Pomorski Uniwersytet Medyczny w Szczecinie

Management
Management of of deep
deep caries
caries
cavities.
cavities. Biomaterials.
Biomaterials.
lek. dent.
lek. dent. Agnieszka
Agnieszka Chamarczuk
Chamarczuk
Stomatologia Zachowawcza
Stomatologia Zachowawcza zz Endodoncją
Endodoncja
Ill rok,
III rok, kierunek
kierunek Lekarsko-Dentystyczny
Lekarsko-Dentystyczny
Katedra ii Zakład
Katedra Zaktad Stomatologii
Stomatologii Zachowawczej
Zachowawczej ii Endodoncji
Endodoncji PUM
PUM
 OBJECTIVES
OBJECTIVES
After seminar
After seminar student
student should
should be
be able
able to:
to:

• recognize
recognize the the clinical
clinical and
and radiological
radiological image
image of of deep
deep carious
carious
lesion;
lesion;
• assess
assess the
the clinical
clinical state
state of
of the
the pulp
pulp tissue;
tissue;
• name
name thethe indications
indications forfor indirect
indirect and
and direct
direct pulp
pulp capping;
capping;
• describe
describe thethe protocol
protocol of of indirect
indirect and
and direct
direct pulp
pulp capping;
capping;
DEEP
DEEP CARIES
CARIES

3
 DEEP
DEEP CARIES
CARIES
According to
According to the
the WHO
WHO classification
classification an
an advancement
advancement of of the
the
carious process
carious process is
is described
described byby four
four stage
stage scale
scale
(D1,D2,D3,D4).
(D1,D2,D3,D4).

Deep caries
Deep caries is
is described
described as
as stage
stage D4.
D4.

CLINICAL IMAGE
• Deep caries is characterized by the presence of extensive and deep cavity,
close to the pulp chamber.
• Cavity needs to be separated from the pulp by a thin layer of healthy
dentine.
 DEEP
DEEP CARIES
CARIES
SUBJECTIVE SYMPTOMS
SUBJECTIVE SYMPTOMS
•e The
The flor
flor of
of the
the cavity
cavity is
is usually
usually sensitive
sensitive to
to probing.
probing.
•e Short
Short pain
pain provoked
provoked by by thermal
thermal stimuli.
stimuli.
• NoNo symptoms
symptoms of of irreversible
irreversible pulpitis.
pulpitis.

RADIOLOGICAL SYMPTOMS
• Radiolucency reaching over 2/3 of the dentin
thickness.
 NEW
NEW APPROACH
APPROACH -- ESE
ESE
According to
According to European
European Society
Society of
of Endodontology
Endodontology 2019
2019 position
position
statement:
statement:

• DEEP CARIES:
DEEP CARIES: Caries
Caries reaching
reaching thethe inner
inner quarter
quarter of
of dentine,
dentine,
but with
but with aa zone
zone ofof hard
hard oror firm
firm dentine
dentine between
between thethe caries
caries
and the
and the pulp,
pulp, which
which isis radiographically
radiographically detectable
detectable when
when
located on
located on an
an interproximal
interproximal or or occlusal
occlusal surface.
surface. There
There is is a
a
risk of
risk of pulp
pulp exposure
exposure during
during operative
operative treatment.
treatment.

• EXTREMELY DEEP
EXTREMELY DEEP CARIES:
CARIES: Caries
Caries penetrating
penetrating the
the entire
entire
thickness of
thickness of the
the dentine,
dentine, radiographically
radiographically detectable
detectable when
when
located on
located on an
an interproximal
interproximal oror occlusal
occlusal surface.
surface. Pulp
Pulp
exposure can’t
exposure can’t be
be avoided
avoided during
during operative
operative treatment.
treatment.
DEEP AND EXTREMELY
DEEP AND EXTREMELY DEEP
DEEP CARIES
CARIES
 ICCMS
ICCMS ™
™ CARIES
CARIES CATEGORIES
CATEGORIES
•° Extensive
Extensive stage
stage caries
caries
(ICDAS™ codes
(ICDAS™ codes 5 5 and
and 6) 6)
•° Code
Code 6:6: Extensive
Extensive distinct
distinct
cavity with
cavity with visible
visible dentin.
dentin.
•° Visible
Visible loss
loss ofof tooth
tooth structure,
structure,
the cavity
the cavity isis both
both deep
deep and and
wide and
wide and dentin
dentin is is clearly
clearly
visible on
visible on the
the walls
walls andand at at the
the
base. An
base. An extensive
extensive cavitycavity
involves at
involves at least
least half
half ofof aa
tooth surface
tooth surface or or possibly
possibly
reaching the
reaching the pulp.
pulp.
 ICCMS™
ICCMS™ RADIOGRAPHIC
RADIOGRAPHIC SCORING
SCORING
SYSTEM
SYSTEM
•° Extensive
Extensive stages.
stages.
•° Radiolucency
Radiolucency
reaching the
reaching the inner
inner
1/3 of
1/3 of dentin,
dentin,
clinically cavitated.
clinically cavitated.
•° Radiolucency
Radiolucency into into the
the
pulp, clinically
pulp, clinically
cavitated.
cavitated.
STATUS
STATUS OF
OF THE
THE PULP
PULP TISSUE
TISSUE

In
In order
order toto make
make a a correct
correct
diagnosis of
diagnosis of deep
deep caries,
caries, the
the pulp
pulp
Status should
status should be be determined
determined at at the
the
Same time!
same time!
 STATUS
STATUS OF
OF THE
THE PULP
PULP TISSUE
TISSUE
Clinical classification
Clinical classification of
of the
the status
status of
of the
the pulp
pulp proposed
proposed by
by Abbott*
Abbott*

• Clinically
Clinically Normal
Normal Pulp
Pulp (based
(based on
on clinical
clinical examination
examination and
and test
test results)
results)
• Reversible
Reversible pulpitis
pulpitis: :
• Acute
Acute
• Chronic
Chronic
• Irreversible
Irreversible pulpitis
pulpitis ::
• Acute
Acute
• Chronic
Chronic
• Necrobiosis
Necrobiosis (part
(part of
of pulp
pulp necrotic
necrotic &
& infected;
infected; the
the rest
rest is
is irreversibly
irreversibly inflamed)
inflamed)
• Pulp
Pulp necrosis
necrosis: :
• No
No sign
sign of
of infection
infection
• Infected
Infected

*Abbott PV.
*Abbott PV. AA clinical
clinical classification
classification of
of the
the status
status of
of the
the pulp and the
pulp and the root
root canal
canal system.
system.
Australian Dental Journal
Australian Dental Supplement 2007;52:17-31.
Journal Supplement 2007;52:17-31.
SYMPTOMATIC AND THERAPEUTIC
SYMPTOMATIC AND THERAPEUTIC
CLASSIFICATION
CLASSIFICATION
•° Clinical
Clinical and
and therapeutic
therapeutic classification
classification of
of the
the status
status of
of the
the pulp,
pulp,
proposed by
proposed by Arabska-Przedpełska
Arabska-Przedpetska. .

Healthy pulp Reversible pulpitis

U U
•¢ Tooth
Tooth fracture
fracture •¢ Dental caries
Dental caries
•¢ Tooth
Tooth preparation
preparation for
for •¢ Tooth wear
Tooth wear
dental restorations
dental restorations •¢ Accidental pulp
Accidental pulp exposure
exposure
•¢ Carious pulp
Carious pulp exposure
exposure

|
Y
Biological treatment of
the pulp
 deep caries, the pulp status
should be
SYMPTOMATIC determined
SYMPTOMATIC AND at
AND THERAPEUTICthe
THERAPEUTIC
same time! a correct
CLASSIFICATION
CLASSIFICATION diagnosis
of deep caries, the pulp status
Irreversible pulpitis
should be
/
determined\
at the
same time! Pulp necrosis

Severely inflamed
Severely inflamed Pulp necrosis
Pulp necrosis with
with
pulp
pulp or without
or without bacterial
bacterial
infection
infection

Endodontic treatment
 HEALTHY
HEALTHY PULP
PULP
A clinically
A clinically normal
normal pulp
pulp is
is asymptomatic.
asymptomatic. It It produces
produces aa mild
mild and
and transient
transient response
response toto
various stimuli,
various stimuli, but
but the
the nature
nature and
and severity
severity of
of the
the response
response maymay vary
vary according
according to
to
the age
the age and
and state
state of
of the
the tooth.
tooth.

