Definition of operative Principles of tooth
dentistry Indication for operative treatment Rationale of pediatric treatment General consideration regarding pediatric dentistry Classification of dental caries
preparation Various materials used in pediatric restorations Amalgam Restoration GIC restoration Resin based composites Comparative studies
Art and science of the DIAGNOSIS, TREATMENT, and
PROGNOSIS of defects of teeth that do not require full coverage restoration for correction. Treatment should result in the restoration of proper tooth form, function, and esthetics, while maintaining the physiologic integrity of the teeth in harmonious relationship with the adjacent hard and soft tissues.
All of which should enhance the general health and
welfare of the patient
) Restoration replacement or repair. etc.
. non esthetic. Wearing of teeth (attrition.Indications for Operative Treatment
Malformed. or fractured
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 –
General considerations for Restoration procedure in
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
if contacts are closed
. 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. bulbous. Difference in tooth morphology-
Primary tooth is small.
Consideration for efficient treatment:
Appointments – Single arch treatment Positive attitude of the dental team
Four handed dentistry
Classification of Cavity Preparation: [Primary & young permanent teeth]
G.V. Class VI [ Simon’s modification]
. Black’s Classification
Class I – V .
Class I: Cavities involving the pit and fissures of the molar
teeth and the buccal and lingual pits of all teeth.
Class II: Cavities involving proximal surface of molar teeth with
access established from the occlusal surface
Class III: Cavities involving the proximal surfaces of the anterior
teeth which may or may not involve a labial or a lingual extension tooth which involve the incisal angle
Class IV: A restoration of the proximal surface of an anterior Class V: Cavities present on the cervical third of all teeth.
including proximal surface where the marginal ridge is not included in the cavity preparation
Two surfaces Complex Cavity.Sturdevant’s Classification:
Simple Cavity.One surface Compound Cavity.+ Two surfaces
Pit & Fissure Cavities Smooth Surface Cavities
3.Mount & Hume Classification:
Extent SITE Minimal 1 Moderate 2 Enlarged 3 Extensive 4
Pit & Fissure 1.3
1.1 2 Cervical 3.3
2.1 1 Contact Area 2.
Black’s concept – “extension for prevention” To prevent the recurrence of caries by placing the margins of
restoration along self cleansing areas.Conventional Concept of Cavity Preparation :
all pits and fissure restoration are class I . Restoration on occlusal two thirds of the facial and lingual surfaces of molars.
. and are assigned to three groups.CLASSIFICATION OF TOOTH PREPARATION
According to BLACK’S CLASSIFICATION:
1. Restoration on occlusal surface of molars and premolars.
Class I :.
2.Class III :Restoration on the proximal surfaces of anterior teeth that do not involve the incisal angles. 3. Class II :Restoration on the proximal surfaces of posterior teeth. Restoration on lingual surface of
Class V :Restoration on the gingival third of the facial or lingual surfaces of all teeth.
. Class IV :Restoration on the proximal surfaces of anterior teeth that do involve the incisal edges.
Class VI :Restoration on the incisal edge of anterior teeth or the occlusal cusp heights of posterior teeth.6.
INITIAL AND FINAL STAGES OF TOOTH PREPARATION
: in this stage.protecting pulp.removing old restorative material if indicated.
.infected carious dentin. limited pulpal or axial depth.
Final tooth preparation:
this stage includes excavating any remaining . the mechanical alterations of the tooth extended to sound tooth structure while adhering to a specific .
. outline form and initial depth Step 2. primary resistance form Step 3. The stages and steps in tooth preparation are as
follows: Initial tooth preparation: Step 1. primary retention form Step 4.
pulp protection. inspecting.if indicated. removal of any remaining infected dentin or
old restorative material.
. final procedures-cleaning . Step 6.sealing. if indicated Step 7.Final tooth preparation:
Step 5. secondary resistance and retention form Step 8.
. except for finishing the enamel walls and margins.5 mm pulpally beyond the DEJ.20.it also includes preparing an initial depth of 0.OUTLINE FORM AND INITIAL DEPTH
it is the placement of the preparation margins in the position they will occupy in the final preparation.
2) Include all faults 3) Place margins such that good finishing of the margins of the restoration is possible. PRINCIPLES:
Remove all friable or weakened enamel.
