4. Class IV and Diastema Flashcards
Definition
It is a lesion that
involves the proximal surfaces of ____ teeth and includes the loss of at least one of the ____
anterior
incisal angles
Preliminaries
*____
*Examination
*____ evaluation
*____
To reveal the full extent of the lesion, proximity to the pulp, and condition of the pulp and surrounding structures
Hot/cold stimulus (how long)
◦If none, is ____ dead?
◦Think about stresses and ____ that might put pressure on the tooth
History Radiographic evaluation diagnostic models pulp strain
ETIOLOGY
Trauma
Especially ____ and young adults
Are usually more ____ than vertical
Caries
Frequently carious Class ____ which has undermined ____ edge, usually ____
Defective restorations Usually ____
7-8 year old patient
• some dentin is exposed
◦Anytime take a ____ in feels pain
children
horizontal
III
incisal
vertical
vertical
breath
Objectives
- To protect remaining dental and pulpal ____
- To re-establish ____
- To provide a ____ treatment to restore involved teeth
Main purpose of incisal edge
• ____ tooth
• ____
tissues
aesthetics
conservative
incise
phonetics (speech)
*Sometimes composite resin restoration is placed as an ____ treatment while determining prognosis of tooth prior to definitive restoration
interim
Preparation
● 3 methods of retention
____
● grooves in ____ or
other shaped undercuts
● ____ or pins
Micro-enamel
● Requires a wider more substantial ____
- etching of the ____ - getting a nice good bond
● ____
- the bonding procedure
macrodentinal
dentin
dovetail
bevel
enamel
microdentinal
Incisal and gingival retention grooves and dovetail extension
– dovetail enhances ____ and retention, but is less ____ and not used often
– Pins are avoided in ____ preparations as there is a risk of ____ or may corrode and shine through thin areas of ____
strength conservative anterior perforation enamel
Preparation
____mm wide bevel for esthetic ____ and increased ____ through acid-etch bonding
The bevel is of UPMOST IMPORTANT
• Much wider 2-3 mm
• GET EVERY BIT YOU CAN!!!!
2-3
blending
retention
Occlusal Assessment May Influence :-
a) ____ of outline
b) ____ form
c) ____ form
d) position of margins which should not be in ____ areas - Want to keep them as ____ away as possible
e) Remember the restoration is going to be subject to downward,
upward, lateral , oblique, rotational and shearing forces
Just goes t show that we have come so far in the bonding procedure Pressure of a human bite: • Anterior ◦\_\_\_\_ lbs/in2 • Posterior ◦\_\_\_\_ lbs/in2
extension retention resistance stress far 57 171
Shade selection
– prior to ____ and placement of rubber dam
- more difficult if ____ restoration without normal ____ coloration
- ____, if necessary
dehydration
large
dentin
prewedge
Beveled Conventional Preparation
Outline form
– preparation walls are as ____ or ____ to long axis of tooth as possible
Results in design to provide greater ____ to biting forces
These days great emphasis
is placed on minimally ____ preparations
Remember you want to take away as little
____ as you possibly can
perpendicular parallel resistance invasive enamel
Outline form
Carbide or diamond bur on high speed
Remove all weakened ____ - In weakened enamel is
____ ENAMEL
Excavate infected ____ Using round bur on slow speed - or ____
Aim for a smooth flowing outline
enamel
decalcified
dnetin
spoon excavator 9
BEVEL
Cavosurfaces of all accessible enamel margins are beveled with ____-shaped diamond
– ____ degree angle
– approximately ____mm
– ____ thickness of enamel
flame
45
2-3
1/2
BEVEL
● Bevel may be ____ for additional retention and esthetics
- For additional enamel to bevel
- Opens up more of the ____ where the bonding can enter
Scalloping > • \_\_\_\_ purpose ◦If use a straight line ◦You may be able to see where the lesion ends and where the tooth starts
scalloped
canals
esthetic
Procedure
● Retention form
– ____ bonding to enamel and dentin
