Restorative and Endo Flashcards by Emily Bryce

What material were you planning on using for the restorations?

Composite for all

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Why did you decide to use composite for these restorations?

More aesthetic
Bonds directly to the tooth
Does not need to be held in with retentive and resistance factors
Less tooth tissue required to be removed
Command cure

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What are some of your concerns with using composite in this patient?

Moisture control may be an issue- bleeding gums.

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Which tooth ended up needing an amalgam?

27 MO
- gingival bleeding due to overhang of GI had caused gingival hyperplasia and also the restoration was subgingival.
- Concern over moisture control.

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What liner was used when placing the amalgam in 27?

Vitrebond- RMGI

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Why do you need a liner before placing an amalgam restoration?

Amalgam has a high thermal diffusivity and thermal conductivity.
Protects the pulp.

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What is the purpose of a liner?

Protection from thermal, chemical or bacterial stimuli.
Therapeutic- calm down inflammation within the pulp and promote plural healing.
Palliative- reduce patient symptoms prior to definitive treatment being carried out.

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Why is vitrebond the ideal cavity liner?

Least soluble
Releases benzoyl iodide and benzoyl bromides which can kill some remaining bacteria present.
Bonds directly to composite.

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Why can ZOE not be used as a lining material with composite?

Eugenol interacts with the setting reaction of composite.

Softens the material and causes it to stain over time.

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How long does amalgam take to set?

24 hours- cannot be polished until 24 hours.

Thermal expansion co-efficient is less for amalgam.

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What post op instructions were given after amalgam placement?

Chew on opposite side of the mouth
Don’t eat or drink for 20-30 minutes

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What is the diagnosis of tooth 26?

Previously initiated therapy
Asymptomatic apical periodontitis

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What was he initially diagnosed with?

Irreversible pulpitis
Symptomatic apical periodontitis

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What was the original pain history of the patient?

S- upper left back
O- couple weeks ago, worst in last couple days
C- throbbing pain, occasional shooting pain
R- whole left side of mouth
A- headache
T- lasts a long time, worse in the evening
E- Hot and cold makes it worse, sore when chewing
S- 8/10

Kept awake at night
Analgesia has not helped

26 was TTP, no mobility, no sinus tract

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What treatment was conducted at the initial emergency appointment?

DO caries removed
Canal orifices accessed- DB, MB and P canals.
CaOH placed in the pulp chamber and coronal parts of the canals.
Cotton wool pellet applied and GIC placed as a temp restoration.

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Why was CaOH placed in the chamber and canal orifice?

Therapeutic- calms down inflammation within the pulp space and also kills any remaining micro-organisms present in the pulp and canal space.
- Anti-bacterial and anti-inflammatory.

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Describe your analysis of tooth 26 radiographically.

3 roots and 3 canals visible radiographically.
Canals look distally curved.
Sclerosed- narrowing of the canal space
Distal margin of the GI is subgingival- looks subcrestal on the PA but looks fine on the OPT.

Why might the caries looks subcrestal on the PA but not on the OPT?

Because of the angle that the radiograph is taken at.

OPT is taken straight on at 90 degrees but the PA was probably taken using the bisecting angle technique- so would be taken at the angle that bisects the imaginary line on the tooth.
- caries and bone levels can be misinterpreted.

Describe the process of RCT in this tooth.

Done under dental dam.

Probably use reciproc.
- Curved canals.

Obturate with GP

Working length- working length radiograph, apex locator, paper points.

What materials might you choose from for the onlay?

Composite
Zirconia
LiDiSi
Gold

Why do you need a cuspal coverage restoration on an endodontically treated tooth?

Studies have shown that teeth restored without cusp coverage restoration are 6 times more likely to fail than with a cuspal coverage restoration.
- Once the marginal ridge is removed, the structural integrity of the tooth is weakened.

The role of a cusp coverage restoration is to reinforce a weakened cusp to prevent the cusp from fracturing.

What concerns might you have about this tooth?

RCT looks like it will be difficult
Subgingival distal margin on tooth 26- moisture control might be an issue
OH is an issue

How are you going to assess the restorability of tooth 26?

