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The Ohio State University College of Dentistry

Division of Pediatric Dentistry and Community Oral Health

Pediatric Dentistry 6551

__________________________________________________________________________ ________________

Course Syllabus Summer 2012

Pediatric Dentistry is an age-defined specialty that provides both primary and specialty comprehensive preventive and therapeutic oral health care for infants and children through adolescence, including those with special health care needs.

PEDIATRIC DENTISTRY 6551
INTRODUCTION TO PEDIATRIC DENTISTRY

July 5, 2012 8:30-9:20 Introduction/ Prevention and Oral Hygiene 9:30-10:20 Fluorides I 10:30-11:20 Fluorides II Pediatric Dentistry: Ch. 14: 220-233 Ch.19: 313-323; Ch.31: 513-519; Ch.38: 690-694 July 6, 2012 7:30-8:20 Restorations in the Primary Dentition I Pediatric Dentistry: pages 341-356 8:30-11:30 LAB: Resins 12:30-1:20 Restorations in the Primary Dentition II Pediatric Dentistry: pages 357-363 1:30-4:30 LAB: Stainless Steel Crowns July 13, 2012 7:30-8:20 Pulp Therapy in the Primary Dentition Pediatric Dentistry: pages 381-391 8:30-12:00 LAB: Pulpotomy 12:10-12:50 Clinic Orientation *LUNCH PROVIDED* 1:00-4:30 LAB: Practical July 16, 2012 4:30-5:30 PM

Dr. Griffen Dr. Griffen Dr. Griffen

Dr. Griffen Dr. Griffen

Dr. Gosnell Dr. Gosnell

Final ExamRoom 1187

Pediatric Dentistry 6551
Introduction to Pediatric Dentistry Summer 2012 Course Director: E. Gosnell, DMD, MS Office: 4126 Postle Hall Telephone: 292-9573 Office Hours: By appointment Course Description Pediatric Dentistry 6551 is an introduction to Pediatric Dentistry. It is a .5 credit hour course. The areas of emphasis are prevention and management of dental caries in the primary and young permanent dentition. The course includes lectures and laboratory sessions on restorative techniques for primary teeth. Course Objectives At the completion of this course, the student should have the basic knowledge necessary to provide restorative dental care to pediatric patients including fluoride therapy, diet counseling, oral hygiene care, sealants, conservative resin and amalgam restorations, and stainless steel crowns. Course Format The course will consist of seven one-hour sessions with assigned reading for each lecture. In addition there will be 4 laboratory sessions with reading material in the syllabus assigned for each laboratory session. Finally, there is a final exam and will be held on Monday, July 16 4:30-5:30 in Postle Hall Room 1187 . The final exam may consist of multiple choice, matching, short answer, and/or identification. Course Textbook Each student is expected to purchase a copy of the course textbook. There will be assigned readings and test material will come from these readings. The text is: Pediatric Dentistry: Infancy through Adolescence. 4th Edition, Pinkham JR, Casamassimo PS, Fields HW, McTigue DJ and Nowak AJ., Elsevier Co. Evaluation Grading is based 95% on the final exam, but also requires successful completion of all laboratory exercises. If all of the instruments, supplies and all typodont teeth are not replaced at the end of the laboratory sessions, grades will be lowered 1 full grade (i.e from an “A” to a “B”). The remaining 5% of the final grade is dependent on completion of the course SEI (Student Evaluation of Instruction online). Absences Due to the nature of this course, the following will be enforced; A. Any student missing a portion of lab for an excused reason (to be discussed directly with Dr.Gosnell – these are limited to; birth, death or illness requiring medical attention) will be given a tentative grade of “I” until deficient portion of the course is completed through arrangements with Dr. Gosnell directly.

B. Any student missing a portion of lab for an unexcused reason will be given a final grade of “I” and will be required to take the entire course (lecture and laboratory) in July 2013 to receive full credit.

Academic Misconduct Students are reminded that all graded work is to be solely their own. Academic misconduct is a very serious offense. Faculty Rule 3335-5-54 will be followed for this course which states "Each instructor shall report to the committee on academic misconduct all instances of what he/she believes may be academic misconduct." Students are expected to adhere to the College of Dentistry Code of Professional Conduct. Laboratory Safety and Infection Control Protocol “Proper infection control and safety protocols to be followed in the pre-clinical laboratory include the following: wearing protective eyewear when working with any hazardous chemicals or laboratory equipment that could cause eye injuries, wearing masks (and using ventilation system) during any procedure that involves generation of dust or an aerosol, wearing gloves while handling any hazardous materials and following the OSU dress code policy in the preclinical laboratory as stated in the College’s Dress Code. This protocol will be monitored and enforced by course faculty to ensure compliance.”

Gretchen J. Thomas Hagman Gerald Kassoy Kara Morris Cecilia Moy Office Associate Mrs. Dr. Peg Greek Mrs. McTigue 4140 Postle Hall 292-0898 Dr. Ann Griffen 4126-A Postle Hall 292-1150 Dr. Casamassimo Children's Hospital or 4132 Postle Hall 292-1509 Dr. Thikkurissy 4126-C Postle Hall 292-1788 Pre-Doctoral Program Director Post-Doctoral Program Director Faculty . Dorothy Harold 292-2027 M. Gosnell 4126-B Postle Hall 292-9573 Dr. F: Th: W: 8:30 1:00 9:30 1:00 -11:30 .4:30 .GENERAL INFORMATION PEDIATRIC CLINICAL DENTISTRY Division of Pediatric Dentistry and Community Oral Health Division Chairman 292-1509 Dr. Hollern 4126 Postle Hall 292-1509 Mrs. F.4:30 – 11:30. S. Dennis J. T.Part Time Dr. Dr. Diego Solis Johnstown/Nisonger 475-0564 Dr.4:30 Clinical Staff Clinic Phone Number Clinic Hours of Operation . Megann Smiley Children’s Hospital 722-5651 Dr.Full Time Clinical Faculty . Ashok Kumar Children’s Hospital 722-5649 Dr. E. Homa Amini Children's Hospital 722-5651 Dr. Paul S. 1. Dr.

