Restorative Dentistry for Primary Dentition PDF

Restorative Dentistry for the Primary Dentition Part 1 Dr. Lama M. Al-Sabe’ BA, M.Sc Paed Dent  Lecture Outline ⚫Intoduction. ⚫Instrumentation and caries removal. ⚫Use of the rubber dam in pediatric restorative dentistry. ⚫Restoration of...

Restorative Dentistry for the Primary Dentition Part 1 Dr. Lama M. Al-Sabe’ BA, M.Sc Paed Dent  Lecture Outline ⚫Intoduction. ⚫Instrumentation and caries removal. ⚫Use of the rubber dam in pediatric restorative dentistry. ⚫Restoration of primary molars ⚫Class I amalgam restorations. ⚫Class II amalgam restorations. ⚫Problems with amalgam restorations. ⚫Finishing of amalgam restorations. ⚫Adhesive materials in primary molars. ⚫Restoration of incisors and canines. ⚫Class III adhesive restorations. ⚫Class V restorations for incisors and canines.  Introduction ⚫Pediatric restorative dentistry is a dynamic combination of ever-imroving materials and tried-and-true techniques. ⚫Many aspects of primary teeth restoration have not changed for decades. ⚫In 1924, G. V. Black outlined several steps for the preparation of carious permanent teeth to receive amalgam restoration. These steps have been adopted, with slight modification, for the restoration of primary teeth. ⚫With an increased use of adhesive restorative materials and bonding systems, there has been a shift to more conservative preparations and restorations.  Introduction ⚫The clinician can stay with the proven, successful materials of the past, such as amalgam and SS, or move to newer, more esthetic materials that offer advantages such as: ⚫Bonding to tooth structure. ⚫Fluoride release. ⚫Improved aesthetics. ⚫Reduction of mercury exposure. ⚫Conservation of tooth structure. ⚫None of esthetic materials have the track record and proven durability of amalgam or SS, but when they are placed appropriately, they can provide useful restorations for the life span of the primary tooth. Instrumentation and Caries Removal ⚫Nearly all instrumentation for restorative procedures is carried out with the high-speed handpiece (100,000 to 300,000 rpm, either electric or air turbine) combined with coolant. ⚫Intermittent cutting at intervals of a few seconds with light, brushing strokes should be done to prevent excessive heat generation. ⚫Protective masks and eyewear should always be worn when using the high- speed air turbine handpiece. Cont…Instrumentation and Caries Removal The coolant techniques: ⚫The coolant may be water spray or air alone. ⚫A water spray coolant is often recommended for high-speed instrumentation; however, there is some evidence that air coolant alone may be used without creating irreversible pulpal damage, and use of both coolant techniques is taught in many pediatric dental residency programs. ⚫There are some instances when a water spray coolant is absolutely necessary. removing old amalgam restorations. using diamond burs.  Cont…Instrumentation and Caries Removal ⚫The low-speed handpiece (500 to 15,000 rpm) is most frequently used for: ⚫Caries removal. ⚫Polishing and finishing procedures. ⚫As with high-speed instrumentation, light pressure and brushing strokes should be used when using the low-speed handpiece.  Cont…Instrumentation and Caries Removal ⚫Use of hand instrumentation is minimal in most operative preparations in the primary dentition. ⚫It is usually limited to: ⚫Final caries removal. ⚫Planing of enamel walls.  Microdentistry ⚫Though use of a handpiece for caries removal and cavity preparation is by far the most popular and frequently used method, there are at least three other methods of treating carious teeth which are: ⚫Air abrasion, ⚫Laser treatment, and ⚫Chemomechanical methods. ⚫With these methods, tooth preparations move from the traditional, conventional preparations used by G. V. Black to much more conservative, “tooth-saving” preparations, known as microdentistry. Depending on the type of carious lesions, method of instrumentation, and restorative material to be used, the clinician can opt for a conventional Black type of cavity preparation or for a much more conservative micropreparation.  Morphologic Considerations ⚫The primary teeth in comparison to the permanent teeth: ⚫Thinner enamel and dentin. ⚫The pulps are larger in relation to crown size. ⚫Pulp horns are closer to the outer surface, esp. M.B. ⚫Primary teeth demonstrate a greater constriction of the crown and have a more prominent cervical contour than permanent teeth.  