Part 11

Treatment of carious
primary teeth

1
Dental caries:- Is a disease of bacterial origin. The causation bacteria are harboured
in adherent dental plaque. The mouth is a natural resorvoir for many of these
bacteria.

Caries is thus a disease which can only develop with:-

a. Bacterial agent- bacteria in the dental plaque capable of producing acid as one
by-product of their metabolism;
b. A suitable substrate- the acid-producing bacteria require a suitable substrate to
metabolize in the dental plaque;
c. A susceptible host- dental tissues which are susceptible to dissolution by plaque
acid;
d. Time- clinical caries only develops after repeated and undisturbed acid action has
led to sufficient demineralization to allow further bacterial invasion of the tooth and
eventual permanent loss of tooth substance.

2
Classification of dental caries
• Black's classification:
• Class I: Cavities on the occlusal surface of premolars
and molars, on the occlusal two-thirds of the facial and
lingual surfaces of molars, and on the lingual surface of
maxillary incisors.
• Class II: Cavities on the proximal surfaces of posterior
teeth.

• Class III: Cavities on the proximal surfaces of the

anterior teeth that do not involve the incisal angle.

• Class IV: Cavities on the proximal surfaces of the

anterior teeth that involve the incisal edge.

• Class V: Cavities on the gingival third of the facial

or lingual surface of all teeth.

• Class VI: Cavities on the incisal edge of the anterior 3

teeth or occlusal cusp heights of posterior teeth.
B. According to location on individual teeth:
1. Pit and fissure caries.
2. Smooth surface caries.

C. According to rapidity of the process:

1. Acute dental caries.
2. Chronic dental caries.

D. -
1. Primary (virgin) caries.
2. Secondary (recurrent) caries.

4
New caries classification (mount and hume)
Based on the principles of adhesive dentistry 1997- for caries called the
sites stages (si/sta)
A- Three sites of susceptibility to caries which are acutually the area
where bacterial plaque tends accumulate (sites 1-3)
1: pits and fissures
2: smooth surfaces
3: root caries
B- five stage scale of caries progression (stages o-4)
0: white stain
1: enamel
2: dentine
3: deep dentine
4: caries which reach the pulp

5
 sta 0 1 2 3 4
si

1 1.0 1.1 1.2 1.3 1.4

2 2.0 2.1 2.2 2.3 2.4

3 3.0 3.1 3.2 3.3 3.4

6
The principal reasons for restoring carious primary teeth
are:-
1. To eradicate disease and restore health. Disease of primary teeth should no
more be ignored like other disease of any other part of the body.
2. To give the child the simplest from of treatment.
Early treatment give a minimal restoration.
3. To prevent child suffering pain
4. To avoid the infection that follows carious
exposure of the pulp.
5. To preserve space that is required for the
eruption of permanent teeth.
6. To ensure comfortable and efficient mastication, and aesthetic
Basic principle in the preparation of cavities in primary teeth:
In preparing cavities for restoring primary teeth, although the basic
principles of cavity preparation are applied, there are certain modifications in
cavity design which make restorative care of these teeth unique. Most of
these modifications have to do with the difference in morphology of the
primary molars from that of the permanent molars

7
Guiding principles for adhesive cavity design:
The following table shows principles of cavity design according to G.V.Black in
comparison with modern concept.
Principles of G.V.Black
cavity design
1. Access  Gaining access to cavity
 Prepare cavity to standard outline
 Remove any remaining caries.
2. Outline  Includes all deep fissures even
form those which are not carious
3. Extension  Extension for prevention i.e.
extend the preparation into self
cleansing areas
Modern concept
 Gaining access to caries
 Remove caries
 Plan the final outline
according to the material used
 Involved carious fissure
while sound deep fissures may
be covered with sealant.
 Prevention of extension
i.e. no need to extend the
preparation into self cleansing
areas or to remove affected
dentine in deep portions. The
approach focuses on healing
instead of removal of
demineralized
8
4. Resistance  Removal of all undermined and  Remove loose and fragile
unsupported tooth structure enamel rods at C.S.A which are
directly exposed to occlusal load
while other unsupported tooth
structure may be conserved and
reinforced by the bonded
restoration.
 Preservation of marginal
ridges in case of early proximal
caries by utilizing slot and tunnel
preparation.
5. Retention  Mechanical macroretentive  Micromechnical retention
interlocking designs: which includes current etching
 Convergence of walls and bonding procedures.
 Dovetail  Beveling which increases
 Undercuts the potential surface area for
retention.
 Axial grooves
6. cleanliness  Finishing the walls and toilet of  Cleanliness of adhesive
the cavity. surfaces to ensure optimal
bonding.
9
Restorative material for primary teeth
In considering the characteristics of an ideal restorative material, it is
apparent that no single material can fulfill all of the clinical needs. The
characteristics of the ideal restorative material are described as fulfilling
requirements applying to the:-
1. Physical and mechanical properties of the material.
2. Technical features of the material from the perspective of the dental
professional.
3. Patient acceptance.
4. Other clinical aspects that contribute to the material„s effectiveness.
The interaction of these factors determine the longevity of the dental
restoration.

