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Rezumat NEACŞU (GHEORGHE) IULIA RUXANDRA PDF
Rezumat NEACŞU (GHEORGHE) IULIA RUXANDRA PDF
POPA
FACULTATEA DE MEDICIN DENTAR
Coordonator tiinific:
Prof. Univ. Dr. SORIN ANDRIAN
Doctorand:
Dr. IULIA RUXANDRA NEACU
(GHEORGHE)
- IAI, 2011
1
Coordonator tiinific:
Prof. Univ. Dr. SORIN ANDRIAN
Doctorand:
Dr. IULIA RUXANDRA NEACU
(GHEORGHE)
- IAI, 2011
CUPRINS
CAP.I. Date actuale privind structura smalului i a dentinei
CAP.II. Tratamentul restaurativ n boala carioas opiuni terapeutice actuale
CAP.III. Rinile compozite- structur, proprieti, implicaii clinice
III.1.Structura rinilor compozite
III.2.Clasificarea rinilor compozite
III.3.Indicaii i contraindicaii
III.4.Avantaje i dezavantaje
III.5.Implicaii clinice
CAP.IV. Mecanisme implicate in adeziunea rinilor compozite la esuturile dure
dentare
IV.1.Clasificare
IV.2.Strategii
IV.3.Implicaii clinice
IV.4.Adeziunea la smal
IV.5.Adeziunea la dentin
CAP.V. Finisarea i lustruirea rinilor compozite: etapa decisiv n asigurarea
succesului restaurator
PARTEA PERSONAL
CAP.VI.Motivaia alegerii temei. Obiective specifice. Metodologie.
CAP.VII. Studiu comparativ privind efectele gravajului acid asupra substratului
amelo-dentinar
CAP.VIII. Studiu paraclinic privind fluorescenta rasinilor compozite anterioare
CAP.IX. Studiu privind starea de suprafa a rinilor compozite obinute n urma
finisrii prin diferite tehnici
CAP. X. Studiu clinic longitudinal privind performanta clinica a restaurarilor din
materiale fizionomice aplicate la nivelul grupului frontal
CAP.XI. Studiu clinic longitudinal privind durabilitatea functionala a restaurarilor
de clasa III si IV realizate prin diverse tehnici.
CONCLUZII FINALE.
ORIGINALITATEA TEZEI
BIBLIOGRAFIE
4
CAP.VI. Motivatia
Metodologie.
cercetarii.
Obiective.
Directii
de
cercetare.
Motivatia cercetarii.
Estetica a devenit un domeniu important al stomatologiei, n condiiile n care n
prezent un tratament care se limiteaz doar la funcie, structur i biologie i nu ia n calcul
impactul estetic al pacientului, poate conduce la rezultate dezastruoase n relaia medicpacient.
Pentru a atinge ateptrile pacientului este esenial ca practicianul s aib
cunotine legate de forma, textura i culoarea restaurarii, precum si nelegerea
proprietilor optice ale esuturilor dentare i ale rasinilor compozite (transluciditatea,
opacitate, fluorescencen a i opalescen a).
Cercetarile axate pe aceste aspecte precum si studiile longitudinale care urmaresc
performanta clinica a restaurarilor fizionomice nu pot decat sa contribuie la cresterea
eficientei stomatologiei restaurative si la mentinerea preferintei pacientilor pentru
tratamente restauratoare conservative cu sacrificiu minim de tesut dentar.
Ca urmare a preocuprilor din practica curent i din cadrul pregtirii doctoratului,
mi-am propus:
- adunarea unui material documentar care s integreze datele din literatura de
specialitate privind materialele, tehnicile i performana clinic a
restaurrilor directe efectuate la nivelul grupului dentar anterior;
- evaluarea rezultatelor clinice prin studii longitudinale la pacienii cu
patologie carioas i cu leziuni necariogene la nivelul grupului dentar
anterior;
- efectuarea unor studii de laborator (pe dini extrai) privind diverse
materiale restaurative i tehnici de restaurare.
