability
• Over-closed bite (loss of vertical dimension of occlusion)
FIG. 17.16 Color Transfer Applicators. (Dr. Thompson’s Sanitary Color
Transfer Applicators, Great Plains Dental Products).
Chairside Reline
With the chairside technique, a chemical-cured acrylic
resin [poly(methyl methacrylate)] supplied as poly-
mer powder and liquid monomer is commonly used.
First, an acrylic bur is used to remove a thin layer of
the tissue-bearing surface of the denture base, so that
a fresh, clean surface is available for chemical bonding
of the lining material to the denture. A lubricant such
as petroleum jelly is applied to the denture teeth and
to non–tissue-bearing surfaces to which the liner should
not adhere. The freshened surface is primed with some
of the liquid (methyl methacrylate monomer) to make
it ready for the liner. The monomer is a good solvent
and will slightly soften the surface, allowing the liner to
bond better. The powder and the liquid are mixed thor-
oughly and applied to the primed denture base. The pa-
FIG. 17.17 Color transfer applicator used to mark denture sore and tient should be advised that the material has a strong
transfer the location to the denture. (Courtesy of Dr. Mark Dellinges,
University of California, SF.)
smell and bad taste. The denture is reseated in the pa-
tient’s mouth. The lips, cheeks, and tongue are moved
through appropriate motions to reestablish the periph-
patient leave the dentures out for a few days. Howev- eral borders (a process called border molding). In essence,
er, most patients do not want to be seen without teeth the reline material makes an impression of the tissues.
and do not select this option. The patient is asked to close into the normal occlusion.
This position is held until the material just begins to
HOME CARE harden. It should be removed from the mouth before
Warm salt water rinses can be useful to reduce inflam- polymerization is complete, because the chemical reac-
mation and speed healing when used 3 to 4 times a tion is exothermic and the heat generated could burn
day. Going to a soft diet will also reduce the pressure the tissues. Also, the hardened material could lock into
produced with eating. When possible, leaving the tissue undercuts, making it difficult and painful to re-
dentures out for a few hours a day will also help with move. Gross excess material extending over the borders
healing. Good oral hygiene is necessary to reduce oral is removed with sharp iris scissors or a scalpel blade.
debris and bacteria. Over-the-counter numbing pastes, The denture is placed into a plastic bag and sprayed
gels and rinses can be helpful in reducing symptoms with an appropriate disinfectant before taking it to the
and help to reduce pain while eating. Acidic and spicy laboratory. The denture is placed into warm water (not
foods may irritate the ulcerated tissue, so they should hot) in a pressure pot in the office laboratory at 20 psi of
be avoided. pressure for about 15 to 20 minutes while the final set
414 CHAPTER 17 Polymers for Prosthetic Dentistry

occurs. The pressure will reduce porosity that may con- and areas where the PIP has been displaced and acryl-
tribute to staining and odor formation. Once completely ic shows through indicate pressure spots. An acrylic
hardened, the excess material is trimmed away and the bur is used to relieve the pressure spots. After all of
denture borders are carefully polished. the pressure spots have been removed, the occlusion
The denture is disinfected before returning it to is checked with articulating paper and adjustments
chairside. Pressure-indicating paste (PIP) is evenly made as needed. The patient is advised that the inte-
coated on the internal aspect of the denture with an rior of the denture is now entirely new and may cause
application brush. The denture is seated evenly in the sore spots much like a new denture. One or more visits
mouth with gentle pressure. The denture is removed may be necessary to complete the adjustments.

A C

B D

E
FIG. 17.18 A, Ulcer in soft tissue lingual to mandibular edentulous ridge caused by the lower denture. B, Denture sore
marked with dye from Color Transfer Applicator. C, Denture dried and reseated. D, The dye is transferred to the denture
indicating the location of the offending pressure area. E, An acrylic bur in a low speed handpiece is used to relieve the
pressure area. F, Now that the location of the irritating denture part has been located, pressure indicating paste (PIP) is
used to detect any remaining pressure spots. G, The denture is reseated and the interior inspected. Areas where pres-
sure from the denture is evenly distributed will show a thin layer of PIP. PIP will be wiped away in areas of heavy pressure.
H, Readjust areas of heavy pressure. I, Final check with PIP shows no pressure spots. (Courtesy of Dr. Mark Dellinges,
University of California, SF.)
 Polymers for Prosthetic Dentistry CHAPTER 17 415

F H

G I
FIG. 17.18—cont’d

An alternative hard reline material (Ufi Gel hard;

LABORATORY RELINE
VOCO) is free of methyl methacrylate. It uses polymer
beads and dimethacrylate as the monomer. It is hand The laboratory reline uses an indirect technique in
mixed or is available in a cartridge for direct applica- which an impression of the tissues is made inside
tion to the denture. The self-mixing cartridge makes the existing denture and a cast is made from this im-
it easy to use and provides a homogeneous, bubble- pression. The technician uses an indexing instrument
free mix. The liner does not generate heat as it po- called a reline jig or device to establish the relationship
lymerizes, so it can be left in the patient’s mouth until between the cast and the denture. The impression ma-
it fully cures, improving the accuracy of the fit. It is terial is removed, along with a thin layer of the tissue-
more pleasant for the patient because it is odorless and bearing denture base surface, as with the chairside tech-
tasteless. nique. The lining material is placed and the denture is
returned to the reline jig, and then the lining material is
Problems Associated with Chairside Reline heat- and pressure-processed to the denture base. This
with Poly(Methyl Methacrylate) process produces a denser, longer lasting reline that is
less prone to staining than a chairside reline. However,
• P orosity from mixing or applying, causing staining and
the negative part of the laboratory reline is that the pa-
odor
• Bad taste and smell
tient will be without the denture for a period of time.
• Potential soft tissue irritation from free monomer On occasion, the heat from processing can warp the
• Poor bonding with the denture base denture base and the occlusion can be changed.
• Heat generation with potential tissue burn if not re-
moved soon enough
OVER-THE-COUNTER LINERS
Some patients are “do-it-yourselfers” who purchase
Caution reline materials in the drugstore and apply them at
When doing a chairside hard reline with poly(methyl home. They do not receive professional advice on
methacrylate), be sure to remove the denture before the the use and care of these liners and often use the
reline material completely hardens. The heat released can liners far beyond their useful life. These materials
burn the tissues and the material could lock into undercuts,
can stiffen with time and can cause damage to the
making it difficult and painful to remove.
tissues, particularly if the occlusion is not properly
416 CHAPTER 17 Polymers for Prosthetic Dentistry

reestablished with the new lining in place. They are bond to the acrylic of the denture base and must have
usually porous and promote the growth of fungi, mechanical retention such as metal pins or retention
and patients can end up with fungal infection of the holes to keep them in the acrylic denture base. They
oral tissues. These over-the-counter products are not have a good esthetic appearance until the surface glaze
recommended. is lost through wear or abrasive polishing. Porcelain
teeth cannot be easily repolished, as can plastic teeth.
They are highly stain resistant, whereas some plastic
DENTURE TEETH teeth will stain over time. They are not indicated for
Plastic (acrylic resin), composite resin, and porcelain use against the natural dentition or most restorative
teeth are used for complete and partial dentures. Each materials, because they are very abrasive (Fig. 17.19).
has certain advantages and disadvantages. They also transmit heavier occlusal forces to the ridge
and therefore may be a factor in patient discomfort,
ACRYLIC RESIN TEETH denture sores, and accelerated ridge resorption. Some
The vast majority of denture teeth used for remov- patients prefer porcelain teeth because they sense a
able dental prostheses are made from acrylic resin. better ability to chew harder or more fibrous foods
Acrylic teeth are tough and chemically bond to the (Fig. 17.20).
acrylic base of the denture. They are easy to grind to
adjust the occlusion or to reshape a tooth to fit the
CHARACTERIZATION OF DENTURES
available space and easy to repolish. They do not
wear down the opposing natural or artificial teeth Dentures can be given individual characteristics to
or restorations. Their main disadvantage is that make them seem more lifelike. Denture teeth can be
they are softer and wear more readily than porce- arranged in the standard “ideal” arch alignment, or
lain teeth. Plastic teeth are made in layers to simu- teeth can be arranged to recreate spaces (diastemas)
late the colors and translucencies of natural teeth. (Fig. 17.21) or overlapping or crooked teeth that the
The gingival portion of the teeth is manufactured patient had with the natural teeth. The denture teeth
so that the acrylic has minimal cross-linking. The can be all one shade or can be selected to simulate
bond of the acrylic tooth to the denture base is bet- the lighter and darker teeth that most people have
ter without cross-linking. Cross-linking in the other in their mouths (e.g., canines are usually darker than
portions of denture teeth makes them tougher and incisors). Some patients request that restorations be
better able to hold up under function. Plastic teeth placed in the denture teeth to simulate restorations
are used more often than porcelain teeth, because they had in their natural teeth. The denture base acryl-
they are somewhat resilient and are thought not to ic itself is made in several shades, and these can be
stress the underlying ridges as much as porcelain selected to replicate the color of the patient’s mucosa
teeth. and gingiva (see Fig. 17.4). The dental technician can
do custom-shading with pigmented resins to simulate
COMPOSITE RESIN TEETH racial pigmentation in the denture base, because racial
Nanohybrid composite material is used to make den- pigmentation is not always uniformly distributed in
ture teeth that have improved properties compared the tissues.
with the simple acrylic resin teeth. Various filler par-
ticles have been used. Highly cross-linked macrofill-
ers have been used to increase the strength and color
stability. High-density microfillers are used to improve
the wear resistance, and silanized silica-based nano-
fillers are used to improve optical properties such as
light reflection. (See Chapter 6 for discussion of com-
posite resin filler particles.) Composite resin teeth have
a more natural appearance and translucency. The teeth
made from hybrid composite resin and nanofillers can
be made by two techniques: (1) pressing the materials
together into a mold or (2) injecting the materials into a
mold. Teeth made by the injection technique have bet-
ter esthetics.

PORCELAIN TEETH
Porcelain teeth are brittle, hard, and very resistant to
wear. Because of their brittleness, they are prone to FIG. 17.19 Maxillary dentures with porcelain teeth have excessively
fracture if the denture is dropped or is overstressed by worn opposing natural teeth. (Courtesy of Steve Eakle, University of
hard foods or accidental biting on a fork. They do not California School of Dentistry, San Francisco, CA.)
 Polymers for Prosthetic Dentistry CHAPTER 17 417

PLASTICS FOR MAXILLOFACIAL PROSTHESES base lost or broken, teeth can be chemically bonded in
place with repair acrylic. Likewise, broken denture bas-
A specialized aspect of a prosthodontic practice may es can be repaired if the fragments can be reassembled.
include the fabrication of maxillofacial prostheses to re-
place facial tissues lost as the result of trauma, disease, CHEMICAL-CURED ACRYLIC REPAIR MATERIAL
surgery, or birth defect. These prostheses must have The broken prosthesis should be disinfected at chairside
specialized characteristics so that they can be colored to before it is transported to the laboratory. For repair of an
match the surrounding skin, tear resistant in thin layers, all-acrylic denture or partial denture, the broken parts
resistant to staining, very flexible, and able to be attached are pieced together and are held with sticky wax. Plaster
to the surrounding skin with adhesives (Fig. 17.22). Ma- or stone is poured into the prosthesis to create a cast on
terials that have been used are synthetic latex, plasticized which the parts can be stabilized while they are being re-
vinyl resins, and silicone rubbers. Of these materials, the paired. Sometimes an impression of the patient’s mouth
best for maxillofacial prostheses is silicone rubber. must be taken to assemble the broken pieces. After the
plaster has set, the fracture line is cut with an acrylic bur
DENTURE REPAIR to create room for a sufficient bulk of repair material, and
the adjacent surfaces several millimeters around the frac-
Acrylic complete and partial dentures can be repaired ture line are ground to expose fresh surfaces for bond-
rather easily when they are broken. The repair of a par- ing. Often mechanical locks or dovetails are cut into the
tial denture with a metal framework is more complex, acrylic fragments to ensure a good, strong union between
depending on the location of the break. If the break oc- fragments. A coating of the liquid monomer is placed on
curs through the framework or the clasp, it can some- the roughened surfaces to wet and prime them, as with
times be repaired by welding in the dental laboratory. the chairside reline procedure. Often the repair material
However, many times such a break means that a new is the same as the chairside reline material. The repair
partial denture must be made. With the acrylic denture material is applied to the fracture in bulk or by the “salt
and pepper” technique. With the salt and pepper tech-
nique, a small quantity of powder is sprinkled onto the
P wet fracture site and is wet with more liquid. This process
of alternately adding powder and liquid continues until
the fracture site is slightly overfilled. The prosthesis on
the cast is then placed into a pressure pot with warm (not
hot) water and about 20 pounds of pressure until cured
Por
a (at least 20 minutes). Once the repair acrylic has cured,
h the prosthesis is removed, and excess material is cut back
and polished. The prosthesis is disinfected and returned
to chairside to try in the patient’s mouth to confirm the fit
and comfort.

Caution
FIG. 17.20 Plastic and porcelain denture teeth. Porcelain teeth (Por) Liquid monomer repair material is highly flammable; do not
do not chemically bond to the denture base, as do plastic teeth (a); use it around an open flame such as a Bunsen burner.
therefore, they have metal pins (P) or retention holes (h) to lock into
the acrylic.

A B
FIG. 17.21 Characterized temporary partial denture (stayplate) to create a lifelike appearance. Patient had naturally
occurring diastemas between her maxillary incisors and wanted to have diastemas in the prosthesis. A, Stayplate with
diastemas between the incisors. B, Natural-looking smile. (Courtesy of Arun Sharma, School of Dentistry, University of
California, San Francisco [San Frncisco, CA].)
418 CHAPTER 17 Polymers for Prosthetic Dentistry

A B
FIG. 17.22 Flexible acrylic prosthesis for nose lost to cancer. A, Metal implant at site of lost nose will hold the prosthesis
in place. B, Lifelike prosthesis made of silicone rubber replaces the nose. (Courtesy of Arun Sharma, School of Dentistry,
University of California, San Francisco [San Francisco, CA].)

LIGHT-CURED REPAIR MATERIAL This technique is somewhat faster than the chemical-
See Procedure 17.2 for more details. cured method.
Light-cured dimethacrylates have a number of use-
ful applications, including repair of broken acrylic
prostheses and fabrication of custom trays and record
CUSTOM IMPRESSION TRAYS AND RECORD BASES
bases (e.g., Triad VLC; Dentsply International). Di- Chemical-cured and light-cured acrylic resins can be
methacrylate is an acrylic resin that contains a chemi- used to construct custom impression trays and the re-
cal activated by light in the blue wavelength range, as cord bases on which wax rims are placed during the
well as an accelerator, inorganic fillers, and pigments process of making dentures. The acrylics contain a
to simulate tissue colors. These materials are cross- high proportion of filler particles to impart strength to
linked to improve their stiffness and strength. the material.

Repair Technique CHEMICAL-CURED TRAY AND RECORD BASE

When used for denture repair, the prosthesis is pre- MATERIAL
pared in the same manner as for chemical-cured See Procedure 17.1 for details.
material, except that a different liquid is painted on
the fractured pieces before the repair material is ap- Custom Tray Fabrication
plied. The repair material is removed from its light- Similar to the other chemical-cured acrylics, the tray ma-
proof package and is placed into the prepared frac- terials are supplied as a powder and a liquid. Before the
ture site. The repair material is coated with a liquid acrylic is mixed, the cast is prepared so that the acrylic
to prevent the development of an oxygen-inhibited does not stick to it. It is handled in one of three ways:
layer of uncured material on the surface (see “Resin- (1) soaking in cold water, (2) coating with a separat-
to-Resin Bonding” in Chapter 6). Uncured material ing material, or (3) lightly coating with petroleum jelly.
at the surface makes it more difficult to polish. The Next, a spacer made from one layer of baseplate wax is
prosthesis on the cast is placed into a chamber with applied to the cast. Some clinicians place three or four
intense blue light (Triad 2000 VLC Unit [Dentsply In- holes about 2 mm in diameter in the wax in the anterior
ternational]; see Fig. 17.33 in Procedure 17.2) for about and posterior ridge regions. The acrylic powder and liq-
10 minutes, and it is rotated on a turntable while the uid are mixed, and when the mixture reaches the dough
light polymerizes the repair material. After curing, it stage, the material is adapted over the tissue portion of
is shaped and polished and delivered to the patient. the cast and pressed into the holes in the wax so that
 Polymers for Prosthetic Dentistry CHAPTER 17 419

some of the acrylic contacts the ridge in the anterior and associated with the chemical-cured material. These ma-
posterior regions. This leaves acrylic elevations inside terials have largely replaced the chemical-cured materi-
the tray after the wax is removed. These elevations cre- als in many offices and laboratories.
ate stops against the tissues when the impression is tak-
en. The space left after removal of the wax creates a uni- INFECTION CONTROL PROCEDURES
form thickness for impression material, and tissue stops Contaminated dentures, custom trays, record bases,
keep the tray from being seated too heavily and com- laboratory relines and other materials that are trans-
pressing large areas of tissue during impression mak- ported back and forth between the dental office and
ing. After the tray material is adapted to the cast and is the dental laboratory should be treated following
still in the dough stage, excess material is cut away with proper infection control procedures. The dental office
a knife and is used to make a handle for the tray. The is responsible for disinfecting these items that have
polymerization reaction is exothermic and the material been in the patient’s mouth before they are sent to the
becomes quite hot. After the acrylic has cooled, the tray laboratory. Likewise, the laboratory should disinfect
should be carefully pried off the cast and the wax spacer the items before delivering them to the dental office.
removed. The tray is trimmed to the appropriate length However, the dental office is ultimately responsible for
with acrylic burs or abrasive bands on a lathe. assuring that items have been disinfected (or sterilized
when possible) before placing them in the patient’s
Record Bases mouth (see the box “Disinfecting Prostheses”).
Record bases are rigid bases that correspond roughly
to the denture base. They are used in the construction
Disinfecting Prostheses
stage of the denture and have wax rims added to them
over the ridge areas. They are used initially to estab- • P roperly disinfect all prostheses before trying in the
lish the proper dimension between upper and lower patient’s mouth.
arches, as well as the position of the centric occlusion. • Disinfect at chairside all prostheses going from the
patient to the commercial or office laboratory, and
Marks can be made in the wax to denote the location
package properly for transport.
of the border of the upper lip, the “smile” line, and the • Iodophors and synthetic phenols are suitable disinfec-
midline of the face as guides for placement of the den- tants for most prostheses.
ture teeth. Later, the denture teeth are set in the wax • Immerse prostheses for 15 minutes in one of these
rims, and the record bases serve to stabilize the wax disinfectants in a denture cup or a plastic bag.
rims during the try-in appointment.

Record Base Fabrication

INSTRUCTIONS FOR NEW DENTURE WEARERS
Record bases are also constructed from the same ma-
terials as the trays. The difference in their construction Approximately 44 million people in the United States
is that wax spacers, tissue stops, and handles are not wear dentures. Losing one’s teeth can have a physical
used. If significant tissue undercuts are present on the and psychological effect on some people. Trying to ad-
cast, they are blocked out with wax before the record just to acrylic prostheses can become a frustrating expe-
bases are constructed. rience if patients do not know what to expect from their
new dentures. It is vitally important to the acceptance
LIGHT-CURED TRAY AND RECORD BASE of the dentures that hygienists and dental assistants as
MATERIAL part of the dental team be able to instruct patients on
Light-cured dimethacrylates can be used for construc- what to expect, how to manage use of their new den-
tion of custom trays and record bases (Procedure 17.2). tures, and how to care for them. The following is infor-
They are similar to light-cured repair materials but mation you can provide to the new denture wearer.
come in one color and do not have fibers to simulate
blood vessels. WHAT TO EXPECT
The technique for making custom trays and record Speaking
bases is the same as for the chemical-cured materials, Dentures may create a feeling of fullness to the mouth
except that instead of mixing powder and liquid, a sheet as you adapt to the additional thickness of the dentures.
of the preformed material is removed from its lightproof Some people may feel a gagging sensation as they swal-
package and adapted over the cast or wax spacer. After low. The tissues and muscles will adapt with time.
excess material is trimmed (and a handle is formed if Most people will have some difficulty pronouncing
a tray), the tray or record base on the cast is placed in some words, especially those with “f” and “s” sounds.
the light-curing unit as described previously for light- Try reading the newspaper out loud and practice words
cured repair materials. The light-cured material gener- that are difficult to pronounce. The lower denture will
ates very little heat during polymerization and is much move when you talk or eat, because the tongue and
easier to use because no mixing is required. It eliminates cheeks move. Avoid the tendency to tongue thrust be-
the concerns about inhaling and handling the monomer cause it will dislodge your dentures.
420 CHAPTER 17 Polymers for Prosthetic Dentistry

Eating your mouth checked for cancer or other mouth dis-

The biting force with your dentures is about 20% of orders. In addition, your dentist will check the fit of
that with your natural teeth. The dentures sit on top your dentures and professionally clean them. The
of tissues that are compressible, so there will be some dentist will advise you as to how often you should
movement of the dentures while eating. Start with soft come in.
foods that are easy to chew. Biting into food with the You should come in sooner than your regular check-
front teeth will tend to dislodge the dentures. People ups if you notice soreness, exceptional looseness,
with dentures tend not to chew the food long enough chipped teeth or acrylic, or if you have dropped and
to grind it into small pieces, because it takes longer broken your dentures. Do not attempt to repair them
than with natural teeth. This can put you at risk for yourself, as you could cause damage that may make a
choking. Chew the food well before swallowing. Cut repair more difficult or impossible.
the food into smaller pieces than you usually do.
To help balance the dentures, chew with food on
both sides of your mouth at the same time. Your den-
tures cover many of your oral tissues, so you may not
CARE OF ACRYLIC RESIN DENTURES
be aware of foods or beverages that are very hot. Take Cleaning the dentures is important in maintaining
care not to burn yourself. the health of the oral tissues. Improper or inade-
quate home care can lead to fungal infections of the
Excess Saliva tissues or damage to the dentures. The most com-
Saliva is important to help you swallow your food, lu- monly used home cleaning aids for dentures are den-
bricate your mouth tissues, and help form a seal with ture brushes and denture soaks or cleaners. Denture
your dentures. However, your mouth will react to the brushes, when used with water or mild soaps, are
presence of the new dentures by producing more sa- not abrasive to the acrylic surface. Household clean-
liva than usual. Your mouth will usually adapt and re- ers can be very abrasive to the acrylic and should
turn to its normal salivary flow in a week or two. not be used. Denture cleaners can be found as tablets
(Efferdent [Prestige Brands] and Polident [GlaxoS-
Fit mithKline]) or powders. They may contain deter-
Your upper denture rests on the bony ridges and the gents, sodium perborate, alkaline compounds, and
hard palate. The borders of the denture help create a flavoring agents. When sodium perborate is placed
seal with the tissues and saliva fills in the gaps between in water it releases oxygen and effervesces, loosen-
the denture and the tissues, so suction is created to ing debris. Diluted household bleach (hypochlorite)
hold the denture in place. Your lower denture will feel will remove some stains and will have an antimicro-
looser, because it does not have the large surface area bial effect. However, it will remove the tissue color
of the palate for support and the tongue is continually from the denture base over time. Bleach should not
moving and lifting the lower denture. You will need be used with prostheses containing metal such as
to learn how to position your tongue to help keep the partial denture frameworks or removable orthodon-
lower denture seated. Avoid using denture adhesive if tic appliances, because it will attack the metal and
possible while you learn to adapt to the new dentures. corrode it.
The patient needs to be instructed on how to care
Soreness for new dentures. The following are home care instruc-
Like a new pair of shoes, your dentures may rub the tions you can provide.
tissues and create sore spots. Biting your cheeks is not
unusual in the first few weeks. Do not attempt to ad- HOME CARE
just the dentures yourself. Call the office and we will Clean the dentures every day, twice if possible, to re-
get you in quickly to relieve the soreness. It might take move plaque and debris. Hold them over a towel or
several visits to eliminate all of the pressure spots. put water in the sink, so if you drop them they will
not break. Clean the tissue surfaces and the teeth and
Looseness outer surfaces of the denture with a denture brush.
If you had teeth extracted just before placement of the Many denture brushes have medium or hard bristles.
dentures, some looseness will occur as the extraction The stiffness of the bristles is not as critical to the abra-
sites heal and the gum shrinks. Your dentist will dis- sion of the acrylic as the cleaner used on the brush. Use
cuss with you when it is time to put a lining material liquid soap, mild hand soap, or a nonabrasive denture
inside the dentures to adapt them to the new position cleaning paste to remove surface debris.
of the gums. Expect some food to get under the denture when
you eat. Remove and rinse the dentures after each meal
Regular Dental Checkups if you cannot brush them, but do not use hot water as
Even though you no longer have your natural teeth, it may warp the dentures. Rinse your mouth as well to
you will need to visit the dentist periodically to have remove food particles.
 Polymers for Prosthetic Dentistry CHAPTER 17 421

At bedtime, clean the tissues that the dentures sit on material. Use only cleaners recommended by the man-
and those surrounding the dentures. Use a soft tooth- ufacturer. Clean soft temporary liners with damp cot-
brush and water to gently clean your gums, palate, ton balls or cotton-tipped applicators for a few days.
tongue, and lining of your cheeks. After about a week it will harden enough to clean with
Remove the dentures overnight or at least for 4 a soft bristle toothbrush.
hours during the day to give the gums a rest. You Wearing a partial denture increases your risk of get-
can prepare a denture soak with commercial denture ting tooth decay. Be sure to brush your remaining teeth
cleaning tablets (such as Efferdent or Polident). Cal- at least twice a day with a fluoride toothpaste, and floss
culus that accumulates on the denture can be soft- at least once a day. Avoid starchy or sugary snacks.
ened and more easily removed by soaking the den-
ture in a solution of white vinegar diluted 1:1 with IN-OFFICE CARE
water. Dentures are soaked overnight in commercial
or homemade soaks. Be sure to rinse them thor- Patients will accumulate calculus on the denture
oughly before putting them back into your mouth, around the surfaces of the maxillary molars and the
because the soaks may contain chemicals that can mandibular anterior teeth, just as they did with their
irritate the tissues. Bleach is an effective organic sol- natural dentition. The dental hygienist can provide a
vent and eliminates yeasts. It should be diluted: 1 service by removing the calculus before returning the
part bleach to 10 parts water. Undiluted household denture to the patient. Calculus can be removed by
bleach should not be used as an overnight soak for placing the prosthesis in a denture cleaning solution
complete or partial dentures. It will fade the color inside a zippered bag placed into an ultrasonic cleaner.
from the acrylic and attack the metal framework and It can also be carefully scaled off with hand instru-
clasps of a partial denture, causing them to darken ments and the area polished with flour of pumice, then
and corrode. Partial dentures with metal compo- tin oxide or acrylic polishing compounds (Fig. 17.24).
nents should be soaked in commercial products that Care must be taken not to wear down the teeth and
do not contain bleach. acrylic base during the polishing process. In addition,
Store your denture in water when you are not wear- tissue-bearing surfaces of the complete denture or par-
ing it to keep it from drying and distorting. tial denture should not be polished.
Clasps on partial dentures can be cleaned with the
pointed brush on the end of the denture brush if the STORAGE OF DENTURES
two-headed variety is used. Use care to keep from Acrylic resin prostheses absorb water and also are sen-
damaging or distorting the clasps. Gently clean the tis- sitive to water loss. The patient should be instructed
sue-bearing surfaces of dentures with soft liners, using to keep the prosthesis wet during periods of storage.
a soft toothbrush. Liquid soap can also be used (Fig. This will prevent dimensional changes and distortion
17.23). that can affect the fit. The prosthesis should be kept
Long- and short-term soft liners may be adversely wet during the dental appointment. It can be stored in
affected by some of the effervescent commercial soaks a denture cup to which water and a little mouthwash
(Efferdent or Polident). Do not soak them in mouth- have been added to freshen it. Prostheses with soft
wash containing alcohol, because it dries out the liners should not be placed in mouthwash containing
alcohol, because the alcohol may adversely affect the
properties of the soft liner. Instructions for care of com-
plete and partial dentures should be given to nursing
home staff and to caregivers for homebound or inca-
pacitated individuals.

Precautions for Patients with Partial or Com-

plete Dentures
• S tore dentures in water to prevent warping from loss
of moisture.
• Do not clean dentures in hot water, because they
may warp.
• Avoid soaking dentures in undiluted chlorine bleach,
because it will remove color from the resin and will at-
tack metal components of partial dentures.
• Clean dentures over a sink partially filled with water or a
towel to avoid breaking the denture if dropped.
• Avoid abrasive toothpastes or household cleaners,
FIG. 17.23 Home care products for cleaning dentures: Brush, liquid because they will scratch or wear the plastic.
soap, denture cleaner tablets, denture cup.
422 CHAPTER 17 Polymers for Prosthetic Dentistry

C
FIG. 17.24 Cleaning a denture in an ultrasonic cleaner. A, Cleaning solution (to remove stain and calculus) placed in plas-
tic zippered bag. B, Denture placed in bag and sealed. C, Bag placed in ultrasonic cleaner for 10 to 14 minutes. D, Den-
tures with large calculus deposits need initial scaling with hand instruments before placing in ultrasonic cleaner. (From
Darby ML, Walsh MM: Dental Hygiene: Theory and Practice (ed 4). St. Louis, 2015, Elsevier. Courtesy of Bertha Chan.)

SUMMARY
mixing, and eliminate the volatile monomer that is po-
Acrylic resins are vitally important to the success of
tentially hazardous. The light-cured resins have applica-
prosthetic dentistry. They are versatile materials that can
tion for fabrication of custom trays and record bases and
be used to replace missing oral structures. The ability of
for denture repair. Acrylic and vinyl resins to which plas-
these resins to chemically bond to one another is impor-
ticizers have been added to soften them are often used in
tant when plastic teeth are linked to the denture base or
maxillofacial prosthodontics for replacement of facial tis-
when they are relined or repaired. When properly han-
sues after trauma or cancer surgery. Noses, cheeks, ears,
dled, they are strong and durable. They can readily be re-
and other structures can be made from these materials
lined to improve the fit as the alveolar bone resorbs over
and colored to match the surrounding skin.
time. Lining materials can be similar to the denture base
The allied oral health provider plays an impor-
material or can be modified with plasticizers to create
tant role in delivering care to individuals who re-
soft liners for tissue conditioning or long-term cushion-
quire prostheses. She or he may be called on to mix,
ing for patients who cannot tolerate hard liners. Many
place, remove, or repair any number of these materi-
relining procedures can be accomplished in the office at
als. Therefore an intimate knowledge of the properties
chairside, so that the patient does not have to be without
and handling characteristics of these materials is very
the prosthesis for any length of time. Simple fractures of
important. In addition, patients need instructions in
the resin also can be repaired readily in the dental office.
proper home care of the prostheses to maintain them
The acrylic resins can be colored with pigments to simu-
and to prevent injury to the oral tissues. Knowledge of
late racial pigmentation, so the denture can be custom-
proper cleaning agents and methods is also necessary.
ized to match the tissue coloration of the patient.
Other resins chemically similar to the methyl meth-
acrylate resins are also used in prosthetic dentistry. The INSTRUCTIONAL VIDEOS
addition of photoinitiators and amine activators produc- See the Evolve Resources site for a variety of educational
es light-cured materials that are easy to use, require no videos that reinforce the material covered in this chapter.
 Polymers for Prosthetic Dentistry CHAPTER 17 423

Procedure 17.1 Fabrication of Custom Acrylic Impression Trays

See Evolve site for Competency Sheet NOTE: As tray material is adapted into these
holes, resin squares will appear inside the tray.
Consider the following with this procedure: safety glasses are
When the impression is taken, these squares will
recommended for the patient, PPE is required for the operator, and
contact the tissues over the ridges and act as stops.
ensure appropriate safety protocols are followed.
The stops will create an even thickness of impression
NOTE: Figs. 17.25 through 17.32, Courtesy of Mark material within the tray (except for the very small
Dellinges, School of Dentistry, University of California, area of the square) and will prevent an uneven seat-
San Francisco (San Francisco, CA). ing of the tray (Fig. 17.26). Some clinicians do not use
these stops.
EQUIPMENT/SUPPLIES (FIG. 17.25) 4. Mix the powder and liquid components of the
• Maxillary or mandibular edentulous cast tray material in the wax cup, in proportions
• Sheet of baseplate wax, Bunsen burner, laboratory recommended by the manufacturer. Stir with a
knife tongue blade or cement spatula until thoroughly
• Tray powder and liquid, tongue blade or cement mixed (Fig. 17.27).
spatula, waxed paper cup NOTE: The mix will be too wet to handle at this
• Laboratory handpiece and acrylic bur, sandpaper stage. Use only in a well ventilated area.
drum (arbor band), and dental lathe
• Cast-separating medium, disposable brush,
petroleum jelly

PROCEDURE STEPS
1. Using the disposable brush, coat the cast with
separating medium and allow it to dry.
NOTE: The separating medium keeps the tray ma-
terial and the wax from sticking to the cast.
2. Warm a sheet of baseplate wax over the Bunsen
burner and place it on the cast. Adapt it to the cast
over the edentulous ridges and into the vestibular
folds. Use the laboratory knife to trim excess wax
away until it is about 2 mm from the depth of the
folds.
NOTE: The wax will be removed after the tray is
fabricated and will create an even space within the tray
for the impression material. FIG. 17.26
3. Cut three 2 × 2-mm square holes in the wax over
the ridges for the maxillary and mandibular
casts: two in the molar area, and one in the
incisor area.

FIG. 17.25 FIG. 17.27

Continued
424 CHAPTER 17 Polymers for Prosthetic Dentistry

Procedure 17.1 Fabrication of Custom Acrylic Impression Trays—cont’d

5. Apply petroleum jelly to the gloved hands. When smooth the rough edges. The completed tray
the mixture is doughy, form it into a thick, wide should extend 2 mm short of the vestibular
rope that is long enough to fit around the entire folds. Confirm the fit of the tray on the cast
ridge (Fig. 17.28). (Fig. 17.32).
NOTE: Petroleum jelly keeps the tray material from
sticking to the gloves.
6. Adapt the resin over the wax, into the holes in the
wax, and into the depth of the vestibular folds.
The tray should be 1 to 2 mm thick (Fig. 17.29).
NOTE: If the tray is too thin, it might be too flexible
to keep the impression from distorting.
7. Cut away excess tray material with the
laboratory knife and quickly adapt it into the
shape of a handle. Wet the tray end of the
handle with monomer and place it on the tray.
Smooth it into place with the fingers. The handle
should be positioned so that it will not be in
the way of the lips when seated in the patient’s
mouth.
NOTE: Wetting the end of the tray with monomer FIG. 17.29
(liquid) dissolves some material at the surface and al-
lows it to stick to the polymerizing tray material.
8. Readapt the tray material to the cast continually
as polymerization takes place.
NOTE: The tray material shrinks as it polymerizes
and tends to pull away from the cast.
9. Remove the tray from the cast once the heat of the
reaction has cooled. Remove wax from inside the
tray. If difficult to remove, heat the wax in warm
(not hot) water (Fig. 17.30).
NOTE: Residual wax must be removed, or it might
prevent the impression material from adhering to the
tray.
10. Trim the tray with an acrylic bur or arbor band
to remove excess material (Fig. 17.31), and
FIG. 17.30

FIG. 17.28 FIG. 17.31

 Polymers for Prosthetic Dentistry CHAPTER 17 425

Procedure 17.1 Fabrication of Custom Acrylic Impression Trays—cont’d

NOTE: The tray must be smooth to the touch, or it

will be uncomfortable in the patient’s mouth. The tray
is left short of the depth of the folds to allow room for
stick compound to be added for border molding. Bor-
der molding uses softened compound to shape the
location for the borders of the denture as the patient’s
cheeks and tongue are manipulated through simulat-
ed functional movements.
NOTE: Some dentists use addition silicone putty or
special thermoplastic materials for border molding.
11. Disinfect the tray by immersion in appropriate
disinfectant and store in a sealed bag labeled with
the patient’s name until ready for use.

