MALIHA SOBANI DIDC BATCH 1

Operative osce notes

PEADS

APEXIFICATION = is a method of inducing a calcified barriers at the apex of a non vital tooth
with incomplete root formation.

APEXOGENESIS= method of vital pulp therapy performed to encourage physiological

development and formation of the root end.

Types of fractures

Concussion: this is often brought to dentist attention until the tooth discolors

Subluxation: if there is slight mobility the parents are advised to keep the child on a soft diet for
1-2 weeks and keep the traumatized area as clean as possible. Marked mobility requires
extraction

Extrusive luxation: marked mobility requires extraction

Lateral luxation: if the crown is displaced palatally, the apex moves buccally and hence away
from the permanent tooth germ, if the occlusion if jagged , conservative treatment to await
some spontaneous realignment is possible. If the crown is displaced buccally, the apex will be
displaced towards the permanent tooth bud, and extraction is indicated to minimize further
damage to the permanent successor.

Intrusive luxation: this is the most common type of injury, the aim is to establish the direction
of displacement by thorough radiographic examination if the tooth is displaced palatally
towards the permanent successor , the primary tooth should be extracted to minimize further
damage. If the root is displaced buccally there should be periodic review for re-eruption. Review
should be weekly for a month. Then monthly for maximum 6 months, most eruption occurs 1-6
months. If these do not occur, ankylosis is likely, and extraction is necessary to prevent ectopic
eruption of the permanent successor.

Avulsion (exarticulation)= replantation of avulsed primary incisor is not recommended because

of the risk to the permanent tooth germ, space maintenance is not necessary following the loss
of primary incisor as only a minor drifting of adjacent teeth occurs. The eruption of the
permanent successor maybe delayed for about a year as a result of abnormal thickening of
connective tissue overlying the tooth germ.

SPLINTING

❖ Trauma may loosen a teeth by damaging the PDL/ fracturing the root
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❖ Splinting immbolizes the tooth in correct anatomical position so that further trauma is
prevented and the healing can occur. Different injuries require different splinting regime.
A functional splint involves one, and rigid splints involves 2. Abutment teeth on either
side of injured tooth.

Regimes: PDL injuries

60% of PDL healing has occurred after ten days, and it is complete within a month , the splinting
period should be as short as possible and the splint should allow some functional movement to
prevent replacement root resorption ( ankylosis) as a general rule exarticulation, avulsion,
injuries require 14 days and luxation injuries require 2-4 weeks of functional splinting.

Root fractures

❖ Generally apical and middle 3rd injuries require 4 weeks of functional splinting
❖ Coronal 3rd splinting may require 8 weeks
❖ Excessive mobility leads to fracture side become filled with granulation tissue.

Dentoalveolar fractures

- These require 3-4 weeks of rigid splinting

VITAL PULP

❖ Pulp capping
❖ Pulpotomy ( partial and complete)

NON VITAL

❖ Pulpectomy

VITAL PULP (PULPCAPPING)

❖ The procedure must be done 24 hours of the incident

❖ The tooth should be isolated with rubber dam
❖ And no instrument should be inserted into the exposure site
❖ Any bleeding should be controlled with sterile cotton wool which may be moistened
with saline or sodium hypochlorite and not with a blast of air from a 3 in one syringe,
which may drive debris and microorganisms into the pulp.
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❖ A layer of setting calcium hydroxide cement is then gently flowed over the exposed
surface and surrounding dentin and quickly over-layed with a bandage of adhesive
material (compomer)
❖ Pending definitive esthetic restoration at a later date a successful direct pulp cap wil
preserve the remaining pulp in health and should promote the deposition of a bridge or
reparative dentin to seal of the exposure site
❖ Review after a month , then 3 months and eventually at 6 months intervals for up to 4
years in order to assess pulp vitality
❖ Periodic radiograph should be taken to monitor dentin bridge formation and root growth
to exclude the development of necrosis, and resorption on the radiograph check the
following
❖ 1) root is growing in length
❖ 2) root is maturing (narrowing)
❖ 3) compare with antimere
❖ 4) if the pulp is not growing , pulp should be assumed non vital

