Management of Deep and Extensive Lesions PDF

Dr. Nesrine Elsahn 9/23/2024 Complete Caries removal Partial caries removal  Differentiation between...

Dr. Nesrine Elsahn 9/23/2024 Complete Caries removal Partial caries removal  Differentiation between affected and infected X  There could be irreparable dentin (Caries detector damage by bacterial dye). invasion so every trace of  Chemo-mechanical caries carious dentin should be removal (Carisolv), ozone, removed. enzymes, guided laser cutting.  step wise excavation and  If pulp exposed then do indirect pulp capping. Endo.  If pulp exposed do direct pulp capping if indicated. Black’s Conservatism Dr. Nesrine Elsahn X Dr. Nesrine Elsahn 1 Dr. Nesrine Elsahn 9/23/2024 Dr. Nesrine Elsahn Dr. Nesrine Elsahn 2 Dr. Nesrine Elsahn 9/23/2024  When a pulpal or axial wall has been established at the proper initial tooth preparation position, and a small amount of infected carious material remains, only this material should be removed, leaving a rounded, concave area in the wall. The level or position of the wall peripheral to the caries removal depression should not be altered. Dr. Nesrine Elsahn Dr. Nesrine Elsahn 3 Dr. Nesrine Elsahn 9/23/2024 Dr. Nesrine Elsahn Dr. Nesrine Elsahn 4 Dr. Nesrine Elsahn 9/23/2024 outer (surface) side Zone 1: Infected Infected Soft & Lighter in color Non-sensitive Zone 2: Turbid Collagen is irreversibly denatured Zone 3: Transparent Un-re-mineralizable Dead Zone 4: Sub-transparent Affected Zone 5: Normal Hard& Discolored Sensitive Collagen matrix is intact Re-mineralizable Inner (pulpal) side Alive Dr. Nesrine Elsahn In the cavity periphery: The excavation endpoint is hard dentin (to seal the margin and increase the longevity of the restoration). In proximity to the pulp: Selective removal to firm dentin for shallow or moderately deep lesions. Selective removal to leathery or even soft dentin for deep lesions with vital painless pulp. Deform when an instrument is pressed into it. Easily scooped up with little force. Doesn’t deform, easily lifted without much force. Resistant to hand excavation, needs pressure to lift it. Only burs or sharp instruments will lift it. Scratchy sound when a probe is taken across the dentin. Dr. Nesrine Elsahn 5 Dr. Nesrine Elsahn 9/23/2024 Acute Caries Chronic caries Dr. Nesrine Elsahn  Rapid process involve multiple  Slow long-standing. teeth. dark brown. lighter colored    Caseous consistency makes the  Leathery. excavation difficult.  Sensitive teeth  Pain is not a common feature  Small opening, limit buffering or  Reparative pulp reaction neutralization pulp destruction Acute Caries Chronic caries Dr. Nesrine Elsahn 6 Dr. Nesrine Elsahn 9/23/2024 The softening front of the lesion always precedes the discoloration front, which always precedes the bacterial front. Dr. Nesrine Elsahn In chronic caries, infected dentin usually is discolored, and because the bacterial front is close to the discoloration front, it is advisable, in caries removal, to remove all soft discolored dentin unless judged to be within 0.5 mm of the pulp. Because the discoloration is slight in acute caries, and the bacterial front is well behind the discoloration front, some discolored dentin may be left, although any “clinically remarkable” discoloration should be removed. Dr. Nesrine Elsahn 7 Dr. Nesrine Elsahn 9/23/2024 Dr. Nesrine Elsahn  Caries which becomes stationary or static and does not show any tendency for further progression  Arrested caries involving dentin shows a marked brown pigmentation.  Sclerosis of dentinal tubules and secondary dentin formation commonly occur.  