A clinically
A clinically normal
normal pulp
pulp will
will react
react to
to cold
cold stimuli
stimuli with
with mild
mild pain
pain which
which disappears
disappears
immediately after
immediately after the
the stimulus
stimulus is
is removed.
removed.

Percussion and
Percussion and palpation
palpation tests
tests will
will not
not elicit
elicit any
any tenderness.
tenderness.

Radiographic examination
Radiographic examination will
will demonstrate
demonstrate normal
normal appearance
appearance of
of the
the periapical
periapical
tissues.
tissues.
 REVERSIBLE
REVERSIBLE PULPITS
PULPITS
A pulp
A pulp with
with reversible
reversible pulpitis
pulpitis has
has mild
mild inflammation
inflammation and
and it
it is
is able
able to
to healing
healing once
once the
the
irritating stimulus
irritating stimulus has
has been
been removed.
removed.

Pain is only felt when a stimuli (usually cold or sweet foods but sometimes heat) is
applied to the tooth, and the pain stop within a few seconds or immediately upon
removal of the stimulus.

The pain
The pain is
is short
short and
and sharp
sharp in
in nature
nature but
but not
not spontaneous.
spontaneous.

There are no significant radiographic changes evident in the periapical region.

 REVERSIBLE
REVERSIBLE PULPITS
PULPITS
Conservative pulp
Conservative pulp therapy
therapy in in conjunction
conjunction with
with the
the removal
removal of of
the cause
the cause usually
usually results
results in in resolution
resolution of
of the
the pulp
pulp
inflammation and
inflammation and the
the return
return of of the
the pulp
pulp to
to a
a clinically
clinically normal
normal
state.
state.

The pulp status should be reviewed after several weeks

(assuming there are no postoperative symptoms).

A three-month
A three-month interval
interval is
is generally
generally considered
considered to
to be
be more
more
reliable as
reliable as healing
healing or
or necrosis
necrosis (if
(if it
it occurs)
occurs) may
may take
take some
some
time to
time to become
become evident.
evident.
 IRREVERSIBLE
IRREVERSIBLE PULPITIS
PULPITIS
Only mild
Only mild temperature
temperature changes
changes are
are required
required to
to induce
induce the
the pain.
pain.

Patient usually
Patient usually complains
complains of
of unprovoked,
unprovoked, spontaneous,
spontaneous, lingering
lingering pain.
pain.

The initial
The initial reaction
reaction is
is a
a very
very sharp
sharp pain
pain to
to hot
hot or
or cold
cold stimuli
stimuli and
and it
it then
then lingers
lingers for
for seconds,
seconds, minutes
minutes to
to hours
hours
after the
after the stimulus
stimulus isis removed.
removed.

Spontaneous (unprovoked)
Spontaneous (unprovoked) pain
pain may
may wake
wake the
the patient
patient at
at night
night and
and may
may become
become worse
worse when
when lying
lying down.
down.

Patients with
Patients with irreversible
irreversible pulpitis
pulpitis may
may have
have difficulty
difficulty locating
locating the
the precise
precise tooth
tooth that
that is
is the
the source
source of
of the
the pain.
pain.
PULP
PULP TESTING
TESTING

18
 PULP
PULP TESTING
TESTING
•° Clinicians
Clinicians perform
perform pulppulp sensibility
sensibility tests
tests to
to estimate
estimate the the
“vitality” -- pulp
“vitality” pulp sensitivity
sensitivity andand therefore
therefore thethe state
state ofof the
the pulp
pulp
tissue.
tissue.
•° Sensibility
Sensibility isis defined
defined as as the
the ability
ability to
to respond
respond to to aa stimulus.
stimulus.
•° Typical
Typical and
and common
common clinical
clinical pulp
pulp tests
tests such
such as
as thermal
thermal andand
electric tests
electric tests dodo not
not detect
detect or or measure
measure bloodblood supply
supply to to the
the
dental pulp.
dental pulp.
 PULP
PULP TESTING
TESTING

Most of
Most of the
the current
current pulp
pulp testing
testing modalities
modalities do do not
not directly
directly
assess the
assess the pulp
pulp vascularity
vascularity and
and this
this is
is exemplified
exemplified byby clinical
clinical
observations, that
observations, that traumatized
traumatized teeth
teeth can
can have
have no
no response
response
to a
to a stimulus
stimulus (such
(such as
as cold)
cold) for
for aa period
period ofof time
time following
following
injury.
injury.

The laser Doppler flowmetry technique technique objectively

objectively measure
measure
the pulp
the pulp blood
blood flow
flow without
without invasive
invasive procedures.
procedures. This
This
electro-optical technique
electro-optical technique uses
uses a a laser
laser source
source that
that is
is aimed
aimed atat
the pulp,
the pulp, and
and the
the laser
laser light
light travels
travels toto the
the pulp
pulp using
using the
the
dentinal tubules
dentinal tubules as as guides.
guides.
 Guiding
Guiding rules
rules for
for the
the clinical
clinical use
use of
of
vitality
vitality tests
tests

Explain the
Explain the procedures
procedures to
to the
the patient.
patient.

Do not
Do not rely
rely on
on only
only one
one test;
test; use
use combinations.
combinations.

Make comparisons
Make comparisons with
with other
other teeth,
teeth, preferably
preferably contralaterals
contralaterals but
but also
also with
with
neighboring teeth.
neighboring teeth.

In cases with doubtful reactions, repeat the tests in a different order, “hiding” the
suspicious tooth.
 PULP
PULP TESTING
TESTING
The 3
The 3 types
types ofof responses
responses can can be
be summarized
summarized as as follows:
follows:
• The pulp
The pulp is is deemed
deemed normal normal whenwhen there there is is aa response
response
to the
to the stimulus
stimulus provided
provided by by the
the sensibility
sensibility testtest and
and
this response
this response is is not
not pronounced
pronounced or or intensified,
intensified, and and it
it
does not
does not linger.
linger.
• Pulpitis is
Pulpitis is present
present when when there
there is is an
an intensified
intensified
response that
response that produces
produces pain. pain. Typically
Typically mild mild pain
pain of of
short duration
short duration is is considered
considered to to indicate
indicate reversible
reversible
pulpitis while
pulpitis while severe
severe pain pain that
that lingers
lingers indicates
indicates
irreversible pulpitis
irreversible pulpitis ..
• The absence
The absence of of responses
responses to to sensibility
sensibility teststests is is usually
usually
associated with
associated with thethe likelihood
likelihood of of pulp
pulp necrosis
necrosis or or
previous root
previous root canal
canal therapy.
therapy.
 COLD
COLD TEST
TEST

Cold air,
Cold air, water
water or
or a
a cold
cold object
object may
may elicit
elicit a
a pain
pain response
response
when placed
when placed at
at a
a tooth
tooth surface.
surface.

The temperature
The temperature changes
changes will
will influence
influence the
the flow
flow of
of dentinal
dentinal
fluid and
fluid and aa make
make mechanical
mechanical stimulation
stimulation of
of pulpal
pulpal nerves.
nerves.

A common method is to apply a cotton pellet soaked in a fast

evaporating fluid, such as ethyl chloride or
dichlorodifluoromethane or carbon dioxide snow.
 COLD
COLD TEST
TEST
•° The
The application
application of of the
the refrigerant
refrigerant spray
spray
requires a
requires a carrier
carrier such
such as
as a
a cotton
cotton pellet
pellet
saturated with
saturated with the
the substance
substance prior
prior to
to direct
direct
contact with
contact with the
the teeth.
teeth.
 HEAT
HEAT TEST
TEST

A gutta-percha
A gutta-percha barbar is
is heated,
heated, then
then
placed on
placed on the
the buccal
buccal surface
surface on
on the
the
tooth until
tooth until the
the reaction
reaction isis provoked.
provoked.