10
Amalgam Restoration:-
1. Amalgam has long been the material of choice for restoring primary and
permanent posterior teeth.
2. The toxicity of mercury has given rise to concern that amalgam restoration
may present a health hazard to the patient and dental staff.
3. However, the modern methods of using and disposing of amalgam ensure
adequate control of environmental pollution.
4. The physical properties of modern dental amalgams are adequate for all.
5. Amalgam restoration is less affected by moisture than are composite resin
or glass ionomer cement.
6. The techniques involved in the use of amalgam are less demanding than
with composite resin or glass-ionomer, and is easier and quicker
7. It is restorative material of choice for posterior teeth, and is used for
occlusal (class I), approximal (class II) and (class V) restoration.

11
Resin-modified glass ionomers (RMGI)
1. resin-modified glass ionomers are glass ionomer cements to which a resin
has been added for strength
2. Resin-modified glass ionomers works by the fundamental acid-base
reaction, which is supplemental by a second resin polymerization reaction.

12
Advantage of resin-modified glass ionomers:-
1. High strength and mechanical properties.
2. Less senstive to water contamination.
3. RMCI also releas fluoride. Fluoride is released from RMGI not only when it
is placed, but also after fluoride treatment and brushing with fluoride tooth
paste. This is because glass ionomer acts as fluoride reservoir.
4. Better esthetics.
5. Rapid setting since its light activated, so it can be finished immediately.
6. Its coefficent of thermal expansion is very close to that of a tooth.
7. Resin-modified glass ionomer is a tooth-colored material that bond to the
tooth
8. Less tooth enamel needs to be removed by the dentist when an adhesive-
colored restoration is placed in a tooth.

13
Disadvantage:
1. Sensitive to water contamination and dehydration
2. Esthetically ,there are less pleasing than composite.
3. Brittle with poor edge strength because of low tensile strength.
4. Short working time and long setting time

Uses:-
• Used in restoration of class I, II ,III, IV, V in primary teeth.
• Used in stress bearing area.
• Useful in child with previous high caries experience.
• When patient cooperation is limited and it is perfarable to simplify
operative procedure as much as possible

14
Surface condition:
• Clean surface is essential to promote proper adhesion of the cement to
the tooth surface

 Mixing of GIC material

• Powder liquid ratio recommended by the manufacture should be
followed .
• A cool dry glass slab may be used to slow down the reaction and
extend the working time.
• The powder should be incorporated rapidly into the liquid using stif
stainless steel spatula.
• The mixing time sould not exceed 45-60 sec.
• The mix should have glossy surface.

15
Placment of material:
The mixed cement is immediately packed by means of plastic
instrument or it can be injected in the cavity using special syringe
and then adapted to the cavity walls as need.
If GIC is used as restorative filling material a pre shaped matrix
should be applied for two reason:
To prevent maximum contour of material , so a minimum
finishing is required
The matrix is protect the seeting cement material from loosing
or ganging any water during the initial seeting.(the matrix is left in
place for 5 minutes)

16
 Composite:-
Composite are composed of a resin matrix, an inorganic filler, and
an interfacial phase. The matrix provides the framework, and
the filler imparts its mechanical properties onto the composite.
Advancement are all focused on:
- Better strength together with
- Better consistency and
- Esthetics
- Advancements also directed toward having materials with flower
consistency
- Some manufactures added fluoride to the composite restorative but the
long-term effectiveness of these additives was questionable
- Occlusal wear is greater in composite than in amalgam restorations but
this only becomes significant after several years.
- Has better strength, esthetics and stability in oral fluids than RMGI.

