Adobe Systems Restorative dentistry III. 5 th lecture 1.Periodontal diseases related to restorative treatment 2.Management of deep caries 3.Preparation trauma 4.Postoperative sensitivity 5.Miniinvasive treatment [USEMAP] Adobe Systems Restorative dentistry III. 5 th lecture 1.Periodontal diseases related to restorative treatment Adobe Systems Mistakes of making filling can cause periodontal diseases ̶Reconstruction of the contact point: ̶Contact point – contact area! ̶The space below the contact area is a caries danger area – plaque accumulation! ̶The interdental papilla is retracting during ageing – interdental oral hygiene is important! Definujte zápatí – název prezentace nebo pracoviště 3 Adobe Systems Mistakes of making filling can cause periodontal diseases ̶Reconstruction of the contact area is very important! ̶Remember – by reconstruction the contact area remember that: ̶Contact area is made of the filling material only. The axial walls are situated 0,5mm from the natural contact area. ̶By reconstruction is important to study the contact area! Definujte zápatí – název prezentace nebo pracoviště 4 Adobe Systems Definujte zápatí – název prezentace nebo pracoviště 5 Clinical conseqences of the most common mistakes – the contact point is missing The contact area is missing Obsah obrázku rentgenový snímek, rozmazání Popis byl vytvořen automaticky Retention of food Plaque accumulation Inflammation Bone resorption Periodontal pocket Adobe Systems Obsah obrázku interiér Popis byl vytvořen automaticky Definujte zápatí – název prezentace nebo pracoviště 6 Obsah obrázku interiér, malé Popis byl vytvořen automaticky Adobe Systems Definujte zápatí – název prezentace nebo pracoviště 7 Obsah obrázku interiér Popis byl vytvořen automaticky Obsah obrázku interiér, rozmazání Popis byl vytvořen automaticky Bad contour, overhang Contact area too narrow Adobe Systems Definujte zápatí – název prezentace nebo pracoviště 8 Clinical conseqences of the most common mistakes – the overhang Obsah obrázku text, rentgenový snímek, rozmazání Popis byl vytvořen automaticky Retention of food Plaque accumulation Inflammation Bone resorption Periodontal pocket Mechanic irrtiation Secondary caries Adobe Systems Definujte zápatí – název prezentace nebo pracoviště 9 Obsah obrázku rentgenový snímek, rozmazání Popis byl vytvořen automaticky Obsah obrázku text, rentgenový snímek, rozmazání Popis byl vytvořen automaticky Adobe Systems Clinical conseqences of the the other mistakes – trauma Separation ring Matrix band Preparation instruments Wedges Necrotizing agent – necrosis of papilla od bone. Definujte zápatí – název prezentace nebo pracoviště 10 Adobe Systems Restorative dentistry III. 5 th lecture 1.Management of deep caries Adobe Systems Deep caries – D4 ̶ ̶Caries pulpae proxima ̶ ̶ ̶Caries ad pulpam penetrans Definujte zápatí – název prezentace nebo pracoviště 12 Adobe Systems Caries pulpae proxima ̶Dentine between the caries lesion and dental pulp ̶No symptoms ̶Indirect pulp therapy: indirect pulp capping Calcium hydroxide cement, premanent filling. Definujte zápatí – název prezentace nebo pracoviště 13 Adobe Systems Caries ad pulpam penetrans ̶Soft carious dentine is reaching the pulp ̶ ̶No symptoms ̶ ̶Symtomatic (pulpitis?) Definujte zápatí – název prezentace nebo pracoviště 14 Adobe Systems Caries ad pulpam penetrans ̶No symptoms ̶ Vitaliy +: 1.Indirect pulp capping (intermittent excavation) 2.Pulpotomy (aseptic approach, rubber dam) Definujte zápatí – název prezentace nebo pracoviště 15 Adobe Systems Caries ad pulpam penetrans ̶Symptoms Vitaliy +: 1.Pulpotomy (aseptic approach, rubber dam) -Partial -Coronal -Deep Definujte zápatí – název prezentace nebo pracoviště 16 Adobe Systems Caries ad pulpam penetrans ̶No symptoms ̶ Vitality - : Endodontic treatment Definujte zápatí – název prezentace nebo pracoviště 17 Adobe Systems Postoperative sensitivity ̶ ̶Pain occuring after the placement of composite restoration ̶Studies have reported the frequency of postoperative sensitivity to be low 5% and high 30% Definujte zápatí – název prezentace nebo pracoviště 18 Adobe Systems Postoperative sensitivity - reasons ̶Polymerization