Because studies
Because studies indicate
indicate that
that the
the
diagnostic accuracy
diagnostic accuracy is is very
very low,
low, heat
heat
should not
should not be
be used
used asas the
the only
only test
test of
of
pulp vitality.
pulp vitality.
 ELECTRIC
ELECTRIC PULP
PULP TEST
TEST

An electric
An electric pulp
pulp tester
tester sends
sends aa weak
weak
electric current
electric current through
through the
the tooth,
tooth,
which stimulates
which stimulates the
the pulpal
pulpal nerves.
nerves.

Various technical
Various technical devices
devices are
are available.
available.
 ELECTRIC
ELECTRIC PULP
PULP TEST
TEST
•° The
The pathway
pathway for for the
the electric
electric current
current is is thought
thought to to be
be from
from the
the probe
probe
tip of
tip of the
the test
test device
device toto the
the tooth,
tooth, along
along the
the lines
lines of
of the
the enamel
enamel
prisms and
prisms and dentine
dentine tubules,
tubules, and
and then
then through
through thethe pulp
pulp tissue.
tissue.
•° To
To ensure
ensure appropriate
appropriate current
current pathway
pathway we we need
need toto place
place the
the probe
probe
tip flat
tip flat against
against the
the contact
contact area
area and
and apply
apply conducting
conducting medium
medium suchsuch
as toothpaste
as toothpaste between
between the the probe
probe tip
tip and
and the
the tooth
tooth surface.
surface.
 ELECTRIC
ELECTRIC PULP
PULP TEST
TEST
•° The
The “circuit”
“circuit” is is completed
completed
via the
via the patient
patient wearing
wearing a a
lip clip
lip clip or
or by
by touching
touching the the
probe handle
probe handle with with his/her
his/her
hand;
hand;
•° Alternatively,
Alternatively, the the operator
operator
can have
can have one
one gloveless
gloveless
hand that
hand that touches
touches the the
patient’s skin.
patient’s skin. i
—_— a = le
 ELECTRIC
ELECTRIC PULP
PULP TEST
TEST
False positive
False positive result:
result:
• The
The contact
contact ofof active
active electrode
electrode withwith gingiva
gingiva oror amalgam
amalgam restoration.
restoration.
• Necrotic
Necrotic pulp
pulp in
in aa state
state ofof gangrene
gangrene (older
(older devices).
devices).
• Incorrect
Incorrect isolation
isolation from
from thethe saliva.
saliva.
• Psychological
Psychological state
state ofof the
the patient,
patient, hyperactivity,
hyperactivity, nervousness.
nervousness.
False negative
False negative result:
result:
• Inaccurate
Inaccurate contact
contact of of the
the electrode
electrode withwith the
the tooth
tooth surface.
surface.
• Contact
Contact ofof the
the electrode
electrode withwith the
the composite
composite filling.
filling.
• Short
Short after
after tooth
tooth trauma
trauma —– pulppulp might
might be be in
in the
the state
state ofof „shock”.
,, shock”.
• Healthy
Healthy immature
immature teethteeth with
with incompletely
incompletely formedformed roots.
roots.
• Teeth
Teeth with
with pulp
pulp chamber
chamber calcification.
calcification.
• Patients
Patients that
that took
took anesthetic
anesthetic pills
pills before
before examination.
examination.
• Teeth
Teeth shortly
shortly after
after orthodontic
orthodontic treatment.
treatment.
 BIOLOGICAL
BIOLOGICAL TREATMENT
TREATMENT BASICS
BASICS

•e Appropriate
Appropriate caries
caries management
management withinwithin vital
vital pulp
pulp therapy
therapy aims
aims
to remove
to remove thethe microbial
microbial irritation
irritation and
and prevent
prevent newnew bacterial
bacterial
insult by
insult by placing
placing a a sealing
sealing dental
dental biomaterial
biomaterial toto protect
protect
exposed dentine
exposed dentine and and pulp
pulp from
from external
external stimuli.
stimuli.
•° The
The aims
aims of
of biological
biological treatment
treatment are:
are:
• to manage
to manage bacterial
bacterial contamination,
contamination,
• arrest caries
arrest caries progression,
progression,
• stimulate tertiary
stimulate tertiary dentine
dentine formation,
formation,
• promote pulpal
promote pulpal repair
repair
• restore the
restore the cavity
cavity to
to create
create aa durable
durable seal
seal for
for long-term
long-term
preservation of
preservation of a
a symptom-free
symptom-free and and functional
functional tooth
tooth with
with a
a
healthy pulp.
healthy pulp.
BIOLOGICAL
BIOLOGICAL TREATMENT
TREATMENT

31
 CARIOUS
CARIOUS EXPOSURE
EXPOSURE
•° Carious
Carious exposure
exposure ofof the
the pulp
pulp is
is an intended procedure,
procedure, that
that is
is
connected with
connected with total
total removal
removal of of carious
carious dentine
dentine closest
closest to
to the
the
pulp chamber.
pulp chamber.
•° This
This procedure
procedure can
can bebe performed
performed only
only in
in strictly
strictly defined
defined
conditions:
conditions:
• Tooth
Tooth without
without clinical
clinical symptoms
symptoms of of pulp
pulp inflammation,
inflammation, confirmed
confirmed
with pulp
with pulp tests.
tests.
• Exposure
Exposure is is made
made during
during the the very
very final
final excavation
excavation ofof the
the deepest
deepest
part of
part of the
the carious
carious lesion,
lesion, where
where the
the rest
rest of
of the
the cavity
cavity is
is free
free of
of
affected dentine.
affected dentine.
• The
The area
area ofof exposure
exposure is is less
less than
than 11 mm.
mm.
• No
No excessive
excessive bleeding
bleeding after
after exposure.
exposure.

Textbook of
Textbook of Endodontology,
Endodontology, 2nd
2nd Edition.
Edition. Gunnar
Gunnar Bergenholtz,
Bergenholtz,
Preben Hørsted-Bindslev,
Preben H@rsted-Bindslev, Claes
Claes Reit.
Reit. ISBN:
ISBN: 978-1-118-69138-0
978-1-118-69138-0
 PULP
PULP HEALING
HEALING
•° Hard-tissue
Hard-tissue repair
repair ofof
pulpal wounds
pulpal wounds is is not
not
unique to
unique to calcium
calcium
hydroxide but
hydroxide but can
can
occur with
occur with a a number
number
of other
of other materials
materials and and
with a
with a variety
variety of of
biologically active
biologically active
matrices and
matrices and
Fig. 4.11 Irreguilar hard-tissue repair of a pulp previously capped with cala-
um hydroxkie (>). A crevke can be probed along the rim of the exposure,
which may indicate that the hard tissue has been formed below a superficial
molecules.
molecules.
layer of necrotic tissue,

Textbook of
Textbook of Endodontology,
Endodontology, 2nd
2nd Edition.
Edition. Gunnar
Gunnar Bergenholtz,
Bergenholtz,
Preben Hørsted-Bindslev,
Preben H@rsted-Bindslev, Claes
Claes Reit.
Reit. ISBN:
ISBN: 978-1-118-69138-0
978-1-118-69138-0
 PULP
PULP HEALING
HEALING
Calcium hydroxide
Calcium hydroxide possesses
possesses antibacterial
antibacterial properties
properties which
which
can minimize
can minimize or
or eliminate
eliminate bacterial
bacterial penetration
penetration and
and next
next
irritation of
irritation of pulpal
pulpal tissue.
tissue.

Recent research
Recent research has
has demonstrated
demonstrated that
that the
the repair
repair mechanism
mechanism may
may be
be
due in
due in part
part to
to the
the release
release of
of bioactive
bioactive molecules
molecules from
from dentin
dentin matrix,
matrix,
including Bone-Morphogenetic Protein (BMP) and
including and Transforming
Growth Factor-Beta One (TBF-β1).