FIG. 17.32

Procedure 17.2 Fabrication of Record Bases with Light-Cured Acrylic Resin

See Evolve site for Competency Sheet 4. Press the material into the vestibule areas of the
cast, using the blunt end of the disposable scalpel.
Consider the following with this procedure: safety glasses are
recommended for the patient, PPE is required for the operator, and
ensure appropriate safety protocols are followed.
NOTE: Figs. 17.33 through 17.39, Courtesy of Dr.
Mark Dellinges, School of Dentistry, University of Cal-
ifornia, San Francisco (San Francisco, CA).

EQUIPMENT/SUPPLIES (FIG. 17.33)

• Edentulous casts (maxillary, mandibular, or both)
• Light-cured record base material (Triad VLC;
Dentsply International)
• Model-releasing agent
• Light-curing unit (Triad 2000 VLC Unit)
• Disposable scalpel blade and handle
• 2 × 2 gauze soaked with alcohol
• Low-speed handpiece with acrylic bur
• Laboratory lathe with sandpaper drum (arbor
band), rag wheel, and pumice

PROCEDURE STEPS
1. Apply a thin layer of model-releasing agent to the
surface of the edentulous casts with a disposable
brush, and let it dry (Fig. 17.34).
2. Remove a sheet of the Triad VLC material from the
protective packaging, and place it over the cast.
NOTE: The packaging prevents light from polymer-
izing the material.
3. Press the material gently onto the cast, being
careful not to trap air between the cast and the
material (Fig. 17.35). FIG. 17.33

Continued
426 CHAPTER 17 Polymers for Prosthetic Dentistry

Procedure 17.2 Fabrication of Custom Acrylic Impression Trays—cont’d

5. Trim away the excess material that extends 9. Remove the record base from the cast, invert the
beyond the depth of the vestibule with the scalpel record base, and cure again.
blade. Smooth the edges with the fingers. NOTE: The record base is inverted to cure the in-
6. (Optional) Cut a 2-cm-long slit in the back of the ternal surface and ensure complete polymerization.
palate of the maxillary record base material to The material is opaque, and light does not penetrate
allow for curing shrinkage. enough to cure entirely through it from the outside.
NOTE: Resins shrink when polymerized. Because
there is a large volume of material, the shrinkage will
be greater. Too much shrinkage will cause the record
base to fit poorly. The slit allows shrinkage to occur
without lifting material away from the palate (Fig.
17.36).
7. Place the cast and record base into the light-curing
unit on the turntable according to manufacturer’s
directions. Activate the turntable and cure for 2 to
4 minutes (Fig. 17.37).
8. (Optional) Place a small amount of the excess
uncured base over the slit, and press with your
fingers. Cure again.
NOTE: This step seals the slit; most of the polymer-
ization shrinkage has already occurred.

Fig. 17.36

FIG. 17.34

FIG. 17.35 FIG. 17.37

 Polymers for Prosthetic Dentistry CHAPTER 17 427

Procedure 17.2 Fabrication of Custom Acrylic Impression Trays—cont’d

10. Wipe the record base after curing with the 14. Confirm the fit on the cast. The record base is now
alcohol-soaked 2 × 2 gauze to remove the slippery ready for the application of wax rims (Fig. 17.39).
film on the surface. 15. Apply sticky wax to the ridge of the record base
NOTE: Resins will have a thin layer of unpolymer- (Fig. 17.40).
ized resin on surfaces in contact with air. Oxygen in- 16. Cut off one third from a sheet of baseplate wax
hibits the polymerization of resin at the surface. This (Fig. 17.41).
same phenomenon is seen on the surfaces of compos- 17. Use the remaining two thirds of the sheet. Warm
ites and sealants. it and roll it into a tight cylinder (Fig. 17.42).
11. Mark with a pencil the excess acrylic that extends 18. Bend the rolled wax into a U-shape. Adapt it to
beyond the border of the vestibule. Grind the the ridge crest of the record base (Fig. 17.43).
excess with an acrylic bur or a sandpaper drum 19. Smooth the facial and occlusal surfaces of the wax
on a lathe in the laboratory to the correct thickness with a hot metal plate (Figs. 17.44 and 17.45).
and length, as directed by the dentist (Fig. 17.38). 20. Use the hot plate to shape the wax rim until it is
12. Thin the area over the ridges with the sandpaper approximately 17 mm high from the apical end of
drum or acrylic bur. Leave it approximately 0.5 the record base to the anterior top edge of the wax
mm thick. and 10 mm wide (Fig. 17.46).
NOTE: If the material is too thick over the ridges, 21. The wax rim can be used to mark the midline of
it will interfere with placement of denture teeth when the patient’s smile and the location of the facial
they are set for the wax try-in appointment. surfaces and incisal edges of the anterior teeth. It
13. Smooth the periphery with pumice on a rag wheel. can also be used to determine the proper vertical
NOTE: This is for the patient’s comfort. dimension of occlusion, so the patient’s bite is

Apply sticky wax to

ridge crest areas of
record base

FIG. 17.40
FIG. 17.38

Cut about 1/3 off of a

sheet of base plate wax

FIG. 17.39 FIG. 17.41

Continued
428 CHAPTER 17 Polymers for Prosthetic Dentistry

Procedure 17.2 Fabrication of Custom Acrylic Impression Trays—cont’d

not propped open or overclosed. If the patient is occlusion. Indices are cut into the wax rims and a
totally edentulous, a lower record base will be used softer wax (e.g., Aluwax; Aluwax Dental Products)
with the upper to record the location of the centric will be warmed and placed in the indices. The
patient will close into the centric occlusion position
and the wax will be cooled to lock in the position
Warm the 2/3 sheet of
base plate wax and form of the upper and lower record bases (Fig. 17.47).
it into a tight roll

Smooth occlusal surface

of wax occlusion rim with
hot plate

FIG. 17.42

Bend roll into a u-shape FIG. 17.45

and adapt to ridge crest
of record base

17 mm
long

10 mm
FIG. 17.43 wide

FIG. 17.46
Smooth buccal and labial
surfaces of wax occlusion rim
with a hot plate

FIG. 17.44 FIG. 17.47

 Polymers for Prosthetic Dentistry CHAPTER 17 429

Get Ready for Exams!

Review Questions 8. W hat is the effect on a denture if it is left on the night-

stand overnight?
Select the one correct response for each of the following a. It will lose water and shrink.
multiple-choice questions. b. It will expand.
1. A polymer is formed by c. It will crack.
a. Breaking down chains of complex, high molecular d. It will oxidize and lose color.
weight molecules by heating them 9. What is the effect on a partial denture framework if
b. Mixing polysulfide and polyether soaked in a chlorine-containing cleaner?
c. Joining monomer molecules together in a long chain a. Nothing will happen.
through carbon bonds b. The metal will clean rapidly and become shiny.
d. Fusing acrylic powder beads together at high c. The metal will dissolve and fracture.
temperature d. The metal will darken and corrode.
2. Cross-linking of polymers 10. The effect that porosity has on an acrylic denture can
a. Is used to improve the physical and mechanical be seen as all of the following EXCEPT one. Which one?
properties of the final resin product a. It contributes to staining.
b. Occurs when long-chain polymers are mixed b. It contributes to growth of microorganisms.
together and the chains physically wrap around c. It weakens the acrylic.
each other d. It decreases the thermal conductivity of the acrylic.
c. Usually results in a weaker material as the degree of
11. The purpose of the use of a pressure pot during
cross-linking increases
­polymerization of a chemical-cured acrylic resin is
d. Occurs when long chains link end-to-end
a. To increase the strength of the acrylic
3. Addition polymerization b. To decrease the porosity
a. Results in porosity in the final material c. To decrease the shrinkage
b. Is the least common method of polymerization used d. All of the above
in dentistry
12. Which type of hard liner has the best physical properties?
c. Produces numerous by-products such as alcohol
a. Chairside chemical-cured liner
and acetone
b. Laboratory chemical-cured liner
d. Is initiated by a free radical
c. Laboratory heat-cured liner
4. The physical stages of the addition polymerization d. None (they are all the same)
­reaction are
13. Methyl methacrylate is which one of the following?
a. Sandy, stringy, dough, and rubber
a. An inhibitor
b. Wet, flexible, and stiff
b. An accelerator
c. Sol, gel, and solid
c. Powder polymer
d. Initial, thermal, and terminal
d. Liquid monomer
5. A heat-processed denture differs from a chemical-cured
14. Long-term soft liners are indicated for all of the follow-
denture. Which one of the following is NOT true for the
ing reasons EXCEPT one. Which one?
heat-processed denture?
a. Chronic soreness with hard acrylic denture bases
a. It is stronger.
b. Severe soft tissue undercuts
b. It is more porous.
c. Sharp, knife-edge ridges
c. It is harder.
d. Soft tissues with chronic fungal infection
d. It has less dimensional change during the first 24
hours after curing. 15. Acrylic resins can be made soft and pliable by the
a. Use of less monomer in the mix
6. High-impact resins are created by
b. Use of less powder in the mix
a. Removal of free monomer
c. Addition of plasticizers
b. Addition of plasticizers
d. Addition of filler particles
c. Heat-treating the resin after it has polymerized
d. Addition of rubber particles to the acrylic 16. All of the following statements about short-term soft
liners are true EXCEPT one. Which one?
7. Which stage of polymerization of acrylic resins is longer
a. They are also called tissue conditioners.
for heat-cured resins during denture processing to allow
b. They can readapt to the tissues as healing takes
adequate time to pack the acrylic resin into the denture
place, because they have a high degree of flow.
flask?
c. They do not need frequent replacement because
a. Sandy
they absorb water and get softer over time.
b. Stringy
d. They are adversely affected by some commercial
c. Dough
denture soaks.
d. Exothermic

Continued
430 CHAPTER 17 Polymers for Prosthetic Dentistry

Get Ready for Exams!

17. O ver-the-counter denture liners have which of the fol- d. Hot water
lowing shortcomings? For answers to Review Questions, see the Appendix.
a. May not reestablish proper occlusion
b. Are generally porous
c. Promote growth of yeasts Case-Based Discussion Topics
d. All of the above
1. A thin, frail 76-year-old widow had complete dentures
18. All of the following are advantages of acrylic denture made about 3 years ago. She comes to the dental
teeth over porcelain teeth EXCEPT one. Which one? office with a chief complaint of “my lower denture hurts
a. They are more wear resistant me when I eat.” In the 3 years since her dentures were
b. They chemically bond to the denture base made, she has had the lower denture relined twice with
c. They are kind to the opposing teeth or ridges hard acrylic. This has not improved her comfort. Her
d. They can easily be ground and shaped to fit the lower ridge is sharp and thin.
available space Can you suggest a process that might make her more com-
19. When a denture is repaired with a chemical-cured fortable? Is the procedure best done in the office or in a
acrylic resin, all of the following procedures are per- commercial dental laboratory? What kinds of materials are
formed EXCEPT one. Which one? often used?
a. the pieces are reassembled and held with sticky wax 2. A 62-year-old retired janitor comes to the dental office to
while a cast is poured inside the denture get his teeth cleaned. He wears an upper complete den-
b. a layer of the old resin surrounding the fracture site is ture and a lower partial denture with a metal framework
removed that replaces teeth #22 to #26. In addition to calculus
c. the resin surrounding the fracture site is wet with on his teeth, he has calculus on his denture and partial
monomer to enhance the chemical bond with the denture.
repair acrylic Describe a method of removing the calculus without scratch-
d. the repair acrylic is mixed, applied to the fracture ing the acrylic. What home care measures can you recom-
site, and allowed to cure at room temperature on the mend for care of his prostheses? What type of cleaner
laboratory bench for the best results should he avoid on his partial denture? What types of brush-
20. Which one of the following statements regarding con- es should he use to clean his prostheses?
struction of custom impression trays is FALSE? 3. A 57-year-old truck driver comes to the dental office with
a. Tray material may be chemical-cured or light-cured. a broken maxillary denture. It is broken in two pieces
b. Tray material is adapted directly to the cast. through the midline of the palatal portion of the denture
c. During polymerization, the chemical-cured material base. The pieces fit together easily. He said he dropped
gets very hot. it in the sink while cleaning it.
d. Baseplate wax is adapted over the cast to develop What steps should be taken to prepare the denture for repair
space for the impression material. in the office? What materials could be used for the repair?
21. Which one of the following statements is FALSE regard- What is the function of the pressure pot? What advice can be
ing the care of dentures by the patient? given to the patient to avoid a similar mishap in the future?
a. Dentures should be stored in water to prevent 4. A 71-year-old retired teacher had an upper denture
warping. made 6 months ago. She returns to the office com-
b. Dentures should be cleaned over a sink filled plaining that the denture has stained heavily in the
with water or over a towel to prevent fracture if palatal portion of the denture base and has developed
dropped. a foul odor.
c. Abrasive pastes or cleaners should not be used, or When you inspect the denture, you confirm a dark stain in
they will scratch the acrylic. the mid-palate but also notice numerous small porosities in
d. The denture should be cleaned in hot water periodi- the acrylic. Cite causes of porosity during processing of the
cally to kill microorganisms. denture. Why has the denture stained and developed a foul
22. Which one of the following statements about liquid odor? What effect does porosity have on the physical and
monomer is FALSE? mechanical properties of the acrylic?
a. Gives a pleasant taste to a hard reline done at 5. A 43 year-old beautician lost her upper teeth last year
chairside due to rapidly progressing periodontal disease asso-
b. Is potentially harmful to breathe ciated with her uncontrolled diabetes. She comes to
c. Can cause allergic reactions or skin irritation the dental office complaining of soreness in her palate
d. May be present in small quantities in a new beneath her denture. It has been getting progressive
denture worse over the past three weeks. She wears her denture
e. Evaporates readily so do not leave the cap to the to bed so her husband will not see her without teeth.
bottle off What is the likely cause of the soreness? What should the
23. All of the following can have an adverse effect on soft dentist prescribe to help her? What can you advise her to
denture liners EXCEPT one. Which one? do regarding her home care? If the denture had been new
a. Some effervescent commercial denture soaks and she had only worn it for a few days and was taking it
b. Liquid hand soap out at night, what else could cause irritation of the palatal
c. Mouthwash containing alcohol tissues?
 Polymers for Prosthetic Dentistry CHAPTER 17 431

BIBLIOGRAPHY Ferracane JL: Polymers for prosthetics. In Materials in Dentistry

(ed 2). Philadelphia, 2001, Lippincott Williams & Wilkins.
Anusavice KL, Shen C, Rawls HR: Prosthetic polymers and res- Leinfelder KF, Terry DA, Connelly ME: The art of denture relin-
ins. In Phillips’ Science of Dental Materials (ed 12). Philadelphia, ing. Inside Dentistry, 3(5), 2007.
2013, Saunders. Powers JM, Wataha JC: Polymers in prosthodontics. In Dental
Bird DL, Robinson DS: Removable prosthodontics. In Modern Materials: Properties and Manipulation (ed 10). St. Louis, 2013,
Dental Assisting (ed 12). St. Louis, 2018. Elsevier. Mosby.
Darby ML, Walsh MM: (editors): Persons with fixed and remov- Vaidyanathan J, Vaidyanathan TK: Dynamic mechanical analy-
able prostheses. In Dental Hygiene Theory and Practice (ed 4). sis of heat, microwave and visible light cure denture base res-
St. Louis, 2015. Elsevier/Saunders. ins. J Mater Sci Mater Med, 6:670–674, 1995.
18 Provisional Restorations

http://evolve.elsevier.com/Eakle/materials/

Chapter Objectives
Upon completion of this chapter, the student should be able to:
1. Explain the purpose of provisional coverage. 8. D ifferentiate among direct and indirect fabrication
2. Describe examples of circumstances that may require techniques.
provisional coverage. 9. Summarize the advantages and disadvantages of acrylic
3. Identify the criteria necessary for a high-quality provisional and composite resin provisional materials.
restoration. 10. Describe the technique for fabrication of preformed
4. Describe the properties of provisional materials. metal and polycarbonate crowns, custom crowns, and
5. Distinguish among properties that are important for intracoronal cement provisional restorations.
coverage in the posterior, anterior, and both areas. 11. Summarize patient education and home care
6. Differentiate between intracoronal and extracoronal instructions.
restorations. 12. Fabricate and cement metal, polycarbonate and custom
7. Summarize the advantages and disadvantages of provisional crowns.
preformed and custom crowns. 13. Place an intracoronal cement provisional restoration.

Key Terms
Provisional Coverage a restoration that temporarily takes tooth and may extend over the cusp tips on facial or
the place of a permanent restoration, typically for up to 2 lingual surfaces or may include the removal of cusps, such
to 4 weeks. In the case of implant, complex prosthodontic as onlays, three-quarter crowns, full crowns, and veneers
and periodontal treatments, provisional restorations may Indirect Fabrication provisional restorations made on a
be required to last for extended periods of time and are cast or milled in a computer-directed machine outside the
called interim restorations patient’s mouth before delivery
Finish Line the continuous edge that borders the prepara- Intracoronal Restoration a restoration within the crown of
tion to which the restoration is fit or finished; it is also the tooth, such as an inlay or amalgam
called the margin Direct Fabrication provisional restorations made directly on
Extracoronal Restoration a restoration that covers all or the prepared tooth/teeth inside the patient’s mouth
part of the external surface of the clinical crown of the
  

The increased retention of natural teeth and advances in The dental auxiliary may be called on to provide a variety
technology in restoring and replacing tooth structure have of functions such as fabricate, repair, remove, or maintain
increased the need for high-quality fixed prosthodontic, pe- the provisional restoration as well as give home care instruc-
dodontic, and endodontic treatments. Fabricating provision- tions. Good provisional coverage not only helps to ensure
al restorations, also referred to as temporary or interim res- the success of the final restoration, it is also an important
torations, is an important component of fixed prosthodontic component in patient satisfaction. Patients who need to
treatment. While the definitive restorations are being fabri- return to the dental office to have their provisional crowns
cated, provisional restorations are critical for both the biolog- recemented or replaced or do not like the esthetics of the res-
ical and biomechanical health of the tooth and periodontium toration may lose confidence in the doctor’s ability.
as well as the comfort of the patient. Once the tooth has been
prepared, the exposed dentin must be protected from the
DENTAL PROCEDURES THAT MAY REQUIRE
thermal, chemical, mechanical, and bacterial effects from the
PROVISIONAL COVERAGE
oral environment. Adjacent soft tissues must be protected,
and the position of the tooth must be maintained. All of this Provisional coverage may be required in general,
must be accomplished with provisional restorations, with pedodontic, endodontic, and prosthodontic cases.
additional considerations of esthetics, function, and patient Whenever a situation arises wherein a permanent
comfort. restorative material cannot be placed at the time of
432
 Provisional Restorations CHAPTER 18 433

preparation, a provisional (temporary) material will may very likely occur. Keeping these criteria in mind,
be chosen (Table 18.1). the clinician can choose the most appropriate material,
The patient wears this provisional restoration to technique, provisional cement, and postoperative in-
protect the tooth for a short period of time, generally structions for the patient.
2 weeks to a month. In cases involving complex treat-
ments such as implants and complex prosthodontic pro- MAINTAIN PREPARED TOOTH POSITION
cedures, a longer time may be required, 6 to 18 months. RELATIVE TO ADJACENT AND OPPOSING TEETH
This short-term or interim period of time may be When a tooth has been prepared to receive a crown,
used to make a final diagnosis, develop a treatment sufficient tooth structure has been removed to create
plan, allow hard or soft tissue healing, and commu- a space between the adjacent teeth and the opposing
nicate with the laboratory for the optimal success of teeth. The provisional restoration must contact adja-
the final restoration. In some cases, the patient may be cent teeth on the mesial and distal sides as well as be
asked to evaluate the provisional restoration to make in occlusion with the opposing teeth. Otherwise, the
cosmetic decisions regarding the final restoration. For tooth’s position can shift within a couple days. When
instance, the patient wishing to close a large diastema shifting occurs the restoration, which was designed
(space) between teeth #8 and #9 may find that the re- to fit the tooth in its original position, may now be
sultant size of the restorations necessary to close this too high because of occlusal/incisal migration or may
space is less esthetically pleasing than the space they not seat properly as a result of lateral migration of
wished to close. the prepared tooth. This shifting will likely require
the patient to have additional chairtime for adjust-
ments before final cementation or possibly result in
CRITERIA FOR PROVISIONAL COVERAGE the need to take a new impression and fabricate a new
Criteria for a properly fabricated and cemented provi- restoration. Provisional restorations should share the
sional restoration include the following: load from forces during normal function or bruxing.
• Maintenance of tooth function and position in the If the provisional restoration itself is too high, the
arch results may be those associated with trauma from
• Protection of hard and soft oral structures including occlusion,which may cause the tooth be become sore
the pulp and mobile.
• Establishment of esthetics and retention
• Provide patient comfort PROTECT THE EXPOSED TOOTH SURFACES
If these criteria are not met, pulpal and periodontal AND MARGINS
irritation, tooth migration, and patient dissatisfaction When the tooth is prepared, the dentinal tubules are
exposed to potentially harmful thermal, chemical, me-
chanical, and bacterial insults. Provisional materials
Table 18.1   Dental Procedures Requiring Provisional placed near the pulp must have no adverse chemical
Coverage effect and must be sufficiently insulating to protect the
PROCEDURE TYPE OF PROVISIONAL COVERAGE pulp from thermal assaults. Some of the materials gen-
Endodontic access Closes endodontic access erate heat as they set and must be handled properly to
preparation preparations between avoid pulpal damage. Maintaining the comfort of the
appointments patient is paramount.
Vitality of the tooth is in Allows the pulp to respond The finish line (or margin) of the preparation is
question to therapeutic agents or to particularly susceptible to fracture if not adequate-
recover from the trauma of ly protected. Well-adapted provisional restorations
preparation protect the finish line from fracture and from mar-
Emergency care Prevents additional damage and ginal leakage of oral fluids and bacteria. If the finish
improves esthetics and func- line is damaged, the permanent restoration will no
tion while awaiting a perma- longer fit precisely, leaving space for future leakage
nent solution of oral fluids and bacteria. The process of caries may
Awaiting permanent Allows time for laboratory fab- even begin during the time the provisional restora-
restoration rication of cast and ceramic tion is in place.
restorations
Restoration of implants For long-term provisional cover-
age while the implant site is
allowed to heal
Caution
Restoration of primary Placed on primary teeth be- Because provisional luting agents are highly soluble and
teeth cause of extensive caries, may wash out from under a provisional restoration, they
pulpotomies, or pulpectomies cannot be expected to make up for marginal deficiencies
until permanent teeth erupt in the restoration.
434 CHAPTER 18 Provisional Restorations

PROTECT THE GINGIVAL TISSUES Inadequate or open contacts likewise can lead to food
Many crown preparations extend 0.5 to 1 mm subgin- impaction. Rough surfaces will act as plaque traps
givally, making the margins and the overall contour and may abrade the tongue or oral mucosa. These sce-
of the provisional restoration critical to periodontal narios may also lead to irritation, inflammation, and
health. Periodontal tissues are susceptible to irritation recession.
from overcontoured, overextended, or overhanging
margins; trauma from food impaction; and buildup Clinical Tip
of plaque. Margins of the provisional must be flush A properly contoured, polished and well-fitting provisional
with the preparation. If a margin is overextended, the restoration is critical to maintaining periodontal health
resultant tissue irritation may lead to bleeding, inflam- around the prepared tooth. Inflamed gingival tissue will
mation and gingival recession, adversely affecting the bleed profusely at the delivery of the final restoration and
cosmetic effect of the permanent restoration. If the potentially interfere with bonding or cementation.
margin is short of the finish line, the tooth may experi-
ence sensitivity.
PROVIDE FUNCTION
All surfaces of the provisional restoration must be
properly contoured, polished and maintain contact The provisional restoration should restore ideal
with adjacent teeth. If surfaces are undercontoured ­occlusal/incisal contact with the opposing teeth and
the process of chewing will excessively force food di- have functional contours and proximal contacts (Fig.
rectly onto the gingiva rather than deflecting it facially 18.2). As previously mentioned, deficiencies in contour
and lingually. An overcontoured restoration may trap or contact of the provisional restoration may lead to
plaque by not allowing for any self-cleansing or gingi- problems that compromise or prevent the ideal place-
val stimulation from the chewing process (Fig. 18.1). ment of a permanent restoration. Patients must be able
to chew normally and clean the provisional restoration
as they would a permanent restoration. However, the
Temporary crown
provisional restoration is not intended to function ex-
actly like the permanent restoration. Modifications in
diet, including the avoidance of sticky and hard foods,
Flow Flow
may be necessary to prevent dislodging or fracturing
of food of food
of the provisional restoration.

ESTHETICS AND SPEECH

In addition, it is important to consider the esthetics
Gingiva Gingiva
along with concerns for function. Provisional restora-
A tions must have the appearance of natural tooth struc-
(Cross section)
ture whenever esthetics is important.
Undercontoured temporary
crown For anterior esthetic restorations, provisional res-
torations may be used as a guide for color, contour,
length, and positioning of the final restoration. This is
an important component for patient satisfaction, as the
patient now has an opportunity to give input concern-
ing the esthetics of the restoration.
Injury Injury Speech is also influenced by the position of the
teeth. Anterior provisionals that are too bulky, thin,
long, short or do not occlude properly can change the
B patient’s speech patterns causing lisps or whistling
Overcontoured temporary sounds when they speak. The provisional restoration
crown must not interfere with normal speech patterns.

Temporary crown

Contact Contact
Plaque Plaque
retention retention
C
FIG. 18.1 A, Properly contoured provisional crown. B, Under-con- FIG. 18.2 Provisional crown duplicates natural tooth contour, contact,
toured provisional crown. C, Over-contoured provisional crown. and occlusion.
 Provisional Restorations CHAPTER 18 435

Clinical Tip resins that do not hold up well when used for long-
span bridges or with patients who are bruxers. The
Matching shades and customizing provisional materials
material chosen must be able to resist the forces of
to duplicate the natural teeth will greatly enhance patient
acceptance and thus the success of the provisional chewing without breaking or coming off the tooth. In
restoration. addition, the restoration should remain intact when re-
moved so that it can be reused when necessary.

RETENTION HARDNESS
The cementation of the provisional restoration is ac- Acrylic materials wear more readily than composite
complished with provisional cement which is not de- resin materials. Surface hardness must be sufficient to
signed to be retentive for extended periods of time. resist abrasion and wear for the period through which
Like a permanent restoration, the fit of the provisional the provisional restoration is to be worn. The material
crown is partly responsible for its retention. The de- should also be able to be polished to a smooth finish
sign, height and taper of the crown preparation are and should retain that smooth surface throughout its
also responsible for the retention of the provisional use. Smooth, polished surfaces will not irritate the
restoration. For many patients, a well-fabricated provi- tongue or oral mucosa, attract less plaque and make
sional restoration is a direct reflection on how the final homecare easier resulting in healthier gingival tissues.
restoration will turn out. The provisional restoration
must be retentive enough to ensure patient confidence TISSUE COMPATIBILITY
during the period in which the final restoration is be- Ideally, the material should not produce any addition-
ing constructed. al irritation to pulpal or gingival tissues during or after
setting reactions. Materials that generate heat when
Criteria for Provisional Coverage setting must be carefully selected depending on the
clinical situation (i.e., deep preparation) and may be
Provisional coverage must: more appropriate for the indirect fabrication technique.
• Reproduce proper proximal contacts and occlusal In addition, for patient comfort, materials should not
alignment
absorb or give off odors or taste.
• Fit the tooth at the finish line (margins)
• Reproduce natural tooth contours ESTHETICS
• Promote gingival health
• Provide pulpal protection Materials used in areas of esthetic concern must match
• Provide function, esthetics, and phonetics (speech) adjacent teeth and must have good color stability and
• Remain stable and retentive stain resistance. Shade selection is important in the
• Provide smooth surfaces management of patient expectations; many materials
are not accurate in this area. Color stability is influ-
enced by the surface quality and porosity of the mate-
rial chosen as well as by the patient’s oral hygiene and
PROPERTIES OF PROVISIONAL MATERIALS consumption of foods and beverages that tend to stain
Materials used to fabricate provisional restorations (e.g., berries, red wine, coffee, tea).
must have properties that meet the specific require-
ment of the clinical treatment and the part of the mouth Clinical Tip
in which they are placed. Although most provisional It is advisable to pick a shade before a tooth is prepared;
restorations are in place typically for 2 to 4 weeks, enamel dehydration from isolation during preparation
provisional coverage on occasion may be required for procedures leaves the teeth lighter in color.
extended periods of time. Strength and hardness are
important for single and multi-unit extracoronal resto-
rations. Biocompatibility with hard and soft tissues is
also important. Provisional restorations located in the
PROVISIONAL CROWN MATERIALS
smile zone must be esthetic. In areas of the mouth with The selection of provisional materials is typically based
difficult access, the ability to manipulate the materials upon cost, ease of handling, esthetics, strength and ac-
is also an important consideration. curacy of margins. Provisional materials include met-
als, polycarbonate, acrylics, composites, and cements.
STRENGTH These materials may be used alone or in combination,
Materials must have sufficient compressive and tensile such as an aluminum shell crown lined with acryl-
strength to resist the forces of mastication. Materials ic. Provisional restorations may be preformed (e.g.,
that are used for provisional bridges must also have stainless steel, tin-silver, aluminum, or polycarbonate
sufficient flexural strength to resist deformation from crowns) or made specifically for individual procedures
flexing during mastication. Acrylics have more frac- (e.g., custom acrylic or composite crowns and intracor-
ture toughness than brittle materials such as composite onal restorations).
436 CHAPTER 18 Provisional Restorations

FIG. 18.4 A selection of pedatric stainless steel crowns. (Courtesy of

Denovo Stainless Steel Crowns.)

method may be time saving, particularly in emergen-

cy situations when the patient has a fractured tooth,
but does not consistently produce the most esthetic or
B well-fitting provisional crown.
FIG. 18.3 A. Polycarbonate and celluloid crown forms. B. Aluminum Preformed crowns come in many sizes and tooth
shell, anodized aluminum and silver-tin crowns. (From Rosenstiel SF, forms available in kits containing anterior or poste-
Land MF, Fujimoto J: Contemporary Fixed Prosthodontics, (ed 5). St rior crown forms or both. Because the prepared tooth
Louis, 2016, Elsevier.)
is much smaller than this preformed shell, a reline of
acrylic or bis-acrylic composite material is generally
Provisional materials, whether they are cement, acrylic, required for a close fit. Metal crowns are typically used
or bis-acrylic composite, are mixed and placed in a plastic only in posterior cases, while polycarbonate and cel-
state and allowed to harden directly in/on the prepara- luloid forms are used on anterior teeth or premolars.
tion or on a stone model. Cements are limited to intracor- Preformed crowns may only be used for single crowns
onal placement; provisional acrylic and composite resin and are not appropriate for temporary bridges.
can be used for extracoronal coverage as well.
Preformed crowns have the advantage of conve- Clinical Tip
nience, in that they are already premade in a variety If the kit of provisional crowns does not come with a
of sizes and anatomic forms. This saves time because measuring gauge, use a millimeter ruler to select the most
it eliminates the need for a crown template and is par- appropriate crown size, measuring the width from mesial
ticularly useful in emergency situations and for badly to distal contacts. All crowns that are tried in and not used
broken-down teeth. Even though they come in differ- must be sterilized before they are returned to the crown kit.
ent sizes, time must be spent in establishing contact,
contour, occlusion, and marginal integrity.
Customized crowns are more versatile and more Stainless Steel Crowns
consistently meet the criteria for successful provisional The stainless steel crown does not tarnish or corrode
restorations. They do, however, require the additional and is the most durable and abrasion-resistant of the
step of making a template or matrix for the final prod- preformed crowns, providing provisional coverage last-
uct. This template captures the external shape of the ing months and even years (Fig. 18.4). The stainless steel
tooth structures as they exist before the preparation. crown has been used traditionally to restore primary
This additional step can be further complicated if the teeth (Fig. 18.5). These durable and economical restora-
original tooth is badly broken down or fractured. tions are also used for adults, in cases where financial or
health concerns would otherwise prohibit restoration of
PREFORMED CROWNS the tooth and result in the recommendation to extract.
The process of temporization using preformed crowns The primary advantage of these crowns is their malle-
includes the use of metal (including stainless steel, ability, which allows them to be bent and burnished to
aluminum or tin-silver), polycarbonate, and celluloid provide for good contacts, occlusion, and marginal in-
crown forms lined with acrylic, bis-acrylic composite tegrity. The crown is cut with crown and bridge scissors
or zinc oxide eugenol materials (Fig. 18.3). The pre- and is crimped and contoured at the contact and mar-
formed crown will become the outer surface of the pro- gins with crimping and contouring pliers. Some manu-
visional crown, and an acrylic or bis-acrylic composite facturers make their crowns pre-crimped at the cervical.
material or thick, hard cement will occupy the inner If the stainless steel crown is an alternate to a cast
portion of the crown. As previously mentioned, this restoration for prolonged periods of time, minimal
 Provisional Restorations CHAPTER 18 437

FIG. 18.5 Stainless steel crowns on mandibular primary molars. (Cour-

tesy of DentalGama.)

reduction of the tooth is ideal to preserve natural tooth

strength and provide protection for the pulp. With the
marginal seal and occlusion intact, these crowns may
be a solution to long-term provisional coverage of pos-
terior teeth even though the adaptations of margins,
the occlusion and overall contours are never as precise
as those of cast restorations.
An alternative to stainless steel crowns is nickel-
B
chromium crowns (e.g., Ni-Chro Crown, 3M ESPE)
which have similar durability, handling characteristics FIG. 18.6 Plastic stretch block for tin-silver alloy provisional crowns.
and appearance. A, Series of tapered stumps of various sizes for different size crowns.
B, Preformed crown is pre-crimped at the cervical and needs to be
stretched by pressing it down on the tapered stump. This will allow it to
Aluminum Shell and Tin-Silver Alloy Crowns pass over the margins of the prepared tooth. (Courtesy of 3M ESPE.)
Aluminum, anodized aluminum shell crowns and
tin-silver alloy crowns (e.g. Iso-Form, 3M ESPE) are
used for provisional coverage of posterior teeth (see
Fig. 18.3B). They are lined with acrylics, bis-acryl-
ic composites or a thick mix of reinforced ZOE ce-
ment to support the soft metal. Without adequate
support under functional forces the crown will dis-
tort and come off. For patients who brux their teeth
a hard liner is preferred over ZOE. A well-fitted
aluminum shell or tin-silver crown can last a few
weeks. (Anodized aluminum shells go through an
electrochemical process to create oxides on the sur-
face of the aluminum to make it more durable and
corrosion-resistant.)
Tin-silver crowns are the softest and most ductile
of the preformed metal crowns and as a consequence,
are easily burnished. They may be pre-crimped (con-
stricted) at the cervical margins. For crown prepara-
tions with a thin finish line, these pre-crimped crowns FIG. 18.7 Plastic measuring gauge used to determine the mesio-distal
width for selecting a posterior provisional crown. (Courtesy of 3M ESPE.)
when seated on the prepared tooth will stretch over
the margins and be closely adapted to the tooth. For
crowns with wider finish lines such as a shoulder mar- Fitting the crown. The mesial-distal width is measured
gin, the crown may need to be expanded to allow it for the most appropriate fit, and some crown kits pro-
to fit over the margins. A plastic stretch block with a vide a gauge for measuring the mesial-distal width
series of tapered stumps is supplied with the Iso-Form (Fig. 18.7). To confirm the correct width of the selected
kit to expand the crown. The crown is pressed down provisional crown without trying it on the tooth, sim-
on the tapered stumps that come in a variety of diam- ply turn it upside down and see if the coronal portion
eters (Fig. 18.6). fits the space. The softness of the metal allows for easy
438 CHAPTER 18 Provisional Restorations

manipulation of the contact, occlusion, and margins,

because the metal can be stretched and burnished
without wrinkling.
Generally, the crowns are too tall for most prepara-
tions and require trimming at the cervical margins to
attain the correct height. To accomplish this, hold the
crown on the prepared tooth with a dental mirror and
use an explorer to scribe a line on the crown at the level
estimated to be the correct crown length that follows the
contour of the finish line of the preparation. Using crown
and bridge scissors begin trimming a little at a time to
avoid overtrimming. If ragged edges are present after
trimming, the margins should be smoothed with a fin-
ishing bur, sandpaper disk or a fine stone. Margins can
be smoothed with a rubber wheel or polishing points. FIG. 18.8 Clear celluloid crown forms for permanent premolar and inci-
Contouring pliers are used to form the cervical contours sor and primary incisor. (Courtesy of 3M ESPE.)
and crimp the margins so they will closely adapt to the
tooth. Prior to placing the supporting liner, the patient which is matched to tooth shade, and then inserted
can bite on the crown a few times to begin forming the onto the prepared tooth. The acrylic mix should reach
occlusal contacts. Because of their softness, these crowns the dough stage before seating the crown on the
wear easily, especially in patients who brux and must be moistened preparation. Acrylic resins will chemically
checked for occlusal integrity if they will be worn for bond with the polycarbonate crown and composites
more than a few weeks (see Procedure 18.1). will bond if the interior of the crown is first primed
with methyl methacrylate liquid. Otherwise, reten-
Clinical Tip tion can be obtained with the composite lining mate-
When selecting a preformed provisional crown, it is better to rial by roughening the interior of the crown.
chose one that is slightly larger than the space rather than
one that is smaller, because a larger one can be shaped and Clinical Tip
trimmed to fit. The smaller one cannot.
Keep the tab of the polycarbonate crown form in place
during fitting; it makes for a convenient handle for trying in
Polycarbonate Crown Forms and removing the crown.
Preformed polycarbonate crown forms are composed
of polycarbonate resin which contains microglass fi-
bers which allow margins to be crimped with pliers Celluloid Crown Forms
and provide strength and durability. These crowns Celluloid crown forms are thin, transparent shells
come in kits with several sizes and shapes for primary made of cellulose acetate (Fig. 18.8). They are available
and permanent teeth and are available in tooth-colored in both primary and permanent anterior tooth shapes
shades, predominately in the A and B shades (see Fig. and sizes and primary posterior teeth.
18.3A). They are more rigid than the soft metal provi-
sional crowns and may have to be adjusted with acryl- Fiting the crown form. In order to select the appropri-
ic burs and disks or may be carefully cut with sharp ate form size, a measurement is made of the incisal
crown scissors. The primary advantage is their esthet- width of the preparation space between the two ad-
ics for replacement of anterior and premolar teeth jacent teeth. The size of the celluloid crown form can
(some manufacturers even have molar forms) and be enlarged by warming the round end of an instru-
their compatibility with acrylic resins to further cus- ment such as a ball burnisher and pressing it into
tomize the fit and margins. As an alternative to poly- the form at the desired location. The size can also be
carbonate, tooth colored crown forms are also made reduced by slitting the crown form vertically on the
from polymethylmethacrylate. lingual surface, lapping the cut edges to fit the crown
preparation and then fusing the edges with a couple
Fitting the crown. An appropriate size crown can be drops of acetone or a hot instrument (use caution).
selected by measuring the mesial-to-distal space be- Preformed celluloid crown forms, like polycarbon-
tween the adjacent teeth to ensure adequate proximal ate crown forms, are filled with acrylic or composite
contacts and confirming that it is long enough to cov- resin provisional material to create the tooth shape
er the preparation. Most crowns are too long initially presented by the form. Usually one or two small holes
and must be trimmed at the cervical margin with are placed in the incisal corners of the crown form to
scissors or an acrylic bur (see Procedure 18.2). After allow excess resin or composite material to flow out
the crown has been adjusted for width and height, when the crown form is seated. This prevents trap-
it is filled with acrylic resin or bis-acrylic composite, ping air and the creation of voids in the material. ­After
 Provisional Restorations CHAPTER 18 439

the fill m
­ aterial cures, the shell is slit with a scalpel
and peeled off the tooth and adjustments to margins,
contours or occlusion are done with an acrylic bur.
Smoothing and polishing can be done with standard
acrylic or composite polishers.

