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Reso OPERATIVE DENTISTRY

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Reso OPERATIVE
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Reso  Operative Dentistry
urce
conte TREATMENT PLANNING
nt SEQUENCE OF TREATMENT

1. Relief of pain  is the most important and initial step.

2. Control of active disease and Achievement of stability   eg OHI, dietary advice,

fluoride application, temporary restoration, amalgam fillings, composite, RCT,
extraction.

3. Reassessment of success of initial treatment, OH, periodontal conditions and

prognosis of teeth.
4.Restorative / Definitive procedures eg .  fixed or removable replacement , crowns,
bridges, etc

4. Regular monitoring , reassessing ,reviewing and maintenance.

 
DENTAL PAIN
CLASSIFIED AS :Pulpal,Peri apical/Peri radicular,Non-dental Pain.

PULPAL PAIN

The dental pulp does not contain any proprioceptive nerve endings,therefore a

characteristic of pulpal pain is that patient unable to localise the effected tooth.
Blood Supply = Vitality(sensibility) 
Not the nerve supply.

REVERSIBLE PULPITIS

Symptoms:  Sharp Pain on cold/hot/sweet immediate onset,difficult to locate,Pain quickly

subsides after the removal of stimulus .Pain last <1minute.

Signs: Exaggerated response to pulp testing.Caries or leaky restoration.

Rx: Remove the aetiology,place a sedative dressing ZOE(temporary) or permanent
restoration with suitable pulp protection.

IRREVERSIBLE PULPITIS

SYMPTOMS:   SPONTANEOUS PAIN last for hours,pulsatile in nature,be worst at night

,characteristic feature pain remains after removal of stimulus. Localisation of pain may be
difficult initially, but as the inflammation spreads to the periodical tooth will become
more sensitive to pressure.
Signs:  reduced or no response to electric pulp tester. in later stage TTP.

Rx: Extirpation of pulp and RCT

 
Different Inflammatory processes on Periapical tissues and resultant radiographic
appearances
State of INFLAMMATION Underlying Inflammatory Radiographic
Changes Appearances
Initial Acute Inflammation - Inflammatory exudate Widening of radiolucent
accumulates in apical line periodontal ligament
periodontal ligament space
space.                   Or
  No apparent changes
- Acute apical periodontitis evident
Initial Spread of - Resorption of destruction Loss of radiopaque line of
 Inflammation of Apical bony socket.
- Periapical Abscess
Further Spread of Further resorption and
Inflammation destruction of apical
alveolar bone.
Initial Low Grade Chronic Minimal destruction of
Inflammation apical bone. The body�s
defence system lay down
dense bone in apical
region
lamina dura at apex.
Area of bone loss at apex
No apparant bone
destruction but dense
sclerotic bone seen.
Sclerosing osteitis.

Table - Classic signs and symptoms for differential diagnoses for dental pain.
Unfortunately, not all symptoms fall into these clear categories
and experience is required for their interpretation
 
Acute
Apical Acute Exposed
Acute Periodon Apical Acute/Lateral   sensitive Food
  Pulpitis titis Abscess periodontal abscess dentine packing
Generalized
pain thermal
Localized swelling , tactile or
Recent pain Tender Pain and often associated osmotic stim Pain after
History with to bite. swelling with bad taste ulus eating
Very well
Well localized.
hot and localized.  pain distur fibrous
  cold. May Dull pain bed sleep. Some pain. food, e.g.
 be very
  severe.       meat.
Poorly
  localized.          
             
May be
Possibly Possibly extraoral Gingival Open
Clinical caries or caries. or Intraoral swelling recession. contact
examinati recent intraoral Exposed points.
on large   swelling nearer to gingival dentine Gingival

over apex at the inflammati

  restoration.   of tooth. margin. Tooth gingival on.
margin. Food
        may be mobile. Sensitive usually
to probe or
          cold present.
          air.  
Vitality Hypersensi May still May be
test tive. be vital, Non-vital. Often vital. Vital. vital or
but
    usually       non-vital.

