Dr. Inas Ayoub Elalem inas.alalem@gmail.com Al Azhar University Gaza, Palestine Uploaded by Dr. Lama El Banna Operative dentistry fourth year

1. ALPINE SKI HOUSE
Dr. Inas Ayoub Elalem
inas.alalem@gmail.com
00970599448344
1
Operative Dentistry IV

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Grading System
2
Final Exam 50 marks
Midterm 27.5 marks
Oral Sheet Exam 10 marks
Assignments 10 marks
Quiz 1 2.5 marks

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Clinical
Part
3

5. Finishing and polishing of dental restorations are important aspects of clinical
procedures that enhance both aesthetics and longevity by preventing residual
surface roughness that cause plaque accumulation, gingival irritation, and
increased surface staining which result in poor or suboptimal aesthetics.

6.  Finishing: Process of removing surface defects or scratches created during the
contouring process through the use of cutting or grinding instruments or both.
 Polishing – Process of providing luster or gloss on a material surface.

7. Finishing
Surface
Polishing
Surface

8.  a. Minimal irritation of soft and hard tissues by
providing a well tolerated surface by the oral tissue
 b. Simulates natural tooth surface aesthetics
 c. Less likely to trap food debris and plaque by
reduction of roughness and scratches
 d. Resist bacterial adhesion and excessive plaque
accumulation resulting in more hygienic restoration
Highly polished surface :
More resistant to cariogenic action than a surface which is not
polished.
polished tooth surface is approximately 15% less soluble in acid
than one with a rough surface.

9.  The larger the abrasive particles, the deeper the scratch will be and
conversely, the smaller the abrasive particle, the finer the scratch will be.
 If the particle size of the abrasive is decreased sufficiently, the scratches
finally become very fine and with extremely fine abrasives, they may
disappear entirely.

10.  Burs: Periocare diamond bur 831-524 (Dentacare)
 Disks: OptiDisc (Kerr)
 Rubber: OneGloss Set (Shofu)
 Brush: Goat-hair brush (Micerium) • Felt: Felt wheel (Micerium)
 Pastes: Shiny A (Micerium), Shiny B (Micerium), Shiny C (Micerium)

11.  Bur: A 75-µm flame-shaped diamond bur is used, at low speed (10,000 rpm), to
carry out 90% of finishing work, including definition of shape and primary and
secondary anatomy.

13.  Disks: Disks are used to define proximal areas and transition angles, in the areas
where the bur is not able to reach. These instruments also are probably the most
comfortable and accurate for defining the incisal and proximal shapes. Four grits
are available: coarse, medium, fine, and superfine. We recommend the medium
grit for removing excess and the fine grit for subtle modifications.

15.  Discs can be used for the contouring of all tooth surfaces as well as bulk reduction
of excess material. Discs will help contour and finish curved surfaces such as
labial proximal line angles, lingual marginal ridges, cervical areas, incisal edges,
shaping and finishing of incisal corners, plus finishing and polishing of labial
surfaces. They are also excellent for contouring and finishing of posterior marginal
ridge areas, and for lingual and buccal surfaces.

16.  The four-grit disc sequence, which is designed to gradually reduce the amount of
roughness caused by initial abrasion until a smooth glossy tooth surface is achieved.
To provide maximum control for the operator, composite finishing should be done
under low-speed/high-torque (speed from 0 rpm to 30,000 rpms).
 Coarse—The coarse grit is the stiffest of all the discs. This grit is used in conjunction
with multi-fluted finishing burs for gross contouring and shaping. When used with
pressure, the coarse disc makes it easy to blend the composite into the tooth surface,
eliminating the white line and raised margins.
 Medium—The medium grit should be used to continue smoothing the restoration
surface. Medium grits remove any remaining imperfections and marks.
 Fine—This part of the grit sequence is where polish really starts to shine through. The
fine grit helps remove the smallest imperfections while adding a nice luster to the
restoration.
 Superfine—The superfine grit further refines the surface smoothness attainable to
create a highly polished restoration.

