‫بسم ال الرحمن الرحيم‬

Amalgam restoration
:Seminar outline

(: I) Amalgam restoration technique

.Selection of alloy -1
.Isolation and matricing -2
.Proportioning and dispensing -3
.Trituration -4
.Mulling and squeezing -5
.Condensation -6
.Precarving burnishing -7
.Carving -8
.Postcarving burnishing -9
Finishing and polishing -10

.II) Mercury hazards)

I) Amalgam restoration manipulation technique)

:Selection of alloy -1

There are many commercial brands of dental amalgam, with different alloy types and different mode of
supply. It is very important to choose amalgam alloy that meets the ADA specification or a similar
specification. Manipulative characteristics such as rate of hardening, smoothness of the mix and the ease
of condensation and finishing are a matter of subjective preference. It is essential that the alloy selected
.be one with which the dentist and assistant feel comfortable

It is recommended to use high copper amalgam or at least the first choice in the most of cases. This type
.has high physical and mechanical properties that are important in posterior region

Conventional lathe cut alloy needs more mercury, gives rough surface on carving and finishing but it
.(offers high resistance to condensation forces (positive pack

Spherical alloy needs less mercury, has high physical properties, good adaptation and high early
.strength. It is less resistant to condensation forces. Hence, it is not preferred for class II

Admixed alloy has the good physical and mechanical properties as a high copper alloy, and is resistant
.to condensation forces (positive pack), making it the best choice for class II restorations

Alloys that are not containing zinc is indicated in cases where isolation is difficult to be achieved
.properly, as in class V restorations

Isolation and matricing -2

Isolation must be done during amalgam manipulation. After the cavity preparation is ready to receive
amalgam, field isolation should be applied, either a complete or partial isolation. Isolation used is
.usually partial, using cotton rolls and saliva ejectors

Contamination should be prevented, especially during trituration and condensation procedures. If such
.contamination occurs when using zinc containing alloy, excessive delayed expansion takes place

Excessive delayed expansion usually starts after 3 to 5 days and may continue for months, reaching
values more than 4%. The effect is due to some type of reaction of Zinc with water. One of the products
of reaction is hydrogen. It is produced by electrolytic action by zinc, the electrolyte, and the anodic
constituents present. This hydrogen does not combine with amalgam constituents but collects within the
restoration. The internal pressure of the hydrogen may build up to levels high enough to cause the
.amalgam to creep and producing this expansion

When one wall is missing after the cavity preparation, as in class II, matrix application is necessary. The
matrix serves as a temporary wall during condensation of amalgam, gives the restoration a shape and
.form, and maintains them till the hardening of the restoration

Wedging is very important to prevent overhanging filling, and also it compensate for the band thickness
by mild separation of teeth. Using a wedge stabilizes the band during condensation of amalgam, which
.enhances condensation that provides proper physical and mechanical properties
 (tofflemire matrix)

:Proportioning and dispensing -3

Mercury ratio is critical to provide a plastic, smooth and coherent mass, without affecting physical and
.mechanical properties of amalgam

Conventional lathe-cut alloys require a relatively large amount of mercury (50% to 60% by weight in the
mixture) to fill in the spaces. Mercury-rich mixtures, after trituration but before placement into the
preparation, historically could be partially condensed by wringing the mass in a squeeze cloth. In the
1960s, Eames was the first to promote a low mercury-to-alloy mixing ratio (Eames technique or no-
squeeze-cloth technique).

For spherical alloys, it is possible to reduce the mercury portion of the mixture to less than 50% by
weight. Most modern precapsulated amalgams are formulated with only 42% to 45% mercury by
weight.

Excess mercury will lead to formation of gamma 1 and gamma 2 on the expense of the stronger gamma
phase that will:
• Increase setting expansion.
• Increase setting time.
• Decrease strength.
• Increase tarnish and corrosion.
• Increase creep.

Less mercury will not be enough to wet all particles of alloy by mercury leading to:
• Friable mix with more voids.
• Decreased strength.
• Increased liability for tarnish and corrosion.

Methods of proportioning:

1- Amalgam balance (by weight)

2- Volumetric dispensing:
Amalgam is supplied in 2 bottles, one for mercury, and the other for the alloy. This method is not
accurate as the balance.

(amalgam balance, mortar and pestle, alloy powder and mercury bottles)

3- Alloy tablet (pellet) and mercury dispenser:

The alloy powder is tablet is pressed into a tablet of standard weight. Mercury is dispensed as standard-
sized droplet from an automatic dropper bottle.