The Ohio State University College of Dentistry Section of Pediatric Dentistry Pediatric Dentistry 6551 (Pre-Clinical Laboratory) __________________________________________________________________________ __________________________ Course Syllabus Summer 2012 .

Course Syllabus Summer 2012 TABLE OF CONTENTS Dentistry 6551 Summer Semester Course Outline Schedule of Laboratory Exercises Instructor and Student Assignments Pediatric Rubber Dam Application Conservative Class I Restorations (Posterior ) Class II Composite Preparations in Primary Molars Pulpotomy and Stainless Steel Crown Procedures for Primary Molars .

LABORATORY DIRECTOR: E. LAB OBJECTIVES: 1. and there will be some assigned readings. 3. is the required textbook for ALL pediatric courses. Understand the indications for the techniques used in the prevention of dental caries. POLICIES AND PROCEDURES: For the exercises that are performed on the typodont. 2. Diagnose and formulate a treatment plan for the treatment of incipient to major dental caries. 4th Edition. 5. You and your row instructor will determine when you are ‘ready to take’ the practical. Understand the indications for the techniques used in the treatment of pulpal pathology. To develop the ability to objectively self-critique clinical work and determine levels of satisfactory (clinically acceptable) work. LAB SCHEDULE: There will be 4 laboratory sessions which will meet as indicated on the master schedule. Saunders Co. consisting of a class II resin preparation and a stainless steel crown preparation and adaptation. 2005. will be given as a self-paced practical. Gosnell. In addition a practical exam will be given at the completion of the lab course. TEXTBOOK(S) AND READING: Reading assignments for this course will come primarily from this syllabus. interaction with the laboratory instructor and performance of the techniques on dentoforms. and technical skills necessary for appropriate restoration and preventive procedures for the child patient. 4. MS LAB DESCRIPTION Pediatric Dentistry 6551 includes a preclinical laboratory series emphasizing selected techniques unique to Pediatric Dentistry. Understand the indications for the techniques used in the restorative treatment of dental caries. The teaching format of the course consists of lecture material. Students are expected to have a copy. The evaluation criteria for all lab work are listed on evaluation forms included in this syllabus. LAB GOALS: 1. experience.. DMD. To develop knowledge. EVALUATION AND GRADING: To complete the laboratory portion of the course the student must complete all laboratory work at a satisfactory level as judged by his/her lab instructor's evaluation. Diagnose and formulate a treatment plan for the treatment of pulpal pathology. if a student significantly deviates from clinical acceptability (a critical error) with their preparation he/she may be asked to re-do the preparation. 2. but the textbook Pediatric Dentistry: Infancy Through Adolescence. There is no grade penalty for repeating a procedure. Pinkham et al. . A practical examination.

There will be sufficient time in the lab to complete all of the necessary work. .Lab work may NOT be completed outside of scheduled time.

Class I/ II Resin Restorations # I (DO) # A (MO) #30 (O) 12:30-1:20 Lecture Restorations in the Primary Dentition II.S Self-paced practical** Clinic Orientation: Lunch provided Lab IV Continue #I.J. Room 1187 1:30-4:30 Lab II # J (SSC) #S (SSC) July 13 1187 7:30-8:20 8:30-12:00 12:10-1:00 1:00-4:30 Lecture Pulp Therapy in the Primary Dentition.J.A.30.30.S. Room Lab III #B (Pulpotomy and SSC) Continue #I.B Self-paced practical** **Self paced practical as determined by bench instructor** .A.Schedule of Laboratory Exercises July 6 7:30-8:20 Room 1187 8:30-11:30 Lecture Lab I Introduction/Restorations in the Primary Dentition I.

pages 343-345 and syllabus material 4. Too far apart? State the number of teeth to be isolated when doing a one surface restoration. 5.RUBBER DAM PLACEMENT READING ASSIGNMENT: OBJECTIVES : The student should be able to: 1. 2. 6. 3. State which rubber dam clamp should be used for: --partially erupted 1st permanent molars --fully erupted 1st permanent molars --second primary molars --first primary molars State how far apart the holes should be punched on a rubber dam. Be familiar with successful placement criteria of the rubber dam. 8. Explain the advantages and indications for a slit-technique for rubber dam placement. A multi-surface restoration? State the appropriate patient/operator positions for placing a rubber dam. 7. and describe what will happen if holes are too close together. State several contraindications for use of the rubber dam. . 4th Edition. chapter 20. Pediatric Dentistry: Infancy through Adolescence . State several advantages of the use of the rubber dam in children.

4. 2. Enhances the quality of work.for second primary molars #2 .for erupted 1st permanent molar #14A. 4. Contraindications: 1. Bands on teeth Patients with poor nasal airway exchange Patients with allergy to latex (if non-latex dam is not available) Rubber dam clamp cannot be retained due to eruption state of the tooth Armamentarium: --Dark.RUBBER DAM APPLICATION IN PEDIATRIC DENTISTRY The rubber dam is used for virtually all restorative procedures in pediatric dentistry. Improved infection control. 7. Great accessibility and visibility: a. Control of moisture. #7 . b. There are a number of advantages for the use of a rubber dam in children.for partially erupted permanent molars #3 . 5. medium gauge 6"x6" or 5"x5" dam material --Rubber dam frame --Clamps #14. #8A . 6. 1. Protects the soft tissues and prevents swallowing of dental instruments. 3. provides dark contrasting background.for premolars and first primary molars --Rubber dam punch --Rubber dam forceps --Scissors --Waxed floss --Cotton pliers Hole Placement: --Use a template --Dividing the dam in sixths --Holes are placed 3.5 mm apart . Improved patient management. It is placed prior to cavity preparation and usually left in place until the final restoration has been completed. Decreased operating time. retracts soft tissue. 3. 2.

