Restorative Dentistry

Contents:

 Introduction
 When to restore carious lesions.
 Differences in cavity preparation for primary and permanent teeth.
 Restorative material in paediatric dentistry.
 Minimal intervention dentistry.
 Restoration of primary anterior teeth.
 Stainless steel crowns.
Introduction:

 Historically, the management of dental caries was based on the

belief that caries was a progressive disease that eventually destroyed
the tooth unless there was surgical and restorative intervention.

 now recognized that restorative treatment of dental caries alone

does not stop the disease process
Management of dental caries :

 Includes:

 Identification of an individual’s risk for caries progression.

 Understanding of the disease process for that individual.
 Active surveillance to assess disease progression.
 Manage with appropriate preventive services.
 Supplemented by restorative therapy when indicated.
Factors requiring consideration:

1. present caries activity

2. past caries activity
3. parent/sibling caries activity
4. sugar consumption (food and drink)
5. oral hygiene
6. fluoride exposure
7. tooth morphology
8. Streptococcus mutans levels
9. saliva characteristics, flow rate, and consistency.
Treatment decisions

Important points in relation to treatment:

 Minimum invasive techqunic.
 Once restoration used, further restoration required.
 When to restore carious lesions:

 Decisions depend on:

- clinical criteria of visual detection of enamel cavitation.
- visual identification of shadowing of the enamel.
- radiographic recognition of enlargement of lesions over time.
The benefits of restorative therapy include

 Removing cavitations or defects to eliminate areas that are susceptible to caries.

 Stopping the progression of tooth demineralization.
 Restoring the integrity of tooth structure.
 Preventing the spread of infection into the dental pulp.
 Preventing the shifting of teeth due to loss of tooth structure.
The risks of restorative therapy include

 Lessening the longevity of teeth by making them more susceptible to fracture.

 Recurrent lesions, restoration failure.
 Pulp exposure during caries excavation, future pulpal complications.
 Iatrogenic damage to adjacent teeth
Differences in cavity preparation for primary
and permanent teeth:
Primary teeth
The cavity preparation is smaller due to
smaller crown size, shallower due to thin
enamel and narrow occlusal table.
The pulpal floor is made saucer shaped
because of higher pulp horns.
The occlusal cavity walls are less convergent
In proximal box preparations, the buccal and
lingual walls are more convergent occlusally.
Buccal and lingual retentive grooves are
contraindicated.
Bevel is not given at the gingival seat as the
enamel rods are directed occlusally.
Width of isthmus is 1/3rd the intercuspal
Permanent teeth
The cavity preparation is comparatively larger
due to larger crown size, deeper due to thick
enamel and wider due to broader occlusal
table.
The pulpal floor is made flat.
The occlusal cavity walls are more convergent
In proximal box preparations, the buccal and
lingual walls are less convergent occlusally.
Buccal and lingual retentive grooves are
indicated for additional retention.
A bevel is given at the gingival seat as the
enamel rods are directed cervically.
Width of isthmus is 1/4th the intercuspal
Restorative materials
Amalgam

Advantages:
• Good durability
• Easy to handle
• Low cost
• Exhibit reducing microleakage with time.
• Less technique sensitive than composite.
Amalgam :

Disadvantages:
 Not aesthetic
 Need mechanical retention
 Mercury toxicity

*There is strong evidence that dental amalgam is efficacious in class I and II cavity
restoration in primary and permanent teeth.
Composite

 Resin-based composite consist of a resin matrix and chemically bonded fillers.

 Classified according to their filler size.
 Filler size affects:
 Polishability/esthetics
 Polymerization depth
 Polymerization shrinkage
 Physical properties
Composite

Advantages:
 Good aesthetics
 More conservative
 Bond to the tooth structure with an adhesive system.

Disadvantages
 Technique sensitive
 Require longer placement time
 Not a material f choice if isolation and patient cooperation is in question.
Composite

 In primary molar : strong evidence that it is successful when used in class I.

 In permanent molar: strong evidence that it is successful when used in class I and
II.
 Enamel and dentine bonding agents decrease marginal staining and detectable
margins for the different types of composite.
Glass ionomer cements

 Use as restorative cements, cavity liner/based, and luting cement.

 there is strong evidence that interim therapeutic restoration/atraumatic restorative
technique (ITR/ART) using high viscosity glass ionomer cements has value as
single surface temporary restoration for both primary and permanent teeth.
Glass ionomer cements

Advantages:
 Chemical bonding to both enamel and dentine
 Thermal expansion similar to that of the tooth structure
 Biocompatibility
 Uptake and release of fluoride
 Decreased moisture sensitivity

Disadvantages:
 Lack of strength.
 Low wear resistance.
Resin modified glass ionomer cements

