Restorative dentistry -treatment of dental caries I. Doc. MUDr. Lenka Roubalíková, Ph.D. 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 parasita 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 Fi m b ri es Biofilm ■ Colonization - multiplication - koagregation Biofilm ental biofilm ■ Komunity Higher metabolic activity Higher resistency (CHX 300x, AF 75x) Hihger virulency Good conditions for survival lenka.roubalikova@tiscali.cz li 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 ofilm Glycolysis Base production Stephan Rozpousteni HA 5,7 FA 4,6 0 ova@tiscali.cz 50 mm 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 (lml). 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 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.org/courses/english/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. 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. Code 4 before sectioning tooth 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: n Žádná nebo nepatrná změna v pnJsvitnosti skloviny po delším osušavání vzduchem (>5 sekund). Žádná demineralizace skloviny anebo Úzká opáknízóna. 1: □ Gpácita nebo diskolorace obtížné viditelné na mokrém povrchu, avšak jasně zřetelná po osušení vzduchem. Demineralizace skloviny omezená na vnějších 50 % vrstvy skloviny 2: □ Opacita nebo dískolorace jasně zřetelná bez osušení vzduch-em. Bez rozpoznatelné kJ i nic ke kavitace. Demineralizace zasa h u|ici mezi' o0 % skloviny a vnější třetinou dentinu 3: □ Lokalizované porušení skloviny v opákní nebo diskolorované skloviněH +/- nasedla diskolorace ze spodního dentinu. Demineralizace zasahuje prostřední třetinu dentinu. 4: Kavltace v opákni a dís-kolorované sklovine ohrožující spodní dentin. Demineralizace zasahujevnitřni třetinu dentinu ■ UniViss - universal scoring systém (okluze) Active/non active lesion Second step: Discoloration Assessment Universal Visual Scoring System for pits and fissures (UiiiViSS occlusal') First Step: Lesion Detection & Severity Assessment First visible signj or a (Bílíš tealon ExtablishEd car lĚSlúrl Micmravřty .nnrMnr lur/ali^ed funic. ChíriLin ejcpuxuie Pu Ip eK|xj£uie feÁrŕ í| N*ľ oi'/itstons or ŕ&;oori:luiiŕ art lelettaDIs. White (Sonrr 1} □ \-~ Wlíľte-Browri (SMre Z} □ H ■ (D.-rkJ Brrv.vn ;Srůrs JJ t J r GJreyisn IranslucerKy (Score 4J UniViss ( smooth surfaces) Bitewing Grading Klinické: Identifikace - Vyšetření: Bitewing rtg Leze skloviny ICDAS E1 Vnější polovina skloviny tu E2 Vnitrní polovina skloviny 1 Leze dentin u ICDAS D1 Vnější "tretina dentinu 2 D2 Prostřední třetina dentinu 3 D3 Vnitrní třetina dentinu 4 Kontrola za 2 roky u počátečních lází D-1 [modrá) a D-2 (červená) D-1 a- EM 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 DIAGNODENT I DIAGNODENT perio probe (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 DIFOTI (Digital Fibre Optic Trans-Illumination) Camera ccd sensor 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 l DIAGNOCam-clasification o - í-Tirst visiDie signs DIAGNOCam- klasifikace am- asitikace nálezu 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 I ■ Ztráta vápníku a fosfátů - zvyšování elektrické vodivosti sklovinl ■ 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 RESTORATIVE DENTISTRY II. 3. YEAR J' T * *" L. Roubalíková lroubalikova@gmail.com 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. 72 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 I X mf-' 1 'MV' ' ^^reffka. rouDai iKova^nscal i. cz Classification Black ■ Class III. acc. to Proximal surfaces of incisors and canines 10 ici ii\ci.i uuuciMi\uvcnuyiiöuciN.CZ 1 Classification acc. to Ii Black ■ Class IV. 1 Proximal surfaces of incisors and canines with lost an incisal ridge - ■ 79 lenka.roubalikova@tiscali.cz Classification acc Black ■ Class V. cervical lesions to 80 lenka.roubalikova@tiscali.cz 1 Indication od filling materials I výplňových materiálů Material of the first choice Material of the second choice Material of the third choice - Materialis possible to use with limitations ■ Material is not indicated Consideration Caries - Size - Location Patient -General health -Cooperation Regional circumstances Intermaxillary relations Bite forces :ions of filling .s 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 III» I ^ -L Material Enamel Enamel cementům Cement urn Amalgam Composite Glassionomer Indirect restoration aesth. Inlay metal Longevity of restorations in posterior teeth lenka.roubalikova@tiscali.cz Failure (> 2 roky) Amalgam Indikace S 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 * 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, M assort 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. Versluis 2000 C - factor Surface of adhesion/free surface of the filling l/l ftiid less is ODtimftl 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 ^1 &pend on High content of the filler causes bigger stress m5estp 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 oh?« Light Polymerization Monomer r