Diagnosis, treatment planning, restoration of clas srevised / dental implant courses

TREATMENT PLANNING,
ISOLATION,RESTORATION OF
CLASS I,III,IV,V LESIONS
INDIAN DENTAL ACADEMYINDIAN DENTAL ACADEMY
Leader in continuing Dental EducationLeader in continuing Dental Education
www.indiandentalacademy.comwww.indiandentalacademy.com

DIAGNOSIS AND
REGISTRATION OF CARIOUS
LESIONS
 Diagnostic tools
The visual-tactile method with light, mirror,
and gentle probing

 The visual method
with temporary
elective
tooth separation

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Indian Dental academy
• www.indiandentalacademy.com
• Leader continuing dental education
• Offer both online and offline dental
courses

 The conventional
bitewing radiographic
method

The fiber-optic
transillumination
method

 DIAGNODent
Laser Device

 Quantitative Light-
induced Fluorescence

Electrical conductance (fixed
Frequency) method

 ELECTRONIC CARIES MONITOR
 CARIES DETECTING DYES
 DIGITAL RADIOGRAPHIC METHOD
 THE RVG SYSTEM
 COMPUTER-AIDED RADIOGRAPHIC METHOD
 THE ENDOSCOPIC FILTERED FLUORESCENCE
METHOD(EFF)

TREATMENT PLANNING
“It is not feasible to describe a precise
treatment planning in the child patient.”
welbury

OBJECTIVES
A CHILD GAINS ADULTHOOD IN A STATE OF GOOD DENTAL
HEALTH
THAT THE CHILD DEVELOPS A POSITIVE ATTITUDE TO
DENTAL CARE

PHYLOSOPHY OF TREATMENT
PLANNING
 TREATMENT PLAN MUST BE DEVELOPED AND
DESIGNED TO PROVIDE HIGH QUALITY
RESTORATIVE CARE FOR EACH INDIVIDUAL
CHILD’S NEED
1.NO RESTORATIVE CARE HAS BEEN ATTEMPTED
2.ALREADY HAD RESTORATIONS

1.NO RESTORATIVE CARE HAS
BEEN ATTEMPTED
 SEQUENCED INTRODUCTION TO THE PROCEDURES OF
RESTORATING TEETH.
 STEP BY STEP PROCEDURE FOR THE CONTROL OF
PAIN (LOCAL ANAESTHESIA), RUBBER DAM, ROTARY
INSTRUMENTS AND RESTORATIONS.

2. HAD ALREADY VISITED
 TOTALLY UNCO-OPERATIVE
 RELUCTANT TO CO-OPERATE BUT PERSUADABLE

COMMUNICATION WITH CHILD AND
PARENT
 Objective - Allay anxiety of first dental visit
 Reception and waiting areas - Should
communicate a sense of friendship and welcome
 Should gain patient’s interest and co-operation
 Show interest in child

Talking to parents
• Never guarantee that we will finish in a certain number of
appointments
• Never guarantee what treatment we will do next
• Don't give encounter forms to parents
• Relay parental concerns to the faculty

– Discuss with the parent WHY the patient needs the
care we are proposing
– Discuss with the parent after each appointment what
was accomplished and patient cooperation (be as
positive as possible)

PRINCIPLES OF TREATMENT
PLANNING
NEW PATIENT
↓
HISTORY AND EXAMINATION
↓
MANAGAMENT OF ACUTE PROBLEMS
↓
ASSESSMENT
↓

↓
LONGTERM TREATMENT OBJECTIVES PATIENT
PARENTAL CO-OPERATION
↓
ASPECTS OF CARE
↓
PREVENTIVE -RESTORATIVE –ESTHETIC
↓ ↓ ↓
DIETARY ADVICES STABILIZATION
DISCOLORATION
FLUORIDE RESTORATIONS SHAPE
ORAL HYGIENE EXTRACTIONS POSITION
FISSURE SEALANTS
↓

↓
DISCUSSION
↓
PARENT-PATIENT-DENTIST-REFERRAL
↓
DEFINITIVE TREATMENT PLAN

AIMS OF THE FIRST SESSION
 To establish good communication with the child and parent
 To obtain important background information (patient’s history)
 To examine the child and obtain radiographs)
 To introduce the child to a simple treatment procedure
 To explain treatment aims to the child and parents

CARIES RISK ASSESSMENT
 RISK FACTORS
 Sucrose exposure
 Previous carious experience
 Levels of cariogenic bacteria
 Oral hygiene practices
 Fluoride exposure
 Saliva
 Social and family practices