Vital pulp therapy

PULPOTOMY

❖ A portion of exposed vital pulp to preserve the radicular vitality allow completion of
apical root development (apexogenis) and further deposition of dentin on the walls of
the root .This procedure is the treatment of choice following trauma where the pulp has
been exposed to the mouth for more 24 hours . The amount of the pulp that has been
removed depends on time, since exposure , which will also determine the depth of
contamination of the pulp attempts must be made to remove only the pulp that is
deened to be contaminated.
❖ If the patient present within 24-48 hours of the incident it is safe to assume that the
contaminated zone is more than 2-4 mm around the exposure site and only the pulp in
the immediate vicinity of the exposure is removed
❖ In modern term, partial pulptomoy ( cvek’s technique ) for more extensive exposures , or
coronal pulp can be removed down the cervical constriction of the tooth.

Pulpotomy procedures

❖ Give a better prognosis then pulp capping for small exposures, exposed for more than 24
hours
❖ Are not recommended if there are signs and symptoms of pathosis
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❖ Under local anesthesis and rubber dam, the pulp tissue is excised with a diamond bur
running it high speed under a constant water cooling , this causes least injury to the
underlying pulp and is preferred to hand excavation or the use of low speed bur .
❖ Microlabial invasion of exposed vital pulp is usually superficial and generally only 2-4mm
of pulp tissue should be removed ( partial pulpotomy)
❖ Excessive bleeding from the residual pulp which can not be controlled with moist cotton
wool or indeed no bleeding at all indicates that further excision is required to reach
healthy tissue ( coronal pulpotomy)
❖ Removal of tissue may occasionally extend more deeply into the tooth ( full coronal
pulpotomy) in an effort to preserve the apical portion of the pulp and safeguard apical
closure
❖ Gently rinse the wound with sterile saline or sodium hypochlorite 1-2% and remove any
shredded tissue or remaining tags of tissue in the coronal portion must be removed as
they may act as a nidus for re-infection and a pathway of coronal leakage.
❖ Apply a calcium hydroxide dressing to the pulp to destroy any remaining microorganisms
and promote calcify repair, in superficial wounds setting calcium hydroxide may be
gently flowed onto the pulp surface , but if the excision is deep it is often easier to
prepare a stiff mixture of calcium hydroxide powder ( analytical grate) in sterile saline or
local anesthetic solution which is carried to the canal in amalgam carrier and gently
packed and placed with plunger.
❖ Overlay the calcium hydroxide dressing with a hard cement to prevent its forceful
injection into the pulp by chewing forces and an adhesive restoration which will seal the
preparation against the re-entry of micrograms

Review

❖ After a month
❖ After 3 months
❖ At 6 montly interval upto 4 years to assess pulp vitality
❖ Periodic ragiograph review should be arraneged to check dentine ridge formation
and root growth and exlude necrosis and resorption
❖ If vitality is lost, non pulp therapy should be undertaken , whether or not there is a
calcific ridge
❖ Success rates for partial pulpotomy are quoted as 97% and for coronal pulpotomy
75%
❖ Elective Pulpectomy – and root canal treatment of a vital pulp may be considered at
a later date only if the root canal treatment is required for restorative purposed
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NON VITAL

Pulpectomy

❖ Where there is death of pulp an immature teeth , clinicians face a challenge

❖ Because there is no further root development , the root has thinned dentin walls liable
to fracture until physiological forces and wide open apex , which is time consuming and
technically difficult to treat
❖ The treatment first requires elimination of bacterial infection from the root canal and
the prevention of re-infection of this space. This infection of the root canal. The space is
straight forward for most cases. However there is no apical constriction to stopped
against which suitable root filling material can be placed to prevent re infection of this
space.
❖ Traditionally the treatment has been aimed at producing a barrier against which a root
canal filling material can be placed, thereby preventing extrusion of material into the
surrounding tissue. This has usually been achieved with prolong dressing of the root
canal with calcium hydroxide to achieve apexification.
❖ Although this technique has been reliable and consistently allowed clinicians to achieve
root canal obturation successful. There has been recent concerns about the long-term
use of calcium hydroxide in root canal, it is thought that through the desiccation of
dentinal proteins, calcium hydroxide might make dentin more brittle and more
predisposed to root fracture.
❖ Indeed an increased prevalence of root fractures has been reported for teeth that have
been prepared using this technique (cavek’s)
❖ Calcium hydroxide should be replaced wherever possible. 2 such alternative mineral
trioxide aggregative, regenerative endodontic technique in preference to the prolong
use of calcium hydroxide
❖ Traditional root end closure , with the use of calcium hydroxide may take 9-24 months
before definitive canal obturation, and restoration is possible