Morphologic Considerations ⚫In prim teeth, en rods of the ging third of the crown extend in an occlusal direction from the DEJ. In contrast to perm teeth in which rods extend in cervical direction. ⚫Broad, flat proximal contact areas. ⚫Whiter than their perm successors. ⚫Relatively narrow occlusal surfaces.  Use of Rubber Dam in Pediatric Restorative Dentistry. ⚫The use of rubber dam is indispensable in pediatric restorative dentistry. ⚫Its adv: ⚫Better access and visualization. ⚫Moisture control. ⚫Improved safety. ⚫Decreased operating time. ⚫Many children tend to become quieter and relaxed. ⚫With R.D. , the child becomes a nasal breather enhances N.O. adminstration.  Cont..Use of Rubber Dam ⚫The few situations that the rubber dam can't be used are: ⚫In the presence of some fixed orthodontic appliances. ⚫When a very recently erupted tooth will not retain a clamp. ⚫In a child with an upper respiratory infection, congested nasal passage, or other nasal obstruction.  Preparing for Placement of the Rubber Dam ⚫Latex, latex-free. ⚫A 5 x 5 inch medium-guage. ⚫The darker the dam the better the contrast. ⚫With preattached disposable frame. ⚫Holes should be punched so that the rubber dam is centered horizontally in the face. ⚫The upper lip should be coverd, not the nostrils.  Cont…Preparing for Placement of the Rubber Dam ⚫Single tooth is isolated class I or V. ⚫At least one tooth anterior and one tooth posterior interproximal lesions. ⚫To isolate several teeth: ⚫Punching numerous holes. ⚫Slit technique.  Thank You Any Question ??  Restorative Dentistry for the Primary Dentition Dr. Lama M. Al-Sabe’ BA, M.Sc Paed Dent  AAPD Guidelines ⚫Restorative treatment shall be based upon the results of an appropriate clinical examination and ideally be part of a comprehensive treatment plan. ⚫The treatment plan shall take into consideration: 1. The developmental status of the dentition. 2. A caries-risk assessment based upon the caries history of the patient. The patient's oral hygiene. Anticipated parental compliance and likelihood of timely recall. 1. The patient's ability to cooperate for treatment.  Objectives of Restorative Treatment ⚫Objectives of restorative treatment are: ⚫To repair or limit the damage from caries. ⚫Protect and preserve the tooth structure. ⚫Maintain pulp vitality whenever possible.  Contemporary Management of Dental Caries ⚫Historically, the management of dental caries was based on the belief that caries was a progressive disease that eventually destroyed the tooth unless there was surgical and restorative intervention. ⚫Nowadays, it is recognized that restorative treatment of dental caries alone does not stop the disease process and restorations have a finite lifespan. Conversely, some carious lesions may not progress and, therefore, may not need restoration. Contemporary Management of Dental Caries ⚫Contemporary management of dental caries includes: ⚫Identification of an individual’s risk for caries progression. ⚫Understanding of the disease process for that individual. ⚫“Active surveillance” to assess disease progression and manage with appropriate preventive services, supplemented by restorative therapy when indicated.  When to Restore? ⚫Decisions for when to restore carious lesions should include: ⚫At least clinical criteria of visual detection of enamel cavitation. ⚫Visual identification of shadowing of the enamel. ⚫Radiographic recognition of enlargement of lesions over time.  Benefits of Restorative Therapy ⚫The benefits of restorative therapy include: ⚫Removing cavitations or defects to eliminate areas that are susceptible to caries. ⚫Stopping the progression of tooth demineralization. ⚫Restoring the integrity of tooth structure. ⚫Preventing the spread of infection into the dental pulp. ⚫Preventing the shifting of teeth due to loss of tooth structure.  Risks of Restorative Therapy ⚫The risks of restorative therapy include: ⚫Lessening the longevity of teeth by making them more susceptible to fracture. ⚫Recurrent lesions. ⚫Restoration failure. ⚫Pulp exposure during caries excavation. ⚫Future pulpal complications. ⚫Iatrogenic damage to adjacent teeth. ⚫Primary teeth may be more susceptible to restoration failures than permanent teeth. Additionally, before restoration of primary teeth, one needs to consider the length of time remaining prior to tooth exfoliation.  Restoration of Primary Molar ⚫The anatomy of the primary molars, makes them the most caries-susceptible primary teeth. ⚫Fissured occlusal surfaces. ⚫Broad, flat interproximal contact areas. ⚫The importance of primary molars in mastication and as maintainers of space for the succedaneous teeth, coupled with the development of suitable economic restorative materials shaped a philosophy of restoring and conserving primary molars.  