L3. Large Posterior Direct Restorations

small side —

large side —

• small side — gingival

• large side — occlusal

The open end of the Tofflemire retainer should not face ____ because you will not be able to take it out correctly.

occlusally

The lingual retainer is angled to go above the _____ teeth

mandibular

Small openings in accessible areas (____/____) are acceptable because overhangs can be removed after curing.

buccal/lingual

Small openings in inaccessible areas (____/_____) are NOT acceptable because overhangs CANNOT be removed after curing.

mesial/distal

The Tofflemire band should be burnished against the _____ for improved contact

adjacent tooth

(T/F)

You can slightly lift up the handle of the retainer when restoring to burnish the band against the tooth.

True

What should you do if there is limited tooth structure remaining for support and retention of the retainer?

1. Adjust Tofflemire mesially so open area is against tooth structure

2. Alternatively, add a small section of matrix

Gaps occur where

matrix enters holder

How do you correct gaps when using a Tofflemire retainer?

• Add an additional piece of matrix to close the gap

• Choose another technique

When restoring with composite, consider using the ____ wedge technique

alternate

alternate wedging

wedge one side and restore, and then repeat for the other side

what do you have to consider when restoring two adjacent preps with amalgam?

condensation pressure may distort proximal contour — must refine contour of first restoration before moving onto the second

what can help prevent improper gingival embrasure contour?

• use one large wedge, or two small wedges

• wedge both from the buccal and lingual

can you add another wedge if the original one is too small?

yes

open margins can be caused by

improper wedge placement or size — too high or too large

how do you correct open margins on restorations?

slot repair technique — slot needs to be large enough

when doing an MOD, you notice that the distal contact is too light. what can you do when restoring the mesial?

use a sectional matrix on the mesial to tighten distal contact

• separating ring will provide better separation

what are the (2) rules of tofflemire placement?

1. 1 mm above marginal ridge

2. 1 mm below gingival cavosurface margin

why is it important for the tofflemire band to be 1 mm above the marginal ridge?

allows for overfilling + carving of marginal ridge

what happens if the tofflemire is overextended occlusally?

may affect occlusal embrasure (too small) and enlargen the occlusal table

proper placement of wedge closes ______, which prevents _____

• closes gingival margin

• prevents overhangs

gaps at the cavomargin allow

overhang

overhangs can cause (2):

• perio defect

• decay

After wedging, you should use an explorer to (3):

1. Check for gaps

2. Remove trapped dam

3. Check for trapped tissue or loose friable enamel

Using a ___ wedge with Tofflemire allows for adequate tooth separation

solid (wooden or plastic)

wedge-wedging

used to close gingival gap found on maxillary first premolar caused by mesial root fluting

double-wedging

• used for wide proximal boxes (B/L)

• wedges are side by side, not stacked

piggy-back wedging

• stacked wedging

• used for deep and large gingival embrasures (recession)

when applying the matrix, the retainer should be on the ___ side with the open end facing ___

• buccal

• gingival

when placing a wedge from the buccal, you should loosen the retainer using the ___ knob and swing the retainer ___ to allow for the wedge to fit.

• large

• buccally

This matrix retainer is used for (2):

1. mandibular left

2. maxillary right

This matrix retainer is used for (2):

1. mandibular right

2. maxillary left

The open end of the retainer faces ____

gingivally

Why should the open end of the retainer face gingivally?

to allow for separate removal of the retainer and band

when removing the matrix band, you should remove the ____ and then the ____ after.

1. retainer

2. band

turn the large knob counterclockwise to _____ diameter

increase

turn the small knob counterclockwise to ________

release band from retainer

the band should be removed at a __° angle into ____ for additional support of the amalgam

• 45°

• remaining tooth structure

over-contoured

overhang

under-contoured

open

you should use an explorer after restoring to check for

margin integrity

when correcting open margins on composite using the slot repair technique, you should:

• remove 1 mm of composite

• create undercut

when correcting open margins on amalgam using the slot repair technique, you should:

remove 2 mm of amalgam

if you over-carve anatomy, you will produce

thin fragile margins

when looking at physiologic occlusal anatomy of your restoration, you are evaluating the (2):

1. primary anatomy

2. size and shape of the cuspal inclines

your restoration should be in ___ with the adjacent teeth in the quadrant

harmony (occlusal equilibrium)

when checking your restoration with articulating paper, all ___ and ___ contacts on the restoration should be consistent with contacts on other teeth in that quadrant.

1. centric

2. excursive

what are (2) types of errors that can happen when evaluating centric occlusion?

1. hyper occlusion

2. hypo occlusion

what are (3) types of incorrect occlusal interferences?

