4. Pediatric Operative

PEDIATRIC OPERATIVE DENTISTRY

Dr. Sajith Bhaskar

Basis of pediatric operative dentistry:

• Maintenance of arch length – preserve primary teeth

• Maintenance of healthy oral environment – transmissible factor

• Prevention and relief of pain – conservative procedure

• Maintenance and improvement of appearance –

smile care

General considerations for Restoration

procedure in children

• Development status of dentition: Stage of root development / resorption

• Caries experience of the patient: Caries risk assessment based on history

• Patient’s oral hygiene

• Patient cooperation & parent compliance

• Individually tailored treatment plan

• Difference in tooth morphology-

Primary tooth is small, bulbous, bell shaped

Definite cervical constriction

Pulpal outline DEJ

Pulp horns are highly placed

Thin & uniform thick enamel

• Symmetry of caries attack

• Proximal decalcification in Cl-II lesions

• Need for bitewing radiograph, if contacts are closed

Consideration for efficient treatment:

• Appointments – Single arch treatment

• Positive attitude of the dental team

• Four handed dentistry

• Use euphemisms

Anatomical variations and Clinical significance:

• Need for early detection - ↑ Penetration of caries [mesial aspect of first primary molar]

• Ideal bur size [1mm] - avoid overextension for cavity and pulpal exposure

• Sufficient bulk of the restorative material – ↑ retention and better instrumentation

• Break contact area – B / L wall extension to embrasure for better cleaning

Classification of Cavity Preparation: [Primary & young permanent teeth]

G.V. Black’s Classification

Class I – V , Class VI [ Simon’s modification]

Sturdevant’s Classification:

Simple Cavity- One surface

Compound Cavity- Two surfaces

Complex Cavity- + Two surfaces

Baume’s Classification:

Pit & Fissure Cavities

Smooth Surface Cavities

Mount & Hume Classification:

• Minimal

1Moderate

2 Enlarged

3 Extensive

4

Pit & Fissure 1

1.1 1.2 1.3 1.4

Contact Area 2

2.1 2.2 2.3 2.4

Cervical 3

3.1 3.2 3.3 3.4

Conventional Concept of Cavity Preparation :

• G.V. Black’s concept – “extension for prevention”

• To prevent the recurrence of caries by placing the margins of restoration along self cleansing areas.

Outline form

• Extend cavity to sound tooth structure

• Include all fissures

• Extend to provide sufficient access

• Margins should include all defective enamel

• Margins kept at self cleansing areas

• Pulpal floor & Axial wall depth- 0.5 mm into dentine

• Clearance from Adjacent tooth in Proximal box preparation – 0.2- 0.3 mm

• Margins should not be in contact with opposing tooth

• Join 2 cavities if less that 0.5 mm tooth structure exists in-between

Resistance form:

Shape given to the cavity to enable the tooth as well as the restoration to withstand the stresses of mastication to which it is subjected

• Pulpal & gingival walls flat-

Perpendicular to occlusal force• Rounded internal line angles to avoid stress

concentration• 90 degree cavo-surface angle• Removal of unsupported enamel

• Adequate bulk of restorative material

• Adequate depth & width of the cavity

• Maintain the Strong Cusp & Ridge areas with adequate dentin support

• Reverse curve in the proximal Cl II cavities

• Gingival cavosurface bevel in cases of permanent teeth

• Width of the cavity not more than 1/4th – 1/5th the inter- cuspal distance

• Pulpal floor 0.5 mm below DEJ

Retention form: Factors of the cavity design that prevent restoration

from being displaced

• Parallel walls / Occlusally converging walls in Cl I & Cl II cavities

• Retention grooves & cores in Cl III & Cl V cavities

• Occlusal dovetail in proximo occlusal cavity

• Pins placed into dentin

• Acid etch for enamel

Convenience form:

• Modify cavo-surface margin for ease of placement of materials

Extension of buccal & lingual walls for visibility & access to deeper portion of cavity

• Proximal caries are instrumented from facial / lingual embrasure, in tooth with intact marginal ridge

Removal of any remaining infected dentin:

Finishing the enamel walls:• Smooth walls • Rounded angles• Place taper / bevel appropriate for restorative material

Cleaning of the cavity:

• Clean & saliva free cavity surfaces to improve the properties of restorative materials

