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Operative II > Large Restorations > Flashcards

Large Restorations Flashcards

1
Q

what are the options for large restorations

A
  • restore: indirect pulp cap or direct pulp cap
  • endo: vital pulp therapy, RCT
  • crown lengthening
  • crown
  • extraction
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2
Q

describe the sensitivity of dentin

A

the DEJ is an extremely sensitive part of the tooth

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3
Q

describe the hydrodynamic theory of pain transmission

A
  • dentinal tubules are filled with odontoblastic processes and wrapped in afferent nerves and dentinal fluid
  • when enamel or cementum is removed during cavity preparation, the external seal of dentin is lost which allows small fluid movements in the tubules
  • this causes distortion in the afferent nerve endings, causing pain
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4
Q

hydrostatic pressure changes within the tubules is caused by external stimuli can:

A

cause pain to the pulp through fluid movement within the tubules

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5
Q

what are the precautions used to protect the dentin

A
  • air- water spray should be used whenever cutting with high speed handpieces to avoid heat build up and destruction of odontoblsatic processes in the dentin
  • dentin should not be dehydrated by air blasts
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6
Q

what can dentin dehydration cause

A

aspiration of odontoblasts into tubules

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7
Q

caries control restorations are performed as part of a larger caries control plan, when one or more of these conditions exist:

A
  • caries is extensive enough that pulpal complications are likely to occur soon
  • it is desirable to quickly eliminate large carious lesions that are a source for caries infection in the patients mouth
  • time does not permit definitive restoration of one or many large lesions
  • the prognosis for the pulp is questionable and definitive restoration should be deferred until the pulp’s condition can be better assessed
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8
Q

caries control restorations refer to a situation when one tooth or multiple teeth at the same appointment are treated quickly by:

A
  • removing the infected dentin
  • medicating the pulp, if necessary
  • restoring the defects with a temporary material. if a temporary material is used, undermined enamel can be left to better retain the temporary
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9
Q

when is an indirect pulp cap used

A

when a deep lesion occurs and there is no clinical or radiographic evidence of irreversible pulp damage

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10
Q

tooth should be in what condition for the indirect pulp cap:

A
  • asymptomatic
  • at most have symptoms consistent with reversible pulpitis- moderate cold sensitivity
  • pain subsiding 15 seconds
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11
Q

the caries is usually ______ than it appears on Xrays

A

deeper

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12
Q

what is the object of an indirect pulp cap

A

to avoid a direct pulp exposure

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13
Q

where are liners applied

A
  • to the deepest parts of the preparation closest to the pulp
  • away from margins
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14
Q

what are the liner materials

A
  • calcium hydroxide
  • resin modified glass ionomer
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15
Q

what are the brand names of calcium hydroxide and when is it used

A
  • Life, Dycal
  • use on deepest preps- pulp capping material
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16
Q

what is the brand name for resin modified glass ionomer, how does it cure, and what does it do

A
  • vitrebond
  • light cured
  • releases fluoride over time
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17
Q

what is the two appointment approach for the indirect pulp cap

A
  • remove all caries, affected and infected dentin, from all areas except the deepest, close to the pulp
  • leave the last little bit of infected dentin, cover it with calcium hydroxide and glass ionomer
  • place a temporary restoration such as IRM or Ketac silver
  • OK to leave undermined enamel temporarily to help hold in the temporary restoration
  • wait several weeks (12 weeks)
  • confirm the patient is asymptomatic and do vitality test before anesthetizing
  • remove the temporary restoration, glass ionomer and CaOH
  • carefully remove the remaining infected dentin
  • leave the affected dentin using a #4 round bur
  • place a new liner of dycal covered by base of vitrebond
  • remove undermined enamel, modify the prep
  • and restore
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18
Q

when is the two appointment approach done for the indirect pulp cap

A
  • when the removal of all the infected dentin is most likely going to result in a pulp exposure
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19
Q

why do you wait 12 weeks in the two appointment approach for indirect pulp cap

A

to allow the body to form reparative dentin in the site of the near exposure
- a dentin bridge will form

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20
Q

why do you use a round bur #4 instead of a spoon excavator in the two appointment approach for the indirect pulp cap

A
  • use on slowspeed just above stall speed with a light, shaving touch
  • the larger bur will put less force per unit area than the hand instrument would do, therefore making it less likely that one would break through into the pulp
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21
Q

when would it be okay to leave a small amount of infected dentin sealed deep in the cavity beneath the liner and base

A

if the cavity has been well sealed and the patient is asymptomatic and the tooth tests vital

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22
Q

why are you able to leave infected dentin in some circumstances

A

the food supply to the bacteria will die and become dormant
- caries progression will be arrested and the pulp will remain in good health

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23
Q

is the single appointment approach or two appointment approach more common in indirect pulp cap

