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Clinical steps of cavity preparation

(4th Year )

Clinical steps of cavity preparation (4th Year ) Dr. Ala’a Al-Haddad BDS, MFDS, MSc, PhD Assistant

Dr. Ala’a Al-Haddad

BDS, MFDS, MSc, PhD

Assistant professor, Conservative Dentistry (University of Jordan) Fixed & Removable Prosthodontics (University of Manchester, UK)

Outline:

  • Background

    • Definitions

    • Indications for restorative intervention

    • Objectives of cavity preparation.

    • Principles in cavity preparation

  • Clinical steps of cavity preparation

    • Pre-operative considerations

    • Operative procedures

      • Amalgum , resin-composite, glass ionmor

  • Definition:

    • What is a cavity?

      • It is a defect in the hard tooth structure resulting from an insult as caries and trauma.

    Definition:  What is a cavity ?  It is a defect in the hard tooth
    • What is tooth preparation?

      • It is mechanical alteration of a defective, injured or diseased tooth to receive a restorative material that re- establish the health state for the tooth including its aesthetics, normal form and function.

     What is tooth preparation ?  It is mechanical alteration of a defective, injured or
     What is tooth preparation ?  It is mechanical alteration of a defective, injured or
     What is tooth preparation ?  It is mechanical alteration of a defective, injured or
    • Conventional preparation:`

      • Tooth preparation that relates to amalgam, gold or ceramic restoration might be considered conventional preparation that require specific form, depth and marginal form.

    • Modified preparation:

      • Tooth preparation for bonded direct restorations as composite or glass ionomer has less need for specific depth, wall and marginal form and is considered to be modified preparations.

    Indications for restorative

    intervention:

    • Repair destroyed tooth

    • Repair fractured tooth either complete or incomplete [green stick fracture].

    • Restore teeth with congenital malformations.

    • Replace defective restoration.

    • Replacement of missing teeth.

    • Need for improved form or aesthetic.

    Indications (cont’d):

    • Repair destroyed tooth

    Indications (cont’d):  Repair destroyed tooth
    Indications (cont’d):  Repair destroyed tooth
    • Repair fractured tooth either complete or incomplete [green stick fracture].

     Repair fractured tooth either complete or incomplete [green stick fracture].
    • Restore teeth with congenital malformations

     Restore teeth with congenital malformations
    • Replace defective restorations

     Replace defective restorations
     Replace defective restorations
    • Replacement of missing teeth

     Replacement of missing teeth
    • Need for improved form or aesthetic.

    Why do we prepare cavities?

    Objectives of tooth preparation:

    • Remove all defects and provide necessary protection to the pulp.

    • Extend the restoration as conservatively as possible.

    • Tooth prep such that under mastication both the tooth and restoration will not fracture or displace.

    • Allow the functional and aesthetic placement of a

    restorative material.

    SO,

    Objectives of tooth preparation:

    • Eliminate:

    • Preserve

    • Restore:

    • Prevent:

    SO, Objectives of tooth preparation:  Eliminate:  Preserve  Restore:  Prevent:

    Clinical steps of cavity preparation

    • Preoperative considerations:

    • Operative procedure:

    Pre-operative Considerations:

    • Diagnosis and treatment planning:

    • Gingival health and periodontal/pulp status.

    • Occlusal evaluation

    • Restorative Material Selection

    • shade selection

    • cavity designing

    • Field Isolation

    Diagnosis and treatment planning:

    • It is all about diagnosis and treatment planning.

    • diagnosis allows for a methodical approach to preventive and restorative therapy.

    Diagnosis and treatment planning:

    • Identification of the Aetiology : ( cavity/ restoration failure)

      • Medical considerations

      • Oral hygiene routine

      • Diet

      • Age.