Esthetic requirements which may affect the choice of
the restorative material and modify the cavity design. they are: Extent of the carious lesion. FACTORS:
Certain factors affect the decision regarding the extent of the outline form . defect or faulty old
. 4)Use enameloplasty wherever possible. 2)Preserve marginal ridge strength. FEATURES:
Generally proper outline form may be established if the following features are incorporated: 1)Preserve cuspal strength. 3)Minimize faciolingual extension.
5 mm apart)
6)Restrict the depth of the preparation into dentin to a maximum of 0.
.5mm.5)Connect two close faults or tooth preparation(less than 0.2-0.
The use of some tooth preparations for composite
. RESTRICTED AND INCREASED EXTENSIONS:
Condition that may warrant consideration of restricted
extensions for smooth surface caries are as follows:
Proximal contours and root proximity Esthetic requirements
Need to adjust tooth contours. Condition that may necessitates increased extensions for
smooth surface caries are as follows
. Restoration of teeth as partial abutments or as units of
Mental or physical handicaps Advanced patient age
without fracture.STEP 2: FORM.
It may be defined as
” the shape and placement of the preparation wall that best enables the restoration and the tooth to withstand.”
. masticatory forces delivered principally in the long axis of the tooth.
To use box shape or mortise form with relatively flat floors. PRINCIPLES:
• THE FUNDAMENTAL PRINCIPLES INVOLVED IN
PRIMARY RESISTANCE FORM ARE AS FOLLOWS:
Restrict the extension of the external walls.
To have slightly rounded angles.
6. To provide enough thickness of restorative material
to prevent its fracture under load.
. To cap weak cusps and envelope or include enough of a weakened tooth with in the restration. To bond the material to tooth structure when
Restorative material thickness Amalgam Cast gold Porcelain Composite
.5mm 1-2mm 2.
• Certain factors affect the resistance form of
Amount of occlusal contact
2) Amount of remaining tooth structure
3) Type of restorative material
• The following features enhance primary resistance form: 1) Relatively flat floors 2) Box shape 3) Including all weakened tooth structure 4) Preservation of tooth and marginal ridges
5) Rounded internal line angles
6) Adequate thickness of the restorative material 7) Reduction of cusp for capping when indicated.
“the shape or form of the conventional preparation that resists displacement or removal of the restoration by tipping or lifting forces.STEP 3.”
PRINCIPLES: the principles of primary retention form
varies according to the restorative material used
For composite resin: 1. For amalgam:
Occlusal convergence 2. Occlusal dovetail
1. Acid etching and bonding 2.
For direct filling gold: Elastic compression of dentin during condensation. For cast metal
Close parallelism of opposing walls with a slight degree of occlusal divergence. 1. Occlusal dovetail
STEP 4. and ease of operation in preparing and restoring the tooth.”
“ the shape or form of the preparation that provides for adequate observation .
Providing adequate width and lateral extensions for tooth preparation for all restorative materials.
4. Occlusal divergence for cast gold inlays. Refining line and point angles.
Providing proximal clearance from the adjacent tooth. FEATURES:
For most conservative restoration at this stage itself
may be complete except for final procedures.
However in case of extensive destruction additional
steps required.FINAL TOOTH PREPARATION STAGE
When the extensions and wall designs have fulfilled
the objectives of initial tooth preparation. the preparation is inspected carefully for other needs.
OR OLD RESTORATIVE MATERIAL IF INDICATED
the elimination of any infected
carious tooth structure or faulty restorative material left in the tooth after initial tooth preparation.
.REMOVAL OF ANY REMAINING ENAMEL PIT OR FISSURE.INFECTED DENTIN.STEP 5.
The deeper portion of carious dentin may generally exhibit two distinct areas:
1. High concentration of irreversibly denatured.
. Must be removed. • •
INFFECTED DENTIN: this is more superficial layer which is soft and leathery.
It does not contain bacteria and is reversibly denatured.
.2. Therefore this layer must be preserved. AFFECTED DENTIN: this is the deeper layer.hard in consistency.
Removal of any old-restoration is indicated
1) It would affect the esthetics of the new restoration 2) It may compromise the retention of new restoration 3) There is evidence of secondary caries
5) The pulp is symptomatic
6) There is marginal deterioration of the old restoration.