    non-vital.        
Percussio Tender to Not
n Not tender. Tender. touch. Too Slight tenderness, Not tender. tender to
tender to percussion
      percuss. more to lateral   . May be
        than axial   sore with
 lateral
percussion
        pressure.   .
Raised
Other temperatu Floss
clinical     re. Deep pockets. Pus   passes the
contact
tests     Looks ill. may be released   easily.

        on probing    
        pocket.    

changes
ranges
form PDL
widening
to obvious
Radiograp Probably Usually radiolucen vertical or horizontal May be
hic caries no cy bone some None.
close to periapica alveolar
findings pulp. No l loss. Usually no bone  
periapical change
  change. in early periapical change. loss.  
stage.
PDL periodonta
    widening l      
membrane
      .      
Findings Carious Necrotic Pus may      
 on exposure of pulp. be drained
via abscess
further pulp.   cavity to      
investigati root canal
ons     without      
local
anaestheti
      c,      
giving
      immediate      
relief of
      pain and      
confirming
      the      
diagnosis.

           

Phoenix abscess is an acute flare up of previously asymptomatic tooth. 

 
Isolation of tooth:
Advantages:

�      Aids visibility
�      Prevent contamination

�      Provide aseptic environment

�      Prevent aspiration of foreign material

Equipment Used:

1.   High volume suction e.g aspiration

2.   Low volume suction e.g Saliva ejector

3.   Compressed air

4.   Absorbents e.g cotton wool roll, carboxymethycellulose.

5.   Rubber dam.(6 inches or 15 cm)

Mandatory when fitting crowns, bridges, inlays & carrying out RCT (mandatory).
  clamps Can be winged or wingless (used for broken tooth or with poor access)

Gingival Retraction:

�      Reduces gingival fluid

�      Expose sub gingival preparation

�      Bleeding from gingival margins is reduced by applying astringent e.g aluminum

chloride.

Electrosurgery:

Is used when margin extends subgingivally & gingival overgrowth is interfering in

restorations, impression taking.

Also used during crown lengthening procedure.

Principles of Cavity Preparation

Basic Principles of Cavity Preparation

1.    Outline Form:
It encompasses the carious lesion, grossly unsupported enamel and is made up of smooth
angles rather than sharp edges.

2.    Resistance Form:
Refers to the features of cavity design that allows tooth and restoration to resist
masticatory stress without fracture.

3.    Retention Form:
Resist displacement of final restoration.

4.    Management of Remaining Caries:

 
�      Cavity to be caries free
�      Great care to be taken to remove all caries and stained dentine form ADJ
�      Stained but hard dentine may be left in deepest part of cavity
�      Soft dentine to be removed.
 
5.    Enamel Margin Finishing
 

Tooth Preparation Walls for Cavity

1.    Internal Wall:

It is prepared (cut) surface that does not extend to external tooth surfaces.
2.    Axial Wall:

Internal wall parallel to long axis of the tooth.

3.    Pulpal Wall:

Internal wall that is perpendicular to long axis of tooth and occlusal of pulp.

4.    External Wall:

It extends to external tooth surface.

5.    Floor

It is prepared wall that is reasonably flat and perpendicular to occlusal forces that are
directed occlusogingivally.
 
Tooth Preparation Angles

1.    Line Angle:
 It is the function of two planal surfaces of different orientation along a line.

2.    Point Angle:
It is the function of three planal surfaces of different orientation.

3.    Cavosurface Angle
It is the angle of tooth structure formed by junction of prepared wall and external surface
of tooth. Should be 90�.Minimun 90-110 for amalgam to prevent ditching.
Marginal strength of restorative material for a particular cavity is a major factor for
determining best CSA.
 
 

 
 
 
GV Black Classified carious lesions into 6 types based on their location:
      Class I: Carious lesions on the occlusal areas

      Class II: Carious lesions on the proximal surface of any tooth

      Class III: Carious lesions on the anterior inter-proximal surfaces of the tooth.

      Class IV: Carious lesions on the anterior inter-proximal surfaces of the tooth including
the incisal corners.

      Class V: Carious lesion on the cervical third of buccal or lingual surface of any teeth

      Class VI: Carious lesion on tip of the cusp of posterior teeth.

 
Class 1 Cavity
     Most widely used material is amalgam
      -If enamel margins are cut to an angle of 90 degrees (or if cusps steeply inclined >70
degrees), the resultant will be adequately retentive.