– additional retention achieved by increasing width of enamel ____ or placing ____
micromechanical
bevels
undercuts
Retention form
Pits and / or grooves
– Using a 1/4 round bur, prepare a groove bisecting the junction of ____ wall and ____ wall and extend length of ____ floor
- At inciso- axial line angle, more in the nature of a ____ than a groove
Up until this point the patient wouldn’t even need an anesthetic
• this is where they start to feel ____
axial
gingival
gingival
pit
pain
Minor Traumatic Fracture
Little or no preparation other than ____ the surfaces in the area of the fracture
● Remove any existing ____ or ____ restorations
● Prepare outline form to include ____, friable enamel
● ____ mm bevel on all available cavo-surfaces
roughening lesions defective weakened 2
Clinical Considerations
● A ____ can be created when the incisal edge is missing and the internal layer of dentin is exposed
– create with small ____
– enamel rods must be supported by ____
retentive trough
inverted cone
dentin
Clinical Considerations
Trough is carried directly into ____ portion of preparation
● ____ cone
● ____mm in depth
• Cut a little grove in the dentin
• But must have remaining ____ on either side
◦This would leave unsupported enamel ◦Enamel rods must be supported by ____
proximal 33 1/2 inverted 1-2 dentin dentin
PROBLEMS??
MECHANICAL STABILITY,- - -which is dependent on the ____ of the material, and it’s ability to resist ____ and fracture
Without this mechanical stability, cracks develop in the restoration, and with propagation of these cracks, may lead to ____ of the restoration
AESTHETICS
The ____ bevel does not allow for sufficient layering to achieve the desired aesthetic result
strength
wear
dislodgement
shallow
Research showed that if the finish line was in the form of a ____, mechanical stability was significantly improved.
The increased space that a chamfer affords, allows for the placement of additional ____ to achieve the desired aesthetic result.
A chamfer finish line on the ____, where most of the ____ is centered, could be an improvement in the design of the prep
chamfer
layers
lingual
stress
What constitutes a beautiful smile?
GOLDEN PROPORTION
Width of ____ is in direct proportion to the width of the ____ and that part of the ____ that shows from the front
The central incisor width length = length of lateral plus ____ portion of canine!
central incisor
lateral incisor
canine
medial
Preliminary Steps
- Determine the Shade of the tooth taking into consideration the following:-
a) The ____, Chroma, and the ____ of the shade
b) No ____ monochromatic shade can mimic the combination of shades that make up the natural
dentition. Teeth are ____.
c) The ____ features of the restoration are somewhat more important than establishing the exact shade - Dark ____
- Incisal ____
- Middle area ____
____: actual color
____: depth of color
____: darkness or lightness
Composite has a ____ effect, takes on color around it t some level
hue value single polychromatic anatomical
cervical
translucent
lighter
hue
chroma
value
chameleon
Class IV Restoration
● Etching, priming, adhesive placement same as Class ____
– place ____ prior to etching to protect adjacent teeth
– Etch beyond ____
III
matrix
bevel
Matrix Application
Place polyester ____ strip and ____ gingivally
Control of matrix strip is difficult and may cause:-
1, Over or under-____ restoration or over-____ of the strip
2, Open ____ point
3, Extrusion of material ____
Need to pull the strip at an ____ so the incisal edge is formed
• but it is quite difficult
matrix wedge contoured angulation contact incisally
angle
Wedging
● Seal ____ margin
● ____ teeth
● Ensure ____ contact
● Push ____ and proximal tissue gingivally to open gingival embrasure
gingival
separate
proximal
rubber dam
Placement
Composite available in 2 forms:-
1, Bulk syringes where the ____ benefit is better, but ____ is more difficult
