Faculty of medicine, Dpt of restorative dentistry, ass.prof. L. Roubalikova1 Restorative dentistry I. 3rd lecture Dental caries in posterior teeth Pit and fissure caries Occlusal surfaces of premolars and molars Foramina coeca All pit and fissure restorations (fillings) 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 lingual surfaces of molars. R.on lingual surface of maxillary incisors. Classification of fissures ̶ 1. Shallow and wide - V or U - 2. Deep and narrow - I or K 4 Pits and fissures ̶ Caries danger areas – plaque accumulation due to morphology of fissures ̶ Structure of hydroxyapatit (carbonated HA) – enamel does not mature completely Morphology of fissures Biofilm Classification of fissures ̶ 1. Shallow and wide - V or U - 2. Deep and narrow - I or K 7 Diagnosis ̶ Visual diagnosis – ICDAS, UNIWISS ̶ Infrared laser fluorescency (uncertain) ̶ Radiogram – if it spreads to dentin ̶ Diagnocam (uncertain) Pit and fissure caries ̶ Class I. acc. to Black Caries danger area Special morphology Special sructure of enamel Diagnosis ̶ Visual criteria ICDAS–INTERNATIONAL CARIES DETECTION AND ASSESMENT SYSTEM ̶ ICDAS(2002)–6 code, later ICDAS –II –4code ̶ 􀂃Caries lesionsin pit and fissures, smooth surfaces, roots and enext to fillings –CARS (Caries Associated with Restoration and Sealants ̶ Blunt probe ̶ Clean and dry surfaces, time of observation 5 s ̶ http://www.icdas.org/courses/english/index.html ICDAS – criteria ̶ 0 no changes observed ICDAS - criteria ̶ 1.- first visual changes observed on dry surface only (opaque, white, brown) ICDAS - criteria ̶ 2. – first visual changes on wett surfaces ICDAS - criteria ̶ 3 – enamel is still present, zone of decalcification is out of fissure, dentin is affected ICDAS - criteria ̶ 4 – dark colour around the fissure (grey, blue, brown), enamel can be broken ICDAS - criteria ̶ 5 – cavitated lesion Clinical picture ̶ Dark colour ̶ White colour (undermined enamel) around cavitation Caries ICDAS 2 ICDAS 1 22 ̶ Pit and fissure caries Occlusal caries ̶ ICDAS 0 – 1 : observation ̶ ICDAS 2: observation or preventive filling ̶ ICDAS 3 – 4: filling therapy Indications of dental materials – occlusal caries ̶ Amalgam ̶ Composite ̶ Glassionomer 25 Definujte zápatí – název prezentace nebo pracoviště26 Consideration ̶ Caries lesion: size and location ̶ Occlusal stress ̶ Level of oral hygiene ̶ Isolation of operating field ̶ Patient´s compliance Definujte zápatí – název prezentace nebo pracoviště27 Amalgam ? Pertinent material qualities and propeties Strength Longevity Ease of use Clinically proven sucess BUT! ▪ Infractions of marginal ridge ▪ Corrosion ▪ Bad aesthetics Amalgam - disadvantages ▪ Easy to place ▪ Good mechanical properties esp. ▪ Price Amalgam - advantages Indications ̶ Moderate to large restorations ̶ If there is heavy occlusal loading (alternative onlay) ̶ Oral hygiene is not optimal (alternative dense glassionomer as middle term temporary) ̶ When ihe proper isolation is not possible ̶ Price Contraindications ̶ Aesthetically prominent areas of posterior teeth ̶ Small - moderate classes I. that can be well isolated GIC only? ̶ Primary dentition ̶ Resin modifies GIC preferable 33 Composite - benefits ̶ Non metallic materiál ̶ Adhesion – no gap ̶ Less amount of hard dental tissues that is necessary to remove ̶ Good resistency of the treated tooth ̶ Aesthetics 34 ▪ Good isolation is necessary ▪ Technique sensitive treatment ▪ Price Composite - disadvantages 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 have heavy occlusal contacts ̶ Restorations that cannot be well isolated ̶ Restorations that extend onto the root surface ̶ Abutment teeth for removable partial dentures Fillings – small to medium lesions ̶ Composite – small to medium lesion (if indication) ̶ Amalgam is a material of second choice ̶ Metal or adhesive inlay is nit be used in medium lesions. Fillings – medium to large defects ̶ Amalgam filling with replacement of cusps ̶ Adhesive inlay, metal inlay or onlay ̶ Composit is not indicated (contraindicated) Pit and fissure sealing indications ̶ Teeth soon after eruption with deep fisures ̶ Disabled patients ̶ Adults - hyposalivation Definujte zápatí – název prezentace nebo pracoviště40 Pit and