Use the guidance in the dental practicality index
- Look at structural integrity, difficulty of endo treatment, perio disease and patient factors.

Structural integrity- subgingival/subcrestal margins, how much tooth tissue will be left after caries removal, can I get a dam and clamp on that tooth, what will I restore it with, do I have enough tooth tissue left to restore it.

Structural integrity- level 2 for subgingival margins
Endo treatment- level 2 for sclerosed canals and curved canals.
Periodontal treament- level 1

Anything above a 6 would make the treatment unadvisable.

If the tooth required to be extracted, what would you do to restore the gap?

27 is restored but has 1 single conical root- not a good candidate for a conventional fixed bridge because you want a large surface area of the roots and a good crown to root ratio.

RPD may be an option.

Implant potentially- if he is willing to go private for this.

Always an option to do nothing.
- May get drifting of adjacent teeth.
- Loss of function?

Review the palatal pits of 11 and 21.

At the time of the initial examination, the pits looked quite sunken in, darker in colour (not indicative of caries) and potentially a difficult area to clean. Combined with the fact the patient is high caries risk- this caused me some concern.

What would you look for if the palatal pits had caries in 11 and 21?

Chalky enamel surrounding the palatal pits. Darker underlying dentine layer.

Why are you choosing to monitor it?

At the time of the examination, there were no clinical signs of caries. However, given that this has been identified as a potentially difficult area to clean and the patient is high caries risk, I felt it was important to monitor it.

How would you monitor the palatal pits of 11 and 21?

Monitor it clinically- won't be able to see this radiographically. Look for signs of chalkiness around the palatal pit. Darkened dentine.

What could you do to reduce the chance of caries?

Fluoride varnish- must check if the patient can have this because they have asthma Fissure seal it Provide specific instruction on how to clean the area.

Why didn't you choose to fill it or fissure seal it?

Didnt want to potentially put another plaque retentive factor in someone's mouth that is high risk if I didn't need to - Potentially down the line this could be an option.

Describe the process of provision of an onlay.

Take sectional impression- using putty matrix Prepare the tooth for onlay Take master impression for the lab- polyether Fabricate temporary using the sectional impression.

What did you tell the patient about before starting cavity prep?

Aiming to do a white filling but depending on what we find, it might end up needing to be a silver filling. - tooth must b very dry to do a white filling. Damage to adjacent teeth Potential risk of pulp exposure which may require further treatment Sensitivity post treatment once the LA wears off. Tooth might be a bit tender to bite on.

Describe the cavity prep required for a composite.

CSMA- greater than 90 degrees with bevel. - Aligns the enamel prisms for micro-mechanical interlocking of material with the enamel. No unsupported enamel or sharp internal line angles Margins not over an occlusal contact Adequate depth of cavity

Describe the cavity prep required for an amalgam.

CSMA is 90 degrees No unsupported enamel No sharp internal line angles Margins not over an occlusal contact Adequate depth of cavity to allow restorative material to be retained. Retention and resistance factors in place.

How often would you recall this patient and what would you do at this appointment?

For caries risk- 6 months For perio risk- 3 months Review 6PPC and full 6PPC done annually. Bitewings every 6 months Full E/O and I/O examination BPE

Which material are you hoping to use/will use?

Composite probably best in this case.

What factors influence material choice?

Tooth being restored Size of cavity Moisture control Aesthetic demands of the tooth Strength required- i.e. more strength required in a posterior tooth Cost of material Ease of adjustment Operator preference

What aspects of the impression taking process do you need to do?

Apply retraction cord with haemostatic agent. Remove retraction cord. Use light body silicone around the margins and occlusal surface and then medium bodied polyether on top. Take alginate impression of opposing arch Interocclusal record. Cement temporary crown.

If you are using composite, what temporary cement can you not use?

Tempbond because it has eugenol in it, which reacts with the composite.

What are you going to use for your temporary?

Protemp- bis-acryl resin. Could also use GI.

If after preparation, you are struggling to get the tooth dry, what could you do?

If the gingivae appears red, bleeding, poor condition- postpone the impression until a later stage. - Give a temporary restoration with good margins and OHI for this area and review in a couple weeks. You could try putting a sectional matrix down that area and do a direct composite onlay.