Root end closure

❖ Gives predictable results if infection is controlled and canal is sealed

❖ Bacterial tight
❖ Infection is controlled by irrigation and disinfection
❖ The canal is enlarged enough only to allow irrigant access and dense obturation
❖ Closure adds nothing to the strength of tooth
❖ Coronal restorations is critical to long-term success
❖ Avoid prolong use of calcium hydroxide in root canal
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❖ The use of MTA to create root end closure should be the technique of choice with
current level of evidence
❖ Consider the use of RET where the root development is so incomplete that the tooth is
deemed to have to poor prognosis even with MTA.

Uncomplicated crown-root fracture

❖ After the removal of the fractured piece of tooth , these vertical fractures are commonly
a few mm incisal to the gingival margin and on the labial surface but down the
cementoenamel junction palatally
❖ Prior to the placement of restoration the fracture margin has to be broad supragingival
but either gingivoplasty or extrusion ( orthodontically or surgically of the root portion )

Complicated crown-root fracture

❖ Proceed as with uncomplicated crown root fractures until the addition of endodontic
requirement
❖ If extrusion is planned the final root length must be no shorter than the final crown
length otherwise the result will be unstable
❖ Root extrusion can be successful in a motivated patient and leads to stable periodontal
conditions

Root fractures

❖ Occurs more frequent in the middle of apical third of the root

❖ The coronal fragment maybe extruded or luxated
❖ If displacement is occurred, the coronal fragment should be repositioned as soon as
possible by gentle digital manipulation and position checked radio graphically
❖ Optimal repositioning favours healing with hard tissue and reduces the risk of pulpal
necrosis
❖ Mobile root fractures need to be splinted to encourage repair of the fracture with the
possible exception of coronal third which may require longer splinting periods
❖ A period of 4 weeks with the semi rigid or functional splint appears to be sufficient to
ensure healing
❖ A functional splint includes ONE ABUTMENT ON EACH SIDE OF THE FRACTURED TOOTH
❖ Splinting for longer period may require individual cases the splint should allowed color
observation, sensitivity testing and access to the root canal, if endodontic treatment is
required
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3 main categories of repair

❖ Repaired with calcified tissue, invisible or hardly discrinable fracture line

❖ Repair with connective tissue, narrow radiolucent fracture line with peripheral rounding
of the fracture edges
❖ Repaired with bone and connective tissue , the tooth fragments are separated by a bony
ridge

Internal splinting

❖ Fractures arising in the coronal pulp and middle third of the root often result in
excessive mobility of the coronal fragment and technique have been described to splint
the coronal and apical portion together internally with a rigid root filling material ,
internal splint have ranged from head strong files to nickel chromium points screwed in
cemented into position.
❖ These approaches are effect single prone root filling procedures and cannot be relied
upon to provide a long term safeguard against the re entry of oral microorganisms to the
canal and fracture line.
❖ Most are doomed to failure and restoration options are preferred

Foil cement splint

❖ Temporary splint made of soft metal ( cooking foil ) and with quick setting ZOE
❖ It is a temporary measure either during the night when it is difficult to fit a composite
wire splint as a single handed operator or while awaiting construction of a laboratory
made splint.

TYPES OF CONSTRUCTING SPLINTS

Composite resin / acrylic and wire splint

❖ This method uses either a composite resin or temporary crown material , the composite
resin is easier to place, but the acrylic resin is easier to remove
❖ Although the acrylic resin does not bound as strong to enamel as composite resin does,
it is suitable for all types of functional splinting.

