Dental restoration

In Italy evidence dated to the Paleolithic, around 13,000 years ago, points to bitumen used to fill a tooth and in Neolithic Slovenia, 6500 years ago, beeswax was used to close a fracture in a tooth. Graeco-Roman literature, such as Pliny the Elder's Naturalis Historia (AD 23–79), contains references to filling materials for hollow teeth. == Tooth preparation ==

, with the beginning of a preparation. Looking into the preparation, the white, outer enamel appears intact, while the yellow, underlying dentin appears recessed. This is because the dentin was decayed and was thus removed. This portion of the enamel is now unsupported, and should be removed to prevent future fracture. Restoring a tooth to good form and function requires two steps: • preparing the tooth for placement of restorative material or materials, and • placement of these materials. The process of preparation usually involves cutting the tooth with a rotary dental handpiece and dental burrs, a dental laser, or through air abrasion (or in the case of atraumatic restorative treatment, hand instruments), to make space for the planned restorative materials and to remove any dental decay or portions of the tooth that are structurally unsound. If permanent restoration cannot be carried out immediately after tooth preparation, temporary restoration may be performed. The prepared tooth, ready for placement of restorative materials, is generally called a tooth preparation. Materials used may be gold, amalgam, dental composites, glass ionomer cement, or porcelain, among others. Preparations may be intracoronal or extracoronal. Intracoronal preparations are those which serve to hold restorative material within the confines of the structure of the crown of a tooth. Examples include all classes of cavity preparations for composite or amalgam as well as those for gold and porcelain inlays. Intracoronal preparations are also made as female recipients to receive the male components of removable partial dentures. Extracoronal preparations provide a core or base upon which restorative material will be placed to bring the tooth back into a functional and aesthetic structure. Examples include crowns and onlays, as well as veneers. In preparing a tooth for a restoration, a number of considerations will determine the type and extent of the preparation. The most important factor to consider is decay. For the most part, the extent of the decay will define the extent of the preparation, and in turn, the subsequent method and appropriate materials for restoration. Another consideration is unsupported tooth structure. When preparing the tooth to receive a restoration, unsupported enamel is removed to allow for a more predictable restoration. While enamel is the hardest substance in the human body, it is particularly brittle, and unsupported enamel fractures easily. A systematic review concluded that for decayed baby (primary) teeth, putting an off‐the‐shelf metal crown over the tooth (Hall technique) or only partially removing decay (also referred to as "selective removal") before placing a filling may be better than the conventional treatment of removing all decay before filling. For decayed adult (permanent) teeth, partial removal (also referred to as "selective removal" ==Direct restorations==

This technique involves placing a soft or malleable filling into the prepared tooth and building up the tooth. The material is then set hard and the tooth is restored. Where a wall of the tooth is missing and needs to be rebuilt, a matrix should be used before placing the material to recreate the shape of the tooth, so it is cleansable and to prevent the teeth from sticking together. Sectional matrices are generally preferred to circumferential matrices when placing composite restorations in that they favour the formation of a contact point. This is important to reduce patient complaints of food impaction between the teeth. However, sectional matrices can be more technique sensitive to use, so care and skill is required to prevent problems occurring in the final restoration. The advantage of direct restorations is that they are usually set quickly and can be placed in a single procedure. The dentist has a variety of different filling options to choose from. A decision is usually made based on the location and severity of the associated cavity. Since the material is required to set while in contact with the tooth, limited energy (heat) is passed to the tooth from the setting process. ==Indirect restorations==