Large open cavity in which there is lack of food retention. Dr. Nesrine Elsahn 8 Dr. Nesrine Elsahn 9/23/2024 Sclerotic Dentin The dentin becomes harder, denser, less sensitive and more protective to the pulp against subsequent irritation, due to deposition of more mineralized peritubular dentin around tome’s fibers. If further irritation occurs, the more peripheral dentinal tubules will be completely obliterated by peritubular dentin, replacing the ends of tomes fibers. This is called a Calcific Barrier. Dr. Nesrine Elsahn Removal of dentin caries (0.5mm from pulp) Complete Partial Step-wise No exposure With exposure Indirect capping excavation Capping Pulp Direct Capping material and protection capping and material and Well sealed and Final final final provisional Restoration restoration restoration restoration for 6-12 weeks Follow up Dr. Nesrine Elsahn 9 Dr. Nesrine Elsahn 9/23/2024 With either type of exposure, a more favorable prognosis for the pulp following direct pulp capping may be expected if: 1. The tooth has been asymptomatic (no spontaneous pain, normal response to thermal testing, and is vital) before the operative procedure. small, less than 0.5 mm in diameter. 2. The exposure is 3. There is No Hemorrhage from the exposure site or it is easily controlled. 4. The exposure occurred in a clean, uncontaminated field (such as provided by rubber dam isolation). 5. The exposure was relatively atraumatic and little desiccation of the tooth occurred. Dr. Nesrine Elsahn Criteria of success: 1. Pulp vitality is preserved 2. Tooth is asymptomatic. 3. No periapical changes radiographically 4. Radiographic evidences of reparative dentine formation. 5. Follow up (annual recall). Dr. Nesrine Elsahn 10 Dr. Nesrine Elsahn 9/23/2024  When a patient has numerous teeth with extensive active caries.  In one appointment, infected dentin is removed from several teeth and temporary restorations are placed.  After all the teeth containing extensive caries are so treated, then individual teeth are restored.  This procedure stops the progress of caries and allows many more teeth to remain serviceable than if a single, seriously involved tooth were treated to completion. Dr. Nesrine Elsahn Dr. Nesrine Elsahn 11 Dr. Nesrine Elsahn 9/23/2024 Dr. Nesrine Elsahn Dr. Nesrine Elsahn 12 Dr. Nesrine Elsahn 9/23/2024 Dr. Nesrine Elsahn Dr. Nesrine Elsahn 13 Dr. Nesrine Elsahn 9/23/2024 Dr. Nesrine Elsahn Dr. Nesrine Elsahn 14 Dr. Nesrine Elsahn 9/23/2024 Dr. Nesrine Elsahn Dr. Nesrine Elsahn 15 Dr. Nesrine Elsahn 9/23/2024 1- Calcium hydroxide:  capable of stimulating tertiary dentin formation. Drawbacks:  Short setting time and very sensitive to moisture.  Poor bonding to dentin.  Material resorption.  Porosities in the newly formed hard tissue (tunnel defect). undesirable areas facilitating the migration of the microorganisms towards the pulp and predisposing the tooth to an endodontic infection.  Doesn’t prevent microleakage in the long run.  Its high PH (12.5) causes liquefaction necrosis at the surface of the pulp tissues. Dr. Nesrine Elsahn 3- CH liner is highly soluble, but if its use is mandatory in direct pulp capping procedures, limit it to the exposure point. It has to be followed by: A. A reinforced or resin modified GI material as a pulp protective base in case of metallic final restorations. B. A sealing protective layer of GI or RMGI liner in case of non metallic restorations, to seal it and to reduce the effect of polymerization shrinkage that might pull the material out. Dr. Nesrine Elsahn 16 Dr. Nesrine Elsahn 9/23/2024 2- MTA:  calcium silicate-based material  used as a material of choice for all dentinal defect due to their biocompatibility & ability to induce Calcium phosphate precipitate at interface to periodontal ligament & bone tissue repair.  