Introduction to Operative Dentistry
Operative Dentistry: Is the art and science of the diagnosis, treatment, and prognosis the defects of teeth. The operative treatment should result in the restoration of proper tooth form, function, and esthetics while maintaining the physiologic integrity of the teeth in harmonious relationship with the adjacent hard and soft tissues.Operative dentistry is the base from which most other aspects of dentistry evolved such as endodontics, prosthodontics, and orthodontics. Considerations: Infection control to safeguard both health service personnel and patients. Examination of not only the affected tooth but also the oral and systemic health of the patient
3) Diagnosis of the dental problem. 4) Treatment plan that has the potential to return the affected area to a state of health and function. 5) Understanding of the material to be used including a realization of both the material's limitations and techniques involved in using it. 6) Understanding of the oral environment into which the restoration will be placed. 7) Biologic knowledge. 8) Understanding of the biologic basis and function of the various tooth components and supporting tissues. 9) Knowledge of correct dental anatomy. 10) Effect of the operative procedure on other dental treatments.
Conservative Approach: Previously tooth preparation for operative dentistry influenced by the concept "extension for prevention". Nowadays improvement in restorative materials and techniques have: (1) significantly reduce the necessity for extensive tooth preparations. (2) strengthen the remaining tooth structure. (3) provide less trauma to the pulp and soft tissues.
Preoperative Treatment Considerations: Patient assessment, examination and diagnosis, and treatment planning are the foundation of sound dental care. The diagnosis and treatment plan depend on thorough assessment and examination of the patient. The results of this assessment must be recorded accurately in the patient record.
Patient Assessment: Infection Control: Before the examination and diagnosis of teeth, periodontium, and orofacial soft tissues, attention is given to infection control to avoid the transmission of disease through the sterilization/ disinfection of all instruments, supplies, and operatory surfaces and the use of barrier techniques such as gloves, masks, protective eyewear, and gowns.
2. Chief Complaint: What prompted the patient to consult a dentist in the first place. The form of the notation should be a few simple phrases in the patient's own words that describe the symptoms causing the discomfort.
3. Medical Review: To identify conditions that could alter, complicate, or contraindicate proposed dental procedures. For instance, the practitioner may identify: (1) communicable diseases ( TP , Hepatitis, HIV). (2) allergies and medications that may contraindicate the use of certain drugs. (3) systemic diseases and cardiac abnormalities that demand a prophylactic antibiotic coverage. (4) physiologic changes associated with aging that may alter clinical presentation and influence treatment.
Communicable Diseases: Dental professionals must be aware of the signs and symptoms of infectious diseases and their routes of transmission for the proper evaluation, diagnosis, and management of patients.
Allergies and Medications: Sometimes patients report that they are "sensitive" or allergic to local anesthetic. when any patient relays a history of "sensitivity" from injected dental anesthetic, the dentist must believe the patient until further investigation. These precautions are necessary because anaphylactic shock following an allergic reaction can be immediate and life threatening.
Medications used by the patient also can affect diagnosis and treatment. For example, xerostomia, is a significant potential side effect of anticholinergic, adrenergic-blocking, antipsychotic, antihistamine, diuretic, and antihypertensive medications. Tricyclic antidepressants may render patients extremely sensitive to epinephrine, antiepileptic agents may cause gingival enlargement.
Systemic Diseases and Cardiac Abnormalities: These are may be required to alter the treatment plane. The manipulation of mucosal surfaces during dental procedures may release blood borne bacteria that lodge on abnormal or damaged heart valves, and possibly resulting in increased risk of bacterial endocarditis. Patients at risk for bacterial endocarditis should be treated prophylactically with an appropriate antibiotic before dental treatment.
Un stable blood pressure, diabetic, angina, or new myocardia infraction usually interfere with routine dental treatment and may be deferred until acceptable condition are achieved, and the patient should be referred for medical evaluation.
Physiologic Changes Associated With Aging: Older persons generally have more medical, physical, and mental problems than their younger counterparts. The majority of older persons have at least one chronic disease (e.g., heart disease, renal dysfunction). Several medications and illnesses can alter oral physiology, oral hygiene, and dental health. Xerostomia result in increased caries incidence, mucosal alterations, and plaque retention. The use of salivary stimulants such as sugar-free candy drops, artificial saliva can be relieve this symptom.
