Restorative dentistry -treatment of dental caries I. Doc. MUDr. Lenka Roubalíková, Ph.D. mál Antony van Leeuwenhoek (1632 -1723) Microscop, microscopic investigation, microbs in oral cavity o první pozoroval a popsal mikroby v ústech 17.století Willoughby Dayton Miller (1853 -1907) 4„Die Mikroorganismen der Mundhöhle", - „The Micro-Organisms of Human Mouth". Theory of dental caries - chemical and parasital. Green Vardiman Black (1836-1915) Definition of preparation (G.V.BIack 1914) Understanding dental caries (G.V. Black 1900) Zubní kaz z hlediska současných poznatků ■ Infekční onemocnění/ je přenosný ■ Je onemocnění s komplexní etiologií ■ Může být ošetřen na molekulární úrovni - kalcium, fosfáty, stroncium, fluoridy Microbiom Human body 1014 Living eels 10%cells of human body Microbiom Oral mikrobiom Dental biofilm ■ Pelicle - monomolekular proteinic layer rich on prolin and phosphate a and glycoprotein rich on sulphate Binden to Ca2+ ions of enamel Protective effect eroaion Dentin hypersensitivity Key role by remineralization Biofilm ■ Adherence Adhezins Fimbries Biofilm ■ Colonization - multiplication - koagregation Biofilm ental biofilm Higher metabolic activity Higher resistency (CHX 300x, AF 75x) Hihger virulency Good conditions for survival Cariogenicity ■ Streptococci: mutans, sanguis, mitis, sobrinus. ■ Laktobacily - Production of acids (acidogenity) - Production of extra aand intracelullar polysacharids - Survival in acidic environment (aciduricity) tabolicprocedures in dental of ilm Glycolysis Base production Stephan Rozpousteni HA 5,7 FA 4,6 0 ova@tiscali.cz 50 min 13 Ireverzibil -cavitated lesion Plaque = biofilm ■ Nespecific hypothesis ~ Plaque is always the reason Non specific hypothesis Only pathogenic plaque is the causal factor Saliva and dental caries ■ 700-800 ml. (0,3ml), stimulated (1ml). Clearence - Microbs - Rests of food Saliva and dental caries ■ Minerals Calcium ans phosphates -oversaturated solution remineralization Proteins Glykoproteins - pelicle, barrier against overgrowing of crystala on the surface Buffer capacity of saliva ■ Bicarbonate system ■ Phosphate system ■ In saliva not in plaque Slina ■ Klíčová role v maturaci skloviny ■ V remineralizaci i n i c i á I n íc h kazivých lézí ■ V remineralizaci demineralizovaných okrsku skloviny Iniciál caries lesion Diagnosis Vizual inspection (ICDAS) Radiography Photography Optical nonfluorescent methods Optical fluorescent methods Transilumination Measurement of electrical impedancy Diagnosis ■ ICDAS- INTERNATIONAL CARIES DETECTION AND ASSESMENT SYSTÉM ■ I Vizal inspection (ICDAS) ICDAS (2002)- 6 code, později ICDAS -II - 4Code Caries lesions in pit and fissures, smooth surfaces, roots ane next to- CARS (Caries Associated with Restoration and Sealants) Blunt probe clean and dry surfaces, time of onservation 5 s. ■ http://www.icdas.orq/courses/enqlish/index.html ICDAS - criteria ■ O - zdravé zubní plošky ICDAS - criteria ■ i - first changes that can be seen on dry tooth surface only (white, brown) ICDAS - criteria 2 - clearly seen changes visible also on moist surfaces, white, brown. Code 2 before sectioning tooth ICDAS -criteria ■ 3 - demineralization, damage of structure of enamel struktury skloviny without dentin exposure, opacity and beown of black spots hnědavé nebo černé aout of pit and fissures, can be seen on moist and dry surface ICDAS - criteria 4 -shadow going from depht od dentin, gray, blue, brown. ICDAS -criteria ■ 5 - clear cavitaionloss od