(alloy tablets)

4- Reusable capsules:
Alloy used for this type is usually alloy tablet, and the mercury is either dispensed into the capsule as a
standard-sized droplet from an automatic dropper bottle, or preweighed mercury envelop. A typical
reusable capsule was a hollow tube with rounded ends constructed as two pieces that could be friction-fit
or screwed together. A small metal or plastic pestle was added to the capsule and it was closed. The
capsule and its contents were then automatically mixed using an amalgamator.

(different shapes of amalgam capsules, and pestles)

:preweighed capsules -5
Modern amalgams are produced from precapsulated alloy and mercury. there are plenty of brands
supply amalgam preweighed capsules of different amounts and different characteristics.

• Types of capsules according to spills:

1-Spill 1
2- Spill 2
3- Spill 3
4- Spill 4

Manufacturers commonly supply capsules containing 400 (spill 1), 600 (spill 2), or 800 mg (spill 3) of
alloy and the appropriate amount of Hg, color coded for ease of identification. Clinical consensus is that
these amounts are sufficient for most restorations. It is usually suggested that if larger amounts are
required that several smaller mixes be made at staggered times so the consistency of the mixed amalgam
remains reasonably constant during the preparation of the restoration. However capsules containing
1200 mg (spill 4) of alloy are available if a large amount of amalgam is needed to produce an amalgam
core on a severely broken down tooth.

• Capsules may be self-activated or non self-activated:

In self activated amalgam capsule the mercury is present in an envelop which rupture by the high
frequency of amalgamator.

(contents of self-activated capsules, mercury envelop alloy powder, color coded capsules)

In non self-activated capsule there is a sheath or diaphragm between mercury and alloy powder, when
the plunger is pressed the diaphragm is dislodged, and mercury begin to wet the powder before
trituration.

(septum between mercury and alloy powder)

• The setting of amalgam within the capsule may be fast, regular or slow.

• A pestle may or may not be present. This pestle is usually plastic. It enhances trituration.

•The capsule may be opened by screwing the cap or by friction(less reliable in mercury hazards)
 •Ultrasonic welded capsules: this capsule is completely sealed. The kit is supplied with plastic
rod used to fracture the capsules by inserting the rod into a hole in the capsule, bending the rod.
The advantage of this type of capsules is control over mercury mishandling.

(ultrasonic welded capsules)

•Direct placement capsules:

it has a nozzle through
which amalgam is placed into the cavity by means of an injecting device. It is more hygienic, for
there is no mercury hazard, and high infection control measure.

4- Trituration:
It is the process by which the alloy and mercury are mixed together to produce a coherent homogenous
plastic shiny mass. This procedure allows the rubbing of the surface oxide on amalgam particles,
exposing an active surface to react with mercury.

Hand trituration:
Clean rough glass mortar and pestle are used in hand trituration. The alloy powder and mercury is
rubbed between mortar and pestle until a workable mass is obtained. the force should be about one kg
120 revolution per mn.

(mortar and pestles)

Mechanical trituration:
May be done by different types of machines and devices:

1- Amalgamator:
The typical amalgamator has been designed to grasp the ends of the capsule in a claw (fork) that is
oscillated in a figure-eight pattern (eccentric movement). This accelerates the mixture toward each end
of the capsule during each throw.
 (amalgamator)

Trituration energy of amalgamator depends on:

• Speed of amalgamator.
• Time of trituration.
• Distance of movement of the fork.
• Weight of the capsule.
• Presence of the pestle.

To guarantee that amalgam alloy and mercury are mixed both efficiently and consistently, it is very
important to periodically calibrate amalgamators. After several years of use, the bearings become worn
and the mixes no longer are sufficiently triturated.

2- Amalgamizer:
Provides automatic dispensing and mechanical mixing.

3- amalgamator-amalgamizer:
Contains both of them.

4- Portable miniamalgamator:
Contains a fork and shank, that is inserted into a straight handpiece. It is small in size, portable, simple,
convenient and chesp method of mechanical trituration.

Advantages of mechanical trituration:

• Uniform reproducible mix.
• Shorter trituration time.
• Greater alloy to mercury ratio can be used.

Undertiturated mix is dull in appearance and crumbly, making it inconvenient to manipulate. The effect
of undertrituration :
• Decreased strength.
• Decrease corrosion resisitance.
• Rough surface full of voids
• Less adaptability.