17.  Rubber tips: These are used to eliminate the grooves that the bur and the disk
leave. They have two main functions: When they are used firmly, a smooth
abrasion results on the composite surface, and when they are used delicately, they
are able to prepolish. The finishing stage is improved with this kind of
instrument. The correct speeds are 10,000 rpm for finishing and 5,000 rpm for
polishing.

18.  Aluminum-oxide cups should be used to polish gingival margins, achieve labial
characterization and anatomy, and effectively reach areas such as the gingival
third and the gingival margins of anterior teeth. Aluminum-oxide points should be
used to create labial grooves in veneers, to finish and polish occlusal surfaces of
posterior teeth, and on lingual surfaces of anterior teeth.

19.  Brush and paste: When a goat-hair brush rotary instrument is combined with 3-
and 1-µm diamond pastes for the initial shine stage, the result is a high gloss. The
hardness of the brush permits the surface to be polished at high speed and deep
zones to be polished at low speed. These brushes generate significant heat; they
can be used at 1,000 rpm with a gentle touch and without water and at 10,000
rpm under abundant water spray.

20.  Felt and paste: A felt wheel, which is a very soft material, is used with a 1-µm
aluminum oxide paste to achieve a very high gloss. These wheels generate
significant heat. They can be used at 1,000 rpm with a gentle touch and without
water and at 20,000 rpm under abundant water spray.

21.  Diamond Strips
 Diamond strips help start the inter- proximal finishing process while maintaining
the integrity of the interproximal contact. A larger-grit (45-µm strip) should be
used for interproximal stripping of natural teeth or for gross removal of material,
and smaller grits (15 µm and 30 µm) should be used to start interproximal
polishing.
 Aluminum Oxide
 Strips should be used to contour and polish interproximal areas. Use of a high-
quality strip will remove tenacious stains and create a high polish at the
interproximal without damaging the soft tissue. It is important that the strip is
thin and will stay intact as it is drawn through the interproximal contact areas.

32. The final appearance shows the
high gloss we can achieve with
hybrid composite resin, presumed
by many authors to be "not
polishable."

33.  Finishing and polishing should be achieved with a low-speed, high-torque
handpiece, typically anywhere from 7,000 rpm to 30,000 rpm. A high-speed
handpiece may be used to pre-contour, but using anything over 30,000 rpm during
finishing and polishing is too high. Low-speed, high-torque is preferable, because
it gives the operator complete control.
 The best finishing and polishing technique depends on the type of restoration the
dentist is presented with. When polishing a Class IV restoration, for instance, the
dentist should rely mainly on discs. However, cups and points will help develop
more realistic characterization when polishing a veneer.

34.  Starting with a coarse disc or a carbide-finishing bur, the restoration can be
completely contoured moving from restorative material to tooth surface, similar to
burnishing metal. This can be done in a wet or dry field. The material should be
extended well past the long bevel, and the dentist should not come back to the beveled
margin. The final restoration should be feather-edged onto the tooth surface past the
beveled margin. If done properly, any white line or raised margin will completely
disappear. At this stage, the disc should be flexed for maximum finishing potential.
 The different grit sizes—medium, fine, and superfine—should be continued through in
succession. An enamel-like luster rapidly appears. The interproximal process should
be started with diamond strips to maintain the integrity of the contact. One or two
times through the interproximal should be sufficient, followed with the fine-superfine
aluminum oxide strip on dry surface until no resistance is felt, and a smooth surface is
apparent.
 For the final polish, an aluminum oxide polishing paste with felt discs and points
should be used. This is the step that really brings out the amazing final polish.

35.  On occlusal or incisal margins, 5/8” or 1/2” coarse disc should be used past the long
bevel. Discs are always preferred on exposed margins. To start finishing from
restoration to tooth surface, a coarse disc is used, followed by medium and then
fine; finishing with the superfine disc to achieve maximum polish. The 3/8” disc
should be used at the gingival margin. Although this is a small diameter, the 3/8”
disc can be flexed to gain access to hard-to-reach areas. The gingival half of the
restoration can be polished nicely using flexible cups, but rubber must be kept off
the occlusal and incisal margins.
 If Class V restoration invades the proximal surfaces, the diamond strips and
aluminum oxide strips should be used in the narrow width for polishing these
surfaces. An aluminum-oxide polishing paste with felt discs and points is
recommended for the final polish.