1. working

2. nonworking

3. protrusive

protrusive interference

(for both maxillary centrals)

• mandibular central + lateral must make contact with (1) maxillary central

canine guidance

when canines are tip to tip, none of the posteriors should be in contact

should there be contact between supporting or nonsupporting cusps?

supporting cusps

what kind of mark is seen when there is hyperocclusion?

bulls eye

when checking for occlusion with articulating paper, which area should NOT have contact?

cavomargin of restoration

working interference occurs between

• 1 supporting cusp

• 1 nonsupporting cusp

what is the working side?

the side the mandible moves to

• inner —> outer incline

• buccal — lingual facing

should you grind down supporting cusps?

NO (unless absolutely necessary)

• you SHOULD move the supporting cusps, but should not shorten then

nonworking interference occurs between

• two inner inclines

• two supporting cusps

when correcting working interference, which cusp should you adjust?

nonsupporting cusp

when correcting nonworking interference, you should adjust

inner incline of maxillary teeth

In protrusive interference, maxillary cusps contact on the ___ incline

distal

In protrusive interference, mandibular teeth contact on the ___ incline

mesial

A premature contact on the buccal facing (inner) incline of the maxillary lingual cusp produces a ___ shift of the mandible

buccal

A premature contact on the lingual facing slope of the maxillary buccal cusp produces a ___ shift of the mandible

lingual

Isthmus ___ affects required occlusal anatomy

width

Restorations with a wide B/L dimension required a ____ for the opposing supporting cusp

recessed area

what happens when you misplace the cusps on a restoration?

• wide occlusal table

• restricted occlusal embrasures

• most likely hyper-occlusion

what should you do if you misplace the cusps and have restricted occlusal embrasures?

• adjust the outer incline of the cusp

• adjust the height of the cusp tip

buccal and lingual embrasures are affected by the ___ and ___ of the contact

• size

• shape

buccal and lingual embrasures are affected by_____ and ______

• external contours

• occlusal table

which of the following is more important:

A. making the marginal ridge of the restoration high so that it is in occlusion

B. making sure the marginal ridge of the restoration is at the same height as the adjacent marginal ridge

B. making sure the marginal ridge of the restoration is at the same height as the adjacent marginal ridge

what could count as clinically substandard when assessing marginal integrity?

open margins

Should you have light or heavy contact for amalgam restorations?

Light — amalgam will fracture under heavy occlusion

what instruments can you use to correct overhang?

• discoid-cleoid

• hollenbach

you can use incremental layering of composite on the _____ of the tooth because it is stickier

oxygen inhibited

do you have to etch and bond every increment of composite in the oxygen inhibited layer?

NO — already sticky

(T/F)

You can add fresh amalgam to set amalgam

False

The red marks indicate ____ interference

working

The black marks indicate ____ interference

centric

(T/F)

The cusp tip of nonsupporting cusps should be as tall or shorter than a supporting cusp.

True

This is an example of ______ interference

working

• BULL — Buccal of Upper, Lingual of Lower

working side interference

• Maxi B

• Mandi L

nonworking side interence

• Maxi L

• Mandi B

(inner inclines)

Identify (4) errors with this restoration

1. Failed attempt at slot prep repair of an open contact

2. Flash

3. Halo at the cavomargin

4. Substandard finish and polish

why do halos form at the cavosurface margin of restorations?

• debris from finishing/polishing gets stuck under the cavosurface margin

  • this debris does NOT bond to the tooth and gets stuck in the restoration edges

what should you do to remove flash?

use a finishing bur (football)

Identify (2) errors with this restoration

1. Hyper-occlusion

2. Adjacent tooth is placed incorrectly (lol)

Identify (2) errors with this restoration

1. Open contact/margin

2. High marginal ridge

How should you fix this restoration?

1. Better band and wedge placement

2. Loosen Tofflemire slightly

3. Correct with partial restoration replacement

Identify (2) errors with this restoration

1. Hyper-occlusion on the cavosurface margin

2. Light distal occlusion

How should you fix this restoration?

1. Adjust restoration so that there is NO contact at the cavosurface margin

2. Slot prep repair to fix light distal contact

What are some possible causes of open or light proximal contact?

• Incorrect wedge size

• Improper burnishing of matrix band

• Overuse of finishing disk at proximal contact

Identify (4) errors with this restoration

1. High marginal ridge

2. Open margin

3. Poor gingival embrasure

4. Finish and polish

How would you correct this restoration?

1. Proper wedge placement technique

2. Proper finishing and polishing technique

3. Evaluate occlusion

This is an example of _____ side interference

non-working

How do you avoid bubbles at the cavosurface margin of your restoration?

• use clean instrument

• use a small amount of bonding agent

How would you correct this restoration?

1. Continue finishing with finishing burr (clockwise)

2. Etch and bond more composite