Pediatric restorative dentistry

- Morphologic Differences ( ) Primary & Permanent Teeth (Quick rev)

1- Crowns: shorter and wider mesiodistally
2- Color: Lighter.
3- Occlusal surface: Narrower.
4- Cervical ridge on the buccal aspect of the primary molars is much more definite, particularly on the
maxillary and mandibular D.  Use T Band
5- Cervical constriction: More.
6- Contact area: very broad and flat.
7- Enamel & Dentin: Thinner.
8- The direction of enamel rods in the gingival third extend in occlusal direction from dentinoenamel
junction in deciduous teeth but extend slightly apically in permanent teeth.
-----------------------------------------------------Let’s Start! ------------------------------------------------------------------------------------------

A- Restoration of primary molars

Case study
A 5 years old child went to the nearby dentist with his mother. History was taken from
the mother who reported elicited pain on eating sweets. On clinical examination the
dentist noted the following:
1- Simple occlusal caries of 75 & 85
2- Distal caries catched by the curved probe of 74 & hypocalcified 84.
3- Treatment plan was tailored and restoration of the molars was considered.
----------------------------------Before studying the case must---------------------------------------------------
 Consider the following factors:
1- Age of the child 2- Caries risk 3- Oral hygiene 4- Child’s cooperation 5- Medical status
6- Cause of defect: 1- Caries 2- Trauma 3- Developmental
 Importance of restoring primary molars
1- Proper mastication
2- To maintain space for the succedaneous teeth (most ideal space maintainer in mouth)
3- Development of suitable economic restorative materials.
 Filling materials used in pediatric restorative dentistry:
1- Amalgam 2- Stainless steel crowns 3- Adhesive materials
 GV Black Classification for dental caries:
 1. Dental Amalgam
 The most commonly used restorative material in posterior teeth for over 150 years
and is still widely used throughout the world today
 Amalgam contains a mixture of metals such as silver, copper, and tin, in addition to
approximately 50% mercury.
 Used in Class 1 & 2 Cavity preparation
A. Class I
- General Considerations: for The outline form
1- Include all retentive fissures and carious area
2- As conservative as possible (extension for prevention).
3- Composed of smoothly flowing arcs and curves (Prevent stress concentration).
4- Ideal pulpal floor depth is 0.5mm into dentin (1.5 mm from enamel surface)
5- No cavosurface margin bevel (CSA 90-100 provide strong amalgam margin (80-90) as
bevel provide thin weak amalgam margin which is brittle and fracture susceptible
(low edge strength).
6- All internal angles should be rounded slightly
7- Dovetail: broad buccolingually than isthmus, which is 1/3 of the intercuspal width
8- B&Li walls should converge slightly in an occlusal direction
9- M&D walls flare at the marginal ridge  not to undercut ridges
10- Oblique ridges should not be crossed unless they are undermined with caries or
are deeply fissured
11- Buccal pit of the Lower E should be restored (if demineralized)
Placement of bases in primary teeth is uncommon as placement of base not allow
enough thickness of amalgam over it>> If necessary, GI material is recommended
- Common errors with class I Amalgam Rest.
1- Undercutting the marginal ridge
2- Not including all of the susceptible fissures
3- Not removing amalgam flashes from cavosurface margins
4- Carving the amalgam too deep
5- Undercarving  fracture of amalgam
- Evidence Based Dentistry:
Type of study systematic review and two randomized controlled trials
Results Primary teeth: success rate of 85 to 96% for up to seven years with an
average annual failure rate of 3.2 percent.
- When fails before 7 y it’s usually related to marginal ridge fracture.
Permanent teeth: from 89.8 to 98.8 percent for up to seven years
 B. Class II
- General considerations
1- The proximal box should be broader at the cervical portion than the occlusal portion
2- The buccal, lingual and gingival walls should break contact with adjacent teeth
3- The buccal and lingual walls create 90-degree angle with the enamel (not beveled)
4- The gingival wall should be flat, not beveled
5- The axial wall should be 0.5mm into dentin
6- The axiopulpal line angle should be beveled or rounded
7- The mesiodistal width of the gingival seat should be 1mm
8- A bucco – axial and a linguo axial retention grooves may be included in the preparation.
9- Axial wall is preferred to be slightly convex (conform to natural tooth anatomy
10- Use Matrix band to act as temporary wall till amalgam setting:
a. T- Band
b. Sectional matrix (indicated mainly for composite)
c. Automatrix (requires special tightening and removal tools)
d. Spot-welded matrix (a spot welder is required at chairside)
e. Tofflemire matrix
- Back-to-back class II Amalgam Restorations procedure :
Wedge placement
 Condense proximal boxes alternatively
 Then continue condensation alternatively
Till both preparations are slightly overfilled.

