Restorative Flashcards
** Treatment planning , 12 mins**
C/O - Bleeding gums
MH - no relevant MH
SH -
* 20 cigs per day (considered quitting)
* 12 units of alcohol per week
* Drinks 1 litre of fizzy juice per day
DH -
* Visited a dentist 2 years ago
* Brushes once a day with no interdental cleaning
* Not aware of clenching or grinding his teeth
** Look at study casts, photographs , radiographs provided**
Explain to the pt your findings/diagnosis and proposed management
** introduction **
- name a designation
** clinical findings **
- Inflammation/ redness of gums especially at the papilla
- toothwear
- instanding lower molar
** Radiographic findings**
- Bone loss ( explain how much)
- Caries 46m
- impaction of lower 3rd molars ( right mesioangular and left distoangular)
** Treatment **
- 46m direct restoration ( discuss options ‘ comp or AM ‘ )
- Third molars - discuss options and recommendation to leave
** Perio diagnosis **
- Generalised / stage 2 / grade B
** Smoking cessation advice **
5 As
** Fizzy drinks **
Explain that they need to reduce as it may contribute to toothwear
** Tooth wear **
* Monitor/ prevention
* Treatment ; conservative or direct palatal restorations
** Bridge prescription / 6 mins **
For a mesial cantilever
** Fill lab card in detail **
- Patient detail sticker on all three sheets / any photos of SH
- Practitioner / practice details
- date and time of recording impressions and for lab work to be back
- stage of treatment , present work and other lab work
** Instructions **
- Please pour up impressions in 100% improved stone and mount on DENAR II semi-adjustable articulator using bite reg provided ( wax or facebow)
- Construct a metal ceramic (NiCr) conventional mesial cantilever to replace tooth XX. Use XX as abutement and XX as pontix
- Shade XX and mention any staining or special effects / surface features and finish
- Include pontic design
- Please construct in canine guidance and ensure pontic is free of excursive movement s
- Please return bridge with cast
** Put your signature at the end **
What are the designs for a bridge pontic and when to use each ?
- Ridge lap - Posteriors (can be cleansed if OHI done well)
- Modified ridge lap - Upper anteriors ( problem with food packing)
- Dome - lower incisors, pre-molar or upper molars ( poor aesthetics if the gingival third of tooth is visible)
- Wash-through - lower molar area
Lab prescription for adhesive bridge
- Please construct minimal preparation adhesive brisge replacing tooth XX . XX as abutement and XX as pontic
- Metal framework - NiCr sandblasted surface with 50 alumina
- Shade and disinfected
if it was a fixed - fixed conventional then for the abutements you should say MCC palatal chamfer , buccal shoulder , occlusal redection
** Radiographic reporting OPT / 6 mins **
Discuss with clinician what you can see, go through OPT in a systemic manner
- ** Demographics ** :
- Type of X-rays
- Age , date
- Type of radiograph
- Justification - ** Quality **
Diagnostically acceptable or no? why? - ** Dentition **
- Teeth present , erupted/ not erupted , primary or permanent , any supernumerary, ectopic, impacted?