• Use of Rubber Dam, Cotton Rolls, High vaccum suction

• Conditioning of cavity

ERRORS IN OUTLINE FORM

A. Excessive s-curve

(90 degree turns)

Make curve more gentle

B. Unsupported enamel rods at cavosurface

Plane proximal walls perpendicular to the cavosurface

C. Sharp turns Blend proximal walls into occlusal isthmus with gentle s-curves

D. Flared proximal walls with acute amalgam angles at cavosurface

Make proximal walls perpendicular to cavosurface blending with s-curve to isthmus

E. Beveling at cavosurface At the gingival cavosurface margin, the gingival wall is finished so that no unsupported enamel rods remain

Cavity modifications in Deciduous teeth: Class-I cavity: • In Case of small carious lesion the Isthmus should not

be more than 1/4th -1/3rd of inter-cuspal width.

• Depth should never be more than 0.5mm into dentin.

• Remove remaining carious lesion [infected dentin] using round bur at slow speed.

• Include lingual development groove with distal pit, for maxillary primary 2nd molars.

• Use preventive resin restoration wherever possible.

Incipient Class I-

In child < 2yrs; caries occasionally seen in pits• Make child sit on parents lap as mode of restrain• No L.A / R.D • Prepare small cavity; extend only to area involved • Use resin modified GIC / amalgam • Use preventive resin restoration if child is cooperative

P & F Class I-• Use preventive resin restoration

Deep Class I-

If Amalgam is the choice of restorative material• Remove all lesion, extend cavity into remaining

groove/ anatomic occlusal defect• Remove carious dentin, round the angles,

parallel cavity walls• Provide adequate thermal insulation to pulp

If Resin is the choice of restorative material• Prepare the cavity in area of involvement• Bevel the cavo-surface• Disease free fissure & groove are sealed as a part of

bonded restoration

Class-II cavity:

• Always place gingival seat beneath free margin of gingival.

• The gingival seat should follow enamel rod inclination, beveling not required in deciduous teeth.

• Due to broad contact area, the gingival floor will be wide to keep the margin in self cleansing area.

• The buccal & lingual walls are kept parallel

• Round the axio- pulpal line angles

Increase the retention, placing grooves along the DEJ in the proximal box.

The proximal box should allow the passage of explorer tip between margins and adjacent tooth in buccal, gingival, lingual direction

•Prepare MOD cavity for deciduous mand 2nd and max 1st molar [when both proximal areas are involved]

•Only if the oblique ridge is involved prepare MOD cavity for deciduous mand 1st and max 2nd molar

•Since contact with Canine is point contact, the proximal box preparation & gingival flare’s minimized in MO cavity of 1st Pri molar, as the pulp horns are highly placed.

Incipient Class II

• Topical Fluoride + Home fluoride + Diet change + Oral hygiene + Checkup

If the tooth & P& F are sound• Small opening is made with lateral & pulpal

movement of bur.• Use resin modified GIC.• No L.A / R.D if child is cooperative

Greater Dentin involvement- If Amalgam is the choice of restorative material• Break the contact area- at gingival seat & at proximal

wall• Extend to defective P & F• If sound occlusal surface – minimal dovetail• Axial wall, Buccal, Lingual wall must be at right angles• Buccal & Lingual proximal wall flare outward & to

cervical aspect• Use good matrix & wedge • Use liners & Base If Resin is the choice of restorative material• Similar cavity preparation as amalgam• If the P & F is only susceptible area, use a sealant• Increase in time & cost makes composite less used

compared to Resin Modified GIC

Class-III cavity: • Class III lesion are seen in children with crowding,

arch inadequacy, Increased caries activity; hence a comprehensive preventive program is used

• If only a Small lesion- Mandible – disking / stripping + F therapy

• Δ’r outline form in open contacts

• Base of the Δ towards gingival aspect

• Gingival wall inclines occlusally parallel to enamel rods.

• Retension pits placed in axio bucco gingival & axio linguo gingival point angles.