In this technique the restoration is fabricated outside of the mouth using the dental impressions of the prepared tooth. Common indirect restorations include inlays and onlays, crowns, bridges, and veneers. Usually a dental technician fabricates the indirect restoration from records the dentist has provided. The finished restoration is usually bonded permanently with a dental cement. It is often done in two separate visits to the dentist. Common indirect restorations are done using gold or ceramics. While the indirect restoration is being prepared, a provisory/temporary restoration is sometimes used to cover the prepared tooth to help maintain the surrounding dental tissues. Removable dental prostheses (mainly dentures) are sometimes considered a form of indirect dental restoration, as they are made to replace missing teeth. There are numerous types of precision attachments (also known as combined restorations) to aid removable prosthetic attachment to teeth, including magnets, clips, hooks, and implants which may themselves be seen as a form of dental restoration. The CEREC method is a chairside CAD/CAM restorative procedure. An optical impression of the prepared tooth is taken using a camera. Next, the specific software takes the digital picture and converts it into a 3D virtual model on the computer screen. A ceramic block that matches the tooth shade is placed in the milling machine. An all-ceramic, tooth-colored restoration is finished and ready to bond in place. Another fabrication method is to import STL and native dental CAD files into CAD/CAM software products that guide the user through the manufacturing process. The software can select the tools, machining sequences and cutting conditions optimized for particular types of materials, such as titanium and zirconium, and for particular prostheses, such as copings and bridges. In some cases, the intricate nature of some implants requires the use of 5-axis machining methods to reach every part of the job. == Cavity classifications ==

Greene Vardiman Black classification: G.V. Black classified the cavities depending on their site: • Class I Caries affecting pit and fissure, on occlusal, buccal, and lingual surfaces of molars and premolars, and palatal of maxillary incisors. • Class II Caries affecting proximal surfaces of molars and premolars. • Class III Caries affecting proximal surfaces of centrals, laterals, and cuspids. • Class V Caries affecting gingival 1/3 of facial or lingual surfaces of anterior or posterior teeth. • Class VI Caries affecting cusp tips of molars, premolars, and cuspids. '''Graham J. Mount's classification:''' Mount classified cavities depending on their site and size. The proposed classification was designed to simplify the identification of lesions and to define their complexity as they enlarge. Site: • Pit/Fissure: 1 • Contact area: 2 • Cervical: 3 Size: • Minimal: 1 • Moderate: 2 • Enlarged: 3 • Extensive: 4 == Materials used ==