      • Para-functional habits

      • Occlusal scheme/ disharmony

      • Caries risk

    • Caries/ cavity detection:

      • Conventional methods

        • Visual

        • Visual and Tactile:

          • Using explorer ( low sensitivity , high specificity)

        • Radiograph ( conventional: bitewing x-ray)

        • The problem is detecting the initial stage of caries ( incipient) in order to consider remineralisation.

          • Removal Vs remineralisation.

     Caries/ cavity detection:  Conventional methods  Visual  Visual and Tactile :  Using
     Caries/ cavity detection:  Conventional methods  Visual  Visual and Tactile :  Using
    • Decay is difficult to detect in radiographs unless

      • larger than 2 mm to 3 mm deep into dentin,

      • or one-third the bucco-lingual distance.

  • A carious lesion that appears radiographically to have

  • penetrated about two thirds of the way through the

    proximal enamel has actually penetrated the EDJ.

    • The depth of the penetration of demineralization in enamel and dentine is actually greater than it appears to be in a bitewing radiographs

    Prevention & preservation:

    • Controlling the advancement of hard tissue destruction can begin with:

      • elimination of the aetiology

      • dietary instructions

      • oral hygiene instructions

      • home fluoride therapy

      • brushing with desensitizing dentifrices

      • discontinuation of poor oral habits.

    • In-office Remineralisation:

      • application of fluorides, calcium, and potassium phosphate.

    • In- office Desensitization:

      • application of potassium oxalate or other tubule- occluding agents.

      • application of dentin adhesives.

      • Iontophoresis

    Caries detection (New methods ):

    • Physical principle Application in caries detection

      • X-rays Digital subtraction radiography.

      • Digital image enhancement.

  • Visible light Fibre optic transillumination (FOTI)

    • Quantitative light-induced fluorescence (QLF)

    • Digital image fibre optic transillumination (DiFOTI)

  • Laser light

    • Laser fluorescence measurement(DiagnoDent)

  • Electrical current

    • Electrical conductance measurement (ECM)

    • Electrical impedance measurement

  • Ultrasound:

    • Ultrasonic caries detector

  • Gingival health/periodontal status:

    • is a critical component of a successful restorative outcome.

    • Gingival inflammation can cause

      • alterations in gingival form and contour.

      • Consequently, inaccurate margin relationship (restoration gingiva)

        • compromised restorative outcome.

  • Periodontal health should be present prior to the initiation of any restorative procedure.

  • Pulp status

  • Occlusal evaluation:

    • Pre-operative occlusal stops and eccentric movement should be studied and recorded

      • Using articulation paper,

      • Articulated diagnostic model.

      • Digitally.

  • Elimination of interferences in the static and dynamic occlusion

    • to achieve an ideal occlusion with maximum distribution of occlusal load.

    • ideal occlusion can be achieved using:

      • Splint therapy.

      • interceptive occlusal equilibration.

      • Orthodontic treatment.

  • Improve cavity designing

    • Restoration margins away from functional occlusion.

    • Protect remaining tooth structure.

    • Improve restoration longevity.

    • Reduce recurrent caries.

  • Restorative Material Selection:

    • Occlusal forces.:

      • Cusp Flexure ( e.g. abfraction)

      • Wedge effect. ( MOD)

      • Heavy forces ( clenching, Bruxism).

  • Carious vs non-carious cavity

  • Caries risk.

    • ( fluoride releasing restorations)

  • Patients factor:

    • Economic status.

    • Age.

    • Aesthetic concerns.

  • Restorative Material Selection:  Occlusal forces.:  Cusp Flexure ( e.g. abfraction)  Wedge effect. (
    • Medical conditions ( oesophageal reflux)

    • Opposing restoration ( same hardness and wear resistance).

    • Direct Vs indirect restoration

    Shade selection: (If applicable)

    • prior to operative procedure.

    • Prior to placement of the dental dam

      • to prevent improper selection as a result of dehydration and resultant elevated colour value.

    • After Bleaching if required.