Laboratory splint

❖ These are used where it is impossible to make satisfactory splint by the direct method
for example: 7-8 year old with traumatized max incisors, un-erupted lateral incisors and
either carious or absent primary canine, both material require alginate impression and
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very loose teeth may need support by wax, metal foil or wire ligature so they are not
removed

Dentine proceeds via three changes

❖ Weak organic acid demineralization

❖ Organic material degenerate or dissolve
❖ Loss of structure incontinuity + invasion of bacteria

ZONES OF DENTIN CARIES

❖ When caries slowly progressive zones are clear and vice versa

Zone 1 =

❖ normal dentin ,
❖ deepest area ,
❖ tubules with odontoblastic process that is smooth,
❖ no crystals are present,
❖ no bacteria present in tubules,
❖ INTERTUBULAR DENTIN has normal collagen,
❖ normal dense apetite crystals

Zone 2 =

❖ AFFECTED DENTIN, also called inner carious dentin,

❖ zone of demineralization of inter tubular dentin ,
❖ initial formation of crystals in the tubules,
❖ odontoblastic process damaged,
❖ affected dentin is softer than normal dentin,
❖ loss of mineral from inter tubular dentin,
❖ large crystals deposition,
❖ Produces PAIN,
❖ collagen crosslinking remains intact in the zone,
❖ it is a template for remineralization of inter tubular dentin.
❖ Capability of SELF REPAIR
❖ Pulp vital

Subzones:

❖ Sub transparent dentin

❖ Transparent dentin
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❖ Turbid dentin

Zone 3 =

❖ INFECTED DENTIN also called outer carious dentin,

❖ zone of bacterial invasion,
❖ widening and distortion of dentinal tubules filled with bacteria,
❖ little mineral is present, and irreversible collagen damage,
❖ NO SELF REPAIR,
❖ no REMINERALIZATION

indirect pulp capping = also known as step wise excavation, partial caries excavation

enamel caries

❖ white spot are chalky white opaque areas, reveal only when tooth surface is desiccated,
and termed NON CAVITATED enamel caries lesion .
❖ these areas loose translucency because of porosity due to demineralization

Enamel caries zones

❖ translucent zone
❖ dark zone
❖ body of zone
❖ organic change

clinical significance of enamel region

plaque biofilm enamel structure restorative tx therapeutic

❖ normal enamel 🡪normal 🡪normal 🡪not indicate 🡪 not indicate

❖ hypocalcified 🡪 normal 🡪 abnormal but not weak🡪 esthetic 🡪 not indicate
❖ non cavitatedd 🡪 cariogenic 🡪 porous and weak 🡪not indicated 🡪 yes
❖ activated 🡪 cariogenic 🡪 cavitated, very weak 🡪indicated 🡪 yes
❖ in active caries 🡪 normal 🡪demineralized + strong 🡪 for esthetic 🡪 not indicate

Conventional methods of caries detection

❖ Visual tactile method

❖ Radiographic
❖ Caries detection dyes
❖ Fiberoptic transillumination
❖ Electronic caries monitor
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Visual tactile method

❖ Detection of white spot ,discoloration ,or frank cavitation

❖ Unreliable
❖ Without aid
❖ Explorer widely used for detection of caries
❖ Sharp tips physically damage small lesions with intact surfaces
❖ Probing can cause fracture and cavitation of insufficient lesions and may spread the
organism in the mouth
❖ Mechanical binding may be due to non carious lesions ( shape of fissure and sharpness
of explorer and force of application )

Smooth surface caries

❖ No signs of cavitation after visual or tactile examination , location where dental plaque
accumulates ( gingival margin )
❖ Surface characteristics : matte not glossy when the tooth is dried

Radiographic

❖ Caries lesions are detectable radiographically when there has been enough
demineralization to allow it to differentiate from normal
❖ They are valuable in detecting proximal caries which may go undetected during clinical
examination
❖ Radiographic examination include : bite wing, IOPA radiographics using paralleling
technique, panaromic tomography
❖ Severe occlusal lesions can be detected clinically and radiographically
❖ Pulp exposure determined radiographically