Drawbacks  Slow setting kinetics (140-170 minutes)  Complicated handling properties  induction of tooth discoloration  incompatibility with other dental materials when layered Dr. Nesrine Elsahn 3- Biodentin A calcium silicate-based dentin substitute Generates thick, dense and homogeneous reactionary dentin. Bioactive and biocompatible. Easy handling. Short setting time (12 minutes After mixing). Permanent dentin replacement. Temporary enamel replacement. Does not cause tooth discoloration. Dr. Nesrine Elsahn 17 Dr. Nesrine Elsahn 9/23/2024 Biodentin Vs MTA The main drawback of using Biodentine is its water-based chemistry and thus poor bonding as the bond is mainly micromechanical to the overlying resin restoration. 4- TheraCal LC Light-curable hydraulic resin-modified tricalcium silicate that sets by hydration. TheraCal LC does not include water for material hydration. Hence, the manufacturer’s instructions implement placing the material on moist dentin. Dr. Nesrine Elsahn 18 Dr. Nesrine Elsahn 9/23/2024 Advantages:  Some studies reported lower solubility and better sealing ability than the other pulp capping materials.  Facilitates the placement of the final restoration: Fast setting Resin based Drawbacks TheraCal is toxic to pulp fibroblasts and has a higher inflammatory effect and a lower bioactive potential than Biodentine due to the resin components. Dr. Nesrine Elsahn Liners and Bases 1. Remaining dentin thickness. 2. Type of restorative material: metallic or not 3. Adhesive properties of RM. Dr. Nesrine Elsahn 19 Dr. Nesrine Elsahn 9/23/2024 Liners and Bases The judgment for the need of specific liner or base depend on: 1. Remaining dentin thickness: when it is decrease the need for more intermediary material will increase. 2. Adhesive properties of restorative material: Adhesive materials should be applied directly except for pulpal medication. 3. Type of restorative material: metallic or non metalic. Dr. Nesrine Elsahn At the pulpal floor (and or) axial wall In the closest relation to the pulp Dr. Nesrine Elsahn 20 Dr. Nesrine Elsahn 9/23/2024 1- Sealers are always recommended with amalgam restorations only at any cavity depth to seal the DT against the metallic corrosive products. 2-In Cavities with moderate depth, In case of metallic final restorations only a reinforced or resin modified GI material is required as a base, or a base which is compatible with the cement selected for indirect metallic restorations. Dr. Nesrine Elsahn  In case of moderate or deep cavities for direct composite restorations:  A layer of flowable composite might be used under packable or highly filled composites 1. To increase the adaptation and sealing. 2. To act as an elastic layer to absorb stresses.  In moderately deep cavities, the sandwich technique and bulk-fill composite may be used. Dr. Nesrine Elsahn 21 Dr. Nesrine Elsahn 9/23/2024 A. The location of cavity margins in relation to central fissure and cusp tip  Dr. Nesrine Elsahn < 1/2 Distance between central fissure and cusp tip . 1/2 - 2/3 Distance between central fissure and cusp tip  based on 1-Thickness / height ratio (depth of the cavity) 2-Stresses (functional or non functional cusp) > 2/3 Distance between central fissure and cusp tip . Dr. Nesrine Elsahn 22 Dr. Nesrine Elsahn 9/23/2024 Spread chewing pressure uniformly Factors affecting selection 1. Extension of the lesion 2. The presence of micro-cracks 3. Chipping of enamel. 4. Occlusal forces and opposing They cover They extend occlusion. Tt may force the at least one facially and cusps apart under chewing cusp lingually pressure Dr. Nesrine Elsahn 3- Conservatism in obtaining the resistanCe and retention form Black’s Conservatism  Cavity width is governed by margin  Cavity width to be extended to provide placement midway between the cusp tip convenience and depth of the fissure  Cavity could be in dentin or in enamel.  Depth almost 0.5mm pulpal to DEJ.  Retention through micromechanical  Retention mainly through macromechanical bonding. Dr. Nesrine Elsahn 23