Both have
Both have demonstrated
demonstrated the
the ability
ability to
to stimulate
stimulate pulp
pulp repair
repair
and dentin
and dentin remineralization
remineralization ..
 DENTINAL
DENTINAL BRIDGE
BRIDGE FORMATION
FORMATION

The sequence
The sequence of of events
events in in the
the healing
healing process
process following
following
treatment of
treatment of aa pulpal
pulpal wound:
wound:
• One
One day
day after
after capping
capping -- superficial
superficial layer
layer of
of tissue
tissue necrosis
necrosis andand
inflammatory cell
inflammatory cell infiltrates;
infiltrates;
• First
First few
few days
days -- blood
blood clots
clots areare resolved
resolved andand the
the tissue
tissue is
is in
inaa
process of
process of reorganization;
reorganization;
• The
The inflammatory
inflammatory reactionreaction is is gradually
gradually reduced
reduced andand a a collagen-
collagen-
rich matrix
rich matrix is is formed
formed in in close
close relation
relation toto the
the necrotic
necrotic zone
zone oror
directly area
directly area to to the
the capping
capping material;
material;
• One
One week
week -- mineralization
mineralization of of the
the amorphous
amorphous tissue;
tissue;
• One
One month
month -- a a dentin-like
dentin-like tissue
tissue with
with tubules
tubules is is formed.
formed.
 CONTRAINDICATIONS
CONTRAINDICATIONS FOR
FOR
BIOLOGICAL
BIOLOGICAL TREATMENT
TREATMENT

Permanent
Permanent mature
mature teeth
teeth

• Heavy general
Heavy general diseases.
diseases.
• Irreversible pulpitis.
Irreversible pulpitis.
• Generally bad
Generally bad oral
oral hygiene.
hygiene.
• Acute periodontitis.
Acute periodontitis.
• Extensive destruction
Extensive destruction of of the
the crown.
crown.
• Uncontrolled bleeding
Uncontrolled bleeding after
after pulp
pulp injury.
injury.
 DEEP
DEEP CARIES
CARIES TREATMENT
TREATMENT IN
IN
PERMANENT
PERMANENT TEETH
TEETH

Biological treatment
Biological treatment includes:
includes:

•° Indirect
Indirect pulp
pulp capping
capping
•° One-visit
One-visit treatment
treatment
•° Stepwise
Stepwise excavation
excavation

•¢ Tooth wear
Tooth wear
_ •¢ Accidental pulp
Accidental pulp exposure
exposure
•* Carious pulp
Carious pulp exposure
exposure
•° Direct
Direct pulp
pulp capping
capping •¢ Tooth trauma
Tooth trauma
INDIRECT
INDIRECT PULP
PULP CAPPING
CAPPING

38
 INDIRECT
INDIRECT PULP
PULP CAPPING
CAPPING
INDICATIONS
INDICATIONS

•° Reversible,
Reversible, asymptomatic
asymptomatic pulpopathies
pulpopathies withwith deep
deep cavities
cavities
•° Posttraumatic
Posttraumatic fracture
fracture class
class IIIl according
according to
to Ellis
Ellis
classification (without
classification (without pulp
pulp exposure)
exposure)
 INDIRECT
INDIRECT PULP
PULP CAPPING
CAPPING
Indirect pulp
Indirect pulp capping:
capping:
•° Application
Application of of aa biomaterial
biomaterial ontoonto aa thin
thin dentine
dentine barrier
barrier inin aa one-
one-
stage carious-tissue
stage carious-tissue removal
removal technique
technique generally
generally toto hard dentine.
Immediate placement
Immediate placement of of aa permanent
permanent restoration.
restoration.
•° Considered
Considered moremore aggressive
aggressive than
than selective
selective carious-tissue
carious-tissue removal
removal
in one-stage
in one-stage and and stepwise
stepwise excavation.
excavation. Leaves
Leaves neither
neither soft
soft nornor firm
firm
carious dentine
carious dentine behind.
behind.
Selective carious-tissue
Selective carious-tissue removal
removal in in one-stage:
one-stage:
•° Application
Application of of aa biomaterial
biomaterial ontoonto aa dentine
dentine barrier
barrier in
in an
an indirect
indirect
one-stage selective
one-stage selective carious-tissue
carious-tissue removal
removal technique.
technique.
•e Removal
Removal to to soft or firm dentine.. Immediate
Immediate placement
placement of of aa
permanent restoration.
permanent restoration.
 INDIRECT
INDIRECT PULP
PULP CAPPING
CAPPING
Stepwise excavation:
Stepwise excavation:
•° Application
Application of of aa biomaterial
biomaterial in in an
an indirect
indirect two-stage selective
selective
carious-tissue removal
carious-tissue removal technique.
technique. Temporary
Temporary restoration
restoration
placement between
placement between visits
visits and
and re-entry
re-entry after
after 6-12
6-12 months.
months.
•° First
First stage
stage involves
involves selective
selective carious
carious removal
removal to to soft dentine,,
to an
to an extent
extent that
that facilitates
facilitates proper
proper placement
placement of of a
a temporary
temporary
restoration, and
restoration, and second
second stage
stage removal
removal toto firm dentine.. Final
Final
placement of
placement of aa permanent
permanent restoration.
restoration.
 INDIRECT
INDIRECT PULP
PULP CAPPING
CAPPING
•° *Partial
*Partial caries
caries removal
removal significantly
significantly reduces
reduces the
the chance
chance of
of pulp
pulp
exposure during
exposure during caries
caries excavation.
excavation.
•° These
These findings
findings are
are confirmed
confirmed by by two
two thorough
thorough systematic
systematic
reviews that
reviews that concluded
concluded the
the following:
following:
• partial
partial caries
caries removal
removal reduced
reduced thethe risk
risk of
of pulp
pulp exposure
exposure by by 98%
98%
compared to
compared to complete
complete caries
caries excavation
excavation in in teeth
teeth with
with deep
deep caries;
caries;
• there
there is
is substantial
substantial evidence
evidence that
that complete
complete caries
caries removal
removal isis not
not
needed for
needed for success,
success, provided
provided the
the restoration
restoration is is well
well sealed.
sealed.

*Hilton T.J.:
*Hilton T.J.: Keys
Keys to
to Clinical
Clinical Success
Success with
with Pulp
Pulp Capping:
Capping: AA Review
Review of
of
the Literature.
the Literature. Oper.
Oper. Dent.
Dent. 2009;
2009; 34(5):
34(5): 615–625.
615-625.
INDIRECT
INDIRECT PULP
PULP CAPPING
CAPPING
•° Procedure
Procedure withwith
Calcium hydroxide
Calcium hydroxide
•° Composite
Composite filling
filling
•° GIC
GIC underlay
underlay
•° Calcium
Calcium hydroxide
hydroxide
setting
setting
DIRECT
DIRECT PULP
PULP CAPPING
CAPPING

