:)Non-surg perio tx

All about titanium implants

warning: lots of kitten caused ruckus

Covers the case studies that are on my first hum path lab (?) exam

Sorry i got interrupted but here’s part two of this lecture for the d2 Oral surgery midterm!

Oral surgery midterm d2

D2 oral surgery midterm

D2 Oral Surgery midterm

Second half of reading a study guide out loud

My fave unit! (Kidding)

Strepococcous pneumoniaeNisseria Haemophilus influenzaePertussis Etc

This is based on the D2 Intro to OMFS first lecture for our weekly quizzes. Covering CV diseases, pulmonary diseases (asthma, COPD), and renal/hepatic concerns.

Radiographic assessment categories (RL = radiolucency) RA → initial stages RA 1: RL outer ½ of enamel RA 2: RL inner ½ of enamel +/- EDJ RA 3: RL limited to outer ⅓ of dentin RB → moderate RB 4: RL reaching middle ⅓ of dentin RC → extensive RC 5: RL reaching inner ⅓ of dentin, clinically cavitated RC 6: RL into pulp, clinically cavitated Visual: Lesion Severity → ICDAS ** to eval a lesion, eval: periphery demin and shadowing 0 = sound surfaces no evidence of visible caries after air drying 1-2 = initial caries first distinct changes in enamel = white spot lesion and/or brown various discoloration no evidence of surface breakdown/underlying shadowing in dentin 3-4 = moderate White or brown spot lesion w/ localized enamel breakdown without visible dentin exposure = 3 WITH underlying dentin shadow = 4 5-6 = extensive A distinct cavity in opaque or discolored enamel without visible dentin Guiding Principles of Carious Tissue Removal to retain tooth and pulpal health as long as possible = AIM Preservation of dental tissues → non demineralized and remineralizable Avoidance of pulp exposure Provision of sound cavity margins to achieve an adequate peripheral seal Controlling the lesion and inactivating remaining bacteria Reversible vs irreversible pulpitis; pulpal inflamm/pain Reversible Pulpitis = instances where the inflammation is mild and tooth pulp reminds healthy enough to save Normal responses to: thermal tests EPT Patients may experience pain/sensitivity Irreversible pulpitis = may experience pain without action to induce pain, sensitivity, and throbbing Cause of pulpal inflammation active caries = mild/severe Cavity preps = mild/severe dental materials = mild/transient Pulpal pain Intra-pulpal pressure on nerve endings secondary to an inflammation response w/ absence of inflammation = Hydrodynamic inflammation Pulpal protection When does the pulp need protection? Full crown preps cervical dentin exposure due to erosion causing pain Presence of mechanical pulp exposure after selective Carie’s removal that have led to medium or deep cavity preps Why must we protect the pulp? Preserve pulpal vitality avoid thermal sensitivity (pain) after restos Avoid removal of sound structure to provide resistance to resto material (amalgam/gold) How to protect pulp eliminate progression of carious lesions collect appropriate information regarding pulpal health before doing restos Using appropriate cutting instruments, use water during prep, no water during caries removal selecting/applying appropriate biological and mechanically resistant dental protective materials

Class III Composite steps: Acid etch → rinse & dry Prime → air dry Adhesive → cure w/ 18J light Place composite & cure after each increment A2D = dentin A1E = enamel Pull-through = lingual → facial Cure F and L Finish and polish Finishing = shaping, contouring, and smoothing the resto Polishing = imparts the shine/surface luster Contouring Proximal Mesial surface → medium-orange SOFLEX disc @ 4500 RPM Gingival embrasures → no. 12 blade remove small amounts at a time to avoid chipping Blade dulls quickly Contouring Lingual Carbide football/egg to remove → excess and contour lingual @ FG 6000 RPM Carefully use SOFLEX disc if needed @ margins Contour, finish, and polish from composite TOWARD the tooth avoid forming flat/concave contours in resto/tooth structure Polishing cups order Green → blue → grey (no water) Green = Jiffy Polisher removes roughness left by diamond bur Blue = Gloss Plus Polisher further smooth the resto Grey = HiLuster Plus obtain high gloss