2, Unit dose ampoules which allow direct injection of material into the preparation. This minimizes entrapping ____, better control of ____ as they are discarded after use
cost
handling
air bubbles
infection
A Dental Composite is:-
A ____ material with a combination of different components bonded together in a ____ base, each of which maintains their original ____ and ____
multiphase
resin
identities
properties
Inserting and Curing
● insert with same technique as Class ____ – hand instrument or syringe
● insert in ____mm increments
● use care not be pull matrix with ____ force
– soft material will be extruded ____ resulting in ____-contoured restoration
III 1-2 excessive incisally under
Inserting and Curing
● Can also place without utilizing a ____ matrix
● Sculpt composite resin and overbulk – overlap ____
● can contour and smooth facial with ____ brush
● Light cure 20 seconds from ____ and 20 seconds from ____
mylar bevel sable facial lingual
Inserting and Curing
No matrix used
– ____ layer will form on surface (thin, tacky layer)
– each layer will ____ attach to the next layer due to this oxygen inhibited layer
● if the surface remains free of ____
Matrix used
– no ____ layer
– need to ____ and add adhesive and polymerize to enhance attachment
If you need to keep roughening and re-bonding you will have changes in ____ etc Flecks of ____
oxygen-inhibited
chemically
contamination
oxygen inhibited
roughen
color
white
Inserting and Curing
● Because of unique esthetic and strength requirements for Class IV, it may be necessary to use 2 types of composite resin:
– \_\_\_\_ resin ● for greater \_\_\_\_ and opacity ● provides backing on \_\_\_\_ – \_\_\_\_ resin ● greater \_\_\_\_ and translucency
On the lingual surface need to have a stronger composite
◦____!!!
On the facial you will use the ____ for esthetic
microhybrid strength lingual nanohybrid polishability
HV
LV
Inserting and Curing
Placement of a hybrid composite resin on ____ and part of ____ surface
• Stronger
• More ____
◦Block out ____ shine front he back on the mouth
lingual
facial
opaque
dark
Inserting and Curing
Use of ____ on facial surface to enhance ____ of restoration by mimicking opacity of ____
opaquer
opacity
dentin
Inserting and Curing
Placement of a ____ composite resin on ____ and ____ surface
microfilled
facial
proximal
ADDITIONAL CONSIDERATIONS
(a) Because the darker inner recesses of the mouth are now exposed, one must deal with the “____” effect. This is achieved by the use of a
darker, more ____ material lingually
(b) The hues, tints and consistencies of the various forms of composite being used must ____, refract, and ____ the light in the same way as the Hydroxyapatite crystals, the enamel rods, and the dentinal tubules did in the healthy tooth
(c) The polishability of the new smaller ____ composites, their distinctive shapes, and orientation in the resin base, compares favorably with the qualities of ____
shine-through
opaque
reflect
transmit
nanohybrid
enamel
Contouring and Polishing
● similar to Class ____
● requires close assessment of ____
length and thickness
● occlusal ____ may need more adjustment and refinement than Class III
III
incisal edge
relationship
Contouring and Polishing
● Finishing burs and sof-lex discs
– barrel-shaped and large round finishing burs to contour
lingual surface
● \_\_\_\_ may be used to remove excess and contour embrasures ● Polish – \_\_\_\_ discs – rubber cups/points and \_\_\_\_ system – polishing paste
12 bard-parker
sof-lex
enhance
Diastema
DEFINITION
A ____ between two adjacent teeth in the ____ arch
space
same
BACKGROUND
*Early Literary mention 0f Diastema in Geoffrey Chaucer’s, “Gap-toothed Wife of ____”
• In parts of Africa, Diastema in women regarded as sign of ____
*In Australia, Diastema is believed to be evidence of ____
- 97% of children ____ years old have Diastemas
- 50% of children between ____ and 8 have Diastemas
- By age of ____, most Diastemas have closed