36.  The coarse disc or contouring bur is used to start contouring and finishing. The
coarse and medium discs can be used to complete the contouring of the veneer. It
is desirable to maintain the character and anatomy placed in the facial surface.
This cannot be done with discs, but cups and points are very useful for this
purpose. To characterize, the cup is placed flat on the tooth surface, flexed slightly,
and run with pressure up and down the tooth surface. Blunting off sharp edges on
a green stone prior to characterizing prevents scarring and over-characterization.
 After a grooved surface has been developed, augmenting with rubber points
highlights the grooves. Polishing the surface is completed with fine and then
superfine polishing discs. To polish the interproximal surfaces, diamond and
aluminum-oxide strips are used as previously described. For the final polish, an
aluminum-oxide polishing paste with felt discs and points is used.

37.  Excessive staining is removed in the usual fashion. A small amount of aluminum-
oxide polishing paste is then applied to each surface and polish. To remove
interproximal staining, each interproximal should be packed with polishing paste,
and a wide, fine/superfine polishing strip is used to polish the surface.

38.  The proper contouring, finishing, and polishing of anterior restorations is a key
component to the long-term success of bonded restorations.
 The importance of three different phases in the finishing and polishing process.
First, the appropriate restorative materials, from composites to polishers, must be
carefully selected to help get the job done right. Then, the dentist must
conceptualize the desired end result, and set up the restoration accordingly. And,
finally, the proper finishing and polishing technique must be executed in order to
achieve maximum restorative success.

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Post Operative Pain
68

69. • Pain is described as an unpleasant sensory and
emotional experience associated with actual or
potential tissue damage.

70. • Thermal stimuli:
The effective thermal stimulus is that
which occurs at the DEJ at the site of neural
excitation. Therefore, pain continues after
removal of the stimulating object and until
change at the DEJ becomes of a sub-threshold
value for pain perception.
• Osmotic stimuli:
When osmotic agents as concentrated sugar
adhere to margins of leaky restoration or
contact dentin they affect a flow of dentinal
fluid with elicitation of pain.

71. • Mechanical stimuli:
Moving instruments on dentin will cause
fluid movement in the dentinal tubules in and
thus elicit pain.
• Electrical stimuli:
Electrical stimulation differs from the other
stimuli in that the stimulus is not transmitted
by dentinal fluid movement. It is rather
transmitted by the passage of electrical charge
via the moisture associated with the organic
material in enamel, cementum and dentin as
well as in dentinal tubules.

72. • Evaporative stimuli:
Drying as with a blast of air, can remove
some fluid from open tubules and cause
capillary movement distally for the dentinal
fluid into the emptied space.

74. • Causes of post-operative pain:
A. Causes related to local anaesthetic problems.
B. Causes related to cavity preparation.
C. Causes related to restorative phase.

75. A. Causes related to local anaesthetic
problems:
Postoperative complications if any will
usually consist of soreness from the trauma
involved at the site of injection. The degree of
trauma produced depends on the application
technique, and how carefully the operator
delivers the anaesthetic solution.
Causes of pain may be:
Needle can become dull after multiple injection, rapid
deposition of the anesthetic solution and using very
cold solution causing: tauma Haematoma
,discoloration & the area usually tender.

76. B. Causes related to cavity preparation:
1. Using of dull instruments: They generate
more heat because more pressure is applied
for cutting. Heat can destruct pulpal tissue
and even burn dentin. Proper cooling is
mandatory for elimination of excessive
heat generated with the rotary instruments.

77. 2. Excessive pressure: This might cause actual
aspiration of odontoblastic nuclei into the
tubule.
3. Vibration: Vibration results in a rebound
response as a result of using eccentric burs.

78. 4. Dentin desiccation: May occur due to
overheating of dentin during cutting, use of
chemicals to sterile the cavity and/or use of air
as a coolant for final cavity toilet. These
factors cause rapid outward movement of fluid
through the dentinal tubules .
5. Actual cutting in dentin: Every square
millimeter of dentin cut exposes 30000 to
45000 dentinal tubules with resultant fluid
movement in each one of them stimulating
nerve damage.