Additional considerations include the limited use of vasoconstrictors in patients with advanced cardiovascular disease. Teeth morphology, shape, and form changes also may be associated with the aging process. Attrition, abrasion, and wear of proximal surfaces. Also variations in pulpal anatomy, physiology, and color changes due to extrinsic staining can occur with age and may lead to increased brittleness of the teeth and reduce in pulp size.
4. Sociological and Psychological Review: During initial visits the clinician should ascertain the patient's attitudes, priorities, expectations, and motivations toward dental care. The results of this exploration will affect the dentist's treatment recommendations.
5. Dental History:5.a) History of Present IllnessThe patient should be encouraged and guided to discuss all aspects of the current problem, in an organized and descriptive manner • Inception: "When did you first notice this pain? Have you ever noticed it before?"• Frequency and course: "How often does this pain occur? Are the episodes becoming more or less frequent or about the same as when you first noticed the pain?"• Intensity: "Is this pain mild, moderate, or severe?"
• Quality: "What is the nature of the pain? Sharp? Dull? Stabbing? Throbbing?"• Location: "Could you point to the tooth that hurts or to the area that you feel is swollen?"• Provoking factors: "Do heat, cold, biting, or chewing cause pain?"• Duration: "When heat (or cold) causes the pain, is it momentary, or does it last longer?"• Spontaneity: "Does the pain ever occur without provocation?"• Attenuating factors: "Does anything relieve the pain-hot or cold liquids, sitting up or lying down?"
5.b) Past Dental History: Reviewing previous dental experiences to reveal information about past dental problems and treatment, frequency of dental care that care may be indication of the patient's future behavior.
Examination and Diagnosis: This section describes the examination and diagnosis of problems with orofacial soft tissues, teeth, restorations, periodontium, and occlusion Clinical Examination: Is the "hands-on" process of observing both normal and abnormal conditions. Diagnosis: Is a determination and judgment of variations from normal.
Examination of Orofacial Soft Tissues: Extraoral Examination: Include Facial asymmetry or distention that might indicate swelling of an odontogenic origin or be produced by a systemic condition. The patient's eyes should be observed for pupillary dilation or constriction, which may signal systemic disease, premedication, or fear.
The patient's skin should be checked for the presence of any lesions, including lacerations, contusions, scars, and discolorations, facial lesions (e.g., a sinus tract draining through the skin). The head and neck examination continues with bimanual palpation of the muscles of mastication for pain or tenderness and TMJ. Palpation the submandibular glands and cervical nodes for abnormalities in size, texture, mobility, and sensitivity to palpation.
Intraoral Examination: The clinical examination is performed systematically in a clean, dry, well-illuminated mouth. Proper instruments including a mirror, explorer, and periodontal probe are required. Start in one area of the mouth and follow a routine pattern of visual examination and palpation of the cheeks, vestibules, mucosa, lips, lingual and facial alveolar mucosa, palate, tonsillar areas, tongue, and floor of the mouth, sinus tracts or localized redness or swelling in the attachment apparatus.
Any sinus tracts should be traced with a gutta-percha cone (a number 35 is generally recommended) to locate the sources of the tracts, since they may not lie directly beneath the openings to the surface.
2. Examination of Teeth and Restorations: Caries Examination: with the aids of (1) visual changes in tooth surface texture or color. (2) tactile sensation when an explorer is used judiciously. (3) radiographs and Cone beam computed tomography (CBCT). (4) transillumination.
Amalgam Examination: Clinical evaluation requires visual observation, tactile sense with the explorer, use of dental floss, interpretation of radiographs. Amalgam restorations are evaluated for: (1) amalgam "blues,". (2) proximal overhangs. (3) marginal gap or ditching. (4) fracture lines. (5) improper anatomic contours. (6) marginal ridge incompatibility. (7) improper proximal contacts. (8) recurrent caries. (9) improper occlusal contacts.
Cast Restorations Examination: Cast restorations should be evaluated clinically in the same manner as amalgam restorations and usually evaluated for fitness, marginal leakage and discoloration, perforation, color, fracture, abutment tooth mobility, gum recession and root exposed, and soft tissue impingement.
