Ch 1 ergonomics in operative dentistry

Risk factors of dentistry physical and psychic:

• Organization nature, biomechanical mature, psychosocial nature, work condition
The primary goal of ergonomics applies:
• Reduce the physical and mental stress, to prevent diseases
1. Working posture: (Mock: working position must Erectus, what meaning, what disease will prevent) .
Change between sitting and standing, interchange the body posture, high precision movements shouldn’t involve
muscular force
The working position should be
• Active (dynamic), need to move to get adequate vision, but not too much inclination.
• Symmetric (stable and balanced), work field in front of, centralized in relation to chest of dentist.
• Erectus, forward and upward position, vertebral column in natural position
Ideal posture: (balance without muscular load)
• Leg 90~125, head →20, torso→ 10, arms →20, forearm ↑10, elbow ←→20,
• 90-degree knee angle: cause of limit lower space to make dentist lean forward
n Consequences: compression on intervertebral discs and abdominal region -> decrees venous circulation
• 110~ 125- degree knee angle: less compression on abdominal, pelvis at neutral position
n Consequences: most are flat seat, lead compression on returning venous circulation (varicose veins).
2. Positioning of the delivery unit and dental chair:
The assistant position: (right) 2~4 o’clock / (left) 8~10 o’clock/ in generally 3 o’clock
Operator’s zone: (right) 7~12 o’clock/ (left) 5~12 o’clock
Dentist mainly work position: 9~11 o’clock
The static zone: (right) 12~2 o’clock/ (left) 10~12 o’clock
The transference zone: (right) 4~7 o’clock/ (left) 5~8 o’clock
• 9 o’clock: basic, reach handpieces & one movement of forearm.
• 7, 8 o’clock: only for external procedures
• 12 o’clock: for operator work on labial and anterior maxillary teeth, use direct vision.
3. Positioning of the patients on the chair:
Supine position (lying on his back), the operator lower the chair
Knee and legs at the same level as head of patient, when the operator lower the chair, dentist’s torso closest as
possible to the back of the chair, the visual and enter mouth can reach by rotating the head of the patient.
4. Positioning of the patient’s head:
🥴head place in the working field facing the dentist’s visual axis.
• For, by flexion, for horizontal position of lower jaw. Backward, by extension, to see upper jaw.
• Left or right, 30-40 angle sideways in relation to the body’s long axis.
• To left or right, rotating along the longitudinal axis of the head.
5. Position of the operating field in relation to the assistant/ must have all the material to the reach of their hands.
The assistants can be higher that 10-15cm above the dentist’s head.
6. The use of overhead chair light, light parallel to the dentist’s line of sight max 15° deviation, light to patient
mouth should around 70-78cm
7. Type of movement during the dental treatment
Class of movement:
Class 1 Finger movement Root canal preparation
Class 2 Finger and wrist movement Cavity preparation
Class 3 Finger, wrist, elbows (forearm) To reach the high-speed handpiece
Class 4 Whole arm Open an auxiliary drawer
Class 5 Torsions of the body and displacement To reach the suction across the patient
Classes 4 and 5 more difficult and time-consuming, work & assistant can eliminate class 4, 5, leaving class 1, 2, 3.
8. Ways to grasp the hand instruments.
Best rest: closest the rest to the area of working, the more thrust worthy it is. The teeth nearby the treatment
Extra oral rest and rest at the opposing arch (should avoided)
Soft tissues rest (only use when can’t rest place on tooth)
9. Work- related musculoskeletal disorders: WMSD
Initially pain, then evolve to incapacity to do some movements. / Carpal tunnel syndrome 手腕綜合症
10. Occupational diseases epidemiology: 72% discomfort or pain on the head, neck, shoulder
11. WMSD revention
Ergonomic training should due preclinical sessions
A. Recommendations for a long working life: Constantly hold instrument strongly should be avoided, thicker
handles need strong pinching to hold, extreme movements of the hand should be avoided, arm should
turn around its fulcrum use as rest place.
B. Activities to keep a more dynamic work model: short and long procedures should change and change,
stretching excises, 10mins break for each 2hrs work, don’t work more than 8hrs/ day.
Ch2 dental instrument:
1. Stainless steel: chromium, carbon, and iron: resistance to corrosion, need sharpened.
2. Classification: exploring, tooth removal, restoring, finishing and polishing instrument
3. Part of hand instrument:
Handle Shank Working end
Grasping end of instrument Connects handle to working end of instrument. May have cutting edge,
Variety of size and style Straight or with 1 or more angles to use in specific area bevel, point

Shanks may be: ↑ closer working point=better we can control (straight= not balances) (Biangled=balanced)
Working end: (noncutting) named nib, use to place materials/ (cutting) have cutting edge. / Some have both edge
Three number formula: 1st Nr width if blade, 2nd Nr length of blade, 3rd Nr angle of blade.
Four number formula: 1st Nr width if blade, 2nd Nr angle formed by the primary cutting edge and long axis of the
instrument handle in clockwise centigrade, 3rd Nr length of blade, 4th Nr angle of blade.