Obiective.
Pentru realizarea acestor scopuri au fost nominalizate urmtoarele obiective:
- elaborarea unui program de evaluare pe baza indicilor Ryge modificai
USPHS care cuprinde:
o diverse materiale adezive utilizate la restaurarea grupului dentar
anterior;
o diverse tehnici de restaurare utilizate la nivelul grupului dentar
anterior
- studierea cazuisticii care s constituie baza de date pentru prelucrare
statistic;
- precizarea investigaiilor paraclinice, a testelor de laborator care permit
analiza proprietilor unor materiale i a efectului unor tehnici de restaurare
asupra proprietilor materialelor utilizate n restaurrile directe anterioare.
Directii de cercetare.
- Compararea modificrilor micromorfologice aprute la nivelul smalului i
a dentinei n urma aciunii timp de 15, 30 i 60 de secunde a acidului
ortofosforic 37% (etapa de condiionarea acid);
- Compararea gradului de fluorescen a unor rini compozite folosite uzual
n restaurrile directe anterioare;
- Compararea topografiei de suprafa a dou rini compozite diferite ca
mrime a particulelor minerale dup finisarea prin dou metode diferite
(etapa de lustruire/finisare);
- Determinarea prin studiu longitudinal a performanei clinice a restaurrilor
estetice din compozit hibrid, compomer, cement glassionomer modificat cu
rini aplicate n caviti proximale medii i extinse de clasa III.
- Determinarea prin studiu longitudinal a performanei clinice a restaurrilor
estetice din compozit hibrid aplicate n caviti de clasa III i IV, realizate
prin diverse tehnici de restaurare.
Metodologie.
Pentru efectuarea studiilor clinice am beneficiat de cazuistic din cadrul:
- Clinicii de Odontologie-Parodontologie a Facultii de Medicin Dentar,
UMF Iasi, perioada 2008-2011;
- Cabinet practic privat
Testele de laborator au fost efectuate n cadrul Institutului de Chimie
Macromolecular Petru Poni Iai.
Studiile clinice au inclus un total de 101 pacieni cu un numr de 180 de leziuni
carioase i non-cariogene care au necesitat restaurri directe din rini compozite,
compomeri, cementuri glassionomer modificate cu rini.
Studiile paraclinice au fost efectuate pe un numr de 38 dini extrai din motive
ortodontice i parodontale. Testele de laborator au fost efectuate cu ajutorul
microscopiei de for atomic (AFM) i a spectrofotometriei.
VII.4.Rezultate si discutii
Aspectele 3D i 2D ale smalului i dentinei nainte i dup gravaj acid (n raport
cu diverse intervale de timp) precum i valorile rugozitii msurate pe imaginile de
microscopie de for atomic sunt prezentate n figurile urmtoare.
of
df
Mean Square F
10
p.
209.632 .08
Test Statisticsb
Indici
rugozitate
Mann-Whitney U
8.000
Wilcoxon W
63.000
Z
-3.184
Asymp. Sig. (2-tailed) .06
Exact Sig. [2*(1-tailed .001a
Sig.)]
a. Not corrected for ties.
b. Grouping Variable: GrdFl
Tabel 4. Rezultatele testului Mann-Witney de comparare a loturilor de dentin cu timp de
acionare a agentului de gravaj de 15 i 30 secunde
Test Statisticsb
Indici
rugozitate
Mann-Whitney U
.000
Wilcoxon W
55.000
Z
-3.784
Asymp. Sig. (2-tailed) .1
Exact Sig. [2*(1-tailed .000a
Sig.)]
a. Not corrected for ties.
b. Grouping Variable: GrdFl
Tabel 5. Rezultatele testului Mann-Witney de comparare a loturilor de dentin cu timp de
acionare a agentului de gravaj de 15 i 60 secunde
Test Statisticsb
Indici
rugozitate
Mann-Whitney U
10.000
Wilcoxon W
65.000
Z
-3.032
Asymp. Sig. (2-tailed) .08
Exact Sig. [2*(1-tailed .002a
Sig.)]
