Restorative dentistry I., II., III. 3. Year L. Roubalíková lroubalikova@gmail.com Dental caries • Etiology and pathogenesis (dental biofilm, remineralization, importance of saliva) lenka.roubalikova@tiscali.cz 3 Understanding dental caries lenka.roubalikova@tiscali.cz 4 crown neck root pulp chamber root canal 5 tooth microbs sugar time Dental caries caries Factors that are necessary for origin of dental caries lenka.roubalikova@tiscali.cz 6 Dental Caries Infectious microbiological disease of the teeth that results in localized dissolution and destruction of the calcified dental tissues. lenka.roubalikova@tiscali.cz 7 Biofilm – Dental Plaque Complex community Microbs live in symbiosis Biofilm is permeable Microbs have good conditions to survive and are much less sensitive to antimicrobial agents in comparison to planctonic form lenka.roubalikova@tiscali.cz 8 Dental Biofilm – Dental Plaque A gelatinous mass of bacteria adhering to the tooth surface. lenka.roubalikova@tiscali.cz 9 Dental biofilm • Adhesion • Colonisation • Maturation lenka.roubalikova@tiscali.cz 10 Sugars Fermentable (mono-, di- tri- sacharides) Sucrose, glucose, lactose Acids Demineralization Demineralization Time Cavitated lesion Non cavitatated lesion lenka.roubalikova@tiscali.cz 12 Importance of saliva • Plaque formation • Microbial source • Mineral source • Microbial clearence (removes microbs from oral cavity) • Buffer capacity lenka.roubalikova@tiscali.cz 13 Caries danger areas (Habitually unclean places) • Pits and fissures • Proximal surfaces • Cervical area No self cleaning lenka.roubalikova@tiscali.cz 14 Predictable (habitually) clean areas • Cusps • Proximal ridge, oblique, transverse ridge • Incisal edge • Buccal or oral surface upon the maximal convexity • Proximal surface upon the contact point Self cleaning lenka.roubalikova@tiscali.cz 15 Caries - depth • Surface caries (caries superficialis) • Middle caries (caries media) • Caries close to pulp (caries pulpae proxima) • Caries penetrating into the pulp (caries ad pulpam penetrans) Deep caries lenka.roubalikova@tiscali.cz 16 lenka.roubalikova@tiscali.cz 17 lenka.roubalikova@tiscali.cz 18 Caries - Topography • Coronal caries • Root surface caries • Enamel caries • Dentin caries • Cementum caries lenka.roubalikova@tiscali.cz 19 Caries Acute Chronic Arrested • Penetrating • Undermining Acc to its history lenka.roubalikova@tiscali.cz 20 Primary caries Secondary caries Recurrent caries lenka.roubalikova@tiscali.cz 21 Diagnosis of dental caries lenka.roubalikova@tiscali.cz 22 Investigation • Mirror • Sharp Probe • Illimunation • Magnification • X- ray, other methods i.e. transillumination, infrared laser fluorescency (Diagnodent, Diagnocam) Dark spot, white spot, hole, defect lenka.roubalikova@tiscali.cz 23 Dental Caries - Treatment • Non cavitated lesion: On molecular basis - Dental hygiene - Fluorides, Calcium, Phosphates - Diet - Antimicrobial agents (ozone, chlorhexidine) lenka.roubalikova@tiscali.cz 24 Dental Caries - Treatment • Cavitated lesion: Preparation Filling Drill anf fill lenka.roubalikova@tiscali.cz 25 Preparation Instrumental treatment Remove caries Leave the rest of the dental tissues - to be restored - to be resistent against the bite forces - to be prevented against the recurrent caries (Black 1914) lenka.roubalikova@tiscali.cz 26 Classification of cavities according to Black lenka.roubalikova@tiscali.cz 27 Class I. Caries in fissures and pits – occlusal surfaces of premolars and molars 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 lingual surfaces of molars. R.on lingual surface of maxillary incisors. lenka.roubalikova@tiscali.cz 29 Class II. Proximal surfaces of molars and premolars lenka.roubalikova@tiscali.cz 30 Class III. Proximal surfaces of incisors and canines without loss of the incisal edge lenka.roubalikova@tiscali.cz 31 Class IV Proximal surfaces of incisors and canines with the loss of incisal edge lenka.roubalikova@tiscali.cz 32 Class V. Cervical area lenka.roubalikova@tiscali.cz 33 Class VI. Caries on abraded incisal edges. Classification of dental caries Mount and Hume • Location 1.Occlusal 2. Proximal 3.Cevical • Size 1.Small 2. Medium 3. Big 3.Large Classification of dental caries Mount and Hume Examples: 1,2 – caries in fissures or a