Overtriturated mix appears soupy and tends to stick to the inside of the capsule, and is difficult to
handle. The effect of overtrituration:
 • Increased physical reaction.
• Increase total contraction.
• Decrease setting expansion.
• Decrease working time.

Properly triturated amalgam is a homogeneous mass with slightly reflective surface.

(properly triturated mix)

5- Mullling and squeezing:

Piece of rubber dam is used to rub the hand mixed amalgam for 2 to 3 seconds, to give a more
homogenous and plastic mass. Then it is squeezed in piece of cloth, to express the excess mercury.

6- Condensation:

Condensation is the process of compressing and directing dental amalgam into the cavity preparation
walls with amalgam condensing instruments, until the cavity is completely filled and overpacked with
dense mass of amalgam.

Proper condensation of amalgam:

• Promotes adaptation of amalgam against cavity walls.
• Compacts the material (pushing alloy powder together) resulting in
• Elimination of voids.
• Reducing amount of residual mercury within the mix.
• Creation of interlocking layers (by the use of serrated condensers).

Mechanical condensation:
Where condensation of amalgam is done by automatic device. Some provide impact type force, others
use rapid vibration. produces similar clinical results to the hand condensation. It produces heat with the
possibility of mercury vapor production (mercury hazard).

Hand condensation:
• Only fresh mix is used:
Condensation of a mix should be completed within the time specified by the manufacturer (usually 2
1/2 to 3 1/2 minutes). Otherwise, crystallization of the unused portion will be too advanced to react
properly (i.e., chemically bond) with the condensed portion. Discard the mix if it becomes dry, and
quickly make another mix to continue the insertion.

• Dry clean field should be ensured.

• Small successive increments:

Use an amalgam carrier to transfer amalgam to the tooth preparation. Increments extruded from the
carrier should be smaller (often only half or less of a full-carrier tip) for a small preparation,
particularly during the initial insertion. Thoroughly condense each portion extruded from the carrier
before placing the next increment. Each condensed increment should fill only one third to one half
the preparation depth.

(amalgam carrier)

• Direction, shape and size of the condenser:

Use a flat-faced, circular or elliptic condenser. Should be serrated to make a mechanical interlocking
between successive layers. There are many condensers according to angles within, monoangled and
the more common contrangled.

Condense the amalgam over the pulpal floor of the preparation (90 degrees). Be careful to condense
the amalgam into the pulpal line angles (45 degrees).

(direction of condenser 45 degrees on line angles)

The initial condenser should be small enough to condense into the line angles but enough not to
"poke holes" in the amalgam mass. Usually a smaller condenser is used while filling the preparation
and a larger one for overpacking.

(serrated condenser)
 (different tip designs)

• Condensation pressure:

Condensable amalgam need 2-5kg force to be condensed. The spherical alloys need less force.
Another thing is that Condensers with larger-diameter nibs require greater condensation pressure.
Heavy pressure with great number of thrusts is needed in case of condensable amalgam (lathe-cut
and admixed alloys), while light pressure with low number of thrusts are needed in case of spherical
alloys.

• Overpacking:

The preparation should be overpacked 1 mm or more using heavy pressure. This will ensure that the
cavosurface margins are completely covered with well condensed amalgam. Final condensation
over cavosurface margins should be done perpendicular to the external enamel surface adjacent to
the margins. It helps reduce the amount of mercury at peripheral surface of amalgam.

(overpacking, large condenser)

 7- Precarve burnishing:

Precarve burnishing is a form of condensation. To ensure that the marginal amalgam is well condensed
before carving, the overpacked amalgam should be burnished immediately with a large burnisher, using
heavy strokes mesiodistally and faciolingually (from center to peripheries). To maximize its
effectiveness, the burnisher head should be large enough that in the final strokes it will contact the cusp
slopes but not the margins.

The objectives of precarve burnishing:

• Ensure proper adaptation of amalgam, especially at the margins.
• Obtaining a smooth amalgam surface.
• Excess mercury is pushed to the surface.
• Can be considered as the first step of shaping the occlusal restorations

(different nib designs of amalgam burnishers)

(large burnisher is used for precarve burnishing, egg burnisher)

8- Carving:
Carving may begin immediately after condensation but with care, it carves easily but liable to miscarve
or overcarve. Amalgam can be carved with any bladed instrument with sharp edge. The most common
carvers are small discoid cleoid carver, Hollenback no 1/2 carver, interproximal carver, spoon and hoe
excavators can also be used.

