Paediatric dentistry III Treatment procedures in primary dentition Skull of a child at about 2 1/2 years  Frontal view  Lateral view  Erupted primary dentition relation between primary teeth and buds of permanent teeth. Crowns of second premolars are not mineralised yet at this age. Skull of a child at about 8 years  Frontal view  Lateral view  First permanent incisors and molars are erupted, second permanent incisors in different stages of eruption. Skull of a child at about 10 years  Frontal view  Lateral view  Permanent dentition before completion of eruption. Primary teeth in different stages of resorption. Age: 0-1 month,- 1 year 1-4 years Newborns, Succlings, Toddlers  Caries shortly after eruption  primarily inferior quality of enamel  dummmy with honey circulary caries  sweetened drinks in the night Pre-school age 4-6 years  Complete primary dentition + l. permanent molars + lower permanent incisors  Caries in primary molars occlusal surfaces approximal surfaces 6 6 6 1 1 6 Early school age 6-12 years  Caries in primary molars  Caries in primary canines  Risk of caries transfer to permanent molars — immature enamel 0 1 2 3 4 Diagrammatic representations of caries on bitewing radiographs. sound on bitewing Radiolucency confined to enamel (up to ½- caries incipiens) Radiolucency in enamel up to enamel-dentine junction Radiolucency in enamel and outer half of dentine (caries superficialis) Radiolucency in enamel and reaching to inner half of dentine (caries pulp. prox.) I. II. III. IV. Developmental stages of root Dental caries - primary dentition Caries depth 2 mm — molar a) car. pulp. proxima b) caries media a) 3 years b) 6 years diameter of the bur – 1 mm, depth - 0,5 mm in dentin Filling silver amalgam + cement – exceptionally GIC+ Dycal (alkaline cement) GIC Compomer Composite resin (+ dentine adhesive,or capping of pulpal wall with alkaline cement) Occlusal caries Working procedure  hand instruments  low revolutions  minimal pressure  checking of the cavity  Compomer  Composite resin  GIC or GIC + base - alkaline cement Approximal caries caries media – marginal ridge is not affected otherwise caries pulpae proxima or caries penetrans The filling should include retention resistency Neighbouring tooth has to be investigated isthmus - 1/3 of the intercuspal distance not less than 1,5 mm gingival wall 1 mm point of contact has to be in filling Approximal caries Dental pulp must not be threatened Mesial horn – easy perforation V IV IV V IV IV Errors during preparation – class II cavity. A. Insufficient preventive extention – fissure complex not invoved totally in the preparation. B. Excessively involved cusps – loss of hard tissues C. Isthmus too large – greater than 1/3 of the intercuspal distance D. Approximal walls divergent too much: the cause of following errors E. The angle between axial and buccal/lingual walls too great F. gingivally small extension – point of contact is not in the filling (in the gingival region) G. gingival wall too great mesio-distally – more than než l mm ClassIII.  Access opening from the labial surface, the size of cavity is given by the caries extent  Access opening in primary maxillary canines may be from the palatatal surface, in mandibular canines from vestibular surface.  The dovetail is usually placed to the strong marginal ridge, not directly to the oral surface Class IV.  Not very frequent  Crown must not be restored esthetically – cover the dentin wound  Teeth before shedding – grinding of approximal surface, impregnation by fluorides Filling in class III. and IV.  Composite resin + etching technique  glassionomer cement  compomers A.R.T. - Alternative Restorative Treatment  New attitude to caries treatment – for use in developing countries (1990)  Originally – no machine driven preparation  Removal of soft demineralized tooth tissue  Only hand instruments  Application of GIC – filling material (+ alkaline cement)  Method recommended by WHO for treatment of teeth in areas of the world where dentistry was inaccessible (South-East Asia, Afrika).  May be used for treatment of uncooperative children.  Minimal preparation  Hand instruments or micromotor (low speed)  Carious masses have to be removed  Filling material - Ketac Molar (finger press technique)  Físsures sealing - Ketac Molar  Very good results - class I. a V. cavities, acceptable in class II. cavities  Class III. and IV. not very successfull - cause unknown  Better any cure than untreated caries! Glassionomer cements in Pediatric Dentistry Properties and indications 1. Fissure sealing 2. Base for amalgam and composite resin fillings 3. Crown cementation (stainless steel) bonding to metals 4. Cementation of orthodontic appliances 5. Restauration of primary teeth – replacement of amalgam  minimal occlusial caries  approximal preparation (buccal, lingual access)  tunnel preparation  minimal preparation in incisors Properties of GIC  abrasion  Of the same rapidity as enamel (x amalgam)  resistance  low, weak link – transition between occlusion and axial wall  fluoride ions release  inhibition of microbs in plaque  enamel resistance increase  light cured - advantage for children Properties of GIC enable their usage as esthetic filling in frontal region Buccal access  caries localization – localization aproximally, gingivally  marginal ridge is not affected or undermined  caries is not very extensive  dove tail is not prepared in the occlusial surface,it is replaced by anchoring in the buccal wall  filling making requires the matrix Tunnel preparation  conditions  non affected marginal ridge  caries of small extent a. access – round bur access channel – to extend bucco-lingually b. removal of carious masses, matrix application + wedge c. esthetic improvement by composite resin(compomer) not necessary d. fissure complex has to be sealed GIC  base for amalgam filling  suitable in large losses of dentine  in dental pulp vicinity + alkaline cement  base for composite resin filling  before composite resin application- roughen mechanically or etching  application to dental pulp vicinity or direct contact has to be avoid  restauration of primary teeth  Ketac Molar or other GIC, especially resin reinforced  filling materials reinforced by metals  Ketac Silver  Miracle-Mix  approximal caries  preparation according to Black  tunnel preparation  buccal access Preventive filling 1. sealant filling  caries confined to enamel of pit or fissure, only sealant. The technique is used rather exceptionally, D1, D2, and D3 (just below dentino-enamel junction) are treated by prophylactic procedures) 2. preventive filling  caries in pits and fissures, reaching to dentine  preventive composite filling  preventive glassionomer filling  indication:  primary molars, premolars, permanent molars  caries lesion D3  small caries lesion  cotraindication:  approximal caries on the treated tooth, more extensive caries (more than 1/3 of intercuspal distance), open approximal defects on any tooth, DMFT/dmft >5, Fissure sealing 1. fissure too narrow not suitable 2. suitable fissure 3. wall protects the cement Filling materials in Paediatric Dentistry 1. Silver amalgam  used rather exceptionally (moisture)  primary dentition  permanent dentition  the base necessary- not into direct contact with dentin of the pulpal wall 2. composite resins  may be used but  aprismatic enamel has to be removed – or prolonged etching  sealants 3. glassionomer cements (polyalkenoats)  filling  sealants  tunnel preparation  buccal access  A.R.T. 4. compomer materials  may be used (dentine adhesives) Filling materials in Paediatric Dentistry 5. cements  zinkoxidsulfate  zinkoxiphosphate  zinkoxideugenol (Caryosan)  karboxyl  alkaline cements (with calcium hydroxide) 6. metals  inlay  crown 7. resin  crown 8. calcium hydroxide  large scale of usage 9. root canal filling materials  the main required property - resorbable