a. Not corrected for ties.
b. Grouping Variable: GrdFl
Tabel 6. Rezultatele testului Mann-Witney de comparare a loturilor de dentin cu timp de
acionare a agentului de gravaj de 30 i 60 secunde
11
VII.5. Concluzii
1. Indiferent de timpul de aciune, acidul ortofosforic 37% a afectat morfologia de
suprafa a smalului i dentinei
2. La nivelul smalului cele mai mari modificri morfologice s-au nregistrat n cazul
aplicrii agentului de gravaj timp de 60 de secunde, dar aceste modificri nu au fost
semnificative statistic fa de cele nregistrate n cazul scurtrii timpului de aplicare la 30 ,
respectiv 15 secunde
3. La nivel dentinar cele mai pronunate modificri de rugozitate au fost obinute n cazul
acionrii agentului de gravaj timp de 60 secunde, urmat de cele obinute dup acionarea
acidului ortofosforic timp de 30 secunde i respective 15 secunde, dar modificrile nu au
fost semnificative din punct de vedere statistic
4. Timpul de aciune al acidului fosforic 37% de 15 secunde conduce la modificri
morfologice la nivelul smalului i dentine comparabile cu timpii crescui de aciune,
motiv pentru care se recomand a fi utilizat n practica stomatologic curent n cazul
sistemelor adezive ce folosesc tehnica de gravaj acid total.
12
VIII.1.Introducere.
Fluorescen a este un tip de fotoluminescen, n care energia radiant de
ultraviolete (UV) este absorbit de un obiect care emite mai trziu energie luminoasa n
spectrul vizibil. Fluorescen a natural a esuturilor dentare este o component important
care ar trebui s fie reprodus n restaurrile cu rin compozite; atribuie vitalitate i
luminozitate restaurrilor. Fluorescena face ca dinii s apar mai strlucitori i mai albi,
alterndu-le astfel culoarea care le este caracteristic n lumina natural. Mult timp s-a
considerat c fluorescena este proprietatea care confer un aspect vital dinilor naturali.
Ulterior a fost considerat un motiv pentru lipsa de coresponden coloristic a
restaurrilor sau a reconstituirilor protetice cu dinii naturali. Motivul este acela c, n
ciuda faptului c, culoarea vizibil a dintelui coincide cu cea a restaurrii, lipsa de armonie
cu structurile dentare adiacente se datoreaz gradului diferit de fluorescen.
Scopul studiului a fost s compare gradul de fluorescen a dou rini compozite folosite
uzual n practica stomatologic
Material i metod
S-au utilizat n acest studiu dou rini compozite care prezint nuane separate
pentru refacerea smalului i a dentinei: Herculite XRV (Kerr Company) i Z250 (3M
ESPE). Au fost alese pentru testare nuanele A3 pentru refacerea smalului n cazul
rinilor Herculite i Z250 i a nuanei A3 pentru refacerea dentinei n cazul materialului
Herculite i dentina universal pentru materialul Z250. Din fiecare material au fost
realizate 6 mostre obinute prin polimerizarea materialelor ntre dou plcue de sticl
transparente utiliznd o lamp LED (LED.B, Guilin Woodpwcker Medical Instrument
Co., Ltd, China) cu o lungime de und cuprins ntre 420-480 nm timp de 40 secunde.
Fluorescena materialelor a fost testat utiliznd spectrometrul LS 55, Perkin Elmer Inc,
USA.
Fig.31. Spectrofotometru LS 55
13
VIII.4.Rezultate si discutii
In figurile 32-34 sunt prezentate valorile spectrului emisiei si maximul atins de
fluorescenta pentru Herculite smalt pentru diverse intervale ale lungimii de unda a
fascicului excitant.
