conservative approach OPERATIVE DENTISTRY

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  • No self cleansable ares
  • conservative approach OPERATIVE DENTISTRY

    1. 1. Conservative Approach •By Dr-Nashwan Mohammed M.Sc , BDS. Dr_nashwan@yahoo.com
    2. 2. Surgical Approach 1) 2) Lack of understanding of the caries process in particular the potential for re-mineralization. The poor physical properties of available restorative materials.
    3. 3. Black’s principles of extension for prevention   Sacrifice sound enamel and dentin to place cavity margins into self cleansing areas or caries immune sites. Dictate the extension of preparation through fissures to allow cavosurface margins to terminate on non-fissured enamel.  The resistance and retention form required to prevent amalgam failures. Implementing through : Caries risk assessment Prevention and remineralization of non cavitated lesion.
    4. 4. Consequences of Black’s principle of extension for prevention I. II. III. Gross weakening of the remaining tooth structure. Structural and marginal failure of the restoration. Increased potential to pulpal irritation.(overextension will maximize the chemical , electrical, thermal, bacterial, osmotic and evaporative stimuli) IV. Increased gingival and periodontal irritation.(subgingival margins, roughness and plaque accumulation) V. VI. VII. Increased restorative display. More time money and effort consumption. Difficult maintenance of the restorative system.
    5. 5.  In the past decades , conservatism was just targeting the minimization of tooth structure cutting whereas in the modern conservative theory there’s an intention to use a medical model and avoid cutting if possible. this would require the detection and discovery of the lesion in its subclinical stage before it initiates any defect that would need repair.
    6. 6. Adoption of medical model would save money , effort and time by : 1. 2. 3. 4. Preventing the development of defects or new cavities. Preventing periodontal problems. Stopping the progress of existing lesions and decay spots. Maintaining existing old restorations.
    7. 7.  It focuses on a minimal invasive dentistry or preservative dentistry, which allows a shift from the traditional surgical approach to a control of defects without cutting or if cutting is to be done it has to be restricted as much as possible.
    8. 8. Conservative approach encompasses the following principles     Control of causative factor or cariogenicity to eliminate further demineralization. Remineralization of early lesions. Minimal surgical intervention for cavitated lesions. Repair rather than replace for defective restorations.
    9. 9. Essentials to allow conservation  The operator.  The tools used.  The restorative materials.  The oral environment conditions.  The socioeconomic conditions of the patient.
    10. 10. The operator    Major role is played by the clinician performing the job. Knowledge and understanding of the defect ,demineralization / remineralization cycle. Treating the disease by allowing re-mineralization to occur more than demineralization. (saturation of saliva with fluoride, calcium and phosphates to drive them inside the tooth thus enhancing remineralization)
    11. 11. The tools used  1. 2. Magnification : loupes. Microscopes
    12. 12.  1. 2. 3. 4. 5. 6. Advanced diagnostic tools to detect incipient lesions: The intraoral camera. Digital radiography. Laser based device. (DIAGNOdent) Light fluorescence. The high resolution transilluminator (Digital imaging fiber optic transillumination tool DIFOTI) Electrical caries monitor (ECM).
    13. 13.
    14. 14. Ideal Cutting Instrument Should Fulfill:         Comfort. Ease of use. Discriminate and remove diseased tissue only. Painless. Silent. Required minimal pressure. No heat generation or vibration. Affordable.
    15. 15.  1. 2. 3. 4. 5. 6. Minimal or non-invasive cutting tools: Air abrasion technology. Chemo-mechanical removal of tooth tissues. Ultrasonic cutting. Laser cutting. Enzymes. Ozone treatment.
    16. 16. The restorative materials
    17. 17.  Adhesion is thus different from micromechanical bonding which relies for retention and sealing on an intermediary joint consisting of a system of numerous resin microtags and resin tooth hybrid created in the top 2-5 лm layer of tooth
    18. 18. So ….. It seems essential to substitute the term adhesion by Bododontics to be more precise in description of this science. Thus …. Bonding allow maximum preservation of tooth structure and hence maximum conservation.
    19. 19.    The cavities to be cut should be complying with the properties of the different restorative materials. These properties thus impose certain depth , width , wall’s inclination and finishing of enamels. Selection of materials that would achieve conservatism becomes imperative and therefore there’s a marked trend to shift to direct tooth colored restoratives rather than metallic and indirect restoratives.
    20. 20. The oral environment conditions    Salivary flow and pH. Resting flow rate range between 0.3-0.4ml/min while stimulated flow rate has an average rate between 1-2ml/min. Buffering effect of saliva Oral microbes , chemical degradation potentials , masticatory forces and chewing habits.
    21. 21. The socioeconomic conditions of the patient   Privileged , educated , employed patients regular dental check ups attendee low caries risk individuals suitable candidate for conservative approach. The opposite individuals would require much more radical approach.