79. C. Causes related to restorative phase:
1. Polymerization shrinkage of the resin
composite:
Polymerization shrinkage results in stresses
initiating adhesive failure at composite/tooth
interface resulting in micro leakage and
secondary caries.

80. 2. Under-cured resin:
Under curing may result if the light source
is not significantly close to the surface of the
material being polymerized, if the light
source is of insufficient intensity, or if the
light is attenuated by passage through
restoration or structure.

81. • A well cured surface layer covering
incompletely the cured deeper portions and
may cause bending of the outer layer, inward
displacement, marginal fracture or open
margin. Furthermore, chemical toxicity most
often results from the monomer or the
bonding agent, which leaches out from the
incompletely cured composite.

82. 3. Errors during bonding procedure:
Failure to stick to the recommended
etching time, etchant concentration and
bonding technique cited by the manufacturer
could result in post operative pain and
improper bonding of the composite to the
cavity walls.

83. 4. Fractured restoration:
During mastication, the fracture line usually
opens up admitting oral fluids and oral
microbes which cause movement of dentinal
fluids and hypersensitivity.

84. 5. Cuspal strain:
This can be seen following a Class II
restoration, and in particular an MOD
restoration. As cavities increase in size,
deformation in response to loading increases.
Cuspal strain may result in adhesive failure
(fatigue failure of the resin bond) or cohesive
failure (fracture of restoration and/or tooth
structure).

85. • Thus, large Class II MOD cavities are ideally
restored with restorations that include cuspal
coverage. Moreover, materials with low elastic
moduli deflect under stress placing
considerable tensile stresses on adjacent cusps
leading to cuspal strain.

86. 6. Finishing procedures:
During finishing of the cervical
margins, cementum may be lost resulting
in exposed dentin. Also, overheating
during finishing may result in thermal
irritation of the pulp with subsequent
hypersensitivity.

88. 7. Cracked tooth:
“Cracked tooth Syndrome”: The tooth will
be painful on eating citrus fruits and foods.
This sharp pain will disappear when pressure
is released. Tooth could be cracked due to
biting on hard object with excessive force,
excessive removal of tooth structure (wide
cavity), parafunctional habits, pin placement,
polymerization shrinkage with large composite
restoration or cracking with high speed hand
piece.

89. 8. Inadequately lined restoration:
Metallic restorations conduct thermal
changes to underlying dentin and pulp which
often causes pain especially the few days’
post restorative procedures. The pain is
elicited after heat or cold application for the
period of stimulation or a little longer.

90. • It often ceases few days later. The greater the
temperature gradient, the more painful and the
longer lasting stimulus. The dentin, which is
effective thermal insulator when present in
good bulk, seems to store the isotherms
because of its conductivity.

91. 9. Galvanism:
-If dissimilar metals are placed in a
mouth -7 an electromotive force will be
created →The electric current will be
conducted through the existing
electrolyte i.e., the saliva and the tissue
fluid of tooth, bone and soft tissue

92. • When two dissimilar restorations
opposing each other come into contact,
the current is suddenly short circuited,
the patients involuntary disclosed teeth.
• If two teeth keep in contact, the electric
cell polarizes and the current intensity
falls below the pain perception threshold.

93. • It is evident that dissimilar metals in the same
mouth which are not in contact, if both are
brought into contact through a metallic object
such as a fork, spoon, saliva ejector or dental
mirror will elicit pain. Treatment is seldom
needed which include painting of one
restoration with thick films of cavity varnish or,
in exceptional cases, may require replacing of
the restorations.

94.  The galvanic current depending on many
factors such as :
a) The difference in electric potential for
dissimilar metals.
b) The electrical resistance of the dentin and
soft tissues which depends on the thickness
of the remaining dentin.

95. c) The current intensity.
d) Pulpal condition: whether or not the pulp is in a
state of hyperalgesia due to inflammation.

96. 10. Barodontalgia:
This refers to pain occurring in a tooth in
association with reduced pressure, which
may occur in aviation. This could be due to
expansion of air voids under a restoration,
gases in a non vital pulp.