 STAINING OF PIT AND
FISSURES
 DISCOLORATION OF THE
ENAMEL
 CONDITION OF THE
MARGINAL RIDGE
WHETHER INTACT OR
BROKEN
 PULPAL PATHOLOGY

SUMMARY OF THE FIRST
APPOINTMENT
Take the history
a. social
b. dental
c. medical
Examine the child
a. extra-oral
b. intra-oral
Take radiographs if required

Perform a simple operative procedure
a. prophylaxis: incisors only (in young child)
or full mouth, including removal of calculus
ifrequired
b. perform simple palliative treatment if necessary
c. possibly topical fluoride treatment or other non
traumatic procedure

Explain aims of treatment to parent
a. Emphasize the need for preventive as well as operative
treatment
b. Request that the child's toothbrush be brought at the next visit
c. Give an estimate of the number of visits that will be required to
complete treatment

An outline for treatment planning
Operative treatment
general Restorations
Extractions
Orthodontic treatment

LONG TERM TREATMENT
PLANNING
Overall assessment of the general attitude of the
child and parents to dental care
“ Delaying the final treatment planning until the
acute problems have resolved is very
worthwhile”

Order of treatment:
general guidance
First visit
 Take radiographs.
 Introduce the child to operative treatment-'polish' a few
teeth or full prophylaxis.

2nd visit
 Assess tooth brushing technique - observe the child
brushing - determine Oral Debris Index Stan oral
hygiene instruction
 Topical fluoride or fissure sealant or preventive resin
restoration.
 Provide a diet record leaflet and explain its purpose to
the parent and/or child.

3rd visit
 Collect diet record leaflet.
 Continue oral hygiene instructions
 Amalgam restoration in maxillary molar-infiltration local
analgesia

Fourth visit
Continue oral hygiene instruction.
At this and subsequent visits, introduce progressively to
more complex restorations.
Delaying treatment of mandibular teeth if possible until
the child happily accepts maxillary infiltrations.
Diet counseling.

Rampant caries
• Consider gross caries removal and temporization
• Discuss baby bottle syndrome if the patient is
young
• Consider diet history and extended oral hygiene
instructions with parent
• Consider fluoride supplementation, either systemic
or topical

Pain
• Always treat the area that is painful to the patient,
regardless of treatment plan order
• Never let a patient leave in pain!

Two factors significantly reduce the survival
rate of restorations
……….walls et al 1985
 Lack of local analgesia
 Age of the patient
 Topical analgesia before giving an injection
 Careful measured technique with full explanation to
the child through out the local anesthesia procedure
flavoured topical gel
fine gauge needle
warmed analgesia solution
slow administration of the solution
constant reinforcementwww.indiandentalacademy.comwww.indiandentalacademy.com

QUADRANT DENTISTRY
 Reduces the number of times local analgesia is used
 Makes maximum use of time available
 Economically beneficial to parents as well as the dentists

ISOLATION OF TEETH
GOALS OF ISOLATION
 MOISTURE CONTROL
 RETRACTION AND ACCESS
 HARM PREVENTION

 SALIVA EJECTORS
 COTTON WOOL ROLLS
 ABSORBENT PADS
 RUBBER DAM

SALIVA EJECTORS
Hygoformic saliva ejector / tongue protector

Cotton rolls,
cellulose wafers,
gauze sponges
Cotton roll holder

Cotton roll alternative
Absorbs without the bulk of rolls

Atropine Sulfate, 0.4mg Tablets.
effectively reduces saliva flow within 60
seconds,
persists for 4-6 hours.

RUBBER DAM ISOLATION
S.C.BarnumS.C.Barnum in 1864 introduced rubber dam into
dentistry
ADVANTAGES:
 Dry clean operating field
 Improved access and visibility
 Improved properties of dental materials
 Protection of the patient and operatorwww.indiandentalacademy.comwww.indiandentalacademy.com

Improves access and visualization
operator efficiency and increased productivity
Superior moisture control
Prevents aspiration or swallowing of foreign bodies
Protects soft tissues
Aids behavior management
Child becomes nasal breather
Helps dentist educate parents

Disadvantages:
Time consumption and patient objection

Certain oral conditions that preclude
the use of rubber dam
 Erupting teeth with insufficient support for retainer
 Third molars
 Extremely malpositioned teeth
 Asthmatic patients
 Psychological reasons
 Latex allergy