A

the single appointment approach

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24
Q

describe the single appointment approach

A
  • remove infected dentin, remove affected dentin from any areas where a pulp exposure is not likely to occur
  • leave the affected dentin only in the deepest area where the possibly of a direct pulp is a concern
  • OK to leave a small amount of infected dentin in deep areas
  • place a liner of CaOH over the deepest area
  • place a base of glass ionomer over the CaOH. there is fluoride release from vitrabond
  • remove all undermined enamel and place the permanent restoration so you dont need to re-enter the tooth and risk an accidental exposure
  • if you dont have enough time to place the permanent restoration, place a temporary restoration
  • if the restoration is deep and patient maybe had RP, wait several months before crowning if a crown is necessary
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25
Q

if sealed off from the oral environment, remineralization of the _____ dentin is possible

A

affected

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26
Q

when is a direct pulp cap used

A

when a small pulpal exposure occurs during cavity preparation

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27
Q

describe a direct pulp cap

A

a thin layer of CaOH is floated over the exposed pulp
- a layer of glass ionomer is placed over the CaOH to stimulate the pulp to from secondary odontoblasts which can produce a dentin bridge across the exposure site

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28
Q

when is a direct pulp cap most successful

A
  • when the exposure is mechanical rather than carious
  • when patient is young and exposure is less than 0.5mm
  • if bleeding at the site is easily controlled and there is no pus or serous exudate
  • if the area has not been contaminated by saliva
  • if there has been little or no mechanical damage to the pulp tissue
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29
Q

why are endodontists not fond of direct pulp caps

A

because CaOH may cause the canals to calcify over time

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30
Q

what should you do to see if the pulp cap worked

A

months later radiograph and pulp testing

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31
Q

pulp caps are more effective on what patients

A

young patients with large pulp chambers and open root canals to provide better circulation to the area where we are trying to induce dentin bridge formation

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32
Q

what part of the pulp do direct pulp caps work better on

A

tips of pulp horns rather than the side of a pulp chamber

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33
Q

should there be pain after doing a direct pulp cap

A

mild to moderate spontaneous pain for as much as three days, if there is spontaneous pain remaining then be concerned

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34
Q

how long might cold sensitivity linger after a direct pulp cap

A

several weeks

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35
Q

if the tooth will require a crown to adequately restore it can you do a direct pulp cap

A

no do endo

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36
Q

a broken or leaky restoration =

A

failure because bacteria will leak into the pulp and kill it

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37
Q

all restorations must:

A

adequately seal the cavity to avoid microleakage, bacterial penetration and recurrent decay

38
Q

when is the smear layer created

A

whenever dentin has been cut

39
Q

how thick is the smear layer and what is it made of

A
  • a few micrometers thick
  • denatured collagen, hydroxyapatite and other cutting debris
40
Q

what does the smear layer do

A
  • acts like a natural bandage over the cut surface since it occludes many dentinal tubules with debris
  • protective barrier
41
Q

how strong is the smear layer

A

relatively weak and can be dissolved with acids

42
Q

when do you not want to bond to the smear layer

A

when using total etch bonding systems

43
Q

what are the products that do dentin bonding

A
  • acid conditioners
  • acidic primers
44
Q

describe acid conditioners

A
  • 35% phosphoric acid pH= 0
  • most dentin bonding systems have acidic conditioners that remove the smear layer and aprtially demineralize the intertubular dentin
45
Q

dentin without a smear layer provides good area for :

A

micromechanical retention

46
Q

describe acidic primers

A
  • HEMA
  • pH = 2.5
  • do not remove smear layer
  • these self etch primers do not treat the dentin with 35% phosphoric acid before bonding
  • they have a weaker bond, but have other advantages
47
Q

when is the hybrid layer exposed

A

after the acid conditioners are applied and rinsed away

48
Q

how is the hybrid layer formed

A
  • a hydrophilic primer or wetting agent is applied to wet the dentin and prepare for easier penetration of the
  • hydrophobic resin bonding agent that can adapt to the moist dentin and co-polymerize with the composite resin restoration
49
Q

what does the bond strength of the hybrid layer develop from

A

resin penetrating and adapting to the demineralized intertubular dentin and exposed collagen fibers

50
Q

what is another name for the hybrid layer

A

the resultant resin interdiffusion zone

51
Q

how long do restorations relying solely on resin bonding to dentin last before being severely weakened

A

4 years

52
Q

what primers offer weaker but longer lasting bond to dentin

A

self etch instead of total etch

53
Q

when would self etch be useful

A

when margins are on dentin, and retention can be obtained mechanically with grooves or undercuts

54
Q

what is the primary consideration when using self etch when margins are on dentin and retention can be obtained mechanically with grooves or undercuts

A

the longevity of seal rather than strength of bond

55
Q

what etch is used in total etch AND self etch

A

35% phosphoric acid

56
Q

adhesive bond strengths to superficial dentin are ______ than those for deep dentin

A

greater

57
Q

deep dentin = ____ tubules

A
  • more
  • larger diameter
58
Q

deep dentin = _____ amount of intertubular dentin in deep areas

A

reduced

59
Q

an important aspect of dentin bonding agents is their ability to:

A

seal cut dentinal surfaces which reduced permeability and microleakage

60
Q

deep dentin _____ permeable than superficial dentin

A

more

61
Q

the defensive functions of the pulp are related to:

A

its reponse to irritation by mechanical, thermal, chemical, or bacterial stimuli

62
Q

what does the deposition of reparative dentin by the replacement odontoblasts lining the pulp cavity act as

A

a protective barrier against caries and various other irritating factors

63
Q

what is the process of formation of reparative dentin

A
  • continuous but slow process
  • takes 100 days to form a reparative dentin layer 0.12mm thick
64
Q

why can inflammation of the pulp become irreversible and result in death

A

because the confined, rigid structure of the dentin limits the inflammatory response and the ability of the pulp to recover

65
Q

how does the size of the pulp cavity change as we get older

A

gets smaller

66
Q

younger pulps are more _____than older pulps

A

reparative

67
Q

what is the contour of the pulp cavity

A

a miniature of the external surface of the tooth

68
Q

a twinge of pain may be due to:

A

sugar, cold or acid from caries first contacting dentin

69
Q

pain lasting a few seconds may be due to:

A

irritant continuously present or applied repeatedly

70
Q

what does constant irritant cause

A

increased blood flow and volume (hyperemia) and inflammation of the pulp

71
Q

what pain constitutes reversible pulpitis

A

pain that does not linger more than 10-15 seconds

72
Q

what can reversible pulpitis pain be treated with

A

a restoration

73
Q

what is the clinical interpretation of pain in irreversible pulpitis

A
  • when pain is either spontaneous or lingers more than 15 seconds
  • infection of pulp has occurred and resolution by operative dentistry treatment is not possible
  • RCT is advised
74
Q

what is the clinical interpretation of pain in pulpal necrosis

A
  • when this irreversible pulpitis is untreated, pulpal necrosis follows
  • spontaneous, continuous, throbbing pain
  • pain elicited by heat that can be relieved by cold
  • later with no response to any stimulus
  • tooth may become sensitive to percussion
  • RCT is needed
75
Q

what is a primary objective during operative proceudres

A
  • preserve the health of the pulp
  • all caries must be removed except for indirect pulp cap
  • avoid overheating the dentin
  • all restorations must be well sealed
76
Q

what tooth pains are not related to caries

A
  • maxillary sinusitis
  • cracked tooth
  • occlusal trauma
77
Q

how does maxillary sinus tooth pain manifest

A
  • cold sensitivity
  • spontaneous pain in maxillary posterior teeth
  • hard to isolate single tooth
78
Q

how does cracked tooth pain manifest

A
  • cold sensitvity
  • sudden unreproducible pain when chewing
79
Q

how does pain from occlusal trauma manifest

A
  • cold sensitivity or pain in chewing
  • tooth movements when the teeth are clenched and moved side to side may be seen - called fremitis
80
Q

describe cementum

A
  • slightly softer than dentin and consists of about 45% - 50% inorganic material by weight, covers the apical root
  • permeable to a variety of materials
  • light yellow and slightly lighter in color than dentin, it has the highest fluoride content of all the mineralized tissue
81
Q

when can dentin be exposed

A

when enamel and cementum do not meet in 10% of people

82
Q

what do normal contours do

A

deflect food only to the extent that the passing food simulates the gingiva by gentle massage

83
Q

what happens if curvatures of tooth contours are too great

A
  • the tissues usually receive inadequate stimulation and a potential plaque trap is created
  • food impaction producing perio disease, carious lesions, possible movement of teeth
84
Q

where are the proximal contacts in all teeth

A
  • located at the incisal third of the max and mand central incisors
  • posteriorly the contact is at the junction of the occlusal and middle thirds which creates a larger occlusal embrasure
85
Q

where should marginal ridge heights be and why

A

at the same height to prevent food impaction

86
Q

what does contact positioned too far apically cause

A

food impaction

87
Q

what are the periodontal concerns

A
  • the level of gingival attachment and gingival sulus
  • gingival health must be maintained by the teeth having correct form and position
  • margin of the cavity prep should be ideally not positioned subG
  • do not destroy attached keratinized tissue
88
Q

what are the caries removal considerations

A
  • caries on axial wall does not indicate cutting the entire axial wall toward the pulp- only remove caries
  • caries on the pulpal floow may need widening of the prep to remove caries but dont deepen the entire pulpal floor - accept an irregular floor
89
Q

what do you do if recurrent caries extends gingivally in the box area

A

have a box within a box rather than deepen the entire box gingivally unless caries require it

90
Q

restoration should be supported by at least:

A

a tripod of natural structure

91
Q

why should you not have the entire floor of restoration covered by CaOH

A

it is too soft to support the restoration

92
Q

if the material is ahrd when set ( such as glass ionomer):

A

the entire pulpal floor can be covered material

Operative II (10 decks)

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