4. Exploring instruments
A. Dental mirrors (espejos), indirect vision, reflect light, retract lips, cheeks, tongue/ {front surface mirrors}
B. Explorers (sondas de exploracion), feel tooth surfaces irregularities, determine the hardness.
C. Tweezers (pinzas), picking up small items, such as cotton pellets and carrying them into the mouth.
5. Hand cutting instruments:
A. Spoon excavator (cucharillas): remove carious dentin/ spoon shape & cutting edges.
6. Restorative instruments:
A. Cement spatulas: mix dental materials, flexible to manipulation.
B. Filling instruments: carry composites, two types: flat nib & blunt edge one perpendicular to other/ flat end
and the other is round condenser nib.
C. Liner applicator: to place Ca hydroxide or GIC, active part is spherical (ball)
7. Instrument grasps 滑過
8. Rotary cutting instruments/ Handpiece, Bur
Handpiece:
A. Straight handpiece: more use in laboratory work, also useful in oral surgery
B. Contra angle handpiece: low speed (Contra angle handpiece)/ high speed (handpiece)
甲、 High speed: to cut enamel and dentin decay (小心 may cause pulp damage too fast reach pulp)
乙、 Low speed: remove dentin carious, shaping, polishing restorations.
At low speeds, tactile sensation is better.
Bur (place in high speed or low speed handpieces)
Part: Head, cuts, polishes, finishes/ Neck, connects shank to head of bur/ Shank, part inserted into handpiece
According to the instruments they fit into:
A. Straight handpiece bur: & a straight and long shank
B. Latch type bur: for contra-angle low speed hand piece, & latch(lock) type at end of shank
C. Friction grip bur for turbine, a chuck tightens bur into handpiece.
According to the material they are made of:
A. Tungsten carbide burs: make clean cut, leaving surface practically smooth, cut dentin, metal, but produce
microcracks in enamel.
B. Dimond burs: high cut capacity, cut make irregular surface/ Normal grain: useful in opening phase, shaping the
cavity/ Fine, ultrafine grain: lower cut capacity. Make bevels 斜面 in enamel or to polish composite.
According to the active part shape:
A. Basic shapes:
甲、 Round bur: open tooth, remove caries, parathion of composite restoration, given rounded walls.
乙、 Pear shape: open tooth, remove caries, preparation of composite restoration.
丙、 Inverted cone: remove caries, build retention in cavity preparation, prepare flat floors.
丁、 Cylinder bur: achieve straight wall and 90 angle between floor and wall cavity.
戊、 Taper bur: prepare expulsive cavities (inlays).
9. Finishing instrument:
Finishing burs: to finish composite restoration, to adjust occlusion, several shapes, and sizes.
A. Lance bur: gingival margin, free surfaces
B. Oval bur: useful in occlusal surfaces, palatal surfaces (anterior teeth)
Rubber points: use in variety shape: cups……, use & other abrasive or polishing pastes.
Finishing strips: to finish, smooth restoration interproximal surface, abrasive textures: sandpaper, synthetic material.
Composite discs: & abrasive cemented, variety of grits, coarse to extra fine, sizes/ to contour restorative material
(coarse grit)/ to polish, smooth restorative material (extra-fine grit)
Mandrel: used by inserting into dental handpiece, attach to mandrel for finishing, polishing inside or outside of oral
Articulating paper forceps: hold inked tape to mark the contact point in mouth.
10. Hazards & cutting instrument (dangers)
Pulpal precautions: cutting instruments can harm the pulp exposure to mechanical vibration, heat, dry and lose
dentinal tubule fluid, transection of odontoblastic processes/ air water spray: for cooling, moistens, lubricates, clean.
Soft tissue precautions: lips, tongue, cheeks more 常 injury, operator must wait for the instrument stop 再拿出
• Never operate unless good access, visualization of cutting area/ rubber dam for isolating the operating site
• When dam not used: can retract the soft tissue & cotton roll.
Eyes precautions: protective glasses, use with rotary instrumentation 髒髒噴發ㄦ
Inhalation precautions: aerosols, vapors produce by cutting, the practices may be inadvertently inhaled producing
irritation and tissue reactions.
Ch3 & 4 operating field isolation:
1. Rubber dam, 2. Application and removal, 3. Other methods of isolation
1. Rubber Dam (dique de goma)
Pros: better access, visibility/ dry, clean operating field/ protect the patient/ improves dental services/ prevents
microbial transmission from patients to dental care team/ patient feel more comfortable
Indications: due endo procedures, prevent swallowing material, contamination of root canal space. / Excavation of
deep caries, prevent contamination of pulp in case of pulpal exposure. / During adhesive restoration, to prevent
salivary contamination/ Bleaching of teeth, prevent damage of adjacent soft tissues by bleaching agents
Contraindications 禁忌: asthmatic patients, mouth breather (can make a hole on the rubber dam)
Instruments and materials: rubber dam, punch (perforador), template (platilla), rubber dam stamp (sello), frame
holder (arco), clamp forceps (portaclamps),
Clamps: anchor, stabilize the dam in posterior tooth to isolated, help in retracting the gingivae
• Part: (Bow) place close distal part of tooth/ (Jaws) have four points that secure clamp on tooth/ (Holes) on
jaws, designed for tips on forceps to place clamp on tooth/ (points) design to secure clamp in cervical part of
tooth/ (winged clamps) for better visibility// the long part place on the buccal surface
• Floss ligatures: 綁住 use retrieval of the clamp is dislodged or breaks
• Other retainer: dental floss place via contact, short strip of rubber dam material, elastic cord (wedjets), wedges
Liquid dam (gingival barrier): protection of gingival, seal leaky rubber dam, stabilized matrices, etc.
Optra Dam (rubber dam + frame)
2. Application and removal
Size of the area to be isolated: at least 1 posterior+ operated tooth + 2 anterior
• Methods of dam placement: (2 step) clamp before (posterior teeth) or after rubber dam (🦋anterior teeth)/ (1
step) place clamp, rubber dam together/ Dam should invert around cervical regions (seal more tightly)
• clamp before rubber dam: test stability, dam is loosely on frame, use floss push dam in contact points.
• clamp after rubber dam: pros: don’t need to pulp dam over clamp/ cons: reduce visibility under gingival tissue.
• 1 step: winded clamps/ cons: may imping the gingival or place the wrong tooth, limit visibility.
Stabilization & impression compound, composite, glass ionomer cement
3. other methods of isolation
Cotton rolls (rollos algodon): place where the salivary gland exist.
Ch5 Adhesive systems in Operative dentistry (1)
Adhesion needs clean surface, diffusion &in enamel and dentin, resin polymerization, good surface wettability.
Composition:
• Acid condition: use 35~37% orthophosphoric acid -> create micro porosities for bonding resin.
n Adhesion to enamel: etching destroys rods -> retentive micro porosities.
n Adhesion to dentin: cause dentin is high content in water and in organic matter so is poor for adhesion. /
So, need micro mechanical bond
• Resin monomers: Primer (Hydrophilic), Bond (Hydrophobic) link between primer and composite
• Acidic resin: self-etching adhesives had 1 or 1+ acid resins in composition/ pH 1.5-2.5/ etch hard tissue
substitute 代替 need orthophosphoric acid./ Resin monomers demineralize, infiltrate
• Solvents: lower viscosity, increase resin infiltration
n Most used solvents (by evaporates speed)
Acetone, Shortest drying time Ethanol, moderate drying time Water, longest drying time
n Remain solvent may impair adhesive polymerization, ↓properties, ↑degradation over time.
• Initiators
• Inorganic fillers: to strengthen interface, compensate shrinkage/ microfillers (glass, colloidal silica),
nanoparticles being use now.
Radiopacifies: to see have adhesive or not. / To assess: sealing, unfilled gaps, air enter/ when use radiolucent
adhesives, can’t distinguish between air enter and thicker layer of adhesive
Smear Layer (organic + inorganic) covering the tooth surface & layer of cutting detritus, to change uppermost layer
for cavity preparation. / The hole of dentin tubules obstructed by debris tags (smear plugs) which extend into tubule
• Etch and rinse: smear layer is dissolved and wash way due rinsing step.
• Self-etch: acidic primers use to modify, disrupt, solubilize the smear layer.
Hybrid Layer: combination of dentin (collagen) and hydrophilic resin (adhesive).
• The thickness of this layer depends on the adhesive system used.
• Formed this layer, act as tooth restoration interface: should dentin etching, hydrophilic and hydrophobic resin.
Dentin etching: the direct placement of acid on dentin produces:
1. Smear layer removal: use acids at low concentrations.
2. Dentin decalcification: maintain the integrity of collagen, depth of decalcification 3-5μ
Hydrophilic resin (use when collagen expose)
When it infiltrated the collagen network, it forms partially resin+ partially dentin.
Hybrid layer zones: include 3 layers. This layer has elasticity to compensates the shrinkage of composite resins.
1. Superficial layer: mostly hydrophilic resin
2. Intermediate layer: true hybrid layer, collagen fibers are perpendicular to tubules coated in resin.
3. Deep layer: less decalcification, can found empty spaces where the resin not reached, under it is normal dentin.
Hydrophobic resin: derived from bis-GMA/ this is well adapted to hole of
con shaped tubules (hybrid layer), but it unattached via the tubules due to
polymerization shrinkage./ it is not well adapted in deeper tubules
• Necessary form bridge between hydrophilic and composite resin,
which above superficial zone of hybrid layer
• Infiltrate tubules which coated hydrophilic resin in it, give stability to
collagen fiber & coated hydrophilic resin. (Mock ->)
Classification by clinical steps:
Three steps: complicated, highest bone strengths, greatest durability/ Etch-> Primer -> Bond.
Two steps: Etch-> Primer & Bond or Self-etching primer -> Bond.
One step: easiest, inacceptable strength/ self-etching primer & bond
EX: Universal🍭 use as SE, ER/ selective etching: SE on dentin, ER on enamel/ this technique is simplest option
Classification by generation: we won’t following this classification.
Calcification by Adhesive strategy: Etch + Rinse (Acid + 2bottles) (Acid + 1bottle)/ Self Etch (2 steps) (1 step, all in one)
Etch and rinse adhesives: (3 steps hydrophilic, hydrophobic resin), 2 step (both resins are in same bottle)
• surface preparation: clean, dry substrate, bevel cavity if need
• Acid placement: gel consistency, syringe or brush, protect near teeth, 15~20s’ for E/ 5~10s’ for D
• Rinse: remove acid, phosphate salts/ Enamel: insufficient rinsing-> decalcification/ over dry dentin-> collapsing
• Dry: at this point substrate is very sensitive to contamination, that why use rubber dam is essential
• Adhesive placement: use brush, sponge, 2 layers are recommended sometime, no excessive adhesive.
3 Steps. Create solid hybrid layer, most effective, isolated hydrophilic resin and penetrates the collagen fiber better.
• 1. Place primer (hydrophilic) leave 10s” (better rubbing in dentin). 2. dry to remove solvent. 3. Place Bond
(hydrophobic), dry and light cure 20s”
2 Steps. Create acceptable (no improved) hybrid layer, but enough for clinic procedures. Pros: time saved/ cons:
interface is hydrophilic (water sorption, degradation)
• 1. Place adhesive, leave 10s.” 2. Dry gently and light cure for 20s”.
Self-etching adhesive: (2 steps, consecutive) (2 steps, mixed) (one step)/ hybrid layer depends on resins’ (acid)ability.
• According to pH: strong: ph ≤ 1, intermediate: ph=1.5, mild: ph ≥ 2
• Strong resins produce deep demineralization in E and D/ Intermediate: decalcify D more gently, thin hybrid
layer, and few resin tags/ Mild: only act superficial D, nanometric hybrid layer+ hydroxyapatite form micro bond.
• Hybrid layer: smear layer, penetrated by acidic resin, incorporated into interface.
• Acidic resin left for 20~30s (x2 for phosphoric acid because less adhesion)
• Pros: reduce sensitivity, infiltration adhesive resin and self-etch process occur simultaneously
2 Steps (consecutive): 1. Place acidic resin, wait 20~30s, dry. 2. Place hydrophobic resin, wait 10s, dry, light cure 20s.
2 Steps (Mixed): 1 mix 1 drop of each bottle, apply in cavity, wait 30s, dry light cure 20s.
1 step: similar above, rub several layers into dentin to ensure impregnation of the entire surface.
Selective etching: This improves penetration and bond strength.
• Etch enamel & phosphoric acid,
rinse, dry -> apply self- etching
adhesive to E and D
simultaneously.
• Chosen 2 step self-etching, 1st
bottle (acidic resin) won’t be use
on E because phosphoric acid is
sufficient 足夠.
• D Unclear adhesion if 污染 by
phosphoric acid,因 self-etching
substrate may change, no smear
layer, decalcified hydroxyapatite.
Ch6 Bonding procedure in clinic
Variables treatment: dentin is more humid than enamel, enamel is mineral, dentin is collagen, dentin has different
histological/ goal of bond: adaptation of restorative material & dental substrate.
Enamel: phosphoric acid (pre etching) can improve chemisorption, increase calcium salt and - charge between E y
MDP containing. Selective enamel etching can improve the bonding of universal adhesives.
Dentin: dentin permeability may affect adhesive dentin decrease bond strength
Caries affects dentin and 3rd dentin:
• white dentin doesn’t need etching, brown (deep caries) need etching.
• Reactionary 3rd dentin: tissue deposited on pulpal aspect in response to dental caries (when put material in).
• Reparative dentin: form by new differentiated, no tubular
• Hybrid layer: caries affected dentin, thicker but more porous than sound dentin.
• Bonding (degree of conversion) to caries affected dentin lower than normal one, because demineralized.
• Transparent area of caries (sclerotic) has stronger chemical bonding to MDP, because higher mineral contents.
• For dentin the best is use of 2 steps adhesive systems not one steps (2 steps, 10 MDP)
Sclerotic dentin in non caries cervical lesions (NCCL): most common symptom of this is sensitivity.
• Because of thick surface Hypermineralized layer in NCCL sclerotic dentin, it is difficulties in bonding procedures.
• Use etch-and-rinse adhesive one can reduce marginal discoloration. (the bacteria of 2nd caries) don’t use self-
etch adhesive strategies.
Substrates change with aging:
• the hardness and modulus of elasticity in higher in old dentin at mantle dentin level.
• Increase age, crown root dentinal thickness increase, density of odontoblasts and pulp fibroblasts decrease.
Remaining dentin thickness:
• Superficial dentin normally results in higher composite dentin bond strength than deep dentin.
• Deep caries, protect the pulp, is better not to use etching if we are 0.5mm from the pulp.
Ch 7 composite resins
Introduction: 3 main components (organic resin polymer matrix) (inorganic filler particles) (silane coupling agent,
initiator, accelerators, pigments)
• Organic matrix: most use Bis-GMA, UDMA also used. This contain mixture dimethacrylate monomers.
• Fillers:♧responsible for majority (4)/ this may add to organic matrix
n mechanical properties, polymerization shrinkage: improve more fillers are add to matrix.
n Composite viscosity: fluidity of monomers, and amount of fillers/ more viscus= fiction between particles.
n surface roughness: improve as more = smaller filler particles are added.
n optical properties: all of those are smaller the particles to improve the properties.
• Other components
n Coupling agents: most use organosilanes, can forming chemical bond between organic matrix and fillers.
n Polymerization initiation systems: hardness of CR depend on polymerization; this reaction begins by an
external supply of energy.
n Additives:
u Stabilizers, inhibitors: ↑storage time, intercept spontaneous radicals.
u Pigments: inorganic stable and insoluble in water, to achieve different shades.
u Optical modifiers: fluorescence, opalescence
u Radiopaque fillers: white, refraction index like polymer, to avoid 改 of shade and optical properties.
Classification (according to)
• Particle size: macrofiller, microfillers, hybrid composites, nanofillers
• Viscosity:
n Conventional: medium consistency, most used 🔫
n Flowable：mow viscosity (cover irregulating on cavity walls), flexible (lower filler content), class V
restoration (cavity liner), apply in thinner layer (as base layer)
n High viscosity/ condensable: main indication (Class II cavity restoration-> better contact point thanks to
condensation), limitation (difficult handling, poor esthetics)
• Applications: anterior (esthetics), posteriors (resistance), cavity liner (flowable), luting (flowable, self-curing),
indirect restoration (no shrinkage), gingival shades (pink)
• Polymerization system: light cured (photochemically activated), self-cured (chemically activated, mixture), heat
cured, dual cured (photochemically +chemically activated)
Properties
• Resistance to wear: abrasion of surface, loss of material begins by organic matrix and end in filler particles.
• Sorption and solubility: sorption leas hygroscopic expansion (occurs in organic matrix contain hydrophilic
radicals), solubility of CR in oral is insignificant 微不足道.
• Elasticity: ability of material returns to initial shape after apply force, organic matrix is elastic, filler is rigid.
• Radiopacity: radiolucent materials for anterior teeth to achieve better esthetic feature.
• Shrinkage: ↓in volume as result of polymerization, more filler particles & less organic matrix= less shrinkage.
• Color: pigment add to composite modify the shade, value, and hue.
• Brightness: depend on type of surface, flat polished surface (lighter), irregular surface (darker)
Problems associated to composite resins:
• Fatigue: repeated forces suffer from fatigue, mastication temp change, fissures (eventually particle detachment)
• Wear: by teeth contact, food, brushing/ Solution: strengthen the bond between organic matrix and inorganic
particles.
• Degree of conversion: monomers converted 轉化 into polymers, effect on: hardness, resistance, sorption,
color stability, biological properties.
n Oxygen: it inhibits polymerization, air bubbles in CR will not polymerization of monomers surround them.
n Fillers: ↑ filler content can polymerization deeper (light goes through filler easier than through resin).
n Pigment: obstacles to light diffusion, darker more difficulty to polymerize.
• Shrinkage: weakly bonded may detached (the bond strength needs greater than shrinkage strength)
1. Microleakage: gingival floor of class 5 and 2 cavities
2. Gaps: even bond strongly to enamel it also can be detached at the dentin. E separation from D.
3. Cusp flexion: opposing wall are weak, shrinkage can lead deformation, reduce intercuspal
distance. Fracture risk and occlusal changes.
4. Enamel fractures: shrinkage lead enamel cracks at cervical level, the white lines: enamel rod
detachment from the Cavo surface margin.
• Empty spaces: air bubble found in composite resin, plaque and pigment accumulated in this area, poor 美.
Insertion problems:
A. Air entrapment: {to avoid it: rounded angles} only detect by RX or hypersensitivity. This may cause, recurrent
caries, filtration, pain, fracture of restoration.
B. Polymerization defects: by composite placement (conventional composite: 2mm), shrinkage in each layer.
C. Cusps flexion: composite placed in triangular layer or oblique layering technique.
D. Shrinkage: thin layer = less shrinkage, progressive light application will allow less abrupt shrinkage.
Polymerization problems: depend on degree of conversion. It depend on technique used and therefore.
• Factors influence polymerization.
1. Duration of application: high intensity lamp -> less time, 800mW = 20s for 2mm composite.
2. Tip diameter: material begin light cured must be same diameter as the tip, near only cured surface not depth.
3. Distance from tip: tip of lamp must be place close to area begin light cured as possible, variety of tip available.
4. Angulation: light must be perpendicular to obturation surface.
5. Efficiency: tip must be in top condition, higher v lower intensities affect time apply, but will not polymerize
deeper.
甲、 When use metal matric band, it advisable to light cured from the buccal and lingual or palatal.
Ch 8 Tooth preparation and carious tissue removal
1. Nomenclature
Basic component of tooth preparations:
• Walls:
n External or surrounding walls (extend to external
tooth surface) (💛)
n Internal wall (facing the pulpal chamber) (💙)
u Pulpal wall/ floor: horizontal plane, next to pulp
chamber
u Axial wall: vertical plane, next to pulp chamber.
• Angles:
n Line angle: linear junction between 2 walls.
n Point angle: point junction between 3 walls.
n Cavosurface angle: form by external surface of
prepare wall.
2. Classification of tooth preparations
According to the number of surfaces involved:
• Simple cavity: 1 tooth surface/ Compound cavities: 2 surfaces/ Complex cavities: more than 2 surfaces.
According to its extension:
• Intracoronal or inlay: interior of the tooth, without cover any
cusp.
• Partial coverage extraconal: 2 types according to NO. cusps
n Only: cover 1 or more cusps but not all of them.
n Overlay: cover all cusp but not cover all smooth surface,
with some facial or lingual surface remaining preserved.
• Full coverage extracoronal or full crown: cover all the susps
and all the smooth surface of tooth.
According to its depth and proximity to pulp:
• Shallow preparation: level before or slight after DEJ
• Medium preparation: 0.5 to 1mm beyond DEJ
• Deep preparation: keep 0.5mm remain dentin.
• Very deep preparation: <0.5mm to pulp, pink
• Pulp exposure: pulp open
Black’s classification:
• Etiologic classification (pit and fissure) (smooth surface)
• Artificial classification (class 1~6)
n 1: occlusal pit and fissure in posterior and anterior teeth.
n 2: Occlusal, involve proximal surface of the posterior teeth.
n 3: proximal surface of anterior teeth without incisal edge.
n 4: proximal surface of anterior teeth, with loss incisal edge.
n 5: gingival third if facial and lingual surface of all teeth.
n 6: tip of cusps and incisal edge.
3. General principles of tooth preparation and carious tissue removal.
Aim of preparation: conserve health tooth structure, protection of the pulp dentin complex, not fracture under bite
and the restoration won’t be displaced, adequate placement of a restorative material.
Biological principles:
• Undermined enamel: loses more than 85% strengths, brittle. Solution: remove it completely, create artificial
support to enamel. GIC use as dentin replacement and fill irregular area.