Rubber dam kit

ClampsClamps
 Bland clamps – jaws are flat and point directly
towards each other
Designed to grasp the tooth at or above
the gingival margin
 Retentive clamps - -jaws are directed gingivally
so that they can grasp tooth below gingival
margin

RETAINER/CLAMPS
Partially erupted permanent
molars
Fully erupted
permanent molars
Second primary molars
First primary molars
Primary incisors

 BW, JW Molar clamps (wingless)
 K Molar Clamps
 GW Premolar clamps
 EW Clamps ( for small tooth)
 AW Molar wingless (erupting tooth)
 Cervical Clamp (Ferrier pattern) for anterior teeth)
 Ivory #7,8,8A,14 A for molars
 #0, 1,2 for premolars
 # 212 for anterior teethwww.indiandentalacademy.comwww.indiandentalacademy.com

Rubber clamp
Four point prong
contact with tooth

Winged - small projections allow it to be mounted
on dam prior to application
Wingless - applied directly to tooth

Rubber dam clamp for broken down and partially
erupted tooth

RUBBER DAM
 Size 5*5 6*6
 Thickness Thin 0.006”
Medium 0.008”
Heavy 0.010”
Extra heavy 0.012”
Special heavy 0.014”
 Color black, green , blue
beige, transparent
Side shiny , dullwww.indiandentalacademy.comwww.indiandentalacademy.com

RUBBER DAM TEMPLATE

RUBBER DAM FRAMES
 ASH PATTERN
 MODIFIED YOUNG’S
PATTERN
 SVENSKA N- O FRAME

Universal U shaped
 Nygaard ostby
 Sauveor (oval)

CLAMP PLACEMENT FORECEPS
STOKES BREWER ASH

RUBBERDAM PUNCH
Ainsworth Ash

Ainsworth Ivory

Punching the holes
 Lower molars & large upper molars
 Upper molars, small molars, 2nd
primary molars
 Canines, premolars and 1st
primary molars
 Upper incisors
 Lower incisors

Additional retention devices
wooden wedges, elastics, latex cord

Rubber dam Application

Why Ligate the Clamp?
 All retainers applied before the rubber dam is in place
must be ligated. A 12” piece of floss should be
attached to the retainer and threaded though both
holes to catch all of the pieces should the retainer
break.
 Prevents the patient accidentally swallowing the
clamp.
 Prevents injury to the dental team from flying debris
caused by an improper seat of the clamp.

Clamp secured with floss

TECHNIQUE 1 – Clamp placement
prior to rubber dam
ADVANTAGESADVANTAGES
 Tooth and gingival margins are clearly visible.
 This will enable to place the clamp precisely with minimal
risk of gingival trauma.
INDICATIONSINDICATIONS
 Posterior teeth in children and adults except 3rd
molars

 Clamp usedClamp used – winged type ; wingless with specially
shaped jaws
Wingless for multiple tooth isolation
 Punching holesPunching holes – 2/3 overlapping

Clamp is placed on the tooth
to be isolated
Clamp is placed on the forceps,
expanded and the forceps is
locked

Clamp forceps are removed
leaving behind clamp on the
tooth
The rubber dam sheet is carried
into the mouth with both index
finger being used to stretch and
place over the clamp

Placement of
rubber dam
frame

TECHNIQUE 2 - Clamp and rubber dam placed
together
INDICATIONS:INDICATIONS:
 Posterior most teeth, 3rd
molars
 Conditions in which other techniques are impractical
DISADVANTAGE:DISADVANTAGE:
 Limited vision
Clamp usedClamp used
 winged clamp www.indiandentalacademy.comwww.indiandentalacademy.com

Extra oral placement of clamp (winged) helpful
when isolating small number of teeth

TECHNIQUE 3 - Clamp placed after
the rubber dam
 It should be carried out with assistance
 Restricted to anterior teeth and possibly pre-molar
because of limited access
 When large sized clamps are used

MULTIPLE TOOTH ISOLATION
 Clamps should not be placed on a tooth which requires which
requires restoration
 If the is narrow mesio-distally then the second tooth to the distal
is preferable
 When several teeth require treatment the operating field is
extended mesially or across the arch to provide clear access
and maximum retention
 Distal tooth will usually be clamped and the mesial is not
clamped

QUADRANT ISOLATION

 ADDITIONAL
RETENSION

Anterior Teeth

ISOLATION OF LOWER INCISORS

Removal of Rubber Dam
 Thoroughly cleanse area.
 Cut/remove interproximal ligatures.
 Stretch rubber dam facially and cut each
interproximal septum with scissors.
 Remove clamp with clamp forceps.
 Remove dam and examine it for any missing
pieces.
 Examine site for remaining rubber; remove with
floss or explorer.
 Rinse oral cavity, wipe off patient’s lips.