Preventive Resin Preparation/ Enamel Biopsy

      Minimal resin composite restoration or sealant restoration

      Minimal access in enamel
     Restored with composite , alternatively GIC can be used
  
Class II Cavity

Different ways to approach approximal carious lesion

 Occlusal through marginal ridge                 
 If teeth are tilted
      Buccally/ lingually
 When adjacent teeth missing directly
 Just occlusally/ leaving the margin Buccally.
 Ridge intact known as Tunnel preparation. ( minimum 2 mm of intact ridge should be
present)

Advantage of Tunnel Prep

      Overall strength of tooth is preserved

      Approach is more oblique so as to preserve marginal ridge

      RMGIC is used to fill the bulk of the preparation and occlusal access cavity restored with
posterior resin composite.

Approach with Composite

Sequence
      Pre-wedge to open contact area
      Prepared cavity with rounded line angles and bevelled approximal margins

   Isolate the tooth

   Acid Etch enamel, apply thin layer of enamel bonding agent and air disperse

      Place dentine bonding agent

      Place matrix, re-wedge

      Apply and cure not more than 0.5 mm of composite at the cervical margin to avoid
shrinkage and marginal failure

      Build and cure remainder in 2mm increments complete occlusal surface.

       
 ZOE cannot be used in composite as it retardes polymerisation

Approach with Amalgam

      Cavity slightly narrower occlusally than gingivally

      CSA = 90-110 degrees

      Remove undermined enamel and rounded internal line angles and removal of caries at
DEJ( to prevent lateral spread)

      Remove unsupported enamel

      Isthumus not more than 1/4 th to 1/5 th of intercuspal distance(1.5-2 mm)

      90 degree butt joint is required in the box

      Place small vertical retention grooves using small rosehead bur in buccal and lingual
walls of approximal box inside ADJ

      Apply metal matrix band and wedge

      Improper placement of both wedge and matrix band cause overhang.

      Improper placement of wedge causes overhang

      If Improper placement of matrix band causes open contact

      If filling inadequate due to improper band placement, band placed too gingivally will
result in gingival overhang

Function of Matrix Band

Restore anatomical contours and establish good contact.

Class III Cavity

      Preferably using palatal approach as buccal enamel should remain intact

      Use labial approach only when direct access is possible (due to anterior teeth crowding)

Class IV Cavity

      Caused either by trauma or collapse of large inter-proximal lesion affecting anterior

teeth.

      Little or no cavity preparation is required

       Long labial bevel helps with retention and allow composite and tooth to blend together
naturally

Class V Cavity

      Cervical caries

      Access lesion, extend until the ADJ is caries free

      Gingival margin outline often sublingual

      GIC has longest longevity

       
Extra points

 Cervical wedge shaped lesion caused by bringing must be restored with hybrid
composites as have better strength.

�       For deep caries. Always treat as reversible pulpitis

�       For ditched amalgam no redoing is required
ne      Newly placed restoration look for occlusion to check high points . If high point pt will
have Pain and apical periodontitis.

�       Every time a cavity is redone , increases cavity on average by 0.6mm.

 BURS: made of steel,stainless steel,tungsten carbide(single use) and diamond drift.
(autoclaved)

�       
Choice of Restorative Material
Amalgam
      Large/ multisurface restoration in molars (high occlusal loads)
      Repair of extensive amalgam restoration
Composite
      Fissure sealant
      Class I and II in posterior teeth
      Class III
      Class V (aesthetics)
      Class IV (considering layering technique)

GIC
      Root caries
      Class III (e.g. xerostomia)

Compomers
      Non-carious cervical lesions
 RMGIC
                Liners and bases
      Luting cements
      Root surface caries
      Cervical caries
 
 
Pinned restoration
-Stainless steel, titanium or GOLD plated

 -Most clinicians avoid dentine pins as pulpal exposure or perforation into periodontal
ligament is a threat.