Advantages and Disadvantages. The advantage with

the transparent form is that the shade selected to
match the teeth is not affected by a predetermined
color of the crown form allowing for a better color
match. The disadvantage is that after the crown form
is removed there is often a space left by the thickness
of the crown form preventing contact with adjacent
teeth and acrylic must be added to re-establish the in-
terproximal contacts. FIG. 18.9 Acrylic (liquid and powder) and composite provisional crown
materials mixed by hand and automix.

Clinical Tip CUSTOMIZED PROVISIONAL CROWNS

If the margins are overextended when fitting preformed Custom provisional crowns more consistently meet
crowns, the gingival tissue will blanch when the patient bites the criteria for successful provisional restorations than
on the crown or as the auxiliary seats the crown under finger
preformed provisional crowns. A customized provi-
pressure. This is a useful sign to know where to trim the
sional allows for better function and fit. Superior es-
excess, especially in areas where the margins cannot be
viewed directly such as interproximal areas. thetics improves patient acceptance and the ability to
fabricate multi-unit provisional bridges makes these
materials extremely popular.

Modifying Preformed Crowns to Close Open Handling

Contacts Materials must be fast and easy to use, reliable, and in-
expensive. The material should have sufficient working
Metal crowns: Place the proximal surface on a paper pad
time and simplified technique to allow for fabrication
and burnish the internal surface at the contact area with a
of the provisional. For many customized provisional
ball burnisher. This stretches the metal outward to extend
the contact area. materials, the working time must also allow for remov-
Polycarbonate crowns: Roughen the contact area and al from the mouth while still elastic for trimming be-
prime it with a drop of methyl methacrylate liquid. Add fore reinsertion. For these materials, tear strength, that
freshly mixed acrylic to the contact area. When it reaches is, the ability of the material to resist tearing or distor-
the doughy stage, re-seat the crown on the prepared tion on removal from the mouth or stone model, is a
tooth to establish contact. Remove the crown and place consideration. The setting time must be fast and must
in warm water to accelerate the set of the acrylic. Once accommodate difficult-to-access areas when light-
set, remove excess acrylic and lightly polish the contact cured materials are used. Materials should be repair-
area. able to account for defects and to modify fit. Adding
An alternative material to use is flowable composite res-
provisional material directly to the margins for repair
in. Add the composite to the roughened and primed con-
will help provide good marginal integrity and relining
tact area, seat the crown on the prepared tooth, and then
light cure the composite. Remove the crown and shape and the provisional crown with a new mix of material will
polish the composite as with the acrylic material. ensure a good fit. Materials must be economical and ef-
Celluloid crown forms: Use a warm ball burnisher to ficient to use; provisional coverage must not be exces-
push out the contact area from the interior to extend the sive in terms of cost of materials or time of fabrication.
contact area. Try it on the prepared tooth and check the
contact.
An alternative method is to make a hole where the con- MATERIALS FOR CUSTOM PROVISIONAL
tact area is located and allow the provisional crown material RESTORATIONS
(acrylic or composite resin) to flow into contact with the ad- Materials used for the fabrication of custom provision-
jacent tooth when the filled crown form is seated. Remove
al restorations fall into two main categories: methacry-
from the tooth before the acrylic sets fully so it does not get
lates and composite resins. (Fig. 18.9).
locked on the tooth. Remove excess material and reseat on
the preparation a few times as it sets. With composite resin,
METHACRYLATE PROVISIONAL MATERIALS
use a 2 to 3 second tack cure and remove excess mate-
(ACRYLICS)
rial from the margins and interproximal embrasure spaces
before the final cure. Acrylic materials in the form of methacrylates have
been used for many years for custom provisionals.
440 CHAPTER 18 Provisional Restorations

and odor is unpleasant. Examples of commercially

available methyl methacrylate materials are Dura-
lay (Reliance Dental Manufacturing) and Jet (Lang
Dental Manufacturing Company). The setting time
is approximately 5 to 6 minutes but fast set formu-
lations are available with a 4-minute setting time,
for example, Jet Set-4 (Lang Dental Manufacturing
Company).

Caution
Methyl methacrylate monomer is flammable, so keep
it away from an open flame. It is not good to inhale the
FIG. 18.10 Kit of methyl methacrylate (acrylic) materials: powders in a fumes or allow the material to contact the skin. Use in a well
variety of shades and a bottle of liquid (monomer). (From Rosenstiel SF, ventilated area.
Land MF, Fujimoto J: Contemporary Fixed Prosthodontics, (ed 4). St
Louis, 2006, Elsevier.)
Ethyl Methacrylate
Their good esthetics, ease of manipulation, and low Ethyl methacrylates (also called polyethyl methac-
cost made them a popular choice over preformed rylates or PEMA) provide some improvements over
crowns. However, these self-curing materials have methyl methacrylates. The powder – liquid formu-
high shrinkage and heat release during polymeriza- lation consists of polymer powder with coloring
tion (exothermic reaction) and patients complain pigment and benzoyl peroxide which initiates the
about the acrylic odor and bad taste. They have a low chemical reaction and ethyl methacrylate liquid.
modulus of elasticity (relatively flexible), have ade- PEMA generates less heat and shrinkage when set-
quate strength but wear easily. For the short time they ting than methyl methacrylate and is better toler-
will be in use, they are stain resistant and dimension- ated by the pulp and oral mucosa. However, they
ally stable. are not as strong as the methyl methacrylates and
The methacrylates can be placed into two sub- have less surface hardness. They are not suitable
groups: methyl methacrylate and ethyl methacrylate. for long span provisional bridges or for use in pa-
These acrylics have several features in common: pow- tients who brux their teeth. Examples of these ma-
der—liquid formulation, come in a variety of tooth terials include Snap (Parkell) and Trim II (Keystone
colors, self-curing, shrink and release heat on setting, Industries).
relatively strong, good polishability and material can
be added to repair them. When the powder and liquid Caution
are mixed, the liquid partly dissolves the powder to
produce a doughy mass that can be used to make pro- Heat generated during the polymerization of self-cured
acrylic can potentially damage the pulp or burn soft tissues,
visional restorations.
especially when used in a large volume such as a bridge.

Methyl Methacrylate
Methyl methacrylate (also called polymethyl meth- Clinical Tip
acrylate or PMMA) is the provisional material that Do not allow acrylic to set completely on a model or
has been used the longest. It consists of a powder prepared tooth; this will cause the material to lock onto the
– liquid formulation containing dibutyl or diethyl preparation. Remove gross excess from the interproximal
phthalate (polymer) powder and methyl methac- and “pump” the material on and off the tooth preparation
rylate (monomer) liquid. It is available in a variety until initial polymerization is complete.
of tooth colors (Fig. 18.10). It has good strength for
both single units and long-span bridges with good
marginal fit. Of the two categories of methacrylates COMPOSITE RESIN PROVISIONAL MATERIALS
PMMA has the most shrinkage (3 - 8%) and heat gen- Composite resin provisional materials were devel-
erated on setting. The greater the volume of material, oped to overcome many of the undesirable features
the more heat will be generated. The pontic area of of the methacrylates. They are biocompatible and
bridges has the most volume and care must be taken kinder to the pulp. These materials can be grouped
so the patient does not receive a tissue burn from into three categories: bis-acryl composite resin, bis-
the heat. The monomer can be toxic to the pulp if in GMA composite resin and urethane dimethacrylate
close proximity and any free monomer not reacted resin. They are a bit more expensive, but are easier to
with the powder can cause irritation to the oral mu- handle, with less odor, and bad taste and with better
cosa in sensitive individuals. Additionally, the taste esthetics.
 Provisional Restorations CHAPTER 18 441

Table 18.2   Features of Acrylic and Composite

Provisional Materials
ACRYLIC COMPOSITE
High heat during Low heat during curing
polymerization
High shrinkage during Low shrinkage during curing
polymerization
Possible tissue irritation Good tissue biocompatibility
Poor taste and smell No unpleasant smell and
mild taste
Difficult to repair Easily repaired
FIG. 18.11 Composite resin provisional materials in 2-paste cartridges Variety of color shades Excellent esthetics.
with automixing delivery tips. (From Rosenstiel SF, Land MF, Fujimoto J: Inexpensive Expensive
Contemporary Fixed Prosthodontics, (ed 4). St Louis, 2006, Elsevier.)

Bis-acrylic Composite Resin Provisional Materials

Bis-acrylic composite provisional materials have health. Their chemistry is compatible with flowable
a chemical structure between that of acrylic resins composites which can be used for repairs and add-
and dental composite materials. Low shrinkage ons. If large repairs are to be made, it is advisable to
and heat release during curing, imperceptible odor, apply a resin bonding agent to the surface first to en-
good shade selection, and biocompatibility are dis- sure a good union between the provisional crown and
tinct advantages over acrylic resins. The presence of the repair material. Examples of bis-GMA materials
micro- and nano-size glass fillers makes them more include TempSpan (Pentron Clinical Technologies)
wear resistant than the acrylics, and they have good and Protemp Crown (3M ESPE).
marginal fit. Early versions were self-curing but a
newer variation is dual-cured. When they polym- Manipulation of Material. The two-paste material is
erize, they leave a thin layer of unset resin on the typically mixed and dispensed from double-barrel
surface (oxygen inhibited layer) that should be re- cartridges placed into a mixing and dispensing gun.
moved. They are more brittle (higher modulus of When the gun trigger is pressed the appropriate
elasticity) than the acrylics and therefore, must be amounts of catalyst and base pastes are mixed and dis-
limited in use to single units or short-span bridges pensed through automixing tips. Automixing helps to
that are not under significant occlusal loading. They prevent operator error and unnecessary waste as well
are esthetically more pleasing in the anterior part of as ease of cleanup. Automix syringes also allow for di-
the mouth than the acrylics but more prone to stain. rect delivery into a template without the incorporation
Examples of bis-acryl products include Integrity of air voids.
Temporary Crown and Bridge Material (self-curing) Light-cured, self-cured, and dual-cured versions of
and Integrity MultiCure (both by Dentsply), Pro- these materials are available. Automixed self-cured
temp Plus (3M ESPE) and Luxatemp Automix Plus materials are dispensed from syringes and may be
(DMG America) (Fig. 18.11). used with any template. Light-cured materials require
clear plastic templates and are difficult to cure in deep
Bis-GMA Composite Resin Provisional Materials areas or those with limited access. Dual-cured mate-
Bis-GMA (bisphenol-A-glycidyl methacrylate) com- rials require additional time to chemical-cure in areas
posite resins are an improvement over bis-acryl the curing light can’t reach, but they allow for removal
composites. They are stronger and less brittle, mak- from undercut areas while the materials are still flex-
ing them suitable for both single- and multiple-unit ible. Then they are trimmed and replaced for final cur-
temporaries as well as long-term temporization. They ing (Table 18.2).
have better esthetics, a wider shade selection and are
less prone to staining. Polymerization shrinkage and Urethane Dimethacrylate Resin Provisional
exothermic heat are reduced, making them kind to the Materials
pulp. They also have good margins and polish well. Urethane dimethacrylate resins are the strongest of
The newest materials, made with nano-fillers, pro- the custom provisional materials. Unlike the other
vide a smooth and lustrous surface with little finish- composite resin materials, they are single component
ing and polishing required. These smoother surfaces materials in a thick paste or putty form. They are light-
are more comfortable for the patient and are easier cured with conventional curing lights or may require a
to keep clean, thereby promoting better periodontal special curing unit for the final cure.
442 CHAPTER 18 Provisional Restorations

mouth. Lastly, it is finished and polished as with other

composite materials.
Radica (Dentsply Prosthetics) is a thermoplastic
material in syringes that is heated in a special unit. A
template made from impression putty is prepared on
the preoperative cast. The teeth on the cast are lightly
prepared to make room for a thin layer of the mate-
rial. Warm material is expressed from the syringe into
the template. Enamel and dentin shades are available
if a layering technique will be used. The template is
seated over the prepared teeth and allowed to cool
and harden. The flexible putty template is removed
and the thermoplastic material can be carved or ad-
ditions made as needed. When the final shape has
FIG. 18.12 Urethane dimethacrylate resin provisional material. (Triad been achieved the material is cured in a special unit
VLC Provisional Material, Courtesy of Dentsply Prosthetic.) (Eclipse or Enterra unit, Dentsply Prosthetics). The
thin provisional shell is lined with any of the methac-
rylates or composite resins and placed in the mouth
Manipulation of Materials. Triad VLC Provi- on the fully prepared teeth using techniques as previ-
sional Material (Dentsply) is a single com- ously described.
ponent urethane dimethacrylate resin with a
putty-like consistency that is available in seven shades Advantages of Composite Resin Provisional
including an enamel shade for creating incisal effects Materials
(Fig. 18.12). The shade (or shades if a layering tech- 1. Easy to use
nique is used) is selected, packed into a clear template 2. Set quickly
made on a preoperative cast and pressed over the pre- 3. Flexible so easier to insert and remove
pared teeth that have been lubricated with a water 4. Minimal polymerization shrinkage and heat
soluble lubricant such as KY jelly or glycerin. Partially 5. Color stable and stain resistant
lift and reseat the template several times to relieve un- 6. Minimal bad taste and odor
dercuts and adapt the margins. A conventional curing 7. Easy to repair using flowable composite
light is used to harden the material. The template is re- 8. Radiopaque
moved with the provisional still in it. The material will
not reach its maximum strength unless cured further in Clinical Tip
a Triad curing unit for two minutes. The provisional is
When using automix dispenser guns, make sure there is
removed from the template and reseated on the prepa- compatibility with the cartridges and the dispenser gun.
ration to check the fit, margins and proximal and oc- Different manufacturers’ materials and dispenser guns are
clusal contacts. It is finished with an acrylic bur and not always compatible.
then a coating of Triad Air Barrier Coating is placed to
eliminate any unset air inhibited layer on the surface.
It is returned to the Triad curing unit for eight minutes METHODS OF FABRICATION OF CUSTOM
for its final cure. Remove any remaining air barrier PROVISIONALS
coating with a soft brush or wheel. Custom provisional crowns can be made by direct fab-
Revotec LC (GC America) is also in a putty-like con- rication (made directly on the prepared tooth) or by
sistency. It is available in a single universal shade and indirect fabrication (out of the mouth on a stone cast or
lacks the esthetics of the bis-GMA composite resins. An by a combination of the two). Often a template is used
appropriate size portion is cut from the tube-shaped as a carrier for the provisional material.
material for the provisional being fabricated. It can
be adapted directly to the prepared tooth and hand Types and Uses of Templates
sculpted or could be placed in a template and adapted A template (also called a mold or matrix) shapes the
much the same way as the Triad material. If applied external contours and anatomy of the provisional,
directly to the preparation, excess material is removed and the prepared tooth or stone cast creates the in-
from the interproximal with a carver before complet- ternal dimensions. Template materials include hard
ing the contours and margins. First, the provisional wax, impression materials (such as alginate, silicone,
is light-cured for a total of 10 seconds from all angles or polyvinyl siloxane), vacuum-formed plastic and
with a halogen lamp to create a gel state so it can be thermoplastic resins (Fig. 18.13). A template can be
removed without distortion. After the provisional is made directly in the mouth prior to the preparation of
removed it is light-cured to its final cure outside the the tooth or teeth or on a stone cast of the unprepared
 Provisional Restorations CHAPTER 18 443

A B

C D

E
FIG. 18.13 Variety of templates used for fabrication of custom provisional restorations. A, Alginate impression B, Baseplate wax C, Clear vacuum-
formed plastic D, Silicon putty E. Polyvinyl siloxane impression. (A-D, From Rosenstiel SF, Land MF, Fujimoto J: Contemporary Fixed Prosthodontics,
(ed 5). St Louis, 2016, Elsevier.)

teeth. If the teeth are broken or require a change in inches, and then the machine is activated to adapt
shape for a more natural provisional, some repair or the molten plastic to the cast. After the material cools
reshaping must be done in the mouth or on the stone it is removed from the cast and trimmed to include
cast. one or two teeth mesial and distal to the tooth/teeth
Alginate and wax are the easiest to use and least ex- to be prepared and approximately 3 to 4 mm below
pensive templates and are used extensively for single- the gingival margin of the area of interest. The tem-
unit, direct-technique provisionals. Polyvinyl siloxane plate is, then, ready for use with a direct or indirect
(PVS) impression material is very popular and is often fabrication technique.
used in its putty form or regular body consistency in
a tray. PVS, while more expensive, has an advantage Direct Technique (See Procedure 18.3)
over wax or alginate in that it can be reused later if the Using the direct technique for provisional coverage,
provisional should break. the provisional is fabricated directly on the prepared
Vacuum-formed plastic is the most common choice tooth using one of the provisional materials in a tem-
for multi-unit and indirect provisional techniques. plate. One popular technique uses a disposable triple
The vacuum-formed plastic template is made us- tray impression with fast set material or bite regis-
ing a technique similar to that used to make whit- tration material as the template. The impression used
ening trays. A stone cast of the unprepared teeth is for the template is taken before the tooth is prepared.
trimmed to remove borders that might entrap air. A After the tooth is prepared, the impression is filled
thin sheet of the stiff plastic material (0.02 mm) is with a provisional material and seated on the pre-
heated on a vacuum former until it sags 1 to 1.25 pared tooth.
444 CHAPTER 18 Provisional Restorations

Clinical Tip
Make sure the prepared tooth is slightly moist when seating
the template containing acrylic. If the preparation is dry, the
acrylic might stick to it and the provisional restoration may
distort upon removal.

If using a composite resin paste-paste system with

an automixing and delivery tip, be sure to keep the tip
in the material as it is extruded to prevent the introduc-
FIG. 18.14 Excess provisional material has flowed into the embrasure tion of air bubbles. After placing the mixed material in
spaces and must be removed before it sets or the provisional restora- the impression, reinsert it into the mouth. If using the
tion must be lifted and reseated several times before it sets to keep the triple tray, the patient is asked to bite into their normal
restoration from being locked on the teeth. (From Rosenstiel SF, Land
occlusion while the material sets.
MF, Fujimoto J: Contemporary Fixed Prosthodontics, (ed 4). St Louis,
2006, Elsevier.) The impression is removed from the patient’s mouth
and the provisional crown is removed from the impres-
sion. If the triple tray is used, the occlusion should be
If using an acrylic material for the provisional, pow- very close to perfect. However, if the tray did not seat
der and liquid must be mixed together to form a paste correctly, the occlusion could be quite high.
(see Fig. 18.30). It must be hand mixed to the proper This technique is fast and provides a provisional
consistency, and care must be taken to avoid trapping restoration that duplicates the original tooth. Some cli-
air during mixing or in delivering the material into the nicians use a clear PVS bite registration material so that
template. After placing the paste in the template, the they can speed the initial set by light-curing the mate-
template is inverted and seated over the moist pre- rial through the clear impression material.
pared teeth. If gross voids are found on the occlusal or
incisal, it may be necessary to place small holes in the Clinical Tip
occlusal or incisal corners of the template to alleviate
If bits of the provisional composite resin crown margins are
hydrostatic pressure that has prevented the material
going to come off, it is usually when the impression is removed
from flowing into these areas. from the prepared tooth. If the margins are thin, some
Caution must be used when using this technique so the material may tear or stick to the prepared tooth. If the
that the provisional crown does not get locked on the marginal defect is minor, seat the provisional crown back on
prepared tooth. This happens when excess provisional the moistened preparation and add some flowable composite
material flows out of the template and hardens in the to repair the margin, then light-cure it. Be sure to lap the
interproximal embrasure spaces locking under the composite up onto the crown a couple millimeters so it has
contact areas of the adjacent teeth (Fig. 18.14). Not only enough surface area to affect a good bond with the crown.
is the crown very difficult to remove (and occasionally
excess material must be cut from the undercuts with a Caution
bur), but heat generated during setting can burn tis-
sues or damage the pulp. To avoid this mishap, the Before using the direct technique, make sure there is
adequate access to the preparation site, the template does
template with acrylic in place is “pumped” on and off
not unduly impinge on the tissues, and tissues in the area
the preparation when the material reaches a rubbery are not inflamed and likely to bleed.
consistency. It can be removed just prior to its final
set and the acrylic provisional crown can be removed
from the template. Gross excess can be trimmed away Indirect Technique
with scissors. The provisional should, then, be placed With the indirect technique the entire provisional
in a cup of room temperature water to finish polymer- is made outside of the mouth, then tried in and ad-
ization. (Hot water will accelerate the set but will cause justed for fit. Any needed corrections to margins,
more shrinkage and distortion.) If these materials are contacts or voids can be made with the addition of
removed from the mouth too early and allowed to po- new material either in the mouth or on the cast. Us-
lymerize off the preparation, the amount of shrinkage ing the indirect technique, a pre-preparation impres-
may be sufficient to prevent them from seating back on sion of the area is made and poured into stone; the
the prepared tooth or the margins may be short. How- template is then made on this model. If it is neces-
ever, more material can be added to fill voids or correct sary to account for missing tooth structure caused
deficient margins. The surface must be clean, and then by caries or trauma, the defect can be corrected on
some of the liquid (monomer) should be used to wet the model with wax, acrylic, light-cured resin, or
the surface so a new mix will bond to it. After it has set other materials. The template can be used indirect-
completely the rough provisional should be finished ly with fabrication of the provisional on the model
and polished for tissue health and patient comfort. of the prepared teeth. The process of producing
 Provisional Restorations CHAPTER 18 445

indirect provisional restorations is similar to the in- remove the provisional from the template and trim
direct composite procedure discussed in Chapter 6 and polish.
Composites, Glass Ionomers, and Compomers.
Clinical Tip
The indirect technique has several advantages over
the direct technique. The indirect technique allows for If the custom provisional restoration is thin in areas, it is
superior access to the preparations (stone replicas), likely the result of one of two things:
1. the preparation has not been reduced enough to allow
saves chairtime and is more convenient for making
for adequate material
multi-unit bridges or crowns in difficult-to-access ar-
2. the template was pressed too hard onto the prepara-
eas. This technique is also desirable when the patient tion causing it to compress toward the preparation
reports previous tissue irritation from methacrylate
monomer or has difficulty maintaining an open mouth
during the procedure. The indirect technique is also Fabricating and cementing provisional restorations in many
recommended when there is a concern for the health of states are functions relegated to registered dental assistants
the pulp due to deep caries or extensive prepping with and hygienists, while in other states they may be expanded
the high-speed handpiece. By fabricating the crown in- functions. Check your state dental practice act for details.
directly, the tooth is not subjected to exothermic heat
and chemical irritants of some provisional materials
before they are set. The marginal fit is better when the ADVANCED TECHNIQUES
material is allowed to set completely on the stone cast Many experienced dental auxiliary are equally capable
rather than with the direct technique where it is re- of fabricating provisional coverage for complicated
moved from the mouth before fully set. cases. At times, the dental laboratory technician may
be called on to help in the fabrication of more difficult
Clinical Tip provisional coverage. Fabrication of provisional cover-
age over implants, for inlay and onlay preparations,
Although the indirect technique requires additional time to
fabricate a stone model or PVS die, this technique may and for long-term coverage will require specialized
well end up saving time in complicated cases and may be skills, knowledge of the requirements of the restorative
required if hard or soft tissue conditions would be further procedure, and specialized alterations to provisional
traumatized by direct fabrication. The indirect procedure materials.
can be delegated to the laboratory.
CAD/CAM Provisional (Temporary) Materials
Acrylate polymer (PMMA) blocks are available for use
Indirect-Direct Technique with CAD/CAM units to fabricate provisional res-
With the indirect-direct technique, a template is made torations. These products provide many advantages
on a pre-treatment cast. Next, the template is filled with over traditional provisional materials. Because they
a provisional material and seated on a lubricated stone are processed with heat and pressure, there is no free
cast where the teeth to be restored have been lightly monomer to irritate tissues and produce a bad taste.
prepared so that they are under-reduced compared to The polymers undergo more complete conversion and
the actual tooth preparation. The result is a thin provi- the materials have improved physical and mechanical
sional shell that has the external form of the finished properties, such as higher flexural strength, improved
provisional but is too thin to serve as the functioning esthetics, and longer lasting color stability (due to de-
provisional restoration. At chairside, it is relined with creased porosity). Polymerization shrinkage and exo-
freshly mixed provisional material and seated directly thermic heat are eliminated. CAD/CAM processing
on the prepared tooth or teeth. So, half of the proce- produces a superior fit and marginal integrity. They
dure is completed out of the mouth and half is com- are durable and can be used for long-term provisionals
pleted directly on the teeth. (up to a year). They are indicated for single crowns,
inlays, onlays and anterior and posterior bridges with
Clinical Tip up to two pontics. Some materials are available in up
Coat the gypsum model with a separating medium to prevent to six shades.
the provisional material from sticking. If placing it in the Examples of commercially available blocks include
patient’s mouth, make sure the tooth is moist with saliva. Telio CAD – Temp (Ivoclar Vivadent), VITA CAD –
Temp in mono- and multi-color blocks (VITA North
If using light-cured material, follow the manufac- America), C-Temp (Kavo), artBlock – Temp (Merz Den-
turer’s directions for the required curing time. If using tal). Disks for multi-unit cases (such as PREMIOtemp
acrylic, remove the template while it is still doughy, CAD/CAM disks, Primotec USA) can also be used to
trim away the excess with scissors, and then “pump” fabricate provisional restoration in the office or in the
up and down on the preparation to prevent it from laboratory using CAD/CAM technology and custom
locking in the embrasures. When final set is achieved, glazing and gingival effects (Fig. 18.15).
446 CHAPTER 18 Provisional Restorations

• W  hat type of permanent restoration is being

fabricated
• What type of permanent cement will be used
The cement must be retentive, have limited solubil-
ity to protect the tooth margins, not detract from the
esthetics of the provisional restoration, be easily and
completely removed, and not interfere with the bond
of the permanent restoration.
A wide variety of provisional cements are available
for the cementation of provisional restorations The
most commonly used are zinc oxide eugenol (ZOE) or
noneugenol formulations, polycarboxylate and resin
cements. ZOE is self-curing, easy to handle, provides
FIG. 18.15 Indirect multi-unit CAD/CAM acrylic provisional restorations a sedative effect for sensitive teeth and has antibac-
customized by a skilled laboratory technician (Luke Kahng, CDT) with terial properties. Polycarboxylate is also self-curing,
glaze and gingival colored composite resin. (From Kahng LS: Step-by- is stronger than ZOE and is more retentive, because
step: Fabricating temporaries with PMMA material. Dental Esthetics,
May 2016.)
it sets harder and has weak bonds to tooth structure.
Resin cements are the strongest, most esthetic and
most versatile, since they can be self-cured, light-cured
Provisional Materials for Inlays and Onlays or dual-cured. If the provisional restoration is in an es-
thetic zone of the mouth and is thin, the stark, opaque
Any of the provisional materials discussed in this chapter white color of ZOE will show through. Resin cements
could be used to make provisional restorations for inlay are available in a variety of tooth colors and would be
or onlay preparations for metal or ceramics using direct a better choice in this situation. However, because of
or indirect techniques. However, some of the materials,
their polymerization shrinkage, resin cements have
especially the acrylics, are much more difficult to handle in
these complex cavity preparations with multiple walls and more microleakage and discoloration at the margins. If
box forms. the final restoration is to be cemented with permanent
Materials that are easier to use include: resin cement, a noneugenol provisional cement must
Bis-acrylic and Bis-GMA Composite Resins – less be chosen, as eugenol in ZOE prevents resins from
shrinkage, low exothermic reaction polymerizing. A detailed description of each type of
Urethane Dimethacrylate Resins – very strong, light – provisional cement is discussed in Chapter 14 Dental
cured, putty consistency Cement.
Triad VLC Provisional Material Before cementation of the provisional restoration, the
Revotec LC preparation is dried and isolated with cotton rolls and
Radica (thermoplastic material)
the cement mixed according to the manufacturer’s di-
CAD/CAM materials – acrylate polymer blocks; eliminate
rections. The walls of the provisional crown are coated
exothermic reaction and polymerization shrinkage at the
chair because they are already cured; increased strength with the cement and then seated onto the tooth. Finger
and better fit. Drawback: requires in-office milling machine pressure is exerted, or the patient is asked to bite down
to deliver at the same appointment as the preparation. firmly on a cotton roll placed on the provisional restora-
Cements for Provisionals – use limited to entirely intrac- tion. Excess cement is removed when appropriately set.
oronal preparations. Not for onlays. Removal of excess cement and the consequences
ZOE and Reinforced ZOE of incomplete cement removal are covered extensive-
Zinc oxide/Calcium sulfate preparations (e.g., Cavit) ly in Chapter 14 Dental Cements.
Polycarboxylate cement (paste-paste system)
Clinical Tip
If a light coating of a water-soluble lubricant or petroleum jelly
HANDLING THE PROVISIONAL RESTORATION is applied to the cervical half of the exterior of the provisional
restoration before loading it with cement, clean up of the
CEMENTING THE PROVISIONAL RESTORATION restoration after the cement sets will be much easier.
Provisional luting cements are used to cement provi-
sional crowns. The choice of appropriate provisional Clinical Tip
luting cement is based on several factors:
Do not fill the entire interior of the crown with cement since
• Properties of the provisional luting cement
the prepared tooth will displace most of it. Lightly coat the
• How long the provisional restoration will be in place walls of the provisional crown with the cement.
• How naturally retentive the preparation is All excess cement must be thoroughly removed, espe-
• What type of provisional restoration is being cially subgingivally, to prevent tissue irritation.
used
 Provisional Restorations CHAPTER 18 447