Class IV = interproximal lesion of anterior tooth Incisal edge is involved Fracture (trauma) secondary caries rampant caries Shade selection: Clean tooth w/ flour of pumice & view patient at EYE LEVEL Proper lighting: under multiple light sources. Natural light is best Environmental factors: remove bright colors from field of view. Bright clothes, make up, gloves, neutral operators walls, etc Shade selection = made quickly to prevent eye fatigue made at BEGINNING of appt (tooth hydration) BEFORE RD placement Polychromatic technique eshethic restorative materials must blend into natural dentition by stimulating: color translucence form texture of teeth RBC come in Many shades and various opacities to match shade and translucency on both enamel and dentin Combo of optical properties from enamel and dentin provides the final appearance of normal tooth structure Optical properties are modified by: age Thickness of tooth tissue degree and quality of calcification Unworn dentition: dentin provides chroma, opacity, and fluorescence enamel modifies the appearance of dentin with translucency and opalescence Based on optical properties, RBCs contain three types of materials: Dentin-like: simulates dentin’s optical properties Enamel-like: simulates enamels optical properties Translucent-like: simulate translucent areas of the teeth As you get older = more chroma → more dentin as you age Class IV RBC Field Control R Dam: first premolar to first premolar (#5-#12) Place retainer W2A on either #5-#12 and retain other tooth w/ floss Matrices Anterior → Mylar strips Posterior → tofflemire, metal matrix bands, sectional matrix Bevel of enamel margins: Facial = 2.0-3.0 mm (esthetic bevel) lingual = 1.0 mm (partial thickness gingival = 1.0 mm (partial thickness) Settings for Bevel: Fine (red) flame-shaped diamond bur @ FG 100,000 RPM Blend w. Dark orange SOFLEX disc @ FG slow speed 4,500 Contact incisally located at HOC of adjacent tooth 1-2mm wide inciso-gingivally visual contact with adjacent tooth definitie but not excessive resistance to passage of dental floss does not shred floss If contact is slightly open → pat facial RBC into IP area with the brush to close contact Facial position = reduce with bur lingually positioned = add composite Light cure Filtek Supreme Ultra Universal = 16J to cure 1.5mm increments = ~26.6s Enamelize used for final polishing and maintenance of esthetic bonding polishing paste = aluminum oxide *** Pits in resto = took too long to cure → contour and cure quickly