 N.B Stainless steel crown is more durable for large multiple surface restorations in
primary teeth ex MOD cavity.
- Problems with amalgam restorations
1- Fracture of the isthmus of class II 
a. Insufficient bulk of amalgam in the isthmus
b. Too shallow preparation c. over carving
2- Marginal failure in the proximal box  excessive flare of the cavosurface margin
3- Failure to remove all caries or to extend preparation into caries-susceptible fissures
4- Overhanging  Improper wedging.
5- Undermining of Ridge.
 Amalgam finishing
1- To eliminate surface scratches (causes food & Plaque Accumulation Tarnish &
corrosion)
2- To remove any amalgam flash not carved away
3- To refine the anatomy and occlusion
- If polishing is not going to be done, >> Burnish the amalgam after initial setting of
amalgam (10 min. after trituration)
Polishing
Using:
a. Three sizes of round finishing burs
b. A pear-shaped and flame-shaped burs
c. Polishing agent as tin oxide, and a pumice slurry
d. Rubber devices  final polishing
e. Sandpaper discs  Proximal finishing
f. Cooling system  Avoid heat generation

Evidence Based Dentistry

Results comparing longevity of amalgam to other restorative materials are inconsistent.
Type Meta-analyses, and Randomized controlled trials
Results 1. Some show: Comparable durability of dental amalgam to other
restorative materials
2. Others show greater longevity for amalgam.
3. A systematic review: survive a minimum of 3.5 to 7 years. (Primary
Molars)
4. 1 meta-analysis and 1 evidence-based review : mean annual
failure rates of amalgam and composite are equal at 2.3
(Permanent molars)
5. FDA declare that amalgam shouldn’t be used under 6 years

Recommendation Amalgam is effective restoration of Class I and Class II cavity

restorations in primary and permanent teeth
Amalgam Safety
Not Safe (False) Safe (True)
Declined in use over the past -But there is insufficient evidence of associations
decade perhaps due to: between mercury release from dental amalgam and the
1- Health effects of mercury various medical complaints.
vapor
 2- Environmental concerns -Two independent randomized controlled trials in
from its mercury content children have examined the effects of mercury release
3- Increased demand for
from amalgam restorations and found no effect on the
esthetic alternatives.
central and peripheral nervous systems and kidney
function

 FDA rules for amalgam use:

