Restorative Flashcards
Tooth 11 has a traumatic exposure. What 2 factors would influence your choice of treatment?
size of exposure
time since exposure
How would you treat traumatic pulpal exposure in practice?
partial or complete pulpotomy
partial- removing 1-3mm of affected pulpal tissue whilst complete is removing full height of coronal pulpal tissue
la -> dam + isolation -> access with hi speed round bur -> remove 2-3mm with bur -> saline irrigation ->
ferric sulfate for haemostasis ->apply hard setting CaOH dressing
need to assess bleeding- if abnormal bleeding- may need to pulpectomy
indicted in: vital traumatically exposed young permanent tooth- espec with incomplete apex.
If restoring deep carious lesion and radiographically you are concerned about extent near pulp how do you procede
indirect pulp cap may be placed.
• Caries should be carefully removed in a progressive manner to reduce pulpal exposure w slowly rotating contra-angle handpiece or sharp hand excavators.
- The cavity should be cleansed with 0.2% w/w chlorhexidine gluconate.
- Stained (not soft) dentine over the pulp should be left in situ and covered with a setting calcium hydroxide cement, for example Dycal
- A stronger lining material (Resin-Modified Glass Ionomer cement - Vitrebond) should then be placed to protect the Ca(OH)2 and the tooth restored with a provisional restoration, for example GIC or RMGI.
- The tooth must be vital, asymptomatic and have no history of previous pulpitis.
- The tooth should be monitored for 3 months and if vital and asymptomatic, the provisional restoration should be removed, stained dentine carefully excavated and definitive restoration placed.
- If there have been any pulpitic symptoms, then RCT should be undertaken.
direct pulp capping restricted to:
teeth with a good prognosis, young patients in good health, lack of pre-existing symptoms, fresh non-carious exposure and minor pulpal haemorrhage.
indications for ledermix use
Ledermix paste or cement (antibiotic/steroid mixture) should not be used as a pulp capping agent. The only indication for the use of Ledermix is as a temporary palliative agent in contact with vital (possibly inflamed) pulp either in a pulp chamber or root canal, when it is intended that the tooth should be extracted or root canal treated
how to carry out first stage of endo- canal preparation
- consent gained. pt to wear bib and glasses
- pre-op radiograph PA grade 1 w/in 3 months of commencing
- assessment of tooth- must be caries free and restorable. perhaps pre-endo build up to allow for dam placement and reduce change of leakage
- LA administered
- dental dam placement. if isolation cannot be achieved XLA indicated. as early as poss. if elected to cut access cavity prior to dam placement all dam equipment should be prepped for immediate placement prior to or as soon as pulp exposed
- Disinfect access opening, clamp and dam with CHX
- Using a diamond bur in the high speed handpiece with water spray and wide bore aspiration, cut the initial outline form of the access opening into dentine.
- Using either a high-speed fissure bur or preferably the slow speed handpiece with a long shank/neck round bur make an opening into the pulp chamber
9.Using a high speed safe tipped endodontic access bur (e.g. Endo Z bur) or slow speed round bur, remove the remainder of the roof of the pulp chamber. do not allow bur to touch pulp chamber floor - Remove contents of the pulp chamber with a discoid excavator.
- Remove any remaining overhanging edges of the pulp chamber roof so that the walls of the access opening are smooth using the safe-tipped endodontic access bur.
- check integrity of dam seal prior to irrigation. opaldam used if necessary
- NaOCl irrigation
- 17% EDTA irrigation as penultimate irrigation- 1 min soak
- establish glide path,
- Once the EWL has been reached with a size 10k file an electronic apex locator should be used to determine proximity to the apical constriction / apical patency. repeated at least three times
- working length radiograph taken and correct working length established.
- coronal flare established with gates glidden (largest to smallest)
- working length radiograph taken and correct working length established.
- Root canal instrumentation
- 10 min NaOCl soak
- Manual irrigation with GP point after final instrumentation
- if finished in one- obturate and post of radiograph before definitive restoration & monitor
if not finished in one appt- non setting CaOH2 (ultracal) placed in root canals, with cotton wool above and GIC above that as temp rest.
if vital pulp remains and anaesthesia difficult to achieve- odontopaste (zoe)
pulpotomy?
removal of portion of diseased pulp in hope to maintaining the vitality of the remaining portion through placement of a therapeutic dressing
factors needed discussed for consent?
procedure
prognosis
risk
alternatives
risks of endo?
post op pain post op swelling instrument fracture material extrusion failure to negotiate to working length perforation root fracture hypochlorite accident need for pain management
dam placement tips?
For posterior teeth punch largest single hole 2 cm diagonally from the centre of the dental dam sheet and turn to appropriate quadrant. For anterior teeth the hole may be punched more peripherally, to ensure the dam does not cover the patient’s nose. When the patient’s mouth is open, the top lip should be covered by the rubber dam.For multiple tooth isolation the rubber sheet can be held against the teeth and points to be punched marked with an indelible pencil.
Suggested clamps : Anteriors “C” or “E” Premolars “E” or EW” Molars “A”, “AW”, “FW” or “K”
measurements taken from pre op radiograph
- length of each root,
- the anatomical reference point
- the estimated working length of each root canal.
- from the anatomical reference point (incisal edge or cusp tip) to the roof of the pulp chamber.