FIG. 18.16 To remove the provisional restoration, grasp it with removal

forceps and gently rock it back and forth while applying mild force in an FIG. 18.17 Provisional cement used for intracoronal provisional
occlusal direction until the cement loosens. (From Rosenstiel SF, Land coverage.
MF, Fujimoto J: Contemporary Fixed Prosthodontics, (ed 4). St Louis,
2006, Elsevier.) local anesthetic may be needed prior to removal of the
provisional restoration. Carefully remove as much ce-
REMOVING THE PROVISIONAL RESTORATION ment as possible with an instrument such as an explor-
The provisional restoration must be fabricated in a er, interproximal carver or spoon excavator using light
way that allows for easy removal without damage to pressure so as not to damage the preparation. Usually
the existing preparation. It is also desirable to preserve very small fragments of cement will still remain. These
the provisional restoration in the event it may need to must be removed to allow complete seating of the fi-
be used again. nal restoration and prevent interference with bonding
Methods to remove the provisional restoration in- procedures. Use slurry of flour of pumice and water
clude the following: in a rubber prophy cup or a soft brush to complete the
• Using an instrument to engage the crown margin, removal of these fine pieces of cement and rinse thor-
pry the provisional off the preparation. Use caution oughly. Do not discard the provisional restoration until
not to damage the preparation margins. the final restoration has been successfully cemented in
• Using a chisel and mallet or crown and bridge re- case it is needed.
moval instrument (also called a reverse hammer) to
gently tap the restoration off the preparation. Keep
the force directed along the long axis of the tooth to
INTRACORONAL CEMENT PROVISIONAL
prevent damage to it.
RESTORATIONS
• Using a pair of temporary removal forceps to grasp The main uses for intracoronal provisional cement res-
it, gently rock the provisional restoration back and torations are for emergency treatments such as for deep
forth and apply mild force in an occlusal direction caries or painful teeth, for protecting preparations for
until the cement loosens and then lift it from the metal or ceramic inlays and to close endodontic ac-
preparation (Fig. 18.16). cess preparations. Cements used for inlay provisional
If the provisional crown had a very snug fit when try- restorations include: ZOE, reinforced ZOE (e.g., IRM,
ing it on, only apply provisional cement to three or four Dentsply), noneugenol zinc oxide, polycarboxylate, and
millimeters of the crown walls around the margins. There zinc oxide/calcium sulfate materials. These cements
will be less cement internally to hold the provisional can also be used to close endodontic access prepara-
crown making removal easier. Do not use this technique tions and additional cements for this purpose include
if the patient grinds his/her teeth. Another technique to zinc phosphate cement and glass ionomer cement.
make removal easier with a snug fitting crown is to add a ZOE cement used for a provisional restoration has
small amount of petroleum jelly to the cement mix. the added benefit of being soothing to inflamed pulp
(Fig. 18.17). However, ZOE cements are highly soluble,
Caution have low strength, and have an unpleasant taste, lim-
All remnants of provisional cement must be completely iting them to short-term and protected intracoronal
removed and the tooth surface cleaned completely to placement. For these reasons, many clinicians use glass
prevent interference with bonding of the permanent ionomer and resin-modified glass ionomer cements as
restoration. an alternative. They are stronger, more durable, and pro-
vide an excellent seal to the tooth structure, preventing
microleakage and the associated sensitivity. They are,
CLEAN-UP however, more difficult to remove completely because
After the provisional restoration has been removed of their bond to tooth structure and may not be the best
there will be remnants of cement stuck to the tooth choice when an inlay will be placed, because any re-
preparation. If the patient’s tooth has been sensitive, a maining cement will prevent the inlay from seating.
448 CHAPTER 18 Provisional Restorations

Polycarboxylate cement (e.g., Ultra Temp, Ultradent cement. Limitations in esthetics of the provisional res-
Products) used for provisional restorations comes in a toration may include imperfections in color matching,
paste-paste, dual-barrel syringe delivery system. It is anatomic contour, and smoothness. Tobacco products
easy to remove when needed and is easy to clean up and certain foods and beverages such as coffee, tea, red
because it is water soluble until it sets. wine, berries and fruit juices may stain the provision-
Zinc oxide/calcium sulfate materials include Cavit- al restoration. To avoid dissatisfaction, patients must
G (3M ESPE). Cavit is a premixed paste that sets in a be reminded that provisional restorations are not the
moist environment. It expands on setting about twice same as permanent ones.
that of ZOE from water sorption. It is relatively easy
to remove from the preparation without having to use Clinical Tip
dental burs. Its drawbacks include low strength, soft- If a provisional crown comes off during a time that the dental
ness, slow set and it breaks down with time. Its con- office is closed, the patient can be instructed to replace it
tainer should be re-capped soon after use because hu- after cleaning the interior of the crown and placing a small
midity will cause it to thicken. amount of denture adhesive into the crown. The patient
should be instructed never to use any household cements.
Clinical Tip
It should be noted that zinc oxide eugenol provisionals
HOME CARE INSTRUCTIONS
should not be used if a permanent restoration is to be
cemented with a resin luting agent, because eugenol- Home care instructions include brushing the restora-
containing cements inhibit polymerization of the resin tion carefully along with the other teeth at least twice
cement. a day. Flossing should be done at least once a day and
the floss should be pulled out to the side under the
Cements are placed directly into the cavity prepara- contact rather than back in an occlusal/incisal direc-
tion with the aid of a matrix band and wedge when tion. Removing the floss back through the contact in
appropriate. The cement is carved and contoured, and an occlusal/incisal direction might dislodge the pro-
then allowed to set. The final check of occlusion is done visional restoration. If the provisional restoration in-
with articulating paper followed by additional carving cludes a pontic, the additional use of floss threaders,
as necessary (see Procedure 18.4). Superfloss® (Oral B) or end-tufted brushes must be
stressed for cleaning the tissue-contacting surface of
the pontic and the proximal embrasures. Maintenance
PATIENT EDUCATION of healthy tissue during provisional coverage is crucial
Scheduled appointment times for fabricating provi- to the success of the permanent restoration. Inflamed
sional restorations must be adequate to instruct and gingival tissues can result in bleeding at the time of
demonstrate appropriate home care techniques, edu- cementation of the permanent restoration that may
cate patients as to the limitations and expectations of compromise the cement seal.
the provisional restoration, and address patient con-
cerns. Patients should understand that provisional
SUMMARY
restorations, although functional, are not as durable,
well-fitting or esthetic as permanent restorations. Provisional restorations protect teeth and periodontal
Because of limitations in the strength of provisional structures in a variety of dental procedures. Regard-
materials and the weak cements used to retain them, less of the material and technique selected, a high-
patients must be instructed that sticky foods may dis- quality provisional restoration must be well adapted
lodge the provisional, hard foods may crack it and to the preparation, have proper contact, contour, and
chewing gum may stick to it. Patients must be in- occlusion and must be functional and acceptable to the
formed that there may be temperature sensitivity and patient. If these criteria are not met, pulpal and peri-
an unpleasant taste associated with the provisional odontal irritation, tooth migration, and patient dis-
material. To avoid complications with treatment result- satisfaction will likely occur. There are many choices
ing from tooth movement or loss of tooth structure, pa- in the selection of provisional restorations and tech-
tients must be told to immediately call the office if the niques for the fabrication of provisional restorations.
provisional becomes dislodged, fractured or lost, even The clinician must select materials and techniques on
if the tooth is not sensitive. Teeth can shift in as little the basis of each patient’s clinical needs and situation.
as 24 hours after loss of the provisional restoration.
Strict adherence to appointment intervals is extremely
important. Patients must return to the office at the ap-
INSTRUCTIONAL VIDEOS
propriate time for placement of the permanent restora- See the Evolve Resources site for a variety of educa-
tion due to the potential wear and breakdown of the tional videos that reinforce the material covered in this
provisional material or washing out of the provisional chapter.
 Provisional Restorations CHAPTER 18 449

Procedure 18.1 Metal Provisional Crown

See Evolve site for Competency Sheet. NOTE: The crown will be considerably higher than
the adjacent teeth (Fig. 18.19).
Consider the following with this procedure: safety glasses are
4. Scribe a line on the facial and lingual crown
recommended for the patient, PPE is required for the operator,
surfaces to match the contour of the gingiva and
ensure appropriate safety protocols are followed, and check your
approximate the amount of crown length that
local state guidelines before performing this procedure.
needs to be trimmed.
EQUIPMENT/SUPPLIES (Fig. 18.18) NOTE: The crown is longer on the facial and lingual
surfaces and shorter on the mesial and distal surfaces,
• Mirror and explorer
forming a wavy line.
• Selection of silver-tin alloy crowns
5. Trim to within 1 mm of the scribed line, using
• Crown and bridge scissors
curved crown and bridge scissors.
• Contouring pliers
NOTE: Try to blend your cutting junctions to avoid
• Ball burnisher
producing burs of metal that will irritate the tissues
• Articulating paper
(Fig. 18.20).
• Dental floss
6. Contour the trimmed areas, using contouring
• Isolation materials
pliers. Advance the pliers around the crown
• Cement and armamentarium
periphery as you continually squeeze the pliers
• Sandpaper disk and rubber wheel
with the ball portion of the pliers inside the crown
PROCEDURE STEPS and the curved beak on the outside of the crown.
NOTE: This crimps the crown edge, adapting its cir-
1. Measure the mesiodistal width of the space
cumference to the finish line (Fig. 18.21).
between adjacent teeth.
7. Retry the crown on the preparation to confirm fit.
2. Choose a crown that has a mesiodistal width
Adjust as needed.
equal to that of the original tooth.
8. Have patient tap the teeth together to adapt the
NOTE: If the crown does not fit, it may be sterilized
soft metal to the occlusion
and placed back in the kit.
3. Try in the crown, noting the occlusal relationship
to adjacent and opposing dentition.

FIG. 18.18 FIG. 18.20

FIG. 18.19 FIG. 18.21

Continued
450 CHAPTER 18 Provisional Restorations

Procedure 18.1 Metal Provisional Crown—cont’d

9. Check the bite with articulating paper; make 13. Seat the crown onto the preparation and have
sure the crown is occluding properly when the the patient bite on a cotton roll or a wooden
patient’s teeth are fully together. stick in a mesiodistal direction to improve force
NOTE: If the crown is interfering with occlusion, distribution.
some reduction will be necessary. Only minor adjust- NOTE: Make sure the patient is not biting only on
ments can be made on the occlusal surface before the the crown, but also on the adjacent teeth in the quad-
surface is perforated (Fig. 18.22). rant; biting only on the crown may force the crown too
10. Check the contacts, using dental floss, to far in a gingival direction (Fig. 18.24).
determine whether contacts are present and in the 14. When appropriate, remove excess facial and
proper location. lingual cement. Remove interproximal cement
NOTE: If contact points need to be established, use by drawing a knotted piece of dental floss
the ball burnisher or contouring pliers with the ball through the contact (Fig. 18.25) followed by an
portion inside and the curved beak outside, and gently explorer.
squeeze to establish contact at the appropriate location.
11. Trim and polish the crown margins with disks
and a rubber wheel to make the crown smooth Optional Steps
and to prevent tissue irritation (Fig. 18.23).
NOTE: The crown may be lined with an acrylic or
12. Isolate the area and mix the cement according to
bis-acrylic composite provisional material to further cus-
the manufacturer’s directions.
tomize the internal fit and support the occlusal portion.
NOTE: Because the metal is soft, the occlusal por-
1. Mix the acrylic or composite provisional material
tion must be supported by a reinforced cement such as
according to the manufacturer’s directions.
IRM. Plain ZOE cement such as TempBond is too weak
2. Place the material into the prepared crown, making
for this purpose.
sure to line the crown to avoid trapping air.

FIG. 18.22 FIG. 18.24

FIG. 18.23 FIG. 18.25

(Continued)
 Provisional Restorations CHAPTER 18 451

Procedure 18.1 Metal Provisional Crown—cont’d

3. Place the crown back on the preparation, and have ZOE cement such as TempBond or a noneugenol
the patient bite in occlusion. version.
4. After the material has reached the desired consist- NOTE: Material should be removed while still elas-
ency, remove the crown and remove the excess. tic to avoid trapping the crown in undercuts.
5. Because the acrylic supports the occlusal portion 6. Polish the crown and proceed with steps 12
of the crown, it may be cemented with weaker through 14 above.

Procedure 18.2 Polycarbonate Provisional Crown

See Evolve site for Competency Sheet. NOTE: Keep the incisal identification tab in place to
use as a handle for try in and removal.
Consider the following with this procedure: safety glasses are
4. Scribe a line on the facial and lingual crown
recommended for the patient, PPE is required for the operator,
surfaces to match the contour of the gingiva and
ensure appropriate safety protocols are followed, and check
approximate the amount of crown length that
your local state guidelines before performing this procedure.
needs to be trimmed.
EQUIPMENT/SUPPLIES (FIG. 18.26) NOTE: The crown is longer on the facial and lingual
surfaces and shorter on the mesial and distal surfaces,
• Mirror and explorer
forming a wavy line.
• Selection of polycarbonate crowns
5. Trim to within 1 mm of the scribed line with
• Articulating paper
scissors or an acrylic bur on a slow-speed
• Dental floss
handpiece. Do not trim from the incisal/occlusal
• Acrylic burs and sandpaper disks
surface to adjust the length.
• Pumice and rag wheel
NOTE: Trim a small amount at a time while con-
• Isolation materials
tinuing to try and retry the crown until the desired
• Cement and armamentarium
amount is removed. If the crown was slightly larger
PROCEDURE STEPS than the space, it may be necessary to trim the proxi-
mal surfaces to establish a good seat (Fig. 18.28).
1. Measure the mesiodistal width of the space
6. Check bite with articulating paper; make sure the
between adjacent teeth.
crown is occluding properly when the patient’s
2. Choose a crown that has a mesiodistal width
teeth are fully together.
equal to that of the original tooth.
NOTE: If the crown is interfering with occlusion,
NOTE: Choose a crown that is slightly larger if an
further reduction will be necessary. Only minor adjust-
exact size cannot be found.
ments can be made on the incisal or occlusal surface
3. Try in the crown, noting the occlusal or incisal
before the surface is perforated. If the crown is fully
relationship to adjacent and opposing dentition.
seated and adjusting the occlusion has caused a perfo-
NOTE: The crown will be considerably higher than
ration in the crown, it is possible that the preparation
the adjacent teeth. If the crown does not fit, it may be
is under-reduced.
sterilized and placed back in the kit (Fig. 18.27).

FIG. 18.26 FIG. 18.27

Continued
452 CHAPTER 18 Provisional Restorations

Procedure 18.2 Polycarbonate Provisional Crown—cont’d

7. Check the contacts, using dental floss, to 11. When appropriate, remove excess facial and
determine whether contacts are present and in the lingual cement. Remove interproximal cement by
proper location. drawing a knotted piece of dental floss through
NOTE: If contact points are too tight or are not at the contact.
appropriate locations, you will have to trim the proxi-
mal surface of the crown to establish correct location. Optional Steps
If contact points are not present, you may have to add NOTE: If the crown is loosely fitting, it may be lined with an
to the proximal surface with acrylic. acrylic or bis-acrylic composite provisional material to further
8. Trim and polish the crown margins with disks customize the internal fit.
and pumice on a rag wheel to make the crown
1. It may be necessary to place one or two small vent
smooth and to prevent tissue irritation.
holes on the incisal corners or occlusal surface to
9. Isolate the area and cement the crown, following
prevent hydrostatic pressure from keeping the
the manufacturer’s directions for mixing the
crown from fully seating.
appropriate cement.
2. Mix the provisional material according to the
NOTE: Completely coat the inside surfaces of the
manufacturer’s directions (Fig. 18.30).
crown to avoid trapping air.
3. Place the material into the prepared crown, making
10. Seat the crown onto the preparation and have
sure to line the crown to avoid trapping of air (Fig.
the patient bite on a cotton roll or a wooden
18.31).
stick in a mesiodistal direction to improve force
distribution.
NOTE: Make sure the patient is not biting only on
the crown, but also on the adjacent teeth in the quad-
rant; biting only on the crown may force the crown too
far in a gingival direction (Fig. 18.29).

FIG. 18.30

FIG. 18.28

FIG. 18.29
FIG. 18.31
 Provisional Restorations CHAPTER 18 453

Procedure 18.2 Polycarbonate Provisional Crown—cont’d

4. Place the crown back on the preparation, and have NOTE: Crown should be pumped on and off the
the patient bite in occlusion (Fig. 18.32). tooth while the lining material is still elastic to avoid
5. After the material has reached the desired trapping the crown in undercuts (Fig. 18.33).
consistency, remove the crown, place it in room 6. Polish the crown, and proceed with steps 8
temperature water until set and then remove the through 11 above (Figs. 18.34 and 18.35).
excess.

FIG. 18.32 FIG. 18.34

FIG. 18.33 FIG. 18.35

454 CHAPTER 18 Provisional Restorations

Procedure 18.3 Custom Provisional Coverage: Direct Technique

See Evolve site for Competency Sheet. 3. Prepare the acrylic or composite resin provisional
material according to the manufacturer’s
Consider the following with this procedure: safety glasses are
directions.
recommended for the patient, PPE is required for the operator,
NOTE: Custom shading must be considered at this
ensure appropriate safety protocols are followed, and check your
time, with matching of adjacent teeth.
local state guidelines before performing this procedure.
4. Dispense the provisional material directly into the
EQUIPMENT/SUPPLIES (FIG. 18.36) template, making sure not to trap air.
NOTE: An automixing tip on the syringe or car-
• Mirror and explorer
tridge that allows delivery of the mixed provisional
• Template of the tooth before preparation
material directly into the template is useful. Begin
• Acrylic or composite provisional material
loading the template from the bottom and keep the tip
• Separating medium
buried in material until loading is complete to avoid
• Dispensing syringe
introducing air into the mix. (Fig. 18.38).
• Acrylic stones and sandpaper disks
5. Place the template back into the patient’s mouth
• Pumice and rag wheel
or onto the lubricated model, aligning it precisely
• Isolation materials
on the prepared tooth.
• Cement and armamentarium
NOTE: A notch cut in the template at a visually ac-
PROCEDURE STEPS cessible location in the mouth will facilitate replace-
ment of the template to the correct position (Fig. 18.39).
Preparing the Template
6. Check the initial set of the material in the patient’s
1. Before preparing the tooth, make a template by mouth; initial set occurs within 1 to 3 minutes.
taking an alginate or triple tray impression of
it or by using a thermoplastic resin button or
vacuum-formed plastic sheet on a stone cast of
the unprepared tooth.
NOTE: Alginate impressions should be kept moist
until used.
2. Trim the template to remove undercuts or excess
material.

Preparing the Provisional Coverage

Coat the prepared tooth with a water soluble lubricant
such as KY Jelly or glycerin.
NOTE: This will aid in separating the provisional
material from the preparation while in a doughy stage
(Fig. 18.37).
2. Remove excess moisture from the template.

FIG. 18.37

FIG. 18.36
FIG. 18.38
 Provisional Restorations CHAPTER 18 455

Procedure 18.3 Custom Provisional Coverage: Direct Technique—cont’d

NOTE: Check material in the patient’s mouth, as NOTE: For acrylic: If slight air voids are pres-
heat and moisture will accelerate the set; use the mate- ent, they may be repaired with freshly mixed mate-
rial that has extruded from the location notch to test rial (Figs. 18.40 and 18.41). For composite resin: fill
the set. voids or repair margins or contacts with flowable
7. Remove the template with provisional material composite.
in place when a firm but still elastic consistency is 11. Finish polishing with flour of pumice or whiting
reached. polishing compound on a rag wheel.
NOTE: If the material is too soft, it will tear or 12. Cement with an appropriate luting agent, and
stretch; if too hard, it may be difficult to remove it from remove excess.
undercut areas. NOTE: The custom provisional may be com-
8. Remove the provisional material from the pletely fabricated on a stone model and then tried
template and allow it to reach its final set. into the mouth and adjusted as necessary (indirect
NOTE: If acrylic materials are used, you must technique).
“pump” the provisional off and on the preparation
when it reaches the doughy stage to avoid locking the
material on the tooth or interproximal undercuts. Re-
move it from the mouth when it starts to get firm and
warm.
If bis-acrylic composite resin materials are used,
you should allow the material to reach its final set out-
side the mouth.
9. Trim excess material with acrylic burs and disks.
NOTE: If bis-acrylic composite material is used, you
will first have to remove the greasy air-inhibited layer
of unset resin with alcohol or it will tend to clog your
disks and burs.
10. Reinsert the provisional and check margins, FIG. 18.40
occlusion and contacts, adjusting as necessary.

FIG. 18.39 FIG. 18.41

456 CHAPTER 18 Provisional Restorations

Procedure 18.4 Intracoronal Cement Provisional Restoration

See Evolve site for Competency Sheet. NOTE: Begin by filling the proximal areas, then
across the pulpal floor (Fig. 18.44).
Consider the following with this procedure: safety glasses are
5. Use the condenser to condense into the
recommended for the patient, PPE is required for the operator,
preparation, while packing the cement firmly to
ensure appropriate safety protocols are followed, and check your
avoid trapping of air.
local state guidelines before performing this procedure.
NOTE: Tap the end of the condenser into the re-
EQUIPMENT/SUPPLIES (FIG. 18.42) maining loose powder to prevent it from sticking to
the cement.
• Mouth mirror and explorer
6. Place and pack cement into the rest of the cavity
• Isolation materials
with the condenser.
• Matrix band and wedges
7. Do not overfill; pack cement only slightly higher
• Matrix retainer
than the cavosurface margin of the preparation.
• Cotton pliers
8. Using the blade of the plastic instrument, wipe
• Burnisher
material toward the margin to ensure a good seal.
• Temporary cement (powder/liquid)
NOTE: Always wipe toward the margins; wiping
• Paper mixing pad
away from the margins will pull material away from
• Cement spatula
this important area (Fig. 18.45).
• Plastic instrument
9. Remove excess material around the matrix in
• Condenser
proximal areas and at occlusal margins.
• Occlusal carver
NOTE: Remove excess carefully, as the material has
• Interproximal carver
not set. The material must be set enough so it is not
• Articulating paper
pulled from the preparation margins.
• Dental floss

PROCEDURE STEPS
1. Isolate the tooth, and note size and class of the cavity.
NOTE: This will determine the amount of cement
necessary and the size of the matrix for placement.
2. Place the matrix and wedge.
NOTE: Be sure to obtain contact with adjacent teeth;
insert the wedges firmly to create some separation of
the teeth and use a burnisher to press the band to the
adjacent tooth at the contact area.
3. Prepare a mix of the temporary cement to a putty-
like consistency.
NOTE: The mix should be lightly coated in powder
FIG. 18.43
and should not stick to your gloved fingers (Fig. 18.43).
4. Roll the mix into a small ball, and place a portion
into a proximal area.

FIG. 18.42 FIG. 18.44

 Provisional Restorations CHAPTER 18 457

Procedure 18.4 Intracoronal Cement Provisional Restoration—cont’d

10. Remove wedges, retainer, and matrix. NOTE: The occlusal anatomy should approximate
NOTE: Be careful not to pull material away with the the original tooth form; it is not necessary to carve de-
band. tailed anatomy (Fig. 18.46).
11. Seal any open proximal margins by wiping still 15. Carve from tooth to filling material, keeping half
pliable cement toward them. the instrument on the tooth and half on the filling.
12. Remove proximal and gingival excess with an NOTE: This prevents breaking the material from
interproximal carver, and then from the marginal the margins or ditching the margins of the material.
ridge. NOTE: if you wish to accelerate the set of the mate-
NOTE: The marginal ridge should be at the same rial, pat a cotton pellet saturated in hot water on the
height as that of the adjacent tooth. surface of the material.
13. Create embrasure. 16. Check the occlusion with articulating paper, and
14. Remove excess from the occlusal surface and adjust as necessary.
carve the anatomic form with an occlusal carver. 17. Check contacts with dental floss.

FIG. 18.45 FIG. 18.46

458 CHAPTER 18 Provisional Restorations

Get Ready for Exams!

Review Questions b. Acrylic provisional material

c. Dual-cured composite resin provisional material
Select the one correct response for each of the following d. Zinc phosphate cement
multiple-choice questions.
9. Provisional custom crowns placed on prepared teeth
1. Intracoronal provisional Class II restorations must may be constructed of
a. Contact adjacent teeth and be crimped with crimp- a. Celluloid
ing pliers to fit snugly b. Acrylic
b. Contact adjacent teeth, be crimped with crimping c. Stainless steel
pliers to fit snugly, and be sealed at the margins d. Polycarbonate
c. Contact adjacent teeth and be sealed at the margins
10. With intracoronal provisional restorations, place the
d. Contact adjacent teeth, be crimped with crimping
cement and
pliers to fit snugly, be sealed at the margins, and be
a. wipe the cement toward the margin
made of metal for strength on posterior teeth
b. wipe the cement away from the margin
2. Polycarbonate crowns are used primarily c. wipe the cement toward the matrix band
a. On molars d. allow the cement to harden before sealing the
b. On anterior teeth and premolars margins
c. For multiunit bridges
11. Criteria for an intracoronal cement provisional restora-
d. For inlays
tion include all of the following except
3. Which one of the following statements is most complete a. Marginal ridges at the same height as adjacent teeth
and correct? If the provisional restoration does not fit b. Sufficient contact with adjacent teeth
the tooth properly, c. Detailed occlusal anatomy
a. Food impaction may occur and periodontal irritation d. Reproduction of the gingival embrasure
may occur
12. Which one of the following statements regarding cemen-
b. Periodontal irritation may occur and tooth migration
tation of custom provisional crowns is true?
may occur
a. The crown should be completely filled with cement
c. Food impaction may occur, periodontal irritation may
to assure a good seal of the crown margins after
occur, and hypersensitivity of the prepared tooth may
seating it
occur
b. After cementation some excess cement can be
d. Food impaction may occur, periodontal irritation may
left in the gingival sulcus to help with the retraction
occur, hypersensitivity of the prepared tooth may
process for a separate impression appointment if
occur, and tooth migration may occur
bleeding has been a problem
4. Important physical properties of provisional materials c. Placing a thin coat of lubricant around the cervical
used for posterior teeth include the following portion of the crown will make cleaning up the provi-
a. Strength sional crown easier after cementation
b. Tissue compatibility d. A thick mix of the cement is preferred for luting for
c. Ease of handling added strength
d. All of the above For answers to Review Questions, see the Appendix.
5. Appropriate choices for extracoronal provisional resto-
rations include
a. Stainless steel crowns
Case-Based Discussion Topics
b. Acrylic and/or composite customized provisionals 1. H
 ow would each of the following situations be best
c. A and B handled?
d. None of the above a. A patient has a badly fractured central incisor. The
6. You will need to obtain a pre-preparation template of preparation is close to the pulp. Which provisional
the tooth before fabricating material and technique would be most appropriate?
a. Intracoronal provisional restorations b. A custom composite provisional crown is deficient at
b. Aluminum crown provisionals the gingival margin of the facial surface. How would
c. Polycarbonate crown provisionals you correct this problem?
d. Custom provisional restorations c. Your patient is concerned about the color match
7. The first step in fitting a stainless steel crown is and smoothness of provisional crowns. Which
a. Determining occlusal/incisal-to-gingival dimensions provisional material and technique would be most
b. Determining mesial/distal dimensions appropriate?
c. Determining the contour of the finish line d. A patient is scheduled for a three-unit posterior
d. Determining occlusal height bridge preparation. The patient has a limited open-
8. Which of the following materials is NOT used to cus- ing because of temporomandibular joint pain. Which
tomize the internal fit of a preformed crown, provisional material and technique would be most
a. Self-cured composite resin provisional material appropriate?
 Provisional Restorations CHAPTER 18 459

BIBLIOGRAPHY Kurtzman GM: Crown and bridge temporization part 1: provision-

al materials. Inside Dentistry, 14(8), September 2008. Available
3M ESPE: Prefabricated Crowns – User Guide. Available at at https://www.aegisdentalnetwork.com/id/2008/09/crown-
multimedia.3m.com/mws/media/68406O/prefabricated- and-bridge-temporization-part-1-provisional-materials.
crowns-user-guide. Kurtzman GM: Crown and bridge temporization part 2: provi-
Anglis L: Provisional restorations and patient satisfaction. Gen sional cements. Inside Dentistry, 14(9), October 2008. Available
Dent, 46:197–199, 1998. at https://www.aegisdentalnetwork.com/id/2008/10/crown-
Berry T, Troendle K: Provisional restorations: Guidelines for and-bridge-temporization-part-2-provisional-cements.
proper selection, placement. Dental Teamwork, November/ Leggat PA, Kedjarune U, Songkhla HY: Toxicity of methyl meth-
December:25–29, 1995. Available at: https://uthscsa.influu- acrylate in dentistry. In Dent Journal, 53(3):126–131, 2003.
ent.utsystem.edu/en/publications/provisional-restorations Miller M (Ed.): Provisional Crowns (vol. 13). Houston, TX, 1999,
-guidelines-for-proper-selection-placemen REALITY Publishing, pp. 3–358 to 3–368
Berry T, Troendle K: Provisional restorations: Guidelines for cus- Schwedhelm ER: Direct technique for the fabrication of acrylic
tom fit, oral hygiene care. Dental Teamwork, January/Febru- provisional restorations. J Contemp Dent Pract, 7:157–173, 2006.
ary:23–27, 1996. Available at: https://uthscsa.influuent.utsys- Strassler HE: In-office provisional restorative materials for fixed
tem.edu/en/publications/provisional-restorations-guidelin prosthodontics part 1: polymeric resin provisional materials.
es-for-a-custom-fit-oral-hygiene Inside Dentistry, 5(4), April 2009. Available at https://www.
Bird DL, Robinson DS (editors): Provisional coverage. Modern Den- aegisdentalnetwork.com/id/2009/04/in-office-
tal Assisting , (ed 12), St. Louis, 2018, Elsevier. provisional-restorative-materials-for-fixed-prosthodontics.
Brinker SP: A modern guide to temporization materials and Strassler HE: In-office provisional restorative materials for fixed
techniques. Inside Dental Assisting, 8(4), July/August 2012. prosthodontics part 2: preformed crown forms. Inside Den-
Available at: https://www.aegisdentalnetwork.com/ida/ tistry, 5(8), September 2009. Available at https://www.aeg-
2012/08/modern-guide-to-temporization-materials-and- isdentalnetwork.com/id/2009/09/in-office-provisional-rest
techniques. orative-materials-for-fixed-prosthodontics-part-1-polymeric-
Comisi JC: Provisional materials: advances lead to extensive op- resin-provisional-materials.
tions for clinicians. Compendium of Dental Education in Den- Strassler HE, Lowe RA: Chairside resin-based provisional re-
tistry, 36(1), January 2015. Available at https://www.aegisd- storative materials for fixed prosthodontics. compendium of
entalnetwork.com/cced/2015/01/provisional-materials-ad continuing education in dentistry, November/December 2011.
vances-lead-to-extensive-options-for-clinicians. Available at: https://cced.cdeworld.com/courses/4552-
Gegauff AG, Holloway JA: In Rosenstiel SF, Land MF, Fujimo- Chairside_Resin-Based_Provisional_Restorative_Materials_f
to J, editors: Interim Fixed Restorations in Contemporary Fixed or_Fixed_Prosthodontics.
Prosthodontics, (ed 4). St Louis, 2006, Mosby. Strassler HE, Morgan RJ: Provisional–temporary cements.
Gottlieb M: Using an old technique with modern materials to Inside Dental Assisting, July/August 8(4), 2012. Available
fabricate esthetic temporary restorations. J Am Dent Assoc, at:https://www.aegisdentalnetwork.com/ida/2012/08/pro
130:99–100, 1999. visional-temporary-cements.
Hester R: Fabricating high-quality provisional restorations for
indirect inlays, onlays or crown preparations. J Am Dent As-
soc, 130:1093–1094, 1997.
19 Preventive and Corrective Oral Appliances

http://evolve.elsevier.com/Eakle/materials/

Chapter Objectives
Upon completion of this chapter, the student should be able to:
1. Describe the uses of mouth guards. 7. E xplain how preventive orthodontics prevent or eliminate
2. List the materials for the fabrication of mouth guards. the need for full-orthodontics.
3. Explain to a patient how to care for a mouth guard. 8. Identify how interceptive orthodontics correct mal-
4. Fabricate a sports mouth guard. alignments of the dentition.
5. Describe what obstructive sleep apnea is. 9. Describe how thermoplastic orthodontic aligners work.
6. Describe the use of oral appliances to prevent snoring or 10. Identify how 3-D printing is being utilized in dentistry.
obstructive sleep apnea.

Key Terms
Mouth Guard an appliance made of hard or pliable material Thumb Sucking Device a fixed or removable appliance
that protects teeth from trauma during sports activities or used to discourage tongue thrusting and thumb sucking
from grinding of the teeth Palatal Expansion Device a fixed appliance used to ex-
Custom-Fit made specifically to fit one individual pand the maxillary arch forcing the maxillary plates apart
Obstructive Sleep Apnea a sleep disorder caused when very slowly while the maxilla is still in development
the muscles that support the soft palate, uvula, and Crossbite Corrector a fixed or removable appliance used
tongue relax and the airway narrows or closes to correct teeth in mal-alignment where the maxillary teeth
Space Maintainer a fixed or removable appliance used to are positioned lingual to the mandibular teeth
prevent adjacent teeth from drifting into the space created Orthodontic Tooth Aligners removable appliances that are
when a tooth is lost designed to gently move teeth into predetermined positions

A number of oral appliances are available to the clinician to the most common type of orofacial injury sustained dur-
prevent damage to teeth, to keep teeth from shifting, to prevent ing sports. The Centers for Disease Control and Preven-
sleep apnea and snoring, and to orthodontically move teeth. tion recommend and most states mandate that partici-
This chapter provides basic knowledge about these appliances. pants in school contact sports wear sports guards (also
Most of these appliances can be fabricated in the dental office called mouth protectors or mouth guards) (Fig. 19.1, B).
by trained staff or in a commercial dental laboratory. The den- Most professional and amateur adult athletes wear
tal auxiliary may be called on to fabricate these appliances or them too. The protective benefits of sports mouth-
to instruct patients in their use and home care. guards have been well documented.
The three basic types of mouth guards for sports are:
PREVENTIVE AND CORRECTIVE ORAL APPLIANCES • Stock guards
• Boil-and-bite guards
SPORTS MOUTH GUARDS • Custom-fit guards
The purpose of sports guards is to protect the teeth and
their supporting structures (gingival tissues and bone). Stock Guards
The widespread use of mouth guards in school sports (Fig. 19.2) Stock guard by Athletic Specialties
prevents thousands of injuries each year. According to Stock guards can be purchased over the counter in
the American Dental Association, more than 200,000 oral sporting goods stores, in some retail stores or online.
injuries are prevented on an annual basis by wearing They usually cost less than $25 and come in sizes rang-
mouthguards. The risk for oral/jaw injuries increases ing from small, medium, and large. Along with being
approximately 1.5 to 2 times when guards are not worn the least expensive, stock guards generally have the
(Fig. 19.1, A). The National Youth Sports Foundation esti- poorest fit, may be uncomfortable to wear, and provide
mates that more than 5 million teeth will be knocked out the least amount of protection. In addition, they are not
in sporting activities this year alone. Dental injuries are adapted to the patient’s bite.
460
 Preventive and Corrective Oral Appliances CHAPTER 19 461

FIG. 19.3 Boil and bite guard prior to and after fitting.
A
that softens when heated. The material is softened in
boiling water, placed in the mouth while still mold-
able, adapted to the teeth and arch by fingers, lips,
and tongue, and then adapted to the bite by closing
the teeth into the guard. Excess material is cut away
with heavy-duty scissors. This type of guard is often
difficult for inexperienced individuals to adapt prop-
erly and may have a poor fit interfering with breathing
and speaking ability, but the fit is usually better than
B stock guards. Boil-and-bite guards can provide a false
protection as they can become very thin when an ath-
FIG. 19.1 Prevention of sports injuries. A, Injury to the lip and teeth lete bites too far into them in a softened state.
that could be avoided with a sports guard. B, Multilayer sports guard.
(Courtesy of Acacia Dental Group.)
Custom-Fit Guards
(Fig. 19.4) Custom-fit sports guards.
Professionally made guards are custom-fit to casts
of the patient’s mouth. Because of the added steps, ma-
terials, and time involved in their fabrication, custom
guards may cost several times more than stock and
boil-and-bite guards. Custom-fit guards can be made
from a single layer of material or from pressure-lami-
nated material in a commercial dental laboratory.
The single-layer guards can be fabricated in the dental
office or a commercial laboratory. A sheet of thermoplas-
tic material is heated in a vacuum-forming machine and
vacuum adapted to the cast (Procedure 19.1). The ma-
terial may be clear or a variety of colors (Fig. 19.1, B). A
strap may be attached for sports such as football, where
the athlete wears a helmet and wants to attach it to the
facemask to make it readily accessible. Because the fit is
excellent and the bite is comfortable, compliance with its
use is much better than with the other types of guards.
Pressure-laminated sports guards fabricated in a
commercial dental laboratory are highly recommend-
ed for contact sports such as hockey, basketball, and
FIG. 19.2 Stock guard. (Courtesy of Athletic Specialties.) football. The thermoplastic material consists of two or
three sheets that are heat-fused together. These guards
Boil-and-Bite Guards are thicker than single-layer guards; provide more
(Fig. 19.3) Boil and bite guard prior to and after fitting. cushion, and durability.
Similar to the stock guards, boil-and-bite guards
can be found in sporting goods stores, retail stores and Protection
online costing less than $50. They are constructed of Sports guards can absorb about 80% of the energy
a horseshoe shaped, flexible thermoplastic material from a traumatic hit to the mouth. Sports guards
462 CHAPTER 19 Preventive and Corrective Oral Appliances

PLAYSAFE Tri-Lamination
3 Times
The Protection

Lamination 1

Lamination 2

Lamination 3

Finished
PLAYSAFE

FIG. 19.4 Playsafe Tri-lamination custom-fit sportsguards. (Photo courtesy of Glidewell Laboratories Copyright © 2020.)

usually cover the upper teeth, gingiva, and bone. On dental professional points out the wear evident on
occasion, they are made to cover both arches at the the teeth. Common signs of chronic bruxing include
same time. They can protect the teeth and jaws from wear facets (flattened tooth surfaces that used to be
fracture by a direct blow or cushion the upper and convex), chipping and wear of incisal edges, stress
lower teeth when an athlete’s jaws are forced togeth- cracks in teeth, fractured cusps, cracked teeth, mo-
er by a blow to the lower jaw. Because these guards bility of teeth, enlarged masseters, and sore muscles
provide cushioning to the jaws during collision with of mastication.
another athlete or the ground, some concussions can Guards are recommended for patients who are
be mitigated or prevented. The guard can prevent lac- bruxers (who grind their teeth). The guard does not
erations to lips for athletes with orthodontic braces or stop the grinding habit, but it protects the teeth from
brackets and protect dental work such as bridges, an- wear, chipping, and even fracture of cusps. Guards
terior veneers, or crowns. Athletes should be directed to protect the teeth from grinding and clenching are
to leave removable prostheses such as orthodontic re- also called occlusal guards, bite splints, or night guards
tainers out when playing sports, because they could (because many people grind their teeth at night when
become dislodged and enter the throat. they are sleeping).
Sports guards need a certain thickness and stiffness Dental offices can provide valuable preventive mea-
to maximize their protective qualities. The heavier the sures for their patients by offering guards. Dental aux-
contact in the sport, the thicker the guard should be to iliaries can play an active role in recommending night
provide maximal protection. For heavy-contact sports, guards, making impressions for their fabrication, and
where injuries are more likely, a thickness of about 5 mm even fabricating them in the office laboratory. They can
is desirable. For less physical sports, 2 mm of thickness be fabricated from the same single-layer thermoplastic
may suffice. Playsafe ™ was invented in 1982 and has materials used for sports guards (soft guards) or from
become the leading custom fabricated sports mouth- processed acrylic (hard guards).
guard. Playsafe ™ mouthguards come in a variety of Patients undergoing treatment for dysfunction
thicknesses depending on the age, dentition, and sports of the temporomandibular joint (commonly called
protection needed. TMD) are often given devices (called TMJ splints)
to wear that can serve three functions: (1) keeping
NIGHT GUARDS (BRUXISM MOUTH GUARDS) the teeth separated, (2) taking stress off the joints,
Many patients who grind their teeth do so most- and (3) protecting the teeth. These splints can also
ly at night while sleeping. They may not even be be made from hard acrylic or soft thermoplastic
aware that they are grinding their teeth until the material.
 Preventive and Corrective Oral Appliances CHAPTER 19 463

A B

C
FIG. 19.5 Bruxism guard. A, Laboratory-processed hard acrylic occlusal guard. B, Soft guard made from thermoplastic
material. C, Patient aligns the guard with the teeth and presses it in place. (A, Photo courtesy of Glidewell Laboratories
Copyright © 2020. B, Courtesy Keystone Industries.)