pit, medium size 3,4 – caries in cervical area, large size Indication od filling materials Material of the first choice Material of the second choice Material of the third choice Materiális possible to use with limitations Material is not indicated Consideration Caries - Size - Location Choice of material Regional circumstances Intermaxillary relations Bite forces Patient - General health - Cooperation LR Indications of filling materials Class I. Material Mount and Hume 11 12 13 14 Amalgam Composite Glassionomer Indirect restoration aesth. Inlay metal Indications of filling materials class II. Material 21 22 23 24 Amalgam Composite Glassionomer Indirect restoration aesth. Inlay metal Indications of filling materials class III. Material 21 22 23 24 Amalgam Composite Glassionomer Indirect restoration aesth. Inlay metal LR Indications of filling materials class IV. Material 21 22 23 24 Amalgam Composite Glassionomer Indirect restoration aesth. Inlay metal LR Indications of filling materials class V. anterior teeth Material 21 22 23 24 Amalgam Composite Glassionomer Indirect restoration aesth. Inlay metal LR Indications of filling materials class V. posterior teeth Material 21 22 23 24 Amalgam Composite Glassionomer Indirect restoration aesth. Inlay metal Indications of filling materials class V. acc. to cavosurface margin Material Enamel Enamel cementum Cement um Amalgam Composite Glassionomer Indirect restoration aesth. Inlay metal Amalgam Indication 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  Big reconstruction (core)  Temporary fillings  (intermittent excavation). Sturdevandt´s Art of Science of Operative Dentistry 45 Amalgam  Highest abrasion resistance  Isolation of operating field is not a critical factor  Preparation must be exact 46 Sturdevandt´s Art of Science… 47 Sturdevandt´s Art of Science… 48 lenka.roubalikovatiscali.cz 49 Sedelmayer J. Amalgám – zapomenuté řemeslo. The most common mistakes Preparation - Sharp edges - Bad configuration of the gingival wall - Rough margins - Weakening opf the proximal ridge Manipulaion - Trituration – rpm, time. 52 Contemporary trends in treatment of dental caries • Miniinvasion • Adhesive techniques Indications • Class III., IV., V. • Aesthetically prominent areas of posterior teeth, small – moderate restoration class I., II. • Large restoration only in areas without heavy occlusal stress • Good level of oral hygiene is necessary Contraindications • Moderate to large restorations esp. Areas with heavy occlusal stress • 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. Glassionomers - advantages • Chemical binding to hard dental tissues • Thermal expansion similar to dentin • Release fluoride ions (caries control restoration) • Not sensitive to moisture Glassionomers-disadvantages • Long time for setting – sensitive to moisture • Difficult sculpting - impossible • Not high aesthetics • Lower mechanical resistance (wear resistance, flexural strength, hardness) Glassionomers - indications • Class V., III. – cavities out of enamel or/and patients with lower level of oral hygiene. • Class I., II. – caries control filling (inner remoneralization), composite material on the top is strongly recommended (weeks – months later). Tunnel fillings. Glassionomers contraindications • Class V., III. – cavities in enamel in patienst with good oral hygiene • Class IV. • Class I., II. – permenent filling (esp. larg – moderate restorations) Composites in posterior teeth Indications • Aesthetically prominent areas of posterior teeth • Small - moderate classes I. that can be well isolated, large cavities only without heavy occlusal stress • 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 diamond burs (roundedn cylinder or ball) Cavosurface margin • Outline includes the caries lesion only • Fissures going into the ceries lesion can be open and sealed (resommended). 