17
Indications:-
1. Good patient cooperation (technique sensitive)
2. Low caries rate patients.
3. When esthetic is needed.
4. Core Build up
5. Luting agent
6. Hypodontia cases
7. Fractured tooth
8. Malformation of teeth.
CONTRA INDICATION:
1. DIFFICULTE ISOLATION
2. HEAVY OCCLUSION
3. SUBGINGIVAL MARGINE
4. BAD ORAL HYGEIN PATIENT
5. SENSITIVITY OF THE TOOTH

18
ADVANTAGES OF COMPOSITE:
1. ESTHATIC
2. PROPERLY PLACED WITH PRINCIPLES
3. ANY PLACSES APPLICATIONS
4. RESNABLE EXPENCES
DISADVANTAGES OF COMPOSITE:
1. SHRINKAGE
2. MICRO LEAKAGE
3. FRACTUBLE
4. DIFFICULTE TO CARVE IT
5. NEED HIG SKILLS
6. CAUSES ALLERGY
Uses:-
Used in restoration of CL I, CL II, CL III, CL IV, CL V in primary teeth.

19
 compomer
1.Compomers are mix between composite and glass ionomer to
have the benefits of both material in term of:-
- biocompability
- fluoride release
- strength and
- esthetics.
2. Compomers are similar to composite, they have a wear rate about (3) times
that of composite
3. Compomers is one of the most successful materials introduced for the
treatment of primary teeth due to:-
a- fluoride releasing potential.
b- bonding capacity to enamel and dentine.
c- no need for acid etch.
d- simple handling properties.

20
Uses:-
a- it can be used in, CL I, CLII, CLIII, CLIV, CLV, restoration of primary teeth
b- can also be used as fissure sealant
c- can be use in restoration of permanent teeth.
Stainless steel crown
1. Stainless steel crown (S.S.C) provide strong durable restoration for
primary teeth.
2. It is indicated in:
a- restoration of badly decayed deciduous teeth
b- pulpotomized molars
c- also can be used as a temporary restoration for decayed permanent
molars.

21
Technique: occlusal (class I) amalgam restoration
1. Gain access to the caries:
• with high-speed handpiece penetrate the occlusal surface within the caries area
where the depth of pulpal floor should be establish just beneath the dentinoenamel
junction (0.5mm) to avoid pulp exposure.
• the outline form should include all pits, fissures and grooves.
2. Remove the caries:
• extend the cavity laterally to remove caries from the wall of the cavity until to
caries free area.
• with slow-speed handpiece remove caries from the floor of the cavity.
. a flat pulpal floor is generally advocated or
. make the pulpal floor slightly concave for:-
a. better distribution of stress in the restoration and
b. to avoid endangering the high pulpal horn.

22
3. Plane the final cavity outline and shape:
• consider whether the cavity need further preparation to provide retention
for the restoration
• all the internal line angle should be round
• the side walls should slightly converge towards occlusal so that the
preparation with follow the outer form of the crown
• dovetail occlusal shape
• in maxillary second molars and mandibular first molars, do not extend
across the occlusal oblique ridge unless they are undermined by caries.

23
4. Wash, dry and assess the cavity preparation
5. Line the cavity:-
• no lining is required in minimal depth cavity
• in deep cavity apply a quick setting calcium hydroxide lining to the direct dentine on
the floor of the cavity.
• after setting remove any excess from the enamel walls with the excavator.
6. Condense amalgam into the cavity with amalgam carier.
Eject part then condense with plugger, again eject part then condense until the cavity is
overfilled by about 1mm, then condense the overfilled amalgam over the margin of
the cavity.
7. Carve the amalgam, remove the excess, do not
reproduct deep fissure.
8. Lightly burnish the amalgam margin
9. Smooth the restoration with a cotton wool pledget
10. Check the occlusion
11. Finish the restoration for at least 24 hours later.

24
Technique approximal surface (class II) amalgam restoration.
1. Gain access to the cavity:
• Use a small round or pear shapped bur
• Penetrate the occlusal surface inside the marginal ridge to reach the caries.
2. Remove the caries and plane the final cavity outline and shape
• The preparations include an occlusal, a is thmus and proximal portion
• The outline form of the occlusal step should be dovetail shaped including all carious
pits, fissure, and developmental
• The side wall of the occlusal steps should converge from the pulpal wall to the
occlusal surface.
• The pulpal floor should be established just beneath the dentinoenamel junction.
• Angles between the side walls and the pulpal floor should be gently rounded
• The area of isthmus should be made as wide as possible buccolingually without
weaking the cuspal area or endangering the pulp. The optimum width of the isthmus
one half of the inter cuspal dimension of the tooth.
• The gingival seat of the proximal box should be established just beneath the free
margin of the interproximal gingival tissue and
• Should be of sufficient depth to break contact with the adjucent tooth (1mm)
• It is unnecessary to bevel the enamel of gingival seat since the enamel rods at the
cervix slop occlusally.
• The proximal box line angle and walls should converge towards the occlusal to
provide and increase retention.
• An axiobuccal and axiolingual retentive grooves may be included in the preparation.
25
3. Wash, dry and assess the cavity preparation
4. Line the cavity
5. Fit a matrix
• The mechanical retainers such as ivory, Tofflemire, and wagner should not be
used when condensing amalgam in primary molars as they will not produce a
desirable finished restoration since the primary molars have prominent
buccocervical ridge marked construction of the crown in the cervical region and
sharply converging buccal and lingual surface toward the occlusal.
• A spot welded band or T-band matrix can be successfully used producing a well
contoured restoration.
6. Condense amalgam into the cavity
7. Carve the amalgam
8. Linghtly burnish the amalgam margin.
9. Smooth the restoration
10. Check the occlusion
11. Finish the restoration