    • Mainly under daylight source illumination

      • preferable under various lighting conditions

        • daylight, colour-corrected, fluorescent light, and dim light

    • Shade Map

    • Composite mock-up

    Shade selection: (If applicable)  prior to operative procedure.  Prior to placement of the dental

    Cavity designing

    Plan an initial cavity design depending on:

    • Tooth location

    • Size of caries lesion/ remaining tooth structure

    • Type of lesion (carious vs non-carious)

    • Restorative Material type.

    • Occlusal factors: (preparation boundaries)

    • Convenience form:

      • Gain access but preserve tooth structure.

    • Removal of old filling.

    • Type of restorative technique.

    Field Isolation:

    • Is crucial to achieve sterile cavity preparation and aseptic operating field

    • Helps in enhancing visibility and access.

    • Protect soft tissue/ prevent accidants

    • Achieve proper moisture control

      • Especially for technique-sensitive restorations that and require meticulous attention to the adhesive protocol.

    • Proper restoration bonding:

      • Reduced marginal contraction gaps, microleakage, marginal staining, and caries recurrence,

      • improved retention, aesthetics and resistance to wear

      • reinforced tooth structure.

    • Field isolation technique:

      • mirrors

      • High vacuum suction/ suction devices.

      • Cotton rolls.

      • Cheek retractors & Mouth props .

      • Retraction cords.

      • Rubber dam.

    Operative Procedure

    • Local aesthesia:

    • Type:

      • selected on the basis of the estimated length of the clinical procedure and the degree of anaesthesia required.

    Operative Procedure  Local aesthesia:  Type:  selected on the basis of the estimated length
    • Ester Vs amide

      • Hypersensitivity and allergic

    reactions in affected patients are

    much less frequent with the amide type of local anaesthetic.

    • Topical anaesthesia

    Operative Procedure  Local aesthesia:  Type:  selected on the basis of the estimated length

    Clinical steps of cavity prep:

    • Diagnosis & Treatment planning.

    • Selection of restorative material and its shade.

    • Patient consent/ agreement.

    • Check Occlusion:

    • Local anaesthesia

    • Isolation

    • Cavity preparation

    • Pulp protection

    • Cavity Filling

    • Occlusal adjustments

    • Finishing and polishing.

    • Prevention and monitoring.

    Steps of cavity preparation:

    • The preparation procedure is divided into two stages:

    • 1) Initial stage:

      • Prepare outline form:

        • the mechanical alterations of the tooth are extended to sound tooth structure while adhering to a specific, limited pulpal or axial depth.

      • Prepare resistance and retention form

        • tooth preparation to retain the restorative material in the tooth and to resist potential fracture of the tooth or restoration from masticatory forces.

      • Convenience form

    • 2) Final stage: it includes

      • excavating any remaining, infected carious dentin;

      • removing old restorative material

      • protecting the pulp;

      • incorporating additional preparation design features

        • to minimize the chance of tooth or restoration fracture against oblique forces.

        • To maximize the retention of the material in the tooth;

    • finishing preparation walls, particularly regarding the margins;

    • performing the final procedures of cleaning, inspecting, and sometimes sealing the preparation.

    Steps of cavity preparation:

    • Intial stage:

      • 1-Outline form

      • 2- Primary Resistance and Retention form

      • 3- Convenience Form

  • Final stage:

    • 4- Removal of remaining Caries & pulpal protection

    • 5- Secondary Resistance and Retention form

    • 7- Finishing of cavity walls

    • 6- Cleaning inspecting and sealing.

  • Outline Form and Initial Depth

    • Definition:

      • placing the cavity margins in the positions they will occupy in the final preparation except for the finishing enamel walls and margins;

    • preparing an initial depth of 0.2~0.8 mm pulpally of the dentinoenamel junction.

    • Principles :

      • 1.All friable and weakened enamel should be removed.

      • 2.All fault should be included

      • 3.All margin should be placed in a position to afford good finishing of margins of restoration.

