operative dentistry motamiz oprd 41 lectures lecture 4 wed

Operative dentistry

Motamiz OPRD 41 Lectures

lecture 5

WED 15-4-2020

Patient Assessment, Examination,

Diagnosis and Treatment Planning

Examination of non carious lesions

1 Tooth wear

Erosion Attrition Abrasion

2 Developmental enamel hypocalcification

3 Fracture or craze line


Attrition

Physical wear of one tooth against another. Affects

the incisal edges and occlusal surfaces of opposing

teeth. May be accelerated by erosion or may be

aused entirely by bruxism or other parafunctional

activities.


Abrasion

Commonly affects the neck of the buccal surfaces of both

anterior and posterior teeth. The etiology is not clear, but

some dentists believe that it is caused by physical wear

from external agents such as:

- Abrasive toothpastes and powders.

- Hard toothbrushes or excessive use of other cleaning aids.


Erosion

a Regurgitation erosion:

Affects palatal surfaces of upper anterior teeth and occlusal and buccal surfaces of lower posterior teeth.


Erosion

b Dietary erosion:

Affects the labial surfaces of

upper anterior teeth. Caused

by an excess of food and

drink with a low pH as Citrus

fruits, Pickles and carbonated

drinks.


c Industrial erosion: Commonly affects the labial surfaces of the

upper anterior teeth and may cause pitting.

Caused by industrial processes which produce

acid fumes or droplets.

It is a cervical, wedge shaped defect that

is angular. Occur due to heavy force in

eccentric occlusion. It has the same clinical

features as abrasion but mare aggressive form.

Erosion

Abfracion


2 Non hereditary developmental enamel

hypocalicification areas

It have man resulted factors

such as childhood fever, trauma

or fluorosis that occurred during

the developmental stages of tooth

formation. It is opaque white and

remain visible regardless if the

tooth is wet or dry.


3- Fracture or craze line

It is usually occurs in teeth with extensive restoration,

weakened cusps and deep developmental fissures

across marginal or cusp ridges. It is detected by dye

material, light reflected from a dental mirror or

transillumination.

Examination of existing restorations

I Clinical examination of Amalgam restorations

Amalgam restorations can be examined using:

a Visual observation.

b Tactile sense with the explorer.

c Dental floss

d Radiographs (Bitewing).


Clinical examination of amalgam restorations may show:

(1) Amalgam blues (2) Proximal overhangs


(3) Marginal ditching

(4) Voids It occurs at the margins of amalgam restorations. It is

at least 0.3 mm deep. Small voids may be corrected

by recontouring or repairing with a small restoration.

It is the deterioration of the

amalgamtooth interface as a result

of wear, fracture or improper tooth

preparation.


(5) Fractures

(6) Improper anatomic contours

Proper anatomy Improper anatomy


(7) Improper proximal contacts

Proper contact

incompatibility ridge ) Marginal8(

caries ) Recurrent9(

Open contact & incompatible marginal ridge height

http://jada.info/content/136/10/1426/F3.expansion.html


Examination of composite restorations

Ideal restoration Recurrent caries

Fractured restoration Marginal discoloration

http://jada.ada.org/content/vol136/issue10/images/large/1426fig7.jpeg


Examination of cast restorations

Proper cast restoration Improper margins

Chipped porcelain

Adjunctive aids for examination

1 Percussion: It is done by gentle tapping of

occlusal or incisal surfaces by the

use of mirror handle.

2 Palpation: It is rubbing the index finger along the facial and

lingual mucosa overlying the apical region to detect

a periapical pathosis in teeth showing tenderness to

Percussion


3 Vitality test •Cold: ethylchloride or

pencil of ice

• Hot: hot gutta percha or instrument

Thermal test

•No response means pulp death

•Tingling sensation means vital pulp.

Electric pulp tester


4 Cavity test: It used round bur without anesthesia, a cavity is made through the restoration into dentin.

5 Anesthetic test: It must be used anesthesia for the suspected tooth and if the symptoms subside, so affected tooth has been identified.

6 Study cast

Clinical examination of non caries lesions:

1- Tooth wear occurs naturally throughout life and so it is common to

find moderate degrees of wear in older people. Tooth wear happened

as a result of: Attrition, Abrasion, abfracture and Erosion.

