4. Class IV and Diastema Flashcards by J L

Definition

It is a lesion that
involves the proximal surfaces of ____ teeth and includes the loss of at least one of the ____

incisal angles

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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

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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

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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)

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*Sometimes composite resin restoration is placed as an ____ treatment while determining prognosis of tooth prior to definitive restoration

interim

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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

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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

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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

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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

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Shade selection
– prior to ____ and placement of rubber dam
- more difficult if ____ restoration without normal ____ coloration
- ____, if necessary

dehydration
large
dentin
prewedge

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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

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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

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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

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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

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Procedure

● Retention form
– ____ bonding to enamel and dentin
– additional retention achieved by increasing width of enamel ____ or placing ____

micromechanical
bevels
undercuts

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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

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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

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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

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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

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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

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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

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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

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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

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Class IV Restoration
● Etching, priming, adhesive placement same as Class ____
– place ____ prior to etching to protect adjacent teeth
– Etch beyond ____

III
matrix
bevel

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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 ```