- Can develop again in ____ for a variety of reasons
bath fertility good luck 5 6 12 adulthood
Diastemas
● Should not be closed without:
– Recognizing and treating the ____ cause
● May correct the diastema
– Evaluation of ____
underlying
occlusion
Location
● ____ incisors
– Most frequent location
● Prominent ____ often prevents normal approximation of erupting central incisors
Usually it’s the frenum that inserts low on gingiva that can cause the diastema
-this is #1 reason of ____
maxillary central
labial frenum
etiology
Etiology
Prominent \_\_\_\_ Congenitally missing teeth Undersized or malformed teeth Interarch \_\_\_\_ size discrepancies Supernumerary teeth \_\_\_\_ in intercrestal bone structure ? Macroglossia \_\_\_\_ problems Flaccid Lips \_\_\_\_ Cysts
* When a tooth is missing, the lateral pressure of the adjacent teeth would cause them to open up * Inherit teeth of mother and jaw of father, and there's a \_\_\_\_, spaces can develop in the teeth * Supernumerary - form mainly at the \_\_\_\_ of teeth, when pressure is at root it can open up the diastema * Clefts - traumatic experience * Macroglossia - swelling of the \_\_\_\_ * Macroglossa + flaccid lips - the muscles of the lips are \_\_\_\_, and the swollen tongue, the pressure of the anterior teeth push forward bc no \_\_\_\_ from the lips * Cysts that form in \_\_\_\_ that form on the root section can cause pressure
labial frenum tooth clefts hormonal dental
discrepancy roots tongue weak resistance jawbone
Etiology
● \_\_\_\_ ● Tongue thrusting ● \_\_\_\_ sucking and \_\_\_\_ biting ● PeriodontalDisease ● \_\_\_\_ loss ● Posterior bite collapse ● \_\_\_\_ overbite
* Tongue thrusting can also result in a class \_\_\_\_ appearance * Posterior - missing a lot of back teeth, and the anterior take the pressure of the VDO and form a diastema
hereditary thumb lip toth deep
II
• The frenum inserts very low - one of the main causes - if you do surgery then the diastema will close down
○ Do at this age because the ____ are still emerging - may put pressure on the centrals and close them
laterals
MORE ABOUT THE FRENUM
1,Embryonic development starts as a band of tissue extending over the ____ from the bottom of the lip to the ____
2, When the 2 halves of the palate join together this tissue is split becoming the ____ anteriorly and the ____ posteriorly
3, The centrals erupt at about ____ years of age with a diastema
4, The laterals erupt at ____ years or so pressing on the roots of the centrals and tipping these 2 teeth
5, When the canines start erupting (____) the resultant pressures tend to ____ the teeth
6, Controversy as to which came first. The frenum or the diastema?
alveolar ridge palatal papilla frenum incisal papilla 5 8 10-12 straighten
Treatment
● ____
● Periodontal
● ____
● Prosthodontic
surgical
orthodontic
Treatment
● Composite resin
– More ____ alternative
– Consider other alternatives
* The \_\_\_\_, quickest and most effective alternative * Can also leave it as it is * Do two class \_\_\_\_ on the mesial of each tooth in order to make them both wider (golden proportion)
practical
cheapest
IV
Treatment
● Preliminary procedures prior to diastema closure
– ____ models
– Diagnostic ____
– Direct “____”
diagnostic
wax up
mock up
General Considerations
● Ideally, length:width ratio ____
– Teeth are ____ than they are wide
– If ratio is dramatically altered, teeth will appear ____
● Midline needs to be ____ to long axis of face
● Need to consider length
10:8
longer
unattractive
parallel
General Considerations
Midline ____ to long axis of face creates an esthetic appearance
parallel
Clinical Considerations
Tooth size discrepancy
• Multiple diastemas - can \_\_\_\_ them or do \_\_\_\_
close
orthodontics
Clinical Considerations
Diagnostic Wax-up of diastema closure
Mock-up, but we wanna use ____ wax instead of ____ -____ wax gives us a diff illusion of the size of things.