Class I Amalgam Restoration General Considerations: ⚫The outline form: ⚫All retentive fissures and carious areas. ⚫As conservative as possible. ⚫Ideal pulpal floor depth is 0.5 mm into dentin (approximately 1.5 mm from the enamel surface). ⚫ The length of the cutting end of the no. 330 bur is 1.5 mm, so this becomes a good tool for gauging cavity depth. ⚫The cavosurface margin should be placed out of stress-bearing areas and should have no bevel. ⚫To help prevent stress concentration, the outline form should be composed of smoothly flowing arcs and curves, and all internal angles should be rounded slightly.  Cont…Class I Amalgam Restoration ⚫When a dovetail is placed (in Es) its BL width > the width of the isthmus. ⚫The isthmus 1/3 of the intercuspal width. ⚫The BL walls should converge slightly in an occlusal direction. ⚫M and D walls should flare at the marginal ridge so as not to undercut ridges. ⚫Oblique ridges should not be crossed unless they are undermined with caries or are deeply fissured. ⚫Prim mand Es often exhibit buccal developmental pits. When carious, these should be restored with a small teardrop or ovoid-shaped restoration, including all the adjacent susceptible pits and fissures.  Cont…Class I Amalgam Restoration Liners and bases: ⚫Neither liners nor bases are very widely used. ⚫Thin liners such as CaOH: ⚫Do not provide thermal insulation. ⚫May hydrolyze gradually, leaving a small void underneath the restoration and ultimately weakening it. Therefore its use is discouraged. ⚫Cavity varnish, though widely used in the past to prevent microleakage, is no longer considered useful.  Cont…Class I Amalgam Restoration Liners and bases: ⚫Placement of bases in prim teeth is also uncommon, but when necessary, use of GI or RMGI is recommended. ⚫Because of the relatively large size of the pulp chamber in prim teeth, preparations that are placed deep enough to require bases are generally found to be into the pulp and hence require other treatment.  Steps of Preparatation and Restoration ⚫1. Administer L.A. & rubber dam. ⚫2. Using a no. 330 bur (high-speed), penetrate into the tooth parallel to its long axis in the central pit region and extend into all susceptible fissures and pits to a depth 0.5 mm in dentin. ⚫3. Remove all carious dentin. ⚫4. Smooth the enamel walls and refine the final outline form (no. 330 bur). ⚫5. Rinse and dry the preparation, and inspect for ⚫ Cariesremoval, ⚫ Sharp cavosurface margins, and ⚫ Removal of all unsupported enamel.  Cont…Steps of Preparatation and Restoration ⚫6. Triturate the amalgam & place one carrier load. ⚫7. By a small condenser, begin condensation of small overlapping increments (until the cavity is slightly overfilled). ⚫8. Use a ball burnisher to begin the initial contouring. Then carving (by small cleoid-discoid carver). ⚫Always keep part of the carving edge of the instrument on the tooth structure so that overcarving of the cavosurface margin does not occur. ⚫Remove all amalgam flash from cavosurface margins. ⚫Keep the carved anatomy shallow. Placing deep anatomy in primary teeth (Le., grooves) can weaken the restoration by creating a thin shelf of amalgam at the cavosurface margin and also by reducing the bulk of amalgam in the central stress-bearing areas, both leading to fracture.  Cont…Steps of Preparatation and Restoration ⚫9. When the amalgam has begun its initial set and resists deformation, begin burnishing (small, round burnisher) to produce a satin-like appearance. Adv: ⚫Smoothing the surface. ⚫Creates a substructure with fewer voids and reduces finishing time. ⚫10. A wet cotton pellet can be wiped across the burnished amalgam for a final smoothing (optional). ⚫11. Remove the rubber dam and check the occlusion (articulating paper, necessary adjustments with the carver). ⚫12. Rinse the oral cavity and massage the soft tissue around the previously clamped tooth.  Common Errors ⚫Some frequent errors made in class I amalgam restorations are: ⚫(1) preparing the cavity too deep; ⚫(2) undercutting the marginal ridges; ⚫(3) carving the anatomy of the amalgam too deep; ⚫(4) not removing amalgam flash from cavosurface margins; ⚫(5) undercarving, which leads to subsequent fracture of amalgam from hyperocclusion; and ⚫(6) not including all susceptible fissures. Note that an alternative to including all of the susceptible fissures is to confine the amalgam preparation to the area of decay and seal the rest of the tooth with a pit and fissure sealant.  