- Reclassified dental amalgam to a Class II device (having some risk) and designated
guidance that included warning labels regarding:
1- Possible harm of mercury vapors
2- Disclosure of mercury content
3- Contraindications for persons with known mercury sensitivity.
4- Pregnancy and Childhood (6yrs) : limited information regarding dental amalgam and
the long-term health outcomes
 Better to apply rubber dam during placement to prevent ingestion of excess.
 Amalgam removal must be done with high suction, rubber dam, Masks
2. Adhesive restorations
- Resin based composite - Poly acid modified resin based composite (Compomer)
- Glass Ionomer -Resin modified Glass Ionomer
Advantages over amalgam:
1. Improved esthetics
2. Bonding to tooth structure
3. Fluoride release
4. Reduction of mercury exposure
5. Conservative tooth reduction
A. Resin Composite
• General principles:
1- Technique sensitive
• Absolute moisture control is a must (Rubber dam - Cotton rolls - High suction)
• Caries removal limited to the carious lesion
• A short bevel to the cavo-surface margin to:
 Increase the surface area for better retention
 Remove the a prismatic enamel surface layer
2- More conservative preparations:
 No need for extension to prevention (PRR)
 Lessened need for undercuts (minor mechanical undercuts are needed)
 Class II
- General considerations
1- Limited to the carious lesion with no (slot preparation) or with little occlusal
extension.
2- Short bevel to the cavo-surface margin
3- No need to extend the labial, lingual and gingival walls out of the contact area:
(As composite is weaker than the amalgam so more extension will Increase chance of
fracture even If self-cleansing property is required)
4- Pre-wedging: to get a slight separation between teeth and a tighter proximal
contact & to protect the gingiva from instrumentation (bleeding)
5- Etching the preparation with an acid for 15-20 sec. and dentin bonding agent (self-
etch)
6- Clear plastic or thin metal matrix (sectional matrix) & Avoid circumferential matrix
use (Not give proper contour of amalgam).
7- A plastic condenser to condense small increments of composite (2-3mm depth)
Finishing
1- Round carbide high speed burs
2- Flame shaped high speed burs
3- Finishing stones

Evidence Based Dentistry

Type randomized controlled trials meta- analyses
result In primary molars: In permanent molars:
1. Successful when used in Successful for Class I and II restorations
Class I restorations. • Enamel and dentin bonding agents decrease
2. success of composite resin marginal staining and detectable margins for
restorations for two years the different types of composites.
in Class II • 1 meta-analysis and 1 evidence-based
review: Class II mean annual failure rates of
amalgam and composite are equal at 2.3

B.Compomer
-Polyacid-modified resin-based composites
-Contain 72% (by weight) strontium fluorosilicate glass and the average particle size is 2.5 micrometers

Advantages
 1- Moisture is attracted to both acid functional monomer and basic ionomer- type in the material &
trigger a reaction that releases fluoride and buffers acidic environments.
2- Fl release , esthetic value, and simple handling properties of Compomer
3- Comparable clinical performance to composite with respect to:
a. Color matching b. cavosurface discoloration c. anatomical form
d. marginal integrity e. secondary caries

Evidence based Dentistry

Type randomized clinical trials
1. Better physical properties compared to GI and RMGIC in primary teeth,
Recommendations

2. no significant difference was found in cariostatic effects

3. not enough data comparing to other restorative materials in permanent teeth of children
Result
&

4. Can be an alternative to other restorative materials in the primary dentition in Class I and
Class II restorations

 Pit & Fissure sealants : (Quick Review):

- Application and mechanical bonding of a flowable resin material to an acid-etched
enamel surface, thereby sealing existing pits and fissures from the oral environment.
- This prevents bacteria from colonizing in the pits, and fissures and nutrients from reaching
the bacteria already present
- Indications:
1. Deep, retentive, susceptible pits and fissures
2. Stained pits and fissures with minimal decalcification
3. Pit and fissure caries or restoration in other primary teeth
4. No radiographic or clinical evidence of inter-proximal decay
5. Other preventive program, fluoride
6. Adequate isolation is possible
7. Corresponding Contralateral tooth is filled or sealed
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CAR (Conservative adhesive restoration) or PRR (Preventive Resin Restoration)