shrinkage ̶Marginal gap ̶Suboptimal adhesion ̶Inadequate polymerization ̶Unvfavourable C- factor and residual dentin thickness ̶Pre-existing tooth related factors, such as cracks Definujte zápatí – název prezentace nebo pracoviště 19 Adobe Systems Postoperative sensitivity ditching marginal discoloration gap cracks Versluis 2000 Secondary caries ̶ Adobe Systems Postoperative sensitivity - reasons ̶Polymerization shrinkage and polymerization stress -Gap in dentin -Cracs in enamel -Cuspal deflection – enamel crazes or fracture lines Cracs may increase flexure of tooth structure under occlusal loading or become an avenue for bacterial ingress. Moreover dentinal fluid in association with the cuspal deflection can potentially induce post op sensitivity depending on the rate and direction of fluid movement. Definujte zápatí – název prezentace nebo pracoviště 21 Adobe Systems Postoperative sensitivity ̶The risk and the intensity of postoperative sensitivity is not associated with the filling materials. (Silorane, bulkfill – no effect) Definujte zápatí – název prezentace nebo pracoviště 22 Adobe Systems Postoperative sensitivity - reasons -Marginal gap Marginal gap is a potential site for bacterial ingress, a portal for fluid exchange leading to the movement of dentinal fluid – post op sensitivity, marginal discoloration, secondary caries Definujte zápatí – název prezentace nebo pracoviště 23 Adobe Systems Postoperative sensitivity - reasons -Factors affecting the marginal adaptation -Contamination -Inadeguate bonding application -C- factor -Absence of enamel at the restorative margin - Definujte zápatí – název prezentace nebo pracoviště 24 Adobe Systems Postoperative sensitivity - reasons -Factors affecting the marginal adaptation -Enamel still remains the most favorable substrate for bonding, long term bond longevity in dentine remains questionable due to hydrolytic degradation of the hybrid layer components. Definujte zápatí – název prezentace nebo pracoviště 25 Adobe Systems Postoperative sensitivity - reasons - Suboptimal adhesion A gap forms beneath the restoration and fills with dentinal fluid, sudden movement of dentinal fluid causes pain. Definujte zápatí – název prezentace nebo pracoviště 26 Adobe Systems Postoperative sensitivity - reasons -_ Suboptimal adhesion The gap formation -A void in the composite materiál being placed on the floor of the cavity -Pulling away of composite from pulpal wall due to shrinkage stress -Gap in the hybrid layer due to insufficient resin infiltration resulting in formation of hybroid layer. Definujte zápatí – název prezentace nebo pracoviště 27 Adobe Systems Postoperative sensitivity - reasons ̶Suboptimal adhesion Flowable at the bottom? Inadequate permeation of the demineralized dentin during the restorative procedure is a significant contributor to postoperative sensitivity. Selfetching adhesive systems? No significant association between the bonding strategy with risk and intensity od postoperative sensitivity. Definujte zápatí – název prezentace nebo pracoviště 28 [USEMAP] Adobe Systems Postoperative sensitivity - reasons ̶Suboptimal adhesion No significant association between the bonding strategy with risk and intensity od postoperative sensitivity. Definujte zápatí – název prezentace nebo pracoviště 29 [USEMAP] flow1 Flowables - importance 1.Excellent marginal adaptation 2.Protection of the adhesive 3.Elastic layer ? 4. [USEMAP] Adobe Systems Postoperative sensitivity - reasons ̶Inadequate polymerization Composites are relatively flexible in comparison to the stiffness of tooth enamel (modulus elasticity) The flexure of composite restorations in relation to the tooth can produce pressure changes in the dentinal tubular fluid and subsequent fluid movement – can provoke pain on chewing. Definujte zápatí – název prezentace nebo pracoviště 31 [USEMAP] Adobe Systems Postoperative sensitivity - reasons ̶Inadequate polymerization ̶When adequate placement – the biting sensitivity is rare but if the degree of polymerization of the materiál is not in the acceptable limits – it leads to soggy bottom phenomenon. Bulk fill materials x incermental techniques showed no significant difference in the occurence of reported post op sensitivity. Definujte zápatí – název prezentace nebo pracoviště 32 [USEMAP] Adobe Systems Postoperative sensitivity - reasons ̶Inadequate polymerization Biological consequences: The process of polymerization is not complete in the set materiál. 