Block type and Ratchet type mouth props

General Considerations
Adhere to GV Black’s principles with respect to
outline, resistance, retention and convenience
form and finishing of enamel walls.

Advantages and disadvantages of materials used
in pediatric dentistry
Advantages Disadvantages
 Amalgam Simple Not adhesive
Quick Requires mechanical
retention in cavity
Cheap Environmental and
occupational hazards
Technique
insensitive Public concerns
Durable
 Composite
Resin Adhesive Technique sensitive
Aesthetic Rubber dam required
Reasonable wear properties
Expensive
Command setwww.indiandentalacademy.comwww.indiandentalacademy.com

 Stainless-steel Very durable Extensive tooth
preparation
crowns
Protects and support Patient cooperation
remaining tooth required
Structure Unaesthetic
 Glass ionomer
Cement Adhesive Brittle
Aesthetic Susceptible to
erosion and wear
Fluoride leaching
 Resin-modified Adhesive Water absorption
glass ionomer Aesthetic Significant wear
Command set
Simple to handle

Polyacid-modified
Adhesive
Technique sensitive
 composite resin
Aesthetic Less fluoride release
than glass ionomer
Command set
Simple to handle
Radio-opacity

Guide to the use of materials
 Primary dentitionPrimary dentition
 Occlusal (class I) Glass ionomer
Composite resin
 Interproximal (class II) Glass ionomer
Amalgam
Composite resin/GIC
sandwich
Stainless-steel crown
 Gross carious breakdown or restoration after pulp therapy
Stainless-steel crown

Permanent dentitionPermanent dentition
Occlusal table Fissure sealant
 Occlusal enamel caries Fissure sealant
 Occlusal caries with minimal involvement of dentin
Preventive resin restoration
 Occlusal caries with extension into dentine
Composite resin
 Interproximal Amalgam
 Incisal edge Composite resin
 Cervical Glass ionomer
Composite resin

ModificationsModifications
View from distal surface
of primary 1st molar
B L

Black-type Modern
 Gain access Gain access to the
(not necessarily caries) caries
 Prepare the cavity to Remove the caries
standard outline & shape
 Remove any remaining caries Plan the final cavity
outline
and shape
Complete the cavity
preparation

Modifications
Relatively wider isthmus width
• one-third the intercuspal
distance
Conservative proximal
extensions
• you can see light, but cannot
pass an explorer tip through

Modifications
No proximal grooves
No reverse curves

Class I cavity preparation
CLASS I – Pit and fissure cavities in the
occlusal surface in posterior and lingual surface in
anterior teeth

Instrumentation
Utilize a # 330 bur
Tip -
• measure width and
length of cutting shank
High speed
Minimal use of hand
instruments

Mandibular Molars Outline Form

It is unnecessary
to cross the
central ridge
Mandibular Molars Outline Form

Maxillary Molars Outline Form

Pulpal Floor Depth –
0.5 - 1 mm into dentin
primary molars - 1.25 to
1.50 mm
Intercuspal width - 1/3rd
Rounded internal line angles
B-L walls slightly undercut
M-D walls flare at marginal
ridges

Flat FloorFlat Floor
Relatively parallel to the cusp tips

Internal Form of a Class I Prep
1) Depth 0.5 into dentin
2) Angle of floor and walls is
rounded
3) Slightly rounded pulpal floor
Avoids pulp
4) sharp cavo-
surface angle

A Maxillary right first and
second
molars (occlusal view)
Maxillary second primary
molar (lingual view)
Mandibular right first and
second primary molars

 Method for glass ionomer restorations
1. Local anesthesia may not always be necessary; however,
rubber dam isolation should be used where possible
2. The outline of the cavity should follow the extent of the
carious lesion. There should be no extension for prevention.
An additional retention form for minimal proximal cavities
can be achieved by placing grooves into the dentine using very
small (size 1 –2 )round burs
 3.Remove all soft caries using a slow round burr or hand
instruments. Be aware of the large pulp chamber as it is easy to
expose the pulp of a primary molar.
 4.Pre-condition the dentine using 10%polyacrylic acid for 10
seconds, wash and dry.