- Restorations ; heavy/ moderate/ mild , any overhangs, fractures , poor margins
- Any signs of trauma - ** Disease **
- Caries ; identify type and position
- PA pathology
- Periodontal disease (bone loss and classify if possible)
- Endo treatment comments ( poorly compacted or good / any separated instruments)
- Check TMJ by looking at condyles and sinuses
- Any cysts/ PA pathology ? ( Explain if unilocular or multilocular, size . position , well/poorly defined , cortication and effects on adjacenet structures
- Comment on 8s if present
** Post and core Crown / 6 mins **
Patient already have a post/core crown on tooth but no endo treatment showing on the radiograph
Lingual caries present without pain
Patient wants no treatment
Explain options to pt and advantages and disadvantages of each
- Introduce yourself and designation / address pt by their name
- Explain findings
“ after looking in your mouth i have seen some decay in one of your lower molar teeth (specify position) with a crown on top and a core that holds the crown to it , because of this i have took an x-ray showing a crown/core and a post , the decay is sitting underneath of the crown”
” normally the tooth with a post crown should have a root canal treatment where the contents of the root canal should be removed (nerves/blood vessels) and the root canal is filled with a rubber filling to prevent any infection “
” because of the decay under your crown and the lack of a root canal filling, the tooth is at risk of becoming infected and painful, this cannot be predicted when it might happen and also i can not tell the extent of the decay from the radiograph itself as I need to remove the post , core and crown to see the full extent of the decay”
** Options **
- Leave and monitor ( every 6 months clinically / every 12 months radiographically)
“ there is active decay and root canal sapce is empty which could result in a higher risk of infection “
** advantages ** : may stay asymptomatic but will flare up , may avoid risks associated with other options
** disadvantages ** : risk of infection , pain , anscess , swelling and tooth breakdown which may lead to tooth loss as the more the decay spreads the less chances we have to fix the problem
- Treat the decay without removing the crown
** advantages ** : less destructive
** disadvantages ** : “ i do not recommend this option as i will likely not able to see the full extent of the caries which would result in removing the crown , and the gold standard is to RCT this tooth as decay may be into the pulp of the tooth “ - Remove crown and remove caries - restore with new crown
** Adv ** : removes the risks of post removal but the risk of infection is still there but will be less as there is no root filling
** dis ** : risk of PA infection, crown may not come off alone without the post
Tooth may be unrestorable after the removal of caries
- Remove post crown and core and RCT
** Adv ** : Removal of decay and sealing the root canal system which may eliminate the infection going forward
** Dis ** :
many appointments required
tooth may be unrestorable as this options is destructive ( discuss post removal risks and RCT risks)
- XLA of tooth
** Adv ** : quick fix , eliniate risk of infection and future pain
** Dis** : XLA risks , space would be present (discuss replacement options)
** Confirm pt decision at the end and answer any questions , reconfirm decision**
** Radiographic faults **
Look at the OPT and choose 10 iatrogenic/developmental faults in the dentition
** iatrogenic faults **
- RCT
Fractured file
perforated file
ledging
GP overfill/underfill
Extruded sealer
Missed canal
- Restorations
Overhangs
fractured
poor margins
post without RCT
perforated post
- External inflammatory / surface/replacement resorption , internal inflammatory resorption , cervical root resorption
** Developmental **
- Cysts - dentigerous , radicular, erupted , keratocyst
- Unerupted , ectopic and impacted/ supranumerary teeth
- Dentinogenesis imperfecta - ( amber radiolucency , bulbous crown and abscess with pulpal obliteration)
- TMD
** Trauma **
- bone fracture
- Tooth fracture
- Displacement
** Crown Critique **
Gold crown fitted onto mounted casts
Use shimstock, articulating paper and calipers to assess crown
One of them is overpreped and the other one there is not enough occlusal clearance
Make decision to redo prep and send back to lab , new imps of new prep
Faults examples
* incisal pin raised , interference with excursion, no natural teeth contacts ( check with shimstock)
* Inadequate reductions
* Remove crown from tooth and check teeth contact or the tooth is underprepped - check with calipers for dimensions
What are the pre-cementation checks for a crown?
- check correct patient and it matches prescription
- Check on cast - any rocking, M/D contact points , marginal integrity and aesthetics , check contact points on adjacent teeth are not damaged
- natural teeth contacting? (with shimstock)
- check reductions
- Check for cracks , defects , breakage and blebs
- Remove crown from cast
Check if natural teeth occlude properly , check if tooth is underprepped - Measure crown thickness with calipers ( 0.5mm circumferential. 1mm for non functional cusps and 1.5mm for functional cusps) - calipers tells you if prep is over or under extended
- when trying in do not force the crown in , no blanching should occur
What is the management for a crown that fails to seat and why it may happen?