• Pulp protection: important function of dentin is to protect pulpal tissue, to avoid loss in deep area of cavity,
base materials may be used. Preserve (don’t remove) sclerotic dentin is the best way to protect pulp.
• Heating of tooth structures: use abrasion instruments (burs) will transmit heat, increase pulp temperature up to
6 degrees above the normal. Temp ↑ 11 degree-> pulp necrosis. (Tooth preparation, polishing restoration).
n To avoid problems: high speed & spray of air water. Contact of interments and tooth shouldn’t continuous
but intermittent. Sharp bur can increase cutting efficiency and reduce heating. Exothermal curing
reaction material used. Low heating light curing units.
• Drying of the dentin: (dry but not too dry). Too dry -> kill the odontoblasts. Result: postoperative sensitivity.
• Iatrogenic damage to adjacent tooth: cutting intact adjacent surface, should protect & interproximal guards.
• Biologic width: distance between bottom of the gingival sulcus and the top of the alveolar bone crest. The
margins of restoration place 1mm↑ inside the sulcus may lead inflammation, bleed, hyperplasia, gingival
recession. The preparation margins should be placed above the gingival margin.
• Gingival tissue: important to avoid damage the gingival, can use wedge or specific instruments to protect it.
• Mechanical principles: the filling material and remaining tooth behave as independent structure cause:
fracture of tooth, displacement of the restoration.
n The response of tooth determined by the magnitude of forces,
the position of the contact surfaces.
n Wedge effect produce tensile stress, lead oblique fracture.
n Fatigue: weakening of materials by damage accumulation, caused by repeatedly applied loads.
n Occlusal contacts: new restoration should reduce the cyclic stress and fatigue of the material and
remaining tooth structure, increase their longevity.
4. Prior to tooth preparation
Adjacent tooth position: need to recovery the space by orthodontic movement before final restoration.
Extrusion: solution is to cut a portion of extruded cusp, recover the space for dental restoration.
Pulpal condition: (radiographic) if need Endo, restorative should postpone, sometimes need temporary restoration.
What a likely accidental exposure pulp, perform carious tissue removal accordingly
Periodontal health, other aspects to be considered: antimicrobial, topic or infiltration anesthetic.
5. Steps of tooth preparation: remove mini tooth tissue.
1.Open cavity 2. Outline form: limit pulpal, axial depth. Angle = round, reinforcing structure preserve (oblique,
marginal ridge) 3. Resistance form: use adhesive. 4. Retention form: bonding system. 5. Convenience form: proximal
use matrix to separate. 6. Caries removal: maintain pulp health, adequate seal.
Carious removal strategies: (hard dentin) (firm dentin) (soft dentin) (soft and firm dentin) Stepwise= 2 steps
A. Nonselective (hard): not recommended, remove soft until reach hard, risk to damage pulp.
B. Selective (firm): sound enamel y hard dentin left in periphery; pulpal area of cavity left firm dentin.
C. Selective(soft): same as↑; pulpal area leathery or if need soft dentin left to avoid pulp expose. (For deep carious)
D. Stepwise excavation: 1st removal soft dentin 放臨時 restoration 12 個月, 2nd remove firm dentin 放永久補體.
Ch 9& 10 Occlusal caries management
Remove damage dental tissue base on the retention, resistance, protection of the pulp dentin.
Cavity in area of bonding, careful preparation of the Cavo surface angle and bevel was requires.
Minimally invasive intervention: lesion control, remineralization, minimal surgical trauma, restoration
• Measure to evaluate the risk of O caries activity, radiographs difficult to determine the O caries.
• Early diagnosis, personal treatment, enhancement of management and improvement of patient.
• Treatment and effective control, implement minimum intervention, prevent 2nd caries.
• Implement the concept of dental care, prevention, plaque control, etc., Ealy caries treatment.
Pits and fissures sealants: use rubber dam, seal with resin after etching to prevent caries.
Indications: sealant are indicated, for prevention or therapeutic use, depend on caries risk, morphology, E caries.
Clinical procedure: 1. Clean, 2 isolate, 3. Etch 30% Acid for 15s, 4. Wash and dry, 5. Sealant apply, 6. Improve
penetration, 7. Leave for 20S, 8. Light cure 60S, 9. Clean instrument, 10. Check.
Therapeutic fissure sealant (enameloplasty): (non caries fissure) clean and keep free from caries, this remove
minimal tooth, but had into caries effect/ use diamonds bur and high speed to gently remove surface until brown not
exist.
Preventive resin restorations PRR: recommended ultraconservative preparation, restoring minimally carious pits and
fissure, PRR develop clean cavity wall for adhesion, arrest and heal by encouraging remineralization.
Principle of the cavities of composite: removal infected tissue and caries staining, retention of the restoration relies
on the etching, extension prevention is not needed.
Class 1 for composites: depth of cavity should be limited to enamel, need to prepare bevel at edge of cavity, remove
large shallow, add auxiliary retention ditch at the bottom and side walls.
Class 1 Cavity:
Preparation: 1. Create access, 2. Remove structure, 2. Create convenience form for the restoration/ retention obtain
by bonding, not need incorporate retention in tooth preparation. / use pearl bur and make rounded internal angle.
Remove caries use round bur, spoon excavator./ the ridge of the tooth 2~1.6mm
Composite restoration: type: microfill (can polish), mybrid and microhybris (rstrong), packable, flowable (linear)
Indication: composite for class 1, 2, 5 on premolar and molars, isthmus width of less than 1/3 intercuspal distance
contraindication: unable to build absolute isolation, Cavo surface margin not all in enamel,
importance of flexural strength: flexural load, inadequate flexural strength will lead to breakage of marginal ridges
even if everything else in the restorative suite is perfect.
Composite shrinkage: technique use, resin elasticity, polymerization rate, cavity configuration (C- factor)
C factor: is the ratio of the bonded to unbonded surface of the restoration. this increase the resin is limited in
direction and becomes less flowable at early polymerization., greater marginal microleakage.
To minimize shrinkage: improving placement techniques, material and composite formulation, curing methods
• The incremental technique: polymerizing & less than 2 mm thick, good marginal quality.
n Horizontal: occlusogingival layering, use for small restoration, ↑ c- factor, ↑seal factor
n Three sites: clear matric, reflective wedges, polymerization vectors toward the gingival margin
n Oblique: prevent distortion of cavity walls and reduce the c-factor, polymerization 1st wall them O surface
n Successive cusps build up: 1st apply single dentin surface without opposing cavity wall, then wedge
shaped, each cusp built separately, minimize c factor in 3D cavity preparations.
Polymerization: soft start polymerization, from low intensity & slow polymerization us higher intensity & fast
Bulk composites: pros: deep depth of cure without affecting esthetics or working time.
Modeling the occlusal surface: put cusp by cusp.
The rule of proportion: composite increments should be toward the center of the occlusal surface in 3D composition.
Occlusal stamping technique: stamp occlusal, and remake occlusal with stamp
Polishing:
• Polish mechanisms: acquired polish (clinician induced)/ inherent polish (ultimate surface)/ microfills (high
acquired, high inherent)/ hybrids (high acquired, acceptable inherent)
Enhance/ composite finishing system:
• Paper backer: for finishing, polishing, use from medium, fine and super fine to extra tin series excellent of
embrasure area.
Ch 11& 12 proximal caries in posterior teeth
Step in restoration: 1. LA 2. Prepare of site 3. Shade selects. 4.
Composite selection: hybrid (mini, midi fill), reinforced micro fill.
Isolation 5. Tooth preparation. 6. E and D bonding
Forces: analyzed by direction, frequency, duration, intensity, habit,
7. matrix placement. 8. Insert composite. 9. Contouring
occlusion ways, tooth structure.
composite. 10 polishing.
Properties: composite, strongest in strength, weakest in shear.
Leakage: (class 2 carrier) common area is direct point contact by sharp opposing cusps. Indicated: create three points
contact in fossa, flat contact.
Common problem: excessive time, open contact, matrix tissues, gingival re decay
More problems: pulp problems, pits, voids, bubbles, unattractive esthetics, difficult isolation, etc.
Problem & posterior composite:
• Wear: most hybrid composite had a wear rate of less than 10 micron per year
• 2nd caries: incomplete polymer, lack adhesion, should use proper adhesive tech, incremental placement.
• Post operative sensitivity: polymer shrinkage, incomplete, bone failure.
• Polymerization shrinkage: material out of control
• Incomplete polymerization: 1.2 mm 1st layer
• Bond failure: proper adhesive tech
Tooth preparation: remove caries, weak structure, maximize enamel bond strength to stained grooves and
decalcified area.
Tunnel preparation: lesion more than 2.5mm from marginal ridge, preparation can enter from occlusal surface.
(Internal preparation) tooth surface adjacent to lesion has demineralized but no damage and need to maintain
integrity of its surface.
Pros: Keep tooth marginal ridge intact, increased the resistance of remaining tooth. / Avoided injury proximal surface
of the near tooth due to cavity preparation. / maintain normal contact & adjacent tooth. / Overhanging of repair
materials is prevented.
Slot preparation: (mini box preparation) (for proximal caries does not touch occlusal surface) can divided into:
1. Close to marginal ridge, cannot preserve integrity, marginal ridge has been destroyed.
2. Locate underneath in interproximal contact. Marginal ridge can’t preserve, cavity only prepared into box shape
without a dovetail.
The prepared into box or disk shape and help of groove retention.
Microscopic preparation: to minimize invasive trauma, use micro drill for microscopic preparation.
Class 2 cavity: lead unnecessary tooth removal, increased proximity to pulp subgingival margins, prevent pulp
exposure, subgingival margins, health, and simplicity.
• Mesial, distal, gingival clearances & less flowable material -> margin seal confirmation.
• Expand internally for initial removal of gross caries. Use caries finder for 10s -> rinse. Remove infect caries.
• If break proximal wall, use metal matric to protect adjacent tooth. Also, can
place a ring to pre separate.
• When caries close to gingival margin should use supragingival protocol.
• Minimally invasive removal can make restoring easier, predictable, healthier
for periodontium.
Defining the angle between axial wall and external walls and external surface is
important. The angle should be approximately(around) 90 degrees. Too thin may
fracture, tooth thick is acceptable but is more difficult to fill due to reconstruction.
Essential burs:
Very small-diameter flame bur: Cylindric bur with rounded head: Tungsten carbide rose head bur:
conservative opening of used for most Class 1 and 2 cavity used to remove infected dentin.
suspect grooves. preparations.