97. 11. Faulty occlusal and proximal contact
relationships:
A high occlusal contact will result in a
tooth sensitive to biting pressure as well as
hot and cold. An amalgam restoration may
adjust itself in a matter of days by abrasion of
the restorations, but with a gold restoration
this correction is not likely. If the high spot is
on the marginal ridge of an amalgam
restoration there is greater danger of fracture
of the amalgam.

98. • If the traumatic occlusion persists, some
mobility may develop, along with the
damage of the supporting structures.
• A light or open proximal contact may result
in food impaction with gingival
inflammation. The gingival inflammation can
be quite severe resulting in a considerable
patient discomfort.

99. 12. Pulp degeneration:
The state of health of an asymptomatic
pulp organ is difficult to determine. Even as
the operator prepares the tooth, the pulp may
have experienced some degree of
degeneration. Although, the preparation is
conservative, the pulp may continue a
degenerative process towards devitalization.

100. • Deep carious lesion with a subsequent properly
based deep restoration may cause a pulp to
devitalize many years later. Care in the
selection and placement of pulp protection
materials is essential to maintain pulp health,
because the preoperative condition of the pulp
cannot be adequately assessed.

101. • A pulp exposure followed by a direct pulp
capping may initiate an immediate hyperaemia
with subsequent endodontic therapy. More often
the organ will fail to reduce a low level of
hyperaemia and the tooth will remain sensitive
to biting, pressure, hot and cold. If the case
remains sensitive for several weeks, it may be
assumed that the pulp cap has failed. A direct
pulp cap is considered to be successful if the
tooth is asymptomatic and gives a positive
vitality test from 3 - 6 months later.

102. 13. Gingival response to operative procedure:
Chemical tissue packs used to facilitate
taking the elastic impressions may cause
considerable soft tissue irritation, particularly
if the tissue packing pressure is too great or
the pack is left in place for too long.

103. • An interim dressing If acrylic temporaries are
not trimmed and finished to their margins, the
excess acrylic or cement used to set them may
cause a retraction of the gingival margin.

104. • Cementing media left in the gingival crevice
may cause gingival irritation ranging from
mild to severe inflammation. Careful checking
and cleansing of the cervical area are essential
as a last step in the setting of a casting.

105. • An overhang may irritate the gingival tissues
to such a degree that the patients will
complain. A composite resin restoration,
improperly finished, may have a cervical flash
extending several millimetres beneath the
gingiva. Amalgam overhangs in the posterior
area may not resemble an acute situation, but
the irritation may result in both soft tissue and
alveolar bone loss, depending on the severity
of the overhang and the response of the
supporting structures.

106. • The over-contoured interproximal
restorations will apply a pressure to the
gingival papilla, producing a chronic
inflammation and leading to hyperplasia or
eventual loss of gingival tissue.
• Over-contoured buccal and lingual
restorations will also apply pressure to the
gingiva, in addition, they contribute to poor
gingival health by preventing thorough
cleansing of the area by natural or artificial
means.

107. 14. Leaking restoration (microleakage):
No restorative material can provide a
completely hermetic seal of the cavity wall.
Although properly constructed amalgam
restoration exhibits clinically satisfactory
adaptation that even improves on aging due
to the deposition of the corrosion products at
the interface, yet at least some leakage may
occur at various degrees.

108. • The ingress of fluids can be the cause of
postoperative pain or hypersensitivity not only
its contents (irritant constituents and oral
microbes), but also by effecting fluid
movement in dentin. Similarly the dissolution
of luting cement under a cast restoration will
cause fluid movement. This problem is
obvious in the case of the resin composite
restorations due to the polymerization
shrinkage and the difference in the coefficient
of thermal expansion and contraction between
the tooth structure and the resin material.

109. 5th Assignment :
•Clinical technique of class II composite restoration Question: “Comparison
of class II amalgam and composite restoration” ( Textbook Art and science of
operative dentistry) CHAPTER 8 Clinical Technique for Direct Composite
resin and GlassIonomer Restorationpages 242- 251
109

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