Full-Cast Gold Restorations

This patient has an amalgam inlay that we will replace with a full-cast gold inlay. In addition, we'll replace an existing gold crown on the second molar.

Here is another view of the full-cast gold case. And I begin using my bur.

This is one of my favorite burs. It's the #846 Inlay Bur, which is shaped perfectly for inlays — whether gold, composite or all-ceramic. This bur just has a really nice taper to it. Hold it straight up and down so you don't get undercuts.

Now I go the extra mile and use a white stone in a high-speed handpiece to smooth out the margins. The lab techs have told me that one of the biggest problems with inlays is reading around the margins. Smoothing the margins also smooths out the pupal floors and the walls, which is fine too.

We have used the Razor Bur from Axis Dental to make an opening in the gold crown. After that, of course, we use the crown spreader. Then, we just rock this restoration right off.

We flip the crown over and you can see where the cut was made on the buccal. You can also see that we cut right through the area of recurring decay. We also find 2 mm of leakage around the margin behind the cut towards the distal surface. This is pretty typical because it is hard to get a good impression on the lower second molar, and you can see we got nice cement on the occlusal surface.

We removed the crown before all of the cement had totally washed out and decay had a opportunity to really do some damage to the tooth. You can see the decay is now about half way across the occlusal surface of the tooth, so it was a good time to get in there and replace the restoration.

This is a #00 cord from Ultradent that is being placed into the sulcus, and without too much difficult, I might add. It just slides into the sulcus because it is such a hollow cord.

Next, we place the top cord, a #2 cord. We will just work this right around the tooth. And this will be in place for eight to 10 minutes.

You can see me snuggling in an Roeko Anatomic Comprecap, and I will ask the patient to bite down on it. Of course, there is no need to do that with inlay preparations.

You can see that patient has smooshed that pretty good. Comprecaps do get moist, which is fine because it keeps the tooth moist. But they do not allow the prep to get wet. It also impedes potenial bleeding, which is why it is critical to leave it in place for eight to 10 minutes.

We now remove the top #2 cord and look at the sulcus, which is now wide open. In fact, you can see on that super gingival very clearly on that mesial lingual, in addition to seeing all the other margins where the sulcus was retracted.

This is a great example of what the sulcus looks like when you take out the top cord. The top cord is responsible for all the retraction in the Two-Cord Impression Technique. The bottom cord, which stays in place, is responsible for stopping all the bleeding because it is at the base of the sulcus (where inflammation occurs). As long as the bottom cord is in place, we are not going to have any issues.

I fill up the inlay prep with impression material, as well.

Again that is medium body PVS, and we have heavy body in the Quad-Tray from the Clinician's Choice. Ask the patient to bite into, verify maximum intercuspation and wait three minutes.

Then remove the impression. Skipping forward to the next appointment: Here we use the Kavo sonic scaler. Look at how it removes Durelon from the tooth. it is just fantastic.

To show the difference between the Kavo sonic scaler and scraping by hand, note how the level of difficulty in the hand technique.

I have removed 99 percent of the Durelon with the KaVo sonic scaler. It's also nice because it will not cut tissue, which you can easily do using a sharp scaler.

I push the crown in to try it on. You can see that an area with super gingival margins and with an impression that has material beyond the margins not only closed margins but also has a great emergence profile, too.

That is what I am checking here as my assistant uses the sickle scaler to hold the crown down.

I feel no opening and a nice smooth transition between the gold margin and the edge of the tooth.

Next I check the contact, and everything is fine there. It is always important to check that because it will give you a false high occlusion if you have a tight contact.

The patient is instructed to bite together on articulation paper.

We can see nice marks on all of the unprepared teeth in that quadrant, which is an important thing to look for. This ensures the tooth is not high on occlusion, and we got one mark on the mesial buccal cusp back on the gold crown itself.

We are going to go ahead and remove that gold crown to get ready for cementation.

I use a cotton ball here to absorb any excess moisture in the area. I don't go in there with a burst of air to try to keep it dry because I have found that with moisture you have dental tubule. You can never dry that completely but you can cause sensitivity by directing a bunch of cold air onto a tooth, even if it is anesthetized.

There is no reason to set up that pulpitus, even if it is reversible pulpitus. So those cotton balls work well to absorb excess moisture. This has been cemented with 3M ESPE RelyX Luting Plus.

It takes about two minutes for RelyX to go through its setting reaction. Once two minutes has passed, we can just clean it up so that it just falls away from restoration in large sheets. It makes clean up very simple.

Now that temporary inlay material has been removed, we can try-in the gold inlay. I pushed that down in place with a sickle scaler. The other tool I like to use to seat this type of restoration is an inlay seater. It's kind of like an old school thing that I remember watching my dad use, and he did a lot of gold inlays and onlays.

It was hard to find for some time, but here is one being used. It has a metal tip going against that cast gold, and it has a big soft pad on the other side for the patient to bite together. It really allows the occlusal forces down to the mesial or distal pit.

The lab nailed the surface texture and anatomy on this tooth. They got everything right. For this case, we use a Lava crown. It really lives up to its reputation of a high-strength, esthetic restoration.

We try the crown in and we like the way it looks. It is almost an axiom that most dentists like to do some finishing of the gold itself, and I just used a #7408 carbide bur to get some margins down.

Do we always need to do this? I am not sure. But it is a nice feeling for us to take material that can be burnished, like gold, and to be able to use it against the tooth to achieve a nice, intimate fit. Would it have been ok if it was slightly bulky? I think it would have been fine, but why not embrace the opportunity to refine the restoration. I do it with #7408 bur and follow it up with the Brownies & Greenies kit of rubber cups and wheels.

Now that we are happy with refinements, it's time to go ahead and cement this. My assistant has made some 3M ESPE RelyX Luting Plus and loads it into a syringe.

I squirt RelyX cement directly into the preparations. I want to be able to see the cement in all the line angles; I really want to coat the preparation. I know a lot of people like to put it on inlay and have the patient bite down, but I prefer to see the cement get all the way and coat the inside of the preparation. Yes, you do end up with some excess cement, but the margins area great and the clean up is easy.

I again have the patient bite down on the inlay seater. This particular one is no longer available, but Hager&Werken makes an inlay seater that is available through all dental dealers. You just have to know what to ask for. I find the inlay seater very handy for this type of restoration.

Here we use Brownies to do the final burnishing. I use it with a lot of water spray because it is in my electric handpiece. The speed of the handpiece is turned way down because there still is a lot of torque, which can cause extreme heat.

Being careful not to overheat these restorations, we smooth the margins with the Brownies&Greenies. This is why gold restorations are the best fitting and longest lasting in dentistry. At times I think it's a shame that the patients have gotten so aesthetically oriented that a lot of them will not allow us to do a gold restoration.

This is a super Greenies point being used on the occlusal surface, and it really does put a nice finishing shine on this restoration.

I also use the same polishing cups and wheels on the second molar. You can see we got some nice restorations here. I am a huge fan of cast gold and wish more patients would be fans, as well. If I had to sum up its benefits in one word, it would be consistency.