Lecture 6 in young permanent teeth-pdf.pdf

Dent 4002 Pediatric Dentistry II Associate Professor Banu Öter, DDS,PhD Bahçeşehir University School of Dental Medicine Department of Pediatric Dentistry Course 6: Principles of Restorative Treatment in young permanent teeth Restorative treatment in pediatric patient 10.10.2022 Course headings...

Dent 4002 Pediatric Dentistry II Associate Professor Banu Öter, DDS,PhD Bahçeşehir University School of Dental Medicine Department of Pediatric Dentistry Course 6: Principles of Restorative Treatment in young permanent teeth Restorative treatment in pediatric patient 10.10.2022 Course headings Operative treatment of dental caries in the young permanent dentition Restorative treatment in young permanent teeth 07.11.2023 Caries in young permanent teeth Caries is a chronic disease. If it starts to affect the permanent teeth the child patient is drawn into a cycle requiring ongoing care for the rest of his/her life. Therefore when treating the young permanent dentition we have to adopt an approach that considers and addresses the whole disease process and not just treat the outcome of the disease. Restorative treatment in young permanent teeth 07.11.2023 Caries is still a considerable problem in children and adolescents. The 2013 Child Dental Health Survey for England, Wales, and Northern Ireland found that, on average, nearly half (46%) of 15-year-olds and a third (34%) of 12-year-olds had obvious decay experience. These children are at high risk of pain and discomfort relating to their teeth. The 2013 survey also looked at the impact on daily life. On average, a fifth of 12- and 15-year-old children reported experiencing difficulty eating, and about half reported that their life had been affected by problems with their teeth or mouth within the previous 3 months (Steele et al. 2015). Restorative treatment in young permanent teeth 07.11.2023 Eruption of permanent molars-unnoticed The first permanent teeth erupt in the mouth at approximately 6 years of age, but may appear as early as 4 years of age. The eruption of the anterior teeth usually causes great excitement, as it is associated with ‘the fluttering of tooth fairy wings’. However, the eruption of the first permanent molars goes largely unnoticed until there is a problem. Restorative treatment in young permanent teeth 07.11.2023 Importance of Extensive deep caries in young permanent teeth When the tooth erupts its roots are incompletely formed and are 20– 40% shorter than the mature root. It takes up to 5 years after eruption for the root to complete its formation and develop an apical constriction. Restorative treatment in pediatric patient 10.10.2022 Extensive deep caries in young permanent teeth Three methods of caries removal have been compared to complete excavation, where all carious dentin is removed. Stepwise excavation is a two-step caries removal process in which carious dentin is partially removed at the first appointment, leaving caries over the pulp, with placement of a temporary filling. At the second appointment, all remaining carious dentin is removed, and a final restoration placed. Restorative treatment in pediatric patient 10.10.2022 Extensive deep caries in young permanent teeth Partial, or one-step, caries excavation removes part of the carious dentin but leaves caries over the pulp, and subsequently places a base and final restoration. No removal of caries before restoration of primary molars in children aged three to 10 years also has been reported. Restorative treatment in pediatric patient 10.10.2022 Extensive deep caries in young permanent teeth Evidence from multiple studies shows that pulp exposures in primary and permanent teeth are significantly reduced when using incomplete caries excavation compared to complete excavation in teeth with a normal pulp or reversible pulpitis. The pulpal vitality of teeth treated with partial excavation compared to stepwise excavation the success rate was significantly higher in partial excavation (80 percent) versus stepwise excavation (56 percent). The risk for permanent restoration failure was similar for incompletely and completely excavated teeth. Restorative treatment in pediatric patient 10.10.2022 Extensive deep caries in young permanent teeth Indirect pulp capping If caries is deep and exposure is likely to occur, Leave caries in the deepest part of the lesion when it is felt that further removal would lead to pulp exposure. Restorative treatment in pediatric patient 10.10.2022 Extensive deep caries in young permanent teeth Indirect pulp capping Place a base over the remaining carious dentine to achieve optimal seal to stimulate healing and repair. It is important to remove caries from all the lateral walls of the cavity before restoration. Traditionally, operators use calcium hydroxide for indirect pulp capping which has a good success rate. Alternatives suggested include adhesive resins and glass ionomer cements or silicate-based material including mineral trioxide aggregate (MTA) and Biodentine®. Restorative treatment in pediatric patient 10.10.2022 A very large carious lesion with a definite risk of pulp exposure Remove caries from the amelodentinal junction. Remove further soft caries from all areas except where the operator considers that such removal will expose the pulp. Place a lining material. Tooth filled with glass ionomer prior to preparation for a preformed metal crown or placement of definitive composite restoration Extensive deep caries in young permanent teeth Whichever material is utilized, the crucial factor is good isolation of the pulp from the oral environment with a restoration of sufficient integrity to keep any remaining bacteria isolated from their source of nutrition such that they either