 A monomer (hema) and a photo initiator were added to improve the properties of GIC.
Advantages:
 Better esthetics than GIC.
 Greater working time than GIC
 Superior strength characteristics
 Fluoride release
 Less sensitive to water than GIC
Disadvantages:
 Lower mechanical properties than composite.
Resin modified glass ionomer cements :

 RMGIC is more successful than conventional glass ionomer as a restorative

material.
 use of RMGIC in:
- small to moderate sized Class II cavities.
- Class I and Class II restorations of primary molars in a high caries risk
pt.
 Conditioning dentin improves the success rate of RMGIC
 Cavosurface beveling leads to high marginal failure in RMGIC restorations and is not
recommended.
 Insufficient evidence to support the use of conventional or resin-modified glass ionomer
cements as long-term restorative material in permanent teeth.
Compomers

 Poly acid modified composite, cross between composite and GIC.

Advantages:
 Good mechanical properties.
 Fluoride release.
 Good esthetics
Disadvantages:
 Relatively new material.
Compomers

 Compomers can be an alternative to other restorative materials in the primary

dentition in Class I and Class II restorations.
 There is not enough data comparing compomers to other restorative materials in
permanent teeth of children.
Maintenance of a clean operating field:

Rubber dam:
 Advantages:
1. Saves time.
2. Aids management.
3. Controls saliva.
4. Provides protection.
5. Helps the dentist educate parents.
Armamentarium For Rubber Dam
Placement:
 5 × 5-inch sheets of medium latex.
 a rubber dam punch,
 clamp forceps,
 a selection of clamps,
 a flat-blade instrument,
 dental floss,
 a rubber dam frame.
 When a quadrant of restorations in
the primary dentition is planned and
no pulp therapy is anticipated,
recommends the “slit-dam method.
Isolite system:
 Is designed to function as a vacuum
suction and to provide intraoral
illumination.
Minimal intervention dentistry
 Definition:
 Those techniques, which respect health, function and esthetics of
oral tissue by preventing disease from occurring, or intercepting its
progress with minimal tissue loss. (Nový and Fuller 2008)
 Stratigies:
1.Early caries diagnosis
2.Classification of caries
3.Assessment of individual caries risk (high, moderate, low)
4. Arresting of active lesions
5.Remineralization of arrested lesions
6.Minimal invasive restorations
7.Repair rather than the replacement of defective restorations
8.Assessing disease management outcomes at pre-established intervals.
Non-invasive treatment

 Non-invasive treatments aim at ’managing’ rather than removing caries lesions.

 They include :
- Biofilm control via mechanical removal of plaque (e.g. dental floss or
interdental brushing by patient).
- Antibacterial treatments (e.g. application of chlorhexidine, varnishes)
- Remineralisation treatments (e.g. topical fluoride)
 The effectiveness dependence on patient cooperation (biofilm removal on
proximal surfaces “flossing”, periodic visits)
 Proximal dental lesions, limited to dentine, are traditionally treated by invasive (drill and
fill) means.
 Recently, micro-invasive approaches for treating proximal caries lesions have been tried.

Methods and materials:

- Sealing via resin sealants, (polyurethane) patches/tapes,
- Glass ionomer cements (GIC)
- Resin infiltration
 These newer methods work by installing a barrier either on the tooth surface or within
the demineralised tissue to protect it against acids and avoid the further loss of minerals
from within the tooth.
 Resin infilteration

 Is an innovative approach primarily to arrest the progression of non-cavitated

interproximal caries lesions.
 The aim of the resin infiltration technique is to allow penetration of a low
viscosity resin into the porous lesion body of enamel caries.
 Enamel is etched with hydrochloric acid prior to the placement of the resin.
 The resin can be placed on facial or lingual tooth surfaces and proximal lesions
 The resin is tooth colored but not radiopaque.
Atraumatic restorative technique

• This method may prevent pain and preserve teeth in individuals who do not have
access to regular and conventional oral health care.
• May be performed with only hand instruments
• Not require complete excavation of dentinal caries before placement of the
restorative material
• Not a totally new concept, but it has enjoyed renewed recognition because of the
development of the more durable restorative materials.
Atraumatic restorative technique

Goals :
 Preserving tooth structure,
 Reducing infection,
 Avoiding discomfort.
Interim therapeutic restorative
technique (ITR).
 ITR utilizes similar techniques as ART, but has different therapeutic goals.
 When circumstances do not permit traditional cavity preparation and/or
placement of traditional dental restorations
 when caries control is necessary prior to placement of definitive restorations.
 The use of ITR reduce the levels of cariogenic oral bacteria immediately
following its placement.
 But level may return after 6 month, if no other treatment is provided.
Interim therapeutic restorative
technique (ITR).
 Used to restore, arrest or prevent the progression of carious lesions in:
1- Young patients.
2 - Uncooperative patients.
3 - Patients with special health care needs.
4 - For step-wise excavation in children with multiple open carious lesions prior to
definitive restoration.
5 - In erupting molars when isolation conditions are not optimal for a definitive
restoration,
6 - For caries control in patients with active lesions prior to treatment performed
under general anesthesia
7 - To restore cavity but not feasible and traditional restoration needs to be
postponed
Preformed metal crowns
(Stainless steel crowns)
Stainless steel crowns

 are prefabricated metal crown forms that are adapted to individual teeth and cemented with
a biocompatible luting agent.
 the use of the SSC restoration is its cost effectiveness based on its durability and longevity.
 Indication:
1. Restorations for primary or young permanent teeth with extensive and/or multiple
caries lesions.
2. Restorations for hypoplastic primary or permanent teeth that cannot be adequately
restored with bonded restorations
Stainless steel crowns