Thank You Any Question ??  Restorative Dentistry for the Primary Dentition Part III Dr. Lama M. Al-Sabe’ BA, M.Sc Paed Dent  Lecture Outline ⚫Intoduction. ⚫Instrumentation and caries removal. ⚫Use of the rubber dam in pediatric restorative dentistry. ⚫Restoration of primary molars ⚫Class I amalgam restorations. ⚫Class II amalgam restorations. ⚫Problems with amalgam restorations. ⚫Finishing of amalgam restorations. ⚫Adhesive materials in primary molars. ⚫Restoration of incisors and canines. ⚫Class III adhesive restorations. ⚫Class V restorations for incisors and canines.  Class II Amalgam Restorations General considerations: ⚫The guidelines for the occlusal portion the same as class I. ⚫The proximal box: ⚫Should be broader at the cervical portion than at the occlusal portion. ⚫The buccal, lingual, and gingival walls should all break contact with the adjacent tooth, just enough to allow the tip of an explorer to pass. ⚫B and L walls a 90-degree angle with the enamel. ⚫The gingival wall flat, not beveled, and all unsupported enamel should be removed.  Class II Amalgam Restorations General considerations: ⚫Cont… The proximal box: ⚫Ideally, the axial wall of the proximal box should be 0.5 mm into dentin and should follow the same contour as the outer proximal contour of the tooth. ⚫Axiopulpal line angle is routinely beveled or rounded. ⚫No buccal or lingual retentive grooves should be placed in the proximal box. ⚫MD width of the ging seat should be 1 mm, which is approximately equal to the width of a no. 330 bur.  Class II vs. SSCs ⚫In prim teeth many practitioners limit class II amalgam restorations to relatively small two-surface restorations. ⚫Three-surface (MOD) restorations may be done, but studies have shown that SSCS are a more durable and predictable. ⚫Messer and Leveringl reported that SSCs placed in 4-year-old and younger children showed a success rate approximately twice that of class II amalgams, for each year up to 10 years of service.  Class II vs. SSCs ⚫Roberts and Sherriff reported that after 5 years, one third of class II amalgams placed in prim teeth had failed or required replacement, whereas only 8% of SSCs required retreatment. ⚫In the preschool child with large proximal carious lesions, SSCs are preferred to amalgams because of their durability. ⚫Similar-sized lesions in teeth that are within 2 or 3 years of exfoliation may be restored with amalgam since the anticipated life span is fairly short. Steps of Preparatation and Restoration ⚫1. Administer appropriate L.A. and place R.D ⚫2. Place wooden wedge interproximally ; ⚫This retracts the gingival papilla during instrumentation, ⚫keeps the operator from cutting the interseptal R.D material and underlying gingiva, ⚫creates some prewedging, which helps to ensure a tight proximal contact of the final restoration.  Steps of Preparatation and Restoration ⚫3. Using a no. 330 bur (high-speed), prepare the occlusal outline form at ideal depth. Maxillary right second and first primary molars Mandibular right first and second primary molars (occlusal view) (occlusal view).  Cont…Steps of Preparatation and Restoration ⚫4. To prepare the proximal box; ⚫begin at the marginal ridge by brushing the bur (BL) in a pendulum motion and in a ging direction at the DEJ. ⚫Continue until contact is just broken between the adjacent tooth and the ging wall and the wedge is seen. ⚫The widest BL width of the box will be at the gingival margin. Mandibular second primary molar (proximal view); note occlusal convergence of proximal walls ⚫If the ging wall is made too deep, the cervical constriction of the primary molar will create a very narrow gingival seat.  Cont…Steps of Preparatation and Restoration ⚫5. Remove any remaining caries. ⚫6. Round the axiopulpal line angle slightly. ⚫7. Remove the wedge and place a matrix band. ⚫8. While holding the matrix band in place, forcefully reinsert the wedge between the matrix band and the adjacent tooth, beneath the ging seat of the preparation.  Cont…Steps of Preparatation and Restoration ⚫9. Triturate the amalgam. With the amalgam carrier, add the amalgam to the preparation in single Increments, beginning in the proximal box. ⚫ 10. Using a small condenser, condense the amalgam into the corners of the proximal box and against the matrix band to ensure the reestablishment of a tight proximal contact. Continue filling and condensing until the entire cavity is overfilled.  Cont…Steps of Preparatation and Restoration ⚫11. Use a small round burnisher to begin the initial contouring of the amalgam. Carving of the occlusal portion is performed with a small cleoid- discoid carver, as in class I restorations.  