Afams master Lesson Plan (mlp) Dental Therapist Program eo 009. 01 Place an Amalgam Restoration



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AFAMS Master Lesson Plan (MLP)

Dental Therapist Program EO 009.01 Place an Amalgam Restoration

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Instructor

Serial/Semester

Location

Start/Finish Time

Date

LESSON OBJECTIVE

Performance: Place an Amalgam Restoration (Class 1,2 and 5)
Conditions:

Given: supervision.

Denied: nil.

Environment: classroom / clinic.



.
Standard:
The Dental Therapist Trainee will place the amalgam restoration by:

  1. Preparing for amalgam restoration

  2. Placing the matrix and wedge

  3. Placing any pre-restorative treatments as required to include

  4. Triturating the Amalgam

  5. Placing the amalgam within the appropriate timeframe

  6. Picking up the amalgam with an appropriate instrument

  7. Condensing the amalgam within the preparation

  8. Repeating picking up, placing and condensing as required

  9. Completing initial carving of the amalgam restoration

  10. Removing the wedge as required

  11. Removing matrix band as required

  12. Removing the rubber dam

  13. Completing final carving

  14. Verifying occlusion as required

  15. Adjusting the occlusion as required

  16. Verifying contacts and marginal integrity by flossing between contacts as required

  17. Burnishing the Amalgam restoration

TEACHING POINTS


  1. Preparing for amalgam restoration

  1. Knowing safe handling of amalgam during procedures

  2. Knowing the supplies and instruments required for amalgam restoration to include:

  1. Plugger

  2. Carver

  3. Burnisher

  4. Tofflemire matrix

  5. Articulating forceps

  6. Articulating paper

  7. Dappen dish

  8. Amalgam capsule/ contents

  9. Amalgam carrier

  1. Knowing the amalgamator mixer setting in accordance with the manufacturer’s recommendations for the specific product.

  1. Placing the matrix and wedge

  1. Techniques

  2. Posterior matrix system

  3. Type of matrix

  1. Placing any pre-restorative treatments as required to include

  1. Liner

  1. Base

  1. Triturating the Amalgam

  1. Grabbing a capsule

  2. Activating the capsule as required

  3. Placing the capsule in the amalgamator

  4. Verifying amalgamator settings in accordance of manufacturer instructions

  5. Pushing the start button

  6. Removing the capsule upon cycle completion

  7. Understanding how to manipulate the working time:

  1. How to increase working time

    1. How to decrease working time



  1. Placing the amalgam within the appropriate timeframe

  1. dispensing the amalgam into a dappen dish

  2. recognizing normal or under mixed consistency of triturated amalgam:

  1. Normal mix consistency:

  1. Smooth

  2. Shiny

  3. Homogenous

  4. Optimal handling.

  1. Under mixed consistency:

  1. Grainy

  2. Dry

  3. Crumbles easily

  1. Difficult to manipulate

  1. Picking up the amalgam with an appropriate instrument

  1. Picking up amalgam with an amalgam carrier in the dappen dish

  2. Placing the amalgam in the preparation

Amalgam carrier technique to place amalgam in the restoration preparation

  1. Condensing the amalgam within the preparation

  1. Using an amalgam plugger with adequate force to achieve:

  1. Complete adaptation to retentive areas, walls and cavosurface margins of the restoration preparation

  2. Complete removal of air voids

        1. Know the consequences of incorrect condensing of the amalgam in the preparation

  1. Repeat picking up, placing and condensing as required



  1. Complete initial carving of the amalgam restoration

        1. Identify carving instruments and when to use them to include:

    1. Discoid cleoid

    2. Hollendback

    3. Amalgam knife

        1. Carving exposed amalgam restoration surfaces, not covered by the matrix band, based on tooth morphology and estimated occlusion