** clinical faults **
* incomplete removal of temporary
* Gingival tissue encroachment (poor temp)
* distortion of impression
* Inadequate prep
** Lab faults **
* interproximal overextension
* marginal overextension
* Resin restoration expansion
* Blebs on fitting surface
** First check interproximal contacts for over extension **
by flossing and using AP to mark areas needing adjustment
Do not open contact too much as may result in the crown being non functional and food packing / drifting
** Next check and adjust fitting surface of restoration **
** mark high spots and remove **
** Next assess marginal fit and aesthetics **
If margins are poor it is best to remake the crown
How to avoid faults of a crown seating well ?
- Complete removal of temp
- Good temporary that avoids gingival overgrowth
- Good impression which is stored and handled well
How would you manage a broken crown?
Send back to lab
How would you assess and manage occlusal interference of a crown?
- Ensure pt gently touches teeth together
- Check ICP and protrusive contacts
- Check with articulating paper (use miller forceps)
- Metal can be sandblasted to make high points more obvious
- Calipers measure to 1/10 of a millimeter
- check with shimstock - restoration and index teeth ( check interproximally and contralaterally - shimstock should be held firmly and evenly by teeth and restorations
- check amount of interference by dropping an incisal pin and calculate the difference
- adjust crown if possible , if it will be too thin then redo prep and send back to lab after adjusting to ICP
How to avoid occlusal interference in a crown?
- measure crown thickness prior to cementing (1.5-2mm)
- Use a sectioned putty index when prepping
- Good provisional as a poor one might lead to over-eruption of opposite teeth - if not severe may use the DAHL technique for a few days
- should be able to get probe in between prepped tooth and opposing tooth
How to manage problems with crown aesthetics?
- Check prior to cementing and show patient
** Identify types of cements with each restoration **?
- GSC - Aquacem and RelyX
- MCC - Aquacem and Relyx
- Ceramic - Aquacem and RelyX
- Porcelain veneer - NX3
- Adhesive cantilever bridge - Panavia
What are the post cementation checks?
(6)
- Remove excess cement
- Check margins
- check interproximal contact points exist and are clear
- Check occlusion with articulating paper
- Check that the restoration is cleansable
- Confirm pt is happy with aesthetics
** Dental dam placement (6mins) **
Please isolate teeth 13-23 and secure with wedgets distally and place floss ligature on tooth 11 and 21
- Use pen to identify holes (template)
- Place opal dam and test with CHX
- Make sure to not cover the nose
- No Clamp needed
** Dental dam placement for 35MOD ** (12 min)
- Select correct clamp from clamp chart and use floss around it
** Clamps : **
anteriors ; C or E
pre-molars - E or EW
molars - A, AW, FW , K - place dam over 36-34 due to contacts
- Hole punch onto dam and place wedjets
- Apply opaldam and light cure
- Check seal using CHX
** dental dam placement for 16 RCT **
- Sit down
- Select correct clamp and apply floss
- Hole punch for single tooth isolation
- Place dam and secure frame
- Opal dam placement and check seal with CHX
** 11D cavity 12min **
- Go palatally if possible
- Avoid damage to adjacent teeth - leave a thin layer of enamel and then controlled break towards the end
- make sure contacts are clear
** 36 MOD amalgam **
Cavity already cut , place matrix band
- Fill with vitrebond then AM , take model out to check occlusion and adjust accordingly
Fill DO cavity with amalgam
- Avoid damage to adj tooth
- make sure cavity margins are nit at contact points (clear contacts(
- Apply vitrebond to pulpal floor
- Dam would normally be placed
- Use CWR for moisture control
- Place matrixband
- Place the amalgam from carrier into cavity and then compact down with amalgam plugger
- Hold down the amalgam and remove the matrix band
- Use carver to smooth the amalgam and remove any overhangs
- Check occlusion
** 14 MO Cavity **
12 mins
- Remove artificial caries with high and slow speed
- Avoid damage to adjacent teeth
- No shapr line angles
- Clear contacts