Incipient caries

❖ Commonly seen in caries susceptible zones

❖ Present as a notch on the outer surface not involving more than half of enamel

Facial and lingual caries

❖ They start as Round lesions enlarged to become Elliptical / semilunar

Occlusal caries

❖ White spot lesion

❖ Lesion visible on bite wing
❖ Arrested when brown or white spot with shiny surface
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Proximal caries

❖ The presence or absence of cavity is relevant to lesion activity but it cannot be

determined from the radiograph unless the lesion is very deep
❖ For an active caries lesion to be arrested, plaque must be regularly removed from the
cavity
❖ High risk caries patient have proximal caries due to no access of tooth brush
❖ Bitewing radiograph will not show the progression of caries
❖ Involve more than outer half of enamel but do not exceed to DEJ

Smooth surface lesions

❖ They are the most visible

❖ They are straightforward
❖ White spot lesion close to the gingival margin
❖ white spot matte and frosty surface

Root surface caries

❖ close to gingival margin and plaque covered

❖ soft of leathery
❖ Also called cemental caries
❖ Ill defined saucer like radiolucency

Table 5.8 arrested vs. active

Table 5.4 difference between hypo-mineralized and caries

Table 5.6 / 5.7

DYES FOR CARIES DETECTION

❖ They selectively complex with carious tooth structure which is lateral discolosed with
fluorescence dyes for enamel caries PROCION, CALCEIN, ZYGLO
❖ For detecting dentin caries🡪 propylene glycol, attaches at denatured collagen that’s why
it is detected

FIBEROPTIC TRANSILLUMINATION

❖ Different index of light transmission for decayed and sound tooth

❖ Decayed tooth structure has decreased index and appears dark

ELECTRIC MEASUREMENT FOR CARIES

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❖ Tooth demineralization due to caries process causes increased porosity of tooth

structure, this porosity contains fluid containing ions leading to increased electrical
conductivity, conversely leads to decrease electrical resistance
❖ Bulk resistance of tooth
❖ 2 systems: vanguard, caries meter L

RECENT ADVANCES

❖ Optical methods : quantitative light induced fluorescence, infrared laser fluorescence

❖ Changes in fluorescence of enamel and dentin due to loss of mineral

Caries risk assessment

❖ Advantage : clinical examination neither predicts caries activity nor susceptibility

Caries definition: bacterial infection that causes demineralization of inorganic and destruction of
organic component of teeth.
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SNOWPLOW TECHNIQUE

❖ Initital thin increment flowable composite placed over gingival/ pulpal floor of cavity
preparation , it is not cured at this stage , then initial increment of heavily filled
restorative resin composite is syringed or pushed into the unset flowable resin
composite.
❖ Most of the flowable resin composite is displaced by the restorative composite and is
subsequently removed from cavity preparation with hand instrument , micro brush, or
brittle brush as a result most flowable composite is not present in cavity instead small
amounts is left in those areas where higher viscosity resin has not adapted, then cured
❖ Advantages : Reduced voids formation, gingival margin leakage in class 2

Polymerization shrinkage

❖ Leads to micro-gaps
❖ Stained margins
❖ Post op sensitivity
❖ Recurrent caries
❖ 90% of polymerization shrinkage occurs in 5 min curing

How to reduce polymerization shrinkage

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❖ Auto cure GIC + composite ( co cured technique ) self etch 🡪 ionic addition , increased
seal for microleakage
❖ Incremental technique , long enamel bevels, low shrinkage material , flexible resin liners,
slow setting RMGIC liner, modified light curing protocol, increased C factor causes
increased shrinkage,

Bevelling of facial and lingual margin of bone of class 2 pre wedging

Overhang

❖ Extension of restoration beyond the prepared cavity margins

❖ Causes: Low skill level of operator , poor visibility, extensive below the gum level ,
restricted mouth opening
❖ 25% of restored teeth ( inlay , crown or filling)
❖ Difficult cleaning of ledge , retention of food and pathology, biofilm, radiograph and
tactile exploration
❖ Increased bone loss, attachment loss, pocket depth, inflammation , recurrent caries
❖ Treatment: removal of overhang , scaling, antibiotics, meticulous oral hygiene practice