Performance can be evaluated by failure mechanism Deformation → mechanical stress fracture → mechanical stress corrosion → chemical action wear → removal by solid erosion → removal by liquid  To reduce local stresses: Multiple simultaneous contacts occlusal forces distributed over larger SA Abrasion vs. attrition  Abrasion → shear force  Softer organic resin matrix = preferentially worn BEFORE harder filler particles  Attrition → direct contact force  Resin matrix and harder fillers are lost TOGETHER  Cracks occur in resin matrix due to occlusal stress  Types of Stress → Deformation  Stress (Pascal, Pa)  internal resistance of a material to an external load  resistance is dependent on the surface area which the load was delivered  SA = more important than the force  Both the applied force and stress are distributed over an area of the body  In dentistry, Occ. forces applied over small areas (cusp tip) → produce very high stresses  Strain  Deformation a body undergoes when a stress acts upon it  measured as a net change in the length of a material following the application of a load  deformation depends on the type of stress  you want ELASTIC deformation = not permanent (plastic)  Modulus of Elasticity (E)  Ability to sustain deformation without permanent change in size or shape; stiffness of material within the elastic deformation  the slope of the linear region of the curve corresponding to 0-A on the Stress-strain curve  ratio of stress to strain (E = stress/strain)  Higher modulus of elasticity = more force required for deformation to happen  COMPOSITE MODULUS OF ELASTICITY = most similar to dentin  Fracture toughness ability to plastically deform w/out fracture materials ability to resist to the propagation of a crack higher fracture toughness =  lower rate of bulk fracture, marginal degradation, and surface wear  There is an optimal level of filler % for fracture toughness = more is not necessarily better but it is stronger up to a certain point  Dentin = most similar in all mech. Categories when compared to RBC  Polymerization, mech properties, and clinical performance  Polymerization shrinkage and stress de-bonding → marginal gaps → microleakage  cusp deflection (post-op sensitivity) or fracture reccurent caries  Incomplete polymerization presence of residual monomers  poor mech properties release of monomers and other components that can reach the pulp → pulpal inflammation  Biocompatibility = ability of a material to perform with an appropriate host response in a specific situation  Measuring biocompatibility - in Vivo/animal test  Animals = usage tests Human subjects = clinical trials  Material is placed in a situation identical to its intended clinical use  Mucous membrane irritation: material placed in contact w/ hamster cheek-pouch or rabbit oral tissue Skin sensitization: Material injected intradermally to test for development of skin hypersensitivity rxion  Implantation: materials that will contact subcutaneous tissue or bone  Dentistry examples: Dental pulp irritation tests (Class V)  dental implants into bone  Mucosa and gingival usage test (evaluate gingival inflammation in terms of resto margins, etc)  Xenoestrogenic effects of RBC Xenoestrogenics = imitate estrogen and are toxic  Bis-GMA, -DMA, -EMA, and -EBDMA are monomers that are derived from BPA (bisphenol A) BPA = xenoestrogenic  In clinical conditions: Esterases in saliva can break ester bonds  Esterase → Bis-GMA = NO BPA formed Esterase → Bis-DMA → BPA FORMED  Some impurities may be present in Bis-GMA based resins  Concerns based on BPA ADA and current evidence = low levels of BPA and brief exposure → no known health risk  1 time exposure of BPA from sealants = 200x lower than the daily level of safe exposure  Responsibilities of the dentist: Follow manufacturer's directions regarding placement and polymerization helps to reduce exposure  washing unpolymerized resin layer away/asking patients to rinse mouths following sealants 

