Management of Proximal Lesions 1 PDF

Dr. Nesrine Elsahn 9/14/2024 Dr. Nesrine Elsahn Detection of proximal caries Anterior teeth are more visible and accessible than posterior teeth ...

Dr. Nesrine Elsahn 9/14/2024 Dr. Nesrine Elsahn Detection of proximal caries Anterior teeth are more visible and accessible than posterior teeth  Visual examination Starts as a white spot on the proximal and the proximo-facial and lingual line angles. It can be visually detected as an alteration of the marginal ridge color after the lesion has considerably developed toward the marginal ridge. 1 Dr. Nesrine Elsahn 9/14/2024  When caries has invaded proximal enamel surface and has demineralized dentin, it leaves a white chalky appearance or a shadow under the marginal ridge. Dr.Nesrine Elsahn 2 Dr. Nesrine Elsahn 9/14/2024 Careful visual and tactile examination after temporary tooth separation (1-2 days) using orthodontic rubber rings (promotes a spacing from 0.2 to 1 mm). After separation, the injection of silicon impression material can help to verify cavitation. Delayed dental separation technique followed by impression. a Radiography showing radiolucent image on the mesial surface; b darkened aspect under the marginal ridge; c–e placing the rubber ring with dental floss straps; f separation was reached; g, h silicone injection into the space; i mold showing the presence of cavitation (arrow) Dr.Nesrine Elsahn 3 Dr. Nesrine Elsahn 9/14/2024 a, b Tooth separation that allowed enough space to have a direct view to the cavity, without the need of impression Dr.Nesrine Elsahn  Extensive cavitation result in undermining of the Marginal ridge that show as dark shadow below the MR. 4 Dr. Nesrine Elsahn 9/14/2024  Brown spots on intact, hard proximal enamel surface adjacent to and usually gingival to the contact area are often seen in older patients, in whom caries activity is low. These discolored areas are a result of extrinsic staining during earlier caries demineralizing episodes, each followed by a remineralization episode. These areas are no longer carious and are usually more resistant to caries as a result of fluorohydroxyapatite formation. Restorative treatment is not indicated.  Tactile examination. Catch Tearing Dr.Nesrine Elsahn 5 Dr. Nesrine Elsahn 9/14/2024  Tactile examination.  On the proximal surfaces, the tactile exam can be performed with a dental floss.  In case the dental floss comes to tear when passing this region, a cavity with sharp edges might be present in the region. Dr.Nesrine Elsahn  Fiber optic transillumination (FOTI and DIFOTI). Radiographically. Digital imaging  Doesn’t detect lesions in the early stages.  Doesn’t distinguish between the presence and absence of cavitation.  Overlapping the images may give false positive results. 6 Dr. Nesrine Elsahn 9/14/2024  It has to be noticed that lesions visible on a radiography have more deeply progressed histologically. Dr. Nesrine Elsahn Radiographic examination of the proximal surfaces has high specificity (95%) but onlyB: Radiographically: a moderate sensitivity (59%). However, sensitivity of 90.5% was observed when a digital software was used. (Logicon Caries Detector, Carestream Dental, Atlanta, GA, USA). 7 Dr. Nesrine Elsahn 9/14/2024 Cervical burnout appears as a radiolucent band around the necks of teeth and is more pronounced at the proximal edges. The X-ray photons overpenetrate or burn out the thinner tooth edge and May give false +ve response create the radiolucent area that mimics cervical caries It disappears in a periapical radiograph of the same tooth Dr.Nesrine Elsahn 8 Dr. Nesrine Elsahn 9/14/2024 Almost no cavitation Cavitation in 10-19% of cases Cavitation in 32% of cases Cavitation in 72% of cases Cavitation in 100% of cases Dr.Nesrine Elsahn Dr.Nesrine Elsahn 9 Dr. Nesrine Elsahn 9/14/2024 Dr.Nesrine Elsahn Dr.Nesrine Elsahn 10 Dr. Nesrine Elsahn 9/14/2024 Lesions hidden inside a periodontal pocket. Those lesions present a very fast progression. Dr.Nesrine Elsahn Dr.Nesrine Elsahn 11 Dr. Nesrine Elsahn 9/14/2024 Dr.Nesrine Elsahn Esthetic requirements and Function  NOC: Non-Operative care  TPOC: Tooth Preserving Operative care PSA: Plaque Stagnation Area Dr. Nesrine Elsahn 12 Dr. Nesrine Elsahn 9/14/2024 Dr. Nesrine Elsahn According to Black According to conservatism Proximal : Proximal Extended midway between axial line angle Facial and lingual margins extend just and facial or lingual margin of contact area. beyond the contact area to free it, with a clearance of 0.5mm for amalgam ( condensation forces might extrude excess material, and excess materials removal requires contact clearance). With composites, freeing the contact is not required but the B and L margins must be intact and smooth. The gingival margin extends below the The gingival margin extends just to crest of the healthy gum margin. include defects. Re-mineralization, proximal sealants (after tooth separation) or lesion infiltration for initial non cavitated lesion. Dr. Nesrine Elsahn 13 Dr. Nesrine Elsahn 9/14/2024 Dr. Nesrine Elsahn Dr. Nesrine Elsahn 14 Dr. Nesrine Elsahn 9/14/2024 Indications Resin infiltrate can be used to effectively arrest the progress of caries that x- rays show have not advanced farther than the outer third of the dentine (E1- D1). If x-rays show the lesion has advanced past the outer third of the dentine, treatment with Icon is no longer indicated. In this case, traditional invasive therapy is required. If initial lesions are detected on the neighboring tooth during an invasive treatment of a cavity, Icon can be used to stop the lesion in a straightforward way. Dr. Nesrine Elsahn  It is based on the infiltration of an initial enamel caries lesion with low-viscosity light-curing resins called infiltrants.  