Types of Materials
Home Care Instructions for Soft Sports or
Three types of material are used in the making of night
Bruxism Guards
guards:
• W ash the guard with room temperature water and liquid • Hard: Acrylic (methyl methacrylate resin and
soap on a toothbrush after each use. monomer)
• Do not soak a soft guard in a commercial denture • Soft: Thermoplastic sheets of poly(vinyl acetate)-
cleaner or an alcohol-containing mouthwash, as these
polyethylene material
products will degrade the guard material over time.
• Allow the guard to air dry. Do not enclose it in an airtight
• Hard and soft: Laminates of hard and soft thermo-
container, because it will grow mold and bacteria. If plastic materials
storing it in a container, use one with perforations where
air can circulate. Hard Acrylic Guard. Patients who grind their teeth
• Do not leave the guard in a closed automobile in the heavily and frequently should have a hard acrylic
sun or expose it to hot water as this will cause warping. guard, due to it being more durable than a soft guard.
• Do not chew on the guard when using it, as you may Hard acrylic guards are usually fabricated in the den-
tear or distort it. tal laboratory (Fig. 19.5).
• Do not leave the guard where the family dog might They typically require more chair-time for adjust-
reach it. They have been known to chew them up. ment, because the acrylic, like other resins, shrinks
• Sports guards eventually wear out, so when it no longer
when it is cured. They also feel tight on the patient’s
fits well or has tears and holes in it, it is time to replace it.
teeth when first tried on.
464 CHAPTER 19 Preventive and Corrective Oral Appliances

Soft Guard. Soft guards are better suited for patients it is sealed in a container while it is still moist, this may
who do not grind their teeth heavily or regularly (dai- promote the growth of bacteria and mold. A rigid con-
ly). Some patients who have had hard guards find the tainer prevents the guard from being distorted by oth-
soft guards more comfortable and easier to get used er articles inadvertently placed on top of it. Staining is
to. Soft guards are made from soft thermoplastic sheets common with all types of guards. Contact with amal-
and may be fabricated in the commercial dental labo- gam restorations will cause a dark gray stain over time
ratory or the dental office by the auxiliary. Soft guards in the area of contact. Solutions containing alcohol,
require much less time to adjust than hard guards. such as mouthwash, and bleach should not be used,
Often chair-side adjustment can be made by heating because they will degrade the material. Commercially
the outside biting surface of the guard with an alcohol available soaks for orthodontic retainers or dentures
torch and, while it is still warm, placing it in the pa- are useful to freshen the hard guards but can degrade
tient’s mouth and having him or her bite into the ma- the soft poly(vinyl acetate)-polyethylene guards over
terials. This process equalizes the bite. Care must be time.
taken to avoid placing the guard in the mouth too hot
and should be checked with the gloved hand first. A Caution
technique for using upper and lower casts mounted on
Patients should be advised not to immerse their sport
a simple hinge articulator to adjust the bite at the time
guards or night guards in hot water, because it can cause
the guard is made is described in Procedure 19.1. Ad-
distortion of the guard.
justing the bite on mounted casts will save c­ hair-time.
The poly(vinyl acetate)-polyethylene sheets used to
make soft guards come in a variety of thicknesses, and
the thinner sheets can also be used for whitening and ORAL APPLIANCES TO TREAT SNORING AND
fluoride trays. OBSTRUCTIVE SLEEP APNEA
While snoring may be considered only an annoy-
Hard and Soft Laminate Guard. Patients who need the ance, obstructive sleep apnea (OSA) can lead to serious
durability of a hard occlusal surface but like the feel health issues if not treated. The most serious poten-
of the soft material may prefer hard and soft laminate tial problems include hypertension, heart attack, heart
guards. Guards made from this material are hard on failure, and stroke. Snoring and OSA are often caused
the biting surface and soft internally, allowing them to by relaxation of the muscles that support the soft pal-
adapt readily to the teeth while being gentle on the soft ate, uvula, and tongue, causing a narrowing or closing
tissues. The material comes in sheets that have a firm of the airway. Breathing becomes inadequate or stops
thermoplastic material laminated with a soft material. for a few seconds, causing the blood oxygen level to
A sheet of the material is softened in a vacuum ma- drop. This alerts the brain to wake the individual up
chine similar to the soft guard material and vacuum just enough to reopen the airway. Often short gasping
adapted to the cast. breaths are taken until the oxygen level is restored.
Someone with a serious problem may wake up 10 to
Design of the Guard 20 times an hour. They wake up in the morning feel-
Most night guards and TMD splints cover the maxil- ing exhausted or, surprisingly, they may not notice the
lary teeth, but some dentists cover the mandibular lack of sleep.
teeth. Some guards or TMD treatment splints may
only cover a few of the anterior teeth (e.g., NTI splints; Risk Factors for OSA
NTI-Chairside Splints), but some experts contend that Risk factors for OSA include a large neck, obesity,
these may actually create a fulcrum that displaces the chronic nasal congestion, high blood pressure, diabe-
condyles from their ideal position in the joints. Some tes, smoking, alcohol use, and a narrow airway. Men
guards may cover both lingual and occlusal surfaces of are twice as likely to have OSA as women. It is more
the teeth and just lap over cusps of the posterior teeth common in people who are middle aged or older. To
and the incisal edges of the anterior teeth. Others cover arrive at the proper diagnosis and plan of treatment,
all of the anterior and posterior teeth. those afflicted may be sent to a sleep specialist at a
sleep center for evaluation where sleep patterns may
Maintenance be monitored overnight.
The auxiliary should instruct the patient in proper
home care of the guard. First and foremost, the guard Treatment of OSA
should be cleaned daily. When it is removed from the Treatment for mild OSA may include weight loss,
mouth, it should be rinsed thoroughly to remove sa- exercise, reduced alcohol intake, smoking cessation,
liva and then brushed with a toothbrush or denture sleeping on one side, and use of nasal decongestants.
brush and liquid soap. After the final rinsing, excess Treatment for more severe OSA may involve the use
water should be shaken off and the guard stored in a of continuous positive airway pressure (CPAP). With
rigid container that is left open so that it can air-dry. If CPAP a mask is worn on the face while sleeping and
 Preventive and Corrective Oral Appliances CHAPTER 19 465

a device attached to it delivers a continuous positive to their application occurring while the dentition and
flow of air to keep the airway open (Fig. 19.6). face are still developing.
Many people find the CPAP mask uncomfortable
and have trouble adjusting to it. A more invasive ap- SPACE MAINTAINERS
proach to OSA is surgery to reduce the soft palate and Space maintainers are used most frequently in pediat-
uvula (uvulopalatopharyngoplasty) to open the air- ric dentistry when a tooth is lost too soon. They pre-
way. Many patients are willing to try oral appliances vent adjacent teeth from drifting and closing the space
as a conservative alternative treatment. created by the lost tooth. The space is needed to allow
the permanent tooth to erupt properly. Sometimes
Function of Appliances space maintainers are used in adults to hold the space
Most appliances do one of three things: (1) lift the from a lost tooth until an implant, bridge, or removable
soft palate, (2) hold the tongue in a more forward partial denture can be placed.
position, or (3) reposition the mandible forward to
bring the tongue away from the airway. There are Types of Space Maintainers
at least 80 different designs for oral appliances. Oral Space maintainers can be removable or fixed. A remov-
appliances do not work for everyone and have the able space maintainer can be in the form of a stayplate
most success in those with mild to moderate OSA or a retainer with a denture tooth or acrylic block at-
(Fig. 19.7). tached. Fixed space maintainers are cemented in place
and may have a wire loop attached to a stainless steel
PREVENTIVE ORTHODONTICS crown or an orthodontic band and extend from the
Preventive orthodontics are intended to prevent or crowned or banded tooth to contact the tooth on the
eliminate mal-positions and irregularities in the de- opposite side of the space.
veloping dentition and orofacial region. Preventive or-
thodontics eliminate the need for full orthodontics due INTERCEPTIVE ORTHODONTICS
Interceptive orthodontics (corrective appliances) cor-
rects problems in the orofacial region as they develop
in an attempt to prevent the need for full orthodontics
or, at a minimum, decrease the amount of time ortho-
dontics are required. The appliance intervention is nec-
essary to prevent a malocclusion.

THUMB SUCKING APPLIANCE

Thumb sucking and tongue thrusting are two main
oral habits interceptive orthodontics or corrective ap-
pliances are utilized to treat. The thumb sucking device
consists of metal protrusions, which resemble spikes
or a rake. When the patient places the tongue or the
FIG. 19.6 Obstructive sleep apnea treatment device continuous posi- thumb on the device, discomfort will occur. This dis-
tive airway pressure (CPAP) device for obstructive sleep apnea. (Cour- comfort is anticipated to break the tongue thrusting or
tesy of CPAP Global.) thumb sucking habit (Fig. 19.8).

FIG. 19.7 Oral appliance for obstructive sleep apnea positions the lower jaw forward to prevent the tongue and soft tis-
sues of the throat from obstructing the airway. (Courtesy of Dental Sleep Apnea Clinic.)
466 CHAPTER 19 Preventive and Corrective Oral Appliances

PALATAL EXPANSION APPLIANCES

Palatal expansion devices are utilized to expand the
maxillary arch when it is too narrow and re-establish the
balance between the width of the maxillary and man-
dibular jaws. Without expansion an abnormal relation-
ship between dental arches would exist. The problems
associated with a narrow palate could include the fol-
lowing: airway obstruction due to a narrow nasal cavity
and crowding of the maxillary teeth (Fig. 19.9).

CROSSBITE CORRECTOR
A crossbite corrector corrects the area where the maxillary
FIG. 19.8 Thumb sucking device. (Courtesy of Dr. Frank Hodges.) teeth are positioned lingual to the mandibular teeth. The
crossbite is corrected by the use of a fixed or removable
device. The device can be a band with an extension that
guides the tooth into the appropriate place (Fig. 19.10).

ORTHODONTIC TOOTH ALIGNERS

Many types of minor tooth movement can be achieved
with removable appliances that direct forces on the
teeth to move them into proper alignment. Traditional
removable appliances usually consist of an acrylic base
with embedded stainless steel wires (see “Wrought
Metal Alloys” in Chapter 11) bent into springs or bows
(Fig. 19.11) and/or expansion screws. A more recent
approach uses a series of clear thermoplastic aligners
FIG. 19.9 Palatal expansion appliance. (Courtesy of Dr. Frank Hodges.) to gradually move the teeth into the desired position.
Because these orthodontic tooth aligners are made from
a clear thermoplastic material, their developer clev-
erly named the process Invisalign (Align Technology,
Inc.). They are used more with adults than children.
They are popular because they are more esthetic than
conventional braces and brackets. However, complex
malocclusions will require conventional orthodontic
treatment with brackets and braces.

How Aligners Are Made

Design software creates a three-dimensional model
from a digital scan of the teeth or a cast of the teeth.
Next, technicians digitally move the individual teeth
into the final desired position, using design software.
Then, the software is used to simulate moving the teeth
FIG. 19.10 Crossbite correcting device. (Courtesy of Dr. Frank Hodges.) in gradual stages, and aligners (made of polyurethane)
are fabricated for each stage of movement (Fig. 19.12).

A B C
FIG. 19.11 Removable tooth movement appliance (Hawley appliance). A, Protruding right maxillary central incisor B,
Hawley appliance with a labial bow that will be activated by tightening the loops. The pressure created on the incisor will
move it lingually. The bow is reactivated as the tooth moves. C, Maxillary incisor has been repositioned with the Hawley
appliance, and the appliance will now serve as a retainer. (Courtesy of Dr. Scott Rooker, Los Altos, CA.)
 Preventive and Corrective Oral Appliances CHAPTER 19 467

Treatment 3-D Printing

The patient wears the aligners approximately 20 hours a The use of 3-D Printing is becoming increasingly popu-
day. Wearing the aligners for a shorter period of time each lar in the field of dentistry. A common application of
day will prolong the treatment. The aligners are removed 3-D Printing is with the use of a desktop 3-D printer to
only to eat, drink, or clean the teeth. Small nobs made fabricate (print) clear orthodontic aligners. The align-
of composite material (called buttons see Chapter 6) are ers can be utilized for the movement of teeth similar to
bonded to the teeth (see Chapter 5) to help the aligners the aligners shown in (see Fig. 19.12) or as a retainer to
grip well and to facilitate tooth movement (Fig. 19.13). maintain the position of the dentition after orthodon-
Elastic may be needed to help rotate teeth or to in- tic treatment has been concluded. The printer utilizes a
trude or extrude them. resin type material to print the appliances.
A new aligner in the series is used every 2 to 4 weeks. 3-D Printing is not new to the medical field; how-
This is repeated until the malocclusion or misalignment ever, its use in dentistry is just now becoming more
is corrected. The last and final step is to make a retainer prevalent. It should be noted that 3-D Printing is not
that will keep the teeth from shifting. It is usually made limited to orthodontic applications. Other applications
from the same clear material as the aligners. for 3-D Printing include the following: prosthodontics,
oral surgery, periodontics, and general dentistry.

SUMMARY
Sports guards prevent many oral injuries each year.
The use of mouth guards not only helps those patients
with TMJ disorders, but is effective in the prevention of
excessive tooth wear and fracture. Space maintainers
prevent loss of space by drifting of adjacent teeth when
teeth are lost prematurely. Treatment of sleep apnea
is a growing segment of the modern dental practice.
More adults are requesting orthodontic treatment to
correct misaligned teeth and they demand “invisible”
braces when possible. So, dental auxiliary must be able
to answer questions about the procedures and materi-
als used. They must also be able to provide home care
instructions for the appliances.

INSTRUCTIONAL VIDEOS
See the Evolve Resources site for a variety of educa-
FIG. 19.12 Removable clear tooth aligner Invisalign. (Courtesy of Align tional videos that reinforce the material covered in this
Technology, San Jose, CA.) chapter.

attachment

aligner over
attachment

FIG. 19.13 Aligner buttons bonded to teeth. Spaces are created in an aligner over the facial surfaces of selected teeth.
Composite resin is packed into these spaces. The teeth are prepared for bonding of the composite buttons. The aligner
is positioned over the teeth and the composite buttons are bonded to the teeth. These buttons aid in tooth movement.
468 CHAPTER 19 Preventive and Corrective Oral Appliances

Procedure 19.1 Fabrication of a Sports Mouth Guard (Protector)

See Evolve site for Competency Sheet. NOTE: The guard material comes in sheets in a
variety of colors that are appealing to young athletes,
Consider the following with this procedure: safety glasses are
or they can be clear.
recommended for the patient, PPE is required for the operator,
Place the maxillary cast on the platform and
4. 
ensure appropriate safety protocols are followed, and check your
center it under the sheet of guard material.
local state guidelines before performing this procedure.
Lower the frame when the sheet of material has
5. 
EQUIPMENT/SUPPLIES (FIG. 19.14) softened and sags an inch or more. Turn on the
vacuum when the molten guard material covers
• Trimmed casts (study models)
the cast. Leave the vacuum on for at least 30
• Mouth guard material: One sheet 6 × 6 inches, 0.15
seconds to allow the molten material to adapt to
inch thick
the cast (Fig. 19.15).
• Vacuum former unit
NOTE: With some machines, the vacuum acti-
• Heavy-duty scissors
vates automatically when the frame is lowered. If air is
• Straight-line hinge articulator
trapped between the cast and the guard material, use
• Petroleum jelly
a wet paper towel to quickly press the guard material
• Alcohol torch
against the cast while the vacuum is still on, to force
• Disinfectant spray and zippered plastic bag
the air out and closely adapt it to the cast.
PROCEDURE STEPS Remove the guard material and the cast from the
6. 
clamping frame and allow it to cool.
Inspect casts (study models) and remove any
1. 
NOTE: Hold it under cold water to cool it rapidly.
blebs of dental stone on the teeth.
Trim excess material from the cast. Carefully
7. 
NOTE: These blebs (bumps) of stone represent
remove the cast from the guard material.
trapped air bubbles in the impression. Painting algi-
NOTE: Removing excess guard material at the
nate on the occlusal surfaces of the teeth and in the
sides of the cast will help free the cast more easily.
palate just before inserting the loaded tray will help
Place the maxillary and mandibular casts
8. 
minimize trapped air in the impression.
together in their proper bite relationship (centric
Trim casts in a horseshoe shape so that the
2. 
occlusion) and mount them on the articulator,
central portion representing the tongue and
using fast-set plaster (Fig. 19.16).
palate areas is mostly removed.
NOTE: To save time trimming the casts, these ar-
eas can be blocked out with a piece of wet, crumpled
paper towel once the impressions are poured.
Insert a sheet of mouth guard material in the
3. 
frame of the vacuum former and clamp it in
place. Lift the clamping frame up to a heating
element and turn on the heat to soften the
material.

FIG. 19.14 FIG. 19.15

 Preventive and Corrective Oral Appliances CHAPTER 19 469

Procedure 19.1 Fabrication of a Sports Mouth Guard (Protector)—cont’d

NOTE: For patients whose bite relationship is not together into the softened guard material
clear, a separate bite registration should be taken when (Fig. 19.18). Repeat this process by heating the
the alginate impressions are made. guard in the molar, premolar, and cuspid areas
Trim excess guard material away, using heavy-
9.  until the mandibular teeth touch the guard
duty scissors, until the guard extends about 3⁄8 evenly in the posterior and anterior.
inch onto the palatal and facial gingiva of the NOTE: A guard corrected in this manner will al-
cast. low the athlete to close comfortably and not be in a
NOTE: The guard is extended over the gingiva to strained jaw position.
give added protection, but is kept short of the depth of 12. Round out, using an acrylic bur in the laboratory
the vestibule so that it will not irritate the tissues when handpiece, the indentations in the guard caused
the athlete bites on the guard. by the mandibular cast. Next, create smooth
10. Place the guard on the maxillary cast and check borders and an occlusal surface by flaming with
to see that the guard material is not too thick in an alcohol torch to soften the material, then
the molar area (Fig. 19.17). The mandibular cast lightly rubbing the surface of the guard with a
should close evenly onto the guard and not prop gloved finger coated with petroleum jelly.
the bite open. NOTE: Be careful not to overheat the guard. Just
11. Correct the bite. If the guard hits the mandibular soften the surface by lightly flaming it. If it is too hot, it
molars first, apply a thin coat of petroleum jelly could cause a burn to the finger. Overheating the guard
to the occlusal surfaces of the mandibular cast, can also cause it to burn.
soften the guard in both right and left molar 13. A commercially purchased strap can be added
areas with an alcohol torch, and close the casts to the anterior part of the guard for those sports
in which a face guard is used. The strap allows
the athlete to remove the guard from the mouth
while not in activity and have it attached to the
face guard and ready to reinsert when needed.
While still on the cast, heat the guard on the
facial surface and heat the back surface of the
strap attachment base with an alcohol torch and
press the two soft surfaces together. Allow it to
cool. Insert the face guard strap into the slot on
the strap attachment base (Figs. 19.19 and 19.20)
14. Wash the guard with liquid soap and water. Rinse
thoroughly and spray it with a disinfectant. Store
it until the delivery appointment in a zippered
plastic bag marked with the patient’s name.
FIG. 19.16

FIG. 19.17 FIG. 19.18

Continued
470 CHAPTER 19 Preventive and Corrective Oral Appliances

Procedure 19.1 Fabrication of a Sports Mouth Guard (Protector)—cont’d

FIG. 19.19 FIG. 19.20

Get Ready for Exams!

Review Questions 6. O bstructive sleep apnea can lead to:

a. Chronic fatigue
Select the one correct response for each of the following b. High blood pressure
multiple-choice questions. c. Heart problems
1. When a soft mouth guard is prescribed by the dentist, d. All of the above
fabrication can be done by: 7. Oral appliances used for obstructive sleep apnea
a. The dental assistant work by:
b. The dental hygienist a. Holding the tongue forward
c. The laboratory technician b. Holding the mandible forward
d. All of the above c. Supporting the tissue of the soft palate
2. This appliance is utilized to correct a mal-occusion d. Any one or more of the above
where the maxillary teeth are positioned lingual to the 8. The treatment objectives of oral appliances for sleep
mandibular teeth: apnea include all of the following except one. Which
a. Thumb sucking device one?
b. Palatal Expander a. Lift the soft palate
c. Crossbite corrector b. Hold the tongue in a more forward position
d. Space maintainer c. Open the nasal passages
3. The main purpose of a sports mouth guard is: d. Reposition the mandible forward to bring the tongue
a. To help protect the teeth and supporting structures away from the airway
during contact sports 9. Which one of the following statements about space
b. To keep the airway open maintainers is true?
c. To keep the tongue out of the way a. They are always cemented into place.
d. To keep teeth in alignment after orthodontic b. They are used only when primary teeth are lost.
treatment c. They prevent teeth adjacent to the space from drift-
4. Custom-made mouth guards and splints may be made of: ing into the space.
a. A plastic material softened by boiling d. Denture teeth are never used in conjunction with
b. Thermoplastic resilient plastic or hard processed space maintainers.
acrylic resin 10. With Invisalign orthodontic treatment the removable
c. Composite resin aligners are changed about every:
d. Tray acrylic a. 2 to 4 weeks
5. A palatal expander is a fixed appliance used to expand the: b. 5 to 8 weeks
a. Mandibular arch c. 9 to 12 weeks
b. Maxillary arch d. 13 to 15 weeks
c. Both maxillary and mandibular arches
d. Neither maxillary nor mandibular arches

Get Ready for Exams!

 Preventive and Corrective Oral Appliances CHAPTER 19 471

Get Ready for Exams!—cont’d

11. W hich one of the following statements about removable Case-Based Discussion Topics
orthodontic aligners is true?
a. All malocclusions can be treated with aligners. 1. U pon examination, a 37-year-old truck driver is found
b. Aligners are made for each stage of tooth movement to have chipped and worn incisal edges on the anterior
simulated by design software. teeth and flattened occlusal surfaces on the first and
c. Aligners are made from processed acrylic resin. second molars. He has almost worn through the enamel.
d. Treatment with aligners takes much longer than His teeth are not mobile, his periodontal health is good,
conventional treatment because a series of aligners and he has no caries. He suspects he clenches and
must be used. grinds when he is driving in heavy traffic. His wife tells
12. Boil and Bite sports guards may appear to be protec- him he grinds his teeth in his sleep.
tive but may not be. This is due to the material becom- Is he a candidate for an occlusal guard? If so, what type of
ing very thin when athletes bite into them in a softened guard material would best be suited for his condition? Should
state. he wear the guard at night, during the day, or both? Why?
a. The first statement is true the second is false 2. A sixteen-year-old boy will be playing left tackle for his
b. The first statement is false the second is true high school football team. He is 6 feet 2 inches, weighs
c. The first and second statement are true 190 pounds, and is very strong.
d. The first and second statement are false Should he wear a sports guard? If so, is a single-layer guard ap-
For answers to Review Questions, see the Appendix. propriate? What types of injuries can a sports guard prevent?

BIBLIOGRAPHY Bird DL, Robinson DS: Orthodontics. In Modern Dental Assisting

(ed 12). Philadelphia, 2018, Elsevier/Saunders.
Academy for Sports Dentistry: Frequently asked questions. Darby ML, Walsh MM: Orthodontic care. In Dental Hygiene:
Available at: http://www.academyforsportsdentistry.org Theo­ry and Practice, St. Louis, 2015, Saunders/Elsevier.
/faq-s. Powers JM, Wataha JC: Mouth protectors. In Dental Materials
American Academy of Dental Sleep Medicine: Oral appliances. Properties and Manipulation, St. Louis, 2013, Mosby.
Available at: http://www.aadsm.org/obstructive_sleep_apn Robinson DS, Bird DL: Orthodontics. In Essentials of Dental As-
ea.php. sisting, St. Louis, 2017, Elsevier.
American Dental Association (ADA) Council on Access: Preven- University of Washington: Classification of space maintainers.
tion and Interprofessional Relations; ADA Council on Scien- In: Atlas of Pediatric Dentistry [web-based textbook]. Atlas main-
tific Affairs: Statement on Athletic Mouthguards 2009. Avail- tained by the Department of Pediatric Dentistry, University
able at: http://www.ada.org/∼/media/ADA/Science%20a of Washington, Seattle, Washington. Available at: http://dep
nd%20Research/Files/SCI_Statement%20on%20Athletic%2
ts.washington.edu/peddent/AtlasDemo/space009.html.G
0Mouthguards_2016Oct24.pdf?la=en.
et Ready for Exams!
appendix

A Answers to Review Questions

Chapter 2 12. a 16. d 8. d

1. c 13.  b 17. a 9.  d
2. d 14. c 18. a 10. c
3. b 15.  b 19. a 11. a
4. c 20. c 12.  b
5. d Chapter 6 21. a 13.  d
6. b 1. a 22. c 14. a
7. c 2. d 23. c 15. c
8. b 3. d 24.  b 16.  d
9. b 4. a 25. a 17. a
10. a 5. c 18. a
11. d 6. c Chapter 8
12. c 7. b 1. c Chapter 11
13. c 8. c 2. b 1. b
14. c 9. d 3. b 2. a
15. d 10. b 4. d 3. a
16. c 11. d 5. b 4. a
12. d 6. b 5. d
Chapter 3 13. c 7. b 6. b
1. a 14. b 8. d 7. a
2. b 15. a 9. b 8. d
3. c 16. d 10. d 9. c
4. c 17. b 10. c
5. d 18. a Chapter 9 11. d
6. b 19. d 1. a 12. a
7. a 20. c 2. c 13. d
8. b 21. d 3. a 14. d
9. c 22. d 4. a 15. d
10. b 23. c 5. d 16. a
24. d 6. b
Chapter 4 25. c 7. d Chapter 12
1. d 26. d 8. c 1. d
2. d 27. b 9. b 2. b
3. d 10. d 3. b
4. c Chapter 7 11. b 4. c
5. c 1. b 12. c 5. e
6. d 2. b 13. c 6. b
7. c 3. c 14. a 7. d
4. c 15. d 8. b
Chapter 5 5. d 16. b 9. d
1. d 6. c 17. c 10. a
2. a 7. b 18. c 11. a
3. d 8. a 12. d
4. c 9. c Chapter 10 13. c
5. b 10. b 1. d 14. a
6. a 11. d 2. c 15. d
7. b 12. b 3. c 16. a
8. e 13. b 4. d 17. b
9. a 14. a 5. c 18. c
10. b 15. d 6. c 19. b
11. c 7. a

472
 APPENDIX A Answers to Review Questions 473

Chapter 13 Chapter 15 4. c 18. a

1. d 1. b 5. a 19.  d
2. c 2. a 6. c 20.  b
3. d 3. c 7. a 21.  d
4. d 4. d 8. a 22. a
5. b 5. c 9.  d 23.  b
6. c 6. d 10. a
7. c 7. d 11. e Chapter 18
8. b 8. a 12.  b 1. c
9. a 9. b 13. c 2. b
10. a 10. a 14.  d 3. d
11. b 11. c 15. a 4. d
12. d 16.  d 5. c
Chapter 14 13. b 17. a 6. d
1. b 14. c 7. b
2. b 15. a Chapter 17 8. d
3. d 16. b 1. c 9. b
4. c 17. b 2. a 10. a
5. b 18. d 3. d 11. c
6. c 19. d 4. a 12. c
7. a 20. b 5. b
8. d 21. b 6. d Chapter 19
9. d 22. a 7. c 1. d
10. d 23. d 8. a 2. c
11. a 24. a 9. d 3. a
12. d 25. d 10. d 4. b
13. d 26. c 11. d 5. b
14. b 27. b 12. c 6. d
15. a 13. d 7. d
16. d Chapter 16 14. d 8. c
17. a 1. b 15. c 9. c
18. a 2. c 16. c 10. a
3. c 17. d 11. b
12. c
Glossary

Abrasive: A material that comprises particles of sufficient Alloy, wrought metal: An alloy that has been mechanically
hardness and sharpness to cut or scratch a softer material when changed into another form to improve its properties.
drawn across its surface. Amalgam, dental: Restorative material that comprises silver-
Addition Polymerization: common form of polymerization for based alloy mixed with mercury.
dental materials; monomer molecules are added one to another Amalgamation: A reaction that occurs when silver-based alloy
sequentially as the reactive group on one molecule initiates is mixed with mercury.
bonding with an adjacent monomer molecule and frees another Amalgam separator: a device that collects amalgam particles
reactive group (free radical) to repeat the process and mercury from evacuation systems that might otherwise
Addition silicone: A silicone rubber impression that also sets escape into the wastewater and therefore enter the environment
by linking of molecules in long chains but produces no by- Anneal: To modify physical properties of a metal by heating it.
product. The most commonly used addition silicones are the Antibacterial mouth rinse: A liquid used to rinse the oral
polyvinyl siloxanes. cavity to reduce or suppress bacteria associated with dental
Adhesion: The act of sticking two things together. In dentistry, caries or periodontal disease.
it is used to describe the bonding or cementation process. Autograft: graft tissue harvested from the patient’s own body
Chemical adhesion occurs when atoms or molecules of Barrier Membrane: protective membrane that prevents the
dissimilar substances bond together and differs from cohesion in-growth of fibrous connective tissue into a graft site and also
in which attraction among atoms and molecules of like (similar) holds the graft material in place
materials holds them together. Base: A thick layer of cement used in a cavity preparation
Adhesive: An intermediate material that causes two materials to protect the pulp from chemical insult or to act as a
to stick together. thermal insulator and to support restorations in deep cavity
Agar: A powder derived from seaweed that is a major preparations.
component of reversible hydrocolloid. Base-Metal Alloy: alloy composed of non-noble metals which
Air Polishing: the process of polishing or finishing using corrode more readily
fine particles with air pressure to remove biofilm and stain Bioactive Dental Materials: materials that interact with living
for enamel surfaces and in pits and fissures; an alternative to tissue and are used to remineralize and repair dentin.
prophy pastes. Air polishing uses soft particles (Mohs ranking Bio-aerosol: A cloud-like mist that contains droplets, tooth
of 3) and an air pressure of approximately 40 to 60 pounds per dust, materials dust, and bacteria of a particle size smaller than
square inch (psi). 5 μm in diameter.
Air Abrasion or Microabrasion: like air polishing but using Biocompatible: The property of a material that allows it not to
greater air pressure (40 to 160 psi) and harder particles impede or adversely affect living tissue.
(aluminum oxide; Mohs harness ranking of 9). Used to cleanse Bite registration: An impression of the occlusal relationship of
cast appliances before cementation, repair porcelain and opposing teeth in centric occlusion (patient’s normal bite).
composite restorations, prepare tooth surfaces before bonding, Bleaching: A cosmetic process that uses chemicals to remove
and cut tooth structure for restorative preparations. discolorations from teeth or to lighten them.
Alginate: A versatile, irreversible hydrocolloid impression Bond or bonding: To connect or fasten; to bind (Webster’s
material that is used most often in the dental office; however, New World Dictionary). Basically, items are joined together at
it lacks the accuracy and fine surface detail needed for the surface in two ways: by mechanical adhesion (physical
impressions for crown and bridge procedures. interlocking) and by chemical adhesion.
All-ceramic restoration: Ceramic restorations with no metal Bonding agent: A low-viscosity resin that penetrates porosities
core. and irregularities in the surface of the tooth or restoration
Allograft: tissue taken from a donor (usually deceased) for created by acid etching, for the purpose of facilitating bonding.
grafting in another human Brittleness: Hard and likely to break or crack.
Alloplast: synthetic graft material Buildup: A restorative material such as amalgam, composite
Alloy: A mixture of two or more metals. resin, or glass ionomer cement that is used to replace missing
Alloy, admixed: A mixture of lathe-cut and spherical alloys for tooth structure in a badly broken-down tooth and to act as
amalgam. support for a restoration such as a crown.
Alloy, base metal: An alloy that comprises non-noble metals. CAD/CAM: Computer-assisted design/computer-assisted
Alloy, high noble: An alloy that contains at least 60% noble machining technology that uses a scanning device to capture
metals, 40% of which must be gold. an image of the preparation and integrates it with computer
Alloy, lathe-cut: Irregularly shaped particles formed by software to design and cut restorations from blocks of dental
shaving fine particles from an alloy ingot for amalgam. materials.
Alloy, noble: An alloy that comprises metals that do not Calcium hydroxide: Used as a low-strength base and a direct
corrode readily. pulp-capping material to stimulate secondary dentin formation.
Alloy, porcelain bonding: Special casting alloy manufactured Cariogenic: Substances or microorganisms that promote dental
for its compatibility with porcelain that has been bonded to it at caries.
high temperature. Casts: Hard replicas of hard and soft tissue of the patient’s oral
Alloy, spherical: Alloy particles produced as small spheres for cavity made from gypsum products. They are also referred to
amalgam. as models.