-self threaded> friction lock> cemented ( for retention)

- one pin per cusp is the rule

- 2mm depth is maximum for restoration

- decreases  compressive and tensile strength

 
Crowns
 Indications

a) Destruction of tooth structure due to caries

- If large amount of tooth structure is destroyed due to caries and insufficient coronal
tooth structure remains to retain restoration within crown, then it needs an extra coronal
restoration or crown.

b) Refine Occlusion

c) Aesthetics
- Discolouration
- Improving shape e.g. peg laterals
- Correcting minor anterior tooth rotations and displacements

d) Part of FPD

e) Telescopic crowns
- When post insertion of FPD does not coincide with the long axis of tooth, the design
involved fabrication of two copings one over the other.
1.    First one to align the tooth properly by changing its morphology and
2.    Second fits over first along the path of insertion.

Types of Crown
1.          Based on tooth coverage
2.    Based on material being used

Based on Tooth Coverage

1.      
2.    Partial veneer crowns

a) 3-quarter crown (with intact buccal surface, used in maxillary posterior teeth where
aesthetics is not of main concern)

b) Reverse 3-quarter crown (with intact lingual surface, usually in mandibular posterior)

c) Seven eight crowns (3-quarter crown, which extends to half of (mesial or distal) of
buccal surface).

d) Proximal half crowns (it is s a 3-quarter crown rotated at 90 degrees with intact distal
surface. Used as a retainer over mesially tilted mandibular teeth and can not be used
when distal surface is damaged.

3.     Conservative/ Dentin Bonded/ Resin Bonded Crowns

      They require minimal tooth preparation, e.g. acid etching.

      Cannot accept heavy occlusal load and are primarily indicated for anterior teeth.

      Useful for tooth wear cases or where preparation taper is large or crown height poor.

Materials Used in Crown Fabrication 

A) All Metallic

1. Dental Gold:

Type I: Class 3 or inlays (soft)

Type II: Inlays, 3-quarter crowns (medium)
Type III: Crowns / Dentures (hard)
Type IV: Posts and denture bases (extra hard)
      Due to increased use of composite and ceramic in-lays, type I and type II are rarely used.
A Preparation of >135 degrees  is advisable to give good marginal fit to restoration and to
allow burnishing.

      White gold contains silver and palladium  ,used in crown and bridgework. More hard and
durable but difficult to cast.
      Addition to gold alloys
      Silver: increased hardness and strength but increased tarnishing and increase porosity.
      Platinum/ Palladium: increased melting point
      Zinc or Indium:preventing oxidation of three metals during melting.

2. Cobalt Chromium Alloys:

                40-50% cobalt
      20-30% Chromium
      Small amount of Ni and carbon. They do not bond to porcelain used in making crown and
bridgework.

3. Ni-Chromium Alloys
      80% Nickel
  20% Chromium
Bonds to porcelain
 It is not as strong as cobalt or chromium
Nickel is possibly carcinogen and allergen.

4. Steel Alloys
Iron and carbon alloy system where carbon acts as interstitial filler in Fe lattice
Types:
a) Martensite: Hard and brittle but not corrosion resistant. Used for scalpel blade.
b) Austenitic steel: (corrosion resistant)
18:8 (Chromium/Nickel)
12:12 (Chromium/Nickel)
B) All Ceramic
They have following generations.
a) The oldest method was die-platinum foil and porcelain mixed with water to give
translucency

b) After this, aluminium reinforced porcelain, which was opaque in nature, so extra
porcelain had to be added.

(INCERAM) and advancement after INCERAM (in 2l reinforced) are procera/milled

porcelain core.

c) Castable glass ceramic: porcelain crown made by using centrifugal casting machine
(DICOR)

d) Pressed ceramic: At high temperature to a die and then building with transitional
porcelain (empress).

e) Laboratory build cores and crowns: CADCAM.

f) Zirconia: They are the latest, very dense white, very strong, porcelain has to be
relatively thick to mask.
 C) Metal Ceramic
Cast Metal Ceramic Restorations Swaged Metal Ceramic Restorations
A. Cast Noble Metal Alloys (Feldspathic Good Alloy Foil Coping
Porcelain).
B. Cast Base Metal Alloys Bonded Platinum Foil Coping
C. Cast titanium (ultralow fusing  
porcelain)
TYPES:

Metal Ceramic Crown (PFM Crown): Porcelain fused to metal

1.   Used when limited occlusal space and high functional loads.

2.   Relies on ability of porcelain to bond to metal oxide.
3.   Usually have metal (when very limited occlusal space) or porcelain on palatal surface.
4.   BUTT JOINT labially (1.5 mm shoulder to allow adequate metal and porcelain)
CHAMFER Margin palatally.(0.5mm)
 
Advantages:
    Long lasting
   Better fit( If the proximal contour /margins not finished properly results in
gingival papillae swelling)
    Increase strength

Disadvantages:
     More reduction
   Non aesthetic as metal will show through.
      Prone to chipping or #
     Grey line around Gum can be seen.