enamel. ICDAS - criteria ■ 6 - large cavitation, big part of enamel and dentin can be lost and dental pulp can be affected ICDAS II - modification 0: Žádná nebo nepatrná změna v prUsvítnosti skloviny po delším osušavání vzduchem (>5 sekund). Žádná dernineralizace skloviny anebo Úzká opikní zóna. 1: Qpácita nebo dískolorace obtížné viditelné na mokrém povrchy avšak jasné zřetelně po osušení vzduchem;- Dernineralizace skloviny omezená na vnějších 50 % vrstvy skloviny 2: Opacita nebo dískolorace jasně zřetelná bez osušení vzduchem. Bez rozpoznatelné kJf nic ke liavitace. Dernineralizace zasahu|ici mezi' 30% skloviny a vnější třetinou den tmu 3: Lokalizované porušení skloviny v opákní nebo diskolorovaná sklovine, +/- nasedla dískolorace ze spodního dentínu. Dernineralizace zasahuje prostředni třetinu dentinu. Kavltace v opákni a dís-kolorované skloviné ohrožující spodní dentin. Derrilneralizace za sáhuje-vnitřní třetinu denttnu. UniViss - universal scoring systém (okluze) Active/non active lesion Second step: Oi scold ration As-EesEme-nt Universal Visual 3Luring System for pits and fissures (UnľViSS occlusal) First StC-p: Lesion Detection & Severity Assessment First visible signs or a c-iflea le-alon Established caric lur/ali^ed Ľ-:ianie: Dunlin ejeprjx ui e Pu Ip ťX:»äU e SrjuiitJ 2uifact? (5«re PI White □ N Wliite-brown (Sŕore ZJ . ... _ ■' r .-ú {Srore S| • hej □ revisi iranslucerKy (Score 4| P5H UniViss ( smooth surfaces) Second stop: Discoloration Assessment Univarsal Visual Scoring System for smooth surfaces |UniVi5S smooth) First Step: Lesion Detection ^Severity Assessment Firtt visible signs öT -a -arlefi lee-Ion Smjns- r Established csti l-stlon Suure E Microcnvity and/or Inca liacd enamel breakdown Dentin eipnsurc SppfS □ Ljigp cavity Pulp capu^urD Srans P Sound surlow (Säue 0) Na rrj'.'ihjlic'i;,; i -1 id i'-n i :J ^:::> ;:i;: k:ri:: ,ji::-'::clcrljM:: White Whiru-broivn I I frVirkj Brown [Stitxc; J) 'Greyisli LriinslumriUM fI W f Bitewing Grading Klinické: Identifikace - Vyšetřeni: B iteming rtg Leze skloviny ICDAS E1 Vnější polovina skloviny tu E2 Vnitrní polovina skloviny 1 Léze dentin u ICDAS D1 Vnější tretina dentinu 2 DZ Prostrední tretina dentlnu 3 D3 Vnitrní tretina dentinu 4 Kontrola za 2 roky u počátečních lází D-1 (modři) a D-2 (červená) D-1 a Ď-2 RTG vyšetření - Bite Wing Optical non fluorescent methods ■ Optickým Caries monitorem (OCM) ■ Distortion of light Optical fluorescent methods Fluorescence absorbtion and irradiation back ■ DIAGNOdent, DIAGNOdent pen# QLF# Vista Proof Infrared laser fluorescency DIAGNOdent, DIAGNOdent pen (Quantitative Light -induced Fluorescency QLF Vista Proof ■ Based on fluorescency Carious defect red, non carious green. ■ Vista Cam iX SoproLife Vista Proof Vista Cam iX SoproLife if SMILE INTRA-ORAL r ^^^^ beginning deep enamel caries enamel carles 1.S ; demean** 7,0 2.5 >3,0 DIFOTI (Digital Fibre Optic Trans-Illumination) Camera ccd sensor Ill AGNOCam DIFOTI (Digital Imaging Fiberoptic Transillumination) light (700-i40onm) Caries lesions and cracs -lught absorption - dark spots (kazivé léze mají větší obsah vody- velká absorpce světla) Documentation DIAGNOCam-j ■ 0- clasification ř \ Dentin / mV 1 hranice sklovina-dentin ■ ■ í-TirsT visiDie signs H 1 J am- asitikace nalezu 4 -caries where also dentin in affected - for miniinvasive treatment 5 - caries in dentin - drill and Transiluminace pomocí optického vlákna- FOTI Přístroje k diagnostice aproximálních kazů (KaVo DIAlux probe) + vyšší