(different carver designs)

All carving should be done with the edge of the blade perpendicular to the margins as the instrument is
moved parallel to the margins. Part of the edge of the carving blade should rest on the unprepared tooth
surface adjacent to the preparation margin. Using this surface as a guide helps to prevent overcarving the
amalgam at the margins and to produce a continuity of surface contour across the margins.

(direction of carving)

Overcarving: Deep occlusal grooves should not be carved into the restoration, because these may thin
the amalgam at the margins, invite chipping, and weaken the restoration. An amalgam restoration that is
more than minimally overcarved (i.e., a submarginal defect greater than 0.2 mm) should be replaced.

Undercarving: leaves thin portions of amalgam (subject to fracture) on the unprepared tooth surface.
Such margins give the appearance that the amalgam has expanded beyond the preparation.

The thin portion of amalgam extending beyond the margin is referred to as flash. An amalgam
restoration that is more than minimally overcarved (i.e., a submarginal defect greater than 0.2 mm)
should be replaced.

If total carving time is short enough, the smoothness of the carved surface may be improved by wiping
with a small, damp ball of cotton held in the operating pliers. All shavings from the carving procedure
should be removed from the mouth with the aid of the oral evacuator.

The restoration is checked by articulating paper for hyperocclusion in centric position of the mandible
and during mandibular excursions. High spots will be marked, which are then removed by additional
carving.

(articulating paper marks before and after occlusal correction)

 9- Postcarve burnishing:
Some operators prefer to postcarve burnish the amalgam surface using a small burnisher when carving is
completed. Postcarve burnishing is done by lightly rubbing the carved surface with a burnisher of
suitable size and shape to improve smoothness and produce a satin (not shiny) appearance. Also it
improves adaptation at the margins and the delicate pressure exerted produce a denser amalgam at the
surface.

With highcopper amalgams, postcarve burnishing may improve the marginal integrity of high-copper
amalgams but it is not recommended as a routine part of the procedure (although it may also improve the
smoothness of the restoration).

Postcarve burnishing in conjunction with precarve burnishing of low-copper amalgams may serve as a
viable substitute for conventional polishing.

(small ball burnisher is used for postcarve burnishing)

10- Finishing and polishing:

The finishing and polishing procedures should not be initiated on an amalgam restoration until the
amalgam has reached its final set, at least 24 hours after it has been placed and carved. Premature
finishing and polishing will interfere with the crystalline structure of the hardening amalgam.

Objectives:
• Eliminates rough surface of amalgam, thus reduce stresses by removal of sharp edges,
and reduces plaque accumulation and possibility of recurrent decay.
• Reduces tarnish and corrosion.
• Maintains periodontal health.
• Any occlusal prematurity that is mistakenly left can be adjusted during this procedure.

Finishing the restoration involves contouring, removal of marginal discrepancies, defining the anatomy,
and smoothing the amalgam surface. Finishing procedures are completed prior to polishing and require
abrasive agents that are coarse enough to remove the bulk from the surface.

Polishing enhances the quality of the restoration by producing the smoothest shiniest surface possible—
one which will offer better resistance to corrosion and tarnish. Polishing procedures require more mildly
.abrasive materials for smoothing and shining the amalgam surface
:Finishing procedure
First instrument to be used is finishing diamond and carborundum stones, then finishing bur is used to
give a smooth surface. Sandpaper disc is not recommended for proximal box finishing because it may
.cause damage to the enamel, soflex discs are more appropriate

(finishing bur)

(carborundum finishing stones, sandpaper disc)

:Polishing procedure is either done by one of the following

:Rubber cups and brushes in conjunction with polishing agents -1
Pumice is an abrasive powder of volcanic origin and is available in a variety of grits. Fine grades of
pumice are used for polishing amalgam restorations. It is usually mixed with water (slurry of
.pumice) to help reduce the heat created by the friction of the abrasive particles during polishing
Tin oxide or Amalgloss is used as the finest abrasive agent. It may be applied in a slurry, applied dry,
applied first as a slurry followed by dry tin oxide. Both pumice and tin oxide are applied to the tooth
.with separate rubber polishing cups

abrasive rubber cups or abrasive-impregnated points and cups (Shofu Brownies, Greenies, Super -2
:(Greenies
These points and cups are very easy to use, readily adapt into all areas of the restoration, and are less
messy than the pumice and tin oxide. The drawbacks to their use are expense and the fact that the rubber
contributes to heat generation

:The creation of heat during the polishing procedure is potentially dangerous for two reasons
.Heat can cause thermal damage to the pulp -1
.Heat may result in mercury vapor -2
:To minimize heat production
• Use light, intermittent pressure with rotary instruments lifting the instrument off of the
restoration frequently. Heavy or prolonged pressure generates heat.