Attrition:

It loss of hard tooth structure due to physical wear of contacting teeth

due to normal physiologic phenomenon as mastication. It affects incisal

edges and occlusal surfaces of opposing teeth. May be accelerated by

pathologic conditions as bruxism or other parafunctional activities.

Abrasion:

It is loss of hard tooth structure due to use of an external object e.g.

hard tooth brush, whitening tooth paste and smokers tooth powder. Also,

habits such as thread biting and pipe smoking can cause wear in the form

of notches in the incisal edges.

It commonly affects the neck of the buccal surfaces of both anterior

and posterior teeth. The surface of the defect is smooth and varies

according to the causative factor. The most common form of the lesion is

the wedge shaped defect resulting from excessive tooth-brushing.

Erosion:

Erosion is loss of hard tooth structure due to chemical agents as acids.

It is the most common and most damaging cause of tooth loss. There are

different types of erosion as:

a-Regurgitation erosion:

Commonly affects the palatal surfaces of upper anterior teeth and the

occlusal and buccal surfaces of lower posterior teeth. Caused by the

regurgitation of hydrochloric acid from the stomach in patients with:

Various digestive disorders.

Anorexia and bulimia nervosa.

Chronic alcoholism

Morning sickness associated with pregnancy.

Voluntary regurgitation.

b- Dietary erosion:

Commonly affects the labial surfaces of upper anterior teeth. Caused

by using food and drink with a low pH, including:

Citrus fruit and fruit juices (citric acid).

Pickles and other food and drink containing vinegar (acetic acid)

Carbonated drinks.

c- Industrial erosion:

Commonly affects the labial surfaces of the upper anterior teeth and

may cause pitting. Caused by industrial processes which produce acid

fumes or droplets.

Abfraction:

It is a cervical, wedge shaped defect that is angular. It is similar to

abrasion but in a more aggressive form. Occurs due to heavy occlusal

force associated with eccentric occlusion. It is hypothesized that bending

forces produce tension stresses at the neck of the affected teeth. These

stresses cause micro-fractures at the CEJ of the teeth resulted in a wedge

shaped or V shaped defect.

2- Non hereditary developmental enamel hypocalicification areas:

Many factors can resulted in enamel hypocalcification such as

childhood fever, trauma or fluorosis that occurred during the

developmental stages of tooth formation. It is opaque white and remains

visible regardless if the tooth is wet or dry.

3- Fracture or craze line:

Craze lines commonly appear in old age and considered as potential

cleavage planes for possible future fractures e.g. in teeth with extensive

restoration and weakened cusps and deep developmental fissures across

marginal or cusp ridges. It can be diagnosed using dye material or light

reflected from a dental mirror. Minor fractures can be treated by

recontouring but in extensive case the tooth should be restored.

Clinical examination of existing restoration:

I- Clinical examination of Amalgam restorations:

Evaluation of all restorations must be done in a clean, dry, well

lighted field using one of the following methods:

a- Visual observation.

b- Tactile sense with the explorer.

b- Dental floss

d- Interpretation of radiographs

Amalgam restorations may have (10) distinct conditions, when they are

evaluated:

1 - Amalgam blues.

2 - Proximal overhangs.

3 - Marginal ditching.

4 - Voids.

5 - Fracture lines.

6 - Improper anatomic contours.

7 - Marginal ridge incompatibility.

8 - Improper proximal contacts.

9 - Recurrent caries.

10- Improper occlusal contacts.

(1) Amalgam blues:

It is seen through the enamel in teeth that have amalgam

restorations. This bluish discoloration resulted either from leaching of

corrosion products of amalgam into the dentinal tubules or from the color

of underlying amalgam as seen through translucent enamel. The latter

occur when no dentin support such as in undermined cusps, marginal

ridges, and region adjacent to proximal margins.

(2) Marginal ditching:

It is the deterioration of the amalgam-tooth interface as a result of

wear, fracture or improper tooth preparation.It can be diagnosed visually

or tactilely using an explorer. Shallow ditching less than 0.5 deep have no

need for restoration replacement. However if the ditch is too deep, the

restoration should be replaced to avoid secondary caries around the

restoration.