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 only. Removal of carious, infected, dentin and remaining defective enamel. • Spoon excavator or a slowly revolving , round carbid bur of appropriate size. • Sharp hand instrument Polymerization shrinkage and polymerization stress Polymerization shrinkage Polymerization shrinkage Surface of adhesion/free surface of the filling 1/1 and less is optimal C – factor (Configuration factor) 5 2 1 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 depend on - Composite material (content of filler) Higher content of filler - lower shrinkage, higher polymerization stress. Forces of polymerization shrinkage depend on Geometry of the cavity (C-factor) Higher C-factor – higher stress Forces of polymerization shrinkage depend on - Placement of the composite: - Create the first layer thin, flowable can be used (Flowables – lower content of filler, higher shrinkage, lower polymerization stress) - Place the material in increments with respect of the C-factor of each layer (each layer with large free surface). Maximum 1,5 mm Forces of polymerization shrinkage depend on - Mode of polymerization Phases - Pre-gel (in this phase the material is still soft) - G-point (material become hard) - Post –gel (end of shrinkage –postgel shrinkage) Monomer Light Polymerization Polymer Pre –gel phase should be prolongated – soft start polymerization Gel Post –gel Now soft start seems not to be so important !!! Pre gel phase should be long – soft start !!!! Marginal adaptation depends on • Placement of composite material • Dry operating field • Adhesive systems Adhesives • Acid etching technique • Selfetching adhesive systems Adhesives • Acid etching technique Etching Washing Priming Bonding Adhesives • Selfetching adhesive systems Priming Bonding Less bonding strength in comparison to acid teching technique Adhesives • Active and passive bonding Active – rubbing with microbrush (selfetching) Passive – without any rubbing (acid etching) WRONG – Higher c- factor Adhesive preparation in a fissure Adhesive preparation Preparation of enamel borders Preparation 45° Next to cusp 50-60°, Never cover the cusp Preparation of enamel borders Incremental technique Flowable Building cusp by cusp Miniinvasive treatment – small cavity, Opening of fissures, preservation of intact areas - ridges Composite filling – class II. • Critical factors - contact area (contact point) - dry operating field (marginal adaptaion) Preparation • Occlusal cavity – class I. • Proximal cavity Preparace 30 - 40° ? Cervical margin In enamel No bevel Cervical margin Out of enamel Preparation technique Interproximal vertical margins Yes No Proximal Preparation with oscillating instrument Matrices Bands (metal,transparent) Retainers Hawe Neos (0,03 mm) Optra (thin matrices – 10 micrometers) Sectional matrices With separator and wedge Optra contact – special instrument OR Contouring of the matrix band using a ball condensor Miniinvasive techniques • Adhesive slot • Tunnel Sedelmayer Adhesive slot preparation Horizontal slot Horizontal slot – oscillating instrument Tunnel preparation 1. Low caries risk 2. Good cooperation of the npatient 3. Marginal ridge without any infraction 1. Loupes or microscope 2. Miniinstruments 3. Capsulated GIC or composite 5. BW post op Success of the tunnel ART ART Bulk fill composites Placement and curing in one layer 4 mm 1. Flowables – SDR Flow (Dentsply), Venus Bulk Fill (Hereaus Kulzer), X-tra fill (VOCO), Filtek Bulk Fill (3M ESPE). 2. Bulk high density composites (Tetric EvoCeram Bulk Fill (Ivoclar –Vivadent) a QuiXfill (Dentsply). 3. Sonic Fill (KaVo) Sonic Fill 1 bulk ( 5 mm) Sonic activation – decreasing of viscosity Inner scattering of light – good aesthetics Long term experience necessary lenka.roubalikova@ti scali.cz 130 lenka.roubalikova@tiscali.cz Bulk Fill composites • Flowables 131SDR Flow (Dentsply), Venus Bulk Fill (Heraeus Kulzer), X-tra fil (VOCO) nebo Filtek Bulk Fill (3M ESPE). Bulk Fill composites • High viscosity Tetric EvoCeram Bulk Fill (Ivoclar Vivadent) a QuiXfil (Dentsply) Sonic Fill Sonic Fill Možnost plnění kavity v jednom bloku (do 5 mm) Sonická „aktivace“ – změna viskozity Vnitřní rozptyl světla – dobrá estetika Chybí dlouhodobé zkušenosti Srovnatelné s jinými materiály 136 Comprehension • Bulk Fill is a new approach to posterior composite restorations • The handling must follow instructions • Maximum layer is 4 mm • Aesthetics is acceptable bur not so high as composite fillings made by incremental technique Postoperative sensitivity marginal discoloration gap cracks in enamel Versluis 2000 Problems – can we solve them? Marginal ditching Recurrent caries Bending of the cusps