Cont…Steps of Preparatation and Restoration ⚫The marginal ridge can be carved with the tip of an explorer or with a Hollenback carver.  Cont…Steps of Preparatation and Restoration ⚫12. Remove the wedge and the matrix band;(drawing the band in a BL direction), ⚫13. Remove excess amalgam at the buccal, lingual, and gingival margins with an explorer or Hollenback carver. ⚫ 14. Gently floss the interproximal contact; ⚫ to check the tightness of the contact, ⚫to check for gingival overhang, ⚫and to remove any loose amalgam particles from the interproximal region. ⚫15. Final burnish, and wet cotton pellet for final smoothing (if necessary). ⚫ 16. Remove R.D. ⚫17. Check the occlusion.  Matrix Application ⚫Matrices should be placed for proximal restorations to: 1. Restore normal contour. 2. Restore normal contact, 3. Prevent the extrusion of restorative material into gingival tissue.  Matrices Types ⚫T-band: ⚫Sectional matrices(strip-T). ⚫Automatrix. ⚫Tofflemiere matrix.  Thank You Any Question ??  Restorative Dentistry for the Primary Dentition Part IV Dr. Lama M. Al-Sabe’ BA, M.Sc Paed Dent  Lecture Outline ⚫Intoduction. ⚫Instrumentation and caries removal. ⚫Use of the rubber dam in pediatric restorative dentistry. ⚫Restoration of primary molars ⚫Class I amalgam restorations. ⚫Class II amalgam restorations. ⚫Problems with amalgam restorations. ⚫Finishing of amalgam restorations. ⚫Adhesive materials in primary molars. ⚫Restoration of incisors and canines. ⚫Class III adhesive restorations. ⚫Class V restorations for incisors and canines. Adjacent or Back-to-Back Class II Amalgam Restorations ⚫A matrix is placed on each tooth and is properly wedged. ⚫T bands, sectional, or automatrices (preferable) multiple matrix holders are difficult to place side by side. ⚫Condensation: ⚫ in small increments, alternately (restorations are filled simultaneously). ⚫ pressure toward the matrix will help ensure a tight interproximal contact. ⚫Carve the marginal ridges to an equal height, and carefully remove the wedge and matrix bands one at a time.  Problems with Amalgam Restorations ⚫Most problems result from a failure to prepare and restore the teeth in a way that takes into account their anatomic or morphologic structural characteristics and limitations. Common problems in class II amalgam restorations: ⚫Fracture of the isthmus restoration being left high in occlusion. insufficient bulk of amalgam in the isthmus. ⚫Marginal failure in the proximal box excessive flare of the cavosurface margin. ⚫Restoration failure failure to remove all caries or to extend prep into caries- susceptible fissures. ⚫*insufficient bulk of amalgam in the isthmus, because the preparation is too shallow, or because the amalgam has been overcarved.  Finishing of Amalgam Restorations ⚫Historically, polishing of amalgams was advocated to: ⚫( 1) Eliminate surface scratches and blemishes, which act as centers of corrosion, ⚫(2) Remove any remaining amalgam flash not carved away. ⚫(3) Refine the anatomy and occlusion.  Cont…Finishing of Amalgam Restorations ⚫There is little evidence that polishing amalgam restorations contributes to their clinical success or longevity. ⚫A study by Straffon and colleagues compared the clinical performance of polished and unpolished amalgams after 3 years. ⚫ There was no significant difference in marginal integrity between carved and burnished-only and polished restorations through 3 years. ⚫ Polishing of class I amalgam restorations did not result in better adapted margins after 36 months of function. ⚫ The surface texture of the polished amalgams was significantly smoother than the burnished-only amalgams. ⚫ However, by 36 months a significant number of the burnished-only restorations had exhibited improvement in surface texture over baseline.  Cont…Finishing of Amalgam Restorations ⚫Because polishing of amalgam is likely not going to be done, it is important that the amalgam at least be well burnished and all excess amalgam marginal flash be removed at the time of placement. ⚫When small overhangs of marginal flash are left fracture under occlusal forces then create a marginal discrepancy.  Cont…Finishing of Amalgam Restorations ⚫There are no contraindications to polishing amalgams. ⚫For final polishing: ⚫A 12-fluted carbide bur (high-speed handpiece). ⚫A rubber polishing point (slow-speed handpiece). ⚫Should not be done for at least 24 hours after placement. ⚫Heat production should be minimized.  