474
 GLOSSARY 475

Ceramics: Materials composed of inorganic metal oxide Cross-Linked Polymers: adjacent long-chain polymers joined
compounds, including porcelain and similar ceramic materials by the bonding of short chains along their sides to enhance the
that require baking at high temperature to fuse small particles properties of the polymer
together to form the restoration, or a pre-formed ceramic Crown: an indirect restoration that covers all or part of the
block from which the restoration is milled using CAD/CAM coronal tooth structure (extracoronal) and is composed of
techniques. metal, ceramic or a combination of the two.
Chemical-set materials: Materials that set through a timed Cure or polymerization: A reaction that links low molecular
chemical reaction with the combination of a catalyst and base. weight resin molecules (monomers) together into high
Chroma: The intensity or strength of a color (e.g., a bold yellow molecular weight chains (polymers) that harden or set. The
has more chroma than a pastel yellow). reaction can be initiated by strictly a chemical reaction (self-
Cleaning: The removal of soft deposits from the surface of cured), by light in the blue wave range (light-cured), by a
restorations and tooth structure. Polishing and cleaning are combination of the two (dual-cured), or by heat.
done to remove surface stains and soft deposits from the Custom-made: Made specifically to fit one individual.
clinical crowns and exposed root surfaces of teeth after all Delayed Expansion: expansion of amalgam containing zinc
hard deposits are removed. Aside from abrasives, there are when it is contaminated with moisture (e.g., saliva) during
also chemical cleaning products that are used primarily for condensation.
removable prostheses. Demineralization: The action usually caused by acids that
Coefficient of thermal expansion (CTE): The measurement removes minerals from the tooth.
of change of volume or length in relationship to change in Density: The measure of the weight of a material compared
temperature. with its volume.
Colloid: Glue-like material composed of two or more Dental amalgam: Restorative material composed of silver-
substances in which one substance does not go into solution but based alloy mixed with mercury.
is suspended within another substance. It has at least two phases: Dental caries: A process whereby bacteria in plaque
a liquid phase called a sol and a semisolid phase called a gel. metabolize carbohydrates and produce acids that remove
Compomer: A composite resin that has polyacid, fluoride- minerals from teeth and permit bacteria to invade.
releasing groups added. Dental stone: A stronger, less porous form of gypsum product
Composite, dual-cured: Composite that contains components used in dentistry.
of light-cured and self-cured composites. When the two parts Depth of Cure: the depth to which light from a curing unit can
are mixed together, it polymerizes by a chemical reaction that penetrate and cure composite resin
can be accelerated with blue light activation. Desensitizing agent: A chemical that seals open dentinal
Composite, flowable: A light-cured, low-viscosity composite tubules to reduce tooth sensitivity to air, sweets, and
resin that contains fewer filler particles. temperature changes.
Composite, hybrid: Composite that contains both macrofiller Diagnostic casts: casts generally made from dental plaster or
and microfiller particles to obtain the strength of a macrofill stone and used for patient education, treatment planning, and
and the polishability of a microfill. tracking the progress of treatment, as with orthodontic models;
Composite, light-cured: Composite that polymerizes when a these casts are also known as study models.
chemical is activated by light in the blue wave range. Dies: Replicas of the prepared teeth that are generally
Composite, macrofilled: An early generation of composite that removable from the working cast.
contained filler particles ranging from 10 to 100 μm. Die stone: The densest form of gypsum product used in
Composite, microfilled: Composite that contains very small dentistry.
filler particles averaging 0.04 μm in diameter. Digital Impression: detailed digital images of the preparation,
Composite, packable: A light-cured, highly viscous, heavily surrounding and opposing teeth, and tissues taken by a digital
filled composite resin for dentists who use a placement scanner for the purpose of making a restoration
technique with composite that is similar to that of amalgam. Dimensional change: A change in the size of matter. For
Composite resin: Direct-placementtooth-colored material that dental materials, this usually manifests as expansion caused by
comprises an organic resin matrix and inorganic filler particles. heating and contraction caused by cooling.
Composite, self-cured: Composite that polymerizes by a Direct fabrication: Provisional restorations made directly
chemical reaction when two resins are mixed together. inside the patient’s mouth.
Compressive force: Force applied to compress an object. Direct restorative materials: Restorations placed directly into
Condensation silicone: A silicone rubber impression material cavity preparations.
that sets by linking of molecules in long chains but produces a Dual set materials: Materials that polymerize by a chemical
liquid by-product through condensation. reaction that occurs when the material is mixed with a
Contamination: Contact with a substance that changes the catalyst or that is initiated by exposure to blue light (or by a
chemical or mechanical properties (e.g., contamination of the combination of chemical or light reaction).
etched surface of the tooth with saliva before bonding). Dual-cured composite: Composite that contains components
Coping: A thin covering like a thimble that serves as a of light-cured and self-cured composites. When the two parts
substructure for a porcelain-bonded-to-metal crown. are mixed together, it polymerizes by a chemical reaction that
Corrosion: Deterioration of a metal caused by a chemical can be accelerated by blue light activation.
attack or electrochemical reaction with dissimilar metals in the Ductility: The ability of an object to be pulled or stretched
presence of a solution containing electrolytes (such as saliva). under tension without rupture.
Corrosive: Usually an acid or strong base that can cause Edge strength: The ability of a material to withstand fracture at
damage to skin, clothing, metals, and equipment. a thin edge such as at the margins of a restoration.
Creep: Gradual change in the shape of a restoration caused by Elastic deformation: deformation of a material that recovers its
compression from occlusion or adjacent teeth and can cause original shape and size when the force is removed
amalgam to bulge out of the cavity preparation. Elasticity: The ability of a material to recover its shape
Crossbite Corrector: a fixed or removable appliance used to completely after deformation from an applied force.
correct teeth in mal-alignment where the maxillary teeth are Elastic Limit: the greatest stress a structure can withstand
positioned lingual to the mandibular teeth. without permanent deformation
476 GLOSSARY

Elastic Modulus (also called Young’s Modulus): a measure Fluoride: A naturally occurring chemical that helps to protect
of the stiffness of a material; the higher the elastic modulus the tooth structure from dental caries.
stiffer the material Fluorosis: Enamel abnormality caused by consumption of
Elastomers: Highly accurate elastic impression materials that excessive levels of fluoride.
have qualities similar to rubber. They are used extensively Free radical: A reactive group on one end of a monomer that
in indirect restorative techniques, such as crown and bridge initiates the joining of adjacent monomer molecules to form a
procedures. polymer.
Enamel Microabrasion: a process that uses hydrochloric Galvanism: An electrical current transmitted between two
acid and an abrasive such as pumice to remove shallow dissimilar metals.
discolorations of the enamel. Gamma-2 phase: A chemical reaction between tin in the silver-
Endosseous (endosteal) implant: Implant placed into the based alloy and mercury that causes corrosion in the amalgam.
bone. Gauge: A measure of the thickness of a wire. For example, an
Erosion: The loss of tooth mineral caused by dietary or gastric 8-gauge wire is thicker than a 16-gauge wire.
acids, not by bacterial metabolism (caries process). Gel: A semisolid state in which colloidal particles form a
Esthetic materials, direct placement: Tooth-colored materials framework that traps liquid (e.g., Jell-O).
that can be placed directly into the cavity preparation without Glass ionomer: A self-cured, tooth-colored, fluoride-releasing
being constructed outside of the mouth first. restorative material that bonds to tooth structure without an
Esthetic materials, indirect placement: Tooth-colored additional bonding agent.
materials that are used to construct restorations outside of the Glass ionomer cement: One of the most versatile cements;
mouth on replicas of the prepared teeth in the dental laboratory used as a permanent luting agent and restorative material, and
or at chairside. Later, they are cemented to the teeth. for low- and high-strength base and core buildups.
Etch-and-Rinse (also called Total-Etch) Technique: a clinical Glazing: Firing porcelain at high temperature to achieve a
technique that includes etching of both enamel and dentin as a smooth, shiny surface.
separate step from the application of bonding agents Grit: The particle size of the abrasive, typically classified as
Etching or conditioning: Terms used interchangeably to coarse, medium, fine, and superfine.
describe the process of preparing the surface of a tooth or a Gypsum: A material found in nature and composed of the
restoration for bonding. The most common etching material dihydrate of calcium sulfate; used to make dental casts and
(etchant) used is phosphoric acid. dies.
Excess residue: A wax film that remains on an object after the Hardness: The resistance of a solid to penetration.
wax is removed. Hazardous chemicals: a chemical that can cause burns to the
Exothermic reaction: The production of heat resulting from the skin, eyes, lungs, etc. poisonous or can cause fire.
reactions of the components of some materials when they are Heat-pressing: Pressing molten ceramic material into a mold at
mixed. high temperature and pressure
Extracoronal restoration: A restoration that covers all or part of Hue: The color of the tooth or restoration. It may include a
the external surface of the tooth and may extend over the cusp mixture of colors, such as yellow-brown.
tips on facial or lingual surfaces such as onlays, ¾ crown, full Hybrid composite: Composite that contains both macrofill and
crowns, and veneers. microfill particles to obtain the strength of a macrofill and the
Extrinsic stains: Stains that occur on the tooth surface. polishability of a microfill.
Fatigue failure: A fracture that results from repeated stresses Hybrid (resin-modified) glass ionomer: A glass ionomer to
that produce microscopic flaws that grow. which resin has been added to improve its physical properties.
Film thickness: The minimum thickness obtainable by a layer Hybrid layer: A resin/dentin layer formed by the penetration
of a material. It is particularly important to dental cements. of the dentin bonding resin through collagen fibrils exposed by
Final Impression: a detailed impression of oral structures used acid etching and into the etched dentin surface. It serves as an
to make an accurate cast from which restorations or prostheses excellent resin-rich layer onto which the restorative material,
are made such as composite resin, can be bonded.
Final set time: The time needed for the reaction that begins Hydrocolloid: Glue-like material that comprises two or more
when the material is mixed to go to completion, and the substances in which one substance does not go into solution
material hardens to its permanent state . but is suspended within another substance. It has at least two
Finish line: The continuous margin that borders the phases: (1) a liquid phase called a sol and (2) a semisolid phase
preparation to which the restoration is fit or finished. called a gel.
Finishing: A procedure used to reduce excess restorative Hydrocolloid, irreversible: An impression material that is
material to develop appropriate occlusion and contour. This mixed to a sol state, and as it sets, it is converted to a gel by a
usually is done with rotary instruments. Finishing removes chemical reaction that irreversibly changes its nature.
surface blemishes and produces a smooth surface. Hydrocolloid, reversible: An impression material that can be
Firing: A process of heating porcelain at high temperature until heated to change a gel into a fluid sol state that can flow around
it fuses. the teeth, then cooled to gel again to make an impression of the
Flash: Feather-like excess of material that extends beyond the shapes of the oral structures.
cavity margins. Hydrodynamic theory of tooth sensitivity: Pain caused by
Flash point: The lowest temperature at which the vapor of movement of pulpal fluid in open (unsealed) dentinal tubules.
a volatile substance will ignite with a flash. A low flash point Actions that cause a change in pressure on the fluid within
means that a substance can catch fire very easily. the dentinal tubules stimulate nerve fibers in the processes of
Flexural stress: Bending caused by a combination of tension odontoblasts in the pulp to send out a pain response.
and compression. Hydrophilic: An attribute that allows a material to tolerate the
Flow: The movement of the wax as it approaches the melting presence of moisture.
range. Hydrophobic: An attribute that does not allow a material to
Flowable composite: A light-cured, low-viscosity composite tolerate or perform well in the presence of moisture.
resin that contains fewer filler particles. Hysteresis: The property of a material to have two different
Fluorapatite: A tooth mineral that results when fluoride is temperatures for melting and solidifying, unlike water, which
incorporated into hydroxyapatite. has one temperature for both.
 GLOSSARY 477

Ignitable: A material or chemical that can erupt into fire easily. Safety Data Sheet (SDS): printed product report from the
Imbibition: The act of absorbing moisture. manufacturer that contains important information about the
Implant, endosseous (endosteal): Implant placed into the chemicals, hazards, cleanup, and special PPE related to a
bone. product.
Implant, subperiosteal: Implant placed on top of the bone and Melting range: A range of melting points of the individual
under the periosteum. components of the wax.
Implant, transosteal: Implant that penetrates entirely through Microfilled composite: Composite that contains very small
the bone. filler particles averaging 0.04 μm in diameter.
Impression compound: An impression material that comprises Microleakage: Leakage of fluid and bacteria caused by
resin and wax with fillers added to make it stronger and more microscopic gaps that occur at the interface of the tooth and the
stable than wax. restoration margins.
Impression plaster: An impression material that comprises a Mixing time: The amount of time allotted to bring the
gypsum product similar to plaster of paris. components of a material together into a homogeneous mix.
Incremental Placement: a technique for composites that Model plaster: The weakest, most porous form of gypsum
places and cures small increments individually to reduce the product used in dentistry.
overall polymerization shrinkage and shrinkage stress in the Monomer: small organic molecules that are joined in long
restoration and permit curing throughout the increment chains to form polymers. As used in dentistry, monomers are
Indirect fabrication: Construction of provisional or final usually liquids.
restorations on a cast outside the patient’s mouth. Mouth guard: A hard or pliable resin that protects teeth from
Indirect restorative materials: Materials used to fabricate trauma during sports activities or from teeth grinding.
restorations outside the mouth that are subsequently placed Nitinol: An alloy of nickel and titanium often used for
into the mouth. orthodontic wires.
Indirect-placement esthetic materials: Tooth-colored materials Non-vital tooth: no longer has a living pulp and ceases to give
that are used to construct restorations outside of the mouth in response to electrical stimuli or temperature changes
the dental laboratory or at chairside on replicas of the prepared Opaque: Optical property in which light is completely
teeth. They are later cemented to the teeth. absorbed by an object.
Initial set time: The time at which the material can no longer Organic resin (polymer) matrix: Thick resin liquids made up
be manipulated within the mouth and coincides with the end of of two or more organic molecules that form a matrix around
working time. filler particles.
Inorganic filler particles: Fine particles of quartz, silica, or Osseointegration: Bone growth in intimate contact with an
glass that give strength and wear resistance to the material. implant.
Insulators: Materials that have low thermal conductivity. Overhang: Excessive restorative material present at the
Interface: The space between the walls of the preparation and cervical cavosurface margin.
the restoration. Over-the-counter (OTC): Available in retail or drug stores
Intermediate: Materials expected to last from a few weeks to a without a doctor’s prescription.
year. Packable composite: A light-cured, highly viscous, heavily
Intracoronal restoration: A restoration within the crown of the filled composite resin for dentists who use a placement
tooth, such as an inlay. technique with a composite that is similar to that of amalgam.
Intraoral Scanner: a type of camera that takes digital images Palatal Expander: a fixed appliance used to expand the
(typically in continuous video form) of oral structures for maxillary arch forcing the maxillary plates apart very slowly
CAD/CAM procedures, such as crown preparations. while the maxilla is still in development.
Intrinsic stains: Stains that are incorporated into the tooth Particulate matter: Very small particles (e.g., dust from dental
structure, usually during the tooth’s development. plaster or stone).
Irreversible hydrocolloid: An alginate impression material Percolation: Movement of fluid within the microscopic gap
that is mixed to a sol state and as it sets converts to a gel by a of the restoration margin as a result of differences in the
chemical reaction that irreversibly changes its nature. expansion and contraction rates of the tooth and the restoration
Light-activated materials: Materials that require light in the with temperature changes associated with ingestion of cold or
blue wave range to initiate a reaction. hot fluids or foods.
Light-cured composite: Composite that polymerizes when a Peri-Implantitis: an infection around an implant that can
chemical is activated by light in the blue wave range. cause gingival inflammation and loss of bone around the
Liner: A thin layer of material used to protect the pulp from implant
the chemical components of dental materials and microleakage, Permanent: Lasting indefinitely.
to stimulate reparative dentin, or to act as a pulp capping. Personal protective equipment (PPE): gloves, masks, gowns,
Lost wax casting technique: a technique for fabricating a eyewear, and other protective equipment for the employee.
metal restoration by encasing the wax pattern in stone then Pigments: Coloring agents that give composites their color.
vaporizing the wax under high temperatures to leave an empty Plastic deformation: deformation of a material causing
impression space (pattern) once occupied by the wax; Molten permanent changes in size or shape due to an applied force
metal is then cast into the space and takes the shape of the Plasticizer: Liquid added to acrylic resin to soften it and make
pattern. it more pliable.
Luting: To cement two components together such as an Polishing: A procedure that produces a shiny, smooth surface
indirect restoration cemented on or in a tooth (e.g., inlays, by eliminating fine scratches, minor surface imperfections, and
crowns, bridges, veneers, orthodontic bracket and bands, posts surface stains using mild abrasives frequently found in the
and pins). form of pastes or compounds.
Macrofilled composite: An early generation of composite that Poly (methyl methacrylate): A polymer that comprises
contained filler particles ranging from 10 to 100 μm. numerous methyl methacrylate monomers linked together into
Malleability: The ability to be compressed and formed into a a long chain.
thin sheet without rupture. Polyether: A rubber impression material with ether functional
Margination: A procedure for removal of excessive restorative groups. It has high accuracy and is popular for crown and
material from margins of restorations. bridge procedures.
478 GLOSSARY

Polymer: A long-chain, high molecular weight molecule Reactive: Ability of a substance to take part in a chemical
produced by the linking of many low molecular weight reaction, resulting in a different end product.
monomer molecules. Remineralization: process that replaces mineral lost from the
Polymerization: The act of forming polymers by joining tooth by an acid attack.
monomers end-to-end. Resilience: The resistance of a material to permanent
Polymerization, addition: A common form of polymerization deformation.
of dental materials. Monomer molecules are added to one Resin-based cement: Modified composite used to bond
another sequentially as the reactive group on one molecule ceramic indirect restorations, conventional crowns and bridges,
initiates bonding with an adjacent monomer molecule and frees and orthodontic brackets.
another reactive group to repeat the process. Restorative agents: Materials used to reconstruct tooth
Polymers, cross-linked: The joining of adjacent long-chain structure.
polymers by bonding of short chains along their sides. Retention: A material’s ability to maintain its position without
Polysulfide: A rubber impression material that has sulfur- displacement under stress.
containing (mercaptan) functional groups. Sealant: A protective coating usually composed of resin that
Polyvinyl siloxane (also referred to as vinyl is bonded to enamel to protect pits and fissures from dental
polysiloxane): Very accurate addition silicone elastomer caries.
impression material. It is used extensively for crown and bridge Secondary bonds: The weaker bond that holds atoms together.
procedures because of its accuracy, dimensional stability, and Unlike with primary bonds, there is no transfer or sharing of
ease of use. electrons.
Porcelain: A tooth-colored ceramic material that comprises Secondary consistency: Thick, putty-like, condensable mix of
crystals of feldspar, alumina, and silica that are fused together material that can be rolled into a ball or rope and is suitable for
at high temperatures to form a hard, uniform, glass-like use as an insulating base.
material. Sedative: To soothe or act in a sedative manner; to relieve pain.
Porcelain-metal restorations: Restorations that have a metal Selective etching: technique where enamel is etched first with
core over which porcelain is fused at high temperature. phosphoric acid prior to the application of self-etch acidic
Porosity: Numerous microscopic holes or voids within a primers that lack sufficient acidity to produce a good etch of the
material often caused during polymerization of resins when a enamel
monomer vaporizes and is lost. Self-cured composite: Composite that polymerizes by a
Post: A metal or nonmetal dowel placed within the root canal chemical reaction when two resins are mixed together.
to retain a core buildup. Self-etch system: A bonding system that does not use a
Post, active: A post that engages the root canal surface like a separate etching procedure with phosphoric acid. The acid is
screw. contained in the resin primer and no rinsing is needed.
Post, custom: A post cast to fit precisely within the root canal Shearing force: Force applied when two surfaces slide against
space; it usually has the core attached. each other or in a twisting or rotating motion.
Post, passive: A post that sits within the prepared canal space Shelf life: The useful life of a material before it deteriorates or
but does not engage the root surface. changes in quality.
Post, pre-formed: A factory-made post supplied in several sizes. Silane coupling agent: A chemical that helps to bind the filler
Pouring: pouring the cast refers to the process of vibrating the particles to the organic matrix.
flowable gypsum product into the impression; this process Silicone, addition: A silicone rubber impression material
must produce a cast that is the exact replica of the structures that sets by linking of molecules in long chains but produces
captured in the impression. no by-product. It is commonly known as polyvinyl siloxane
Power whitening: in-office whitening procedure that uses and is the most popular material for crown and bridge
strong whitening agents and may use a high-intensity light procedures because of its accuracy, dimensional stability, and
source to accelerate the whitening process. ease of use.
Precious metal: The classification of metal based upon its high Silicone, condensation: A silicone rubber impression material
cost. that sets by linking of molecules in long chains but produces a
Preliminary Impression: an impression of the dentition or liquid by-product through condensation.
edentulous arch and surrounding tissues taken as a precursor Sintering: Fusion of ceramic particles at their borders by
to other treatment; often used to make casts (models) of oral heating them to the point that they just start to melt.
structures for planning, and to construct custom trays or Slip-casting: Process whereby ceramic powder is mixed with
provisional restorations a water-based liquid to form a mass or slip. The slip is pressed
Prevention/preventive aids: Chemicals, devices, or procedures into a form and is baked at high temperature.
that reduce or eliminate disease or tooth destruction in the oral Smear layer: A tenacious layer of debris on the enamel or
cavity. dentin surface resulting from cutting the tooth during cavity
Primary bonds: The strongest bonds that hold atoms together preparation. It comprises fine particles of cut tooth structure,
because they involve the exchanging or sharing of electrons. bacteria, and salivary components.
Primary consistency: Less-viscous mix of material that flows Soft liner, long-term: A soft material that lines a denture for
easily, can be drawn to a 1-inch string with a spatula when use in patients who have problems with hard-acrylic denture
lifted from the center of its mass, and is suitable for luting. bases. It is expected to last 1 to 3 years.
Proportional limit: The greatest stress a structure can Soft liner, short-term: A soft provisional material that lines a
withstand without permanent deformation. denture for a short period of time to improve tissue health. It is
Prosthesis: A device used for the replacement of missing also called a tissue conditioner, and it typically lasts from a few
tissues. It can serve both cosmetic and functional roles. days to a few weeks.
Provisional coverage: A restoration that temporarily occupies Sol: A liquid state in which colloidal particles are suspended.
the place of a permanent restoration, typically for up to 2 to 3 Through cooling or by chemical reaction, it can change into a
weeks. In the case of implant and complex prosthodontic and gel.
periodontally involved cases, provisional restorations may be Solder: An alloy used to join two metals together or to repair
used to last for extended periods of time. These restorations are cast metal restorations.
also commonly referred to as temporaries. Solubility: Susceptible to being dissolved.
 GLOSSARY 479

Splatter: Small particles that may contain blood, saliva, oral Ultimate strength: The maximum amount of stress a material
particulate matter, water, and microbes. can withstand without breaking.
Stiffness: A material’s resistance to deformation. Universal Bonding System: a bonding system capable of
Strain: Distortion or deformation that occurs when an object bonding to tooth structure as well as most restorative dental
cannot resist a stress. materials.
Stress: The internal force, which resists the applied force. Value: How light or dark a color is. A low value is darker and a
Subperiosteal implant: Implant placed on top of the bone and high value is brighter.
under the periosteum. Varnish: A thin layer placed on the floor and walls of the
Substantivity: Property of a material to have a prolonged cavity preparation to seal the dentinal tubules and minimize
therapeutic effect after its initial use. microleakage.
Surface energy: The electrical charge that attracts atoms to a Veneer: Thin layer of ceramic or composite resin material
surface. that is bonded to the fronts of teeth to improve their
Surfactant: A chemical that lowers the surface tension of a appearance.
substance so it is more readily wetted. For example, oil beads Viscosity: The ability of a liquid material to flow.
on the surface of water, but soap acts as a surfactant to allow Vital tooth: has a living pulp, which produces response to
the oil to spread over the surface. temperature change or electrical stimuli.
Sutures: natural or synthetic material with the appearance Vitality: A life-like quality.
of thread used to hold tissues together or to reposition tissues Walking bleach technique: whitening technique for non-vital
after trauma or surgical procedures. They can be absorbable teeth in which whitening materials are sealed inside the tooth
(sutures broken down naturally by the body’s enzymes and crown for a few days and the patient “walks” around with the
absorbed) or non-absorbable (sutures made of materials that whitening material in place.
are not broken down by the body and require removal by a Water sorption: The ability to absorb moisture.
dental professional) Wax pattern: A duplicate of the restoration carved in wax.
Syneresis: A characteristic of gels to contract and squeeze out Wet dentin bonding: Bonding to dentin that is kept moist
some liquid, which then accumulates on the surface. after acid etching to facilitate penetration of bonding resins into
Tarnish: Discoloration that results from oxidation of a thin etched dentin.
layer of metal at its surface. It is not as destructive as corrosion. Wetting: The ability of a liquid to wet or intimately contact a
Temporary/Provisional: Materials expected to last from a few solid surface. Water beading on a waxed car is an example of
days to a few weeks. poor wetting.
Tensile force: Force applied in opposite directions to stretch an Working casts: Casts generally made from one of the dental
object. stones and strong enough to resist the stresses of fabricating an
Therapeutic agents: Materials used to treat disease. indirect restoration or prosthesis; these casts are also known as
Thermal conductivity: The rate at which heat flows through a master casts or working models.
material. Working time: The lapse of time from the start of mixing the
Thixotropic: a characteristic of some gels and liquids to flow material until it begins to harden and is no longer workable
more readily under mechanical force such as mixing, stirring or because it has reached its initial set
shaking. Xenograft: graft tissue taken from an animal (usually bovine)
Thumb Sucking Device: a fixed or removable appliance used for use in a human
to discourage tongue thrusting and thumb sucking Yield strength: The amount of stress at which a substance
Total-etch (also called Etch and Rinse) system: A bonding deforms.
system that includes etching of both enamel and dentin as a Yield stress: the stress at which plastic deformation begins;
separate step from the application of bonding agents. also called yield point on a stress-strain curve.
Toughness: The ability of a material to resist fracture. Young’s Modulus or Elastic Modulus: measures the resistance
Toxicity: The strength of a product or a of a chemical to cause of a material to being deformed or its stiffness.
damage to the body. Zinc oxide eugenol: A hard and brittle impression material
Translucency: Varying degrees of light passing through and used in complete denture procedures. A variation of this
being absorbed by an object. material is used as a provisional filling material.
Transosteal implant: Implant that penetrates entirely through Zinc oxide eugenol cement: A cement generally used as a
the bone. provisional material or to temporarily cement provisional
Transparent: Light passing directly through an object. coverage.
Trimming: The process of removing excess hardened gypsum Zinc phosphate cement: The oldest of the cements; used
from the cast for ease in working with the cast and for primarily for permanent luting.
appearance in presentation. Zinc polycarboxylate cement: The first cement developed with
Triturator (amalgamator): A mechanical device used to mix adhesive bonds; used primarily for permanent luting.
silver-based alloy particles with mercury to produce amalgam.
Index

A Accelerators, gypsum setting time and, Adhesion

Abrasion, 270–292 382 definition of, 8, 16, 55, 293
factors affecting, 272–274 Accuracy, 326, 328 of dental cement, 301–302,
materials used in, 275–277 Acetone, 62 301b, 302f
aluminum oxide, 276 Acid etchant, 59 Adhesive, use of, 338, 342f
calcium carbonate, 276 Acid etching, 57 Adhesive cements, 299, 308–309,
diamond, 275 Acid reflux, 125 309b
potassium and sodium, 277 Acids Adhesive resins, 62
pumice, 276 chemical spills, control of, 44 Admixed alloy, 193
rouge, 276 in layer of skin, 40 definition of, 192
sand, 276 Acrylic example of, 193f
silicon carbide, 275 staining of, 14, 180–181 Admixed amalgam, 195t
silicon dioxide, 276 wearing of, 180–181 Adverse response, definition of, 8,
sodium bicarbonate, 276 Acrylic denture bases, polishing of, 10–11
tin oxide, 276 283, 283f Aerosols, 287
tungsten carbide finishing burs, Acrylic provisional materials, 439–440, Agar, 326. See also Reversible
275–276 439f, 439b hydrocolloid.
mode of delivery of, 274–275, 274f properties of, 441t Air abrasion, 270, 274, 286, 286f,
bonded abrasives, 274, 275f Acrylic resins (plastics), 401–406 286b
coated abrasives, 274–275, 275f allergic reaction to, 402, 402b Air polishing, 263–264, 264f, 270, 274,
loose abrasives, 275 for denture bases, 403, 403f 281t, 284–286, 285f, 286b
paste abrasives, 275 dentures, care of, 420–421 contraindications for, 264
particles injection molding of, 406 Alginate. See also Irreversible
number of with contact on light-cured, 406, 425f, 425b–428b hydrocolloid.
surface, 273 microwave processing of, 406 definition of, 326–327
size irregularity and hardness of, modifiers of, 401 substitutes of, 342
272–273, 273f, 273b polymerization reaction of, 403–406, Alginate impressions, 336, 338f
patient education in, 287 403f, 404t, 404b criteria for acceptable, 337t
preparations used for, 277–279 properties of, 401–402 dispensing of, 333–334, 333b–334b,
dentifrice, 278–279, 279f, 279b, chemical-cured, 402 334f
280t dimensional change as, 401 mixing of, 334, 335f
denture cleansers, 279, 279b heat-cured, 402, 402t procedure for making, 361b–364b,
prophylaxis paste, 277–278, 278b polymerization shrinkage as, 363f–365f
resistance, of gypsum, 377 401 troubleshooting for, 337t
safety/infection control, 287, porosity as, 402, 402f, 402b Alginate system, two-phase of, 336,
287b strength as, 401 338f, 340f
speed and pressure, 273–274, thermal conductivity as, 401 All-metal casting alloys, 221, 222f
273b teeth, 416 All-ceramic restorations, 167
Abrasive particles, 264, 264f uses of, 401, 401f advantages and disadvantages of, 168
Abrasives, 270, 272 Active posts, 234 CAD/CAM for, 173–178, 174f
microparticles, 274 Acute chemical toxicity, 42–43 cementation of, 184–185, 185b
three-body, 274 ADA. See American Dental fabrication of, 172
loose, 275 Association finishing and polishing, 183–184,
paste, 275 ADA Professional Product Review, 5 183f
two-body, 274 ADA Seal of Acceptance, 244 principles of, 183–184, 184b
bonded, 274, 275f Addition polymerization, 86, 400–401 heat-pressing and, 172–173
coated, 275f definition of, 399 introduction of, 168
Absorbable sutures, 240, 258, 258f Addition silicone, 339 layers in, 181f
Absorption, directly through breaks in definition of, 327 maintenance of, 185
skin, 40 features of, 345t removal of, 185

Note: Page numbers by f indicate figures; t, indicate tables, and b indicate boxes.

