牙体牙髓学——龋病的治疗

Operative Dentistry,Operative Dentistry,Operative dentistry is the art and science of the diagnosis, treatment, and prognosis of defects of teeth which do not require full coverage restorations for correction.,enamel,pulpodentinal complex,cementum,Periodontal,牙体修复原则,去净龋坏牙体组织保守治疗的原则抗力形和固位形,充填材料的选择,性能要求 物理和机械，化学，生物学选择要点 牙齿部位，窝洞部位和咬合力，病人情况，其他因素,Cavity Preparation,The mechanical alteration of a defective , injured, or diseased tooth in order to best receive a restorative material which will re-establish a healthy state for the tooth including esthetic corrections where indicated, along with normal form and function.,Classification of cavity,Cavities may be classified according to the location where the carious lesion beginsClass Class Class Class Class Class ,G.V.Black in 1908,Class I,All pit and fissure cavities are Class I. Cavities on occlusal surface; Cavities on occlusal two-thirds of the facial and lingual surfaces of molars;Cavities on lingual surface of maxillary incisor.,Class II,A cavity occurring on the proximal surface of posterior teeth are Class II.MO mesial and occlusal DO distal and occlusal MOD mesial, occlusal and dista,Class III,Cavities on the proximal surfaces of anterior teeth that do not involve the incisal angles are Class III.,Class IV,Cavities on the proximal surfaces of anterior teeth that do involve the incisal angles are Class IV.,Class V,Cavities on the gingival third of the facial or lingual surfaces of all teeth ( not pit and fissure cavities ) are Class V.,Class VI,Cavities on the incisal edge of anterior teeth or the occlusal cusp heights of posterior teeth are Class VI.,Cavity,Simple cavity: only one tooth surface is involved.,Compound cavity: two surfaces are involved.,Complex cavity: three or more surfaces are involved.,Cavity Structure,walls angles cavity,Walls,Internal walls: a prepared cavity surface that does not extend to the external tooth surface.,Axial walls: an internal wall parallel with the long axis of the tooth and occlusal of the tooth.,Pulpal walls: an internal wall that is both perpendicular to the long axis of the tooth and occlusal of the pulp.,a side or surface of the cavity preparation that aids in enclosing the restorative material.,Walls,External walls: a prepared cavity surface that extend to the external tooth surface. The external walls takes the name ofthe tooth surface that the wall is toward.,.,Angles,Line angle: the junction of the two planal surfaces of different orientation along a line.,Angles,Point angle: the junction of three planal surfaces of different orientation.,Angles,Cavosurface angle: the angle of tooth structure formed by the junction of a prepared cavity wall and the external surface of the tooth.,Also referred to as the cavity margin or cavosurface margin.,Resistance Form,定义洞深：盒状洞形阶梯结构窝洞外形去除无机釉薄壁弱尖的处理,Retention form,Lateral retentionundercutdovetailtrapeziaadhesive,深龋的治疗,原则：正确判断牙髓状况,治疗方法,垫底充填,安抚治疗,间接盖髓术,治疗方案,根面龋,保守治疗,充填治疗,窝洞预备的基本原则,Removal of Remaining CariesWhen the dentin has a firm feel with the explorer, removal of the tooth structure should cease, even if stained dentin remains.只需去除感染牙本质（崩解层和透入层）根据硬度和着色两个标准来判断,二、保护牙髓组织 间断操作，锋利器械，冷却 不向髓腔加压 了解解剖结构、增龄变化,三、尽量保留健康牙体组织 最小程度扩展洞形 龈缘位置 尽量不做预防性扩展 釉质成形术 enameloplasty,注意患者全身状况,窝洞预备基本步骤,The design of the cavity preparation for either a tooth with initial caries or replacement restoration is based on the location of the caries, the amount and extent of the caries, the amount of lost tooth structure, and the restorative material to be used.,一、预备洞形1、开阔洞口及进入病变区：不同窝洞进入通道的选择,2、设计预备洞的外形 以病变为基础 扩展 避开承受咬合力的部位 圆滑曲线The dentist must establish an outline form, which determines the overall shape of the preparation along the cavity margins of the restoration and the tooth surfaces. The outline form is determined by the size and shape of the carious lesion and by the need for a suitable design that will hold a restoration firmly in place.,邻面的颊舌洞缘位置,在规定的深度扩展洞形,3、抗力形和固位形,4、Finishing the Enamel Walls and Margins This is a process of angling, beveling, and smoothing the walls of the cavity preparation to achieve the best marginal seal possible between the restorative material and tooth structure. The dentist may use burs, diamond stones, or hand-cutting instruments (chisels, hoes, hatchets, and gingival margin trimmers) to complete the walls by removing loose or unsupported enamel to create the strongest possible enamel wall.,5、无痛制洞法 锋利器械，正确手法 局部麻醉 anesthesia 化学机械去龋,二、术区隔离 棉卷隔离,Reasons for use of rubber dam,Protectionaspiration or swallowing of instruments or irrigantsSoft tissue injury caused by instruments EfficiencyImprove visibility (dry field and reduced mirror fogging)Minimize patient conversationMinimize the need for frequent rinsingReduced risk of cross-contamination Legal considerations,Four-handed dentistryClose support四手操作,选择性辅助隔离法： refraction cord,mouth prop,三、窝洞消毒,CAVITY LINERS AND BASES are used primarily to protect the pulp and to aid the pulp in recovering from irritation resulting from cavity preparation. 1、窝洞封闭：洞漆、树脂粘结剂 2、衬洞：隔绝化学和温度刺激 常用洞衬剂 3、垫底：隔绝温度、化学、电流及机械刺激。常用材料,根据余留牙本