• Use slow to moderate speed with rotary instruments. High speeds increase friction and
thus generate heat. Increase speed only to produce the final high shine.

• Use abrasive agents that are wet rather than dry. Some abrasive materials (pumice and tin
oxide, for example) can be mixed with water or alcohol to help lubricate and cool the agents.

• Use compressed air directed at the amalgam surface during polishing.

 (II) Mercury hazards:

Amalgams have been used for 150 years; about 200 million amalgams are inserted each year in the
United States and Europe. In spite of its substantial history, however, periodically concern arises about
the biocompatibility of amalgam. Allergic reactions to mercury in amalgam restorations do occur, albeit
infrequently. This is not surprising, because there is no material that 100% of the population is immune
to 100% of the time.

It has been estimated that a patient with 9 amalgam occlusal surfaces will inhale daily only about 1% of
the amount the Occupational Safety and Health Administration (OSHA) allows to be inhaled in the
workplace.

Forms of mercury:
• Elemental mercury
• Inorganic mercury.
• Organic mercury (methyl and ethyl mercury).
The most toxic is the organic, followed by mercury vapor, then the least toxic are the inorganic
compounds.

(Absorption efficiency of mercury)

Biological effects of mercury:

1- Sensitization (allergic reaction): normal allergic reaction.

2- Mercurialism: symptoms are excitability, headache, fatigue, loss of memory, kidney disease.

3- Amalgam tattoo: remnants of amalgam may be mistakenly contaminate an extraction socket, after
healing of the socket, grayish discoloration of the soft tissue is presented.

(arrow points at the grayish discoloration of amalgam tatoo)

4- biological effect on the tooth: mercury overexpansion may lead to tooth splitting, especially in
endodontically treated teeth. Amalgam blue is the discoloration of tooth structure that is not underlined
by varnish or cement.

RISKS TO DENTISTS AND OFFICE PERSONNEL:

Of the two groups of people (i.e., patients and dental office personnel) potentially at risk to mercury
exposure with dental amalgam, the dental office personnel are at greater risk because of frequent
handling of the freshly mixed material. The concern with the potential for mercury toxicity therefore
centers primarily on dental office personnel.

In the dental office, the sources of mercury exposure related to amalgam include:
1- Amalgam raw materials being stored for use (usually as precapsulated packages);
2- Mixed but unhardened amalgam during trituration, insertion, and intraoral hardening;
3- Amalgam scrap that has insufficient alloy to completely consume the mercury present;
4- Amalgam undergoing finishing and polishing operations;
5- Amalgam restorations being removed. Each of these is more carefully considered in the following
paragraphs.

Recommendations for mercury hygiene are:

1- Store mercury in unbreakable, tightly sealed containers.

2- To confine and facilitate the recovery of spilled mercury or amalgam, perform all operations
involving mercury over areas that have impervious and suitably lipped surfaces.

3- Clean up any spilled mercury immediately. Droplets may be picked up with narrow-bore tubing
connected (via a wash-bottle trap) to the low-volume aspirator of the dental unit.

4- Use tightly closed capsules during amalgamation.

5-Use a no-touch technique for handling the amalgam.

6-Salvage all amalgam scrap and store it under water that contains sodium thiosulfate (photographic
fixer is convenient).

7-Work in well-ventilated spaces.

8-Avoid carpeting dental operatories; decontamination of carpeting is very difficult.

9-Eliminate the use of mercury-containing solutions.

10-Avoid heating mercury or amalgam.

11-Use water spray and suction when grinding dental amalgam.

12-Use conventional dental amalgam condensing procedures, manual and mechanical, but do not use
ultrasonic amalgam condensers.

13-Perform yearly mercury determinations on all personnel regularly employed in dental offices.

14-Determine mercury vapor levels in operatories periodically.

15-Alert all personnel who handle mercury, especially during training or indoctrination periods, of the
potential hazard of mercury vapor and the necessity for observing good mercury and amalgam hygiene
practices.