        2. Carving amalgam to achieve:

          1. Restored form and function

          2. Smooth surface

          3. Anatomically correct appearance

          4. Continuous surface contour from amalgam to tooth structure

  1. Remove amalgam waste by rinsing and suction

  1. Removing the wedge as required

  1. Pull large end of wedge with forceps or pliers

  2. Verify the integrity of the wedge

  3. Keep the wedge for additional restorations on the same patient or dispose

  1. Removing matrix band as required

  1. Technique to remove the matrix band to include:

  1. Loosen tightening screw

  2. Hold matrix in place with finger or appropriate instrument

  3. Remove the Universal retainer, leaving the matrix band in place

  4. Remove the matrix band carefully by sliding motion so as to avoid fracturing the restoration

  1. Keeping the matrix band for additional restoration on the same patient or dispose

  2. Verify there is no fracture of the restoration and that the interproximal contact appears adequate.

  1. Removing the rubber dam

  1. Remove the retainer with the retainer forceps

  2. Carefully stretch the rubber dam towards cheek and cut the interproximal rubber dam with scissors

  3. Pull interproximal rubber dam toward the tongue

  4. Lift the rubber dam off the teeth

  5. Verify the integrity of the rubber dam by laying flat on table top

  6. Find remaining pieces of rubber dam and remove with appropriate instrument

  7. Clean and rinse mouth for patient comfort and visibility

  8. Advise the patient not to close their mouth as final carving is not complete and the restoration may fracture from tooth contacts



  1. Complete final carving

  1. Finalizing the carving with consideration for tooth morphology and patient occlusion

        1. Using the carving:

  1. Discoid cleoid

  2. Hollendback

  3. Amalgam knife

  1. Verify criteria:

  1. Surface quality:

  1. Smoothness

  1. Margin integrity:

  1. Adaptation to walls and cavosurface margin

  2. No flash, ditching or overhang

  1. Contour and function:

  1. Morphological contours restored

  2. Proximal contact restored

  3. Occlusal contacts correspond with the opposing dentition

  4. Defined anatomy

  5. No fractured portion of the restoration

  1. Damage to other structures:

  1. Minimal or no damage to soft tissue or adjacent teeth

  1. Verifying occlusion as required

  1. Verify for maximum intercuspation:

  1. Define maximum intercuspation

  2. Marking occlusal contacts with articulating paper

  1. Verify for excursive interferences:

    1. Define excursive interferences

    2. Marking excursive contacts during excursions

  2. Using proper supplies and instruments required

  1. Articulating forceps

  2. Articulating paper

  1. Comparing indication marks on opposite and neighboring teeth and restoration:

  1. No mark means too light contact

  2. Heavy mark means too strong contact

  3. Equal imprint means right adjustment of occlusal contacts

  1. Knowing the consequence of restoration fracture at this step:

  1. Redo the restoration (this could be at any step from 13-17)

  1. Adjusting the occlusion as required

  1. Selective additional carving of marked areas on newly placed restoration to remove interferences

  2. Repeat the verification and adjustments in maximum intercuspidation and excursive occlusion until complete:

  1. When occlusion marking appears evenly distributed along arch and are in appropriate locations based on morphology

  1. Know consequences of a high contact:

  1. Fracture of restoration or opposing tooth

  2. Irritation of periodontal tissues

  3. Causing temporomandibular joint problem or muscular discomfort related to grinding

  4. Sensitivity and pain for the patient

  1. Verifying contacts and marginal integrity by flossing between contacts as required:

  1. Ensuring an adequate resistance to floss is present

  2. Ensuring no interproximal overhang by smooth passing of floss with no tearing, shredding or catching

  3. Remove overhang as needed with the same instruments and techniques

  4. Understand the consequences of an inadequate restored interproximal contact



  1. Burnishing the Amalgam restoration

  1. Using a burnisher

  2. Finalizing a smooth restoration surface by applying a firm pressure on all accessible surfaces to create a smooth, shiny surface






INSTRUCTIONAL STRATEGY

Method: Practical/demonstration Method

Media: Skills lab/polyclinic

Environment: Instructional Environment.




OTHER LESSON SPECIFICATIONS

Type of Lesson: Practical

End of Lesson Test:

Instructional Time: 20 hours

Resources dentaform (dental model), operative set-up (to include amalgam, triturator), scrap amalgam container

Reference(s):

The Fundamentals of Operative Dentistry by Summit, et al. ISBN 0-86715-452-7



LESSON PLAN APPROVAL

__________________________________________________________ _______________________



Signature of AHPI Director Date


INTRODUCTION



Allocated Time:

30 Minutes

Review:

The placement of Amalgam will follow PO 008 (Prepare a Tooth for Restoration). The act will be continous from cavity preparation to restoration on a patient, as it is in the patient’s best interest to have the complete restorative phase completed at once







Objective:

The student should be able to restore Class 1, 2 and 5 amalgam preparations..