Guiding Principles of Carious Tissue Removal  to retain tooth and pulpal health as long as possible = AIM Preservation of dental tissues → non demineralized and remineralizable  Avoidance of pulp exposure  Provision of sound cavity margins to achieve an adequate peripheral seal  Controlling the lesion and inactivating remaining bacteria  Reversible vs irreversible pulpitis; pulpal inflamm/pain Reversible Pulpitis = instances where the inflammation is mild and tooth pulp reminds healthy enough to save  Normal responses to: thermal tests EPT  Patients may experience pain/sensitivity  Irreversible pulpitis = may experience pain without action to induce pain, sensitivity, and throbbing  Cause of pulpal inflammation active caries = mild/severe Cavity preps = mild/severe  dental materials = mild/transient  Pulpal pain Intra-pulpal pressure on nerve endings secondary to an inflammation response  w/ absence of inflammation = Hydrodynamic inflammation  Pulpal protection When does the pulp need protection? Full crown preps  cervical dentin exposure due to erosion causing pain  Presence of mechanical pulp exposure  after selective Caries removal that have led to medium or deep cavity preps  Why must we protect the pulp? Preserve pulpal vitality avoid thermal sensitivity (pain) after restos  Avoid removal of sound structure to provide resistance to resto material (amalgam/gold)  How to protect pulp  eliminate progression of carious lesions  collect appropriate information regarding pulpal health before doing restos  Using appropriate cutting instruments, use water during prep, no water during caries removal  selecting/applying appropriate biological and mechanically resistant dental protective materials  Protective materials = provide a protective coat for freshly cut enamel/dentin  Cavity liners  Cement/resin coating of minimal thickness (<0.5mm) Physical barrier to bacteria and their products  provides therapeutic benefit = F- release, dentinal seal, and bacterial action = promoting pulpal health  do not place on enamel  RMGI (vitrebond) Apply after partial caries removal to → areas nearest the pulp… STAY AWAY FROM MARGINS  Chemical bond to tooth structure F- release  Good mechanical properties favorable pulpal response due to → F- release, initial low pH, physical barrier to bacterial penetration  RM Calcium silicates (TheraCal LC) Place the Ca[OH]2 liner in the deepest part of the prep covering the pulp exposure  place liner on moist dentin only  pulpal and axial walls, alway from all margins and enamel  Establishes a tight seal to prevent bacterial invasion  stimulates apatite formation and secondary dentin formation  Maintain an antibacterial alkaline-related biological environment  after placing and curing, follow w layer of → Vitrebond and/or normal bonding procedures  Cavity sealers provide a protective coating to the walls of a prepared cavity and a barrier to leakage at the interface all walls in their entirety are coated  oxalates → place prior to amalgam restos  Superseal Acidic nature → demins smear layer and peritubular dentin  reacts with CaHydroxyapatite to form → fine granular calcium oxalate precipitate  Precipitate occludes → dentinal tubules  dental adhesives Moderate lesions vs. extensive lesions Moderate lesions (not reaching inner third of dentin) = restoration longevity may be more important → clinically means removing more tissue so that foundation is stronger  Extensive-deep lesions (radiographiaclly involving inner pulpal third or quarter of dentin or with clinically assessed risk of pulpal exposure)  preservation of pulpal health should be prioritized → clinically means LESS tissue removed, soft area left, and cavity liner placed to prevent sensitivity that may arise from caries near pulp  Do NOT place cavity liners peripherally. Messes w/ RBC adhesion to enamel walls.  everything around lesion should stay intact to promote adhesion   Avoid pulp exposure, UNLESS pulpal Dx = reversible pulpitis 