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If placed too close together. A floss safety must always be placed on a rubber dam clamp before trying in onto a tooth. ask the child to "put her or his chin toward the ceiling" for the best visibility. Patient Positioning: The patient should be in a supine position with the operator at the 11 o'clock position. at least one tooth anterior and one tooth posterior to the tooth to be restored should be isolated (when available). Because first primary molars are difficult to clamp. For maxillary teeth. Isolate canine to canine. the second primary molar should be clamped and both molars isolated. . Single tooth isolation is permissible for sealants and one surface restorations with one exception. 3. 5. Holes for maxillary anterior teeth are punched 1" from the top border of the dam material. When restorations involving proximal surfaces or crowns are to be done. 2. the dam will fill the interproximal embrasures Rules for Isolation: 1. Isolate canine to canine. the dam will leak If placed too far apart.a. b. 4. Holes for mandibular anterior teeth are punched 2" from the lower border of the dam material.

however. 3. --Dam does not leak. Stretch and cut rubber dam septa. or ligature. This allows for fast application of the dam and provides good retraction of cheeks and lips and accessibility and visibility to the operating field. dam and frame as a unit. --Dam is stabilized anteriorly with wedge. This method is preferred because of the good visibility it allows the operator of the tooth to be clamped and of the gingival tissue. Moisture control is not optimal but this is of little consequence for crown preparations. 2. 4. 2. Inspect dam for missing pieces. Use of a wooden wedge between interproximal contacts. 5. Placement of clamp. 3. Criteria for successful Placement of rubber dam --Material covers the upper lip but not the nose. Is used in pediatric dentistry when it is anticipated that the rubber dam interproximal septa will be severed during rotary instrumentation. Slit technique. Remove dam. and cut the dam septa with scissors prior to placement. Remove all ligatures or other objects used to stabilize. --Clamp is stable and does not impinge on the gingiva. Removal of the rubber dam 1. Inspect mouth. The most frequent use of this technique will be for preparation for stainless steel crowns. then dam and frame are placed over the clamp. Possibility of soft tissue impingement is most likely with decreased visibility. Placement of clamp.Application Techniques: 1. rubber dam piece. frame and clamp as a unit. . visibility of the tooth to be clamped is greatly reduced over method 1. This method may be used. Simply punch the holes. Stabilization of the anterior extent of the isolation 1 . 2. isolating at least three teeth. --Dam is centered on the face. 3. --Placement is accomplished in 5 minutes or less. --Tell-show-do used when applying rubber dam. --Correct number of teeth are isolated. Ligation. --Dam is inverted into gingival sulcus. Use of small piece of rubber dam material "flossed" between the interproximal contacts.

CONSERVATIVE CLASS I RESTORATIONS CONSERVATIVE CLASS I COMPOSITE .

and when it might be used. 4. 3. 5. Describe how to repair a sealant or conservative class I. 2.READING ASSIGNMENT: Syllabus material and Assigned reading: Pediatric Dentistry Infancy through Adolescence pages 352-356 OBJECTIVES : The student should be able to: 1. Identify and differentiate between a sealant and conservative class I. . Identify the common reason for failure or loss of a sealant/class I composite. Define what a conservative class I resin restoration is. List and discuss the technique for preparation and applicantion of a conservative class I.

7. Tooth surface chalky-white after etching. No voids found in the sealant. Occlusion adjusted. 2. Resin placed in cavity preparation. Occlusal surface free of plaque and debris. Sealant can not be dislodged with an explorer. Caries removed. Sealant applied over and to ALL susceptible pits and fissures on the tooth. 4. . 3.Conservative Class I Preparation and Restoration Self-Evaluation CONSERVATIVE CLASS I COMPOSITE 1. 6. 5. rinsing and drying. 8.

The preventive approach of sealing susceptible pits and fissures is combined with conservative cavity preparation of caries occurring on the same occlusal surface. 4. For the laboratory situation you will need a high speed (330) to remove the darkened ‘carious’ material until you see white tissue. It is a logical extension of sealant philosophy and technique. This results in a restoration that conserves tooth structure and is both therapeutic and preventive. . These preparations are filled with a flowable or a conventional resin and covered over with a sealant to protect the remaining grooves and pits. Instead of the traditional amalgam cavity preparation "extension for prevention" beyond the area of decay into the adjacent pits and fissures. 3. this approach limits cavity preparation to the discrete areas of decay. but simply restoring the preparation with composite and sealant. CRITERIA 1.What is a CONSERVATIVE CLASS I COMPOSITE? The conservative class I restoration is indicated for small carious lesions that progress into dentin. Questionable carious areas Incipient lesions Well-confined carious lesions Enamel defects LABORATORY SIMULATION Your dentoform contains a plastic tooth (#30) which has been prepared to simulate a caries situation. 2. You will not be placing a base. To be considered a restoration the preparation must extend into dentin. The preparation that results is your conservative Class I composite preparation.

a 330 bur is used to conservatively remove the decay. Finally. a glass ionomer liner (L) is placed over the dentin.CONSERVATIVE RESTORATION (D-E): D. Again. In this example. In this diagram the caries extends into the dentin. a sealant (S) is placed over all the remaining susceptible pits and fissures. E. This is followed by a bonding agent (BA) and posterior resin (CR) material. .

Larger cavities may require two coats. Remove water by a combination of air and suction. NOTE: The appropriate ADA billing code is determined by the depth of the preparation. 2. 3. Prepare tooth with an appropriate bur by removing only carious areas and/or those areas suspected of being carious. A 15 second application of etchant is sufficient for both primary and permanent teeth. Cure restorative material.TECHNIQUE CONSERVATIVE CLASS I & SEALANT W/ CARIES EXCAVATION 1. Place sealant over remaining grooves and pits and cure again. If it does not. 6. The entire etched surface(s) should have a dull whitish appearance. at any time during the etching procedure necessitates a 10 second re-etch followed by rinsing and drying. Place appropriate base material on floor of the preparation if needed. 4.) 8. Cure bonding agent for 10-15 seconds. A deep lesion (> 3mm) may need incremental fill and cure to insure adequate polymerization of material. NOTE: DO NOT USE SAME BRUSH TIP THAT WAS USED TO APPLY THE ETCHING AGENT. Dry tooth with contaminant-free stream of compressed air. Salivary contamination. restoring to surface level enamel. Using the applicator gun or syringe (for flowable). Rinse the tooth for 5 seconds with an air-water spray. Remove all debris from tooth by thoroughly washing and drying. no matter how slight. Apply etchant (acid) to the prepared areas and all remaining grooves and developmental defects. 5. (Two thin coats are better than one thick and pooled coat. Apply very thin layer of bond to prepared areas and entire groove structure using the disposable brush tip provided and air thin. 9. The preparation must extend into dentin to be billed as a composite restoration. extrude into the cavity. re-etch. NOTE: ALL GROOVES DO NOT NEED TO BE OPENED AND NO EXTENSION FOR PREVENTION IS REQUIRED. SEALANT PORTION . (For the lab exercise remove only the dark simulated carious material). 7.