PORCELAIN JACKET CROWN:

Indications:
1.   Aesthics is of prime concern.
2.   Usually Butt joint around whole preparation (minimum, 1mm shoulder to allow adequate
porcelain for aesthetics)
3.   Need 1.5mm thickness of porcelain incisally.
4.     
 
 
FULL GOLD CROWN
1.   Chamfer finish line overall (0.5 mm)
2.   Functional cusp bevel 1.5 mm
3.   Other occlusal areas 1mm
 
EXTRA POINTS
     functioncal cusp  are palatal for upper, buccal for lower
    non- functional cusp is BULL buccal upper and lower lingual
     for any crown ideal is 6 degree taper, upto 10 degrees is acceptable
   after 18 years crowns and bridges should be given.
 

 
Materials Wear-Off Opposing Teeth

Porcelain > Amalgam > gold. Composite itself gets worn-off against enamel. 
Steps in Crown Preparation
1. Assessment of Tooth to be Crowned
 
It involves:
 
-       Radiograph for periapical assessment, bone support, periodontal support,
caries etc.
-       Vitality test
-       Percussion test
-       Periodontal assessment by probing around tooth
-       Mobility test
-       Palpation around apices of teeth in buccal and lingual sulcus.
 
2. Shade Taking
3. Bite Registration
4. Taking Impression for Temporary Crown of Tooth to be prepared and alginate
impression of opposing arch.
 
 
 
Core Restorations
 Badly broken down teeth require extensive multisurface restoration known as core.
Various types of cores can be used depending upon  whether tooth is vital or root filled.
 

 
Non-Vital / Root Filled Teeth
 Nayyor core/ coronal-radicular amalgam core/amalcore
�      Used for core placement in root filled pre-molars and molars

Technique
Remove GP to a depth 3-4 mm and place restorative material into coronal pulp chamber
before building the rest of core.

Post Retained Crowns

- provides retention and support  but not strength
Indications
�      When there is insufficient coronal dentine to withstand occlusal forces or retain a crown
�      The post length should be two third of root length
�      In general, sound root canal filling must be present (leave 4mm) with no apical
pathology evident before post placement.
  the circled part shows the  ferrule
effect
Types:
1.
      Prefabricated or custom made
      Parallel sided or tapered
      Threaded, smooth or serrated
2.
      Lab mode (indirect)
      Prefabricated (direct)

 Cast Post Core Systems

       Made of cast gold, sometimes wrought gold post and cast gold core.

Here, pressure on as much coronal dentine as possible.

      Resist rotational forces by means of anti-rotational grooves or parallel pins.

 Prefabricated Post core Systems

Material Used:
      Stainless Steel
      Brass
      Titanium
      Nickel-Chromium
      Ceramic
      Carbon Fibre
Advantages
1.    They can be placed directly so avoiding laboratory stage
2.    Easy to use
3.    Cheap

Wrought posts are the strongest.

      Parallel sided posts are more retentive than tapered
      Lateral perforation are commonly associated with parallel post than tapered
 Parallel-sided non-threaded posts are accepted to be the one of the most retentive

Red post is duralay taken for direct impression for prepared root canal for custom-made
post.

Problems
1.    Root perforation (failing to judge root alignment)
2.    Root fracture (very wide posts)(vertical)                                                                              
3.    Post de-bonding (shots, tapered roots)
4.    Fracture post
5.    Corrosion
6.    Avoid threaded one as it increases
-       Internal stress
-       Large post in curved roots
-       Large diameter in small tapered post.
Perforations
Depends on location of perforation
      If in coronal third, try to incorporate into design of post crown. E.g. Diaphragm post and
core
      If middle third  seal perforations (lateral condensation)
      For apical 2/3rd  surgical approach. If building/ repairing  use MTA.
 