    22. 22. Certain data have to be collected prior to decision making about the necessity of operative procedure. Diet assessment To Drill or not to Drill ? Or when to Prepare a Cavity ? Caries risk evaluation Clinical examination Radiographic examination
    23. 23. Diet assessment      Estimation of food cariogenicity. Frequency of intake of meals and snacks. Patient motivation for adopting healthy habits. Failures are faced due to the difficulty of convincing the patient to change their dietary habits. Diet counselor.
    24. 24. Caries risk assessment  It is based on the fact that for caries to develop , there are several factors that should be present to contribute to its occurance. By modifying the factor that play the major , this could successfully prevent the development of the disease.
    25. 25. Caries risk assessment  This done to predict If an individual would Develop caries at A certain time in A specified period Of time        Amount of plaque. Type of bacteria. Type of diet. Salivary secretion. Salivary buffering capacity. Amounts of fluoride ingested. Socioeconomic conditions. Patient’s general health.
    26. 26.  No Care Advised According to this caries risk assessment the patient could be either : Preventive Care Advised Operative Care Advised
    27. 27. Clinical assessment  Allow identification of the defect and correlation of previously gather data with the clinical picture. Upon diagnosis , the defect should be classified as carious or non-carious and dealt with accordingly.
    28. 28. Biological or medical model of treatment  This model deals with caries as a disease that should be treated prior to any restorative procedures Diet and habits modification. Salivary flow and buffering capacity adjustment. Mechanical preventive measures ( calculus and Biofilm control) to fit into a dental office preventive Program. Use of antimicrobials to fit into a home care preventive Program. Remineralization of initial lesions. Fissure sealing for susceptible sites. Close follow up to monitor the healing procedure. Perform minimal intervention and prevention for diseased tissues that can’t be remineralized and restore them conservatively.
    29. 29. Surgical Model of Treatment    The diseased tissues are beyond healing and couldn’t be remineralized. Drilling and cutting away the diseased tissue without giving attention to the MO as a causative factors. Cavity is prepared minimally with maximum preservation of tooth strength and anatomy followed by its restoration for maximum longevity.
    30. 30. Features of a conservative cavity      Include all defective enamel and dentin. No extension beyond defective areas. Convenient instrumentation and material placement. Freeing of all margins with adjacent surfaces. Necessary resistance and retention forms.
    31. 31. Black’s versus Mount and Hume’s   Black’s classification doesn’t specify the size of the lesion. Mount and Hume classified the lesion based on site and size (Si/Sta) Site/Stage 0 1 2 3 4 1 1.0 1.1 1.2 1.3 1.4 2 2.0 2.1 2.2 2.3 2.4 3 3.0 3.1 3.2 3.3 3.4
    32. 32. Extension for prevention concept Obtaining the resistance form Removal of remaining carious dentin Conservative cavity design
    33. 33. According to Black Occlusal: According to conservatism Caries and convenience dictate the outline. Removal of all pits and fissures. Only carious fissures. Mesially and distally extended midway between the marginal ridge and depth of the triangular fossa. Shallow fissures can be treated by enameloplasty or slanting bur technique. Proximal : Extended midway between axial line angle and facial or lingual margin of contact area. The gingival margin extends below the crest of the healthy gum margin. Pit and fissure sealant when there is a catch. Proximal Facial and lingual margins extend just beyond the contact area to free it. With a clearance of 0.5mm. The gingival margin extends just to include defects. Facial and lingual surfaces all margins are dictated by the outline of the defect.
    34. 34. Obtaining the resistance and retention form Black’s    Cavity width is governed by margin placement midway between the cusp tip and depth of the fissure Depth almost 0.5mm pulpual to DEJ. Retention mainly through macromechanical Conservatism    Cavity width to be extended to provide convenience Cavity could be in dentin or in enamel. Retention through micromechanical bonding.
    35. 35. Removal of Remaining Carious Dentin Black’s   All caries must be removed , if pulp exposed then do Endo. There could be irreparable damage by bacterial invasion so every trace of carious dentin should be removed. Conservatism    Differentiation between affected and infected dentin (Caries detector dye) Chemo-mechanical caries removal (Carisolv) Smartprep burs , Polymer burs.
    36. 36. Conservative Cavity Design Irritaion initiates  Based on the shape and extent of An acidic-medium No Self Cleansable Areas  the lesion. No flat floors nor squaring of the cavity. But with refinements to satisfy certain requirements. Ginival crevice are not immune from caries.(Subgingival Margins)
    37. 37. Examples of Conservative Cavity Design     Preventive resin restoration. Simple box preparation. Slot preparation Tunnel preparation.(APA , Cermet GI)
    38. 38.  Thank you

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