Pediatric Operative Dentistry

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 Intended Learning Outcomes

• Differentiate between primary and permanent teeth and its clinical

significance in operative procedures (C4)
• Explain various modifications in cavity preparation done for primary
and young permanent teeth (C2)
 Why restore decayed teeth?

• The best dental treatment that clinicians can provide as any

treatment – preventive or restorative – will shape their dental future.
• The objective of any restorative treatment is to:
• Repair or limit the damage of dental caries.
• Protect and preserve remaining the pulp and remaining tooth structure.
• Ensure adequate function.
• Restore aesthetics (where applicable).
• Provide ease in maintaining good oral hygiene.
* Space maintenance
Restorative Tx- Part of comprehensive Tx Plan
Based on:
• Developmental status of dentition
• Caries risk assessment
• Patient’s oral hygiene
• Anticipated parental compliance
• Patient’s ability to communicate
Restorations in primary teeth differ from permanent teeth due to
morphological variations
Differences in crowns
• are shorter
• have a narrower occlusal table
• have a more pronounced
cervical constriction and a
prominent cervical contour
Primary Teeth
• Have broad, gingivally located
contact areas, there will be gingival
divergence of buccal and lingual
walls
• Interproximal lesions need to be
extensive before they are clinically
observable as a grey shadow
undermining the marginal ridge
• The buccal and lingual margins of
the interproximal box must extend
far enough towards the embrasure
at the gingival margin to make
them accessible for cleansing
• As caries starts at or below the
contact area, so the gingival seat
must be taken below the contact
 Primary teeth
• have enamel rods that run in a slightly occlusal direction from the DEJ
Pulps of primary teeth

• are larger than that of the

permanent tooth in relation to
crown size
• are closer to the outer surface of
the tooth
• the mesial pulp horn is
pronounced occlusally
• more closely follow the surface of
the crown
• usually have a pulp horn under
each cusp
 Clinical implication of Morphologic
considerations for primary teeth
• Thin enamel – depth of cavity less than permanent
• Direction of enamel rods – horizontal or occlusal – no gingival bevel for
Class II
• Broad contact areas – more width of proximal box
• Marked cervical constriction – minimal M-D extension to prevent pulp
exposure
• Narrow occlusal table – B-L extension not to involve cuspal height
• Prominent pulp horns – especially MB – care while making occlusal or
proximal box
• Pulpal roof concave – cavity should be slightly concave
 Principles in cavity preparation
• Initial tooth preparation
• Outline form and initial depth
• Primary resistance form
• Primary retention form
• Convenience form

• Final tooth preparation

• Removal of infected dentin
• Pulp protection
• Secondary resistance and retention form
• Finishing external walls
• Cleansing of cavity
Class I Amalgam Preps
• Outline form- include all retentive
fissures and carious areas
• Pulpal Floor Depth - 0.5 - 1 mm into
dentin(about 1.5mm from enamel
surface) (1)
Md Molars outline
• Cavosurface margin- non-stress bearing
areas, no bevel (4)
• Intercuspal width - 1/3rd
• If a dovetail placed in Md second molar
its width greater than the isthmus width
to provide resistance against occlusal
torque
Mx molars outline
• Rounded internal line angles (2&3)
• B-L walls converge occlusally
• M-D walls flare at marginal ridges to
prevent undercuts in the marginal ridge
Common errors with Class I amalgam
restorations
• Cavity too deep
• Undercutting marginal ridge
• Carving the anatomy of amalgam too deep
• Not removing flash from cavosurface margin
• Undercarving leading to subsequent fracture from hyperocclusion
• Not including susceptible fissures
 Class II Amalgam Preparations
• Proximal box – greater width to keep
margins in self cleansable areas
• Box to converge occlusally, paralleling
external tooth surface
• More B-L extension of gingival floor
• Axial wall to follow contour of external
surface
• Point contact between canine and first
molar – proximal box extension
minimized
• Gingival bevel not given
• Retention grooves given carefully
• MB pulp horn lies at a depth of 1.6
mm from mesial surface – limit depth
to 1 mm
• Isthmus width less than 1/3
intercuspal width
Common errors in Class II Amalgam cavity
preparation
• Failure to extend outline into
susceptible pits and fissures(A)
• Failure to follow outline of cusps(B)
• Isthmus too wide (C)
• Flare of proximal walls too great (D)
• Angle formed by axial, buccal and
lingual walls too great (E)
• Gingival contact with adjacent tooth
not broken (F)
• Axial wall not conforming to proximal
contour of the tooth and MD width of
gingival floor is greater than 1mm.(G)
Recently newer materials
• Composite resins replacement for Amalgam restorations
• Polyacid modified resin-based composites(Compomers)
• Resin-modified glass ionomer cements ( Vitremer)
• Glass ionomers
Advantages Disadvantages
Improved esthetics Exacting technique

Elimination of mercury Increased operator time

Low thermal conductivity Potential marginal leakage

More conservation of tooth structure Possible postoperative sensitivity

Bonding of material to tooth Tendency to open or lose contacts

Cavity Modifications
• Preventive Resin Restorations
• Atraumatic Restorative Technique
• Lamination technique
• Tunnel cavity
• Slot / Minibox restoration
Class I& II Preparations for primary molars
with adhesive Restorative materials
• Steps in preparation and restorations same as that of amalgam but
for a few modifications
• Absolute moisture control is a must.
• Tooth preps for class II have undergone several changes with no
consensus as to exact design to receive an adhesive material unlike
for amalgam
• Leinfelder (1996) recommended that class II preparation be primarily
limited to region of caries with little or no occlusal extensions –
“Slot preparation”
Class II preparation for Adhesive restorative
material
• Slot preparation- No need to extend the proximal line angles to self
cleansing areas as it leads to a larger restoration with greater chance
for occlusal wear
• Short bevel on cavo surface margin – increase surface area for
bonding and to remove aprismatic layer of enamel.
Class III advesive restorations
• Challenging to do:
• Often extend subgingivally – isolation compromised
• Large size of pulps preparations need to be kept small
• Retention solely with acid etching not adequate – need to put mechanical
retention is required
• Retention gained by –
• retentive locks on facial and lingual surface
• beveling cavosurface margin – increase surface area of etched enamel
Lamination Technique
• Combines GIC and composite such that advantage of one
compensates disadvantage of other
• GIC – better bonding but lacks fracture strength
• Composite – fracture strength but poor long term bonding
• Use fast setting high strength GIC as base / dentin substitute followed
by placement of most wear resistant composite - esthetic and long
lasting
 Steps
• Cavity preparation
• Restore with GIC
• Trim if required to create space for composite
• Expose and bevel all well supported enamel margin
• Smear layer formed due to re-preparation
• Etch
• Apply bonding agent
• Built incrementally with composite
• Finish & polish
LAMINATION TECHNIQUE
 Tunnel cavity
• Done if the cavity is very small and more than 2.5mm from crest of
marginal ridge
• Approach the dentin from occlusal fossa medial to the marginal ridge
using tapered diamond
• Aim diagonally & develop a small access cavity
• Once lesion is located, upright the bur into the marginal ridge and
bend it to buccal and then to lingual → triangular entry tunnel
• Use round bur to clear remaining soft caries
• If inner wall of proximal enamel is involved, break through to external
surface
• Fill with GIC