25 – 50% od the monomer double bonds remain unreacted and this monomer has the potential to irritate the pulp. Adequate polymerization is important! Definujte zápatí – název prezentace nebo pracoviště 33 [USEMAP] Adobe Systems Postoperative sensitivity - reasons ̶Unvfavourable C- factor and residual dentin thickness High C- factor – higher risk of gap formation as well as cracs (see the explanation in the first lecture) Remaining dentin thickness: Increased cavity depth and reduced dentine thickness – higher risk of postoperative sensitivity. Base of GIC? Definujte zápatí – název prezentace nebo pracoviště 34 [USEMAP] Adobe Systems Postoperative sensitivity - reasons ̶ ̶ ̶Pre-existing tooth relatefd factors, such as cracks Definujte zápatí – název prezentace nebo pracoviště 35 [USEMAP] Adobe Systems Postoperative sensitivity - reasons ̶Pre-existing tooth relatefd factors, such as cracks Restoration of a tooth with an unidentified crack can result in symptoms that can be confused with postoperative sensitivity. Definujte zápatí – název prezentace nebo pracoviště 36 [USEMAP] Adobe Systems Postoperative sensitivity - reasons ̶Pre-existing tooth relatefd factors, such as cracks ̶Cracs can be developed in the tooth structure due to masticatory insults over the period of time. Cavities with an intercuspal width exceeding one quarter are at increased risk of crack development. ̶Consider cuspal coverage! Definujte zápatí – název prezentace nebo pracoviště 37 [USEMAP] estetikapostr1 [USEMAP] 2 mm [USEMAP] Adobe Systems Clinical symptoms ̶Pain Øusually by chewing Øon cold or hot stimuli Øon tactile stimuli Øspontaneus 40 [USEMAP] Adobe Systems Postoperative sensitivity strategy ̶Perfect investigation - Check occlusion -Check margins (sealing?) -Check tooth structure If some reason is found: remove it If not – we can wait for appr. 6 weeks ̶ Definujte zápatí – název prezentace nebo pracoviště 41 [USEMAP] Adobe Systems Postoperative sensitivity strategy - If the symptoms are getting worse - remove the filling, check the tooth structure carefully, - use calcium hydroxide with the temporary filling material or bioactive materiál (Biodentine), - Make a new filling. Definujte zápatí – název prezentace nebo pracoviště 42 [USEMAP] Adobe Systems Postoperative sensitivity prevention ̶Correct indication ̶Excellent isolation ̶Careful investigation using magnification and illumination ̶Proper etching ̶Proper drying ̶Proper curing Definujte zápatí – název prezentace nebo pracoviště 43 [USEMAP] Adobe Systems Definujte zápatí – název prezentace nebo pracoviště 44 Preparation techniques and their clinical consequences – preparation trauma [USEMAP] Adobe Systems Preparation Power driven -Rotary -Alternative Hand - Excavator - Chisel - Definujte zápatí – název prezentace nebo pracoviště 45 [USEMAP] Adobe Systems Preparation techniques ̶Pressure – max hand preparation – risk of excavators ̶Vibrations ̶Heat – due to friction - increases with rpm (turbine max) Definujte zápatí – název prezentace nebo pracoviště 46 [USEMAP] Adobe Systems Consequences in enamel, dentin, cementum ̶Rotary preparation with high speed handpiece, turbine: ̶ ̶Enamel :shattered borders, cracs. Prevention: gentle interrupted preparation, water cooling. ̶Dentine: burnt areas, denaturation of protein. ̶Dental pulp: aspiration of odontoblasts into dentine tubules, hyperaemia, infiltration, inflammation. ̶ Definujte zápatí – název prezentace nebo pracoviště 47 [USEMAP] Adobe Systems Prevention ̶ ̶Gentle interrupted preparation ̶Sharp instruments, well centered ̶Sufficient watercooling by using highspeed rpm (50ml/min) ̶The biggest preparation instruments for the excavation of carious dentin ̶ ̶ Definujte zápatí – název prezentace nebo pracoviště 48 [USEMAP] Adobe Systems From extension for prevention to prevention of extension ! 