The surface layer is eroded and desiccated, followed by resin infiltrant application. The resin penetrates into the lesion microporosities driven by capillary force and is hardened by light curing.  Infiltrated lesions lose their whitish appearance and look similar to sound enamel. Additionally, the treatment prevents lesion progression. This technique might be an alternative to microabrasion and restorative treatment in treating of white spot lesions of esthetically relevant teeth. Dr. Nesrine Elsahn 15 Dr. Nesrine Elsahn 9/14/2024  Icon-Etch (15% hydrochloric acid gel) applied for 2 minutes erosion  Icon-Dry (Ethanol) applied for 30 seconds desiccation  Icon-Infiltrant (low viscosity resin)applied for 5 minutes infiltration by capillary force  Approximal-Tips  Dental wedges Dr. Nesrine Elsahn Dr. Nesrine Elsahn 16 Dr. Nesrine Elsahn 9/14/2024 Dr. Nesrine Elsahn Resin infiltration technique Pre-operative bitewing showing amalgam with marginal excess at 15 and several proximal initial lesions, including 14 (D) and 15 (D) Dr. Nesrine Elsahn 17 Dr. Nesrine Elsahn 9/14/2024 Resin infiltration technique Isolation by rubber dam and interdental wedges (amalgam in 15 removed) Etching (Icon Etch®) the demineralized area for two minutes (15D), Rinsing (30 s), Drying with air syringe Dehydration with 99% ethanol (Icon Dry®) Application of the infiltration resin using the proximal nozzle Dr. Nesrine Elsahn  Light polymerization of the infiltration resin from all angles for 40 s, after withdrawing the nozzle and removing excess resin with dental floss  Postoperative radiograph shows that the two lesions on 15 and 14 treated by resin infiltration have not progressed. Dr. Nesrine Elsahn 18 Dr. Nesrine Elsahn 9/14/2024 1. Simple class II design 2. Conventional. 3. Box-only (occlusal slot). 4. Tunnel. 5. Buccal or lingual slot. Conventional Box Tunnel Dr. Nesrine Elsahn a. Missing adjacent tooth. b. Senile caries with gingival recession. (accessible areas – very wide embrasure ) c. Rotated tooth with proximal surface facial or lingual d. Direct access through adjacent cavity Dr. Nesrine Elsahn 19 Dr. Nesrine Elsahn 9/14/2024  Indicated when the occlusal pits and fissures are caries free  Prepared with access from occlusal surface  Box shape cavity extending buccally and lingually to include the proximal caries. Composite and amalgam Preparation design!! Dr. Nesrine Elsahn The early proximal lesion on a posterior tooth will commence in enamel immediately below the contact area because this is where plaque will accumulate and mature. As the lesion develops, some degree of breakdown and cavitation of the enamel will eventually occur, but this will remain confined to the area below the contact until it is quite advanced. There will generally be a zone of demineralized enamel surrounding the cavitation. “The contact area may remain sound and the marginal ridge may be quite strong, provided the lesion is more than 2.5 mm below the crest of the marginal ridge“(Wilson and mcLean, 1988). Dr. Nesrine Elsahn 20 Dr. Nesrine Elsahn 9/14/2024 Indications and Contraindications Use of tunnel preparation can be considered when small, proximal carious lesions necessitate restoration with intact strong marginal ridge. Preparation should be avoided: i. Large carious lesion are diagnosed, where access is particularly difficult ii. Overlying marginal ridge is subjected to heavy occlusion or demonstrates a crack Dr. Nesrine Elsahn  “Access to the lesion through the occlusal surfaces should be limited to the extent required to achieve visibility and should be undertaken from an area that is not under direct occlusal load” (Knight, 1984).  Fossa immediately next to medial marginal ridge is the most suitable position for entry.  Glass ionomer is best suited for such cavities as it readily flows into a small cavity and has the ability to remineralize the enamel margins and any dentin on axial wall.  Two variations are described: Closed ‘tunnel’ : Which leaves the demineralized approximal enamel intact Open ‘tunnel’ : Which is accessed from occlusal and exits through the approximal surface Dr. Nesrine Elsahn 21 Dr. Nesrine Elsahn 9/14/2024 Although it preserves the marginal ridge,  Highly technique sensitive, demanding careful control of the preparation by the operator  Angulations of preparation often passes close pulp  Visibility is decreased and caries removal is more uncertain - caries detecting solution  Fragile marginal ridge - at least 2.5 mm apical to crest of the marginal ridge (Mount 1997) Dr. Nesrine Elsahn Indications The occlusal surface is intact Wide embrasure or gingival rescission Dr. Nesrine Elsahn 22 Dr. Nesrine Elsahn 9/14/2024  When facial or lingual slot design is used, retentive grooves are placed occlusally and cervically. Dr. Nesrine Elsahn Dr. Nesrine Elsahn 23