ChCh:
1- combines the preventive approach of sealing susceptible pits and fissures with
conservative cavity preparation of caries on the same occlusal surface
2- limits cavity preparation to the discrete areas of decay
 3- Filling with an adhesive material, usually resin based composite or Compomer, and then
Sealing the entire occlusal surface
Types: Type A, B, C >>> (full details in Pit & Fissure sealants Lecture)
- Teeth that are suitable for CARs: Small, discrete regions of decay
- Moisture control is important
- Filling materials:
A. adhesive resin composites B. Compomer C. Amalgam, and GIC (if tooth isolation is
difficult)
C. Glass ionomer cements
- Restorative cements, cavity liner/base, and luting cement
- Originally, glass ionomer materials:
a. Difficult to handle b. poor wear resistance c. brittle.
- Advancements in conventional glass ionomer formulation led to better properties,
including the formation of resin-modified glass ionomers  improvement in handling
characteristics, decreased setting time, increased strength, and improved wear resistance
- Several properties that make them favorable for use in CHILDREN including:
1- Chemical bonding to both enamel and dentin
2- Thermal expansion similar to that of tooth structure
3- Biocompatibility
4- Decreased moisture sensitivity when compared to resins
5- Uptake and release of fluoride (less susceptible teeth to acid challenge):
- One study has shown that fluoride release can occur for at least 1 year.
- reservoir of fluoride  uptake can occur from dentifrices, mouth rinses, and topical
fluoride applications
- SO used as luting cement for: a. Stst crowns b. Space maintainers, c. Orthodontic bands
- This fluoride protection, useful in patients at high risk for caries
- Used also on Interim therapeutic restorations (ITR) and the atraumatic/alternative
restorative technique (ART) due to Fl release property.
- ART: using hand instrumentation for decay removal and application of fluoride releasing
materials (Glass Ionomer).
- Indications of ITR/ART :
1. Very young patients
2. Uncooperative patients
3. Patients with special health care needs for whom traditional cavity preparation and/or
placement of traditional dental restorations are not feasible or need to be postponed.
 4. Children with multiple open carious lesions, prior to definitive restoration of the teeth
(For caries control)

Evidence Based Dentistry

Study randomized clinical trial systematic review and meta- analysis
Result In primary tooth: overall median time from Not recommended for Class II restorations in
treatment to failure of GI restored teeth was primary molars.
1.2 years - Composite is better alternative regarding
good moisture control

For RMGIC
Study meta-analysis
Result -RMGIC is more successful than conventional glass ionomer as a restorative material in
primary teeth
- Moderate sized Class II cavities: withstand occlusal forces on primary molars for at
least 1 year.
-Because of fluoride release: used in high caries risk population
- Conditioning dentin improves the success rate of RMGIC
- 1 randomized clinical trial, cavosurface beveling leads to high marginal failure in
RMGIC restorations and is not recommended
1. Class I restorations in primary teeth than conventional GIC. (systematic review)
Recommendation

2. Can be used in Class II restorations in primary teeth. (Experts Opinions’)

3. There is insufficient evidence to use GI or RMGIC as long-term restorative material
in permanent teeth
* But can be used in newly erupted permanent molar when clamping & isolation are
not feasible.
4. From a meta-analysis, there is strong evidence that interim therapeutic
restoration/atraumatic restorative technique (ITR/ART) using high viscosity glass
ionomer cements has value as single surface temporary restoration for both primary
and permanent teeth.
 3. Stainless Steel crowns
 Indications:
1. Extensive carious lesions
2. Hypoplastic teeth
3. High caries risk & Young age
4. Following pulpotomy or pulpecomy
5. Dentinogenesis or amelogenesis imperfecta
6. Disabled children ex Cerebral Palsy
7. As an abutment for space maintainer or prosthetic appliance
8. Dental treatment under general anesthesia
 Types:
a. Pre-trimmed b. Precontoured B. Preveneered
-Have straight, flat, and - These are festooned - have resin based composite bonded
noncontoured sides and Precontoured to buccal and occlusal surfaces in the
-They are festooned to - Minimal trimming and laboratory
follow a line parallel to the contouring may be - Not widely used:
gingival crest required A. More expensive
-They still require B. Require more tooth reduction
contouring and some C. Allow for only minimal crimping
trimming for adaptation