Fine-grained flame bur: used to Arkansas stone (FG): used to Brownie polisher (CA): used to
finish Class 2 box walls. smooth the cavity margin. polish the cavity margin.

Restoration of proximal caries:

Proximal surface functions: preservation tooth tissue, protect underlying periodontal structure, transfer masticatory
force from tooth to tooth.
Matrix: support for restoration material due proximal wall construction.
Tofflemire matrix: burnish the band using an egg burnisher on a 2x2 gauze.
Sectional matrix: omni matrix, transparente matrix, auto matrix, palodent 360,

Wedges:
Wedge function: stabilize the matrix to avoid over contours or under contours, simplify sectional matrix insertion,
assist the separator ring in temporary movement of the tooth between which it is positioned.
Wedge insertion: the curved part of tip positioned on top of dam above interproximal papilla. If wedge slides too
easily, the wedge must be considered unsuitable.
Wood wedge: most common in the market. Can modified by creating an intermediate bulge using.
Plastic wedge: cannot absorb water and expand, but its anatomical shape well suited to gingiva.
Expansion wedge: can adapt to cavity margin makes them a practical choice in cavities & a concave cervical shoulder.
Proximal contact studies: packable like hybrids (diameter, tightness), best contacts (sectional matrix system)
Prevent open, broken contact: anatomically contoured circumferential matrix, contact formers, custom wedging,
resin with suitable flexural strength, adequate curing.
Manauta custom ring: less wear (small particle size, heavier filled, non-contact areas, less surface area)
Composite wear: reduced wear with smaller particles (less plucking leaving voids), higher filer load for enhanced
properties (correlations between wear and fracture toughness and flexure strength), higher cure of resin matrix to
resist scratching and gouging by abrasives.
Ch 13 & 14. Proximal caries in anterior teeth and cervical caries
The difference in the cavity preparation will depend on if the angle of the incisal part of the tooth is involved or not.
General steps: 1. anesthesia for comfort and ↓salivary 2. Occlusal assessment for restoration 3. Selected composite
shade. 4. isolation 5. If restoration involve proximal contact, insert the wedge.
Class III:
The restored can choice facial or lingual entry into the tooth, the lingual approach is preferable.
The pros of choice lingual face: 1. the facial is conserve for esthetic, 2. shade of composite matching is less critical,
3. discoloration or deterioration of the restoration is less visible.
Indication for facial approach include: 1. the caries is positioned facially, enter from facial can conserve tooth
structure, 2. Teeth irregular aligned, enter from facial can conserve tooth structure, 3. Extensive caries extends onto
the facial surface, 4. A faulty restoration that originally was place in facial and need to be replaced.
The preparation initiated from lingual by use round bur of size compatible to lesion, direct perpendicular to enamel.
The outline should not: 1. Include the entire proximal contact area, 2. Extend onto the facial surface, 3. Be extended
subgingival. (Some undermined enamel can be left, but very friable enamel at margins should be removed.)

Class IV:
The beveled edges and size of the dental defects should be considered for resin composite restoration.
² For tooth defect in one side and the incisal part is intact, removal carious and all the enamel edges beveled.
² Defects exceed mesiodistally half width of incisal, or distance between incisal and gingival exceed 2/3 of crown,
with intact pulp, only short bevel at least 1.0mm around cavity needs to be prepared.
Increase width of bevel can enhance enamel bond strength, and spreading the material attain better aesthetic.
Preparation:
• Conventional class IV tooth preparation90-degree Cavo surface margins use 在沒碰到牙根,
• Beveled Conventional class IV tooth preparation: indicated for restoring large class IV areas.
Outline form: use round carbide bur or diamond instrument establish initial axial wall depth at 0.5mm into dentin.
Bevel the Cavo surface margin of all enamel margins, 45-deree angle, width of bevel 0.25 to 2mm.
The Cavo surface margins are prepared with beveled configuration, initially no deeper than 0.2mm inside the DEJ.