fissure sealing - cointraindications ̶ Shallow fissures, good oral hygiene DMF = 0 ̶ High caries risk (DMF high) – risk of proximal caries ̶ Proximal caries, occlusal caries (ICDS – 3 and more) Definujte zápatí – název prezentace nebo pracoviště41 Adhesive preparation in a fissure – sealant filling Adhesive preparation – caries lesion in dentin Preventive filling - indications ̶ Primary molars ̶ Premolars ̶ Permanent molars (ICDAS 3 and more) Definujte zápatí – název prezentace nebo pracoviště44 Preventive filling - contraindications ̶ High caries risk, DMF ˃ 5 ̶ Large dental caries (more than 1/3 intercuspidal distance, underminig chronic caries ̶ Proximal surfaces must be intact or max D1 ̶ Proximal cavitated lesions Definujte zápatí – název prezentace nebo pracoviště45 46 Preventive filling – GIC + composite Preventive composite filling Preventive glassionomer filling Sealant filling Composit material ̶ Small cavities – preparation is limited on caries lesion only, small instruments no extention, fissure sealing around and sealant also covers the filling. This is preventive composite filling. ̶ Medium cavities – preparation is limited on caries lesion, GIC replaces lost entin, composite filling on the top. ̶ Larger cavities – preparation involved the fissures, box. Box (remember rounded edges) Preparation of enamel borders – no bevel The beveling dependens on the orientation of enamel rods Preparation 45° The composite material is built cusp by cusp Isolated cavities Preparation of fissural complex Pre –gel Gel point Post -gel Polymerization shrinkage and polymerization stress Postoperative sensitivity ditching marginal discoloration gap cracks Versluis 2000 Secondary caries Risks – high C-factor Flowables - importance 1. Excellent marginal adaptation 2. Protection of the adhesive 3. Elastic layer ? 1 2 3 Placement of the materiál Incremental technique with respect to C-factor of each layer Adhesives ̶ Acid etching technique Etching Washing Priming Bonding Adhesives ̶ Selfetching adhesive systems Priming Bonding Adhesives ̶ Active and passive bonding Active – rubbing with microbrush - selfetching Passive – without any rubbing – acid etching Cavosurface margin for amalgam ̶ Ideal outline includes all occlusal pits and fissures. If crista transversa (1st lower premolar)or obliqua (1st and 2nd upper molar)are not affected, it is strongly recommended no to prepare them. Box with undercut Retention principles ̶ Prepare the box – the bottom is in dentin ̶ Undercuts can be prepared! No undermine proximal ridge!§ Principles of resistance ̶ No undermined enamel left (proximal ridge shoule not be undermined!!!) ̶ No sharp edges ̶ The thickness of amalgam 2 mm Margin too next to cup Sharp edges The pulpal wall and pulp chamber Pulpal wall is parallel to the pulp chamber Removal of carious, infected, dentin ̶ Spoon excavator or a slowly revolving , round carbid bur of appropriate size. 75 Protection of dentin wound ̶ Dentin wound should be covered – protection of dental pulp against irritation Physicial -thermal -osmotic Chemical Combination 76 Protection of dentin wound Isolation Filling (small cavities) Base (moderate – large cavities- depth 2mm and more approx.) For amalgam – zinkoxidphosphate cement 77 When amalgam is used: Base is made usually of zinkoxidphosphate cement It is placed only on pulpal wall Box with undercut Base CLASS II. Proximal caries in posterior teeth Direct restorations - Amalgam - Composite - Glassionomer - Indirect restorations –inlays, onlays Composite Ceramics Metal alloy83 Class II. Defects affecting one or both proximal surfaces of posterior teeth. Location: Interdental space ̶ Interdental space is a caries danger area (below the contact point). ̶ Interdental space is infilled with interdental palilla, that moves apically during the time and the space is open. ̶ Dental caries begins below the contact point. lroubal@med.muni.cz 85 Class II. 86 Origin: Proximal surface below the contact point Propagation of dental caries from the occlusal surface lroubal@med.muni.cz 87 Symptoms ➢No symptoms ➢Increased sensitivity (cold, sweet) ➢Retention of food ➢Defect (carious lesion is open – the enamel is broken) ➢Bite sensitivity (when carious