Composite Restorations Examination: Tooth-colored restorations should be evaluated clinically in the same manner as amalgam restorations and evaluated for improper contour or proximal contact, an overhanging proximal margin, recurrent caries, or other condition that impairs cleaning, and dark marginal staining.
Clinical Examination for Additional Defects: Nonhereditary hypocalcified areas of enamel: Localized intact, hard white areas on the facial or lingual surfaces, or on cusp tips of the teeth that may have resulted from factors such as childhood fever, trauma, or fluorosis that occurred during the developmental stages of tooth formation, or arrested and remineralized incipient caries. Chemical erosion: Is the loss of surface tooth structure by chemical action in the continued presence of demineralizing agents (acids).
Abrasion: Is abnormal tooth surface loss resulting from direct frictional forces between the teeth and external objects, Such wear is caused by improper brushing techniques or other habits such as holding a pipe stem between the teeth, tobacco chewing, and chewing on hard objects such as pens or pencils.
Attrition: Is mechanical wear of the incisal or occlusal tooth structure as a result of functional or parafunctional movements of the mandible. Although a certain degree of attrition is expected with age, it is important to note abnormally advanced attrition. If significant abnormal attrition is present, the patient's functional movements must be evaluated and inquiry made about any habits creating this problem such as tooth grinding, or bruxism, usually due to stress.
Fracture or craze lines: in a tooth are often visible, especially with advancing age, and should be considered as potential cleavage planes for possible future fractures. Appropriate dye materials or light reflected from a dental mirror, Transillumination aid in detecting fracture lines.
Transillumination Holding a fiberoptic illuminating device horizontally at the gingival sulcus in a dimly lit treatment room may reveal a vertical fracture line or it may make a suspected line more visible. Normally the crown of an intact tooth will be illuminated uniformly by the fiberoptic light. If a fracture exists, the light will illuminate the side of the crown that it contacts. However, the portion of the crown on the opposite side of the fracture will remain dark.
dental anomalies: that include variations in size, shape, structure, or number of teeth such as dens in dente, macrodontia, microdontia, gemination, concrescence, dilaceration, amelogenesis imperfecta, and dentinogenesis imperfecta.
Radiographic Examination of Teeth and Restorations. Clinical situations for which radiographs may be indicated: For diagnosis of proximal-surface caries, deep carious lesions, restoration overhangs, or poorly contoured restorations. Previous periodontal or root canal therapy, swelling, mobility of teeth fistula or sinus tract infection. Familial history of dental anomalies. Clinical evidence of periodontal disease. History of trauma, evidence of foreign objects. growth abnormalities. Malposed or clinically impacted teeth, Unusual tooth morphology, calcification. Abutment teeth for fixed or removable partial prosthesis.
Transillumination
Adjunctive Aids for Examining of Teeth and Restorations: Percussion Test: Tenderness indicates some degree of inflammation in the periodontal ligament. This inflammation may be caused by occlusion, trauma, sinusitis, periodontal disease, or extension of pulpal disease into the periodontal ligament. The clinician should beginning with one that is not suspected so the patient is aware of normal sensation. The blunt handle of a mouth mirror should be used . Each tooth should be percussed on the facial, occlusal, and lingual sides.Care must be taken when interpreting a positive response on maxillary teeth because teeth in close proximity to the maxillary sinuses also may exhibit pain on percussion when the patient is suffering from maxillary sinusitis.
Palpation: Is performed by rubbing the index finger along the facial and lingual mucosa overlying the apical region of the tooth. An alveolar abscess in an advanced stage or other periapical pathosis may cause tenderness to palpation.
Pulp Vitality: ----Thermal test, A cotton applicator tip sprayed with a freezing agent or hot gutta-percha is applied directly to the tooth . Healthy pulp: The response will subside within a few seconds following removal of the stimulus. Hyperemia : Pain lasting 10 to 15 seconds or less after stimulation. Irreversible pulpitis: Intense pain of longer duration from hot or cold. Pain that results from heat but is quickly relieved by cold also suggests irreversible pulpitis. Necrotic pulp: Lack of response to thermal tests.
-----The electric pulp tester: A small electric current delivered to the tooth causes a tingling sensation when the pulp is vital and no response when the pulp is nonvital. It is important to obtain readings on adjacent and contra lateral teeth. The electric pulp tester is placed on the tooth and not on a restoration. ------Preparation Test: By using a round bur and no anesthetic.
