FUNDAMENTAL PROCEDURES IN GOLD FOIL OPERATIONS
GEORGE A. ELLSPERMAN, D.D.S.
620 HERALD BLDG. BELLINGHAM, WASHINGTON
Read before the American Academy of Gold Foil Operators Meeting, New Orleans, La., Nov. 1, 1957.
Received for publication Nov. 27, 1957
THERE IS A RAPIDLY growing interest in gold foil and an urge on the part of many good operative dentists to obtain greater knowledge and skill regarding its use. Articles have been written on the virtues of gold foil, the use of the rubber dam, certain variations in gold foil cavity preparations, and the condensing of gold foil. In this article, I intend to stress the basic fundamental procedures embracing teamwork, instrumentation; standardization of cavities, condensers, and the condensing of gold foil. It is only after these fundamental procedures are fully understood and executed with skill that we are in a position to make changes such as minimizing labial outlines or variations in methods of condensing gold foil.
THE RUBBER DAM
Nothing is more fundamental in gold foil procedures than the use of the rubber dam. As a component part of the overall operation, the rubber dam technique should be so standardized that the teamwork between the assistant and the dentist becomes a flowing of steps. Each movement of one coordinates with that of the other. In this manner, the rubber clam is placed every time so that it covers the same number of teeth for a given operation. For example, when a gold foil restoration is to he placed in any of the four anterior teeth, the rubber clam would be placed on all teeth from cuspid to cuspid. For these restorations in the cuspid or bicuspids, the rubber dam would be placed on all teeth from the first molar to the central incisor. Other than this, the rule is that the rubber dam be carried to the tooth distal to the one being operated.
It is basic to use a ten one-thousandth thickness of rubber clam, 6 inches square. This weight of rubber dam is designated as extra heavy, and it is slightly more difficult to pass between the contact areas than a light rubber dam would he. A firm stretching of the rubber, together with the passing of the ligature, one lip of the rubber dam preceding through the contact, makes the operation most simple. However, the advantage over the light or medium is startling. There will be no folds, and the steady pull on the gingival tissue in the embrasure permits the proper placing of the gingival cavity outline. The invagination of this heavy dam around the teeth maintains a tight seal. In short, the entire operating field leaves little to be desired.
RUBBER DAM CLAMPS
The standardization of rubber dam clamps has been badly abused. Many dentists have tried to use too many clamps. Trial and error procedures have resulted in wasted time and money. In my hands, the best universal rubber dam clamp for upper molars is the S. S. White No. 18 (Fig. 1). While it can be used as a splendid universal clamp, in most cases, there are times when it will not balance due to the fact that both jaws of the clamp are the same shape. Two clamps that will fill this need are the Ivory 12 A and 13 A (Fig. 2), but to he usable, these clamps must he altered by cutting away the wings and refining the jaws. My choice for a lower molar clamp is an S. S. White No. 26 (Fig. 1). Rare, indeed, is the time when one of these four clamps cannot be used with rigidity and firmness on any one of the molar teeth.
It is not my purpose in this article to give a technique in sequence for the Class III or Class V gold foil operations but rather to assert and emphasize certain fundamentals which are a part of these steps.
Nothing is more fundamental to gold foil restorations than cavity outlines, but they are abused so frequently. Many uninformed dentists have told me in an apologetic manner that their patients would not permit gold to be placed in the front of their mouths. I usually tell them that they are talking about fillings which are so shaped that they reflect light as intensely as a small headlight. I am discussing a restoration for treating initial caries that is so line-like and in such perfect harmony with the tooth that it is not noticeable. In teeth where extensive caries make this impractical, a compromise can be made, and baked porcelain inlays can he used. Many fine porcelain inlays still give good service after 25 years.
Great care should be exercised in establishing the outline form for a Class III gold foil, and it should be completely accomplished before work is done on the interior form of the cavity. A delicate, keenly sharp, 11.5 mm. width, reverse bevel chisel is used to form an abrupt curve in the incisal one-third, and a straight line margin is carried toward the gingiva to join the straight gingival outline. The gingival margin is placed just beneath the free margin of the gum tissue, and the straight labial line is in harmonious parallel relation to the lobe of the tooth. This Class III outline should he so line-like and so parallel to the lobe of the tooth that it takes careful observation to be seen. The outline form is conservative and yet, with slight separation, the cavity can be filled from the labial surface for the major portion of the malleting. The lingual outline form is cut in a similar manner to join the gingival margin with a shoulder. The linguogingival shoulder and the lingual surface is malleted from the lingual side of the tooth.