lesion is open) lroubal@med.muni.cz 88 Diagnosis ➢Visual changes of tooth structure (chalk white colour). ➢Transillumination (white light, or Diagno Cam). ➢Radiography lroubal@med.muni.cz 89 lroubal@med.muni.cz 90 lroubal@med.muni.cz 91 Bite wing lroubal@med.muni.cz 92 lroubal@med.muni.cz 93 D1 – radiolucency till ½ the enamel D2 – radiolucency till the border of enamel and dentin D3 – radiolucency till ½ dentin D4 - radiolicency more than ½ dentin DIAGNOCam lroubal@med.muni.cz 97 lroubal@med.muni.cz 98 lroubal@med.muni.cz 99 lroubal@med.muni.cz 100 Sedelmayer RTG vyšetření – Bite 4 stupňový grading Choice of the material depends on ̶ Size of carious lesion ̶ Level of oral hygiene ̶ Occlusal loading ̶ Cooperation of the patient and other factors lroubal@med.muni.cz 101 lroubal@med.muni.cz 102 Preparation - amalgam ➢Conventional preparation acc. to the Black´s rules ➢Slot preparation ➢Large preparation – cusp(s) involved lroubal@med.muni.cz 103 Preparation - adhesive materials (composites, glass ionomers) ➢ Conventional preparation for composites ➢Adhesive slot ➢Tunnel preparation 104 Occlusal cavity Proximal cavity - box Conventional preparation amalgam 105 Pulpal wallsAxial wall Gingival wall Isthmus lroubal@med.muni.cz 106 Access to the cavity From the occlusal surface Through the undermined enamel Separation using wooden wedges is useful lroubal@med.muni.cz 107 Pre op lroubal@med.muni.cz 108 Access to the cavity lroubal@med.muni.cz 109 Breaking the thin enamel layer out of the cavit Wooden wedge lroubal@med.muni.cz 110 ➢ Remove of the gingiva that grows into the cavity lroubal@med.muni.cz 111 Cavosurface margin and extention for prevention Proximal box: Vestibullary and orally – axial walls (the border between the oral/vestibular and proximal surface. Below the free gingiva (0,5 mm) Occlusal Class I. lroubal@med.muni.cz 112 v American rule Tangents from the middle of treated tooth to the next tooth – where these cross the treated Tooth there are borders of the preparation lroubal@med.muni.cz 113 Study the contact area The contact point is made of the filling The axial wall is 0,5 mm vestibulary resp.orally from the contact point lroubal@med.muni.cz 114 Retention ➢Occlusal cavity ➢ Undercuts ➢Grooves 115 Axiální stěny divergují gingiválně Rýhy a zářezy Autoretention Grooves Proximal cavity – box Slight divergency of axial walls Gingival wall follows the cementoenamel junction Gingival wall is below free gingiva lroubal@med.muni.cz 116 Resistancy ➢No undermined enamel ➢No sharp edges ➢Isthmus is 1/3 – 1/4 intercuspidal distance ➢ Angle between axial and gingival wall: 90°, or 85° ➢Width of gingival wall is 1 mm at least ➢ Thickness of the filling 2 – 4 mm (4mm if cusp replacing) lroubal@med.muni.cz 117 Cavosurface angle Gingival wall Isthmus 118 Excavation of carious dentin Rounded bur (Caries Detector, Kuraray, Japonsko; Caries Marker, VOCO,Německo) lroubal@med.muni.cz 119 Finishing of the walls of the cavity ➢ Red coded diamond bur ➢Chisel on the gingival wall (if in enamel) 120 121 lroubal@med.muni.cz 122 lroubal@med.muni.cz 123 Final check ➢Goog light, miror lroubal@med.muni.cz 124 Pulpal wall Axial wall Gingival wall Isthmus lroubal@med.muni.cz 125 Matrix placement ➢Matrix primarily is used when a proximal surface is to be restored The objectives: - Provide proper contact - Provide proper contour - Confine the restorative material - Reduce the amount of excess material lroubal@med.muni.cz 126 Matrices ➢Ivory I retainer Ivory 1 ➢ Hawe Neos retainer Ivory 8 ➢Tofelmire matrix and retainer lroubal@med.muni.cz 127 lroubal@med.muni.cz 128 lroubal@med.muni.cz 129 Wedges ➢ Wooden wedges - tighten the matrix band - compress the gingiva - separate the teeth lroubal@med.muni.cz 130 Wedging ➢Slip the matrix band over the tooth )apical to the gingiva margin – 0,5, - 1 mm) ➢Tighten the matrix, check it with probe ➢Place a wedge ➢Turn the retainer ¼ counterclockwise ➢ Contour the band 131 Amalgamators lroubal@med.muni.cz 132 Condensation of amalgam ◼ Condensor – with the straight front ◼Power driven condensation How big should the front be? lroubal@med.muni.cz 133 lroubal@med.muni.cz 134 lroubal@med.muni.cz 135 lroubal@med.muni.cz 136 lroubal@med.muni.cz 137 