Before removing rubber dam. a small amount of material can be added provided no salivary contamination has occurred. If area to be polymerized is larger than tip of light. 3. 6. 4. The time should be increased proportionally to ensure that all areas are equally exposed to light.1. tip should be moved slowly over entire surface. it is exposed to a suitable visible light source for 40 seconds on each surface keeping end of light tip 1-2 mm from surface. 5. Once the sealant material has been placed to operator's satisfaction. 2. Sealant should extend up cuspal inclines to just clear occlusion. . Check for presence of sealant material on the proximal surfaces. restoration should be checked for (1) voids by gently passing an explorer over it and (2) retention by trying todislodge it. If a void is encountered. Care should be taken to avoid entrapment of air by not trying to force resin material into orifices of the preparation or fissures with tip of brush. Check the occlusion and make any necessary adjustments with light strokes of appropriate stones or finishing burs. Retention failures are usually caused by moisture contamination and necessitate repeating application procedure beginning with etching. A gentle lapping motion is used to feather-edge resin material to enamel. Slowly “paint” the sealant into the grooves and any development pits with the brush tip on the sealant syringe.

CLASS II COMPOSITE RESTORATIONS IN PRIMARY MOLARS .

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10. State the preferred bur for preparing a class II composite. Be familiar with evaluative criteria for class II composite preparations (See self-evaluation form). 5. 2. 7. Discuss or list several principles regarding the occlusal outline of primary class II compsite preparations. 8. State how 2 back-to-back composites should be condensed and restored.CLASS II COMPOSITE PREPARATION FOR PRIMARY TEETH READING ASSIGNMENT: Pediatric Dentistry: Infancy through Adolescence. 9. 12. Draw the outline form of class II composite preparations on primary teeth. State where the retention and resistance form is found in class II composite preparation. 13. Discuss or list several principles regarding the proximal box of primary class II preparations. 6. 11. Discuss the absence of a requirement for retentive grooves in the proximal box. Describe what can happen and why if the gingival floor of the proximal box is placed too far gingivally. syllabus material OBJECTIVES: The student should be able to: 1. Pages 355-357. . 3. List several anatomic considerations to be made when restoring primary teeth. 4th edition. Be familiar with some common errors of class II preparations. Be familiar with the use of a matrix band. 4. State the appropriate pulpal. axial and gingival depths of a primary class II composite preparation.

5 mm of enamel surrounding the preparation. 3.distal axis. 6. Occlusal depth > 1.CLASS II COMPOSITE PRIMARY TEETH SELF EVALUATION FORM 1.0-1. Buccal and lingual proximal walls parallel to the external surface. Gingival .0mm but not more than 2.0 mm. . 8. fluid.0 mm.axial line angle 90o Axial .0-1. 9. 2. 11. Isthmus width 1/3 of the occlusal table. Occlusal outline form: parallels the mesial . Occlusal outline form: curved. 4.2. flat.pulpal line angle beveled. Axial wall depth 1. Proximal box cervical depth just below contact. and level. Occlusal width 1. continuous. Pulpal floor perpendicular to the long axis. Buccal and lingual proximal margins can be explored with explorer tip. 5. or 1. 12. 10.5 mm from contact area.0 . 7.

4. 8. Primary teeth have broad. Primary teeth are whiter in color than their permanent successors. Several anatomic differences must be distinguished before restorative procedures are begun. Primary teeth have relatively narrow occlusal surfaces compared to their permanent successors. General Considerations The outline form for several class II composite preparations can be seen below. 5. In primary teeth. 6. Primary teeth have thinner enamel and dentin thickness than permanent teeth. This is in contrast to the permanent dentition in which the rods extend in a cervical direction. 1. . 3. The pulps of primary teeth are larger in relation to crown size than permanent pulps. the enamel rods of the gingival third of the crown extend in an occlusal direction from the dentino-enamel junction. The pulp horns of primary teeth are closer to the outer surface of the tooth than permanent pulps. they are not miniature permanent teeth. 2. the student will learn to prepare primary molars for composite restorations with an understanding of the modifications required and the anatomical reasons for the modifications. The mesio-buccal pulp horn is the most prominent. 7. flat proximal contact areas. Primary teeth demonstrate greater constriction of the crown and have a more prominent cervical contour than permanent teeth.Anatomic Considerations of Primary Teeth Although some primary teeth show resemblance to their permanent successors. In this course. The principles of class II composite preparation for primary teeth are essentially the same as that taught in restorative dentistry with a few modifications because of some of the morphological features of primary molars.

5 mm. The gingival wall should be flat. but studies have shown that stainless steel crowns are a more durable and predictable restoration for large and multisurface caries restorations. 330 bur is 1. Oblique ridges should not be crossed unless they are undermined with caries or are deeply fissured. Three surface (MOD) restorations may be done. The isthmus should be one third of the intercuspal width.       The proximal box should be:  Broader at the cervical than at the occlusal.  Ideal pulpal floor depth is 0. When a dovetail is placed in the second primary molars.     The buccal. flowing arcs and curves. and all internal angles should be rounded slightly. the outline form should be composed of smooth. not beveled. Ideally. which is approximately equal to the width of a No. lingual. so this becomes a good tool for gauging cavity depth. with no bevel. which may displace the restoration mesially or distally. the axio-pulpal line angle is routinely beveled or rounded.5 mm into dentin (approximately 1. The mesio-distal width of the gingival floor should be 1 mm. NO BUCCAL OR LINGUAL RETENTIVE GROOVES SHOULD BE PLACED IN THE PROXIMAL BOX. and gingival walls should all break contact with the adjacent tooth. Since occlusal forces may permit a concentration of stress within the amalgam around sharp angles. 330 bur. and the bucco -lingual walls should converge slightly in an occlusal direction. To help prevent stress concentration. its bucco -lingual width should be greater than the width of the isthmus to produce a locking form to provide resistance against occlusal torque.5 mm into dentin and should follow the same contour as the outer proximal contour of the tooth. just enough to allow the tip of an explorer to pass The buccal and lingual walls should create a 90 degree angle with the enamel.The occlusal outline form should:  Include all carious areas andt should be as conservative as possible. The length of the cutting end of the No. The cavosurface margin should be placed out of stress-bearing areas. .    In primary teeth many practitioners limit class II composite restorations to relatively small two surface restorations. the axial wall of the proximal box should be 0.5 mm from the enamel surface). The mesial and distal walls should flare at the marginal ridge so as not to undercut ridges. and all unsupported enamel should be removed.