5.When using encapsulated materials, ensure that the capsules
are compressed for atleast 3 seconds to facilitate adequate
mixing of the powder and liquid components.
Mix for 10 seconds in the amalgamator, discard the rest
3 –4 mm of the mixed materials as this is often unsatisfactory.
Place the remainder directly into the cavity.
6.Once the relatively thick material has been placed into the
cavity it is compressed with a ball burnisher – the use of a
small amount of bonding agent prevents sticking to the
instrument.

POSTERIOR COMPOSITE
RESTORATION

Amalgam
composite
composite

INCREMENTAL PLACEMENT OF
COMPOMER OR COMPOSITE

Incipient Class I Cavity in a Very Young
Child
child under 2 years of age
small cavity preparation made without the aid of
the rubber dam or local anesthetic
objective -to restore the tooth with amalgam to
arrest decay and to prevent further tooth
destruction without a lengthily or involved dental
appointment

CLASS III CAVITY PREPARATION
CLASS III – Proximal surface of anterior teeth
without the involvement of the incisal angle

 Conserve as much tooth structure as possible
 Stress on access and caries removal only
 Composite – bevel cavosurface margin
throughout

EXTENSION – LOCK/ KEYWAY SHOULD BE POSITIONED TO
ONE
SIDE OF THE MIDLINE IN MIDDLE ONE THIRD OF
THE LINGUAL SURFACE
OUTLINE – THE LOCK SHOULD HAVE A SMOOTH FLOWING
AND ROUNDED OUTLINE
ISTHMUS – ROUNDED MARGIN ,LARGE ENOUGH TO
ACOMMODATE COMPOSITE / AMALGAM

PROXIMAL WALLS - SHOULD BE PLACED AT RIGHT
ANGLES TO THE CAVOSURFACE
DEPTH- 0.5 TO DENTIN,FOLLOW CONTOUR
OF THE EXTERNAL SURFACE
EXTENSION- JUST BEYOND THE CONTACT AREA
OF THE ADJACENT TOOTH
ADDITIONAL RETENSION - PIT AT THE GINGIVO-LABIAL
JUNCTION

CLASS IV CAVITY PREPARATION
CLASS IV – Proximal surface of anterior teeth
with the involvement of the incisal angle

 Interproximal slice & labial and
lingual dove tails
 Include any class V lesions
 At the gingival aspect a definite
interproximal shoulder / gingival
seat

Restoration of Proximal-Incisal Caries
in Primary Anterior Teeth
Esthetic Resin Restoration
Stainless Steel Crown
Open-Face Steel Crowns
Direct Resin Crowns

CLASS V CAVITY PREPARATION
 CLASS V – Cavities in the gingival third

 # 330 bur is used to cut the cavity
 Outline form – limited to carious lesion and adjacent
decalcified areas
 Kidney shaped, a gently curved outline form is
acceptable as a square, sharp outline form at the
mesial and distal margins
 Remaining caries is removed with slow running ,round
#2 bur
 Gingival enamel margin should follow a regular curve
parallel to the gingival attachment unless the lesion
extends subgingivally.

Bevelled conventional preparation

REFERENCESREFERENCES
 A MANUAL OF PAEDODONTICS .A MANUAL OF PAEDODONTICS .
R.J.ANDLAW AND W.P.ROCK
 KENNEDY’S PAEDIATRIC OPERATIVE DENTISTRYKENNEDY’S PAEDIATRIC OPERATIVE DENTISTRY
M.E.J. CURZON 4TH
EDITION
 ART & SCIENCE OF OPERATIVE DENTISTRYART & SCIENCE OF OPERATIVE DENTISTRY
T.M.ROBERSON 4TH
EDITION
 HAND BOOK OF PEDIATRIC DENTISTRYHAND BOOK OF PEDIATRIC DENTISTRY

 PICKARD`S MANUAL OF OPERATIVE DENTISTRYPICKARD`S MANUAL OF OPERATIVE DENTISTRY
 G.J MOUNTS BASIC PRINCIPLES OF FORG.J MOUNTS BASIC PRINCIPLES OF FOR
RESTORATIVE DENTISTRYRESTORATIVE DENTISTRY
 OPEARTIVE DENTISTRY 1983;8:57-63 :148-151OPEARTIVE DENTISTRY 1983;8:57-63 :148-151
 QNINTESSENCE INT 2000;31:527-533 535-QNINTESSENCE INT 2000;31:527-533 535-
546 :621-629546 :621-629
 JADA 1996;127:107-108JADA 1996;127:107-108
 JOURNAL OF PEDIATRIC DENTISTRY 2002;24:JOURNAL OF PEDIATRIC DENTISTRY 2002;24:
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