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Indications:
- Individual tooth factors:
- Large carious lesion – substantial loss of normal tooth anatomy
A lesion that is sitting in or on the pulp
Extensive loss of tooth structure
**good indication is a substantial loss of the marginal ridge in a
primary tooth**
- Vital pulp:
o Reversible pulpitis symptoms – pain for short duration, no
swellings
o Must be absence of swelling/tenderness/pus/ mobility/pain
- Dental factors:
o Large carious lesion with substantial loss of the marginal ridge
Large carious lesion nearing the pulp
o Relatively intact dentition
o Lack of permanent successor
o Minimal root resoption
- Patient factors:
o Compliant child and family
Contraindications:
- OPPOSITE OF INDICATIONS… Neglected dentition, poor compliance
- Individual tooth factors:
o Evidence of irreversible pulpitis / necrosis (hx of spontanout pain)
No bleeding from the pulp (necrotic)
Hyperaemic pulp – excessive bleeding
o Mobility
Tooth close to exfoliation
o Radiographically:
Periapical pathosis
Internal root resoption
Radicular bone loss
Pulp calcification
- Dental factors:
o Unrestorable crown
o Inability to place rubber dam
Materials in pulpotomy:
Irrigants,,,
Formocresol:
Intention is Devitlisation of the coronal aspect (destroy coronal pulp)
Bactericidal and devitalizing properties
High success rate (higher success rate than ferric suplphate)
o Very effective, but no longer used due to cancer risk
Ferric sulphate:
Intention of retention of maximal vital tissue without
induringformation of reparative dentine
Has a homeostatic effect causing the coagulation of the blood,
stopping the bleeding
Calcium hydroxide:
Intention of formation of reparative dentine
o Stimulates underlying odontoblasts to lay down dentine
Not overly effective (60%)
Antibacterial activity
The removal of as much necrotic and infected pulp as possible, including pulp in
the root canals
…to fill them with a suitable material in order to preserve the
tooth, and allow for physiological root resoption
Indications
- Tooth with irreversible pulpitis or necrotic pulp tissue
o …the contraindications for a pulpotomy
o Persistent bleeding during pulpotomy (only seen when complting
pulpotomy)
- Lack of permanent successor
Contraindications
- Periradicular involvement extending into the permanent tooth bud
- Root resorption of more than 1/3 or the root (exfoliation)
- Excessive internal root resoption
- Caries perforating the floor of the pulp chamber
The process:
- La and rubber dam
- Remove necrotic pulp
o Locate, instrument and irrigate canals (NaOCl)
o Clean to within 2-3mm of the expex
- Fill canal with plain ZOE or non-setting calcium hydroxide
- Restore with SSC
Stainless steal crowns: The gold standard for primary restorations
…Indications with gross caries, coronal destruction, pulp therapy
Advantages:
- Durable (>3 years)
- Longer clinical lifespan than 2/3 surface CR or amagam restoration
Disadvantages:
- Const
- Requirement of LA in placement
- Aesthetics poor
- Can be difficult to fit – especially with space loss
Indications:
Extensive caries
Following pulp therapy (pulpotomy or pulpectomy)
Malformed / hyperplastic or hypomineralise teeth
Severe bruxism (extensive tooth wear
Contraindications:
Poor aesthetics
Teeth close to exfoliation (within 12-26 months) – overservising of
primary teeth
o Option of extraction and placement of space maintainer (placed if
exfoliation is more than 3 months off)
Inadequate tooth structure
Evidence of a non-vital pulp (without pulp therapy being completed)
Involved the cementing of the crown with GIC, without completion of any cavity
preparation/caries removal (negating the need for LA)
Indications:
- Proximal lesions, cavitated and non-cavitated
o Small to moderate
- Occlusal carious lesions, cavitated and non-cavitated
- Radiographically – lesions not extending beyond the middle 1/3 of
dentine (see a clear band of dentine between pulp and lesion)
Contraindications:
- Caries that extends beyonf the middle 1/3 of dentine radiographically
- Signs and syptoms of irriverisble pulpitis
- Heavily brocken down tooth (deemed unrestorable with conventional
restorations)
Technique:
- Place separators interproximal a few days prior to placing the crown
- Check that the carious lesion is free from PA pathosis and pulpal pathosis
- Select the crown size, fill with a suitable (1 size above that indicated from
size chart of M-D length)
- Trial the crown to ensure tight ‘snapping fit’
- Fill with a suitable material (GIC) and place on the tooth
- Have the pt bite down
- Clear away excess cement
- Occlusion will even out within a few weeks
The 4 D’s……
Clinically:
- More generalized (as opposed to hypomineralisation – occurring on
molars and incisors)
- In its mildest form – fluorosis is a form of hypomineralisation
- Fluorosis manifests as the mottling of enamel – ranging from white flecks
to confluent opacities throughout enamel (with pitting and discoloration)
Management:
Severely affected cases may require: either in a localized or a more generalized
manner, or porcelain veneers.
- Microabrasion – used with caution (potentially destructive to soft and
hard tissues)
o Use of 14% HCl acid (with or without pumice)
Rubber dam always used
Slowly rotating rubber cup for 10 seconds, rinse thoroughly
with water and assess (completed a maximum of 10 times)
o Alternatives – pumice and etch,
- Polishing surface with polishing burs
- Application of CPPACP after treatment with NaOCl
- Restoration with composite resin, veneers
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http://www.thed3group.org/the-basics.html
Enamel Hypoplasia = developmental deficiency in the thickness of enamel
- Disturbances in the matrix formation
- Characterized by thin/pitting/grooved enamel
- High concentrations of fluoride may possibly cause hypoplasia
Management:
- Restoration with CR
- Possible SSC for grosly effected teeth
- Realisitic assessment of the prognosis of 1st molars – orthodontic referral
if extraction required.
- Onlays, veneers, crowns – delayed until late adolescence
Ameologenesis imperfecta
- Inherited defects of the enamel of both primary and permanent teeth (but
not always congenital aetiology).
- Many classifications – but generally classified by the type of enamel
deficit and the mode of inheritance
o Hypoplastic – enamel thin, or pitted
o Hypocalcified – enamel is dull, no shine, opaque white/honey/
brown
o Hypomaturation – mottled/frosty looking white, opacities,
condfined to coronal 1/3 of tooth (snow capped)
- Usually both primary and secondary dentition are effected
- Clinical features:
o Thin enamel.
o Lack of contact points between teeth.
o Enamel may be rough, smooth, or randomly pitted.