A rubber dam and wedge are placed before the preparation is started. On occasions it may be necessary to use the slow speed handpiece for gross removal of deep decay. The preparation should be parallel to the long axis of the tooth. Establish the occlusal outline form of the preparation with a #330 bur.5 mm wide (Fig C) 3. Proximal view which illustrates the movement of the #330 bur toward the gingival. . To start the proximal box of the preparation. move the #330 bur in a gingival direction at the dentino-enamel junction (Fig.Class II Cavity Preparation MESIO-OCCLUSAL CAVITY OF MANDIBULAR RIGHT SECOND PRIMARY MOLAR Methods of cavity preparation described in this handout are applicable to the student using the highspeed handpiece. Establish the width of the isthmus approximately one-third the distance between the cusps or 1. The walls are made parallel or slightly divergent to each other to prevent pulpal exposure and weakening of the cusps by undermining. (Fig C) The occlusal portion is cut through the enamel just into the dentin.0 to 1. 4). for accessibility and for use in cavity preparation for hyperactive children. 1. 2. Consequently the slow speed handpiece should be mounted and ready for use prior to an operative appointment for children.

The buccal and lingual margins of the proximal box are extended only to a cleansable area.4. 6. Do not increase the width of the isthmus. 5. Move the bur bucco-lingually with a pendulum motion so that the widest bucco-lingual width of the box is at the gingival margin. The proximal box-outline will look like an inverted cone (Fig. Proximal view which illustrates the angulation of the handpiece and the #330 bur when cutting the proximal box. Do not place retention grooves or points. 6). The mesio-distal depth of the gingival floor would be approximately 1. Figure 7: The axial wall of the proximal box should conform to the proximal outline of the tooth. buccal and lingual margins. 7). The proximal box is extended gingivally to break contact with the adjacent tooth and to a depth where the tip of an explorer can be passed through (Fig.0 mm. . 5). Figure 6: Tip of the explorer passed through the interproximal at the gingival. The bucco-lingual outline of the axial wall should conform to the curvature of the proximal form of the tooth to reduce the possibility of encroachment of the pulp (Fig.

7. no special equipment is needed 2. Two major types of matrix bands are available for use in pediatric dentistry. 9). 1 . Tofflemire matrix: can be difficult to place as multiple matrices . T-band: allows for multiple matrices. Figure 10: Occlusal view of completed Class II preparation on a Second Primary Molar. REMEMBER! The retention of a class II composite comes primarily from the slight undercuts of the occlusal portion and the divergence of the proximal box walls. Illustrates the rounding of the pulpo-axial anglewith a #330 bur. Use the #330 bur to bevel the pulpo-axial line angle (Fig. RESTORATION OF CLASS II Matrix Application Matrices must be placed for interproximal restorations to aid in restoring normal contour and normal contact areas and to prevent extrusion of restorative materials into gingival tissues.

Check to see that the height of the newly restored marginal ridge is approximately equal to the adjacent marginal ridge. condense the composite into the corners of the proximal box and against the matrix band to ensure the re-establishment of a tight proximal contact. Check the occlusion for irregularities with articulating paper. Using a small condenser. Place pulp protection as necessary. and to remove any loose resin particles from the interproximal region. The wedge should hold the band tightly against the tooth but should not push the band into the proximal box. Difficulty getting the matrix placed gingivally. 6. 10. beginning in the proximal box. 11.) 4. as in Class I restorations. Carving of the occlusal portion is performed with a small cleoid-discoid carver. Carefully remove the wedge and the matrix band. 2. LABORATORY SIMULATION Some technical problems inherent in the lab situation due to the rubberized gingiva and varying tooth size include: 1. While holding the matrix band in place. 5. Over-contouring of the interproximal box (you should carve the box with normal contour and not attempt to establish contact there before you prepare the tooth. lingual. 9. (not in lab situation) Place a matrix band. Gently floss the interproximal contact to check the tightness of the contact. 2. 4. Using the composite carrier. Remove excess composite at the buccal. 7. 8. and gingival margins with an explorer. . and adjust as needed. Continue filling and condensing until the entire cavity is overfilled. to check for gingival overhang. Otherwise. 3. forcefully insert a wedge between the matrix band and the adjacent tooth. because of spacing in the dentoform. Remove the rubber dam carefully. you may find the preparation is too wide interproximally. It may be necessary to trim the wedge slightly to achieve a proper fit. Two wedges may be needed. add the composite to the preparation in single increments. 3. Difficulty wedging due to space between the teeth. so before you prep and during the preparation be sure to check on the mesial-distal orientation of the tooth. beneath the gingival seat of the preparation.Steps of Restoration of Class II Composite Restorations 1. The wedge is placed with a pair of Howe pliers or cotton forceps from the widest embrasure. Remember these teeth rotate in the sockets.

SOME COMMON ERRORS OF CLASS II PREPARATIONS .

resulting in pulp involvement. The axial wall and pulpal floor are too deep. The divergence of the buccal and lingual walls is lost because of improper angulation of the bur resulting in relatively thin and unsupported cusp areas. Figure 17 .Restorative Dentistry for Children / The Class II Figure 14: The flare of the proximal box is too wide. Figure 14 Figure 15 Figures 15 and 16: Figure 17: Figure 16 The flare of the proximal box is carried too wide.

Figure 18: Because of the prominent cervical bulge of primary molars. increasing the depth of the gingival floor can result in penetration of the tooth at the constriction. Figure 18 .

PULPOTOMY AND STAINLESS STEEL CROWN PROCEDURES FOR PRIMARY MOLARS .