44
 DIRECT
DIRECT PULP
PULP CAPPING
CAPPING
INDICATIONS
INDICATIONS

•° Reversible,
Reversible, asymptomatic
asymptomatic pulpopathies
pulpopathies of of carious
carious etiology
etiology
with accidental
with accidental exposure
exposure of of the
the pulp
pulp (within
(within healthy
healthy
dentin) of
dentin) of nono more
more than
than 1mm
1mm which
which arose
arose during
during cavity
cavity
preparation
preparation
•° Ellis
Ellis class
class III
III post-traumatic
post-traumatic crowncrown fractures
fractures (with
(with pulp
pulp
exposure) not
exposure) not larger
larger than
than 1mm,
1mm, if if the
the patient
patient presents
presents forfor
treatment no
treatment no later
later than
than on
on the
the second
second dayday after
after the
the
trauma (24
trauma (24 hours).
hours).
 DIRECT
DIRECT PULP
PULP CAPPING
CAPPING
Direct pulp
Direct pulp capping:
capping:
•° Following
Following the the preservation
preservation of of an
an aseptic
aseptic working
working field,
field,
application of
application of aa biomaterial
biomaterial directly
directly onto
onto the
the exposed
exposed pulp,
pulp,
prior to
prior to immediate
immediate placement
placement of of a
a permanent
permanent restoration.
restoration.
•° IfIf successful,
successful, this
this procedure
procedure precludes
precludes the the need
need for
for more
more
invasive, more
invasive, more extensive
extensive and and more
more expensive
expensive treatment.
treatment.
•° The
The placement
placement of of aa permanent,
permanent, well-sealed
well-sealed restoration
restoration at at the
the
time of
time of pulp
pulp capping
capping is is crucial
crucial toto clinical
clinical success.
success.
 DIRECT
DIRECT PULP
PULP CAPPING
CAPPING
•° Some
Some studies
studies have
have shown
shown that that a a tooth
tooth is is more
more likely
likely to
to survive
survive
direct pulp
direct pulp capping
capping if if the
the initial
initial exposure
exposure is is due
due toto mechanical
mechanical
reasons rather
reasons rather than
than caries.
caries.
•° In
In exposures
exposures by by caries,
caries, there
there maymay be be aa massive
massive penetration
penetration of of
bacterial organisms
bacterial organisms to to the
the tissue.
tissue. This
This usually
usually results
results inin aa
localized acute
localized acute inflammation
inflammation of of the
the pulp.
pulp.
•° It
It is
is generally
generally agreed
agreed that that the
the most
most successful
successful prognosis
prognosis exists
exists
when perforation
when perforation is is made
made during
during the
the very
very final
final excavation
excavation of of
the deepest
the deepest part
part of
of the
the carious
carious lesion
lesion and
and when
when there
there isis only
only a a
small exposure.
small exposure.
 DIRECT
DIRECT PULP
PULP CAPPING
CAPPING
Class I:
Class I:
•° No
No preoperative
preoperative presence
presence of of aa deep
deep carious
carious lesion.
lesion. Pulp
Pulp
exposure judged
exposure clinically to
judged clinically to be
be through
through sound
sound dentine
dentine with
with an
an
expectation that
expectation that the
the underlying
underlying pulp pulp tissue
tissue isis healthy
healthy
(exposure due
(exposure due to
to aa traumatic injury to to the
the tooth
tooth or or an
an
iatrogenic exposure).).
Class II:
Class Il:
•° Preoperative
Preoperative presence
presence of of aa deep
deep or or extremely deep carious
lesion.. Pulp
Pulp exposure
exposure judged clinically to
judged clinically to be
be through
through a a zone
zone of
of
bacterial contamination
bacterial contamination with with an an expectation
expectation that that the
the
underlying pulp
underlying pulp tissue
tissue is
is inflamed.
inflamed. Increase
Increase operative
operative protocol
protocol
recommended (aseptic
recommended (aseptic procedure
procedure using using magnification,
magnification,
disinfectant, and
disinfectant, and application
application of of aa calcium
calcium silicate
silicate cement).
cement).
 DIRECT
DIRECT PULP
PULP CAPPING
CAPPING
•° Procedure
Procedure with
with
Calcium hydroxide:
Calcium hydroxide:
•° Composite
Composite filling
filling
•° GIC
GIC
•° Calcium
Calcium hydroxide
hydroxide
setting
setting
•° Calcium
Calcium hydroxide
hydroxide
non setting
non setting
BIODENTINE
BIODENTINE
Biodentine”
&
a=

septodont
Biodentine is
Biodentine is in
in the
the form
form of of aa liquid
liquid
and aa powder
and powder thatthat are
are mixed
mixed together
together
in a
in a shaker.
shaker.
Powder: tricalcium
Powder: tricalcium silicate,
silicate, dicalcium
dicalcium
silicate and
silicate and fillers
fillers (sodium
(sodium carbonate)
carbonate)
Fluid: calcium
Fluid: calcium chloride
chloride solution
solution 50
BIODENTINE
BIODENTINE INDICATIONS
INDICATIONS
SE

•° In
In the
the crown:
crown: temporary
temporary Biodentine™ Clinical
enamel restoration,
enamel restoration, VS
permanent dentine
permanent dentine
restoration, deep
restoration, deep or
or large
large Minimally invasive

carious lesions,
carious lesions, deep
deep provin teh nade ston
bd bd treat tt missnisegee

Structure

cervical or
cervical or radicular
radicular lesions,
lesions, 7
pulp capping,
pulp capping, pulpotomy.
pulpotomy. . termediate ain comescke
lial
•° In
In the
the root:
root: root
root and
and —al a
furcation perforations,
perforations,
< eee i»
furcation ® limiting bactera!

internal/external
internal/external
resorptions, apexification,
resorptions, apexification,
ye bridge formation

retrograde surgical
retrograde surgical filling.
filling. =
51
BIODENTINE
BIODENTINE --
INDIRECT PULP
INDIRECT PULP CAPPING
CAPPING

STEP 1.
STEP 1.
Remove caries
Remove caries from
from thethe occlusal
occlusal
surface and
surface and side
side walls.
walls. Change
Change thethe
drill to
drill to a a sterile
sterile one
one and
and clean
clean the
the
wall closest
wall closest to to the
the pulp
pulp chamber
chamber

STEP 2.
STEP 2.
Fill the
Fill the entire
entire cavity
cavity with
with the
the
material Biodentin.
material Biodentin.
Working time/setting
Working time/setting time:
time: 9-
9-
12min
12min
We can
We can observe
observe the
the tooth
tooth and
and test
test
its vitality
its vitality for
for about
about 3-6
3-6 months
months 52
STEP 3.
STEP 3.
Remove part
Remove part of
of the
the Biodentine
Biodentine
material, the
material, the part
part on
on the
the wall
wall
closest to
closest to the
the pulp
pulp chamber
chamber cancan be
be
left as
left as underlay
underlay

STEP 4.
STEP 4.
Fill the
Fill the cavity
cavity with
with composite
composite
material using
material using standard
standard methods
methods
(cavity etching,
(cavity etching, bonding
bonding system,
system,
composite filling)
composite filling)

53
BIODENTINE
BIODENTINE --
DIRECT PULP
DIRECT PULP CAPPING
CAPPING
Biodentine™: Step by step procedure

beta LEN aes

Sas) ikea Wien Ex ad BL eB OA sted ee Vso May pet st4
Proceed to caries excavation, Let the pulp appear and allow Control bleeding by applying a If bleeding contro! is achieved
first rinsing with 5% NaOCl, then bleeding. cotton pellet, moistened with within & min, fill the cavity with
using regular carbide/diamond 5% NaOCi. Biodentine™ and proceed to
burs. final enamel restoration within
6 months.

54
MINERAL
MINERAL TRIOXIDE
TRIOXIDE
AGGREGATE
AGGREGATE

ing
Material for fill
of root canals
and rebuilding
ypeinigns
Materat dow yct?
te yw kowzermov
jodbudowy Amna

55
MTA
MTA ADVANTAGES
ADVANTAGES

•° It
It is
is biocompatible
biocompatible
•° Doesn't
Doesn't resorb
resorb
•° Shows
Shows good
good marginal
marginal adhesion
adhesion
•° Has
Has odontotropic
odontotropic and and antibacterial
antibacterial properties
properties
•° Shows
Shows better
better mechanical
mechanical strength
strength than
than the
the non-
non-
setting calcium
setting calcium hydroxide
hydroxide
•° High,
High, basic
basic pH
pH initially
initially 10.2
10.2 and
and after
after setting
setting 12.5
12.5

56
MTA
MTA INDICATIONS
INDICATIONS
•° ProRoot®
ProRoot® MTA MTA rootroot repair
repair material
material isis indicated
indicated for
for use
use as:
as:
•° AAroot-end filling material;
root-end filling material;
•° For
For the
the repair
repair of of root
root canals
canals as
as an
an apical
apical plug
plug during
during
apexification;
apexification;
•° For
For repair
repair of
of root
root perforations
perforations during
during rootroot canal
canal therapy;
therapy;
•° As
As aa consequence
consequence of of internal
internal resorption;
resorption;
•° As
As aa pulp
pulp capping
capping material;
material;
•° Pulpotomy
Pulpotomy of of primary
primary teeth
teeth in
in the
the child
child (ages
(ages >2-12
>2-12
years) and
years) and adolescent
adolescent (ages(ages >12-21
>12-21 years)
years)