 
Non-Carious Tooth Surface Loss
Tooth Wear
It is defined as the surface loss of dental hard tissues other than by caries/ trauma and is
sometimes known as "Tooth Surface Loss".
 Dental Erosion
It is irreversible loss of dental hard tissue due to chemical process not involving bacteria
and not directly associated with mechanical or traumatic factors or with dental caries.

Identifying Erosion

      Teeth loose their micro-anatomical enamel features and develop a "glazed" or "silky"
appearance.

      Teeth loose normal contours causing curved enamel areas to flatten and become
"dished-out"eventually.

      Scooping or cupping particularly on the occlusal surfaces can be seen as dentine

becomes exposed.

Intrinsic Acidic Sources Extrinsic Acidic Sources

Gastro-oesophegal reflex Environmental
Vomiting Dietary
Rumination  
 
Medication and Oral Hygiene Products
      Vitamin C tablets
      Aspirin
      Fe preparation
Lifestyle
      Exposure to extrinsic acidic sources
      Xerostomia
Gastro-oesophegal reflex
Sphincter Incompetence
      Oesophagitis 
 Alcohol
      Hiatus Hernia
      Pregnancy
      Diet
      Drugs e.g. diazepam
      Neuromuscular e.g. cerebral palsy.

Vomiting
      Psychosomatic
      Stress Induced
      Eating disorder (anorexia and bulimia nervosa).
 
  
Metabolic and Endocrine
      Uremia
      Diabetes
      Pregnancy

Attrition
�      It is the wear that occurs from tooth to tooth contact without the presence of food.
�      It occurs from tooth grinding either nocturnally while asleep or diurnally.

Identifying Attrition
�      Presence of facets
�      Enamel flaking and cusp fractures
�      Symptoms of various craniomandibular disorders.

Aetiology
�      Bruxism
�      Lack of posterior support and occlusal collapse
�      Salivary flow and composition
�      Compromised tooth structure (Amelogenesis/ Dentinogenesis Imperfecta).

Abrasion
It is the loss of tooth substance by wears due to factor other than tooth contact.

Aetiology
�      Aggressive oral hygiene technique (tooth brush, toothpaste and interdental cleaning)
�      Habitual chewing (pens/ pencils, fingernails, nut shells).
�      Occupational, chewing (electrical wire, fishing line, ironmongery) etc.
 
Abfraction
�      It is the loss of cervical hard tissue due to occlusal overloading.
�      Possibly a form of stress corrosion involving interaction between occlusal loading and
 erosion.
�      Check pH of medication, mouthwash.

Treatment Options for NCTSL

1.    Cast metal (nickel / chromium or gold)
Advantages
�      Very durable
�      Very accurate fit
�      Does not abrade opposing dentition
�      Suitable for posterior restorations in para-function.

Disadvantages
�      Cosmetically unacceptable
�      Cannot be repaired.
 
2.    Composite
  Advantages Disadvantages
Direct Least expensive, cant be Difficult for palatal veneer,
added and repaired, limited control over inter-
aesthetic better proximal contour
Indirect Control over occlusal Unproven durability.
contour and vertical
dimension, can be used as
palatal veneer
 
3.    Porcelain
Advantages:
�      Best aesthetic
�      Good abrasion resistance
Management
�      Early and accurate diagnosis
�      After diagnosis monitor progression
Diagnosis
�      Careful and detailed history
�      Importance of medical and social history
�      Smith and Knight tooth wear index
�      Study casts (every 6 months)
�      Clinical pictures
�      Putty indices
�      Dietary analysis (diet chart every 3 -4 days of which at-lest 1 days should be weekened).

Palliative Measures
�      Fluoride mouthwash and varnish
�      Desensitising toothpaste
�      Topical application of Desensitising agents
�      Anti- reflux medication
�      Sugar free chewing gums

Management Based on Diet Chart

�      Limit acidic food stuffs and drinks to meal times
�      After intake of alkaline food have something to neutralize the effect (cheese, milk)
�      Avoid tooth brushing after intake of acidic substances
�      Well tolerated by gingival tissues
 Provisional Intervention
         . Provide an adhesively retained gold onlay.
           Provision of posterior support e.g. partial dentures
   Increase in vertical dimension e.g. splint, temporary denture.