(3) Proximal overhangs:

It is diagnosed visually, tactilely using an explorer,

radiographically or by using dental floss. Overhangs resulted in plaque

accumulation and so it requires restoration replacement.

(4) Voids:

It is occur at the margins of amalgam restorations. It is at least 0.3

mm deep and is located in the gingival third of the tooth crown so it must

be repaired or replaced. Small voids in the marginal area where the

enamel is thicker may be corrected by recontouring or repairing with a

small restoration.

(5) Fracture lines:

Isthmus fracture is the most common fracture line occurs in amalgam

restoration. It indicates replacement of the defective restoration.

(6) Improper anatomic contours:

Inadequate embrasure form or proximal contact which prevents the

use of dental floss, indicates recontouring or replacement of the

restoration.

(7) Marginal ridge incompatibility:

Marginal ridge of amalgam restoration should be compatible with the

adjacent marginal ridge. If marginal ridges are not compatible and are

associated with poor tissue health, food impaction or inability to use

dental floss so restoration should be recontoured or replaced.

(8) Improper proximal contacts:

This leads to poor interproximal tissue health and/or food impaction

so restoration should be replaced.

(9) Recurrent caries:

It is detected visually, tactilely or radiographically. It considered an

indication for repair or replacement.

(10) Improper occlusal contacts:

It cause improper occlusal function which results in inefficient

mastication and/or tooth movement. This condition needs correction or

replacement.

Clinical examination of cast restorations:

It should be evaluated in the same manner as amalgam. In case of

any defect or tissue harm repair replacement of the restoration should be

considered.

Clinical examination of composite restorations:

Tooth colored restorations should be evaluated clinically in the

same manner as amalgam and cast restorations. Corrective procedures

include recontouring, polishing repairing or replacing should be done.

The main concern with anterior teeth is the esthetics. Marginal

discoloration that is non carious may be corrected by a small repair

restoration along the margin. If the stain is superficial it can be removed

by resurfacing. But in deep stains or those involve the bulk of the

restoration, total replacement or veneering would be indicated.

Adjunctive aids for examining teeth and restorations:

1- Percussion:

It is done by gentle tapping the occlusal or incisal surface of the

teeth by the use of mirror handle to determine the presence of tenderness

indicating periapical involvement:

A- Pain on vertical percussion indicating periapical involvement.

B- Pain on lateral percussion indicating periodontal involvement.

C- Sometimes the maxillary teeth exhibit a false pain on percussion in

case of chronic sinusitis.

2- Palpation:

It is done with teeth tender to percussion to determine the presence

of periapical or periodontal abscess. It is performed by rubbing the index

finger along the facial and lingual mucosa overlying the apical region to

detect periapical pathosis.

3- Vitality test:

A- Thermal test:

It is used to detect the pulp vitality, either by cold or hot testing.

- A cotton applicator tip sprayed with a freezing agent

(ethychloride).

- Pencil of ice.

- Hot instrument.

- Hot guttapercha directly to tooth.

B- Electric pulp tester:

It should be placed on the tooth and not on the restoration. It causes

tingling effect when the pulp is vital. In case of no response, this

indicates pulp death. It is important to obtain readings on adjacent and

contra-lateral teeth to evaluate the affected tooth response.

4- Cavity Test:

It is used when there is no other means to diagnose the pulp vitality

or in presence of large restoration in the tooth. Round bur is used without

anesthesia to drill a cavity through the restoration into dentin.

Lack of sensitivity may indicate a non vital pulp. But it give a

false-negative response in case of sclerotic dentin or Multi-rooted teeth.

5- Anesthetic test:

If the patient is not able to localize the affected tooth, anesthesia

test used to determine the suspected tooth. If the symptoms subside, so

the affecting tooth has been identified.

6- Study cast:

The dentist can gain much information through an evaluation of

study cast. In accessible area can be seen:

- Understanding of occlusal relationships such as tilted, rotated or

extruded teeth, cross bite and plunger cusps.

- Development of treatment plan without patient presence which will

be saving time.

operative dentistry motamiz oprd 41 lectures lecture 4 wed

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