Too little time, consideration, skill, and care is given to the outline form by nearly all gold foil operators. Initial caries occurring' in 'the distal surfaces of central or lateral incisors or cuspids can be restored with gold foil and should never be objectionable. Yet, if the outline form is slightly out of harmony, overcut, or with irregular margins, the completed foil will rightly bring unhappiness to a patient with a pride in appearance. A skillful dentist also need feel no hesitancy in filling initial caries in the mesial as well as distal surfaces of anterior teeth with gold foil.
INTERIOR CAVITY FORM
The interior form of the cavity consists of an axial wall encompassed by labial, lingual, and gingival walls with their line angles and point angles. The retention is provided between the gingival wall and the incisal angle. It is fundamental in the instrumentation of the Class III cavity preparation that the hoe, angle formers, and axial wall plane be used in a cutting manner with the blade parallel to the wall, rather than by a digging action.
MALLETING AND CONDENSING GOLD FOIL
A few fundamentals in the malleting and condensing of the Class III gold foil must be respected. The proper condensing instruments must be used for the specific purpose for which they were designed.
A suitable holding instrument must he used to receive and hold the first few pellets positioned in the cavity for malleting. The following sequence of use of condensing instruments is effective: Carlson-type Ferrier condensers of 0.5 and 0.55 mm. in diameter (No. 1 and No. 2) and having an angle of seven degrees
permit the dentist to work around the adjacent tooth and to maintain a proper line of force into the cavity for adequate condensation.
A No. 6 S. S. White bayonet with a 0.5 mm. condensing point and occasionally No. 8 and 9 Ferrier bayonets can he used to advantage. These condensers permit the proper line of force to be directed into the labiogingival point angle and the incisal point angle.
A Ferrier F. foot condenser which has a diameter of not over 0.55 mm, is used to assure condensation of the foil over the cavosurface margins in areas of difficult access, such as the middle third of the gingival margin, the linguogingival shoulder, and possibly over the contact area. While these instruments are fundamental, Dr. Alex Jeffery has designed some bayonet condensers for use in the invisible Class III foil. These have short nibs and greater offsets, making them very useful in difficult Class III work.
Gold foil cannot be wished to place. The middle third area of the gingival wall at the cavosurface and the linguogingival angle at the cavosurface must be stepped and condensed before the mass of subsequent gold cuts off the access. To correct an error at this point can be an onerous chore.
CLASS V GOLD FOIL FILLINGS
A fine gold foil filling is the most enduring restoration for gumline caries or erosion. In only a few mouths are they noticeable and then only in a wide smile.
The Class V gold foil presents different problems from those of Class III fillings. The gingival wall of the cavity should be placed gingival to any evidence of erosion or caries and where it will be covered by gingival tissue. There should be just enough cementum between the gingival outline and the labial jaw of the gingival clamp for proper finishing. The mesial and distal outlines should be placed so that the gingival tissues in the embrasures will cover or very nearly cover them. It is better for the outline form of the cavity to be overextended than to be under-extended.
The S. S. White No. 212 gingival clamp (Fig. 3) should be used universally for all teeth except molars, and even there it will be found to be very usable. The labial bow of the clamp allows an excellent working field without interference, and the labial jaw slopes to approximate the gingival tissue, thus permitting the placing and cutting of the gingival wall of the cavity. In accomplishing these features, this clamp could not be made to balance without support. However, with a purposely blunt labial jaw, it may be slid to place and, while it is held in position, it can be blocked with compound.
The fundamental instrumentation for Class V cavities consists of outlining the cavity with a 33 1/2 inverted cone bur. The end cutting surface is used on the gingival, mesial, and distal walls, and the side of the bur is used to make the incisal or occlusal outline. The incisal or occlusal outline may be developed more rapidly by the use of the small straight diamond wheel. This instrument should not he used in a high-speed handpiece, however. The walls and interior of the cavity are finished with the Nos. 21, 22, and 23 hoes. The retention in the finished cavity is provided between the gingival and incisal or occlusal walls and their line and point angles. The mesial and distal walls are obtuse and flaring from the axial wall to give proper strength to these portions of the tooth.
For Class V cavities, the straight condensers having diameters of 0.5, 0.55, and 0.6 mm. are fundamental. It will be noted from these dimensions that the condensing area of these instruments is very small. Yet, with accurate stepping, a fast malleting cadence by the assistant, and by using an easily controlled instrument it can produce a better result rapidly. All mechanical condensers have annoyingly cumbersome tubes, and a mechanical handpiece must be tripped in order to step. It matters not how many blows are delivered; time is lost in the tripping of the instrument. The average Class V foil should require no more than 15 minutes of hand malleting time. In stepping the plugger point, it should be watched constantly to avoid possible pits in the gold from uneven stepping. Each step should overlap the preceding one by half. The surface of the gold should not he burnished, but it should be condensed and flowed against the cavity walls for a tight seal. In emphasis I repeat, the average Class V foil filling will take from 12 to 15 minutes of hand malleting time. I know of no mechanical condenser using the same size condenser point that will equal this.