yellow
blue
blue
Procedure
● ____ teeth
● Select ____
• Even though you're doing a bonding with composite, perhaps it's not a good idea to put a rubber dam
clean
shade
Procedure
● Shade selection guidelines
– Less than 1mm diastema
● Close with 1 or 2 shades of ____
● ____ and ____ not important considerations
• Only ____ up the tooth, do not need to do anything aesthetically
– Greater than 1mm diastema
● ____ and ____
● ____ shade (dentin) to block out shine through
● Translucent shade for ____
Use microhybrid lingually, nanohybrid facially
nanohybrid
shine through
strength
roughen
microhybrid
nanohybrid
opaque
enamel
Diastema Closure
Measure width of ____ with calipers (clinically)
Also measure width of each ____
interdental space
tooth
Procedure
● ____ recommended
– Rubber dam may cause some difficulty in relating contour of restoration directly to proximal tissue
● Often restoration must begin ____ to appear natural
• Do not want one tooth wider than the other • Don't use rubber dam - because the restoration must begin \_\_\_\_ ○ Can use gauze, cotton rolls ○ \_\_\_\_ under the gingival to prevent any seepage
cotton isolation
subgingivally
subgingivally
retraction cord
Procedure
● Clinically, place retraction cord into gingival crevice in order to :-
1,Retract ____
2, Prevent ____ from crevice
soft tissue
seepage
Procedure
● Course ____-shaped diamond to roughen proximal surfaces
• Both \_\_\_\_ and \_\_\_\_
flame
lingually
facially
Procedure
● ____ interproximally
● Etch the enamel past prepared, ____ surface
– Should exhibit ____ appearance
● Place ____
matrix band
roughened
frosty
bonding agent
Procedure
● Teeth restored ____ at a time!
● ____ is placed extending subgingivally
● Usually, ____ is not used
● Composite resin placed with ____ instrument
one
polyester strip
wedge
hand
Procedure
● Be careful to press material ____ to blend with lingual surface
● Gently close matrix ____, beginning with gingival aspect
Matrix strip closed with ____ and ____
lingually
facially
thumb
forefinger
Procedure ● Do not pull strip too \_\_\_\_ – May be undercontoured \_\_\_\_ and/or – May be undercontoured \_\_\_\_
tightly
faciolingually
mesiodistally
Procedure
Light cure for minimum: 20 seconds ____
20 seconds ____
Slightly ____ to facilitate finishing to ideal contour
facially
lingually
overcontour
Procedure ● Remove \_\_\_\_ ● Contouring and finishing – \_\_\_\_ finishing burs – Fine diamonds – \_\_\_\_ discs – Finishing strips proximally Check occlusion with articulating paper
____ to finalize contour
strip
carbide
abrasive
finishing strip
Procedure
● Final polishing when ____ restoration is completed
● Correct mesiodistal dimension of ____ tooth needs to be established before second tooth is restored
● Width of ____ tooth = width of ____ tooth + remaining ____
contralateral first first second space
Procedure
● After etching, rinsing and drying, ____ restoration is completed
Attain tight contact with ____ band
second
matrix
Procedure
● Final polishing
– ____ polishing
points
– Polishing ____
rubber
paste
Procedure
Final luster obtained with polishing ____
with ____ cup
paste
prophy
Procedure
● ____ floss to detect any excess material or overhang
Diastema closed
unwaxed
DISCUSSION
1, Over time the colors may change and may have to be modified after ____ years
2. Violation of the “____”
3. The ____ profile
4. ____ should be done before Diastema closure
5. ____ causes and treatments.
6. Reversabilty
* Rule of three - 3 anterior lobes (4 total) - with the golden proportion, the width of each lobe has to be \_\_\_\_; when making mesial lobe wider - changing whole appearance of the tooth * Emergence profile - any class IV, and particularly diastema - you have to be careful of how deep the contour emerges from the \_\_\_\_, must look natural, if it's bad you can cause \_\_\_\_
7-10 rule of three emergence bleaching multifactorial proportional gingiva gingivitis