Discuss the use of hemostatic agents to control pulpal bleeding. 4th Edition pp 379-387 and syllabus material OBJECTIVES : The student should be able to: 1. Identify the instruments used to excise coronal pulpal tissue. List several findings which contraindicate pulpotomy treatment on a primary molar. Identify the vitality of the pulp of a tooth indicated for a pulpotomy.PULPOTOMY TREATMENT READING ASSIGNMENT: Pediatric Dentistry: Infancy through Adolescence . State the number of root canals in each primary molar and name them. Identify the appropriate restoration to be placed over a tooth with a pulpotomy. 4. 8. State the medicament and filling materials for primary tooth pulpotomies at OSU. 3. . 2. 6. Draw and describe access openings for primary molars. 5. 7.

Remove all red from chamber without perforating. . Create access opening and de-roof chamber. Fill chamber with ZOE B&T (Zinc Oxide Eugenol Base and Temporary Filling Material).PULPOTOMY PROCEDURE SELF EVALUATION FORM PULPOTOMY PROCEDURE 1 2 3.

remove all dental caries except that over the exposure site. Prepare an access opening that is sufficiently large by connecting the pulp horns. (3) tenderness to percussion. . Formocresol induces a chronic inflammatory response and is potentially immumogenic. (11) inter-radicular radiolucency. (6) sulcular drainage. however concern is mounting over its safety.PULPOTOMY PROCEDURES FOR PRIMARY MOLARS Pulpotomy is indicated for vital primary teeth whose pulps have been exposed. Access and caries removal Using local anesthesia and with a rubber dam in place. Many other dental schools teach the use of formocresol for primary teeth pulpotomy’s and this material is commonly used in dental practice today. It is the treatment of choice when there is no sign of the following: (1) spontaneous pain. and then remove the entire roof of the pulp.mutagenic and even carcinogenic. The Division of Pediatric Dentistry and Community Oral Health at The Ohio State University recommends the use of ferric sulfate for the vital pulpotomy procedure in primary molars. (7) internal resorption. Technique for a ferric sulfate pulpotomy is as follows: 1. (5) fistulas. (10) periapical radiolucency. (2) swelling. (9) pathologic external root resorption. we have elected to switch to ferric sulfate because recent research indicates that it’s success approaches that of formocresol without its potential toxicity concern. (8) pulpal calcifications. Formocresol puplotomies have demonstrated a high rate of clinical success. While the likelihood of these events occuring may be low with a low concentration of formocresol. or (12) excessive pulpal bleeding or a putrescent odor. (4) abnormal mobility.

PULPOTOMY TREATMENT .

. extreme care must be taken to avoid perforating the pulpal floor. Be certain to remove the entire roof of the pulp chamber as small tissue tags remaining under the roof may cause the continued bleeding. Zinc oxide and eugenol base and final restoration PLEASE NOTE: ALL COTTON PELLETS ARE REMOVED FROM THE TOOTH PRIOR TO FILLING WITH ZOE MATERIAL. Mandibular molars have 2 canals (mesial. Such changes preclude the tooth from remaining a good candidate for the pulpotomy procedure and pulpectomy or extraction is indicated. A deep purple hemorrhage or an excessive amount of bleeding that persists in spite of cotton pellet pressure is indicative of inflammatory pulp changes that have extended into the radicular pulp. 5. Coronal pulp amputation Using a large sterile. NOTE: Maxillary primary molars have 3 canals (mesiobuccal. hemostasis should have been gained and be apparent. should be placed at the same appointment as the ferric sulfate pulpotomy.2. incise and remove all pulp tissue within the coronal chamber. 4. A large. When the pellet is removed. The final restoration should be a stainless steel crown and. lingual). since bleeding behavior is a clinical evaluation that is critical to judging the radicular pulp status. even though a minor amount of wound bleeding may be evident. distobuccal. Ferric sulfate application A cotton pellet soaked in ferric sulfate should be placed over the radicular pulp stumps for approximately 15 seconds with a rubbing motion. The pulp stumps are then blotted dry with cotton pellets. ZOE IS PLACED IN DIRECT CONTACT WITH THE PULPAL STUMPS. It should be noted that no intrapulpal local anesthesia should be used in attempting to minimize the hemorrhage. Hemorrhage control and evaluation One or more sterile cotton pellets should be placed over each pulp amputation site (canal orifice). distal) 3. large spoon excavator. The operator should be able to locate and visualize all of the pulpal canals. round bur in a slow speed handpiece is preferred by most dentists. and pressure should be applied for several minutes. but for the inexperienced. A regular mix of zinc oxide and eugenol (or a reinforced product such as IRM) should be placed at the base of the coronal pulp chamber directly on the amputation sites and should be lightly condensed so as to fill the access opening completely.

State several reasons why an SSC may not seat completely during try-on. At the completion of this laboratory exercise the students should be able to: 1. 4.buccal . State or illustrate the appropriate contour and shape to the gingival margins of 1st and 2nd primary molars. 7.STAINLESS STEEL CROWN (SSC) (Chrome Steel Crown) READING ASSIGNMENT: material OBJECTIVES : The student should be able to: 1. Describe indications. 10. 8. 2. 9. 6. contraindications. State the appropriate amount of reduction on each surface for a SSC: . Describe the difference between "contouring" and "crimping" an SSC. 11. 3. List the bur(s) used in the preparation of a SSC. (See Self-Evaluation Form). Pediatric Dentistry: Infancy through Adolesence pages 357-363 and Syllabus 5. Identify the difference between a "3M Ion" crown and a "Unitek" crown. State 3 advantages of a tight marginal fit for a SSC. Prepare and adapt a stainless steel crown on a primary molar. State the appropriate gingival length of a SSC.occlusal . .lingual State the type of finish line desired for a SSC preparation.proximal . Be familiar with several evaluative criteria for SSCs. advantages and disadvantages of the SSC restoration for primary and young permanent teeth.