Importance:

Restoring the cavity preparation is the last stage of of the restorative cycle. If the restorative phase is completed improperly, there are many consequences – including decreased restoration performance (longevity), poor interproximal contacts, poor occlusal contact development, overhang development, and pulpal death.







Fit:

This lesson concludes PO 008 and PO 009.







Approach:

The instructor will review the checklist (see below) for each procedure. Then use training aids to demonstrate the technique and the students will practice on the dentaform (typodont).







Control Statement:

If you have any questions during the lesson please feel free to ask.






BODY

1. Teaching Point: Place a Class 1, 2, and 5 Amalgam Restoration

Allocated Time:

20 Hours

PERFORMANCE STEPS:

1. The Instructor will have a Dental Model (dentoform) and demonstrate to the students how to restore a premolar or molar Class I, II and V Amalgams using the steps below.

2. Each student will take their Dental Model (dentaform) restore their Class 1 ,2, and 5 prepared teeth from EO 008.02.

3. Review the Standards Para of this document for the details.



Practical: Sequence of Events:

Phase

Amalgam Restoration

Stage

Remarks

Phase 1

Class I

Class I amalgam Demtonstration

The instructor will demonstrate the restoration of a Class I Amalgam using a previously prepared Class I cavity.

Student Practice

The students will then practice restoring their previously prepared dentaform teeth – Class I Amalgams

Practical Informal Evaluation

The instructor will evaluate the student’s restorations and critique the quality of the occlusion, margins, and anatomy.

Phase 2

Class 5

Class 5 amalgam Demonstration

The instructor will demonstrate the restoration of a Class 5 Amalgam using a previously prepared Class 5 cavity.

Student Practice

The students will then practice restoring their previously prepared dentaform teeth – Class 5 Amalgams

Practical Informal Evaluation

The instructor will evaluate the student’s restorations and critique the quality of the occlusion, margins, and anatomy.

Phase 3

Class 2

Class 2 amalgam Demonstration

The instructor will demonstrate the restoration of a Class 2 Amalgam using a previously prepared Class 2 cavity.

Student Practice

The students will then practice restoring their previously prepared dentaform teeth – Class 2 Amalgams

Practical Informal Evaluation

The instructor will evaluate the student’s restorations and critique the quality of the occlusion, margins, and anatomy.

Restoration Quality Control Checklist applicable to all amalgam restorations.

RESTORATION QUALITY CHECKLIST

Criteria/Quality

Description

Excellent

Satisfactory

Poor, unsatisfactory

Short Margins

Restoration Margin relative to tooth structure

None

Minor

Major

Flashing, Overhangs

Excess Restoration beyond tooth structure

A little (for finishing)


A lot

Major


Restoration

Anatomy


Surface contour

Natural

Functional

Poor

Surface

Smooth

Semi-smooth

Rough

Voids

None

Very few

Many

Contact Points

Check with floss/visualization


Definite &

in correct location

Definite but in wrong location


none


Marginal Ridges

Lingual embrasure anatomy

Natural

Functional

None

Height relative to next tooth

Equal

Functional

Not even close

Occlusion

Check MI and excursive patterns


Natural

Functional

Too High


Too Low




Sequential condensation of amalgam within a cavity. Thorough condensation brings mercury toward the surface. When the cavity has been overfilled the excess mercury-rich amalgam is scraped away and discarded.



Proper adaptation of the amalgam to the cavity walls to ensure no voids



Final condensation over cavosurface margins should be done perpendicular to the external enamel surface directly over and adjacent to the margins of the cavity preparation.



The ball burnisher is used to rub or burnish the amalgam up against the cavo surface margin. It will also remove some of the excess amalgam at the same time and is the first step in shaping the occlusal surface.



Carving the Amalgam

It is important to expose the margins of the cavity preparation in an easily accessible part of the mass, then follow the gentle curves of the external outline of the preparation.

Because of its granular nature, carving may be directed from the enamel toward the amalgam or parallel with the margin, but never from the amalgam toward the enamel.This diagram shows a cleoid-discoid carver directed inwards (from enamel to amalgam).

Carving without an enamel guide frequently leads to a scooped-out occlusal surface. Usually you will end up overcarving if you do not use tooth structure as a guide.



Reproduce tooth anatomy lost to decay and the cavity preparation.



Overcarving and deep occlusal grooves weaken the restoration and invite chipping of the thinned-out amalgam at the occlusal margins.