Posterior Composites or Amalgams ⚫As early as the mid-1960s composite resins were suggested as aesthetic replacements for class I and class II amalgam restorations in molars. ⚫After 2 years the greatest problem being occlusal wear. ⚫Further improvements; ⚫Smaller filler particles, increases in material strength, ⚫improvement of dentin-bonding agents, ⚫have led to improved clinical results.  Posterior Composites or Amalgams ⚫In a 5-year study comparing posterior composites and amalgams, Norman and colleagues reported that: ⚫Both materials were satisfactory over the time period studied. ⚫The only significant statistical differences were a poorer marginal integrity for the amalgam and a greater wear rate for the resin.  Cont…Posterior Composites or Amalgams ⚫Another study, Bernardo and colleagues (7-year clinical study): ⚫ Composite to be an acceptable restorative material. However, amalgam demonstrated fewer failures than composites, particularly in restorations with 3 or more surfaces. ⚫Composite recurrent decay was the main cause of failure of the post comp (3.5 times greater than amalgam). ⚫Amalgam a little more prone to failure because of fracture. *Composite recurrent decay was the main cause of failure of the post comp restorations. The risk of secondary caries was 3.5 times greater in composite restorations than amalgam,  Cont…Posterior Composites or Amalgams ⚫The ADA’s Council on Scientific Affairs has concluded that when used correctly in the prim and perm dentition, the expected lifetimes of resinbased composites can be comparable to that of amalgam in class I, II, and V restorations. ⚫The use of resin-based composite materials in prim molars offer the advantages of : ⚫Improved aesthetics. ⚫Elimination of mercury. ⚫Low thermal conductivity. ⚫More conservation of tooth structure. ⚫Easier reparability. ⚫Bonding of the restorative material to the tooth.  Cont…Posterior Composites or Amalgams ⚫Disadvantages include: ⚫An exacting technique. ⚫Incompatibility with moisture contamination during placement. ⚫Increased operator time. ⚫Potential marginal leakage. ⚫Possible postoperative sensitivity. ⚫A tendency to open or lose contacts.  Adhesive Materials Options: ⚫Resin-based composites. ⚫Polyacid-modified resinbased composites; or compomers [Dyract eXtra]. ⚫Resin-modified glass ionomers [Vitremer ]. ⚫Glass ionomers [Ketac Nano]. ⚫As adhesive restorations improve and aesthetic and other concerns are raised about amalgam, resin-based composites and resin ionomer products have become more widely used in both prim and perm post teeth.  Adhesive Materials ⚫Compomer : provide useful, predictable restorations. ⚫Resin-modified glass ionomer cement (RMGI): More color change and occlusal wear than resin-based comp or compomers, but still function well in class I, II, III, and V restorations. ⚫Glass ionomer cements: Less satisfactory results than the other adhesive materials. Its use for multisurface or large restorations in prim molars, except for teeth with a very limited life span, is generally not recommended or indicated.  General Principles General principles for restoring primary posterior teeth with resin-based composite: ⚫(1) Highly technique sensitive, (very negatively affected by any moisture ). RMGI can tolerate some moisture and might be used as an aesthetic material in such a situation. ⚫(2) More conservative preparations. ⚫(3) Because of bonding to tooth structure, the need for mechanical retention in the prep is lessened. ⚫(4) Historically, occlusal wear used to be the most common problem with posterior resin- based comp, but with the new hybrid and nanoparticle resins, wear is generally no longer a concern.  Cont…General Principles General principles for restoring primary posterior teeth with resin-based composite: ⚫(5) Secondary or recurrent caries is the most frequent reason for clinical replacement of composite restorations. Extreme care ( moisture control and adequate adaptation ). ⚫(6) Dentinbonding agents and resin-based composites and compomers have all improved dramatically. Recent studies conservative proximal box -only preparations to perform as well as G. V. Black's traditional class II preparations, (esp, compomer ).  Class I & II Preparation Few differences btw comp &amalgam: ⚫Absolute moisture control is a must, making a rubber dam almost mandatory. ⚫No current consensus about the precise design of a class II prep. ⚫A 2001 survey of ped dent departments in North American dental schools found that: 57% of the dental schools teach a conservative "box-only" prep (with and without retention grooves). 