2. 7. mesial and distal (for the Unitek crown only).CHROME STEEL CROWN PREPARATION SELF-EVALUATION 1. mesial. 3. Surface is contoured in gingival 1/3 of buccal. Proximal cut. CHROME STEEL CROWN ADAPTATION SELF-EVALUATION 1.5 mm and follows cusp form. 6. Cervical bulge remains. there is minimal or no buccal or lingual reduction. 4. Crown is crimped at gingival margin and tightly adapted to tooth surface on buccal. lingual and distal. 4. Occlusal surface is reduced 1-1. The aim of the stainless steel crown is to restore: Occlusion Contact (if present before procedure) Gingival health . 2. Crown is trimmed to 1 mm below gingival margin (for the Unitek crown only). contact is cleared. 3. 5. Proximal cuts end cervically without chamfer or ledge. lingual. and crown margin is fluid in form and follows contour of gingiva. All line angles are gently rounded. reduction not greater than 1 mm. Proximal walls are straight when viewed from occlusal and perpendicular to arch perimeter. Proximal walls are parallel or slightly convergent to occlusal.

2. To restore primary teeth as abutments for fixed appliances.Indications for Stainless Steel Crowns on Primary Teeth 1. 4. The occlusal anatomy of these crowns is more prominent. Procedure for Stainless Steel Crown Preparation Important Note: The stainless steel crowns which are available to the clinician and which will be utilized in the laboratory are referred to as the "3M" (or "Ion") crowns. The "Ion" (or "3M") crown is a pre-trimmed. pre-contoured. dentinogenesis imperfecta. 7. To restore primary teeth following a pulpotomy or pulpectomy. To provide temporary restoration of permanent molars. To restore carious primary teeth that would otherwise require large amalgam restorations. Although they have been pre-contoured and pre-crimped. and pre-crimped crown. To restore primary teeth with multiple carious lesions in patients with high decay rates where recurrent caries is expected. 5. 8. further contouring and crimping is sometimes necessary. To restore primary teeth to provide retention for removable appliances.amelogenesis imperfecta. . To restore teeth in patients with hereditary anomalies . In most instances no trimming of the gingival margin is required. To provide temporary restoration for fractured teeth. 3. 6. To restore teeth with hypoplastic enamel. with more secondary anatomy than you see on the uncrimped "Unitek" crowns. 9.

then remove decay with a large. 6. If problems are later encountered in selecting an appropriate crown size or in fitting a crown over a large mesio-buccal bulge. Bucco-lingual reduction for the stainless steel crown preparation is generally limited to this bevelling and is confined to the occlusal one third of the crown.0-1. as well as buccal or facial. 330 bur in the high speed handpiece. Care must be taken not to damage adjacent tooth structure. The occluso-buccal and occluso-lingual line angles are rounded by holding the bur at a 30-45 degree angle to the occlusal surface and sweeping it in a mesio-distal direction. 3. lingual. is discussed here. Contact with the adjacent tooth must be broken gingivally and bucco-lingually. 169L taper fissure bur or a thin. 5. Make depth cuts by cutting the occlusal grooves to a depth of 1. Evaluate the preoperative occlusion. and extend through the buccal. tapered diamond. The buccal and lingual proximal line angles are rounded by holding the bur parallel to the tooth's long axis and blending the surfaces together. . Administer appropriate local anesthesia. Proximal reduction is accomplished with the tapered fissure bur or thin. ensuring that all soft tissues surrounding the tooth to be crowned are well anesthetized.5 mm.5 mm. it is important to obtain lingual or palatal anesthesia. Next. Because gingival tissues all around the tooth may be manipulated during crown placement. and place a rubber dam. Reduction of the occlusal surface is carried out with a No. Ledges formed by deep caries should not be removed. place the bur on its side and uniformly reduce the remaining occlusal surface by 1. All of the angles of the preparation should be rounded to remove corners but not so much as to create a round preparation. maintaining vertical walls with only a slight convergence in an occlusal direction. more reduction of the buccal and lingual tooth structure may become necessary. requiring minimal tooth reduction. using the side of the bur or diamond. and proximal surfaces. 2. Note the dental midline and the cusp-fossa relationship bilaterally. tapered diamond in the high speed handpiece. Establish access with a No. Either Unitek or Ni-Chro Ion crowns may be used following these steps. Round all line angles. The gingival proximal margin should have a feather-edge finish line. 4.) 1. Only one such preparation.Steps of Preparation and Placement of Stainless Steel Crowns (Note: Several different preparation designs have been advocated over the years. Alternatively a number 8 round bur may be used. round bur in the slow speed handpiece or with a spoon excavator. maintaining the cuspal inclines of the crown.

Some teeth are an in-between size. If proximal contact needs to be established. A properly trimmed crown will extend approximately 1 mm into the gingival sulcus. and (3) maintaining gingival health. on next page). ensuring a good fit. Selection of a crown begins as a trial and-error procedure. A tight marginal fit aids in (1) mechanical retention of the crown. Crimping: Final close adaptation of the margin of the crown to the tooth surface is achieved by crimping the cervical 1 mm of the margin circumferentially. and examine the proximal contacts. or contact may not have been broken with the adjacent tooth. The No. 114 ball and socket pliers (Figure 21 –A. Remember that the “Ion” crown is pre-contoured. so that one crown size is too small to seat and the next larger size fits very loosely. this may not be required with the “Ion” crown. contour and crimp the crown so that it fits tightly. Observe the gingival tissue for blanching. (The Ion [3M] pre-contoured crowns do not usually require trimming. 137 pliers may be used for this. examine the gingival margins with an explorer for areas of poor fit. even after contouring.) 8. The selected crown is tried onto the preparation by seating the lingual first and applying pressure in a buccal direction so that the crown slides over the buccal surface into the gingival sulcus. Friction should be felt as the crown slips over the buccal bulge. If the crown does not seat to the same level as the adjacent teeth. establish a preliminary occlusal relationship by comparing adjacent marginal ridge heights. preventing a complete seating of the crown. After seating the crown. it can be done with a ball and socket pliers after removal of the crown. 137 Gordon pliers.7. Contouring: Contouring involves bending the gingival one third of the crown's margins inward to restore anatomic features of the natural crown and to reduce the marginal circumference of the crown. The goal is to place the smallest crown that can be seated on the tooth and to establish pre-existing proximal contacts. is also available. After seating a crown. a gingival proximal ledge may exist. a special crimping plier. this indicates the crown is too long or is grossly over-contoured. After contouring and crimping. (Figure B. If necessary. firm resistance should be encountered when the crown is seated. Further tooth reduction may be necessary in these cases to seat the smaller crown size. If an extensive area of gingival blanching occurs around the crown. the occlusal reduction may be inadequate. on next page) or with a No. (2) protection of the cement from exposure to oral fluids. Contouring is accomplished circumferentially with a No. the crown may be too long. .