ACJ importance in endo
most reliable anatomic landmark to aid location of canal orifices.
irrigant of choice in endo
2.5-5.25% sodium hypochlorite NaOCl
used in a Luer lock syringe with a gauge 27 Endo needle.
irrigation necessities
label irrigants with adhesive labels 1 min to dispense 3ml syringe never forced under pressure never wedged at end of root canal rubber stopper used to provide length measurement
Aspirate effluent using a plastic disposable saliva ejector with the round tip removed or a Yankauer tip in high volume aspirator, held as close to the access cavity as possible. It is essential that irrigating solutions do not pool around the tooth.
irrigate gently with 17% EDTA solution to remove the smear layer. EDTA should be used as the penultimate irrigant and placed in the canal for one minute.
Final irrigation with Sodium hypochlorite prior to obturation, a 10 minute “soak” is recommended, this can be carried out whilst the dental nurse prepares the equipment and materials required for interappointment dressing or obturation.
Manual dynamic irrigation should be performed following completion of instrumentation. This should be done very gently with a standardized gutta percha point with an apical diameter equal to or smaller than
the master apical file( For example if the master Cone is an F2 ProTaper rotary then a standardised GP cone of apical diameter 0.25mm should be used.)
guidelines for use of NaOCl
- Careful pre-operative radiographic assessment is essential – be vigilant of open apices and perforations and discuss with senior staff if either is suspected prior to commencing treatment.
- It is important that the pre-endodontic restorative state of the tooth is assessed. A pre-endodontic build-up is necessary if isolation is likely to be compromised.
- Ensure the patient is provided with a disposable bib to protect clothing. This must adequately cover clothing. If necessary use two bibs overlapping.
- Provide patient with protective eyewear.
- Always use dental dam to isolate the tooth requiring RCT and ensure this is sealed well with OrasealTM. The oral seal should be “moulded” to the tooth contours with a damp cotton wool pledget. Placing the clamp prior to dam placement can facilitate visualisation. Ensure floss is used to secure the clamp during placement and removed after dam is seated.
- Test the dental dam seal by irrigating with chlorhexidine first to ensure no leakage.
- Dam placement must be checked by the supervising clinician
. 8. Ensure that all syringes are clearly labelled with adhesive labels. - Always use a side-vented needle for irrigation of the root canal.
- Always use a Luer-Lok 27G needle and ensure this is securely attached to a 3mL syringe – test this before use.
- Fill syringe less – approximately 3/4s full to aid control.
- Always use a silicone stop on the needle and set to 2mm short of working length.
- Always pass the endodontic syringe behind the patient’s head and never over the patient’s face.
- The irrigating needle should not bind in the root canal at any time.
- Whilst irrigating, depress the plunger with index finger rather than thumb to reduce the pressure.
- Report any irrigation/endodontic incident to senior staff immediately.
what is a DG16 used for
a DG16 Endodontic probe - used to identifying root canal orifices
. Following developmental root fusion lines can aid in orifice location
difference between EWL and CWL
estimated and calculated
Careful assessment of the working length radiograph along with the apex locator results should allow calculation or the Corrected Working Length
CWL is calculated by adjusting accordingly from if file short or long of radiographic apex. ideally the working length should be approximately 2 mm from the radiographic apex.
CWL = KLI x ALT
/ ALI
known length of instrument x apparent length tooth
/ apparent length instrument
modified double flare technique?
The modified double flare technique allows production of a continuously tapering funnel-shaped preparation. The process involves development of an initial coronal flare, followed by an apical flare. These distinct regions of preparation, upon intersection create a continuous taper. Preparation involves the use of Gate Glidden drills and stainless steel K-files. The K-files are instruments with a 2% taper.
how to carry out obturation
Under dental dam isolation, irrigate the canal thoroughly using NaOCl.
If the root canal filling is being undertaken at a separate visit from canal preparation, wash out all the inter-visit dressing and confirm CWL with a small file and an apex locator, then check that the master apical file still reaches CWL before proceeding to fill the canal.
DO NOT insert the master file immediately or any material in the canal will be compacted at the apex and will block the canal.
Dry the root canal(s) thoroughly using narrow bore aspiration and matched size and measured length of sterile paper points in locking tweezers.
Select “Master” Gutta Percha point – standardized GP point - that will fit canal to the CWL and give the sensation of “tug back”.
Mix root canal sealer (AHPlus).
Using a paper point (coated lightly with sealer) coat the walls of the root canal thinly with sealer
Coat the master point tip lightly with sealer and insert slowly and carefully to WL using sterile locking tweezers. Then:
(a) Gently place a size A or B finger spreader in canal alongside the master point.
The spreader should be left in place for at least 20 seconds to achieve the desired compaction
repeat with more accessory points until firm mass of GP
heat old instrument and use to cut off end of GP mass
condense GP remaining in orifice and remove all obturation material in pulp chamber flush to orifice
WHat factors does a dentist consider when considering implantation?
smoking status bone quality and quantity occlusion aesthetics oral hygiene pt motivation
what bone dimensions are needed for implants and how are they best assessed
assessed via cbct
1.5mm horizontal around implant
3mm between implants
>5mm between bone crest and contact point
3 alternatives for implant in space
1 nothing
2 bridge
3 rpd
how can you check that a bridge has debonded
probe, floss, visually, mobility, push and check for air bubbles
factors needing to be considered before bridge placement
oh
abutment health (perio and caries)
occlusion
length of span