Fig.32.Herculite smalt/330-630nm
Fig.35.Herculite dent./330-630nm
Fig.38.Z250 smalt/330-630nm
14
Fig.41.Z250 dent./330-630nm
Fig.42.Z250 dent./370-650nm
Fig.43.Z250 dent./410-650nm
Fig.44. Variaia fluorescenei materialelor la cele trei intervale diferite ale lungimilor de und
VIII.5. Concluzii
1. La valori ale undei de stimulare cuprinse ntre 330 i 630 nm i 370 i 650 nm
materialul care a nregistrat cea mai mare fluorescen a fost Z 250 pentru refacerea
dentinei
2. La valori ale undei de stimulare cuprinse ntre 410 i 650 nm, cele mai mari
valori ale fluorescenei au fost obinute n cazul materialului Herculite pentru refacerea
dentinei
3. Pentru ambele materiale testate valorile fluorescenei n cazul rinilor pentru
nlocirea dentinei au fost mai mari dect cele nregistrate n cazul rinilor pentru refacerea
smalului
4. La lungimile de und cele mai mari (410-650 nm) s-au nregistrat i cele mai
ridicate valori ale fluorescenei n cazul ambelor rini compozite
15
17
0,5-4 m
1.8-8 m
5-35 m
Fig.49. Aspectul de suprafa i histograma unei seciuni realizat prin rina compozit
Z250 dup finisarea cu sistemul Po-Go
10-35 m
Fig.50. Aspectul de suprafa i histograma unei seciuni realizat prin rina compozit
Charisma dup finisarea cu sistemul Po-Go
18
0.2-12 m
Fig.51. Aspectul de suprafa i histograma unei seciuni realizat prin rina compozit
Z250 dup finisarea cu sistemul Soflex
0.5-20 m
Fig.52. Aspectul de suprafa i histograma unei seciuni realizat prin rina compozit
Charisma dup finisarea cu sistemul Soflex
Tabel 7.a-b. Analiza statistica starea de suprafa Charisma vs. Z250, Soflex vs. Po-Gi
19
IX.5.Concluzii
1.Suprafeele nefinisate, n contact cu matricea, ale ambelor rini compozite luate n
studiu au fost mai netede dect cele finisate
2.Rina hibrid a nregistrat dup finisare o rugozitate de suprafa mai mare dect rina
microhibrid, indiferent de sistemul folosit pentru finisare, dar diferenele au fost
nesemnificative
3.Sistemul Sof Lex a condus la obinerea unor suprafee ale rinilor compozite cu o
rugozitate mai mare dect sistemul Po-Go, dar diferenele nu au fost semnificative
4.Rina compozit microhibrid n asociere cu sistemul Po-Go a condus la cele mai bune
rezultate din punctul de vedere al rugozitii de suprafa.
20
X.3.Material si metod
Au fost tratate restaurativ de ctre un singur practician (doctorandul) un numr de
60 leziuni carioase proximale (clasa III) de profunzime medie, localizate la nivelul
grupului frontal anterior maxilar i mandibular, de dimensiuni medii i extinse. Studiul a
fost efectuat pe un numr de 45 de pacieni (24- sex feminin, 21-sex masculin) cu vrste
cuprinse ntre 18-40 ani. Materialele utilizate au fost urmtoarele:
-lot I (RC)-compozit hibrid Filtek 250 (3M/ESPE);
- lot II (C)-compomer Dyract (DeTreyDentsply);
-lot III (RMGC)- cement glassionomer modificat cu rini Fuji IILC (GC).
Utilizarea materialelor s-a realizat conform instruciunilor productorilor.
Restaurrile au fost evaluate la intervale de 6 luni, 12 luni, respectiv 24 luni.
Evaluarea statusului functional al restaurrilor s-a realizat prin intermediul indicilor Ryge
modificai USPHS (US Public Health Service) pentru urmtorii parametri (tabel 1):
adaptare marginal, coloraie marginal, culoare, stare de suprafa, contur anatomic. A
fost calculat deasemenea rata de retenie, lundu-se n considerare eecul n cazul
absenei complete sau pariale a materialului din cavitate.