    • Features:

    • 1.Preserving cuspal strength.

    • 2.Preserving marginal ridge.

    • 3.Minimizing facio-lingual extension.

    • 4.Using enameloplasty

    • 5.Connectiong two close faults of the tooth which are < 0.5 mm apart

    • 6.Restricting depth of penetration into dentin

      • for pits and fissure: 0.2 mm

    • 1.Preserving cuspal strength

      • avoiding termination of the margin on extreme eminence, such as cusp height

      • if extension of primary groove includes > half of cusp incline, then CUSP CAPPING consider.

      • 2. Preserving marginal ridge strength

        • Remaining Marginal ridge should be greater than 1.6 mm for

    premolar & 2mm for molar •

    • If Remaining Marginal ridge will be less than 1.6 mm, there may be the chances of fracture due to undermining the ridge.

    • Direction of mesial & distal walls

      • When >1.6 mm thickness width is remained at mesial /distal marginal ridge, then mesial / distal wall should

    be parallel.

    • When <=1.6 mm thickness width is remained at mesial /distal marginal ridge , then mesial / distal wall should be divergent.

    • Tunnel Technique:

      • Cavity preparation to remove proximal without removing marginal ridge

      • preserve marginal ridge, so strength

      • Contact area not disturbed

      • Minimal overhange

     Tunnel Technique:  Cavity preparation to remove proximal without removing marginal ridge  preserve marginal
     Tunnel Technique:  Cavity preparation to remove proximal without removing marginal ridge  preserve marginal
    • Restorations:

      • Amalgam

      • Sandwich technique.

    • Tunnel Technique:

     Tunnel Technique:
     Tunnel Technique:
    • 3. Minimizing facio lingual Extension

      • Minimizing facio lingual Extension ,which prevents the weakening of cusp.

      • For conservative class I CAVITY facio-lingual width should be 1 to 1.5 mm.

    • 4. Depth of preparation Restricting depth of penetration into dentin for pits and fissure-0.2 for smooth surface-0.2 to 0.8.

    • this is

      • 1.To avoid the seating of the restoration on the very sensitive DEJ.

      • 2.To give the bulk of restoration.

      • 3.To take advantages of dentin elasticity during insertion and function.

    • 5. Enameloplasty :

      • This is the procedure of reshaping the enamel surface by making it rounded / Saucered ,the area becomes cleansable and finishable.

      • It is indicated when remaining fissure is not greater than 1/3 rd of enamel thickness.

    Caries removal:

    • Use slow speed bur / hand instruments.

    • From cavity walls, then from pulpal/axial walls

    • Areas to remove:

      • Infected area.

      • Decalcified load bearing areas.

      • Decalcified cavo-surface margins.

  • Infected dentin Vs affected dentin?.

  • Dentin caries:

    Two histopathological zones:

    • The peripheral caries-infected zone:

      • close to EDJ,

      • irreversibly damaged,

      • necrotic and softened by long standing bacterial contamination and proteolytic denaturation of collagen and acid demineralization of the inorganic component.

  • The deeper caries-affected zone:

    • reversibly damaged by virtue of carious process,

    • has the potential to repair under the correct conditions as the collagen is not denatured.

    • Infected Dentin:

      • The soft, wet, and necrotic nature means it is an inferior chemical and physical substrate for adhesion and seal formation.

      • Low compressive strength.

      • sticky and soft to a sharp dental explorer ( Mashy brown)

  • Affected Dentin:

    • potentially repairable caries-affected dentine has been shown to exhibit adequate adhesive bonding potential, especially when surrounded by a periphery of sound dentine and enamel.

    • Better compressive strength.

    • tacky ('scratchy ) in nature and blends to the hard sound dentin)

  • How much dentine caries should

    be excavated?

    • The answer to the above question is specific to the individual tooth/lesion, oral cavity, patient and dentist.