lroubal@med.muni.cz 138 lroubal@med.muni.cz 139 lroubal@med.muni.cz 140 lroubal@med.muni.cz 141 Base ➢Zinkoxidphosphate cement o ➢Zinkoxidkarboxylate cement x ➢Glass ionomer cementx ➢Zinkoxideugenolx On pulpal walls only! lroubal@med.muni.cz 142 The base must be hardened lroubal@med.muni.cz 143 Instruments ◼Preparation ◼Filling ◼Finishing and polishing 144 Condensor with the straight front 145 Frahm 146 147 Sapin lroubal@med.muni.cz 148 Discoid-cleoid 149 Amalgam carrier lroubal@med.muni.cz 150 Carving Burnishing Indications: Amalgam ̶ Moderate to large restorations ̶ If there is heavy occlusal loading (alternative onlay) ̶ Oral hygiene is not optimal (alternative dense glassionomer as middle term temporary) ̶ When ihe proper isolation is not possible ̶ Price Contraindications: Amalgam ̶ Aesthetically prominent areas of posterior teeth ̶ Small - moderate classes I. that can be well isolated Indications: Composite ̶ Aesthetically prominent areas of posterior teeth ̶ Small - moderate classes I. that can be well isolated ̶ Good level of oral hygiene is necessary Contraindications: Composite ̶ Moderate to large restorations ̶ Restorations that have heavy occlusal contacts ̶ Restorations that cannot be well isolated ̶ Restorations that extend onto the root surface (subgingival – margin relocation or lenghtening of the crown is necessary) ̶ Abutment teeth for removable partial dentures Composite - possibilities ̶ Conventional cavity (oclusal and proximal cavity) ̶ Adhesive slot ̶ Tunnel preparation ̶ Cusp replacement – direct, indirect. Definujte zápatí – název prezentace nebo pracoviště155 Interproximal borders Yes No Composite Amalgam Preparation 30 - 40° ? Cervical borders In enamel No bevel Cervical borders In dentin Preparation technique Oscillating instruments Class II. and contact point ̶ Matrix band + matrix retainer - Metal band (in primary teeth) Without matrix retainer Plastic band (polyester – e.g. Lucifix matrix) Sectional matrices with separator Contact point Contact area Matrix band and matrix retainer Composite filling class II. Contact point Sectional matrices ̶ Sectional matrices with separator Good adaptation Separation using wedge and separator 182 Sectional pre-contoured metal matrix system provided the highest contact tightness with the highest length of contact arc. Restorations with circumferential precontoured metal matrix system provided higher LCA than those with circumferential straight metal matrix with Tofflemire retainer and circumferential pre-contoured transparent matrix system“ Kampouropoulos D, Paximada C, Loukidis M, Kakaboura A. The influence of matrix type on the proximal contact in class II resin composite restorations. Oper Dent 2010; 35; 454-462 183 Use of the sectional matrix system in twosurface Class II cavities resulted in statistically significantly tighter proximal contacts than the use of the circumferential matrix system. For the three-surface no statistically significant differences in contact tightness were found between the different matrix systems.“ Wirsching E, LoomansB A, Klaiber B, Dörfer C E. Influence of matrix systems on proximal contact tightness of 2-and 3-surface posterior composite restorations in vivo. J Dent 2011; 39: 386–390 185 Step 1: Pre - wedging The wedge is inserted before preparation: Compression of gingiva Separation of teeth Together with the matrix protection of damage of neighbouring tooth Matrix for the filling can be inserted easier. 186 Step 2: preparation ̶ Preparation with the protection of neighbouring tooth using the metal strip or matrix. Definujte zápatí – název prezentace nebo pracoviště187 Step 3: adaptation of wedge, matrix and separator ̶ The wedge can be new or the same as previous, inserted from oral or vestibular side ̶ The matrix is 0,5 mm below the gingival wall ̶ Separator separates teeth Definujte zápatí – název prezentace nebo pracoviště188 Step 4 Making filling Definujte zápatí – název prezentace nebo pracoviště189 Kompozitní výplň II. třídy Kompozitní výplň II. třídy Kompozitní výplň II. třídy Sedelmayer Adhezivní slotová preparace Approximal Caries Approximal Caries Tunnel preparation Success? Low caries risk Special smal instruments Magnification BW post op