CLASS I AMALGAM RESTORATION

CHECK LIST

YES

NO

COMMENTS

  1. Assemble armamentarium

(Plugger,Carver,Burnisher,Tofflemire matrix,Articulating forceps,Articulating paper,Dappen dish,Amalgam capsule/ contents, Amalgam carrier)







In a patient, a verification of exising occlusion would occur before local anesthetias

  1. Place any pre-restorative treatments as required.










  1. Triturating the Amalgam







Ensure Proper Mix of Amalgam – Calibrate amalgamator is required.

  1. Dispensing the amalgam within the appropriate timeframe into a dappen dish and recogznizing a good mix.










  1. Pickup/Carry the amalgam from the dappen dish to the operating field.










  1. Fill the cavity preparation- proper condesnation forces and overfilling of the preparation







Ensure sufficient overfill to facilitate carving

  1. Complete Precarve burnishing and initial carving of the resotration










  1. Remove Rubber Dam










  1. Check Occlusion










  1. Complete final carving of the restoration










  1. Verification of occlusion (MI) and remove excursive interferences.










  1. Final burnishing of the restoration











CLASS 5 AMALGAM RESTORATION

CHECK LIST

YES

NO

COMMENTS

  1. Assemble armamentarium

(Plugger,Carver,Burnisher,Tofflemire matrix,Articulating forceps,Articulating paper,Dappen dish,Amalgam capsule/ contents, Amalgam carrier)







In a patient, a verification of exising occlusion would occur before local anesthetias

  1. Place any pre-restorative treatments as required.










  1. Triturating the Amalgam







Ensure Proper Mix of Amalgam – Calibrate amalgamator is required.

  1. Dispensing the amalgam within the appropriate timeframe into a dappen dish and recogznizing a good mix.










  1. Pickup/Carry the amalgam from the dappen dish to the operating field.










  1. Fill the cavity preparation- proper condesnation forces and overfilling of the preparation







Ensure sufficient overfill to facilitate carving

  1. Complete Precarve burnishing and initial carving of the resotration










  1. Remove Matrix band/Wedge










  1. Use explorer to check interproximal to remove excess flash










  1. Remove Rubber Dam










  1. Check Occlusion










  1. Complete final carving of the restoration







Use of explorer to check interproximally to remove any excess flash

  1. Verification of occlusion (MI) and remove excursive interferences.










  1. Final burnishing of the restoration










CLASS 2 AMALGAM RESTORATION

CHECK LIST

YES

NO

COMMENTS

a. Assemble armamentarium

(Plugger,Carver,Burnisher,Tofflemire matrix,Articulating forceps,Articulating paper,Dappen dish,Amalgam capsule/ contents, Amalgam carrier)









In a patient, a verification of exising occlusion would occur before local anesthetias

  1. Place any pre-restorative treatments as required.










  1. Place a matrix and wedge

                  1. Burnish matrix against the adjacent tooth

Ensure matrix is sufficiently occlusal to aid in overfilling the preparation










  1. Triturating the Amalgam







Ensure Proper Mix of Amalgam – Calibrate amalgamator if required.

  1. Dispensing the amalgam within the appropriate timeframe into a dappen dish and recogznizing a good mix.







Mix should be shiny and not crumble

  1. Pickup/Carry the amalgam from the dappen dish to the operating field.










  1. Fill the cavity preparation- proper condensation forces and overfilling of the preparation







Ensure sufficient overfill to facilitate carving

  1. Complete Precarve burnishing and initial carving of the resotration










  1. Remove Rubber Dam










  1. Remove Matrix and Wedge







Pull diagonally to prevent fracture of the marginal ridge

  1. Check Occlusion










  1. Complete final carving of the restoration










  1. Verification of occlusion (MI) and remove excursive interferences.










  1. Final burnishing of the restoration












END OF LESSON TEST



Allocated Time:

5 Minutes

Instructions:

The Instructor will simply as the group a following questions

Test Questions or Performance Expected:3/4

    1. Does a post carve burnish help to seal the restoration?

    2. Do you need a wedge in a class 2 amalgam? Why?

    3. True or false – A matrix band is required for a class 2 amalgam?

    4. The occlusion must be checked after final carving of the restoration?




Test Key:

1 – Yes

2 – Yes – to facilitate interproximal contact formation and prevent excess proximal amalgam flash. It can also secure the matrix band

3 – True

4- Yes











CONCLUSION

This is a the final part of the restorative procedure but an important part. Take the time to understand the concepts.


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