Study casts: They are helpful in providing an understanding of occlusal relationships (tooth interdigitation, the functional occlusion, and any occlusal abnormalities that may need treatment like tilted, rotated, or extruded teeth, cross-bites), developing the treatment plan, and educating the patient, study the wear facets, defective restorations, coronal contours, proximal contacts, and embrasure spaces between the teeth.
Selective Anesthesia Test In special clinical situations, the use of intraligamentary anesthesia is an effective diagnostic tool. For example, If the patient continues to have vague, diffuse, strong pain, and prior testing has been inconclusive, intraligamentary anesthesia may be used to help identify the source of pain. Administration of 0.2 ml of local anesthetic into the distal sulcus of the offending tooth will briefly stop the pain.
3. Periodontium Examination: The periodontium is evaluated clinically for the gingival color and texture and for periodontal health and tooth mobility. Also evaluated radiographically for bone levels, localized or generalized bone loss, biologic width (between the base of the sulcus and the alveolar bone crest), root caries.
4. Examination of Occlusion: Signs of occlusal trauma (enamel cracks or tooth mobility), occlusal abnormalities (malposed teeth, Supererupted teeth, spacing, fractured teeth), maximum intercuspation, vertical overlap, horizontal overlap, The presence of missing teeth and the relationship of the maxillary and mandibular midlines, movements of the mandible, signs of abnormal wear that contributed to habits such as nocturnal bruxism or parafunctional habits.
Treatment Planning: Treatment plans are influenced by patient preferences, motivation, systemic health, emotional status, understanding of indications and contraindications and financial capabilities.
Treatment Plan Sequencing: Is the process of scheduling the needed procedures into a time frame sequenced in phases, including an urgent phase, a control phase, a reevaluation phase, a definitive phase, and a maintenance phase. Urgent Phase: Patient presenting with swelling, pain, bleeding, or infection should managed as soon as possible after thorough review of the patient's medical condition and history.
Control Phase: The goals of this phase are to remove etiologic factors and stabilize the patient's dental health by: (1) eliminate active disease such as caries and inflammation, (2) remove conditions preventing maintenance, (3) eliminate potential causes of disease, and (4) begin preventive dentistry activities. Treatment include extractions, endodontics, periodontal debridement and scaling, occlusal adjustment as needed, caries removal, replacement or repair of defective restorations.
Reevaluation Phase: The holding phase is a time between the control and definitive phases that allows for resolution of inflammation and time for healing. Home care habits are reinforced, motivation for further treatment is assessed, and initial treatment and pulpal responses are reevaluated before definitive care is begun.
Definitive Phase: This may include oral surgical and operative procedure after endodontic, periodontic, orthodontic treatments, and before before fixed or removable prosthodontic treatment. Maintenance Phase: This phase includes regular recall examinations that (1) may reveal the need for adjustments to prevent future breakdown. (2) provide an opportunity to reinforce home care.
Indications for Operative Treatment: Operative preventive treatment: a caries-preventive program should be instituted for the caries-active or high-risk patient to alter the oral environment to encourage remineralization of incipient smooth-surface lesions also treating caries-prone pits with sealants. Restoration of incipient lesions. Esthetic Treatment: They include direct and indirect esthetic restorations, and bleaching.
4. Restoration of caries (Classes I, II, III, IV, and V); diastema closure; esthetic and/or functional correction of malformed, discolored, or fractured teeth. 5. Treatment of Abrasion, Erosion, and Attrition. 6. Treatment of Root-Surface Caries. 7. Treatment of Root-Surface Sensitivity: topical fluoride, fluoride rinses, oxalate solutions, dentin bonding agents, laser, sealants, and desensitizing toothpastes.
8. Repairing and Resurfacing Existing Restorations: Many times amalgam, composite, or cast restorations can be repaired or recontoured as opposed to complete removal and replacement. 9. Replacement of Existing Restorations: In case of marginal void that cannot be repaired, poor proximal contour or a gingival overhang, marginal ridge discrepancy that contributes to food impaction, over contour of a facial or lingual surface, recurrent caries that cannot be treated by a repair restoration.