CLASS V steps (summarized) Access → 330 FG Peripheral cavity removal w/ round #2 Round #6 or spoon excavator used for pulpal/axial walls *** using a larger bur  = removes less tissue  Outline form → 330  Caries removal is first done @ periphery and along DEJ  do until we see clean DEJ!  Explorer used for → assessment of surface texture only  be careful in deeper areas to not damage pulp  do not use in axial area When material has set, excess is shaved away w/ → No. 12 surgical blade  Contoruing/finishing = use hand instruments as much as possible while preserving smooth surface  If you use rotary instruments = DO NOT DEHYRDRATE SURFACE OF RESTO  Goals of Caries Removal in the Prep: Axial wall → selective removal to FIRM DENTIN Periphery walls (O,M,G,D) → Hard dentin DEJ  Occlusal and Gingival walls → parallel to slightly divergent  M and D walls → divergent  Margin (Butt joint margin) → NO bevels. Smooth margins and walls.  Sandwich Tech Lecture Full thickness bevel → all the way to DEJ  Partial thickness = not entire enamel GI or RMGI Dentin replacement = GIs similar thermal conductivity and coefficient of thermal expansion Fl release= takes place at setting rxn, the initial release is high and decreases with time Chemical bonding to dentin  Why RMGI? Superior mechanical properties than GI Can be contoured and polished v similar to RBC  Stronger in acidic environment = don’t want it to erode easily  Conventional GI = poor maintenance of anatomical form  Conventional GI suffers rapid surface degradation  Conventional GI doesn’t present optimal esthetics = not easy to polish  Sandwich technique = layers of GI (conventional or RM) between dentin and perm restorative material (resin composite or amalgam)  Overall Indications of Close Sammy Technique Pulp protection selective Caries removal preparation extends very close to pulp Fl-release promotes affected dentin remin Remaining enamel at the gingival margin better bonding with composite than GI (GI on composite will decrease mech. Properties of resto)  GI best at bonding with dentin Anterior Resto indications for CLOSE SAMMY veneered w/ composite to:  Enhance esthetics  enhance polishability  increase abrasion resistance  Posterior Restos for CLOSE SAMMY veneered w/ composite or Amalgam for increased fracture and wear resistance  Open Sammy Technique layering of two directly placed materials where both exposed to saliva  AKA: Bonded-base technique (summit)  helps w/ fl- release to oral environment  Open Sammy indications: Restoration of deep cervical lesions w/ dentin or cementum margins (severely damaged teeth w/ no enamel on the margins) Need material that contains Fl to reduce potential recurrent Caries ( = high risk pts) The selective material for open sandwich technique is RMGI Closed Sammy Technique  layering of two directly placed materials, one covering the other Dentin is covered by RMGI/GI  GI/RMGI = completely covered by the overlaying Resto (RC or amalgam) Liner/base = GI is placed internally (on dentin) and completely surrounded with a second material (Amalgam or RBC) NO GI is exposed to saliva  Closed Sandwich Technique Steps  Prep → NO BEVEL. Butt joint only  Rinse and dry → DON’T DESICATE, leave dentin moist (GIC needs water for Rxn)  Apply GI/RMGI → place GI over pulpal and/or axial wall  Check margins → do not place GI over any margins/on enamel  Etch and rinse Prime → Prime remaining exposed dentin- no primer on GI  Final Resto  Open Sandwich Steps Prep → NO BEVEL on cementum. Butt joint only.  Rinse and dry Apply RMGI → place RMGI over PULPAL/AXIAL walls  Light Cure Etch and rinse  Prime Final Resto  Technique Indication Contact w/ saliva? Surfaces Material Closed sammy Pulp protection (enamel on margins)  No Axial and pulpal walls GI or RMGI Open sammy Deep cervical lesions w/ dentin or cementum margins  Yes = Fl- release to oral einvronemnt  ANY (except surfaces under occlusal forces)  RMGI

Occlusal Curvatures and axial positions  Curve of spee: 2d curvature = buccal cusp tips of premolars and molars posteriorly, curvature begins @ tip of canines and curves upwards from anterior → posterior  Max molar roots = inclined MESIALLY Mandi molar roots = inclined DISTALLY  Curve of Wilson: the medio-lateral curvature of the occlusal plane of posterior teeth → complements the paths of the condoles during mandible movement  Also 2d  Crowns of MANDI posterior teeth incline to the lingual (Lingual Lower) Crowns of MAX posterior teeth incline toward buccal (Buccal Upper)  Molars have greater inclination bc the curve  → deeper posterior  Sphere of Monson AKA compensating occlusal curvature = 3d sphere shaped curvature for occlusal plane Concave curve for mandi, convex for maxillary = combo of curve and spee and curve of Wilson Axial position/Root inclination Axial position = the inclination of a tooth from vertical axis  Normally described in mesiodistal and faciolingual direction (but a combo of the two) = opposite of BULL Crown is normally inclined in the OPPOSITE direction = BULL Crown surface form  From facial/lingual aspects ALL permanent teeth = rougly trapezoidal  Tooth  Shape of Crown Info Anterior Tringular  Proximal view → triangular  Base = cervical 3rd Apex = incisal 3rd Apex = wedge in tearing, biting, and incising food Max posteriors Trapezoidal  Proximal view → trapezoidal  Base = cervical  Wedge → aids in distribution of forces during mastication and self-cleaning process Mandi posteriors Rhomboidal  Proximal → rhomboidal  Crowns = inclined toward the lingual  = proper interlocking of the Mandi and max posterior teeth during mastication  Contact areas Increase in size with age = Abrasive contact in proximals broaden the area  Mesiodistal length of dental arches = get shorter = as teeth become narrower mesiodistally, they are moving closer to midline  Proper contact location = stabilizes dental arch and prevents food packing  Contact areas become more cervically located from anterior → posterior in each quad (basically just move down towards cervical 3rd from midline to molars)  Distal contact area normally = more cervical location than mesial contact  Relative size increases from anterior to posterior in each quad Posterior teeth → contact areas = normally located to the buccal of center in the faciolingual dimension  Cervical Line: Curvatures CEJ = cervical line = line around the tooth where enamel and cementum meet  Separates anatomical crown and root → only visible when not covered by soft tissue It is stable (unlike gingival line → everchanging) Gingival line = gingival margin/crest → imaginary line which marks the level of termination of nonattached soft tissue surrounding the tooth  Separates the clinical crown and root → is always visible  Epithelial attachment = actual attachment of the soft tissue of the mouth to the tooth  Can be distinguished From the PDL  Connection for soft gingival tissue  PDL = attachment of the hard tissue (bone_ to the tooths root structure  Usually a sulcus between gingival Marin and epithelial attachment  Cervical Line Countour Rules Cervical line normally curved (convex) or bulges TOWARD the apical on the → lingual and facial teeth surfaces CL is normally convex toward the incisal/occlusal on → the mesial and distal surfaces The amount (depth) of cervical line curvature on any tooth is normally GREATER on the MESIAL compared to distal  Cervical lines on adjacent prox. Surfaces of adj. teeth have → approx same depth of curvature Depth of curvature on all surfaces = greatest on → central incisors and decreases POSTERIORLY 