• In middle 1/3rd of the tooth, dove tail may be placed, in Canine [Max canine- Lingual & Mand canine- Labial

Class-IV cavity:

• Proximal reduction through incisal angle• Labial / lingual lock in cervical 1/3rd or in occlusal

2/3rd • Definite inter proximal shoulder is prepared at gingival

aspect• Initial finishing with flame shaped bur • Final finishing with rubber cups & polishing set

• Pre formed SS band• Open faced SS crowns• Direct Resin Crowns

Young Permanent teeth:

Anterior teeth• Affected by- Discolored, Undersize, Malposed,

Fractured• Bonded composite Resin Veneering- Done for teeth

not responding to bleaching & micro-abrasion• < 0.5 mm reduction done & composite resin placed• Bonded Laminate Veneering- Increased esthetic due

to natural hue & normal appearance• Require good oral health• 0.5 – 1mm tooth reduced, 0.25-0.5 mm cervical

champher, 0.5 mm subgingival placed• Incisal edge avoided

Posterior Teeth:

• Increased defects, Pits & Fissures in erupting tooth. • Irregular enamel [gnarled] pattern at the entry of

fissures. • Due to high occlusal load, increased chance of plaque

accumulation • Fissures can be 1.5 – 2 mm depth & possibility to

penetrate right into dentin. • In cases of Caries in the distal aspect in 2nd pri molar,

increased chance of demineralization in the Mesial aspect of erupting 1st per molar

Recent Concepts:

“Constriction for Conservation”

• Cavity design should be dictated under the site & extent of the lesion

• Need not extend to a caries free area

• Choice of material should be one with biological activity & assist in the process of remineralization

• Only that part of the tooth crown completely degenerated & broken down should be removed & the remainder even though demineralized & softened should be retained & remineralized

• Eliminate any site of cavitation, to completely control plaque accumulation

Minimal intervention / Minimally invasive /

Preservative dentistry

[Martin etal 2000]

• Remineralization of early lesion

• Reduction in cariogenic bacteria

• Repair of defective restoration rather that replacement

• Disease control

Kinetic Cavity Preparation:

• Fine particles of powder fired at high, controlled manner

• No vibrations, no pain sensation

• No sedation required

• Multiple quadrant dentistry possible, hence better time utilization

Preventive resin Restorations:

• Deep Pit & Fissures- unfilled resins / sealants

• Minimal carious lesion- Filler resins in caries lesion + Sealant over susceptible fissures

• Isolated carious lesion- unfilled resin + Filler resin + sealant over the resin

• Procedure: [incases of isolated lesions extending upto DEJ]

• Diagnose using dental aids• Check occlusal contact points using articulating paper-

ensure caries not in stress bearing area• L.A / R.D used as needed• Prepare cavity on caries area• Wash, dry, inspect• Acid etching done: wash + air dry 30-40 sec• Lingual groove- Max 2nd pri molar / Buccal groove-

Mand 2nd pri molar involved• Thin layer of bonding agent + air dried + Light cured• Restoration with Resin modified GIC / Composite +

light cured• Check occlusal contact points using articulating paper• Remaining fissures are sealent using P& F sealant

Advantage:

• Fluoride release, True Adhesion• Minimal cavity preparation, prevent unnecessary

healthy tooth structure removal• Halt the destruction of tooth• Less invasive in cases of restoration replacement

Dis Advantage: • Technique sensitive, Poor wear resistance

• Precaution: Excellent isolation

A.R.T Restoration:

Alternative Restorative Treatment

Atraumatic Restorative Treatment

• ART consists of manually cleaning dental cavities with hand instruments and filling them with an adhesive, fluoride releasing material.

• Indications:

Uncooperative patients, Young patients,

Patients with special needs,

Situation where traditional cavity preparation placement of traditional material not possible

• Advantages:

Availability and inexpensive, Tooth conservation,

Limitation of pain, Simple infection control,

Fluoride release, Reachable at door steps

• Limitations:

Survival rate, Technique acceptance, Limited use, Hand fatigue

Lamination Technique:

• Combination of GIC + Composite

• Compensating the weakness of one material with the strength of the other

• Using Fast setting high strength GIC as base & Placement of most wear resistant Composite as enamel replacement

Tunnel Preparation:

• Approach the dentinal cavity from occlusal fossa , medial to marginal ridge

• Diagonally prepare cavity with a small access

• Debride the walls using chisel

• Restore with GIC

Slot preparation / Mini Box Cavity:

• Preparing small proximal cavity from outer surface of marginal ridge

• Using lamination method for restoration