Bleaching
Aim to whiten darkened/discoloured teeth.
�      According to new law, the percentage of hydrogen peroxide allowed in tooth whitening
or bleaching products is 6%
�      In the first use of cycle by the dentist, the tooth whitening products containing or
releasing not more than 0.1% of H2O2.
�      According to new regulation use of hydrogen peroxide and other compounds or
mixtures that release H2O2, including carbamide peroxide and zinc peroxide, 10%
carbamide peroxide yield 3.6% H2O2, therefore 16% carbamide peroxide would be
permitted releasing up to 6% H2O2.

Mechanism of Options
�      Bleaching agents diffuse through porous enamel.
�      Oxidation of larger chromogens is broken down into smaller molecules that reflect less
light.
Clinical Techniques
Vital Teeth
�      Over the counter products
�      Professional home use
�      Professional surgery applied products
Over the Counter Products
�      Bleaching gels
�      White strips (USA)
�      Usually effective in about 2 weeks

Professional Home-Use Products

�      Night-guard vital bleaching

�      Applied for 2-3 hours per day for 2-3 weeks using custom fabricated bleaching tray.

Professional Surgery Applied Products

Here, higher concentrations of H2O2 are used. Due to increased concentration, bleaching
is quicker (approx. 1 hour).

Technique Involves
1.    Pre-op assessment, shade guide/photos/check allergies/warn patient that composite
restorations will need replacing.
2.    Prophylaxis 
3.    Protect gingival either with sealed rubber dam or paint on dam (flowable composite).
4.    Activate hydrogen peroxide liquid and prepare fresh mix of bleaching gel.
5.    Apply to teeth in small zone 2-3mm thick
6.    Activate with light, if using
7.    May need to repeat 2-3 times over 1 hour.
Patient may have sensitivity.
1.    Use fluoride gels or potassium nitrate containing toothpaste applied topically.

Non-Vital Teeth
�      Chairside bleaching
�      Walking bleaching technique
�      Inside-Outside bleaching
Chair-side Bleaching
1.    Remove restoration obturating access cavity and only grossly stained dentine
2.    Apply rubber dam and seal margins with varnish or unfilled resin
3.    Cut back coronal gutta-percha to just below gingival level and seal with thin layer of GIC
4.    Etch dentine with phosphoric acid gel for 30 -60s to remove smear layer and open up
dentine tubules. Wash and dry
5.    Load cotton pledget with H2O2 and place in coronal pulp chambers
6.    Apply heat using flat plastic or similar instrument.
7.    Repeat 5 or 6 times.

Walking Bleach Technique

1.    Remove palatal restoration, apply rubber dam and seal coronal access cavity as for chair-
side bleaching
2.    Combine hydrogen peroxide with sodium perborate
3.    Etch dentine with phosphoric acid gel for 30-60s to remove smear layer and open up
dentine tubules; wash and dry.
4.    Apply peroxide/ perborate mix to coronal dentine and seal with cotton pledget and GIC
5.    Review in 1 week, need to repeat 3 or 4 times
6.    Restore with dentine-bonded composite.

In-lays
Inter-coronal restorations fabricated in laboratory and cemented into place.
Types
1.    Gold
2.    Composite
3.    Porcelain
    Fermit(temporary)
Uses
1.    Class II mainly
Advantages
1.    Alternative to amalgam
2.    Protects weakened cusp
3.    Aesthetic
Disdvantages
1.    Require 2 clinical stages
2.    Increased tooth tissue destruction
3.    Micro leakage
4.    Recurrent caries
5.    Marginal diagnoses not easy on radiograph with composite or porcelain

Onlays
Extra-coronal restorations given on occlusal surface of a tooth.
Types
As of inlays
Uses
1.    Tooth wear where less destruction alternative has to be given to increase vertical
dimension of occlusion
2.    For fractured cusp
3.    Arrested caries
4.    More supragingival.