57
MTA
MTA TYPES
TYPES
•° Working
Working time:time: 5 5 minutes
minutes
•° Setting
Setting time:
time:
•e 3-4
3-4 hours
hours (old(old one)
one) -- inin this
this
case, the
case, the tooth
tooth is is treated
treated in in
two stages.
two stages. First
First stage,
stage, after
after
placing the
placing the MTA
MTA material
material in in
the cavity,
the cavity, secure
secure it it with
with a a
moist (but
moist (but not
not wet!)
wet!) cotton
cotton
ball with
ball with aa temporary
temporary filling filling
•° 10-20min
10-20min (new (new one)-
one)- we we
can make
can make the the final
final filling
filling on
on
the same
the same visit
visit
58
 MTA-
MTA- HOW
HOW TO
TO USE
USE
• Complete
Complete a a cavity
cavity preparation
preparation outlineoutline under
under dental
dental dam
dam isolation,
isolation, using
using high-speed
high-speed burs,
burs,
under constant
under constant waterwater cooling.
cooling.
• Excavate
Excavate any any carious
carious tooth
tooth structure
structure using
using a a round
round burbur in
in aa hand
hand piece
piece at
at low
low speed
speed oror use
use
hand instruments.
hand instruments.
• Rinse
Rinse thethe cavity
cavity and
and exposure
exposure site(s)
site(s) with
with 2.6%
2.6% -- 5%5% NaOCl.
NaOCl. Heavy
Heavy bleeding
bleeding maymay be
be controlled
controlled
with a
with a cotton
cotton pellet
pellet moistened
moistened with with NaOCl.
NaOCl.
• Prepare
Prepare MTA MTA according
according to to mixing
mixing instructions
instructions provided.
provided.
• Apply
Apply a a small
small amount
amount of of MTA
MTA overover the
the exposure
exposure usingusing aa small
small ball
ball applicator,
applicator, or or similar
similar device.
device.
• Remove
Remove the the excess
excess moisture
moisture at at the
the site
site with
with a a dry
dry cotton
cotton pellet.
pellet.
• Apply
Apply a a small
small amount
amount of of flowable
flowable compomer
compomer (or (or an
an equivalent
equivalent light-cured
light-cured resin,
resin, glass-ionomer
glass-ionomer
liner) to
liner) to cover
cover thethe MTA
MTA material,
material, and and light
light cure
cure according
according to to its
its instructions.
instructions.
• Etch
Etch the
the remaining
remaining cavitycavity walls
walls with
with 34%
34% -- 37%
37% phosphoric
phosphoric acidacid gel
gel for
for 15
15 seconds.
seconds. Rinse
Rinse
thoroughly.
thoroughly.
• Dry
Dry the
the cavity
cavity gently,
gently, leaving
leaving the
the dentin
dentin moist,
moist, butbut not
not wet.
wet. Apply
Apply bonding
bonding material.
material. Cure
Cure
according to
according to its
its instructions.
instructions.
• Place
Place composite
composite material
material to to complete
complete the the restoration.
restoration.
• Cure
Cure according
according to to its
its instructions.
instructions.
• Assess
Assess the the pulp
pulp sensibility
sensibility (responsiveness
(responsiveness to to tests)
tests) every
every 6 6 months
months and and evaluate
evaluate the
the tooth
tooth
59
Radiographically every
• Radiographically every three
three to to six
six months
months or or as
as needed.
needed.
TOOTH
TOOTH CONTROL
CONTROL AFTER
AFTER
BIOLOGICAL
BIOLOGICAL TREATMENT
TREATMENT
•e We
We must
must remember
remember to to check
check the
the vitality
vitality ofof the
the tooth
tooth after
after
biological treatment-not
biological treatment-not only only during
during the the visit
visit at
at which
which we we
performed the
performed the procedure,
procedure, but but also
also during
during follow-up
follow-up visits!
visits!
•° We
We can
can also
also take
take dental
dental radiographs
radiographs at at follow-up
follow-up visits
visits
•° We
We should
should inform
inform thethe patient
patient that
that the the tooth
tooth may
may be be tender
tender a a
few days
few days after
after the
the direct
direct pulp
pulp capping
capping procedure.
procedure.
•° The
The patient
patient should
should report
report toto us
us all
all abnormalities
abnormalities relatedrelated to to the
the
tooth after
tooth after the
the end
end ofof treatment
treatment (for (for example,
example, spontaneous
spontaneous
pain, bite
pain, bite discomfort,
discomfort, swelling
swelling of of the
the gum
gum around
around thethe top
top ofof
the tooth
the tooth root).
root). The
The symptoms
symptoms may may indicate
indicate a a failure
failure ofof
biological treatment
biological treatment and and the
the need
need for for endodontic
endodontic treatment
treatment of of
the tooth.
the tooth.
60
 Bibliography
Bibliography
• Textbook
Textbook of of Endodontology,
Endodontology, 2nd 2nd Edition.
Edition. Gunnar
Gunnar Bergenholtz,
Bergenholtz,
Preben Hørsted-Bindslev,
Preben H@rsted-Bindslev, ClaesClaes Reit.
Reit. ISBN:
ISBN: 978-1-118-69138-0
978-1-118-69138-0
• Stomatologia
Stomatologia Zachowawcza
Zachowawcza zz Endodoncją.
Endodoncja. Zarys Zarys Kliniczny
Kliniczny pod
pod red.
red.
Zbigniewa Jańczuka.
Zbigniewa Janczuka. Warszawa
Warszawa 2014.
2014.
• European
European Society
Society of of Endodontology
Endodontology (ESE): (ESE): Management
Management of of deep
deep
caries and
caries and the
the exposed
exposed pulp.
pulp. Int
Int Endod
Endod J.J. 2019
2019 Jul;52(7):923-934.
Jul;52(7):923-934.
doi: 10.1111/iej.13080.
doi: 10.1111/iej.13080.
• American
American Association
Association of of Endodontists:
Endodontists: Endodontic
Endodontic Diagnosis.
Diagnosis.
httos://www.aae.org/specialty/wp-
https://www.aae.org/specialty/wp-
content/uploads/sites/2/2017/07/endodonticdiagnosisfall2013.pdf
content/uploads/sites/2/2017/07/endodonticdiagnosisfall2013.pdf
• T.J.
T.J. Hilton,
Hilton, J.L. Ferracane: Comparison
J.L. Ferracane: Comparison of of CaOH
CaOH withwith MTA
MTA forfor direct
direct
pulp capping:
pulp capping: aa PBRN
PBRN randomized
randomized clinical
clinical trial.
trial. JJ Dent
Dent Res.
Res. 2013
2013
Jul;92(7):16-22.
Jul;92(7):16-22. doi: doi: 10.1177/0022034513484336.
10.1177/0022034513484336.
• SEPTODONT
SEPTODONT Case Case Studies
Studies Collection.
Collection. March
March 2012
2012
Thank
Thank you
you:):) 62
 Pomorski Uniwersytet Medyeany w Szczecinie

COMPLICATIONS
COMPLICATIONS IN
IN RESTORATIVE
RESTORATIVE
DENTISTRY
DENTISTRY

Conservative
Conservative dentistry
dentistry

Katedra
Katedra ii Zakład
Zaktad Stomatologii
Stomatologii Zachowawczej
Zachowawczej i1 Endodoncji
Endodoncji
 Pomorski Uniwersytet Medyczny w Szczecinie

Errors
Errors in
in diagnostics
diagnostics

• Lack
Lack of
of knowledge
knowledge about
about caries
caries diagnosis
diagnosis criteria
criteria

• Insufficient
Insufficient number
number of
of diagnostic
diagnostic methods
methods
~y

• Hyperdiagnosis
Hyperdiagnosis
invasive treatment
invasive treatment of
of stained
stained fissures
fissures instead
instead of
of prophylaxis
prophylaxis

• Hypodiagnosis
Hypodiagnosis —– deep
deep cavities
cavities undetected
undetected on
on interproximal
interproximal surfaces
surfaces
• visual • Radiological