26
Technique: (class I) composite resin restoration:
1. Prepare cavity
• As for amalgam
• The enamel margin of the cavity may be bevelled.
2. Line the cavity
• Use a quick-setting calcium hydroxide.
3. Place a matrix
• use a thin metal matrix material
• place a wedge at the cervical margin.
• difficult to obtain a satisfactory approximal surface contour and a good contact with
the adjacent tooth is one of the disadvantages use of composite.
4. Etch the enamel at the margin of the cavity
• apply 30-50% phosphoric acid to the enamel for 1-1½ minutes
• wash for 15 seconds
• dry for 30 seconds
5. Apply bonding agent
• apply it to the dentist wall of the cavity and to the enamel
• allow to polymerize, or polymerize with a light source.

27
6. Insert composite restoration material
• carry the first increment into the deepest part of the cavity
• condense it with small hand instrument.
• add further increment and condense
• polymerize each increment before adding further material.
7. Remove the matrix, trim excess and polish
Technique: approximal surface (class II) glass-ionomer
restoration
1. Prepare a cavity
• prepare cavity as for amalgam
• although glass-ionomer cement adheres to enamel and dentine, it is better, if
possible, to provide mechanical retention within the cavity
2. Line the cavity only if it is deep
• place quick-setting calcium hydroxide on the deep part of the cavity only (only the
minimum area of dentine)
3. Place a matrix
4. Clean the cavity walls
• use the conditioning solution supplied by the manufactuer.
• apply it by cotton wool pledget for 10-15 seconds.
• wash with water and light drying.
28
5. Insert the glass-ionomer cement
• prevent moisture contamination while filling the cavity.
• carry the first increment into the deepest part of the cavity
• condense with hand instrument
• add further increment quickly and condense.
- When the cement has hardened apply a layer of special varnish of a light
cure unfilled composite of the surface of restoration (do not polymerize the
resin at this stage).
6. Remove the matrix and trim excess
7. Polish the restoration
- delay polishing for several minutes]
- polish under air-water spray
- apply another thin layer of varnish and polymerized it.
Technique: class III composite resin restoration
1. Gain access to the caries
- when ever possible, gain access to the cavity from the palatal or lingual
aspect.
- penetrate the enamel without risking damage to the adjacent tooth
29
2. Remove the caries
• if the carious lesion has not advance into the dentine and if removal of the caries
will not involve or weaken the incisal angle, a small conventional class III cavity
may be prepared
• if the caries is more extensive a dovetail preparation can be made
• in small cavities, a slight general undercut of the walls is sufficient this may be on
the gingival and incisal aspects
• in a large cavity with a weak palatal wall, prepare a retentive “lock” in the palatal
surface.
3. Wash, dry and assess the cavity preparation
• wash the cavity with water
• dry with compressed air
• confirm that the cavity is caries free and other wise satisfactory.
4. Line the cavity
• apply quick-setting calcium hydroxide.
5. Etch the enamel at the margin
• with 30-50 phosphoric acid
• after 1 minute wash with water and
• dry thoroughly.

30
6. Fit a matrix
• use a cellulose acetate or other suitable matrix strip.
• placing a wedge, other wise hold the strip in place with finger.
7. Fill the cavity
8. Finish the restoration
• remove the matrix
• trim excess with zirconium silicate discs leave a smooth surface.
• polish using composite polishing paste

Technique: class IV composite resin restoration

1. If caries is not extensive, disking by sand paper disc is performed to
removed the decay, then fluoride is applied topically
2. When caries is extensive, regular class IV cavity preparation, then composite
restoration can be used with
a- anterior chrome steel crown with facing or
b- acrylic jacket can be used

31
Technique: class V
1. Class V cavity are prepared like those in permanent teeth, although the
depth is not carried more than 1-5 mm.
2. All decalcified area are included in the out line form of the cavity
3. In deep cavity protective base should be used
4. It is not necessary to bevel the gingival wall.

32