Reversible/irreversible

❖ Reversible: pulpal hyperemia, short lived pain recover by application of hot and cold ,
reverse pain acute, sensitive to cold (acute)
❖ Irreversible/ chronic= pulp necrosis, acute pulpitis, chronic , dull, bearable pain, requires
pulp extra patin and tooth extraction , sensitive to HOT

Bitewing radiograph

❖ Intraoral 0.005 MSV

❖ For periapical and bite wing 31 multiply by 41 mm / 22 multiply by 45mm
❖ Occlusal – 57 multiple by 76mm
❖ Patient bite on a wing of card projecting from the tube side of the wing
❖ Shows occlusal and interproximal of enamel, EDJ and bone level surrounding tooth
❖ Pre molar , molar , carries assessment of filling and crown and periodontology

CHAIR POSITION FROM SLIDES

Sandwich technique (class 5)

❖ Intermediate layer of GIC, between dentin and resin composite

❖ Gic with class 2 resin composite is termed BONDED BASE TECHNIQUE
❖ Open bonded base technique : in which gic at the gingival margin is exposed
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❖ Closed: GIC covered at the gingival margin

Pulp capping

❖ Endodontic treatment designed to Maintains the vitality of the endodontium

❖ 4 rules :
❖ Vital pulp and no pain
❖ Pain elicited during pulp testing with hot and cold stimuli should not linger after the
stimulus is removed
❖ Periapical radiograph shows no evidence of periapical radiolucency
❖ Bacteria must be excluded from the site

Direct pulp capping

❖ Pulp can be exposed due to trauma, caries or mechanical reasons, iatrogenic

❖ It is attempt to maintain the vitality of the pulp by placing material directly over the
exposed pulp
❖ Pulp heals normally, regenerate reparative dentin, prevent need of more extensive
treatment
❖ Successful : mechanical exposure is best managed

Indirect

❖ Carious lesion is deep

❖ Carious lesion is allowed to remain adjacent to vital pulp , cover with a cavity sealer or
liner prior to restoration is termed indirect pulp capping
❖ Partial caries removal , put sealer and liner and place for 4-12 months.
❖ See four things;
❖ Lesions color changes from light brown to dark brown
❖ Tissue consistency changes from soft and wet to hard and dry
❖ Streptococcus mutans and lactobacilli reduced
❖ Radiograph shows no change or Decrease in radiolucency

Direct pulp

❖ ZOE
❖ Gic
❖ Rmgic
❖ Adhesive
❖ Calcium hydroxide
❖ MTA
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Calcium hydroxide

❖ Gold standard for direct pulp capping

❖ Antibacterial properties, it has a repair mechanism , releases BMP, TGFB1, stimulate pulp
repair
❖ Reparative dentin
❖ 100% reduction in microorganisms in one hour contact

Disadvantage

❖ Self cure highly soluble

❖ Dissolution will cause bridging
❖ No inherent adhesive quality
❖ POOR SEAL
❖ Tunnel defect formation

MTA

❖ Calcium hydroxide in the form of tri calcium silicate, and di calcium silicate, tri calcium
aluminate
❖ Bismuth oxide that gives radiopacity
❖ A silicate cement
❖ Reaction with water will make calcium hydroxide

Advantage

❖ Anti bacterial
❖ High pH
❖ Biocompatibility
❖ Radiopacity
❖ Ability to release bio active dentin matrix protein

Difference between MTA AND CALCIUM HYDROXIDE

❖ White and gray colors

❖ Gray color is due to iron
❖ Significant is MTA does provide seal

Disadvantage

❖ High solubility
❖ Presence of iron , darken the tooth
❖ Prolong setting time ( 2 hours 45 mins)
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❖ Multiple visits
❖ Very expensive

Indirect pulp

❖ Calcium hydroxide , RMGIC on top as a liner and then restorative material

Key hole preparation / facial lingual slot preparation

❖ Entire preparation is apical to proximal contact

DO MATRIX SLIDE ( WEDGES ) DR FARAH

AMALGAM – key points

Composite layering technique VLC posterior

Go through radiographs one more time