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 Pomorski Uniwersytet Medyeany w Szczecinie

Errors
Errors in
in cavity
cavity preparation
preparation
 Pomorski Uniwersytet Medyeany w Szczecinie
Too wide
Too wide cavity
cavity opening
opening

Loading…
Outline form of
cavity
——
wae |

1 \ Outline of fF / i
4 carious Outline of
&
lesion carious
lesion

(A) Correct (B) Incorrect

 Pomorski Uniwersytet Medyeany w Szczecinie

Too narrow
Too narrow cavity
cavity opening
opening

•°* Enamel
Enamel overhangs
overhangs

•° Too
Too thin
thin layer
layer of
of composite-
composite- fracture
fracture

•° Carious
Carious dentine
dentine left
left at
at the
the bottom
bottom of
of cavity
cavity

•° Pulp
Pulp injury
injury
 Pomorski Uniwersytet Medycany w Szczecinie

Injury
Injury of
of adjacent
adjacent tooth
tooth

•° Inproper
Inproper place
place of
of cavity
cavity opening
opening

•° Inproper
Inproper instruments
instruments used
used (too
(too big)
big)

•° Insufficent
Insufficent access
access to
to the
the tooth
tooth
 Pomorski Uniwersytet Medyeany w Szczecinie

Errors in
Errors 1n cavity
cavity filling
filling
 Pomorski Uniwersytet Medycany w Szczecinie

Tooth-
Tooth- tooth
tooth contacts
contacts restoration
restoration

• Inproper
Inproper interproximal
interproximal contacts
contacts

•°* — Inproper
Inproper bite Loading…
bite adjustments:
adjustments:

1. Too
Too high
high restoration-
restoration- pain,
pain, need
need of
of endodontic
endodontic treatment,
treatment, cracks,
cracks,
fractures
fractures

2. Too
Too low
low restoration:
restoration: passive
passive eruption-
eruption- cemento-enamel junction
cemento-enamel junction
exposure
exposure

3. Incorrect
Incorrect anatomical
anatomical restoration-
restoration- too
too active
active contacts,
contacts, incorect
incorect
contacts-
contacts- occlusal
occlusal parafunctions
parafunctions
Incorrect
Incorrect interproximal
interproximal contacts
contacts

tice Contact too broad occlusogingtvally

and buccolingually
Contact too thin occlusogingivail
and niccceentany :

LY Sy
DY
Contact too occlusally placed

Contact too buccal Contact too lingual Contact too occlusal

Cy, Open contact

Contact with too much convexity Contact with too much concavity
Incorrect Wedge
Incorrect Wedge position
position
 pe

EMBRASURE FORM...
results in unhealthy
gingiva due to lack of s
stimulation. uado 001 pesojo oo)
wea einseiquiy joer

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embrasure form...
healthy gingiva...due to
adequte stimulation.

andentalacademy.com
 1. Lack
Lack of
of interproximal
interproximal
contact
contact

2. overhang
overhang

3. Inproper
Inproper position
position of
of
contact
contact point
point

1. Destruction
Destruction ofof periodontal
periodontal
tissues
tissues
2. Loss
Loss of
of alveolar
alveolar bone
bone
3. Secondary
Secondary caries
caries
 Proper
Proper architecture
architecture of
of buccal/palatal
buccal/palatal walls
walls

FOlmect conto Pat nder-contoured

/X /X a~
 Pomorski Uniwersytet Medycany w Szczecinie

Polymerization stress
Polymerization stress
management
management
Polymerization Stress Bond Strength

a Composite adhesion
Composite adhesion toto
Polymerization
Polymerization etched enamel
etched enamel via
via
stress
stress forces
forces 13–17
13-17 bonding system
bonding system 20-30
20-30
MPa
MPa MPa
MPa
 Potencjalne
Potencjalne konsekwencje
konsekwencje skurczu
skurczu i1 napięcia polimeryzacyjnego
napiecia polimeryzacyjnego

Bond strength : Polymerization

stress

When the
When the contraction
contraction force
force exceeds
exceeds thethe bond
bond strength
strength of
of the
the material
material to
to
the cavity
the cavity walls,
walls, polymerization
polymerization contraction
contraction creates
creates aa marginal
marginal gapgap
between the
between the filling
filling and
and thethe tooth
tooth tissue,
tissue, causing
causing a a micro-leakage
micro-leakage
responsible for
responsible for early
early and
and late
late complications.
complications.

vv

Discoloration
Discoloration of filling borders;
of filling borders; postoperative
postoperative pain;
pain; secondary
secondary caries
caries
 Polymerization
Bond strength tradi

On the
On the other
other hand,
hand, ifif the
the bond
bond strength
strength ofof the
the material
material is
is greater
greater than
than the
the
strength of
strength of polymerization
polymerization stress,
stress, which
which occurs
occurs inin the
the case
case ofof a
a cavity
cavity
reconstruction with
reconstruction with preserved
preserved thin
thin walls,
walls, deformation
deformation occurs
occurs and
and a a
possible cascade
possible cascade ofof many
many complications
complications occurs..
occurs..

Fractures,
Fractures, postoperative
postoperative pain
pain
 microleakage
microleakage

Borders
Borders
Discoloration
Discoloration ~—_ n ,
— / Secondary caries
Secondary caries
Sa / f

—— /
a /

____, Enamel
Enamel fractures,
fractures,
cusp
cusp fractures
fractures

Empty
Empty spaces
spaces ~ Postoperative
Postoperative
hypersensitivity
hypersensitivity
 Polymerization stress
Polymerization stress management
management
1.
1. Extending
Extending the
the pre-gel
pre-gel phase
phase -- reducing
reducing the
the
irradiance
irradiance in
in the
the first
first phase
phase of
of polymerization
polymerization
 2.
2. Size
Size and
and depth
depth of
of cavity
cavity

The
The shape
shape ofof the
the cavity
cavity has
has a a huge
huge impact
impact onon the
the size
size of
of the
the
polymerization
polymerization stress.
stress. The
The polymerization
polymerization stress
stress is
is small
small
when
when the
the cavity
cavity c-factor
c-factor isis less
less than
than 11 and
and increases
increases rapidly
rapidly
after
after exceeding
exceeding thethe value
value ofof 3.
3.

Vv

GIC
GIC intermediate
 3.
3. Material
Material application
application technique
technique

Volume
Volume of of material
material applied
applied
The
The greater
greater the
the volume
volume of
of the
the applied
applied material,
material, the
the greater
greater the
the volumetric
volumetric
shrinkage
shrinkage and
and thus
thus the
the greater
greater the
the contraction
contraction tension.
tension.

The
The layered
layered technique
technique of
of filling
filling cavities
cavities is
is still
still the
the most
most effective
effective method
method of
of
reducing
reducing systolic
systolic tension.
 3.
3. Material
Material application
application technique
technique

Increments

Bulk Fill
4.
4. Characterstics
Characterstics of
of the
the restorative
restorative material
material

5.
5. Quality
Quality and
and application
application method
method of
of bonding
bonding
system
 Discoloration
Discoloration of
of
restorations
restorations margins
margins

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 Pomorski Uniwersytet Medyczny w Szczecinie
Discoloration
Discoloration of
of
restorations
restorations margins
margins

Causes
Causes

•° The
The preparation
preparation margin
margin is
is not
not defined
defined

•° Excess
Excess of
of the
the composite
composite material
material

•° Improper
Improper polishing
polishing (material
(material overheating)
overheating)

•° Material
Material features
features (water
(water sorption)
sorption)
 Pomorski Uniwersytet Medyeany w Szczecinie
Discoloration
Discoloration of
of
restorations
restorations margins
margins

Solution:
Solution:

Analysis of the cause in order to eliminate it in the future

Filling
Filling refurbishment
refurbishment -- refinishing
refinishing and
and polishing
polishing

Filling
Filling replacement
replacement
 Pomorski Uniwersytet Medycany w Szczecinie
Unsatisfactory
Unsatisfactory aesthetic
aesthetic effect
effect -- wrong
wrong color
color