senzitivita než RTG snímek a opakovatelnost vyšetření - necitlivost přístroje na léze kolem výplní a nemožnost zhotovovat snímky a dokumentovat stav Měření elektrického odporu Ztráta vápníku a fosfátů - zvyšování elektrické vodivosti sklovin CarieScan Pro - měření impedance střídavého proudu vyslaného skrze zub, impedance zdravé zubní tkáně je vyšší, než demineralizované Sensor (hrot) - manžeta - retní háček slouží k uzavření elektrického obvodu - software (barevné kódování + číselná hodnota 0-100) Combination of diagnostic method gives best results Occlusal caries ICDAS + BW snímky Okluzní kazy dentinu - ICDAS + fluorescenční vyšetrení Léze skloviny - laserová fluorescence + ICDAS + BW Další možné techniky diagnostiky kazu...z praxe Užití zubní nitě- diagnostická pomůcka na detekování proximálních kazů a posouzení bodů kontaktu Dočasné separace- běžně užívané v orthodontické praxi, rychlá, levná neinvazivní metoda V případě nejisté diagnózy pomáhá rozhodnout ■ - 2 návštěvy- nasazení a za 24 hod(či více dní) vytáhnutí 1 RESTORATIVE DENTISTRY II. 3.YEAR Preparation Preparation is an instrumental treatment of carious tooth that that leaves the rest of the tooth that is restorable, resistent and that prevent the origin of dental caries at the same surface. Prevention of extension ! After good understanding of reasons of dental Caries we will be able to treat iteffectively. (G. V. Black 1900) enka.roubalikova@tiscali.cz 73 Classification of dental caries acc to Black Classification of dental caries Mount and Hume ■ Location l.Occlusal 2. Proximal 3. Cevical ■ Size l.Small 2. Medium 3- Big 3. Large Classification acc. to Black ■ Class II. Proximal surfaces in premolars and molars ^^wfKa.rouDaiiKovaonscali.cz Classification Black ■ Class III. acc. to Proximal surfaces of incisors and canines lost an incisal ridge "* IO ICI ll\CI.I UUUCIMI\UVCHU/llÖUClli.CZ 1 Classification acc. to Ii Black ■ Class IV. 1 Proximal surfaces of incisors and canines with lost an incisal ridge ■ |Jlwir 79 lenka.roubalikova@tiscali.cz Classification acc Black ■ Class V. cervical lesions to 80 lenka.roubalikova@tiscali.cz 1 Indication od filling materials ] výplňových materiálů Material of the first choice Material of the second choice Material of the third choice - Materialis possible to use with limitations i Material is not indicated Consideration Caries - Size - Location Patient -General health -Cooperation Regional circumstances Intermaxillary relations Bite forces ma Cl ions of filling Material Mount and Hume 11 Amalgam Composite Glassionomer Indirect restoration aesth Inlay metal dications of filling ass II. Material 21 22 23 Amalgam Composite Glassionomer Indirect restoration aesth. Inlay metal dications of filling ass III. Material 21 22 23 Amalgam Composite Glassionomer Indirect restoration aesth. Inlay metal s of f nterio Material 21 22 Amalgam Composite Glassionomer Indirect restoration aesth. Inlay metal Indications of filling materials class V. posterior teeth ng materials surface ma i 3 J- Material Enamel Enamel cementům Cement urn Amalgam Composite Glassionomer Indirect restoration aesth. Inlay metal Longevity of restorations in posterior teeth 1 ♦ 1 I lenka.roubalikova@tiscali.cz 90 Failure (> 2 roky) Amalgam Indikace •f Moderate to large cavities (heavy occlusal stress, difficut isolation of operating field, subgingival cavities, cavities reaching the root). 