The crown is filled approximately two thirds with cement. and re-examine the occlusion and the soft tissues before dismissing the patient. Look for movement of the crown occluso-gingivally with biting pressure. 13. after it has partially set. special care must be taken when handling the crown in the mouth. Dry the tooth with compressed air. 10. have the patient close into centric occlusion and confirm that the occlusion has not been altered. The rubber dam must be removed. Rinse and dry the crown inside and out. Cement should be expressed from all margins. 11. Examine the occlusion bilaterally with the patient in centric occlusion. 12. a spoon or cleoid-discoid can be used to engage the gingival margin and dislodge the crown. A glass ionomer cement is preferred. The handle of a mirror or the flat end of a band pusher may be used to ensure complete seating. Cement must be removed from the gingival sulcus.When removing the crown. and prepare to cement it. and the crown replaced so that the occlusion may be checked. A 2 X 2 inch gauze pad should be placed posterior to the tooth being crowned to act as a safety net to prevent the crown from dropping into the oropharynx. will reach a rubbery consistency. After the rubber dam is removed. Excess cement may be removed at this stage with an explorer tip. . 9. A thumb or finger should be kept over the crown during removal so that the movement of the crown is controlled. or the patient may be instructed to bite on a cotton roll. The interproximal areas can be cleaned by tying a knot in a piece of dental floss and drawing the floss through the interproximal region. Before the cement sets. with all inner surfaces covered. Alternatively the excess cement may be rinsed from the tooth before initial setting. and seat the crown completely. Rinse the oral cavity well. and check for excessive gingival blanching. Glass ionomer cement.

1984) With few exceptions most stainless steel crowns look good in the mouth. But more importantly. the spaces between the margins of the crown and tooth surfaces lessen. crowns that extend well beyond a tooth's height of contour are very difficult to adapt closely to the tooth surface. the contours of the lingual marginal gingiva of all first primary molars resemble smiles. these deficiencies seem to have little adverse effects on the supporting periodontal tissues. jagged angles. The margins of the finished. engaging the natural undercuts. The shape or contour of the gingival margins differ from first to second primary molar. . the crowns will continue to appear clinically acceptable for many years. Proximal contours of crowns are not well reproduced. The proximal contours of almost all primary teeth frown (Figure B next page). The length of a stainless steel crown should allow the crown to fit just into the gingival sulcus. Fortunately. when the margins of the metal crown nearly approximate the greatest diameter of the tooth. If you can picture the letter S on its side and stretched out somewhat. and (2) shape of the crown's gingival margins. As you look at the marginal gingiva around the second primary molar you will note that the occluso-gingival heights gradually become shorter along the crests of the gingival margins towards both the mesial and distal surfaces. There are no corners. As a stainless steel crown is trimmed in length such that its gingival margins come closer to the greatest diameters (heights of contour) of the tooth crown. trimmed steel crown consist of a series of curves or arcs as determined by the marginal gingivae of the tooth being restored. Keeping the principles of crown length and marginal shape in mind will ensure optimal adaptation and clinical success of the crown. The margins of the trimmed crown should approximate the shape of the gingival crest around the tooth. demonstrates the different gingival contours. as well as from buccal to lingual to proximal. next page. However. Except in cases of bruxism when crowns may be worn and flattened down. Due to the mesio-buccal cervical bulge the gingival margin dips down as it is traced from distal to mesial. For primary teeth the buccal. Thus. The buccal gingiva of the first primary molar has a different outline.Two Principles for Obtaining Optimal Adaptation of Stainless Steel Crowns to Primary Molars (Spedding. The radiographic appearance of the crowns is usually not as encouraging. and if a tooth crown is placed on top of this curved line. The deficiencies though can be largely avoided when attention is paid to two key principles: (1) crown length. Figure A. In other words. because the shortest occluso-cervical heights are about midpoint buccolingually. the term *stretched-out-S” can be used to describe the contour. Often they are too long. the crown length should extend just slightly apical to the tooth's height of contour. right angles or straight lines found on these margins. Radiographically. the spaces are small enough so that the metal can be adapted closely to the tooth. lingual and proximal heights of contour happen to be just above the gingival crest. The outline of buccal and lingual gingiva around second primary molars resemble smiles. By keeping these shapes in mind when trimming the stainless steel crowns the close adaptation to the tooth will be made much easier. margins are noted to be poorly adapted to proximal tooth surfaces. Contouring and crimping pliers are necessary to apply the appropriate gingival adaptation.

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try removing with a discoid instrument. 1.next page). 3. Crown is normally removed with a spoon. shape crown outward. B. If arch length will not permit a larger crown being used. Reduce ledge to feather edge or seat edge of crown below the ledge and "swing" crown to seat it (See Figure. REMEMBER: DO NOT DESTROY THE NATURAL UNDERCUT AND ALL REDUCTION MUST END WITH NO LEDGE. Reduce buccal and lingual surfaces. Check occlusal reduction Large cervical bulges or unusual contour of buccal or lingual 1. CROWN THAT IS LOOSE A. E. C. DIFFICULTY IN REMOVING CROWN DURING ADAPTATION A. Adapt as indicated. Impingement (length) or trapping (width) of gingival tissue. 3. Crown may be over adapted (made too small).COMMON CLINICAL SITUATIONS AND THEIR SOLUTIONS DURING ADAPTATION OF CHROME STEEL CROWNS 1. it should pass freely between proximals. stretch the smaller crown or reduce overall size of tooth being prepared. B. Ledge on preparation 1. Contact not cleared 1. Check with explorer. Insufficient occlusal reduction 1. F. Contour and crimp. Check to see that crown is fitting properly into cervical sulcus. D. Try smaller size. DIFFICULTY IN SEATING CROWN A. Crown is tightly adapted. Crown that is too small 1. Select larger crown 2. Clear contact if indicated. 2. Try removing from lingual. . Normally crown is removed from buccal to lingual.