VARIATIONS IN TECHNIQUE
There seems to be considerable interest in several variations of the standard technique. Among these are (1) the use of mat foil, (2) the use of large foot pluggers, and (3) the use of new mechanical condensers. All of these are used for the obvious purpose of saving time. However, I suggest that fundamentals be thoroughly understood before these variations are attempted. It would seem to he unjustified for a dentist to carefully cut a fine detailed cavity with line angles, point angles, and true walls, only to introduce large masses of gold foil which cannot be condensed completely into these angles.
Little purpose is served, although it is interesting to make metallurgical tests of finished malleted foil fillings. Samples made by two different dentists using the
same technique will show a different result. A specimen produced on a laboratory bench for the purpose of test will vary, no doubt, from one produced in the mouth. Therefore, we may assume that whatever the technique (whether a combination of soft and cohesive foil, mat foil with a veneer of cohesive, or cohesive foil alone), gold foil must be properly stepped. It must be condensed with a small plugger point, and it must be flowed against the walls with the proper line of force to obtain a perfect seal against the tooth. These are fundamentals.
GOLD FOIL PELLETS
Since time is a fundamental factor in the production of a gold foil restoration, the dentist can ill afford to use a manufacturer's pellets. Many years ago, hand-rolled pellets were supplied by the manufacturer.* The resultant shortage of help (luring the war years caused them to discontinue this item. However, a skillful assistant, with practice, can roll a full book of gold foil (one-tenth of an ounce) in an hour and a quarter so as to produce pellets in four sizes.
Each book of No. 4 soft gold foil should he first marked and drawn into 16 1-inch squares (Fig. 4). The full 1-inch square becomes the 1/16 pellet, which is the largest size. To make the 1/32 pellet, one more cut is made, leaving a piece 1/2 by 1 inch. The next smaller size is the 1/64 which measures 1/2 by 1/2 inch. The smallest pellet is the 1/128 which measures 1/4 by 1/2 inch.
All of these are rolled in much the same manner. After separating the gold from the dividing paper, the cotton pliers are used in the right hand to grasp each piece in the center, crumpling it slightly, until the corners all turn up as it is placed between thumb and forefinger of the left hand. With a light touch of the pliers, the corners are tucked into the center as the fingers gently roll the gold into a ball. Thus, the corners are within the pellet and not on the outside of the ball of foil.
The J. M. Ney Co., Hartford, Conn.
GOLD FOIL CYLINDERS
The technique for using hand-rolled cylinders to line Class V cavities is not fundamental, but it is far superior to one of using only cohesive foil. The advantages are better protection of the margins and reduced malleting and finishing time. Hand-rolled cylinders for Class V cavity use are the 1/16 and 3/32 of a sheet of gold in size (Fig. 5). They are made by creasing the piece of foil with a straight edge plaster spatula and folding it without pressure several times into a soft ribbon. Starting at one end of the ribbon with a jeweler's broach, it is rolled without pressure into a small cylinder. They are used in the Class V cavity by introducing and flattening one against each of the four cavity walls. Cohesive foil is then placed into the axial wall and condensed, with succeeding pellets being built up to the proper form. Subsequently, the remaining soft foil is pinched off over the margins.
The "invisible" Class III foil filling is not classed as a fundamental. This type of cavity is difficult to cut and difficult to fill and, while it is not beyond the scope of skillful gold foil operators, an overemphasis on this type of restoration with its possible uncertain results may bring discouragement. A technique which is difficult to standardize and not frequently indicated is not fundamental.
FINISHING THE RESTORATIONS
The finishing of the gold foil filling with the painstaking care and precision required to restore the original anatomy of the tooth is more time-consuming than the malleting. Beveled files, knives, and extra long (18-inch) strips, and sparing use of sanding disks are used for this purpose. Great care must be exercised to avoid ditching or abrading margins of the cementum in any way.
In a discussion of fundamentals, the motive involved is an honorable one. t seeks to call attention to definite procedures and techniques and an armamentarium which, when used properly, will produce clinically beautiful enduring restorations. It has no quarrel or conflict with any other branch of the dental art. ts sole purpose is to bring about the saving of human teeth.
Reprinted from The Journal of PHOSTHETIC, DENTISTRY, St. LouisVol. 8, No. 6. Pages 1019-1025, November-December, 1958 (Printed in the U. S. A.)
Scanned and edited by Dr. John R. Sechena