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12В настоящем исследовании получены ультраструктурные данные о тяжелом поражении кар-диомиоцитов у пациентов с клиническим диагнозом ишемическая кардиомиопатия. Это распространенный апоптоз, гибернация, ремоделирование кардиомиоцитов, разрыв в области вставочных дисков, что необратимо нарушает нормальное сокращение миокарда.
Если дилатационная кардиомиопатия является полиэтиологичным заболеванием, то при ишемиче-ской кардиомиопатии главным является наличие гипоксии и ишемии миокарда, хотя не исключена также генетическая предрасположенность к развитию заболевания, о чем говорят последние исследования [9].
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PREVENTION OF ENDODONTIC COMPLICATIONS IN PROSTHETICS WITH CERAMIC RESTORATIONS IN THE FRONTAL AREA OF THE DENTITION
Kovshar I.
Ph.D., Associate Professor of General Dentistry Department Shuturminsky V.
D.M.,
Head of Odessa Medical Institute of International Humanitarian University
Abstract
The aim of the study was to evaluate the clinical effectiveness of the original method of preventing endodontic complications in aesthetic prosthetics using ceramic restorations. An original method of preparing the tooth surface for ceramic restoration and the prevention of endodontic complications is proposed, its effectiveness is proved. A high degree of patients' satisfaction with the treatment and good functional and aesthetic results indicate the advisability of continuing research in the development of new methods of aesthetic prosthetics and the prevention of complications.
Keywords: aesthetic dentistry, prosthetics, veneers, ceramic restorations, prevention.
Due to the rapid development of the chemical industry in the second half of the 20th century, the development of new adhesive systems, ceramic restorations (veneers) gained widespread use. In this regard, ways and methods of fixing ceramic restorations and preparation of the teeth began to improve. The problem of prevention of immediate and distant complications, such as increased sensitivity, the development of pulpitis and periodontitis, ditching and dislocation after fixation of the ceramic restorations (veneers) also became urgent. Changing approaches to the use of veneers in
practical dentistry started their widespread use in the practice of an orthopedic dentist [1, 2].
Presently, practically optimal methods have been developed for the preparation of the dental hard tissues for ceramic restorations [1, 2, 4, 5]. According to the studies by Kesrak P. (2012), a minimally invasive preparation of the teeth within the enamel allows to increase the clinical efficacy of treatment with ceramic restorations and reduce the risk of postoperative complications [3]. On the other hand, recently the indications for the use of ceramic restorations are expanding. Not infrequently, as a result of odontopreparation, the dentin is
exposed, which can result in the appearance of hypersensitivity to chemical, thermal and mechanical stimuli [4-7].
Taking it into consideration, it is worth noting that different authors have proposed various methods of treating the surgical field before fixing ceramic restorations. However, there is no full guarantee to eliminate these complications. In this regard, the use of medical ozone was proposed, which was successfully used in other fields of medicine and dentistry. In particular, medical ozone has been successfully used in the endodontic practice [8,9]. In 2011-2012 we have shown the successful use of medical ozone for prosthetics with ceramic restorations [10].
In addition, despite certain progress in the development of ways and methods of aesthetic prosthetics, there is very little data on adaptation changes in the mi-crovasculature and the pulp homeorhesis system and periodontal tissues. Therefore, the improvement of our methods proposed for the prevention of postoperative complications using ceramic restorations requires further study and improvement. The aim of the study was to assess the clinical effectiveness of the use of pharmaceutical constructions made from Protempt-4 Garant, with preliminary treatment of the prosthetic field with medical ozone.
Materials and methods. The study was conducted on the basis of the "University Dental Clinic of Moscow State University" during 2018-2019. The study involved 42 patients who underwent ceramic restorations on non-aesthetic anterior and posterior teeth, including closing of three diastems, as well as correcting the shape of the dentition. Two clinical groups were formed: 1 (main), of 21 persons in whom medical ozone and pharmaceutical constructions made of Protempt-4 Garant were used, 2 (comparison group), 21 people, in whom preparation of the prosthetic field was made according to the standard methods.
After replacing the old composite restorations and professional hygiene, the preparation of the hard dental tissues was made. When there was a need for alignment of the dentition, more hard tissue was removed and the dentin was exposed, which increased the risk of a larger number of postoperative complications. Accordingly, all pharmaceutical constructions were made immediately after the removal of working impressions.
All ceramic restorations were made of IPS e.max Press. The inner surface of ceramic restorations was etched with 5% HF for 60 seconds, followed by 35% phosphoric acid (for washing away precipitates). Before silanization of the RelyX Ceramic Primer ceramic
restorations, they were washed in an ultrasonic bath with distilled water.
All ceramic restorations were fixed on the RelyX Veneer, with the gingival margin pre-treated with the Astringent Retraction Paste. After professional cleaning, the prosthetic field was treated with Scotchgel 35% phosphoric acid for 15 seconds, then washed, dried and Single Bond Universal Adhesive applied on it. After a preliminary, two second prepolymerization, excess fixation material was removed without pressure on the ceramic restoration. The final polymerization was carried out for 20 seconds on each side of the veneer.