Class V:
In the gingival one third of the facial and lingual tooth surface. Aesthetic consideration, composite use in anterior 牙.
• For small, medium class V, no need special shape and retention groove, need bevel for enamel wall slope. But
when no enamel on gingival, the slide ditch should be axiogingival line angle.
Outline form: extension of M, D, O (incisal) and gingival walls is dictated by extent of the caries, defect, or old
restorative material indicated for replacement.
3 types of class V:
EE: entirely in Enamel ED: O (incisal)wall in Enamel, DD: entirely in dentin
🦷Enamel caries, cause by bacterial gingival wall in Dentin 🦷Cause by bacterial infection sue
infection due plaque, may extend 🦷Cause by abfraction, abrasion, xerostomia, poor plaque control
onto root erosion
Restoration:
Anatomy histology of dental tissue + effect of these tissues on light = optical properties of teeth
5. vertical ridges 5. Perikymata
6. Vertical grooves 6. Enamel pits and vertical irregularities
7. Horizontal ridges
8. Horizontal grooves
Enamel (very translucent) is more translucent than Dentin.
Resin composites: types and available shades of resin composites (textures, opacities, shades, size, and shapes).
Micro filled Micro hybrid Nano filled
Filler size 0.01-0.12 um 0.01-3 um 0.005-0.1 um
Appearance Optical properties like enamel Good gloss, lister and Good gloss, luster, and
smoothness smoothness
Polish ability Highly polishable Polishable Highly polishable
Usage Non-stress bearing esthetic Anterior and posterior Very high aesthetic properties
restorations restorations (anterior restorations)
Composite selection:
• anterior/ stress (class 4): hybrid (mini or midi fill), hybrid/ micro fill veneer combo
• anterior/ non-stress (class3, 5): hybrid (mini fill)/ micro fill
shade selection: once effect teeth dehydration the teeth may appear whiter. So we need to take color as soon as
possible once placed lip retractor.
Thickness of the material: ↑thickness =↓translucency = ↑opacity
Color instability: the major pros of resin composites, which may be a major cause for replacement of restoration.
Factors affect color: aging, staining, effect of polishing.
Ch 15. Restorations with Glass ionomer cements
GIC as acid base cement, also call glass polyalkenoate cement.
Composition: polymeric acid (homo or copolymer of acrylic acid/ ↑molecular weight, ↑viscous), basic glass (based
on aluminosilicate glasses+F+PO4+Ca), water [can be powder + liquid/ capsule/ paste + past]
Role of water: it allows the polymer to act as acid, it is medium in setting reaction, it is component to set cement/ it
can be lost from surface due place GIC, we can place varnish v petroleum jelly to prevent it.
Setting: 2-3mins from mixing (acid, base reaction)
Properties:
• physical preparties affect by: hoe cement prepared, ratio of powder and liquid, concentration of polyacid,
particle size of glass powder.
• Compared & resin: ↓compressive strength, ↓resistance to wear, no exothermic reaction, ↓modulus elasticity.
Fluoride release: ability↓ with maturation
• most important advantage of GIC, can sustained for long time (lower-level diffusion-based release).
• Buffering: release F in acidic condition, can ↑ pH of external medium. (Protects tooth from further decay).
• Clinical beneficial: inhibit dentin demineralization, reduces hyposensitivity (cold).
• F also taken up by GIC, even F free GIC exposed to F were also become F releasing when treated.
Adhesion to the tooth:
• Important clinical advantage: it helps retention of GIC in tooth, it reduces marginal leakage (↓bacteria,
microorganisms enter the space under restoration to promote decay)
n Higher bond to enamel than dentin, this mean bonding take place to mineral phase.
n Bond strength develop quick, 80% bond being in 15mins, after which it ↑ for several days.
• Adhesion of GIC can be attributed to: (bonding failure is usually cohesive 內聚的(excellent adhesion))
n micromechanical interlocking: GIC self-etching due polyacid component
n true chemical bonding: ionic bond between polyacid and Ca ions of tooth
classification of GIC (according to clinical use)
Ü luting and bonding: crowns bridges, inlays, orthodontic apply (fast setting)
Ü restorative: for anterior and posteriors
Ü lining or base: low P:L for liner to adaptation to cavity walls, higher ratio for bases
Resin modified GIC: it includes monomer (HEMA) component and relate initiator system (camphorquinone).
• RMGIC set by neutralization (acid-base reaction) and addition polymerization=(produce) complicated structure.
• Physical properties like conventional GIC: release F, ions. Biocompatibility compromised (↓), esthetic↑.
Compomers: cross between GIC and composite resin (COMP + OMER), improve optical than GIC, but less than
composite. (No acid base reaction, no bonding to tooth, low F release, real GIC?)
GIC vs composite resin: ↓esthetic (improve & RMGIC), fast surface wear (less resistance to erosion, abrasion),
moisture sensitive due initial setting, composite require bond (GIC PAA)
Technique:
• Restoration: clean, dry cavity/ P:L ratio/ shake powder before use/ liquid bottle held vertically/manufacturer’s
instruction on mixing time are followed/ the material inserted while wet and bright/ water contamination is
prevented (petroleum jelly)/ finishing procedures are performed in the next appointment
• Cautions:
n liquid don’t stored in the refrigerator, but powder, mix pad, glass slab 🉑 kept in the 冰箱, ↑working time.
n Capsules, use as soon as possible after break sheath, use the mixing device at 4000 rpm.
Contraindication of GIC (restorations):
• Proximal cavity involving the marginal ridge (unless opposing cusp does not impact the marginal ridge)
• Anterior teeth, Great loss of buccal enamel., Areas submitted to heavy occlusal force.
Choosing a restorative material:
• Posterior region: usually composite, GIC (some cases)
• Anterior region: (better optical) composite > compomers > GIC
• Cervical defects: GIC, RMGIC treat for high-risk caries patient (F release). Composite treat for erosion, abrasion.
Sandwich restoration:
• Layering various restorative material in cavity preparation, use in proximal (class2), cervical (class 5) + extends
close or below CEJ cavity preparation.
Closed sandwich technique Open sandwich technique
The composite completely encases the GIC. GIC exposed to the oral at base of restoration.
• Deep cavities (adhesion to dentin is challenging, postoperative sensitivities a concern): GIC used as build up
material, followed by bonding agent, and composite.
• Occlusal cavities restored with GIC (small, not under heavy occlusal forces)
• Proximal cavities can be restored with GIC if the opposing cusps do not impact the marginal ridge.
Ch 16. Repairing composite restorations
• Over the time the resin may deterioration, degradation
• Failed composite restorations are treated by replacement rather than repair, replacement only when repair is
not possible.
• The FDI categorizes 4 approaches for management of defective restoration:
n No treatment -> Refurbishment -> Repair -> Replacement
1. No treatment: discoloration and ditching around margins may be left untreated (because is not functional
impairment), this must be monitored!
2. Refurbishment 翻新: defects can be corrected without damage, without adding new restorative (except glaze 釉)
a Removal of overhangs, recontouring, removal of discoloration, glazing a surface, sealing pores (polishing)
3. Repair: minimally invasive treatment involves remove defective part of restoration, by restoration of prepared
defect.
a Indication: who require less chair time/ regular monitoring patients/ low caries risk/ bulk fracture less
than 1/2 restoration.
b Advantages: ↓cost, time to patient, less invasive procedure, prevent further stimulation pulp tissue
c Mechanism: the aged and repaired composite interface is fragile link. Should choose appropriate adhesive
system and restorative material for successful repair.
i.Bonding of new to old resin may involve:
→ Chemical bonding of the organic matric of new material via copolymerization
→ Chemical bonding & exposed filler particle of the substrate
→ Micromechanical retention to substrate surface (surface roughening)
d Surface roughening
i.Acid: 37% phosphoric acid, 10% hydrofluoric acid, 30% citric acid, 7% maleic acid/ but has study say
hydrofluoric acid is best for repair bond strength, because when it exposes to dentin will form
calcium fluoride which can block the dentin tubule and prevent infiltration of adhesive resin go into
dentin tubule.
1. The effect of etching will depend on the composition of filler particles.
ii.Diamond abrasives: using burs is efficient, cost effective, because it does not need additional equipment,
chemical substance. It effects composite surface micromorphology, interlocking & repair material.
iii.Air abrasion: pseudo mechanical, non-rotary method of cutting, removing dental hard tissue.
iv.Laser: erbium laser-> best option for surface treatment of composite restorations. “Energized water
abrades composite surface without increase the surface temperature, to avoid form microcracks.”
v.Effect of the existing old composite: effect of repair depends on the material used. The old to new
composite adaption depend on surface roughness, which influenced by:
→ Filler particle size, distribution of fillers, filler hardness, type of resin matrix, degree of cure.
4. Replacement: complete removal of the entire restoration & generalized or sever problems, followed by the
placement of a new restoration.
5. The restorative cycle of the tooth: restoration replacement invariably leads to an acceleration of the restorative
cycle of the tooth.