13 a 24 p Mounta and Hume S Big reconstruction (core) S Temporary fillings - j S (intermittent excavation). Sturdevandťs Arto ofEcience of Operative ka.rou .cz Amalgam > Highest abrasion resistance > Isolation of operating field is not a critical factor > Preparation must be exact The most common mistakes Preparation -Sharp edges -Bad configuration of the gingival wall -Rough margins -Weakening opfthe proximal ridge Manipulaion - Trituration - rpm, time. 97 Loss of resistance - 63% MOD cavity Ferrari, Scotti: Fibre reinforced posts. Milano, Masson 2001 Contemporary trends in treatment of dental caries ■ Miniinvasion ■ Adhesive techniques Indications ■ Aesthetically prominent areas of posterior teeth ■ Small - moderate classes I. that can be well isolated ■ Good level of oral hygiene is necessary Contraindications Moderate to large restorations Restorations that are not in highly aesthetics areas Restorations that have heavy occlusal contacts Restorations that cannot be well isolated Restorations that extend onto the root surface Abutment teeth for removable partioal dentures Temporary or caries control restorations. COMPOSITES IN POSTERIOR TEETH All pit and fissure restorations They are assigned in to three groups. R. on occlusal surface of premolars and molars R. in foramina coeca - usually on occlusal two thirds of the facial and linqual surfaces of molars. R.on lingual surface of maxillary incisors Indications ■ Aesthetically prominent areas of posterior teeth ■ Small - moderate classes I. that can be well isolated ■ Good level of oral hygiene is necessary Contraindications Moderate to large restorations Restorations that are not in highly aesthetics areas Restorations that have heavy occlusal contacts Restorations that cannot be well isolated Restorations that extend onto the root surface Abutment teeth for removable partioal dentures Temporary or caries control restorations. Clinical technique ■ From the occlusal surface using the fissure bur (or diamond burs) Outline Outline includes the caries lesion only Fissures going into the ceries lesion can be open and sealed. Retention principles ■ Prepare the box or deep dish - the bottom is in dentin ■ Do not prepare any undercuts! ■ Do not bevel enamel, finish the border with diamond bur inly. Removal of carious., infected, dentin and remaining defective enamel. ■ Spoon excavator or a slowly revolving, round carbid bur of appropriate size. C - factor Surface of adhesion/free surface of the filling L/l 3iid less is ootiniBl Forces of polymerization shrinkage depend on - Composite material (content of filler) - Geometry of the cavity (C-factor) - Placement of the composite - Mode of polymerization Forces of polymerization shrinkage Flowable com 4&pend on High content of the filler causes bigger stress ,mS es"fe P G S S ) Composite (polymerization Forces of polymerization shrinkage depend on Geometry of the cavity (C-factor) Forces of polymerization shrinkage depend on - Mode of polymerization Phases - Pre-gel - G-point - Post-gel Light ^ Polymerization -► f in o Polymer Pre gel phase should be long - soft start!!!! Bulk Fill composites Flowables SDR Flow (Dentsply), Venus Bulk Fill (Heraeus Kulzer), X-tra fil (VOCO) nebo Filtek Bulk Fill (3M ESPE). 124 Bulk Fill composites High c viscosity i Tetric EvoCeram Bulk Fill (Ivoclar Vivadent) a QuiXfil (Dentsply) Sonic Fill Bulk up to 5 mm Sonic activation - change of viscosity Internal light diffusion Long term evaluation desirable Bulk Fill materials are heterogenous group ■ The problem of polymerization stress is not completely solved!