    • numerous inter-relating co-variables that have to be considered:

      • Pulp status

      • Lesion depth

      • Extent of viable tooth structure

      • caries risk

    • Transillumination

    • rely upon tactile sensation and the hardness of the dentin.

    • Using caries detecting solution/dyes.

      • binds to denatured collagen of the infected dentin

      • Pink haze concept.

  • plastic or ceramic burs,

  • enzymatic caries-dissolving agents,

  • air abrasion

  • laser ablation

    • Schwendicke et al. (2013) concluded that:

      • incomplete caries removal seems advantageous compared with complete excavation, especially in

    proximity to the pulp.

    • “there is currently no evidence that incompletely excavated teeth are more prone to complications.”

    Vital pulp therapy:

    • Indirect pulp capping

      • incomplete caries removal with no re-entry

      • stepwise or two-step excavation

  • Direct pulp capping

  • Pulpotomy:

    • Partial pulpotomy

    • Full pulpotomy

  • Secondary retention and resistance

    • Grooves

    • Bevelling

    • Boxes

    • Slots

    • Amalgam pins/ coves.

    • Screw pins

    • Amalgam Bonding

    • Endo treated tooth:

      • Nayyer core

      • Intraradicular Post

    Finishing and inspecting:

    Finishing and inspecting:
    Finishing and inspecting:
    Finishing and inspecting:
    Finishing and inspecting:

    Restoration placement:

    New methods for cavity preparation/caries removal:

    • Chemo-mechanical

    • Air-abrasion

    • Laser.

    Chemo-mechanical:

    • use of a chemical solution which softens carious dentine.

      • Sodium hypochlorite

    Chemo-mechanical:  use of a chemical solution which softens carious dentine.  Sodium hypochlorite  given
    • given sufficient time, it partially breaks down

    the organic material and kills the bacteria,

    rendering the lesion caries free

    • Local analgesia is not usually required.

    • Carisolv:

      • The gel is placed over the carious lesion.

      • After 1020 minutes the gel is washed away and the cavity can be restored with an adhesive material

    Laser:

    • Light Amplification by Stimulated Emission of Radiation.

    • Different applications:

    Laser:  Light Amplification by Stimulated Emission of Radiation.  Different applications:  based upon the
    • based upon the absorption rates of its wavelength in hard or soft tissue.

    • the need for local anaesthesia is reduced but not completely eliminated.

    • less time than normal.

    • lack of any tactile sense.

    Laser:  Light Amplification by Stimulated Emission of Radiation.  Different applications:  based upon the

    Er:YAG Laser

    • Erbium Yttrium Aluminium Garnet Laser

    • The choice for cavity preparation.

    • wavelength of 2940nm.

    • highly absorbed in water

      • so it is useful for the selective removal of caries.

    Er:YAG Laser  Erbium Yttrium Aluminium Garnet Laser  The choice for cavity preparation.  wavelength
    Er:YAG Laser  Erbium Yttrium Aluminium Garnet Laser  The choice for cavity preparation.  wavelength

    Air-abrasion:

    • also called (kinetic cavity preparation).

    Air-abrasion:  also called (kinetic cavity preparation).  uses the kinetic energy to remove tooth structure
    • uses the kinetic energy to remove tooth structure :

      • microfine (20-50 micron diameter) particles

        • Mainly alumina

      • a high pressure air stream ( 80-100 psi)

      • Causes brittle micro- fracture.

  • Anesthesia may be avoided due to air cooling

  • Used for:

    • tooth cutting/etching

    • Remove old filling.

    • Caries removal.

  • Air-abrasion:  also called (kinetic cavity preparation).  uses the kinetic energy to remove tooth structure

    Thank You

    • Ala’a Al-Haddad

    • E-mail: A.Haddad@ju.edu.jo

    Thank You  Ala’a Al-Haddad  E-mail: A.Haddad@ju.edu.jo
    Thank You  Ala’a Al-Haddad  E-mail: A.Haddad@ju.edu.jo