This may be done with a round carbide bur in
an airotar handpiece with air water spray at low speed
STEP6.PULP PROTECTION, IF INDICATED
is actually not a step in tooth preparation in the strict sense but since it is a step in adapting the preparation for receiving the final restoration it s considered under final tooth preparation.
step is achieved by the use varnish,liners,bases or bonding agents. of cavity
The choice of the pulp protection agent is based on:
1)Extent of tooth destruction and preparation to the pulp. 2) Type of restorative material to be used
. Liners and bases are applied without pressure in
exposure areas. It is recommended to have approximately a 1mm thickness of calcium hyroxide over near or actual exposure areas.
The varnish prevents penetration of material into
the dentin and helps to prevent micro leakage.
Mechanical features 2. Conditioning procedures
. SECONDARY RESISTANCE AND RETENTION FORM
This step is necessary in case of compound and
complex cavity preparation where additional preparational features are required to improve resistance and retention form.
Secondary resistance and retention form features are of two
steps and amalgam pins
Mechanical features: these include the following:Retention grooves and coves
beveled enamel margins
These are employed for bonded restoration like glass
. composite or ceramic restoration.2) conditioning procedures:
These include etching and bonding.
STEP 8. when indicated.FINISHING THE EXTERNAL WALLS OF THE PREPARATION
the preparation walls is the further development. of a specific cavosurface design and degree of smoothness or roughness that produces the maximum effectiveness of the restorative material being used.”
2. To provide close adaptation between the restoration and the tooth structure so that marginal seal is maintained.
3. To provide maximum strength for both the tooth and the restorative material at and near the margins.
To allow a smooth marginal junction between the restoration and the tooth.
Certain factors decide the type of finishing necessary for the external walls:
1) The direction of the enamel walls 2) Support of enamel rods at the DEJ and at preparation
.3) Choice of the restorative material
4) Location of the margin 5) Degree of smoothness desired.
. FEATURES: this vary according to the type of restorative
1)design of the cavosurface angle For amalgam:.
.cavosurface or butt joint recommended.bevels are indicated.
2)Degree of smoothness or roughness of the wallthis also vary with the type of restorative material used
Morphologic considerations for pediatric operative dentistry
Shape of crown
Enamel and dentin thickness
Contact area between primary teeth
Inclination of enamel rods
Location of pulp horns
. as follows. Restorations on Occlusal Surface of Premolars and Molars Restorations on Occlusal Two Thirds of the Facial and Lingual Surfaces of Molars Restorations on Lingual Surface of Maxillary Incisors.Class I Restorations
All pit-and-fissure restorations are Class I. and they are
assigned to three groups.
Class I restorations in primary and permanent teeth. 2008
Dental amalgam is recommended for:
.rior teeth. 2. 4. Class II restorations in permanent molars and pre. Class V restorations in primary and permanent poste. 3.molars.AAPD. Class II restorations in primary molars where the preparation does not extend beyond the proximal line angles.
Class III and V restorations in permanent teeth in high risk patients or teeth that cannot be isolated.
. 5. high-risk patients. 2008
Glass ionomers can be recommended as: 1. luting cements. and V restorations in primary teeth. ITR. 2. caries control with:
a. restoration repair. III. c. 3.AAPD. cavity base and liner. d. ART. Class I. II. 4. b.
ventive resin restorations are appropriate. strip crowns in the primary and permanent dentitions. Contraindications: Resin-based composites are not the restorations of choice in the following situations: 1. where a tooth cannot be isolated to obtain moisture control. Class III.tend beyond the proximal line angles. 6. Class I pit-and-fissure caries where conservative pre. IV. 4. Class II restorations in permanent teeth that extend approximately one third to one half the buccolingual intercuspal width of the tooth. 2. in individuals needing large multiple surface restora. 5.AAPD.tions in the posterior primary dentition
. V restorations in primary and permanent teeth. 3. 2. Class I caries extending into dentin.2008
Resin-based composites are indicated for: 1. Class II restorations in primary teeth that do not ex.