1tridareal mod black1 [USEMAP] Adobe Systems Primum non nocere ! Minimal intervention = Approach Non invasive Minimally invasive [USEMAP] Adobe Systems ̶ bednarvych bednarsehoji Kopie bednarzhojen1 hrmkovavych hromkovanejlepsi ? vacha3 vacha2 [USEMAP] Adobe Systems Prevention od extension q Ethiology and patogenesis of dental caries q Biomechanical properties of the tooth q Diagnosis q Filling materials q Preparations techniques Changes in the treatment concepts, size and shape of cavities black1 [USEMAP] Adobe Systems Biomechanics korenovenastavby mod MOD - 63% Endodontics - 9% Dehydratation -14% Ferrari M, Scotti R. Fiber posts. Characteristics and clinical applications. Milano: Masson,2002.c [USEMAP] Adobe Systems Illumination, magnification Clean surfaces Dry field Ø Dry field lupovky kamera1 [USEMAP] Adobe Systems Miniinvasive treatment - techniques q Mechanical q Chemo – mechanical q Kinetic q Laser [USEMAP] Adobe Systems qMechanical preparation q ØRotary ØSonic , ultrasonic ØART Ø [USEMAP] Adobe Systems ØRotary (micro and miniinstruments) mikrodia mikrokomet [USEMAP] malakavitaokluze Minicavities Fissure opening oklplocha peceteni5 peceteni6 [USEMAP] okluze otviranifissur malicke kavity malickekavity na okluzi kdepreparovat [USEMAP] slotak Wardovaprep Sedelmayer slotbazant Sedelmayer J. Amalgám – zapomenuté řemeslo. Brno, 2000. Bažant V. Konservační zubní lékařství, SPN Praha,1962. slot1 Slot preparation with macroretention [USEMAP] slot1 slot2 Sedelmayer slot3 slot4 Adhesive slot [USEMAP] tunel1 tunel2 tunel3 Tunnel preparation [USEMAP] tunel1a tuneldetail1 [USEMAP] 1202161355_8 tunelpovyplni tunel logosov [USEMAP] tunel1 tunel2 1.Low caries risk 2.Compliance 3.Marginal ridge without infraction 4.D3 1. Magnification 2. Miniinstruments 3. Disinfection of cavities 4. GIC or composite 5. BW post op Success? [USEMAP] Adobe Systems ØSonic and ultrasonic preparation – oscillating instruments sonicminikonc soniczboku1 soniczboku2 sonickomp2 sonickomp3 [USEMAP] 7902 7907 [USEMAP] cislo1 cislo2 kavita Ultrasonic preparation üWalls are smoother in comparison to rotary preparation üTime of the preparation is significant longer üExkavation of carious dentin is nor sufficient üMarginal adaptation of composite filling is not significantgly better Roubalíková L. Ultrasonická preparace v ošetření zubního kazu , PDD 2004. [USEMAP] 7a 7a ØART [USEMAP] 7b ØART logosov [USEMAP] 7b ØART –atraumatic restorative technique 7c logosov [USEMAP] Adobe Systems ART üMiniinvasive üRemineralization üLarge lesions üChildren üDisabled patients ü art art3 [USEMAP] Ø Chemomechanical preparation 7a logosov 7c [USEMAP] Adobe Systems carisolvprehled carisolvnástroj carisolvzub2 pochemomech1 ØChemo – mechanical preparation [USEMAP] üNo anesthesia needed üSmell of chlor üNo noise üFor anxious and disabled patients üTime consuming • Rafique S, Banerjee A, Fiske J. Clinical trial of an air-abrasion/Carisolv gel regimen for restorative treatment for dentally anxious patients. Caries Res 2002; 186 (Suppl.3)36:39. [USEMAP] Adobe Systems ØKinetic preparation – sandblasting – air abrasion kineticka [USEMAP] Adobe Systems üGood accepted by patients üTime consuming üExcavation of dentine is not sufficient üRough borders üDust Pietrini DR. Air abrasion for 21st century. Dent Today 2000;19:106-108 [USEMAP] Adobe Systems Ø Laser princippreparace [USEMAP] Adobe Systems Er,Cr:YSGG Laser Er: YAG logosov [USEMAP] Adobe Systems ̶ fokusace laserilustr kavitalaser logosov [USEMAP] cahl1 cahl2 cahl3 cahlhotovo Roubalíková L, Wilhelm Z, Bilder J. : Use of Er:YAG laser in non carious cervical lesions. Clin Oral Invest, v tisku, 2004. logosov [USEMAP] vacha3 vacha1 vacha2 [USEMAP] Adobe Systems Adhesive preparation Sklovina lasernapis kyselina s napisem adhesesnapisem logosov [USEMAP] Adobe Systems Adhesive preparation Dentin Lenka Roubalikova, CZ snapisemlaseddentin dentinkyselina adhese s napisemdent [USEMAP] Adobe Systems üGood accepted üTime consuming üAntimicrobial effect üRisk of perforation of pulp chambre üPrice [USEMAP] lenka.roubalikova@tiscali.cz 86 Obsah obrázku objekt v exteriéru, ohňostroje Popis byl vytvořen automaticky [USEMAP] Thank you !