480
 INDEX 481

All-ceramic restorations (Continued) Amalgam (Continued) Application, materials classified

shade matching for, 187–188 hydrogen gas formation, 195 by, 33
shade selection for, dental assistant/ setting reactions of, 194–195 Arch wire, in orthodontics, 230
hygienist and, 186, 186f setting transformation of, Aromatic esters, 401
shade taking, 185–186 194–195 Astringent, definition of, 327
device, 188, 188f placement and condensation of, Astringents/hemostatic agents, 346,
sintering, 169f, 172 205–206, 205f, 205b–206b 346b, 347f
slip-casting and, 172 placement of, 205 Atom, 26–27, 26f
Allergy, to nickel, 224–225 polishing of, 14, 206–207, 207b Atraumatic restorative treatment, for
Allied oral health practitioner, practices for waste of, 211t glass ionomer cements, 113–114
role of, 1 repair of, 208–209 Attrition, 274
Allografts, 239, 253–254, 255f restrictions on use of, 211 Atypical wedge placement, 201, 201f,
Alloplasts, 239, 255, 256f strength of, 195 201b
Alloys, 205f, 220–225 tarnish of, 196 Autografts, 239, 253–255
composition of, 194, 194t thermal conductivity of, 196–197 Automixing dental cement,
definition of, 192 trituration of, 204, 204b, 205f advantages and disadvantages of,
dispensing of, 203–204 use of, 193 314t
selection of, 203, 204t working and setting times, 204–205 Auxiliary materials, 10
stainless steel, 230 Amalgam bonding, 73–74 definition of, 8
structure of, 221 Amalgam restorations
used in dental amalgam, 193–197 finishing of, 271f, 281–282, 282f B
zinc, 194 procedure for, 288f–289f, Balsa wood triangular sticks, for
Alumina, 170 288b–289b implant home care, 261
glass-infiltrated polishing of, 283 Bands
flexural strength of, 171t Amalgam War, 3 matrix, 100
indications and contraindications Amalgamation, 193 orthodontic, 231, 231f
to, 179t definition of, 192 cement for, 296–297
selection of, rationale for, 178 Amalgamator (triturator), 192, 204 Barrier membrane, 240, 256, 257f
Aluminum oxide American Dental Association (ADA) Base, 86–87, 295–296, 296b
in abrasion, 276 evidence-based dentistry, 2 definition of, 293
for polishing composite restorations, Journal of, 5 high-strength, 295
282 Professional Product Review, 5 line drawing of, 295f
Aluminum shell crowns, 437, 437f Seal of Acceptance, 5 low-strength, 295
Aluminum trihydroxide powders, in example of, 5f Base-metal alloy, 220, 222
air polishing, 284 for toothpaste, 279, 280t orthodontic wires as, 230
Amalgam, 192–219 stance on dental amalgam safety, Base-metal dental casting alloys, 223
advantages and disadvantages of, 209–210 Baseplate wax, 387, 387f
207b standards in dentistry and, 5, 5f Beryllium, 225, 225b
allergy to, 209 American National Standards Institute Bioactive cements, 312
alloy used in, 193–197 (ANSI), 5 Bioactive dental materials, 116
ANSI/ADA standard No.1 for, 195, American National Standards definition of, 84
195t Institute/American Dental Bio-aerosol
applications for, 197 Association (ANSI/ADA), dental, 38–39
bonding of, 209 Standard No.1, for amalgam, 195, in dental setting, 39–40, 39f
burnishing and carving of, 206, 195t Biocompatibility, 70, 70b, 224–225, 224f
212b–217b American Society of Dental Surgeons, of base metals, 224–225
class II, placing and carving of, 199b, 3 of ceramics, 172
212b–217b, 213f–217f Amorphous solid, 28 of composite resin, 87–88
composition of, 194, 194t Anneal, 220 of dental cement, 301, 301b
corrosion of, 196, 196f Annealing, 224 of glass ionomer cements, 111
creep in, 195–196 Anorexia nervosa, 125 Biocompatible, 2
definition of, 192 ANSI. See American National definition of, 8
delayed expansion of, 195, 196f Standards Institute dental materials and, 10, 11f
dimensional change of, 195 Antibacterial agents, for implant home Biofilm, definition of, 9
expansion and contraction of, 195 care, 261–262 Biointegration, 239, 243
failure of, 208b Antibacterial mouth rinse Biological contaminants, exposure to,
finishing of, 206–207 chlorhexidine gluconate as, 125 39, 39f
longevity of, 207–211 side effects of, 126 Biomechanics, 11
manipulation of, 203 definition of, 123 Bis-acrylic composite provisional
matrix bands and, 197–202, Listerine as, 126 material, 441
197f–199f Antibiotics, teeth staining from, properties of, 441t
mercury and 149–150 Bis-acrylic urethane, 95
health concerns for, 209 Appearance, gold teeth and, 4 Bis-GMA, 84–85
482 INDEX

Bisphenol A (BPA), 88 Bonding resins, 65f CAD/CAM (Continued)

exposure to, 42 components of, 62 for ceramic inlays, onlays, and fixed
Bisphosphonates, as contraindication dentin, 62–63 partial dentures (bridges), 182,
to dental implants, 241 enamel, 61–62, 61f 182b
Bite registration, 326, 328 Bonding restorations, benefits of, 63b ceramic materials in, 176–178
procedure for making, with Bonding systems, 64t firing the blocks, 177, 177f
elastomeric material, 367b–368b, classification of, 64, 64b glass-based, 176–178
368f–369f etch-and-rinse, 64–66 milling the blocks, 176–177, 177f
Bite registration materials history of development of, 63–64 nonglass, 176, 176f
addition silicone as, 341–342 main steps of, 71b resin hybrid, 177–178, 177f
application of, 343f self-etch, 66–68 stains and glazes, 177
Bite registration trays, 330 time line of development of, 63b chairside
Bite registration wax, 388–389 total-etch, 63 benefits of, 173–175
procedure for, 394f–396f, 395b–397b two-bottle self-etch, 67, 67f drawbacks of, 175–176
Biting force, 11 universal, 67–68, 68f, 68b definition of, 167
Bleaching, 148–159. See also Whitening. Bone grafting, 252–257 incorporation into private practice,
contraindications to, 156b materials for, 255t 173–175
dental auxiliary in, role of, 157 newer additions to, 255–256 restorations, 175–176
at home potential risks with, 255b CAD/CAM provisional (temporary)
clinical procedures for, 162f–165f purpose of, 252–253 materials, 445–446, 446f, 446b
over-the-counter products for, types of, 253–256 Calcination, 376
156–157 Bone morphogenetic protein (BMP), Calcium carbonate
in-office 255–256 in abrasion, 276
of nonvital teeth, 154–155, 154f Border molding, 413–414 in toothpaste, 278–279
procedure for, 161f–162f, Boxing method, for casts, 384, 384f Calcium hydroxide
161b–162b Boxing wax, 388 alkaline pH of, 295
varnish, 154 Brackets, orthodontic, 231, 231f cavity liner, 208f
of vital teeth, 152, 152f–153f, cement for, 296–297, 297f as low-strength base/liner, 295
161f–162f, 161b–162b Brazing, soldering and, 229 Calcium sodium phosphosilicate
non-dental options of, 157, 157b Bridge powder, in air polishing, 284
potential side effects of, 157–158 creation of, 2–3 Calcium sulfate hemihydrate, 376
restorative considerations before, fixed partial, 182 Canadian Centre for Occupational
158, 158b procedures, components of Health (CCOH) Bloodborne
retreatment for, 158–159 impression making for, 345–351 Pathogens Standard, 39
rinses, 157 Brittleness, 25 Candida albicans, in silicone liners, 408
tooth sensitivity from, 157 Brushes, for implant home care, 261, Carbamide peroxide, 71, 150–151
toothpastes for, 157 261f–262f Cariogenic bacteria
BMP. See Bone morphogenetic protein Bruxism, 11 definition of, 123
Body and incisal porcelains, 181 Bruxism guard, mouth, 462–464 fluoride preventing, 124
Boil-and-bite guards, 461, 461f design of, 464 Carving, of amalgam, 206
Bond, strength, 57–58 home care instructions for, 463b Cast, 375f
Bonded abrasives, 274, 275f maintenance of, 464, 464b construction of, 3
Bonding, 295–296 types of materials for, 463–464, 463f definition of, 374
of amalgam, 73–74, 209 Buccal mucosa, inflammatory response disinfection of, 356
ceramic, 73, 73b, 77f–78f, 79b–80b of, 209f pouring procedure for
of ceramic veneers, 74, 75t Buildup, 293, 296, 296f anatomic portion, 391b–393b,
clinical applications of, 72–75 Bulimia, 125 392f–393f
definition of, 8, 16–17, 55 Bulk-fill composites, 93–94 art portion, 393f–394f, 393b–394b
dentin for, 61–62 definition of, 84 separating impression from, 384–385
to etched surface, 56 Buonocore, Michael, 58 procedure for, 394f
metal, 73 Burlew wheels, 276 Casting alloys
orthodontic bracket, 74 Burnishing color of, 223
preparation for, 56, 57f of amalgam, 206 noble metals for, 223, 223t
principles of, 55–82 definition of, 192 properties of, 223–224
retention and, 16 Burns, chemicals, causing, 40 Casting metal
self-etch, 66–68, 66f biocompatibility, 225
surface wetting and, 57, 57f C IdentAlloy program, 228
systems, 63–64 CAD simulation, for dental implants, removable prosthetic, 227–228, 228f
“wet” dentin, 62 244 resistance to tarnish and corrosion,
Bonding agents, 62, 62b CAD/CAM 224
definition of, 55 for all-ceramic restorations, 174f, Casting wax, 387
universal, 67–68, 68f, 68b 178b Catalyst, 33, 86–87
use of, 134, 134b basic components of, 173, 175f Caveman, dental caries in, 2–3
 INDEX 483

Cavity sealer, 207, 207f–208f Chemical (Continued) Compomers, 83–122, 115f

Cavity varnish, 293 hazardous waste disposal, 46, 46b, definition of, 84
CBCT. See Cone beam computed 47t fluoride release, 115
tomography toxicity, acute and chronic, 42–43 properties of, 116t
CDC. See Centers for Disease Control Chemical cleaning products, 271 setting reaction in, 115
and Prevention Chemical containers, labeling of, 49, Composite resin, 85–110
Celluloid crown, 438, 438f 49f, 50b classification by filler size, 90–92
Cement Chemical cure, of composite resin, classification methods for, 93t
for crown, 296f 86–87 clinical handling of, 95–96
line drawing of, 295f Chemical-cured acrylic resin, 402 comparison of properties of, 95t
primary consistency of, 293 for custom impression tray and compomers, 115–116
properties of, 300t record base material, 418–419 components of, 85–86
viscosity and film thickness of, for denture repair, 417, 417b coupling agent, 86
300–301 polymerization of, 404 filler particles as, 85, 85f–86f
secondary consistency of, 297 pour technique for, 404 matrix, 85
Cement-retained implant crowns, 250, Chemical-cured resins, 307 pigments, 86
250b, 253f Chemical-cured sealant, 136t contaminants of, 98–99
Cementation, 294–299 Chemical inventory, hazard continuing improvements of, 92
of all-ceramic restorations, 184–185, communication program, 48 cross-contamination of, 99, 99b
185b Chemical properties, 32 definition of, 83
preparation of, 184 Chemical-resistant glove, 43 degree of conversion of, 89
tooth preparation in, 184 Chemical retention, 16 dental assistant/hygienist
try-in of, 184 Chemical safety, in dental office, 40–42, involvement, 96
cleanup, disinfection, and 40b dispensing of, 99, 99f, 99b
sterilization after, 315 Chemical set materials, 26, 33–34 failure of, 107–109
loading crown for, 314f, 314b Chemical spills, 44 finishing and polishing of, 106–107,
luting agent for, 299b acids, 44 107b, 108f
preparation for, 309–310 eyewash, 44, 45f, 45t history of development of, 84–85
of zirconia, 170 flammable liquids, 44 incremental placement of, 89, 89f
Centers for Disease Control and mercury, 44, 44f indirect-placement of, 109, 110f
Prevention (CDC), 39 ventilation, 44 materials for, 109–110
mouth guard, use of, 460 Chlorhexidine, 246 introduction of, 168
Ceramic inlays/onlays, 182 Chlorhexidine gluconate, 125–126, layering (stratification) of, 99
Ceramic restorations 125f–126f, 261–262 light-curing of, 102–107
finishing of, 282–283, 283b side effects of, 126 matrix systems of, 100–102
polishing of, 284 Chroma, 96 modes of cure of, 86–87
Ceramic veneers, bonding of, 74, 75t for ceramic restorations, 185 polymerization and, 86–87
Ceramics, 167–191 definition of, 8, 18 posterior, advantages and
classification of, 168 Chronic chemical toxicity, 43 disadvantages of, 96t
clinical applications of, 178–185 Circumferential matrix systems, of repair of, 109
definition of, 167 composite resin, 102 resin-to-resin bonding, 98, 98f
as dental implant coating, 243 Class II composite resin restoration, selection of materials for, 95–96
introduction of, 168 placement of, 117f–119f, 117b–119b shade guides for, 97–98, 97f, 98b
processing techniques of, 172–173 Clay retraction material, 350f shade matching for, 96–98, 97b
properties of Cleaning, 270 surface sealers of, 107
optical, 171–172, 172f Cleanup, of gypsum, 384, 384b uses of, 95
physical, 171–172 Closed-bite trays. See Triple trays Composite resin provisional materials,
thermal, 171 Closed-tray impression, 239, 250, 440–441, 441f, 442b
selection of, rationale for, 178 251f Composite resin repair, 74
CEREC system, 173 Coated abrasives, 274–275, 275f Composite resin teeth, 416
Cermets, 112 Coefficient of thermal expansion Composite restorations
Cervical matrices, in matrix systems, of of ceramics, 171 finishing of, 282, 282f, 282b
composite resin, 102, 103f definition of, 8, 15 polishing of
Chairside Economical Restoration of microleakage and, 71 during oral prophylaxis, 283–284
Esthetic Ceramic (CEREC) system, Coffee, staining from, 14 procedure for, 290f–291f,
173 Colloid, 326, 330–331 290b–291b
Chairside reline, for dentures, 413–415, Coloring resins, 86 Composites
415b Community water fluoridation laboratory-processed, 109–110
Chalk, 276 program, 4, 4f physical and mechanical properties
Checkups, dental, dentures and, 420 Compatibility of, 87–90
Chemical of provisional material, 435 biocompatibility, 87–88
disposal of, 45–46 resins, 70–71 coefficient of thermal expansion
empty containers, 45 Compomer cements, 311 and, 89
484 INDEX

Composites (Continued) Corrosion (Continued) Density, 29, 29f

elastic modulus and, 89–90 gamma phase and, 194–195 of alloys, 224
polymerization shrinkage, oral environment and, 14 definition of, 25
88–89 resistance to, 224 of solids, 29
radiopacity of, 90 Corrosive, 38, 46 Dental assistant
shelf life of, 99 Covalent bonds, 26–27 in chairside CAD/CAM systems,
strength, 88 Cover screw, 239, 242, 247f role of, 175
thermal conductivity of, 89 Creep, 195–196 esthetic materials, handling of, 168
water sorption of, 90 in alloy, 204 Dental auxiliary, role of, 1–2, 2b
wear, 88 definition of, 192 in bleaching, 157
provisional (temporary) restorative, Crocker, Charles, 4 Dental bio-aerosol, 39–40, 40b
95 Crossbite corrector, 466, 466f Dental caries
Composition definition of, 460 antibacterial rinses for, 125–126, 127f
of material, 33 Cross-linked polymers classification of, 91t
and reaction, 33 definition of, 399 definition of, 123
of resin, shrinkage of, 71 formation of, 400 teeth susceptibility to, 131–133
Compressive force Crown Dental casting alloys, 221
definition of, 8 cement-retained implant, 250, 250b, Dental cement, 3–4, 293–325
oral environment and, 11 253f classification of, 294
Compressive strength, amalgam and, components of impression making delivery system for, 314t
195 for, 345–351 loading crown for, 314f
Condensation definition of, 167 manipulation of, 312–316
definition of, 192, 205–206 designs of, 225f, 226, 227f considerations for, 313b
final evaluation of matrix bands double-bite impression for, mixing of, 313, 313f, 313b,
before, 201–202, 202f 364b–367b, 366f–368f 317b–319b
Condensation polymerization, 401 film thickness and, 17 storage of, 312
Condensation silicone, 327, 339 implant, 242 working and setting times of,
Conditioning loading for cementation, 314, 314f, 313–314
bonding and, 56 314b properties of, 299–302
definition of, 55 provisional, 230, 232f, 434f biocompatibility and
Cone beam computed tomography screw-retained, 250, 252f anticariogenic properties, 301
(CBCT), 239, 244 seating and cementing for, esthetics, 302
Containers, labeling, exemptions to, 296f, 314b radiopacity, 302
49–50 Crystal formation, 224 retention and adhesion, 301–302,
Contaminants, 62 Crystalline structure 302b
biological, exposure to, 39, 39f density and, 29, 29f solubility of, 300
bonding site, 71–72, 72b solids and, 28 strength of, 300, 300b
of composite resin, 98–99 Cure, definition of, 55 viscosity and film thickness,
dental impressions as, 355 Curing 300–301
Contamination, definition of, 56 methods, 400 radiopaque, 305f
Contraction by restoration type, 310b removal of excess, 310, 310b,
of alloy, 204 modes of, 70 314–315, 315b
of amalgam, 195 Custom-fit, definition of, 460 resin-based cements (adhesive and
effects of, 15 Custom-fit guards, 461, 462f self-adhesive resin), 307–311
Conventional feldspathic porcelain, Custom impression trays, advantages and disadvantages of,
179 418–419 310b
Copal resin varnish, 207, 207f chemical-cured, 418–419, 423f–428f, composition of, 307
Copal varnish, 295 423b–425b procedure for, 321f–322f, 321b
Coping, 220 fabrication of, 418–419 properties of, 307
Copolymers, formation of, 400 light-cured, 419 timeline for, 312b
Copper, as composition of amalgam Custom post, 234 uses of, 294t
alloy, 194t Custom trays, 330, 330f, 358f–362f, cavity varnish, 295
Cord packing instruments, 346, 346b, 358b–361b pulpal protection, 294–296
347f Custom whitening trays, fabrication zinc oxide eugenol as, 311–312
Cord placement, evaluation of, 347 of, procedure for, 164b–165b advantages and disadvantages of,
Cordless impression device, 352f Customized provisional crowns, 439, 312b
Core buildup composites, 94–95, 94f, 439f composition of, 311
95b manipulation of, 312
Corrective impression wax, 388 D primary and secondary
Corrosion Deformation, 30 consistency of, 316f–317f,
in alloy, 204, 224 Demineralization 316b–317b
of amalgam, 196, 196f definition of, 123 properties of, 311–312
definition of, 8, 192 dental caries and, 124 zinc phosphate as, 303–304
 INDEX 485

Dental cement (Continued) Dental materials (Continued) Dentures (Continued)

advantages and disadvantages of, precautions for storing chemicals, components of, 405b
303b 44–45, 45b digital, 406–407, 407f–408f
composition of, 303 retention, 16–17, 17f advantages of, 407b
manipulation of, 303–304 study of, 2b fabrication of, steps in, 404b
primary consistency of, 317f–318f, Dental office of George Washington, 3
317b–318b mercury and, 211b hard relining materials for, 413–415,
properties of, 303 other waxes utilized in, 389 413b
zinc polycarboxylate as, 304 Dental personnel, microorganisms chairside reline, 413–415, 415b
advantages and disadvantages of, exposure to, 39 laboratory reline, 415
304b Dental plaster, composition of, 33 home care of, 420–421, 421f
composition of, 304 Dental stone, 376b, 379 in-office care of, 421, 422f
manipulation of, 304, 304b for casts, 376 soft relining materials for, 408–409
primary consistency of, definition of, 374 spring closed, 3f
318b–319b, 319f high-strength, 377f storage of, 421, 421b
properties of, 304 high-strength/low-expansion teeth, 416
Dental ceramics, 168–170 type IV, 379 wearers of, instructions for, 419–420
Dental environment, material hazards type V, 379–380 Depth of cure, 87
in, 38–39, 39b properties of, 379t definition of, 83
Dental fluorosis, severe, 4f Dental waxes Dermatitis, 40
Dental hygienist classification of, 386–389, 386f, 387t Desensitizing agents, 137–138, 138f,
in chairside CAD/CAM systems, composition and properties of, 139t, 140b
role of, 175 385–386 bleaching and, 157
esthetic materials, handling of, lost wax technique for, 389–390, 390f categories/components of, 138
168 manipulation of, 389–390 definition of, 123, 137–138
intraoral tasks, 1 Dentifrice, abrasion tooth sensitivity, causes of, 137
role of, in bleaching, 157 before, 278–279, 279f, 279b, 280t treatment for, 137–138, 138f
Dental implants, 239–269.e1 factors contributing to, 279b Desensitizing system, 138
benefits of, 241 Dentin Diagnostic casts, 375f
components of, 241–242, 242f bonding agent, 60 definition of, 326–328, 374
contraindications for, 241 hardness of, 272–273 fabricating and trimming of,
designs, 243–244, 243f smear layer in, 59 382–384, 383f
dimensions of, 243–244 Dentin bonding resins, 62–63 boxing method in, 384, 384f
home care of, 260–262 Dentin etching, 59–63 double-pour method in, 383
hygiene visit after, 262–264 smear layer in, 59, 59f single-step method in, 383–384
indications for, 241 Dentin matrix, 59–60 poured, criteria for evaluation of, 384b
longevity, 259 Dentistry, evidence-based, 2, 2f trimming of, 382–384, 395f–396f,
materials for, 242–243 Denture cleansers, before abrasion, 395b–397b
surface treatment of, 244 279, 279b, 280f procedure for, 395f–396f,
types of, 240f Denture liners, 408–416 395b–397b
endosseous, 240–241, 241f hard relining materials for, 413–415, uses of, 379b
subperiosteal, 240 413b Diamond, in abrasion, 272, 275, 276f
transosteal, 240 chairside reline, 413–415, 415b Diamond polishing paste, 283f
Dental impression compound, 355 laboratory reline, 415 Diastema, 10f
uses for, 355, 358f infection control procedures for, 419, Die stone, 376b, 377f
Dental laboratory infection control, 419b definition of, 374
46–47, 47f, 47b over-the-counter, 415–416 resin-reinforced, 380
Dental materials, 1–7, 6b soft relining materials for, 408–409 Dies
allied oral health practitioners, 1 Denture repair, 417–418 definition of, 374
biocompatibility of, 10 Denture sores metal-plated and epoxy, 380
biofilm on, 20 cause of, 410–411, 411b Digital impressions, 250, 252f, 351–354
biomechanics, 11 detection and management of, 409 advantages of, 353, 354b
classification of, 9 home care for, 413 definition of, 327
developments in, 6 signs and symptoms of, 409, 411f disadvantages of, 353–354, 354b
esthetics and color and, 18 treatment for, 411–413 expanded use of, 354, 358f
exothermic reaction, 16b use of dye transfer method, learning curve, 351–352
force, stress and strain, 11–13 411–413, 413f–415f scanning devices of, 352–353, 353t,
handling and safety of, 38–54, 52b use of pressure indicating paste, 355f
historical development of, 2–5, 4t 411, 411f–412f soft tissue management of, 354
materials of, 9 Dentures Dimensional change
oral biofilm and, 19–20, 20b bases, acrylic resin for, 403, 403f of acrylic resins, 401
physical and mechanical properties care of acrylic resin, 420–421 of amalgam, 195
of, 25–37 characterization of, 416, 417f definition of, 8, 15
486 INDEX

Dimensional stability, definition of, Empty containers, disposal of Etching

326, 328 chemical, 45 definition of, 55
Direct fabrication, 432 Enamel of dentin, 59–63
Direct-placement esthetic materials, 85 bonding and, 61–62, 61f, 76f–77f, smear layer, 59
definition of, 83 76b–77b enamel, 58–59, 58f, 58b
Direct restorative material, 33 resin tags, 61–62, 61f, 62b times, 58–59
definition of, 25 composition of, 150–151, 151f Etching sclerotic dentin, 60
Direct technique, for provisional erosion from stomach acid, 125f Ethanol, 62
coverage, 443–445, 444f, 444b hardness and, 29 Ethyl methacrylate provisional
Disclosing agents, for implant home remineralization of etched, unsealed, materials, 440, 440b
care, 261–262 135 Etruscans, bridges creation, 2–3
Disinfecting solutions, selecting, 356 Enamel bonding resins, 61–62, 61f Evidence-based decision-making
Disinfection Enamel etching (EBDM), 2
after cementation, 315 acid, 59f Excess residue
of casts, 356 composition of, 58 definition of, 374
of impressions, 355–356, 355b–356b, Enamel microabrasion, 159–160, 159f of dental waxes, 386
356t adverse outcomes of, 160 Exothermic reaction, 376
Double-bite impression, 327f definition of, 148 Expansion
procedure for making, for crown, Endodontic files and reamers, 232, 233f of alloy, 204
364b–367b, 366f–368f Endodontic posts, 220, 236 cause of, 71
Double-pour method, for casts, 383 bonding of, 74–75, 75b delayed, 195
Dough stage, of polymerization, 404 classification of, 234, 234t of amalgam, 196f
Doxycycline, teeth staining from, custom, 234 definition of, 192
149–150 preformed, 234–236, 234f–235f effects of, 15
Dual set material, 26, 33–34 purpose of, 234 Extracoronal restoration, 432
Dual-cure process, 70 Endosseous implant, 239–241, 241f Extrinsic stains
Dual-cured composites, 87 components of, 241–242, 242f causes and colors of, 149, 149t, 150f
definition of, 83 immediate loading, 248 definition of, 148
Dual-cured resins, 307 immediate-placement surgical example of, 149f
Ductility, 25, 31, 31f procedure, 247–248 Eye protection, 43
Durability, 25, 31–32 one-stage surgical procedure, 247, for light-curing, 105–106
of bond, 58 247f Eyewash, availability of, 44, 45f, 45t
Dusts, inhalation of, 40–41 two-stage surgical procedure,
Dye transfer method, use of, 411–413, 246–247 F
413f–415f first stage, 246–247, 247f Facemask, 44
second stage, 247 Fast-set alginates
E End-tuft brushes, 261, 261f setting time for, 331–332
Eating, dentures and, 420 Environment, safety for, mercury and, working time for, 331
EBDM. See Evidence-based 210–211 Fatigue, 31, 32f
decision-making Epithelial seal, 244 Fatigue failure
Eco-conscience green practices, 50–51, Epoxy dies, 380 definition of, 8
50b–51b Erosion oral environment and, 13
Edge strength, 25, 31 definition of, 123 Feldspathic porcelain, 169, 169f, 169b
Elastic deformation, 25, 30 protection against, 125 flexural strength of, 171t
Elastic impression materials from stomach acid, enamel, 125f indications and contraindications
elastomers as, 336–344 Esthetic dentistry, 18 to, 179t
features of, 345t Esthetic material Felt cones, 287, 287f
hydrocolloids as, 330–336 advances in, 168 Filler particles, composite resin and,
polyethers as, 343–344 ceramics as, 168 85, 85f–86f
Elastic limit, 25, 30 dental assistant/hygienist handling Film thickness
Elastic modulus, 25, 89–90, 220, 224 of, 168 definition of, 8, 17
definition of, 83 direct-placement, 85 of dental cement, 300–301, 300b
Elastic recovery, 338 Esthetic resin cements, 307–308 of zinc phosphate, 303
Elasticity, 25, 30 Esthetics Final impression, 326, 328
Elastomers, 336–344 of dental cement, 302, 308b Final set time, 26, 33
bite registration with, 367b–368b, provisional coverage for, 434–435, Finish line, 432
368f–369f 435b Finishing 21, 270, 280b
definition of, 327 of provisional material, 435–436 of amalgam restorations, 281–282,
polysulfides as, 338 of zirconia, improvement of, 171, 282f
Electrical conductivity, of alloys, 224 171b procedure for, 288f–289f,
Electrons, of primary bonds, 26 Etch-and-rinse systems, 70 288b–289b
Employee training, labeling Etch-and-rinse (also called total-etch) benefits of, 280
exemptions, 50, 50b technique, definition of, 55 of ceramics, 282–283, 283b
 INDEX 487

Finishing (Continued) Fluorosis, 124 Glass ionomer cements (GICs)

of composite restorations, 282, 282b definition of, 123 (Continued)
flash, margination and removal of, example of, 124f predosed capsule, procedure for,
280–281, 281f, 281b Foams, in fluoride applications, 319f–320f, 319b–320b
of gold alloy, 282 128–129, 129f properties of, comparison of, 116t
in laboratory, 286, 286f Food and Drug Administration, 5–6 resin-modified, 306–307
patient education in, 287 Force restorative materials for, 112–114, 113f
of restoration, characteristics of, compressive, 8, 11 traditional
283b shearing, 11–12 advantages and disadvantages of,
safety/infection control, 287, tensile, 11 305b
287b types of, 11 composition of, 305
Firing, 220 Fracture toughness, 8, 13 manipulation of, 305–306, 306f
Fissure sealants, 93 definition of, 167 mixing of, 306b
glass ionomer cements as, 112–113 Free radical, definition of, 399 properties of, 305
Fit, of dentures, 420 Function, provisional coverage for, uses for, 112–114
Fixed bridge, 167 434f Glass ionomer surface sealer, as
Fixed partial dentures (bridges), 182 desensitizing agent, 139t
Flammable liquids, in control of G Glass ionomers, 83–122
chemical spills, 44 Galvanic shock, 14–15 Glazing, 182, 182f, 220
Flash, 270 Galvanism Gloves, chemical-resistant, 43
definition of, 327 definition of, 8, 14–15, 15f Glycine, for abrasion, 276, 278f
margination and removal of, effects of, 196 Gold
280–281, 281f, 281b electric current and, 14–15 solders, 229
Flash point, 38 Gamma phase, 194–195 tooth restoration for, 3–4, 3f
dental materials solvent, 44 Gamma-1 phase, 194–195 Gold alloy
Flexural strength, 167 Gamma-2 phase, 192, 194–195 finishing of, 282
Flexural stress, 8, 12 Gas polishing of, during oral
Flosses, for implant home care, 261, characteristics of, 28 prophylaxis, 284, 284f
262f inhalation of, 40–41 Goodyear brothers, 3
Flow Gauge, 220 Grains, 224
definition of, 374 of wire, 230 Grit, 270, 273, 273f
of dental waxes, 386 Gel, 326, 350 as three-body abrasive, 275
Flowable composites, 92–93, 93f in fluoride applications, 128–129, Gypsum products, 374–398
amalgam and, 208–209 129f behaviors of, 376–378
definition of, 84 GICs. See Glass ionomer cements chemical properties of, 376
Fluorapatite, 124 Gingival retraction, 345–350 classification of, 378–380
definition of, 123 Giomers, 116, 116t cleanup of, 384, 384b
Fluoride, 124–131, 127f Glass-based ceramics, 169–170 desirable qualities of, 375
antibacterial rinses for the control of definition of, 167 dimensional accuracy of, 377
dental caries, 125–126, 127f preparation of, 184 fabricating and trimming
bacterial inhibition and, 125 Glass ionomer cements (GICs), 110, diagnostic/working casts in,
definition of, 123 304–307 382–384, 383f
home-use in, 132t advantages and disadvantages of, final setting time of, 381–382,
in-office in, 132t 114b 381b–382b
methods of delivery of, 126–130 atraumatic restorative treatment for, infection control and safety issues
dietary supplements as, 126 113–114 in, 384
in-office application (topical) as, bond to enamel and dentin, 111, manipulation of, 380–385
127–129 114b factors in, 383t
over-the-counter rinses, 130, 130f cermets for, 112 material selection in, 380, 380f
prophylaxis paste, 130 clinical application of, 114–115, 115f mixing in, 381, 381f
self-applied topical gels and conventional, 110–114 proportioning (water-to-powder
pastes as, 129–130, 129f–130f definition of, 84 ratio) in, 380–381, 380b, 381t
toothpaste as, 130 as fissure sealant, 112–113 metal-plated and epoxy dies and
protection against erosion, 125 hybrid, 306–307 resin-reinforced die stone in,
safety in, 130–131, 131b advantages and disadvantages of, 380
topical, applying, 142f–143f, 306b mixing procedure for, 391f, 391b
142b–143b lamination or “sandwich” technique equipment/supplies for, 391f
topical and systemic effects of, for, 112, 112b, 113f physical properties of, 377–378
124–125 liners and bases for, 112 production of, 376
Fluoride-containing prophylaxis luting cements for, 112 properties of, 376–378, 376b, 379t,
pastes, 130 packaging of, 111–112 379b
Fluoride varnish, as desensitizing physical and mechanical properties reproduction of detail of, 377–378,
agent, 139t of, 111 378f
488 INDEX

Gypsum products (Continued) High-strength stone, properties of, 377, Implant

separating impression from cast in, 379t abutment, 241–242
384–385 Home care, for implant, 260–262 analog, 248
setting time in, 381, 382f antibacterial agents, 261–262 fixture, 239, 241
accelerators and retarders in, 382 brushes, 261, 261f–262f longevity, 259
altering W/P ratio in, 382 disclosing agents, 261–262 adverse outcomes from, 259b
control of, 382 flosses, 261, 262f implant failure, 259
spatulation in, 382 wooden plaque removers, 261 long-term success, 259
temperature in, 382 Home whitening, 155, 156b maintenance, 260–264, 260f
using clean equipment and chemical used in, 155 home care, 260–262
impressions, 382, 383t clinical procedures for, 162f–165f, hygiene visit, 262–264
solubility of, 378, 378b, 379t 162b–163b placement and restoration, 245–248
storage of, 384, 384b instructions for, 158b immediate loading, 248
trimming of, 383f, 385, 385f, 385b over-the-counter products for, immediate-placement surgical
type IV and V, 380 156–157 procedure, 247–248
uses and qualities of, 375, 376f Home whitening process, 155–156 informed consent, 245
Hue, 96 one-stage surgical procedure, 247,
H for ceramic restorations, 185 247f
Hand mixing dental cement, definition of, 8, 18 operatory, preparation for surgery,
advantages and disadvantages of, Humidity, in manipulation of 246
314t materials, 35 operatory preparation, 246
Hand protection, 43, 43f Hybrid composites, 91 patient, preparation of, 246
Hand spatulation, of gypsum definition of, 83 postsurgical instructions, 246
materials, 381 Hybrid glass ionomer cements, surgical risks, 245–246
Hard acrylic guard, for mouth, 463 306–307 two-stage surgical procedure,
Hard laminate guard, for mouth, 464 advantages and disadvantages of, 246–247
Hard liner, definition of, 399 306b planning and surgery, image-
Hard relining materials, for dentures, manipulation of, 306–307, 307b guided, 244–245
413–415, 413b Hybrid (resin-modified) ionomers, advantages of, 244–245
chairside reline, 413–415, 415b 114–115 software for, 244
laboratory reline, 415 definition of, 84 polishing of, 284
Hardness, 29 properties of, comparison of, 116t Implant abutment, 239
abrasion and, 270, 272–273 Hybrid layer Implant analog, 239
of alloys, 224 definition of, 55–56 Implant maintenance
definition of, 25 formation of, 65, 65f home care
of gypsum, 377 Hydrocolloid. See also Irreversible aids for, 262b
of provisional material, 435 hydrocolloid; Reversible antibacterial agents, 261–262
of solids, 29 hydrocolloid. brushes, 261, 261f–262f
Hardness tests, 29–30 definition of, 326 disclosing agents, 261–262
Hazard communication program, Hydrodynamic theory of tooth flosses, 261, 262f
48–49, 49f, 49b sensitivity, 72 wooden plaque removers, 261
chemical inventory, 48 definition of, 56 hygiene visit
containers, labeling of, 49, 49f, 50b Hydrofluoric acid, 73b implant surface, cleaning of,
exemptions to, 49–50 Hydrogen bonds, 27–28 263–264, 263f–264f
safety data sheets, 48–49, 48b Hydrogen gas, amalgam and, 195 mobility, 263
written, 48 Hydrogen peroxide, 71, 151 probing, 263, 263f
Hazardous chemical, 38, 40, 41f Hydrophilic, 55 radiographic assessment, 262–264
Hazardous waste disposal, of Hydrophobic, 62 visual assessment, 262–263
chemical, 46, 46b, 47t definition of, 55 Implant planning, 245f
Healing abutment, 239 Hydroxyapatite crystals, 59–60 Impression
Healing screw, 247f Hygiene visit, for implant home care, abutment, 239, 248
Heat-cured acrylic resin, 402, 402t 262–264 accurate, obtaining, 351b
polymerization of, 404–405 Hypersensitivity as contaminated, 355
Heat-pressing, 167, 172–173 from bleaching, 155 criteria for clinically acceptable, 337t,
High-copper alloy cause of, 10 338f
admix and spherical, 195t disinfection of, 355–356, 356t
common, 195t I procedure for, 370b
compressive strength of, 195 Identalloy program, 228–231, 228f double-bite, 327f
corrosion and, 196 Ignitable, 38, 46 for crown, 364b–367b, 366f–368f
handling characteristics of, 202–203, Imbibition, 327, 337–338 handling of, 336
203t Immediate-placement surgical optical scanners and, 173
High-noble alloy, 220, 222 procedure, for endosseous troubleshooting for, 337t
High-strength base/liners, 295 implant, 247–248 types of, 328
 INDEX 489