Treatment modalities for Pit and fissure caries
Recommended by Hyatt (1923)
Pit and fissure selants and PRR
Conventional cavity preparation
Amalgam Primary and permanent Composite restorations
Glass ionomer restoration
. Outline form: Include all carious pits
and fissures Include deep susceptible pits and fissures Overdestruction of cusps not acceptable Isthmus.atleast 0.5 mm
below DEJ Flat pupal floor when ever possible Rounded internal line angles Cavo surface margin.¼ to 1/3
Resistance form-Class I.
Cavity preparation for 1st primary molar-conservative amalgam Cavity Preserve central ridge
Try not to enter dentin untill
involved Slightly convergent walls Mesial pulp horns approximating DEJ
primary molar.5 mm into Include buccal developmental groove
.separate buccal and
If buccal /lingual extension made-
converging occlusally with square external line angles dentin
Extension should be cut 0.Mandibular
Occlusolingual or occlusobuccal cavity
may be formed
Preserve if possible.
mesial pit and grooves seperating them. distal pit. Avoid crossing oblique ridge
.2nd maxillary primary molaramalgam
Usually carious attack limited to central pit.
330 bur to carefully remove the carious enamel.Occlusal lesions in enamel onlyIncipient caries
Incipient pit & fissure
lesions can be prepared by using a no. round or a no. ¼. 2 small. 1/8 or 1/16 size according to the size of carious lesionFor enameloplasy Air abrasion can also be used
Conditioning of enamel Gel/liquid etchant placed Washed with air water spray Enamel dried throughly (moist for acetone based adhesive) Primer and adhesive placed Placement of resin based composite: flowable
composite preferred over pit and fissure sealant Pit in centric occlusion restored with resin based composite
Occlusal lesion involving superficial to middle third of dentin depth
Preparation design: Outline.extent of lesion Carious dentin at base of lesion should be visible-convenience form Underlying enamel can be preserved
Carious dentin removed using round
bur and spoon excavator Sharp line angles avoided Flat ended fissure burs contraindicated Disclosing agents might be used
Choice of material
GIC.indicated in active lesions
Primary focus towards removal of soft caries Fluoride releasing properties considered
Minimal tooth destruction
RMGI or composite resin restorations indicated-
thin film. Conditioning of enamel Enamel should be dried. avoid pooling at base Placement of composite or compomer 2mm increment.to be place immediately after etchant befor bonding agent is placed Bonding agent.20 sec curing
.frosty white appearence Complete dehydration of dentin not recommended GIC base might be used as dentin replacement.
Enamel conditioned using Dentin conditioned using polyacrylic acid Final bevel placed after GIC base placement
.Occlusal lesion Involving deep dentin
Indirect pulp capping might be required Calcium hydroxide base placed –confined to
near exposure site phosphoric acid
If GIC used.
Resin based Composite or compomer placed
Resin based composites and compomers in primary molars-DCNA 2000
.Rebonding ofany remaining pits and restoration After polymerization
fissures might be filled using sealants or flowable composites.
Rationale for use of various material
newer materials with better adhesive properties are recommended so that minimal destruction of the tooth structure is required. better aesthetics and a more functionally appropriate stress bearing strength
Therefore . since the form of cavity preparation in
primary teeth is partly governed by their anatomy .
The more ideal materials are expected to have better
fluoride releasing properties .
Minimal intervention in the management of dental caries.pdf FDI statement. 134:87-95
. J. McLean M E. van Amerngen et al.NovDec:395-39 Murdoch-Kinch C A.J Dent Child 1995.aapd. Two yeas results with box only resin compposite restorations.References
Pediatric Dentistry: A Clinical Approach by Goran Koch
Kennedy's paediatric operative dentistry by Martin E. Roberts. Minimally invasive 90 dentistry. F.
Curzon. David Bernard Kennedy 4th ed
http://www. J. FDI general assembly 1 October 2002 Kreulen CM.org/media/Policies_Guidelines/P_CariesRis
kAssess. J Am Dent Assoc 2003(Jan).
Int Dent J 1991.41:55-59
. Mosby 1998.
Mount GJ and Hume WR: Preservation and restoration of tooth structure. Hume WR. Minimal intervention dentistry: rationale of cavity design.28:301-303 Mount GJ. Minimal treatment of the carious lesion. 121-154 Mount GJ.28:92-99 Mount GJ. A revised classification of carious lesions by site and size. Operative dent 2003. Quintessence Int 1997.