• Choosing
Choosing the the wrong
wrong color
color –— partial
partial cavity
cavity preparation
preparation
(left
(left caries),
caries), overdrying
overdrying ofof the
the tissues,
tissues, improper
improper lighting,
lighting,
incorrect
incorrect color
color of
of the
the interior
interior of
of the
the office
office

• Choosing
Choosing the
the wrong
wrong material
material transparency
transparency

• Discoloration
Discoloration of
of the
the restoration
restoration -- incorrect
incorrect polishing,
polishing,
wrong
wrong type
type of
of material
material applied,
applied, contamination
contamination (wrong
(wrong
instruments,
instruments, blood)
blood)

• Yellowing
Yellowing of
of the
the restoration
restoration -- insufficient
insufficient polymerization
polymerization
 Pomorski Uniwersytet Medyeany w Szczecinie

Insufficient polymerization
Insufficient polymerization

1.
1. Insufficient
Insufficient conversion
conversion
2. Increase
Increase inin water
water sorption
sorption andand solubility
solubility -- clinically
clinically manifested
manifested asas color
color
instability
instability -- color
color change
change is is related
related to to oxidation
oxidation caused
caused byby water
water exchange
exchange
inside
inside the
the polymer
polymer matrix
matrix and
and its
its interaction
interaction with
with unreacted
unreacted polymer
polymer and
and
unused
unused initiator
initiator oror accelerator
accelerator
 Pomorski Uniwersytet Medycany w Szczecinie

The
e degree
degree of
of polymerization
polymerization of
of the
the composite
composite material
material (MZ)
(MZ) is
is influenced
influenced
by
by many
many factors:
factors:

shade
shade MZ,MZ,
light
light curing
curing time,
time,
thickness
thickness of of the
the MZMZ layer,
layer,
type
type of
of curing
curing lamp
lamp (LCU)
(LCU)
cavity
cavity diameter,
diameter,
location
location of of the
the cavity
cavity
distance
distance of
of the
the LCU
LCU tip
tip from
from the
the hardened
hardened MZ
MZ surface,
surface,
substrate
substrate through
through which
which is
is hardened,
hardened, e.g. e.g. hardening
hardening by
by ceramics,
ceramics, enamel
enamel
or
or dentin),
dentin),
type
type of filler
of filler
Temperature
Temperature

(AlQahtani
(AlQahtani i| in.,
in., 2013;
2013; AlQahtani
AlQahtani ii in.,
in., 2015;
2015; Chang
Chang ii Kim,
Kim, 2014;
2014; Reges
Reges i| in.,
in., 2008;
2008;
Rueggeberg
Rueggeberg i| in.,
in., 1993).
1993).
 Pomorski Uniwersytet Medyeany w Szczecinie

Influence
Influence of
of LCU
LCU

• Type
Type of
of curing
curing lamp
lamp (LCU)
(LCU)

• Lamp
Lamp quality
quality

• Technical
Technical condition
condition of
of the
the lamp
lamp

• Distance
Distance of
of the
the LCU
LCU tip
tip from
from the
the hardened
hardened surface
surface MZ
MZ

• Defect
Defect diameter,
diameter,

• The
The location
location of
of the
the cavity
cavity
 Rodzaj lampy polimeryzacyjnej (LCU)

• Light
Light intensity
intensity

• The
The spectrum
spectrum of
of the
the emitted
emitted light
light

• Heat
Heat dissipation
dissipation

• Polymerization
Polymerization mode
mode
Pomorski Uniwersytet Medyeany w Szczecinie
Quality
Quality of
of LCU
LCU
 Technical condition

586 mW/cm” 569 mW/cm” 529 mW/cm?

Kaja
Kaja Wichrowska,
Wichrowska, Jerzy
Jerzy Sokołowski
Sokotowski Wpływ jakości powierzchni
Wptyw jakosci powierzchni końcówki
koncowki światłowodu
Swiatlowodu na
na wartość
wartos¢ natężenia
natezenia światła
Swiatta halogenowej
halogenowej lampy
lampy polimeryzacyjnej
polimeryzacyjnej Dent.
Dent. Med.
Med. Probl.
Probl. 2010,
2010, 47,
47, 3,
3, 309–313
309-313
 en distance
A StANE? of
OF the
he LCU
LEY tiptip from thehardened
trom the hardened MZ surface
Mz surtace
Effect of Distance on Irradiance and Beam Homogeneity from 4 Light-Emitting
Diode Curing
Diode Curing Units
Units — JJ Can
Can Dent
Dent Assoc
Assoc 2011;77:b9
2011;77:b9 Richard
Richard Price
Price

0
i+

2+

Or 3F
1+ 4+
24 5+

3+ 6+

st | v
™
5+ sl(mm) |i C
©
for)
&
<=
a
o
a
o
0

2 A
it
©
=
5 ;

4 ® “
irradiance (mWi/cm’) sf 4
500 1000 __1500__2000_ 2500 3000 3500 Bia ‘ coal P
CEJ CEJ
 Pomorski Uniwersytet Medycany w Szczecinie
Localization
Localization of
of the
the
cavity
cavity
 Pomorski Uniwersytet Medyeany w Szczecinie
Cavity
Cavity diameter
diameter

LIGHT TIP
COVERS
ENTIRE TOOTH ©

12 mm

Irradiance
(mWicm’*)

M2500
Me 2250
ME 2000
Me 1750
1500
1250
1000
Mm 750
Mm 500
| <400
 Pomorski Uniwersytet Medycany w Szczecinie

Effect
Effect of procedural errors
of procedural errors

•° Total
Total loss
loss of
of restoration
restoration

•* marginal
marginal fissure,
fissure, discoloration
discoloration of
of the
the
filling,
filling, secondary
secondary caries
caries

•° Cracked
Cracked tooth
tooth or
or filling
filling

•° Post-treatment
Post-treatment hypersensitivity
hypersensitivity

•° Pulp
Pulp pathology
pathology
 Pomorski Uniwersytet Medyczny w Szczecinie

Total
Total loss
loss of
of restoration
restoration

•* Contamination
Contamination of
of the
the defect
defect with
with saliva
saliva or
or blood
blood
during
during etching,
etching, application
application of
of aa bonding
bonding system
system or
or
filling
filling with
with composite
composite material
material

•° Incorrect
Incorrect shaping
shaping of
of the
the cavity
cavity

•* Polymerization
Polymerization shrinkage
shrinkage and
and polymerization
polymerization
stresses
stresses
Enamel fractures and cracks
 Pomorski Uniwersytet Medyeany w Szczecinie
Causes
Causes
• Leaving
Leaving the
the tooth
tooth wall
wall too
too thin
thin

• Leaving
Leaving carious
carious dentine
dentine in
in the
the defect
defect

• Filling
Filling too
too high
high is
is assumed
assumed

• Too
Too thick
thick underlay
underlay is
is applied
applied

• Incorrect
Incorrect fill
fill contours
contours

• Incorrect
Incorrect technique
technique of
of applying
applying the
the material
material to
to the
 cavity
Pomorski Uniwersytet Medyeany w Szczecinie

microleakage
microleakage

•° Failure
Failure in
in maintaining
maintaining the
the dryness
dryness of
of the
the treatment
treatment
area
area and
and restoring
restoring the
the tooth
tooth in
in presence
presence of
of blood
blood and
and
saliva
saliva inside
inside the
the cavity
cavity

•°* Polymerization
Polymerization shrinkage
shrinkage and
and generation
generation of
of shrinkage
shrinkage
tensions
tensions
 Pomorski Uniwersytet Medycany w Szczecinie

microleakage
microleakage

Assessment of
Assessment of the
the quality
quality of of the
the connection
connection of of the
the
filling
filling with
with the
the margin
margin of of the
the defect.
defect.
In
In case
case of
of aa macroscopic
macroscopic leakage,
leakage, the the filling
filling must
must bebe
repaired
repaired oror replaced.
replaced.
If
If there
there is
is no
no visible
visible leakage
leakage -- sealing
sealing the
the edges
edges of
of
the
the filling.
filling.