N.B: cementation of crown is better to be done by GIC

 Surface Reduction
A. Occlusal surface (1.5 mm) & better to avoid flattening of occlusal surface & follow
contours of occlusal surface.
B. Proximal surfaces (feather edge gingival margins) (No finish line) (Just open the contact
area).
- Prepare occlusal & Proximal then try crown to determine whether it’s essential to prepare
buccal & Lingual surfaces or not.
C. Buccal surface: only in the case of excessively large mesiobuccal bulge (May not
prepared).
D. NO reduction for the lingual surface except in difficulty in selecting an appropriate
crown size (rare)
 E. Take care from adjacent tooth injury (especially mesial surface of permanent molar)
- Can avoid this injury using wedge or applying elastic of orthodontics for 2 -3 days.
F. When prepare 2 adjacent teeth prepare the 1st and keep the 2nd as indication for the
amount of reduction then start preparation of the 2nd tooth.
 Crown cementation : from lingual to buccal to allow excess cement to escape buccally
for easier removal and less child discomfort
 Chair-side veneered crown: same but remove the metal from buccal aspect chairside to
allow esthetics
-If the buccal aspect is defective it can be restored by esthetic restorative material.
 Evidence Based Dentistry

Result - Better longevity than amalgam restoration

- Despite the possible bias in this study (as possible damage in teeth restored by amalgam in that
study was more extensive than SSC teeth>> but SSC remain the best.
- Retrospective studies in class II show 7% failure rate of SSC in comparison with 26% failure rate
in Amalgam after 5 years.
- Systematic review in pulpotomy show higher success rate of SCC than amalgam restored tooth

- Pediatric crowns are under-utilized, most likely because of their cost.

- Other restoration options do not provide their durability specially when caries extends
beyond ideal restorative parameters
- Esthetics: science of beauty: that particular detail of an animate or inanimate object
that makes it appealing to the eye.
- Well contoured & well aligned white teeth set the standard for beauty  attractive and
indicative of nutritional health, self-esteem, hygienic pride.
- Parents and children alike would preferred to have a tooth-colored crowns

Zirconia Crowns
Excellent esthetics, but are very expensive & require extensive tooth reduction.
Types:
1. Kinder Crowns
2. _______ Crowns
 Restoration of primary anterior teeth and canines
Indications:
1. Caries
2. Trauma
3. Developmental defects of teeth
 Filling materials used:
a. Adhesive materials, usually resin-based composites or glass ionomer products, are
placed in class III, IV and class V.
b. Amalgam  History.

Class III adhesive restorations

 Challenging:
1- Caries often extend subgingivally, difficult isolation and hemorrhage control.
2- Large size of pulp horns (the preparation must be kept very small)
3- Inadequate retention of the restoration with only acid etching; additional mechanical
retention is required.
 Aids of mechanical retention:
1- Retentive locks in the facial and lingual surfaces
2- Beveling the cavo-surface margin to increase Surface area  Increase retention.
3- Preparing the entire facial surface by 0.5 mm and veneering the surface for
additional bonding
4- Dovetail in Labial or Lingual surface
Restoring the distal surface of primary canines:
- The proximal box is directed at a different angle toward the gingiva.
- Either amalgam or adhesive restorative materials may be used in this location.
- Dovetail: choose aspect of approach according to caries site either Lingual or Labial

Class V restorations for anterior teeth

 Adhesive filling materials or amalgam

Preparation:
 1- Burs no.330  1mm from the outer enamel surface
2- Move laterally into sound dentine and enamel (walls), slightly flared near the
proximal surfaces
3- The pulpal wall should be convex
4- Mechanical retention (amalgam): small undercuts, gingivoaxial and incisoaxial line
angles.
5- Resin based composites: a short bevel is placed around the cavosurface margins.
Etching, bonding, filling and finishing
 When Class III is accompanied by Class V can use retentive lock of C Shape  join both
cavities to Increase retention (Not needed in permanent)
 Class IV can be done, but if a great deal of tooth structure lost, full coverage with full
crown.

Full coronal coverage

Indications:
1. large proximal lesions
2. Pulp therapy
3. Fractured ant. tooth
4. Hypoplastic defect
5. Discolored incisors
6. Small proximal lesions and cervical decalcification

Types :
1- Adhesive resin-based composite crowns (celluloid crown) (Most Simple)
2- SSCs ( History)
3- Open face SSCs (chair-side veneered)
4- Veneered SSCs (pre-veneered)
5- Esthetic Zercnia crowns

Preparation:
1. Incisal: 1.5 ml
2. Proximal: Just opening the contact
3. Facial: 1 mm
4. Lingual: .5 mm