remain dormant or die. Restorative treatment in pediatric patient 10.10.2022 Extensive deep caries in young permanent teeth Reinvestigation of such affected teeth after about 6 months when the pulp has had an opportunity to lay down reparative dentine used to be the standard approach. Studies have found that the remaining carious dentine mostly remineralizes and hardens, and caries progression does not occur in the absence of microleakage. Stepwise removal of caries and indirect pulp capping is the treatment of choice for symptomless immature molars with extensive caries Restorative treatment in pediatric patient 10.10.2022 Extensive deep caries in young permanent teeth Direct pulp capping When a small exposure is encountered during cavity preparation the operator can place a direct pulp cap. Again, the aim is to preserve the vitality of the pulp and avoid any exposure when possible. Calcium hydroxide has traditionally been used as the remedial agent. Total etching and sealing with a dentine bonding agent has been tried, but this resulted in increased non-vitality and so it is contraindicated. Successful results have been reported with MTA and Biodentine® as pulpcapping agents. Restorative treatment in pediatric patient 10.10.2022 Direct pulp capping in young permanent teeth It is important to assess the situation correctly before embarking on the treatment for all techniques in which the pulp is preserved. It is important that: • there is no history of spontaneous pain • there is no swelling, mobility, or discomfort to percussion • there is a normal periodontal appearance radiographically • pulp tissue appears normal and vital • cessation of bleeding from the pulp exposure site with isotonic irrigation occurs within 2 minutes Restorative treatment in pediatric patient 10.10.2022 Where a pulp exposure occurs in an immature permanent molar, cut out the superficial pulp tissue (about 2mm) with a high-speed diamond bur. Bleeding should cease easily Pressure with saline-soaked cotton-wool pledget consolidates the position. It is important to stress that the haemorrhage must cease before placing the lining Place a calcium hydroxide lining. Place a glass ionomer base over the calcium hydroxide. Restore with etched bonded composite resin to provide a hermetic seal. There is no need to re-investigate the site, so consider the restoration as definitive. Treatment for hypomineralized, hypomature or hypoplastic first permanent molars. This term covers a range of developmental anomalies from a small white, yellow, or brown patch to extensive loss of tissue from almost the whole enamel surface. - MIH affects up to 25% of the population. - Hypomineralized molars can be extremely sensitive Restorative treatment in pediatric patient 10.10.2022 Treatment for hypomineralized, hypomature or hypoplastic first permanent molars. Restorative treatment in pediatric patient 10.10.2022 Treatment for hypomineralized, hypomature or hypoplastic first permanent molars. For the sensitivity. • repeated application of 5% sodium fluoride varnish (Duraphat®) • commercially available ‘sensitive tooth’ toothpastes • daily use of 0.4% stannous fluoride gels • CPP–ACP Restorative treatment in pediatric patient 10.10.2022 Treatment for hypomineralized, hypomature or hypoplastic first permanent molars. Fissure sealants and glass ionomer placed on hypomineralized molars as a temporary measure to reduce sensitivity. Restorative treatment in pediatric patient 10.10.2022 Treatment for hypomineralized, hypomature or hypoplastic first permanent molars. 1- If the decision is extraction of first molars in the future as part of a longer-view orthodontic plan, need temporization to render them comfortable because of the high sensitivity. 2- If the intention is long-term maintenance of the molar, use conventional restorative techniques. However, it is difficult to determine where the margins of a preparation should be left, as seemingly normal enamel (to visual examination) sometimes breaks down 3- Amalgam is of limited use because further breakdown often occurs at the margins, and as it is non-adhesive it does not restore the strength of the tooth. 4- Composite resins should have a good success rate when used with an appropriate bonding agent in welldemarcated lesions. Restorative treatment in pediatric patient 10.10.2022 Caries and further breakdown around an amalgam in a hypomineralized molar Advanced restorative techniques Management of more complicated clinical problems associated with children and adolescents: tooth discolouration, inherited enamel and dentine defects, hypodontia, and tooth surface loss. Vital bleaching—chairside and at home technique. Inside/outside bleaching. Hydrochloric acid–pumice micro-abrasion technique. Non-vital bleaching. Restorative treatment in pediatric patient 10.10.2022 Advanced restorative techniques Localized composite resin restorations. Composite veneers—direct and indirect. Porcelain veneers. Adhesive metal castings. Full crowns. Bridgework—adhesive and fixed Restorative treatment in pediatric patient 10.10.2022 (a) A young patient with amelogenesis imperfecta. (b) Contoured matrix strip in position. (c) Incremental placement of dentine shade composite. (d) Postoperative view showing final composite veneers Advanced restorative techniques Resin infiltration technique: It is a novel technology that bridges the gap between prevention and restoration of carious lesions up to the first third of dentin (D-1) and can camouflage aesthetically disfiguring white lesions on the buccal surface. Restorative treatment in pediatric patient 10.10.2022 Dent 4002 Pediatric Dentistry II Associate Professor Banu Öter, DDS,PhD Bahçeşehir University School of Dental Medicine Department of Pediatric Dentistry