(Mock, list 4 approaches for the management of defective composite restorations, from the most to the least
conservative approach)
Ch 17. Dental pulp protection
Extraction and Root canal treatment (RCT): 🦷& unprovoked spontaneous pain, necrotic and partially necrotic pulps,
radiographic pathology, excessive hyperemia due to irreversible pulpitis.
Protection of the dental pulp complex: indirect protection (IPC), direct protection (DPC, curettage, pulpotomy)
Factor effect dentin pulp complex protection: correct diagnosis, depth, age, sclerotic dentin, cleaning agent,
protective material, restorative material. (Success, preserve pulp vitality)
• The materials to protect the dentin pulp complex classified: (Mock: the difference between those materials)
❋❋❋ Thickness Place Function Examples
Liner 0.2-1mm Over pulpal or axial walls Physical barrier, thermal Calcium hydroxide, GIC, MTA
(deep area of preparation) electrical in isolator,
therapeutic action
Bases ↑1mm Missing dentin, Retentive Protect and replace dentin, GIC, bio dentine, flowable
area Give an adequate geometry composites
Direct pulp protection: direct pulp capping, pulp curettage, pulpotomy/ Protective material maintain vitality, healing
Ü Direct pulp capping: (🦷& vital, healthy pulps or & reversible inflammation) may by dental trauma, accidental
exposure due caries removal. (Mock: indirect pulp capping procedure)
• Procedure:
1. Anamnesis, radiographic exam, and clinical diagnosis of the pulp condition
2. Anesthesia -> 3. isolation with rubber dam -> 4. Caries excavation with high, low speed burs
5. Pulp bleeding control: 放 cotton pellet soak in solution on the exposed pulp (H20, saline,次氯酸鈉)
6. Sealing expose: pulp tissue & pulp capping material (Ca2OH, MTA, bio dentine)
7. Place liner (RMGIC) if need, and conventional restorative material
• Points to discuss: to avoid contamination of exposed pulp area, bleeding controlled, blood clot, way, and
amount to apply material, what can we do if not sure whether the patient will be in pain after the final
restoration?
Ü Pulp curettage (partial pulpotomy): superficial removal of a small amount of the pulpal tissue, exposing the
underling tissue without inflammation or bacterial. 🦷 & contaminated superficial pulpal tissue. May by dental
trauma & pulp horn projected outward the dentin wall, or patient delayed looking for dental treatment.
• Procedure:
1. Anamnesis, radiographic exam, and clinical diagnosis of the pulp condition
2. Anesthesia -> 3. isolation with rubber dam -> 4. Caries excavation with high, low speed burs
5.superficial curettage the exposed pulp uses sharp spoon excavator or large diameter round diamond
point, on high speed and irrigation.
6. Pulp bleeding control: 放 cotton pellet soak in solution on the exposed pulp (H20, saline,次氯酸鈉)
7. Drying & sterile small cotton pellets/ paper points.
8. Sealing expose: pulp tissue & pulp capping material (Ca2OH, MTA, bio dentine)
9. Place liner (RMGIC) if need, and conventional restorative material
Ü Pulpotomy: remove inflamed coronary pulp tissue, maintaining integrity of the radicular pulp (teeth & pulp
exposed more than 24hrs.) There is no bone rarefaction on the periapical region or internal resorption, 有
integrity lamina dura.
• Procedure:
1. Anamnesis, radiographic exam, and clinical diagnosis of the pulp condition
2. Anesthesia -> 3. isolation with rubber dam -> 4. Caries excavation with high, low speed burs
5. Open pulp chamber & diamond burs on high-speed handpiece
6. Cut coronary pulp tissue & sterile, sharp spoon excavator or round diamond point, on high speed, &
good refrigeration.
7. Pulp bleeding control: 放 cotton pellet soak in solution on the exposed pulp (H20, saline,次氯酸鈉)
8. Drying & sterile small cotton pellets/ paper points.
9. Sealing expose: pulp tissue & pulp capping material (Ca2OH, MTA, bio dentine)
10. Place liner (RMGIC) if need, and conventional restorative material
• Points to discuss: if in one root there is pulp with no conditions to be preserved, will sensitivity tests be
trustworthy? How will the success be determined?
Materias:
🥉Calcium hydroxide (CAOH): steps: 1. powder + distilled water = 1st paste, 2nd. Cement (📝only limited to expose
pulpal area, don’t extend to dentin wall.) (📝 it need to cover a layer GIC over it 因為 CAOH 不會凝固)
👍: most common, high pH can coagulation, antibacterial, stimulate odontoblasts to form tertiary dentine.
👎: may form bridge under CAOH, contain tunnel defects, lack innate adhesive and sealing abilities, poor physical
properties, dissolution over time.
🥈MTA (mineral trioxide aggregate):
👍: High pH, low solubility, high biocompatibility, bioactivity, good sealing, hydrophilicity, radiopacity, less
toxic than CAOH, antibacterial, MTA has better clinical y histologic responses than CAOH in DPC.
👎: May cause discoloration, manipulation y placement can be challenging, traditional MTA-> long setting time.
Traditional MTA: (Treat in 1 session) MTA+ GIC or RMGIC over it -> final restoration.
(Treat in 2 session) 1st MTA + cotton & distill water + temporary restoration. 2nd remove temporary
restoration -> final restoration.
🥇Modified MTA: (bio dentine, MTA angelus, Neo putty) add hydration accelerators, setting time manageable (10-15
mins), incorporated powder y liquid in a capsule that can be triturated (bio dentine).
Indirect pulp protection: indirect pulp capping (1 step)/ stepwise excavation (2 steps)
✴Use when pulpal tissue not exposure, apply of protective materials over remaining dentin. It stimulates the
remineralization and isolates the pulp for prevent irritating effect of direct restorative material.
Indirect pulp capping: (🦷& vital y health pulps) protect deep and very deep preparation, where no sclerotic dentin.
Remove infected dentin, Leave affect dentin.
• Procedure:
1. Isolation with rubber dam -> 2. Caries excavation with high, low speed burs and spoon excavator.
3. Disinfection & 2% chlorhexidine digluconate (optional).
4. Place IPC in close approximation but not in direct contact & pulp: -> 5. Place final restoration
Remain dentin ≧0.5mm Remain dentin < 0.5mm (pink floor)
RMGI (≦ 1mm) 1st layer: CAOH cement/ MTA/ Modified MTA/ light cured resin modified Ca silicate
2nd layer: RMGI if necessary
Materials:
🧱GIC (glass ionomer cement):
👍: chemical bonding, fluoride release, coefficient of linear thermal expansion like tooth structure.
👎: toxic (less), not recommended on cases of direct pulp protection, syneresis and water absorption.
Tip: use polyacrylic acid etching to improve bonding of GIC. / When preparation is filled with a conventional GIC, the
surface must be protected. / When GIC used as line or base, the acid etching 不可超過 20s，會破壞 material.
🧱Light- cure resin modified calcium silicate (RMCS) (Theracal LC):
Leave the dentin moist, apply a thin layer (1mm increment), light polymerize for 20s.

Stepwise Technique: (use in pulp health young patient) (use in🦷 a thin layer carious dentin separates the pulp, if
removed, pulp may exposure) (2 clinical session)
• Can remain 30days to 1 year. ↓carious activity + remineralizer demineralized dentin, form sclerotic, tertiary dentin.
↓ number of microorganisms, ↓risk of pulp exposes due next time remove remain carious or cavity opening.

The ultimate adjective of pulp capping procedures:

• To manage bacteria
• To arrest any residual caries progression
• Stimulate pulp cells to form new dentin.
• To provide a biocompatible and durable seal that protect the pulp complex from bacteria and noxious agents.
Ch 18. Non- invasive Therapy
Therapies that: do not destroy enamel, dentin, directly address casual factors: biofilm, diet, mineralization.
Caries management by modifying
♧ by Biofilm: to control, (not elimination), modify of goal “caries prevention”.
Dental plaque:
• Mechanical: good oral hygiene, self-applied (tooth brushing, interdental hygiene), professional (OHI and F
apply, costly).
• Chemical: unspecific antimicrobial effects by chlorhexidine, xylitol, triclosan/ copolymer, essential oil,
sodium lauryl sulfate, metal ions (all chem should be limited to high-risk patient).
• Biological: if favoring factors remain (cariogenic diet), remove, or kill bacteria and pathogens may not be
effective/ most recent aim to alter the ecology of the plaque rather than eliminate bacteria. / vaccination:
active immunization (antigens to against s.mutans) or passive immunization (antibodies against cariogenic
bacteria)/ probiotics: administer live microorganisms which confer a health benefit on the host.
♧ by Diet:
Imbalance: between teeth and biofilm the caries occurs (pH drops), main factors: composition, mode of intake.
Carbohydrate fermentation: Frequency more important than the amount of sugar intake,
• High sucrose diet: high risk develops cariogenic bacteria, extended period of acid and demineralization.
• Frequency of sugar intake: ↑eating pattern ↑risk, pH not return to neutrality, 持續 demineralization.
• Consistency of sugar intake: sticky sugary food, lead supply of fermentable sugar to microorganisms.
Sugar alcohols (polyols): Xylitol (cariogenic bacteria can’t metabolize it/ but cause diarrhea, and high cost)
Sorbitol (like xylitol, but xylitol has higher caries reduction)
Maltitol (use in many foods, laxative effect of excessive consumption)
Intense sweeteners: non-natural or substitutes sugar, sweetness with zero energy contribution.
Protective foods: proteins (provide urea, rise pH), cheeses (contain Ca lactate, stimulate salivation), fats (barrier),
fresh fruit vegetables (increase salivary flow rate, provide antioxidants)
Risk group: child (Ecc nursing caries), frequent sugar intake/ elderly (↓知識, low income, poor dentition, xerostomia)
♧ by Mineralization:
Fluoride (calcium fluoride CaF2), F can reduce caries progression but can’t completely prevent caries.
CPP-ACP (another remineralization agent) (Casein phosphor peptide-amorphous calcium phosphate), this is
bioavailable to diffuse into enamel lesion promote remineralization.
To sum up: biological targets for various therapeutic strategies
Ch 19. Microinvasive Therapy
Therapy that only slightly influence the enamel and dentin, it includes sealants, infiltration.
♧Fissure sealing
The sealant restoration spectrum: can add F in materials, the main different between sealant and filling is sealing
requires only etching. Epidemiological consideration: difficult distinguishing sealant from small restoration.
Anatomy of the fissure system: fissures are developed by grooves, main on occlusal, plaque stagnation areas. Deep
fissures are the main risk factors for the development of caries.
• At eruption: form loose organic mesh inside fissure by fill enamel protein and cellular remnant.
• 🦷penetrates the mucosal lining: salivary proteins are added, bacteria influx (biofilm), food debris into fissures.
• After several weeks: biofilm has taken on a distinct structure, ↑microorganisms and extracellular matrix.
• Sealant place within a few months to few years after eruption (usually 2-4 years after eruption)
Should mechanical preparation be done? If clinician decides to remove fissure enamel, it become invasive
treatment, also call preventive resin restoration.
Preventive or therapeutic sealants? IT MAY BE HARD TO DISTINGUISH SOUND AND INITIALLY DECAYED FISSURES!
• Preventive: place 後牙 after eruption, prevent caries develop.
• Therapeutic: dentist suspects a caries formation may have
already started.
Sealing over caries: place therapeutic sealant in Activity level of the
lesion. The risk of sealing over caries is minimal, if the sealant fails,
the tooth is at no greater risk than before.
Clinical procedure for occlusal sealing: 1. Isolation, 2. Acid etching 3. rinse, dry. 4 sealants 5. light cure 6. Evaluate
What about the proximal surfaces? Materia for proximal sealing are adhesives or sealants.
♧Caries infiltration
Development of caries infiltration: use strong acid (15% hydrochloric acid) + resin infiltrates (highly liquid). Diffuse
barrier within the caries itself.
Masking effect: + side effect, the enamel caries loses whitish after infiltration sot visually like healthy enamel.
Infiltration to prevent caries progression: use resin infiltrates in lesion up to a maximum of D1, Caution: high risk
patient, the lesion which can’t be completely fill by infiltrate might be increase.
Recommended use (Icon): (indication) proximal lesions extend max to D1, esthetically relevant lesion
1.clean affect, adjacent 🦷, place 2.separate 🦷& wedge, leave wedge 3. apply etch onto lesion (2 mins)
rubber dam due entire procedure
4. suction etch, rinse, dry 5. apply icon-dry onto the lesion, 6. apply infiltrate onto lesion, wait
wait for 30s, dry & air. for 3 minutes, remove excess.
7.Light cure 40s 8.Repeat 6&7 wait for set 1min 9.Remove wedge, dam, polishing
Follow up: visual inspection due routine examinations, (discoloration area can repolished)
How to intervene? The decision between sealing and resin infiltration should be guided by individual considerations
(clinical experience, cost, applicability)
Non-cavitied lesions Cavitated lesions
Noninvasive therapy: low risk patients, lesion confined Minimally invasive, tooth preserving preparation for a
to enamel. direct adhesive restoration.
Microinvasive therapy: high risk patients, lesion
extended into dentin
Ch 20. Temporary fillings
Provisional restoration to seal and protect tooth until can do permanent restoration. The material: soft, pliable, easily
to remove. Time: a few weeks to few months. Aim: preserve remain tooth, prevent further damage, contamination.
Indication: Pain (pain relief until definitive treat (RCT)), Broken tooth (restore function until permanent restoration),
Endodontic treatment (pre-endo treatment, after root canal obturation, before the permanent restoration is place)
Materials:
♧Resin-based:
👍Esthetics, Bonding, High compressive strength 👎polymerization shrinkage, sensitivity to moisture
• Polymer matric reinforced with inorganic fillers (calcium sulfate based): widely used, good marginal seal.
n Cavit original (temp fillings), Cavit W (endodontic), Cavit G (Inlay)
• Bis acryl composite: (wear resistance)
• Methacrylate based composite: (good esthetics)
• RMGIC: (low shrinkage)
• UDM composite: (low shrinkage)
♧Non-resin-based:
👍Easy to handle, sedative effect, antibacterial, low cost. 👎limit esthetic y strength, shrinkage, poor wear resistance
• ZOE (zinc oxide eugenol): (long lasting, soothing effect)
• ZON (zinc oxide non-eugenol): patients allergic to eugenol
• GI: F release, bond to teeth, can be permanent restoration.
Endodontic treatment:
Pre-endodontic restorations: (the fist step toward successful result)
• Situations need endo: previously restored, carious, fractured, a combination of these three.
Steps:
1. Remove all lesion (if pulp expose, need to prevent adhesive or composite from collecting there with a cotton.)
2. Place gingival retraction cord around tooth, provide hemostasis, visualization of subgingival tooth margins.
3. Use matric band and restorative material of your choice.
4. Use diamond bur to reduce occlusal surface and contour the restoration, then place rubber dam on.
This can increase tooth surface for clamp stability, prevent further breakdown of the tooth by caries fracture, it
allows the access cavity to become a reservoir of the irritant.
Intermediate restoration: (after RC obturation, before permanent restoration is placed), to maintain sterility until
coronal restoration is placed by root canal obturation.
This use due endo must follow 3 criteria:
1. Tooth: must continue functioning
2. Operator: must have adequate access to the RCS
3. Patient: must be able to maintain normal hygiene measures
Materials containing eugenol: residual eugenol may have deleterious effect on physical properties (reduce bond
strength, even precluded bonding of composite resin, etc.)
Cotton pellet VS Teflon:
Cotton Used for many years, available, inexpensive/ easily adapted/ absorbent 吸水性
Teflon Non- absorbent/ Inert/ more expensive
Ch 21. Occlusion in operative dentistry
Mandibular positions:
• Maximum intercuspal position (MIP): maximal intercuspation,
intercuspal position, habitual occlusion habitual centric, centric
occlusion, acquired centric.
• Centric relation (CR): centric maxillomandibular relationship (CMMR), retruded ais position.
Maximum Intercuspal Position (MIP): best fit regardless of condylar position, it is tooth determined position. In this
position, a max occlusal can be applied, max number of occlusal contacts is found.
Centric relation (CR): condylar dis in the anterior superior position against articular eminences. This position is
independent of tooth contact.
Cusps:
• Supporting: mandibular buccal, maxillary palatal, round y blunt
• Non supporting mandibular L, maxillary B, well-shaped y point
Type of occlusal contact in MIP:
A. Supporting cusp against a flat surface: occlusal force directed perpendicular to this surface (recommended for
restoration)
B. Occlusal contacts on inclined planes: cause tooth fracture, tooth jiggling, mandibular deflection.
Detecting, marking occlusal contacts: articulating papers, wax or impression materials, feeler gauges, t-scans
Articulating papers: to verify the existence of occlusal contacts using shim stock.
👎thick paper lead inaccurate/ false positive and larger points of occlusal contact.
Occlusal interference: ideal occlusion CR and MIP don’t have posterior interferences.
• Use occlusal examination to identify occlusal interference: OI-> centric, WS, NWS, protrusive.
The conformative approach: the restoration in harmony & the existing jaw relation.
Justification: reason why conformative approach is favored because it is safest. (Include all about occlusion)
Improve occlusion within the restrictions of conformative approach: not change patient’s occlusion. It doesn’t
mean the new restoration should reproduce the exact occlusion that the tooth in need to restoration has.
Technique: The EDEC principle (examine, design, execute, check)
• Examine occlusion (static in “CR” and dynamic “side to side”) before picking up handpiece.
• Design: visualize the design of cavity preparation
• Execute: the finishing the restoration is facilitated if there is a definite aim to carving or shaping
• Check: check the occlusion does not precent all the other teeth from touching in the same way as did before.
Avoid tooth to margin contacts:
• Fissures, marginal leakage, even fractures
• Try to move the contact toward the Centre of the restoration/ the tooth.
n If isn’t possible: extend the restoration.
Ch 22. Decision making in managing the caries process.
1. The doctor patient relationship: paternalistic model, Authoritarian
model, Informed or consumer model, shared decision-making model
(patient assumes responsibility for all the decisions).
2. Decisions: noninvasive, microinvasive, or invasive? It is difficult to
identify the correct point in time for invasive therapy.
Noninvasive methods: low-cost intervention, not reimburse.
♧by inserting the 1stfilling, the death spiral of tooth is initiated, increases
chance of tooth lose.
3. Philosophies in cariology:
A. Philosophy “Drill and Fill”: infected dentin should be completely removed.
B. New Philosophy “Heal and Seal”: reduce factors reduce caries. This includes noninvasive, microinvasive, invasive
interventions.
甲、 Pulp protecting caries excavation: complete removal of bacteria is possible or even necessary?
4. Limits to noninvasive therapies:
A. Caries progression: accessibility to its cleaning, surface quality, cariogenic biofilm, extent of the caries, age.
B. Speed of caries progression: age dependence, proximal surface, degree description.
5. Limits to microinvasive therapies: Avoidance of overtreatment, the problem of undertreatment.
Represent a bridge between noninvasive and minimally invasive interventions.
• Is the lesion unarrestable? Only those lesions are expected to progress by means of noninvasive measure
should be sealed or infiltrated. Need monitoring over a period better than evaluating in one visit.
• What’s the real extension? The sealing or infiltrating lesions larger than they appear. Result may undertreat,
6. Limits to invasive therapies: limit life of restoration, sacrifice health enamel and dentin, high cost, stress.
Restoration chose: The positive aspects should outweigh the negative aspect of invasive therapy.
The direct restoration can survival about 10 years, so 15 years ~ 80 years need to fill replaced six times.
Each replace dental hard tissue is removed, restoration spiral frequently ends in expensive therapies such as crowns,
root canals, or even tooth replacement. Early invasive treatment should be postponed as long as possible.
7. Decision trees and choice of therapy
How to intervene in the caries process in adults? 1. Patient’s level: caries risk, 2. Tooth level: non-cavitated lesions,
Cavitated lesions.
Need: visual and/or tactile methods and/or the radiographic lesion to detect cavitation.

Old Adults: Gingival recession/ Large restorations/ Declined cognitive functions/ Hyposalivation/ Side-effects of poly-
Pharmacy/ General diseases/ Soft diet/ Exposed roots/ Interproximal spaces difficult to clean.
Root caries management: use resin modified or conventional glass ionomer cement. Glass-ionomer cement may be
preferable if handing and moisture control are compromised.
Mock: exam part B pulp expose or not, need to include the materials (include etching, bonding, cement, bio dentin,
etc.), setting time, matrix, wedge, steps, {how to mix bio dentin, drops, time, and where to apply materials}
Indirect clapping because (pulp no expose), Bio dentin or MTA chose 1.