36% use and teach the traditional G. V. Black amalgam prep.  Cont…Class I & II Preparation Leinfelder recommended slot preparation : ⚫class II prep restricted to the region of the caries with little to no occlusal extensions. ⚫Extending the proximal box line angles in “self-cleansing" areas is not necessary ⚫A short bevel to the cavosurface margin to increase surface area for bonding and to remove the aprismatic layer of enamel. Class II slot preparation  Thank You Any Question ??  Restorative Dentistry for the Primary Dentition Part V Dr. Lama M. Al-Sabe’ BA, M.Sc Paed Dent  Lecture Outline ⚫Intoduction. ⚫Instrumentation and caries removal. ⚫Use of the rubber dam in pediatric restorative dentistry. ⚫Restoration of primary molars ⚫Class I amalgam restorations. ⚫Class II amalgam restorations. ⚫Problems with amalgam restorations. ⚫Finishing of amalgam restorations. ⚫Adhesive materials in primary molars. ⚫Restoration of incisors and canines. ⚫Class III adhesive restorations. ⚫Class V restorations for incisors and canines.  Cont…Class I & II Preparation Leinfelder recommended slot preparation : ⚫Prewedging of teeth. ⚫Matrices: ⚫Clear plastic or thin steel matrices may be used. ⚫Steel bands or strips are easier to use and more reliable in producing adequate contact areas. ⚫Circumferential matrix bands that are tightly constricted around the tooth may leave open proximal contacts. ⚫After it is in place and a wedge firmly inserted, the use of a small ball burnisher can be used to burnish the band in the area of the contact point against the adjacent tooth tight prox contact.  Cont…Class I & II Preparation Leinfelder recommended slot preparation : ⚫If RMGI liner is to be used should be placed and cured before the etchant. ⚫Etching: 15 - 20 sec with an acid gel. ⚫After thoroughly rinsing the etch from the tooth, a dentin bonding agent is applied and cured. ⚫No more than a 2-mm depth of composite should be polymerized at one time.  Back- to- back class II resin-based comp restorations ⚫With two matrix bands in place, etch and bond both preparations. ⚫Completely fill, contour, and polymerize one of the restorations. ⚫To ensure a tight contact between the two restorations, after the first restoration is polymerized use a small ball burnisher and burnish the matrix band against the newly placed restoration in the area where you want to create the contact point. ⚫Then add, contour, and polymerize the resin-based composite material in the second preparation. ⚫Remove the wedge and bands and finishing and polishing procedures are identical to single restoration placement.  Restoration of Primary Incisors and Canines Indications: ⚫(1) Caries. ⚫(2) Trauma. ⚫(3) Developmental defects of the tooth's hard tissue.  Class III Adhesive Restorations ⚫Very challenging: ⚫Extend subgingivally difficult isolation and hemorrhage control. ⚫Large pulp size preparations must be kept very small.  Cont…Class III Adhesive Restorations ⚫A simple slot preparation merely removes decay and has a short cavosurface bevel. ⚫Retention is gained by: ⚫Acid etching. ⚫Retentive locks on the facial or lingual surface ( in children, esp those with bruxism). ⚫By beveling the cavosurface margin to increase the surface area of the enamel etched. ⚫Preparing the entire facial surface by 0.5 mm and veneering the surface.  Class III Restorations in Primary Canines ⚫Slightly different prep from that for incisors. ⚫The proximal box is directed at a different angle toward the gingiva. ⚫Either amalgam or adhesive materials may be used. ⚫The preparation, with the exception of a short cavosurface bevel for resin materials, is identical regardless of the restorative material chosen. ⚫A dovetail may be placed on the facial surface, except when amalgam is chosen for a maxillary canine; in that situation, the dovetail is placed on the palatal surface.  Cont…Class III Restorations in Primary Canines Modified Class III Cavity Preparation ⚫It uses a dovetail on the lingual or on the labial surfaces of the tooth. ⚫Lingual lock max canine. ⚫Labial lock mand canine (esthetic requirement is not so important). ⚫Allows for additional retention and access necessary to insert the restorative material properly.  Clinical Steps ⚫Administer appropriate anesthesia. ⚫Place the rubber dam. ligation of individual teeth with dental floss provides the best stability. ⚫Place a wooden wedge interproximally.  