Impression making In-office whitening Leucite-reinforced ceramics

components of, for crown and of nonvital teeth, 152, 152f glass, flexural strength of, 171t
bridge procedures, 345–351 procedure for, 161f–162f, 161b–162b indications and contraindications
criteria for successful, 350, 350b of vital teeth, 152, 152f, 161f–162f, to, 179t
evaluation of, 350–351, 351b, 354f 161b–162b selection of, rationale for, 178
objective for, 332–333 Inorganic filler particles, 85 Lichenoid reactions, 88
tray selection for, 333–336, 333f definition of, 83 Light-activated materials, 26, 33–34
Impression materials, 326–373 Inorganic salts, as desensitizing agent, Light-cured cements, 314b
key properties of, 328 139t Light-cured composites, 87, 102–107, 106b
types of, 328 Insulators, 8 definition of, 83
Impression plaster, 355, 378 Interceptive orthodontics, 465 factors affecting, 102, 102b, 104f
Impression tray, 328–330, 418–419 Interface, 8, 17–18 guidelines for, 106b
chemical-cured, 418–419, 423f–428f, Intermediate, 293 matching of, 105, 105b
423b–425b Intermediate restoration, 26, 33 methods of, 105–106, 105b
example of, 329f cement consistency for, 297 position of, 103–105
fabrication of, 418–419 International Organization for precautions of, 106b
light-cured, 419 Standardization (ISO), 6 in proximal box, 103–104
loading, 334–335 Interproximal brushes, 261, 262f rapid, 104–105
removing of, 336 Intracoronal cement provisionals, types of, 104, 104f, 104b
seating, 335, 335f–336f, 335b 447–448, 447f, 448b Light-cured resins, 65, 406, 425f,
selection of, 333–336, 333f procedure for, 456f–457f, 458 425b–428b
sterilization of, 356–357 Intracoronal restoration, definition of, for denture repair, 418
Impression wax, 355, 388–389 432 Light-cured sealant, 136t
Incremental placement, of composites, Intraoral scanner, 351 Light-curing, 307, 309b
89, 89f definition of, 327 Liner, 295
definition of, 83 Intrinsic stains definition of, 293
Indirect chairside technique, for causes and colors of, 149–150, 149t, high-strength, 295
composite resin, 109–110 150f line drawing of, 295f
Indirect-direct technique, for definition of, 148 low-strength, 295
provisional coverage, example of, from tetracycline, 155f Lingual retainer, 231
445, 445b Investment materials, 380 Liquids
Indirect fabrication, 432 Ionic bonding, 27 characteristics of, 29
Indirect-placement esthetic materials, Ionic bonds, 27 etchant, 59
109 Irreversible hydrocolloid (alginate), flammable, in control of chemical
definition of, 84 326, 331–332 spills, 44
Indirect restorative material, 33 composition of, 331–332, 332t Liquidus, 223
definition of, 25 dimensional stability of, 332 Listerine, 126
Indirect technique, for provisional disinfection of, 356t Lithium disilicate ceramic, 170
coverage, 444–445, 445b impression making, 332–336 definition of, 167
Inelastic impression materials permanent deformation of, 332 flexural strength of, 171t
dental impression compound, uses setting reaction of, 331–332 indications and contraindications
for, 355, 358f setting time for, 331–332, 332b to, 179t
impression plaster as, 355 tear strength of, 332 selection of, rationale for, 178
wax as, 355 uses of, 331b Longevity, of materials, 33
Infection control working time for, 331 Long-term soft liners, 408–409,
in gypsum products, 384 ISO. See International Organization for 409f
for light-curing, 106 Standardization definition of, 399
Infectious disease, personal chemical Ivory, as denture material, 3f Loose abrasives, 275
protection, 43 Looseness, of dentures, 420
Informed consent, in teeth whitening, J Lost wax technique, 389–390,
155–156 Josephine, Empress, 4 389f–390f
Ingestion, of chemicals, 42 Journal of the American Dental definition of, 374
Inhalation, of chemicals, 40–41 Association, 5 Low-copper alloy
Inhalation protection, 44 compressive strength of, 195
Inhibitors, 86–87 K creep and, 195–196
Initial set time, 26, 33 Knoop hardness test, 272–273, 272t Low-fusing porcelain, 169
Initiation, of free radicals, 400 Low-strength base/liner, 295,
Inlay, definition of, 167 L 295b
Inlay wax, 386–387, 387f Labeling, exemptions, 49–50 Luting, 293, 296–297
In-office fluoride treatment, Laboratory reline, for dentures, 415 Luting cements, 112
132t Lathe-cut alloy, 192–193 classification of, 302–311
In-office tartar and stain remover, Length of treatment, in teeth functions of, 302b
279f whitening, 155 loading crown for, 314, 314b
490 INDEX

M Metal matrix band, posterior, types of, National Fire Protection Association
Macrofilled composites, 90 197f labels, 49–50
definition of, 83 Metal-plated dies, 380 National Institute of Occupational
Malleability, 25, 31, 31f Metallic bonds, 27 Safety and Health (NIOSH)-
Mandibular impressions, criteria for Metals approved dust and mist respirator
acceptable, 337t moisture and acid levels in, 13–14 facemask, 44
Manipulation in orthodontics, 230–231 National Institutes of Health (NIH),
considerations for, 313b structure of, 221 amalgam safety, 193
of dental cement, mixing of, 313, Metamerism, 18, 18f, 96 Neoprene apron, 44
313f, 317b–319b Methyl methacrylate provisional Nickel, allergy to, 224–225
of gypsum products, 380–385 materials, 440, 440f, 440b Night guards, 462–464
factors in, 383t Microabrasion, 270, 286, 286f, 286b design of, 464
material selection in, 380, 380f enamel, 159–160, 159f home care instructions for, 463b
mixing in, 381, 381f adverse outcomes of, 160 maintenance of, 464, 464b
proportioning (water-to-powder Microfilled composites, 90–91, 116t types of materials for, 463–464
ratio) in, 380–381, 380b, 381t definition of, 83 NIH. See National Institutes of Health
of material, 34–35, 34b Microhybrids, 91 Nitinol, 230
variables for, 34 definition of, 84 Noble alloy, 220, 222
Margin, breakdown, 31, 31f–32f Microleakage, 18f, 71, 71f Noble metal dental casting alloys,
Margination, 270, 280–281, 281b definition of, 8, 17–18, 56 222–223, 222t
indications for, 281b effects of, 17–18 Noble metals, biocompatibility of,
Margins, care on, 315–316 Microorganism, 39 224–225
Mastication, stress during, 13 Microparticle abrasives, 274 Non-absorbable sutures, 240, 258, 258f
Masticatory force, 11 Microwave processing, of acrylic resin, Non-adhesive cements, 299
Materials, classification of, 32–33 406 Non-glass-based ceramics, 170
Matrix bands, 197–202, 197f–199f Mineralizing agents, as desensitizing definition of, 167
Matrix system , 197–207, 199f agent, 139t preparation of, 184
application of, 204 Mini-implants, 239, 243–244, 250–252 Non-vital tooth, definition of, 148
of composite resin, 100–102 uses for, 252, 254f–255f
Mixing, in manipulation of materials, O
bands in, 100, 101f
cervical matrices, 102, 103f 35, 35f Obstructive sleep apnea
circumferential, 102 Mixing time, 26, 33 definition of, 460
sectional, 100–102, 103f Model plaster function of appliance, 465, 465f
wedges in, 100, 101f definition of, 374 oral appliances for prevention of,
Matter, three states of, 28–29 formation of, 376b 464–465
Maxillary impressions, criteria for properties of, 379t risk factors for, 464
acceptable, 337t use of, 378–379, 379b treatment of, 464–465, 465f
Maxillofacial prostheses, plastics for, Mohs scale of hardness, 270, 272–273, Occlusion, checking, 206, 206b
417, 418f 272t Occupational Safety and Health
McKay, Frederick, 4 Moist dentin, for bonding, 60–61, 61f Administration (OSHA), 39
Mechanical properties, of dental Moisture contamination, 34 Hazard Communication Standard,
materials, 29–32 Monomers, 85 47
Mechanical retention, 16 definition of, 83, 399 mercury exposure, 210
Melting range, 223 Mouth guards Odontoblasts, hypersensitivity and,
definition of, 374 definition of, 460 72, 137
of dental waxes, 386 sports, 460–462, 461f Office staff, safety for, mercury and,
Mercury, 205f boil-and-bite guards and, 461, 461f 210
alloy and custom-fit guards and, 461, 462f Oil-based luting cements, 311–312
hydrogen gas formation, 194–195 fabrication of, 468f–470f, One-bottle adhesive systems, 65–66
setting reactions of, 194–195 468b–469b One-bottle self-etch bonding systems,
setting transformation of, protection by, 461–462 67, 67f–68f, 67b
194–195 stock guards and, 460, 461f One-stage surgical procedure, for
dispensing of, 203–204 use of, 460–462, 461f endosseous implant, 247, 247f
exposure to, 42, 42b Onlay, definition of, 167
N Opacity, of ceramics, 172
handling of spills of, 211b
health concerns for, 209 Nanocomposites Opaque, 8, 18
office staff exposure to, 211b of composite resin, 92, 92f Open-tray impression, 239, 248–250,
safety procedures for, 209 definition of, 84 248b, 249f
vapor reduction, methods for, 211b properties of, comparison of, 116t Optical reader, 188, 188f
Mercury spill kits, 44, 44f Nanohybrids, 92 Optical scanner, 173
Mercury vapor definition of, 84 Oral appliances, preventive and
reduction of, 211b Nano-ionomers, 114 corrective, 460–471
release of, 209 definition of, 84 Oral disease, biofilm and, 19
 INDEX 491

Oral environment Percolation Polishing, 270–292, 278b

esthetics and, 18 cause of, 71 in laboratory, 286, 286f
moisture and acid levels, 13–14, 14f definition of, 9, 15, 56 during oral prophylaxis, 283–286
patient concerns, 9 Peri-implant disease, cement- air abrasion, 286, 286f, 286b
and patient considerations, 8–24 associated, 315, 315f, 315b air polishing, 284–286, 285f, 286b
preventive/therapeutic materials, 9 Peri-implantitis, 240 of amalgams, 283
temperature of, 15–16 Permanent, 293, 297 of composite, 283–284, 290f–291f,
Oral prophylaxis, polishing in, 283–286 Permanent dipoles, 28 290b–291b
Organic resin matrix, 85 Permanent restoration, 25, 33 of gold alloys and ceramics, 284
definition of, 83 Peroxide whitening, history of, 150 of implants, 284
Orthodontic band, 231 Personal chemical protection, 43–44 of resin/cement interface, 284
cement for, 296–297 eye protection, 43 patient education in, 287
Orthodontic bracket, 231 hand protection, 43, 43f safety/infection control, 287, 287b
bonding, 74, 79f–80f inhalation protection, 44 Polo, Marco, 4
cement for, 296–297, 296f–297f protective clothing, 43–44 Poly (methyl methacrylate), 399
Orthodontic plaster, 379b Personal protective equipment (PPE), Polycarbonate crown, 438–439, 439b
Orthodontic tooth aligners, 466–467, 38–39 procedure for, 452f–453f, 454b–455b
466f PFM. See Porcelain-fused-to-metal Polyether, 343–344
creating, 466, 467f pH, of saliva, 13–14 block out undercuts, 343–344, 346f
definition of, 460 Phosphoric acid etching, dentin and, consistency and setting reaction of,
treatment for, 467, 467f 59–61, 60f, 61b 343
Orthodontic wax, 389 Physical properties, of dental definition of, 327
Orthodontics, metals used in, 230–231 materials, 29 disinfection of, 356t
brackets and bands, 231, 231f Physical structure, of materials, 26–27 features of, 345t
endodontic files and reamers, 232, Pigments, 85 hydrophilic nature, 344
233f composite resin and, 86 mixing and dispensing of, 343, 344f
retainers, removable orthodontic definition of, 83 properties of, 343, 345f
appliances and, 231, 231f PIP. See Pressure indicating paste working and setting times of, 344
space maintainers, 231 Pit and fissure sealants, 33, 93, 131–137 Polymer chains, cross-linking of, 86,
wires, 230–231 application of, 141f 87f
OSHA. See Occupational Safety and bite interference by, 135 Polymerization, 86–87
Health Administration chemical-cured and light-cured, addition, 400–401
Osseointegration, 239, 243, 243f, 247 advantages and disadvantages of chemical-cured resins, 404
OTC. See Over-the-counter of, 136t condensation, 401
Overglazing, 182 color and wear of, 134 definition of, 55, 70, 83, 399
Overhang, 270, 280–281, 281f composition of, 133–134, 134b formation of, 400
Over-the-counter (OTC), 123, 126f effectiveness of, 136 of heat-cured resins, 404–405
fluoride rinses, 130, 130f etched, unsealed enamel, methods of, 400
Over-the-counter (OTC) liners, 415–416 remineralization of, 135 physical stages of, 404
Oxidation etching precautions of, 135 reactions, 400–401
galvanism and, 196 filler content/color of, 133t of resin-based cements, 307
tarnish and, 14 glass ionomer cement as a sealant, Polymerization shrinkage, 86, 88–89
Oxygen-inhibited layer, 70 136–137 of acrylic resins, 401
definition of, 56 indications for, 131–133, 133f clinical consequences of, 88
of sealant, 135, 135b oxygen-inhibited layer of, 135, reducing the effects of, 88–89, 89f
135b Polymers, 86
P patient record entries of, 135, 135b definition of, 399
Packable composites, 94 placement of, 134–135, 134b formation of, 400
Paint-on whitening materials, purpose of, 131, 133f review of, 400–401
156–157 susceptibility of teeth to fissure for prosthetic dentistry, 399–431
Palatal expansion appliances, 466, 466f caries, 133 Polysulfides, 338, 338b
Palatal expansion device, definition troubleshooting problems with, 136, definition of, 327
of, 460 136f, 137t Polyvinyl siloxane (PVS), 339–344
Palladium, 223 working time for, 134 bite registration, 341
Particulate matter, 38–39 Plaque removers, for implant home definition of, 327
exposure to, 38–39 care, 261 disinfection of, 356t
Passive post, 234 Plastic deformation, 25, 30 dispensing system of, 339–340, 340b,
Paste abrasives, 275 Plasticizer 342f
Patient education, restoration and, 287, aromatic esters as, 401 features of, 345t
442 definition of, 399 hydrophobic nature of, 339
Patient safety, 51–52, 51b, 52f Platelet-rich fibrin, 256 mismatch between cast from
mercury and, 210 Platinum, 223 alginate impression, 342,
Pattern waxes, 386–387 Pneumatic press, 404–405 344f
492 INDEX

Polyvinyl siloxane (PVS) (Continued) Predose package, 33b Provisional crown, 434f
putty/wash techniques, 340–342 Predosed capsules, advantages and cementing of, 446, 446b
surface detail of, 339 disadvantages of, 314t materials for, 435
viscosities of, 339 Preformed post, 234–236, 234f–235f procedure for
working and setting time of, 340 Preformed/prefabricated crowns, 436, metal, 449f–450f, 449b–451b
Porcelain 436f, 436b polycarbonate, 451f–453f,
alumina, 169 Preliminary impression, definition of, 451b–455b
body and incisal, 181 326, 328 Provisional materials
composition of, 169 Pre-polymerized filler, 88 acrylic, 439–440, 439f, 439b
definition of, 167 Pressure indicating paste (PIP), use of, aluminum shell crowns, 437, 437f
failure, 182 411, 411f–412f bis-acrylic composite, 441, 441t
feldspathic, 169, 169f, 169b Prevention/preventive aids, 123 composite resin, 440–441, 441f, 442b
fracture of, 13 Preventive dentistry, fluoride and, 4 customized, 439, 439f
fusing temperatures of, 169 Preventive material, 33 ethyl methacrylate, 440, 440b
hardness of, 29, 272–273 Pre-wedging, 201, 202f fitting the crown, 437–438, 437f, 438b
low-fusing, 169 Primary bond, 25–27, 28b manipulation of, 441, 442f, 442b
metal oxides and, 182 types of, 26, 27f methods of fabrication, 442–443
reinforced, 170 Primary consistency, 300 type and uses of templates,
selection of, rationale for, 178 zinc oxide eugenol procedure for, 442–443, 443f
uses of, 169 316f–317f, 316b–317b methyl methacrylate, 440, 440f, 440b
Porcelain-bonded-to-metal (PBM) zinc phosphate procedure for, polycarbonate crown forms,
restorations, 181, 225–228 317f–318f, 317b–318b 438–439, 438b–439b
layers of, 181f zinc polycarboxylate procedure for, preformed/prefabricated crowns as,
porcelain failure of, 181f 318b–319b, 319f 436, 436f, 436b
Porcelain bonding alloys, 220, 225–228, Primer, 55 properties of, 435–439
225f Probiotics, biofilm and, 19–20 esthetics, 435–436, 435b
Porcelain-fused-to-metal (PFM) Processing waxes, 388 hardness, 435
restorations, 181 Propagation, of free radicals, 400 strength, 435
soldering of, 225 Prophylactic polishing paste, 273, 273f, tissue compatibility, 435
Porcelain-metal restoration, 167, 278b stainless steel crowns as, 436–437,
180–182 before abrasion, 277–278, 278b 436f–437f
advantage of, 180–181 Prophylaxis pastes, for implants, Provisional resin cements, 310–311,
coefficient of thermal expansion of, 182 263 311f
color modification in, 182 Prosthesis, 242 Provisional restorations, 432–459
color selection in, 181 definition of, 399 cement consistency for, 297
glazing and, 182, 182f maxillofacial, plastics for, 417, 418f removal of, 447, 447f, 447b
metal oxides and, 182 Protective clothing, 43–44 Provisional/temporary, 297
sintering and, 181 Provisional coverage Pulp-capping agent, 295
Porcelain teeth, 3, 416, 416f–417f advanced techniques for, 445–446 Pumice, 273, 274f
Porcelain veneers, 179 criteria for, 433 in abrasion, 276
example of, 180f esthetics and speech, 434, 435b for amalgams, 272
Porosity exposed tooth surfaces, 433–435, Pure metals, 221, 221f
of acrylic resins, 402, 402f, 402b 433b Putty/wash techniques, 340–342
definition of, 399 function, 434, 434f for matrix, 341
Postoperative sensitivity, 17–18, 72, 72b gingival tissues, 434, 434f, 434b one-step technique, 340, 340b
Potassium, in abrasion, 277 retention, 435, 435b potential distortions of, 341, 341b
Potassium nitrate, as desensitizing tooth position, 433 removing of set impression, 341
agent, 139t custom, direct technique for, two-step technique, 341, 341b
Pour technique, for chemical-cured 454f–455f, 456b–457b PVS. See Polyvinyl siloxane
resins, 404 definition of, 432
Pouring dental procedures requiring, Q
of cast, procedure for 432–433, 433t Quartz, 90
anatomic portion, 391b–393b, 392f direct technique for, 443–445, 444f,
art portion, 393f–394f, 393b–394b 444b R
definition of, 374 indirect technique for, 444–445, Radiopacity
of gypsum in casts, 375f, 381 445b of composite resin, 90, 90f
Power whitening indirect-direct technique for, 445, of dental cement, 302
definition of, 148 445b of glass ionomer cements, 111
in-office, 152–154, 153f, 153b–154b intracoronal cement provisionals for, Rag wheel, 286, 286f
PPE. See Personal protective 447–448, 447f, 448b Ratios, in manipulation of materials, 35
equipment patient education for, 442, 448b Reaction
Precementation check, 312–313 vacuum former acetate technique exothermic, definition of, 8, 16b
Precious metals, 220, 223 for, 443 of material, 33–34, 34f
 INDEX 493

Reactive, 38, 46 Restorative phase (Continued) Sealants (Continued)

Record bases, 418–419 removable prosthesis, retention of, indications for, 131–133
chemical-cured, 418–419 250, 254f oxygen-inhibited layer of, 135, 135b
fabrication of, 419, 425f, 425b–428b retention of implant crown, 250 patient record entries of, 135, 135b
light-cured, 419 Retainer pit and fissure, 33, 131–137
Reflectance, of ceramics, 172 lingual, 231, 231f placement of, 134–135, 134b
Regular-set alginates in matrix bands, 197, 199f troubleshooting problems with, 136,
setting time for, 331–332 placement of band in, 197–198 137t
working time for, 331 removable, 231 working time for, 134
Reline, for dentures, 408–416 Retainerless matrix systems, 202, 203f Secondary bonds, 25–26, 28b
Reline jig, 415 Retarders, gypsum setting time and, of materials, 27–28
Remineralization, 124, 138–140 382 Secondary consistency, 293, 297
definition of, 123 Retention for temporary/provisional and
products of, 138–139, 140f definition of, 9, 16 intermediate restorations, 295
resin infiltration, 139–140, 140f, 140b of dental cement, 301–302, 301b zinc oxide eugenol procedure for,
Removable partial denture (RPD), provisional coverage for, 435, 435b 316f–317f, 316b–317b
processing of, 405, 405f–406f, 405b restorative materials and, 16–17 Sectional matrix systems, 202
Removable prosthesis, procedure for Retentive undercuts, 16f of composite resin, 100–102, 103f
cleaning of, 279b Retraction cord, 346f Sedative, 293, 297
Removable retainer, 231 checklist of, 347, 348f zinc oxide eugenol as, 311
Resilience, 9, 13, 13t, 25, 30 evaluation of, 348–349, 349f Sedative provisional restoration, 297
Resin agents, as desensitizing agent, methods of, 345 Selective etching, definition of, 55
139t Retraction paste, 350 Self-adhesive resin cements, 309, 309f,
Resin-based cements (adhesive and Reversible hydrocolloid (agar), 331 309b
self-adhesive resin), 307–311, 307b, definition of, 326 Self-adhesive technique, for indirect
308f Rim-lock trays, 329 restorations, 322f–323f, 322b–323b
advantages and disadvantages of, RMGIC. See Resin-modified glass Self-applied topical gels and pastes,
310b ionomer cements 129–130, 130f
categories of, 307–309 Root canal sealers, 297 Self-cured composites, 86–87
composition of, 307 Root canal therapy, 232 definition of, 83
procedure for, 321f–322f, 321b Root resorption, risk of, in teeth Self-curing process, 70, 307, 309b
properties of, 307 whitening, 154–155 Self-etch bonding systems, 66–68
Resin bonding agent, 56, 57f Rotary brushes, 261 definition of, 55
Resin/cement interface, polishing of, Rotary files, 232–236 Self-etch cements, 308
284 Rotary instruments, 232 Self-etch systems, 71, 71b
Resin cement systems, 184 Rouge, in abrasion, 276, 277f Self-etching technique, 62–63
Resin-modified glass ionomer cements RPD. See Removable partial denture Separating medium, 404–405
(RMGIC), 306–307 Rubber base, 338 Separator, amalgam, 192
Resin-reinforced die stone, 380 Rubber stage, of polymerization, 404 Shade guides, example of, 187f
Resin tags, 56 Shade matching, for all-ceramic
Resin-to-resin bonding, 98, 98f S restorations, 187–188
Resins, staining of, 14 Safety Shade taking
Restoration fluoride and, 130–131, 131b for ceramic restorations, 185–186
bleaching and, 158 issues, in gypsum products, 384 dental assistant/hygienist in, 186,
bonding of, 72 Safety data sheets (SDS), 38, 40 186f
cement consistency for, 300 Saliva characterizing, 186–188
conditions for assessing, 22b abrasion and, 273 device, 188, 188f
curing methods for, 310b excess, dentures and, 420 example of, 187f
loading of, 314 pH of, 13–14 involving dental assistant/hygienist
microleakage, 71 Sand, abrasion and, 276 and patient in, 186, 186f
permanent, intermediate, and “Sandwich” technique, for glass lighting for, 186
temporary/provisional, 297 ionomer cements, 112, 112b, 113f matching of, 186
try-in of, 309 Sandy stage, of polymerization, 404 Shearing force, 9, 11–12
Restorative materials, 10–11 Screw-retained crowns, 250, 252f Sheba, teeth of, 4
allied oral health practitioners, 17 SDS. See Safety data sheets Shelf life
definition of, 9 Sealants definition of, 26
detection of, 21f–22f bite interference by, 135 of material, 35
thermal properties of tooth and, color and wear of, 134 Short-term soft liners, 408–409, 409f–410f
15t composition of, 133, 134b application of, 408–409
Restorative phase, 248–250 definition of, 123 definition of, 399
implant impression and laboratory dental, application of, 144b–145b Silane coupling agent
components, 248 effectiveness of, 136 composite resin and, 85
impression procedures, 248–250 glass ionomer cement as, 136–137 definition of, 83
494 INDEX

Silica particles, 287 Speaking, dentures and, 419 Surgical dressings

Silicon carbide, in abrasion, 275 Spectrophotometer, 188, 188f cement for, 297–299, 299f, 299b
Silicon dioxide, in abrasion, 276 Spherical alloy, 193, 195t materials and supplies for mixing,
Silicone, 350 definition of, 192 298f
addition, 327 Splatter, 38–40 placement of, 298f
condensation, 327 Sports mouth guards, 460–462, 461f well-placed, criteria for, 299b
Silicone die technique, 342 boil-and-bite guards and, 461, 461f Sutures, 240, 257–259
Silicone rubber impression materials custom-fit guards and, 461, 462f characteristics of, 258
addition, 339 fabrication of, 468f–470f, 468b–469b needles for, 258, 259f
condensation, 339 protection by, 461–462 removal, 265f–266f, 265b–266b, 266f,
types of, 339 stock guards and, 460, 461f 269, e1b
Silver, 194 types of, 460 techniques for, 258–259, 259f
as component of amalgam alloy, Spring closed denture, 3f types of, 258–259
194t Staining, 14 Systemic diseases, biofilm and, 20
Silver alloy phase, 194–195 of acrylic, 180–181
Silver-based amalgam alloys, of restorations, 287 T
classification of, 193–194 Stainless steel alloy, 230 TADs. See Temporary anchor devices
Silver diamine fluoride, 127, 127f, 128t Stainless steel crowns, 436–437, Tarnish
application of, 127–128, 128f, 143b, 436f–437f causes of, 196, 196f
144f–145f Stains, on teeth definition of, 9, 14, 192
Silver paste, 3 causes and colors of, 149t and oxidation, 14
Single-step method, for casts, 383–384 types of, 148–150 resistance to, 224
Sintered composite alloys, 227, 228f, 228b Standards in dentistry, American Tea, staining from, 14
Sintering, 169f, 172, 181, 220, 227 Dental Association (ADA) and, Tear resistance, definition of, 326, 328
definition of, 167 5, 5f Tear strength, of irreversible
Sinus lift, 240, 256–257, 257f Sticky wax, 388 hydrocolloid, 332
Skin, chemicals absorbed in, 40 Stiffness, 25, 30 Teeth whitening
Slip-casting, 167, 172 Stock guards, 460, 461f contraindications for, 156b
Smear layer, 59 Stock trays, 329–330 materials for, 151
definition of, 55 sectional, 330 procedures, 148–166
Snoring, oral appliances for prevention Storage, of gypsum products, Temperature
of, 464–465 384, 384b gypsum setting time and, 382
Sodium, in abrasion, 277 Storing chemicals, precausations for, hypersensitivity and, 137
Sodium bicarbonate 44–45, 45f, 45b in manipulation of materials, 35
in abrasion, 276, 277f Strain of oral environment, 15–16
in toothpaste, 278–279 definition of, 9, 12 Temporary anchor devices (TADs),
Soft guard, for mouth, 464 example of, 12f 239, 252, 255f
Soft laminate guard, for mouth, 464 Strength Temporary dipoles, 28
Soft relining materials, for dentures, of acrylic resins, 401 Temporary/provisional, 293, 297
408–409 of alloys, 224 Temporary restorations, 26
Sol of amalgam, 195 Tensile force
definition of, 326 of dental cement, 300, 300b definition of, 9
gelling of, 330–331 of gypsum, 377, 377b oral environment and, 11
Solders, 220, 229 of provisional material, 435 Tensile strength, of glass ionomer
gold, 229 of zinc oxide, 312 cements, 111
silver, 229–230, 229f of zinc phosphate, 303 Tension, amalgam and, 195
stainless steel alloys in, 230 Stress, 30, 30f Termination, of free radicals, 401
Solids, characteristics of, 28, 28f definition of, 9 Tetracycline, teeth staining from,
Solidus, 223 dental materials and, 12, 12f–13f 149–150
Solomon, King, 4 during mastication, 13 Therapeutic materials, 33
Solubility Stress-strain curve, 12–13, 12f–13f definition of, 9
definition of, 9 Stringy stage, of polymerization, 404 Thermal conductivity
of dental cement, 300 Sub-gingival air polishing, 270, of acrylic resins, 401
dental materials and, 14 285–286, 285f of alloys, 224
of glass ionomer cements, 111 Subperiosteal implants, 240 of composite resin, 89
of gypsum, 378, 378b, 379t Substantivity, 123 conductor for, 15
of zinc phosphate, 303 Sulcus, prepacking of, 345–346, 347f definition of, 9, 15–16
Solvents, type of, 62 Supra-gingival air polishing, 270, Thermal expansion
Soreness, from dentures, 420 284–285, 285f and contraction, of glass ionomer
Space maintainers, 465 Surface characteristics, 17 cements, 111
definition of, 460 Surface energy, definition of, 9, 17 of dental waxes, 386
types of, 466, 466f Surfactant, 327, 339 of metals, 224
Spatulation of gypsum, 381f, 382 in impression materials, 378 Thixotropy, 25, 29
 INDEX 495

Three-body abrasives, 274 Tungsten carbide finishing burs, in Water

loose, 275 abrasion, 275–276, 276f abrasion and, 273
paste, 275 Two-body abrasives, 274 air polishing and, 284
Thumb sucking appliance, 465, 466f Two-bottle adhesive systems, 65–66, hydrogen bonds and, 27
Thumb sucking device, definition of, 65f–66f Water-based luting cements, 303
460 Two-cord retraction technique, 346–347 Water sorption
Tin, 194 Two-stage surgical procedure, for definition of, 9
as component of amalgam alloy, 194t endosseous implant, 246–247 dental materials and, 14
Tin oxide first stage, 246–247, 247f Wax bite, 342, 343f
in abrasion, 276, 277f second stage, 247 registration, 358f, 368b–370b,
for implants, 263 369f–370f, 369f, 370f
Tissue conditioners, 408–409, 409f–410f U Wax pattern, definition of, 374
Titanium UDMA. See Urethane dimethacrylate Wear resistance, of glass ionomer
alloy screws, 242–243 Ultimate strength, 9, 13, 30 cements, 111
oxides of, 243 definition of, 25 Wearing, of acrylic, 180–181
Tofflemire-type retainer, 197 Ultrasonic implant tips, 263, 264f Wedge, 199–201, 200f
use of, 199f Undercut, retention and, 16 in matrix systems, of composite
Tongue, surface changes and, 274 Universal bonding adhesive, clinical resin, 100, 101f
Tooth application of, 69, 69f, 70b Welding, 229
dental caries susceptibility, 131–133 Universal bonding system, definition “Wet” dentin bonding, 62
placement of band in, 198–199, 200f of, 55 definition of, 55
sensitivity of, mechanism of, 137, Universal composites, 92 Wettability, 338, 338b
137b definition of, 84 Wetting
Tooth loss, 6 Urethane dimethacrylate (UDMA), 85 definition of, 9, 17, 55
Tooth restoration, gold for, 3–4, 3f Utility wax, 388, 388f of gypsum materials, 378
Tooth structure, 59f liquid adhesive and, 17
bond to, of glass ionomer cements, V Whitening
111 Vacuum former acetate technique, for contraindications of, 158b
Tooth whitening rinses, 157 provisional coverage, 443 definition of, 148
Toothpaste, 274 Value, 96 indications for, 156b
abrasion from, 279f for ceramic restorations, 185 materials, 151
ADA committee statement on, 5 definition of, 9, 18 pretreatment evaluation of, 151
as desensitizing agent, 139t Van der Waals forces, 27 treatment methods, 151
fluoride-containing, 130 Vapor, inhalation of, 40–41 Whitening strips, 156, 156f
tooth whitening, 157 Varnish, 295 Whiting, 276
Torque wrench, 242, 250 sodium fluoride, applications, 128, Wire
Torsion/torque, 9, 12, 12f 129f, 141f, 141b gauge of, 230
Total-etch cements, 308 Veneer, 179–180, 180b in orthodontics, 230–231
Toughness, 25, 31 definition of, 167 Wooden plaque removers, for implant
fracture, 8, 13 materials used for, 179 home care, 261
Toxicity, 38 porcelain, 179, 180f Working casts, 379f
Traditional glass ionomer cements Ventilation, type of chemical, 44 definition of, 374
advantages and disadvantages of, Vinyl polyether silicone hybrid, 344 fabricating and trimming of,
305b Vinyl polysiloxane (VPS), 339–344 382–384, 383f
composition of, 305 Viscosity, 25, 29 boxing method in, 384, 384f
manipulation of, 305–306 of cement, 300–301 double-pour method in, 383
properties of, 305 definition of, 9, 17 single-step method in, 383–384
Translucency, 9 of dental cement, 300–301, 301b Working time, 26, 33
of ceramics, 171–172 of zinc oxide, 312 Written hazard communication
Transosteal implant, 240 Vita bleaching guide 3D master, program, 48
Transparency, of ceramics, 171, 172f 152–155 Wrought metal alloys, 220, 229, 230f
Transparent, 9, 18 Vital tooth, definition of, 148
X
Tray whitening systems, over-the- Vitality, 9, 18
counter, 157 of ceramics, 172 Xenografts, 239, 254–255, 256f
Trimming, 385, 385f, 385b Vitapan classical shade, 19f Y
definition of, 374 Vomiting, tooth erosion and, 125
Yield strength, 220, 227–228
of diagnostic casts, 385 VPS. See Vinyl polysiloxane
Yield stress, 25, 30
procedure for, 395f–396f, Vulcanite, 3
Young’s Modulus, 25, 30, 89–90
395b–397b
Triple trays (closed-bite trays), 330 W Z
Trituration, 204, 204b, 205f “Walking bleach” technique, 154 Zinc, 194
alloy and, 204 definition of, 148 as component of amalgam alloy, 194t
Triturator (amalgamator), 192, 204 Washington, George, 3, 3f Zinc oxide, as base material, 295, 296b
496 INDEX

Zinc oxide eugenol (ZOE), 311–312 manipulation of, 303–304, 304b Zirconia, 170
advantages and disadvantages of, primary consistency of, 317f–318f, definition of, 167
312b 317b–318b in dental implants, 243
composition of, 311 properties of, 303 esthetics of, improvement of, 171, 171b
impression material, 355 Zinc polycarboxylate, 304 flexural strength of, 171t
manipulation of, 312, 312b advantages and disadvantages of, glass-infiltrated, indications and
primary and secondary consistency 304b contraindications to, 179t
of, 316f–317f, 316b–317b composition of, 304 with or without veneering,
properties of, 311–312, 312b manipulation of, 304, 304b indications and
Zinc phosphate, 303–304 primary consistency of, 318b–319b, contraindications to, 179t
advantages and disadvantages of, 303b 319f selection of, rationale for, 178
composition of, 303 properties of, 304 ZOE. See Zinc oxide eugenol
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Conversion Tables

TEMPERATURE WEIGHT
Celsius (°C) = 5/9 Fahrenheit (°F) - 32 METRIC
Fahrenheit (°F) = 9/5 Celsius (°C) + 32 1 kilogram (kg) = 1000 grams (g)
1 gram (g) = 0.001 kilogram (kg) = 1,000,000
LINEAR MEASUREMENT micrograms (μg)
1 milligram (mg) = 0.001 gram
METRIC
1 meter (m) = 100 centimeters (cm) CONVERTING METRIC TO US (ENGLISH)
1 centimeter (cm) = 0.01 meter (m) MEASUREMENTS
1 millimeter (mm) = 0.001 meter (m) 1 kilogram (kg) = 2.2 pounds (lb)
1 micrometer (μm, also called micron) = 0.001 1 gram (g) = 0.0022 pound (lb) = 0.035 ounce (oz)
millimeter (mm) 28.35 gram (g) = 1 ounce (oz)
1 nanometer (nm) = 0.000001 mm
1 Angstrom (Å) = 0.0000001 mm COMMON MEASURES OF WEIGHT FOR GOLD
1 troy ounce = 20 pennyweight (dwt)
CONVERTING US (ENGLISH) MEASUREMENTS
1 pennyweight = 1.555 grams = 24 grains (gr)
TO METRIC
1 grain (gr) = 0.065 gram
1 inch (in) = 25.4 millimeters (mm) = 2.54 centimeters
(cm) MEASURES OF GOLD CONTENT
39.37 inches (in) = 1 meter (m) 24 carat = 100% gold = 1000 fine
3.28 feet (ft) = 1 meter 12 carat = 50% gold = 500 fine
1 yard (yd) = 0.9144 meter (m)

MEASURES OF FORCE (PER AREA)

LIQUID MEASUREMENT
1 kilogram/square centimeter (kg/cm2) = 14.223
METRIC
pounds/square inch (lb/in2)
1 liter (l) = 1000 milliliters (ml) = 1000 cubic centimeters 1 kg/cm2 = 0.0981 megapascals (MPa)
(cc) 1 meganewton/square meter (MN/m2) = 145 lb/in2
CONVERTING US (ENGLISH) MEASUREMENTS
TO METRIC
1 quart (qt) = 0.946 liter (l)
1 ounce (oz) = 29.6 milliliters (ml)