Criterii de excludere (lot de pacieni): pacieni
necorespunztoare (risc cariogen crescut);ocluzie traumatic.
21
cu
bruxism;
igien
22
100%
100%
100%
100%
90%
100%
98%
80%
96%
70%
60%
95%
94%
50%
40%
30%
20%
10%
0%
RC
92%
90%
RMGC
88%
RC
90%
C
RMGC
86%
84%
S1
RC
S1
RC
RMGC
RMGC
96%
95%
94%
80%
70%
60%
92%
90%
90%
50%
88%
RC
40%
86%
30%
RMGC
20%
85%
84%
40%
RC
C
30%
RMGC
10%
82%
0%
80%
S1
RC
S1
RC
C
RMGC
RMGC
60%
16%
60%
15%
14%
50%
12%
10%
45%
40%
10%
8%
RC
6%
RC
C
20%
20%
RMGC
5%
4%
30%
RMGC
10%
2%
0%
0%
RC
S1
RC
S1
C
RMGC
RMGC
23
16%
100%
90%
14%
80%
12%
70%
60%
15%
10%
50%
40%
30%
20%
10%
0%
10%
RC
8%
RC
6%
RMGC
4%
RMGC
2%
0%
0%
0%
0%
RC
S1
0%
RC
S1
RMGC
RMGC
100%
80%
100%
80%
70%
70%
99%
65%
60%
98%
50%
97%
96%
95%
95%
95%
94%
RC
40%
RC
30%
RMGC
20%
RMGC
10%
93%
0%
92%
S1
RC
S1
RC
RMGC
RMGC
5%
5%
30%
5%
30%
5%
25%
4%
4%
3%
20%
20%
3%
2%
2%
1%
1%
0%
RC
15%
10%
20%
RC
C
RMGC
RMGC
5%
0%
0%
RC
S1
S1
RC
RMGC
RMGC
100%
10%
90%
9%
80%
8%
70%
60%
10%
7%
6%
50%
40%
30%
20%
10%
0%
5%
4%
3%
2%
1%
0%
RC
C
RMGC
0%
0%
RC
0%
S1
5%
C
RMGC
RC
C
RMGC
RC
0%
C
RMGC
S1
100%
70%
70%
95%
65%
90%
60%
85%
80%
50%
70%
60%
40%
50%
40%
30%
20%
10%
0%
RC
45%
RC
30%
C
RMGC
20%
RMGC
10%
10%
0%
S1
RC
S1
RC
C
RMGC
RMGC
60%
55%
50%
60%
50%
40%
40%
30%
30%
RC
C
20%
RC
25%
RMGC
15%
10%
25%
20%
RMGC
10%
5%
0%
0%
S1
RC
S1
RC
C
RMGC
RMGC
30%
30%
90%
25%
80%
70%
60%
20%
50%
40%
30%
20%
10%
0%
15%
RC
C
RC
10%
0%
0%
RMGC
5%
5%
RC
10%
RMGC
0%
0%
S1
S1
RC
C
RMGC
RMGC
25
100%
100%
80%
100%
90%
80%
70%
80%
70%
60%
75%
70%
60%
50%
50%
40%
30%
20%
10%
0%
RC
40%
RC
30%
RMGC
20%
RMGC
15%
10%
0%
S1
RC
S1
RC
C
RMGC
RMGC
30%
30%
90%
25%
80%
70%
60%
20%
50%
40%
30%
20%
10%
0%
RC
20%
15%
10%
RMGC
RC
10%
C
RMGC
5%
0%
0%
0%
RC
0%
S1
RC
RMGC
S1
C
RMGC
X.5.CONCLUZII
1.Materialele adezive utilizate n terapia restaurativ a leziunilor proximale de dimensiuni
mici si medii localizate la nivelul grupului frontal prezint rate de retenie de 100% la un
interval de 12 luni n condiiile unei tehnici de lucru corecte i a controlului riscului
cariogen;
2.La un interval de 24 luni cementurile glassionomer modificate cu rini prezint
performane clinice foarte bune n ceea ce privete parametrii adaptare marginal i
coloraie marginal, dar rezultate inferioare rinilor compozite i compomerilor privind
parametrii forma anatomic, starea de suprafa, culoarea;
3.Restaurrile din rini compozite microhibride au prezentat rezultate bune pentru
parametrii adaptare marginal, coloraie marginal i rezultate foarte bune privind
culoarea, starea de suprafa, conturul anatomic;
4.Restaurrile din compomer aplicate cu sistemul adeziv self-etch au prezentat rezultate
inferioare privind adaptarea marginal i coloraia marginal n raport cu restaurrile din
rina compozit microhibrid i rezultate similare cu acestea privind parametrii culoare,
stare de suprafa, culoare.