Fixed Bridges
�      A bridge is a dental prosthesis that replaces a missing tooth or teeth and is attached
permanently to one or more natural teeth (or implants).
�     cannot be removed  by the patient.

Definitions
Abutment tooth:  Tooth that supports a bridge.

Retainer: Part of a bridge, which is cemented to an abutment tooth.

Pontic: Each replacement tooth in a bridge. (artifical tooth)

Unit: no of units= no of retainers + no of pontic

Pier Abutment : Non-terminal abutment. 

Indication
1.    Aesthetics
2.    Occlusal stability
3.    Prevention of drifting, tilting and over-eruption
4.    Function (for posterior teeth)
5.    Minimal soft tissue coverage.

Disadvantages
1.    More expensive
2.    Suitable for short spans
3.    Extensive tooth preparation
4.    Abutment must be in good alignment and functionally stable.

Conventional Fixed-Fixed Bridge

All joints are cast in one piece to connect abutment teeth rigidity.

Clinical Procedures
1.    Abutment Preparation
Tooth preparation should be undertaken according to design
�      Metal occlusal surface (less tooth surface)
�      Porcelain occlusal (more tooth reduction occlusally)
�      Metal collar (chamfer margin).
 
2.    Impressions: Elastomeric impression of abutments, often with use of gingival retraction
cord.
 
3.    Occlusal Registration: Recorded either in wax or polyvinylsiloxane.
4.    Shade taking
5.    Temporary Bridge
6.    Try-in of Casting
7.    Check prior to bridge cementation
           Marginal fit
          Occlusion
         Aesthetics
         patient consent
         Access for oral hygiene measures
         Speech
8.    Trial Cementation: Cement bridge temporarily for a short period (1-2 weeks)

9.    Final Cementation: With GIC, ZnPolycarboxylate

10. Review: Periodic radiograph are useful for easily detection of caries, endodontic or

periodontal problems involving abutment teeth. 
Life Span: 10-15 years.

Cantilever Bridge
This type of bridge has pontic connected to retainer at one end only.

Indications
1.    Low occlusal load
2.    Replacement of lateral incisors with canine as abutment
3.    Replacement of one pre-molar
4.    Can use twin abutments e.g.: first molar and second pre-molar as abutment to first pre-
molar.

Advantages
1.    One abutment does not require parallelism
2.    More conservative of tooth tissue

Disadvantages
1.    Excess forces on abutment.

Fixed Movable Bridges

A fixed-moveable bridge has a joint allowing limited movement between pontic and
retainer.
Uses
For malaligned abutment teeth, e.g. mesially tilted lower molar.

Spring Cantilever Bridges

Support a pontic at some distance from the retainer.
�      A gold bar which is in contact with palatal mucosa connect pontic to retainer
�      Rarely used.
Use
Replacing spaced anterior teeth.
Adhesive Bridges/ Resin bonded bridge

�      Works on micro-mechanical bonding of composite resin or chemically active resin to

etched enamel and etched or sandblasted metal.

Indications
1.    Short span
2.    Sound enamel available
3.    Favourable occlusion
4.    Small occlusion forces (no Bruxism)
5.    Intermediate restoration 
6.    Missing lateral incisors
7.    Young patient with large pulps
8.    Virgin abutment teeth
9.    Splinting teeth

Types:

1.    Unperforated Framework (micromechanical bonding)   Maryland Bridge

2.    Perforated Framework (macromechanical retention)  Rochette Bridge

3.    Temporary (uses natural tooth or acrylic or composite as pontic).

�      Most commonly Unperforated frameworks are used.

�      Covers maximum area of available enamel  180 degree wrap around

Design

�      Incorporate largest area of enamel without compromising aesthetic

�      Need 0.5 mm occlusal clearance, supragingival chamfer margins.

 Life Span = approx. 7-8 years.
 
maximum retention is  6>7> 4
maximum support 6>7>4
 PRINCIPAL SOURCES AND FURTHER READING:
-Operative dentistry  dental update, The British Dental Journal
- B.G.N Smith 1997 Planning and making crowns and Bridges
- Pickard's Manual of Operative dentistry.
-Oxford Handbook of Clinical dentistry 5th edition chapter 6