Additionally, the first group patients, after preparation of the hard tooth tissues, wore an occlusal tray into which a medical ozone-oxygen mixture was supplied. The occlusal tray has been on the treated teeth for two minutes. The procedure was repeated before fixing the ceramic restorations. After that, a working impression was taken. Then an auxiliary impression was taken, which was removed from the model (WaxUp), filled with plastic for the manufacture of Protempt-4 Garant pharmaceutical construction, and temporary crowns were obtained that protected the prosthetic field for the period of construction of permanent ceramic restorations. The fixation of temporary constructions was carried out pointwise to the center of the vestibular surface of the tooth using the Single Bond Universal Adhesive.
After having fixed ceramic restorations, control examinations of the patients of both groups were carried out. We evaluated the marginal fit of the veneer, the presence of complaints of sensitivity, color stability according to the Vita Classical color scale. The condition of the gingival margin of the tooth, on which the ceramic restoration was fixed, was also evaluated. The patient's satisfaction was assessed by analyzing the developed and proposed questionnaire. The marginal fit was analyzed in digital photographs by threefold magnification. The cervical position of the veneer above the level of the gingival margin allows providing dry and clean working surfaces during fitting and adhesive fixation. After fixation, there is also a visual control at the polishing stage, which eliminates the soft tissues trauma. Subsequently, this will make it possible to conduct quality oral hygiene independently. On control examinations, we can control the integrity of the borders of the ceramic restoration-tooth tissue. Edge adaptation and edge penetration were determined at four points of the restored tooth: mesio-cervical, mid-cervical from the vestibular side, distal cervical and palatal incisor (Fig. 1)
a) b)
Fig. 1 Assessment of the marginal fit: (a - general view, b - triple increase)
Patients of both groups underwent electroodon-tometry (EOM) of the teeth, which were restored by ceramic restorations. To create the same conditions for the study, the boundary values of EOM were determined on the palatine surface. As a reference standard, all patients used EOM data from the teeth in the same jaw that were not restored by ceramic restorations. Electroodontometry was performed in the patients using the apparatus Digitest.
Statistical processing was carried out by nonpara-metric methods using the software Statistica 8.0.
Results and discussion. When assessing the clinical effect of using ceramic restorations during the follow-up visits (1, 3, 6 and 12 months), their aesthetic parameters (color matching and surface preservation) corresponded to the optimal state. Color compliance was monitored at all stages of the follow-up visits by the Vita Classical color scale, visually compared with the standard and ceramic restoration. The safety of the edge and the surface of the veneer itself were determined by a sharp probe and in the light of a surgical lamp, while changing the angle of illumination of the surface of the veneer. We did not reveal hypersensitivity and other complaints in the patients of the main group (Fig. 2)
Fig. 2 - Edge fit and complete preservation of the veneer surface after 12 months of the follow-up
Pulp irritation occurred in 3 (three) patients of the comparison group. After a year of the follow-up, one patient of the comparison group was revealed to have a dead pulp - we associate this with a large restoration of 21 teeth. After that, endodontic treatment was performed. In patients of the main group, endodontic complications were not detected.
Quite interesting results were obtained during electrodontometry. As studies have shown, the electro-
excitability of the pulp treated with medical ozone before fixing ceramic restorations did not differ much from the values obtained in the diagnosis of intact teeth — the sensitivity threshold was 6.2 ± 0.1 mcA. However, in 4 patients (19%) of the comparison group who had been fixed veneers, the sensitivity threshold decreased and made 18.8 ± 0.2 mcA, which may indicate a disturbance of the local blood flow and risk of endodontic complications, the development of inflammatory processes in the pulp (Tab. ).
Table.
The results of determining the electroodontometric indices of the tooth pulp (mcA) throughout the treatment, units
Clinical group Initial values After treatment After veneer fixing In 1 month In 3 months In 12 months
I (n=21) 6.1±0.1 6.4±0.1 6.5±0.1 6.6±0.1 6.5±0.1 6.3±0.2
II (n=21) 6.2±0.1 7.0±0.2 10.5±0.3* 8.9±0.1* 8.6±0.1* 7.6±0.2*
Note: * - difference between groups having statistical value (p<0.05)
It should be noted that the indices of electroodon-tometry correlated with the level of satisfaction with the completed treatment (r = -0.69 p <0.05).
Conclusions:
1. The use of medical ozone in the preparation of the hard dental tissues results in a stable state of the pulp, which means the prevention of endodontic complications.
2. The method proposed for the treatment and prevention of endodontic complications using ceramic restorations and medical ozone gives a high degree of satisfaction with the treatment as well as good functional and aesthetic results in the long-term follow-up.
3. Instrumental studies showed that the electric excitability of the pulp of teeth treated with medical ozone was at the level of intact teeth, which indicates the min-
imization of complications in aesthetic prosthetics using ozone and plastic for the production of Protempt-4 Garant pharmaceutical constructions.
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