26
27
28
30
31
In graficele 66-70 sunt prezentate rezultatele privind rata de retenie i parametrii adaptare
marginal, coloraie marginal, culoare, stare de suprafa, forma anatomic pentru lotul de
restaurri de clasa IV.
32
33
34
XI.5.CONCLUZII
35
CONCLUZII GENERALE
Rina hibrid a nregistrat dup finisare o rugozitate de suprafa mai mare dect
rina microhibrid, indiferent de sistemul folosit pentru finisare, dar diferenele au
fost nesemnificative
Sistemul Sof Lex a condus la obinerea unor suprafee ale rinilor compozite cu o
rugozitate mai mare dect sistemul Po-Go, dar diferenele nu au fost semnificative
36
37
ORIGINALITATEA STUDIULUI
In cercetarea noastr am pornit de la constatarea c majoritatea investigaiilor axate
pe posibilitile de mbuntire a performanelor clinice ale restaurrilor din rini
compozite se adreseaz n special grupului dentar lateral.
Putem afirma c aria tehnicilor de restaurare i a performanelor clinice la nivelul
grupului dentar anterior este acoperit ntr-o proporie mai mic, de aici necesitatea unor
investigaii atat clinice cat i paraclinice care s se adreseze materialelor de restaurare i
unor tehnici de restaurare mai eficiente dar mai puin utilizate n practica curent.
Cercetarile axate pe aceste aspecte precum i studiile longitudinale care urmaresc
performana clinic a restaurrilor fizionomice vor aduce un aport semnifcativ la cresterea
eficientei stomatologiei restaurative i la meninerea preferinei pacientilor pentru
tratamente restauratoare conservative cu sacrificiu minim de esut dentar.
Ca elemente de originalitate ale cercetrilor noastre pot fi amintite:
- utilizarea microscopiei de for atomic n msurarea rugozitii suprafeelor de
smal i dentin dup condiionarea acid pe diverse intervale de timp; imaginile
originale prezentate sunt extrem de sugestive, studiul axat pe evaluarea
modificrilor micromorfologice ale smalului i dentinei cu ajutorul microscopiei
de for atomic fiind unul dintre puinele realizate n Romania;
- studiul care investigheaz cu ajutorul spectrofotometriei una dintre proprietile
optice fundamentale ale unor rini compozite (fluorescena) poate fi considerat un
studiu de pionierat n ceea ce privete materialele de restaurare direct, aceast
proprietate fiind investigat pan acum n special n cazul materialelor de
restaurare indirect (ceramica);
- investigarea statusului suprafeei restaurrilor din rini compozite n raport cu
tipul de material i tipul sistemului de finisare/lustruire utilizat are o not de
originalitate prin prisma metodei de laborator utilizate (microscopia de for
atomic);
- studiul axat pe investigarea unor clase diferite de materiale utilizate n restaurrile
de clasa III este unul dintre puinele realizate n Romania care se ocup de
compararea performanelor clinice ale restaurrilor realizate din materiale adezive
diverse;
- investigarea unor tehnici de restaurare mai puin utilizate n practica curent
reprezint o cercetare util n contextul n care datele din literatur sunt reduse;
acest ultim studiu poate sta la baza unor ghiduri de practic care s ofere informaii
utile medicilor stomatologi.
38
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