Alloys The following casting alloys are mostly used for making crowns, bridges and dentures. Titanium, usually commercially pure but sometimes a 90% alloy, is used as the anchor for dental implants as it is biocompatible and can integrate into bone. ;Precious metallic alloys • gold (high purity: 99.7%) • gold alloys (with high gold content) • gold-platina alloy • silver-palladium alloy ;Base metallic alloys • cobalt-chrome alloy • nickel-chrome alloy Amalgam Amalgams are alloys formed by a reaction between two or more metals, one of which is mercury. It is a hard restorative material and is silvery-grey in colour. One of the oldest direct restorative materials still in use, dental amalgam was widely used in the past with a high degree of success, although recently its popularity has declined due to a number of reasons, including the development of alternative bonded restorative materials, increase in demand for more aesthetic restorations and public perceptions concerning the potential health risks of the material. The composition of dental amalgam is controlled by the ISO Standard for dental amalgam alloy (ISO 1559). Inorganic filler such as silica, quartz or various glasses, are added to reduce polymerization shrinkage by occupying volume and to confirm radio-opacity of products due to translucency in property, which can be helpful in diagnosis of dental caries around dental restorations. The filler particles give the composites wear resistance as well. Compositions vary widely, with proprietary mixes of resins forming the matrix, as well as engineered filler glasses and glass ceramics. A coupling agent such as silane is used to enhance the bond between resin matrix and filler particles. An initiator package begins the polymerization reaction of the resins when external energy (light/heat, etc.) is applied. For example, camphorquinone can be excited by visible blue light with critical wavelength of 460-480 nm to yield necessary free radicals to start the process. After tooth preparation, a thin primer or bonding agent is used. Modern photo-polymerised composites are applied and cured in relatively thin layers as determined by their opacity. After some curing, the final surface will be shaped and polished. Glass ionomer cement A glass ionomer cement (GIC) is a class of materials commonly used in dentistry as direct filling materials and/or for luting indirect restorations. GIC can also be placed as a lining material in some restorations for extra protection. These tooth-coloured materials were introduced in 1972 for use as restorative materials for anterior teeth (particularly for eroded areas). The desirable properties of glass ionomer cements make them useful materials in the restoration of carious lesions in low-stress areas such as smooth-surface and small anterior proximal cavities in primary teeth. Advantages of using glass ionomer cement: Compomers were formed by modifying dental composites with poly-acid in an effort to combine the desirable properties of dental composites, namely their good aesthetics, and glass ionomer cements, namely their ability to release fluoride over a long time. Whilst this combination of good aesthetics and fluoride release may seem to give compomers a selective advantage, their poor mechanical properties (detailed below) limits their use. Some of the materials used are glass-bonded porcelain (Vitablock), lithium disilicate glass-ceramic (a ceramic crystallizing from a glass by special heat treatment), and phase stabilized zirconia (zirconium dioxide, ZrO2). Previous attempts to utilize high-performance ceramics such as zirconium-oxide were thwarted by the fact that this material could not be processed using the traditional methods used in dentistry. Because of its high strength and comparatively much higher fracture toughness, sintered zirconium oxide can be used in posterior crowns and bridges, implant abutments, and root dowel pins. Lithium disilicate (used in the latest Chairside Economical Restoration of Esthetic Ceramics CEREC product) also has the fracture resistance needed for use on molars. Some all-ceramic restorations, such as porcelain-fused-to-alumina set the standard for high aesthetics in dentistry because they are strong and their color and translucency mimic natural tooth enamel. Cast metals and porcelain-on-metal were the standard material for crowns and bridges for long time. The full ceramic restorations are now the major choice of patients and are of commonly applied by dentists. Comparison • Composites and amalgam are used mainly for direct restoration. Composites can be made of color matching the tooth, and the surface can be polished after the filling procedure has been completed. • Amalgam fillings expand with age, possibly cracking the tooth and requiring repair and filling replacement, but chance of leakage of filling is less. • Composite fillings shrink with age and may pull away from the tooth allowing leakage. If leakage is not noticed early, recurrent decay may occur. • A 2003 study showed that fillings have a finite lifespan: an average of 12.8 years for amalgam and 7.8 years for composite resins. Fillings fail because of changes in the filling, tooth or the bond between them. Secondary cavity formation can also affect the structural integrity the original filling. Fillings are recommended for small to medium-sized restorations. • Inlays and onlays are more expensive indirect restoration alternative to direct fillings. They are supposed to be more durable, but long-term studies did not always detect a significantly lower failure rate of ceramic or composite inlays compared to composite direct fillings. • Porcelain, cobalt-chrome, and gold are used for indirect restorations like crowns and partial coverage crowns (onlays). Traditional porcelains are brittle and are not always recommended for molar restorations. Some hard porcelains cause excessive wear on opposing teeth. Experimental The US National Institute of Dental Research and international organizations as well as commercial suppliers conduct research on new materials. In 2010, researchers reported that they were able to stimulate mineralization of an enamel-like layer of fluorapatite in vivo. Filling material that is compatible with pulp tissue has been developed; it could be used where previously a root canal or extraction was required, according to 2016 reports. == Restoration using dental implants ==

Dental implants are anchors placed in bone, usually made from titanium or titanium alloy. They can support dental restorations which replace missing teeth. Some restorative applications include supporting crowns, bridges, or dental prostheses. == Complications ==

Irritation of the nerve When a deep cavity had been filled, there is a possibility that the nerve may have been irritated. This can result in short term sensitivity to cold and hot substances, and pain when biting down on the specific tooth. It may settle down on its own. If not, then alternative treatment such as root canal treatment may be considered to resolve the pain while keeping the tooth. Weakening of tooth structure In situations where a relatively larger amount of tooth structure has been lost or replaced with a filling material, the overall strength of the tooth may be affected. This significantly increases the risk of the tooth fracturing off in the future when excess force is placed on the tooth, such as trauma or grinding teeth at night, leading to cracked tooth syndrome. == See also ==