Dental formula  A dental formula = indicates the dentiiton of only 1 side of the mouth but includes both MAX and MAND. Quadrants.  Must be multiplied by 2 to provide the number of teeth in entire dentition  PERM DENTAL FORMULA: I 2/2: C 1/1 : P 2/2; M3/ 3 = 32 TEETH TOTAL  BABY DENTAL FORMULA: I 2/2: C 1/1: M 2/2 = 10 TEETH TOTAL    General Eruption Pattern   Deciduous:   MAND Central incisor   MAND Lat incisor  MAX Central incisor   MAX Lat incisor  MAND 1st molar   MAX 1st molar  MAND canine  MAX canine  MAND 2nd molar  MAX 2nd molar     Decid. Eruption Ages in Months  Central incisor mand = 6  Central incisor max = 7.5  Lat incsor mand = 7  Lat incisor max = 9  Mand canine = 16  Max canine = 14  Mand 2nd molar = 20  MAX 2nd molar = 24       Perm dentition erupt sequence: with ages in years  Mandibular 1st molar = 6-7  Max 1st molar = 6-7  Mand C. incisor = 6-7  Mand L. incisor = 7-8  Max C. incisor = 7-8  Max L. incisor = 8-9  Mand canine = 9-10  Mand 1st premolar = 10-11  Max 1st premolar = 10-11  Mand second premolar = 11-12  Max second premolar = 11-12  Max canine = 11-12  Mand 2nd molar = 11-13  Max 2nd molar = 12-13  Mand 3rd molar =17-21  Max 3rd molar = 17-21      Numbering systems  Universal numbering system   Perm = Upper right third molar is #1 and then you go all the way to number 16. Start the next arch off at lower left 3rd molar = #17 and then lower right third molar = #32  Deciduous teeth = Numbered 1-20 in the same fashion as perm teeth but lowercase "d" is added after the number. Most common, just use letters to address baby teeth, A-T retrospectively.   Palmer notation method  Breaks mouths into 4 quadrants of 8 teeth  1 = C.incis  2 = Lat.incis  3 = canine DDA  4 = 1st PM  5 = 2nd PM  6-8 = 1-3rd molars   Use letters A-E for baby teeth   Signs tell the quadrants   FDI system   Binomial system = the first number = quadrant and second number = tooth # (1-8)  PERM = 1 at top right, two, 3 = LL, 4 = LR  BABY = 5,6,7,8