Cont… Clinical Steps ⚫Create access, and remove caries with a no. 330 bur or a no. 2 round bur (high-speed), using a facial access. ⚫The axial wall : ⚫Ideally placed 0.5 mm into dentin. ⚫A round bur (low-speed) to remove deep decay. ⚫The gingival and lingual walls should just break contact with the adjacent tooth. ⚫It is not necessary to break contact with the incisal wall of the preparation to maintain adequate tooth structure.  Cont… Clinical Steps ⚫To enhance retention, a dovetail or lock may be placed on the labial or lingual surface. ⚫Should not extend more than halfway across the labial surf. ⚫In the middle horizontal third of the tooth. ⚫May extend across the cervical, if there is presence of cervical decalcification.  Cont… Clinical Steps ⚫Place a short bevel (0.5 mm) at the cavosurface margin. ⚫With a fine, tapered diamond or with a flame-shaped composite finishing bur. ⚫Clean and dry the preparation with water and compressed air. ⚫Place a plastic or sectional metal matrix. ⚫Cut in half horizontally. ⚫The matrix is placed interproximally. ⚫A wedge is reinserted.  Cont… Clinical Steps ⚫Etch (15 - 20) seconds. ⚫After etching, rinse and dry the preparation well. (If a self-etching bonding agent is used, this step is eliminated). ⚫Place a dentin-bonding agent. ⚫Gently blow compressed air into the preparation to disperse a thin layer of bonding agent evenly over both dentin and enamel. ⚫Polymerize the bonding agent.  Cont… Clinical Steps ⚫With a plastic instrument or a pressure syringe, place the composite in the preparation. ⚫Pull the matrix tightly around the cavity prep with finger pressure and hold until cured. ⚫Hold the visible light as closely as possible to the composite and polymerize according to the manufacturer's instructions.  Cont… Clinical Steps ⚫Finishing and polishing can be performed immediately following polymerization. ⚫Gross finishing or contouring can be performed with fine-grit diamonds or with carbide finishing burs. flame carbide finishing bur ⚫A flame carbide finishing bur (12 to 20 flutes) is excellent for finishing the facial and interproximal surfaces. ⚫The lingual surface is best finished with a round or pear-shaped carbide finishing bur. A lubricated, pointed white stone may also be used for smoothing. pear-shaped carbide finishing bur.  Cont… Clinical Steps ⚫Composite polishing gloss may be used for final polishing to create a luster like appearance. ⚫Final interproximal polishing of the restoration is completed with sandpaper strips. ⚫These strips will be best used if they are cut into thin strips 2 to 3 mm in width. Mounted abrasive disks can be used to finish the facial and lingual surfaces.  Cont… Clinical Steps ⚫As an optional step, after polishing is completed, an unfilled resin glaze may be added to the polished restoration. ⚫Provides a better marginal seal and a smooth, finished surface. ⚫Before addition, the restoration and surrounding enamel should first be etched for (15-20 sec) to remove surface debris. ⚫After rinsing and drying, the resin is painted onto the restoration and is polymerized. ⚫Care not to bond adjacent teeth together with the resin glaze. ⚫Remove the rubber dam and floss the interproximal areas to check for overhangs and to remove excess glaze material.  Class V Restorations for Incisors & Canines ⚫ may be adhesive materials (most frequently) or amalgams. ⚫ most often needed on the facial surface of canines. ⚫ Like Cl III adhesive restorations, except that no matrix is used.  Clinical Steps ⚫Penetrate the tooth in the area of caries with a no. 330 bur until dentin is reached (approximately 1 mm from the outer enamel surface). ⚫Move the bur laterally into sound dentin and enamel, thus establishing the walls of the cavity. ⚫The pulpal wall convex, parallel to the outer enamel surface. ⚫The lateral walls slightly flared near the prox surfaces to prevent undermining of enamel. ⚫The final external outline is determined by the extent of caries.  Cont…Clinical Steps ⚫Mechanical retention: ⚫Can be achieved with a no. 35 inverted cone bur or a no. 1/2 round bur, creating small undercuts in the gingivoaxial and incisoaxial line angles. ⚫For resin-based composites, a short bevel is placed around the entire cavosurface margin. ⚫Etching, bonding, material placement, and finishing (similar to that described for classIII adhesive restorations, except that no matrix is used).  Cavity Preparation in Primary Teeth ⚫This figure illustrates four high-speed carbide burs designed to cut efficiently and yet allow conservative cavity preparations with rounded line angles and point angles. ⚫These burs are: rounded-end, high-speed carbide burs No. 329, No. 330, No. 245, and No. 256.  Thank You Any Question ??