3. Restorations for teeth with hereditary anomalies, such as dentinogenesis

imperfecta or amelogenesis imperfecta
4 Restorations for pulpotomized or pulpectomized primary or young permanent
teeth when there is increased danger of fracture of the remaining coronal tooth structure
5. Restorations for fractured teeth
6. Restorations for primary teeth to be used as abutments for appliances
7. Attachments for habit-breaking and orthodontic appliances
Stainless steel crowns

Preparation of the tooth:

 A local anesthetic should be
administered
a rubber dam placed
 The proximal surfaces are reduced
using a No. 69L bur at high speed
 A wooden wedge may be placed tightly between the surface being reduced and
the adjacent surface to provide a slight separation between the teeth for better
access
 The gingival margin of the preparation on the proximal surface should be a
smooth feathered edge with no ledge or shoulder present
Stainless steel crowns

 The cusps and the occlusal portion of the tooth may then be reduced
 The general contour of the occlusal surface is followed, and approximately 1 mm
of clearance with the opposing teeth is required.
 remove all sharp line and point angles.
 Not necessary to reduce the buccal or lingual surfaces (to have an undercut on
these surfaces to aid in the retention of the contoured crown).
Stainless steel crowns

Selection of crown size:

 The smallest crown that completely covers the preparation should be chosen.
 The operator must establish the correct occlusogingival crown length.
 The crown margins should be shaped circumferentially to follow the natural
contours of the tooth’s marginal gingivae.
 The crown should be reduced in height, if necessary, until it clears the occlusion
and is approximately 0.5 to 1 mm beneath the free margin of the gingival tissue.
 The occlusion should be checked.
 Cemented with a glass ionomer cement.
 Seat the crown from lingual to buccal,
pressing down firmly.
 Remove excess cement when set with a
probe and dental floss
Restoration of primary anterior
teeth
(full coverage)
Indications:

 Unaesthetic tooth due to discoloration.

 Tooth with trauma and significant tooth loss.
 Tooth with pulp therapy and significant tooth loss.
 Tooth with large interproximal area of caries.
 Tooth with structural defect (hypoplastic).
Types:

 Stainless steel crown.

 Open faced SSC.
 Resin (composite) strip crown.
 Preveneered SSC.
 Zirconia crown.
Stainless steel crown

 For posterior teeth.

 Aesthetic: poor
 Durability:
- v.good.
- very retentive.
- wears: well.
 time for placement:
- fast
- aesthetic not a concern.
 Selection criteria:
- when aesthetic not a concern.
- severely large decayed tooth.
- when gingival hemorrhage and
moisture can not controlled.
- pt. cooperation less than ideal.
Open faced SSC

 Aesthetic:
- fair.
- metal shows under composite.
 Durability:
- good.
- retentive but composite face
may be dislodge
 time for placement:
- long.
- 2 steps: cementation of the
crown then placement of the composite.
 Selection criteria:
- severely decayed tooth.
- when aesthetic is concern.
- when durability and retention
needed.
Resin (composite) strip crown

 Aesthetic:
- V. good
 Durability:
- need adequate tooth structure.
- use in trauma or traumatic
occlusion.
Resin (composite) strip crown

 Time for placement:

- most sensitive method.
- depend on ability to isolate
tooth and control moisture.
 Selection criteria:
- aesthetic highly concern.
- cooperative pt.
- pt. not prone to trauma.
- adequate tooth structure.
Preveneered SSC

 Aesthetic:
- good.
- limited shades.
 Durability:
- good.
- face may break.
Preveneered SSC

 Time for placement:

- moderate.
- longer than SSC due to
reduction and adaptation.
 Selection criteria:
- when aesthetic is concern.
- pt. prone to trauma and bruxism.
- more expensive than other
restoration.
- severely decayed tooth.
Zirconia crown

 Aesthetic:
- v. good.
 Durability:
- v. good required adequate tooth
structure.
- less prone to fracture than
composite strip crown.
Zirconia crown

 Time for placement:

- not a sensitive techq.as composite
strip crown.
 Selection criteria:
- aesthetic is a great concern.
- cooperative pt.
- adequate tooth structure.
- severely decayed tooth.
 Any
questions ????