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بسم هللا الرحمن الرحيم

-Today we will talk about intracoronal restorations in pediatric

dentistry…

Lecture outline:

*intracoronal restorative materials: amalgam, composit,

RMGIs, PMCR.

*choice of material in pediatric restorations.

*anterior restorations.

*posterior restorations.

Firstly….

are any restoration that placed in :intracoronal restorations-

the tooth, so you make a cavity and fill it .

is something that we put on cap or :extracoronal restoration-

around the tooth.

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Now, we will start talking about amalgam as an intracoronal

restorative materials..

the advantages of using amalgam are:

*simple-ease of manipulation

*quick.

*cheap.

*technique insensitive.

*durable.

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: Disadvantages

*not adhesive.

*not esthetic.

*require mechanical retention in cavity.

*environmental & occupational hazards, which regard to

toxicity from mercury.

* public concerns.

Now, why is it not being adhesive?? Why this is a

disadvantage??

……. They see that when we deal with an adhesive restorative

material like composit or GI I don’t have to have a certain cavity

design (a certain depth and a certain width) I just follow the

caries, but with amalgam because it is not adhesive I need to

have mechanical retentive properties of the cavity, this mean

that we have to remove extra tooth structure in order to get

the kind of design that’s mean that it is not conservative to the

tooth structure.

clinical uses:

*class I restorations in primary and permanent teeth.

* 2-surface class II restorations in primary molars where the

preparation does not extend beyond the proximal line angle, it

means a very small class II.

*class II restorations in permanent molars and premolars.

*class IV restorations in primary and permanent teeth.

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:INDICATIONS_

*patient at moderate risk for caries.

*patient uncooperative (poor moisture control).

Now,the success rate for:

……class I amalgam is 93%.

……class II amalgam is 71%.

……all primary molar amalgams are 79%.

When you compare amalgam with SSC's, you have a 92%

success rate, that’s why when we do treatment planning

usually we have a class II, we put a crown.

the method for interproximal class II amalgam Now,

restoration in primary molars :

1 ) LA, RD

2)small bur in order to remove the caries, and you need to

include an isthmus & dovetail for retention and you need to

break the contact point , with the slow speed bur you need to

remove the deep caries and then you place liners,(in pediatric

dentistry we always place liners), why??

……. Because we have a very big pulps, high pulp horns, & wide

dentinal tubules, so you have to protect the pulp.

3) place matrix band,wedge,amalgam,condense,carve,burnish.

4)then you check the contact point with floss.

5)remove the rubber dam and check the occlusion.

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Now,this is an example of single tooth isolation by rubber dam..

You punch a hall on each tooth in the

dam.. the dam is a sheet of rubber and you use a puncher and

tooth single you just make a hall for each tooth, this is called

isolation.

you make a hall for a quadrant isolation,Here .. we have a

group of teeth

Now, the modified outline for primary molars is where the

occlusal outline shouldn’t extend into all the fissures but needs

to incorporate a small isthmus and dovetail for retention.

The fracture in class II amalgam occur in the isthmus (the

isthmus is the narrowest part in the dovetail occlusaly ) so after

the fracture microorganism will go inside the tooth and cause

abscess formation, so specially in small teeth the SSC is better

because class II is quite wide and extend beyond the line angle.

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COMPOSITE :

:Advantages

*adhesive.

*aesthetic.

*reasonable wear properties.

*command set, once you done you can cure.

:Disadvantages

*technique sensitive.

* rubber dam is required.

*expensive, (more expensive than amalgam but it's not that

expensive) .

*polymerization shrinkage is one of the chemical

properties that can happen, but we can minimize it.

Basic chemistry:

*monomer/resin:Bis-GMA or UDMA.

*filler: quartz or glass

*silane coupling agent.

*photo-initiator.

*stabilizer.

*pigments.

*radioactive agent like <yttrium tri-fluoride>

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why do we need it??bonding agent Now, the

It bond the primer and the composite resin together, in the

past they used a primer then a bonding agent then the

composite, so after acid etching we put a primer and this will

form a layer with the collagen fiber in the dentine, then the

bond will bind to the primer, then the composite will bind to

the bond .

Most modern bonding systems use an intermediary priming

agent which allows a hydrophobic bonding agent to bond to

the wet surface of dentine below and create a superficial bond

to the hydrophobic composite.

<< the idea is the composite is hydrophobic and the bonding

is hydrophobic also, but the primer is hydrophilic so it can binds

to the dentine then allow the others to bind consequently >>

A mechanical interlocking is achieved after the acid etching

because they have a porous area.

In the fifth-generation we don’t have all 3 layers, we have a

bottle of bonding agent which contain the primer and the

bonding agent together, the most recently one is the seventh

generation in which you have an acid etch, the primer and the

bonding agent in one bottle, you just place it, then dry it and

finally light cure it. But most of the studies done comparing

between the fifth and the seventh generation shows that the

fifth-generation has better retentive coat, because when we do

each step alone you guarantee that everything is done

properly.

The filler content:

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*anything which unfilled has no resin in it.

*anything with a sealant or bonding agent has 50%.

* a flowable composite from 50% - 70% .

*composite resin has from 70% - 85%.

we have..Now according the filler size:

*microfilled ( .01-.1)

*macrofilled. (>5.0-50)

*hybrid < micro and macro filled mixture> (.05-5.0)

Clinical uses of composite:

-In primary molars, composite is a satisfactory restorative

material, providing that the child is cooperative because it is a

technique sensitive .

And we can use it in pits a fissure caries , we just use a small

round bur , remove the caries from different areas and we just

placed composite and then fissure seal the all surface.. the idea

is that we don’t have to open all the fissures together y3ne we

don’t have to make them as one cavity, so this is a very

conservative of the tooth structure.

But if we have a deep caries which reach the pulp, upon caries

removal we do pulpatomy and then we place a SSC.

NOW, let's go back to the clinical uses of composite which is :

*small pit and fissure caries-PRR in bothe primary and

permanent dentition.

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*occlusal surface caries extending into dentine.

*class II restorations in primary teeth that do not extend

beyond the proximal line angles.

*class II restoration in permanent teeth that extend

approximately one-third to one-half of the buccolingual

intercuspal width of the tooth.

*class V restorations in primary and permanent teeth .

*class III restorations in primary and permanent teeth.

*class IV restorations in primary and permanent teeth.

*strip crown in the primary and permanent dentition.

Composite resin contraindications:

*where a tooth cannot be isolated to obtain moisture

control.

*individual needing large multiple surface restorations in the

posterior primary dentition.

*high risk patient that have multiple caries and tooth

demineralization, exhibit poor oral hygiene and compliance

with daily oral hygiene we need something more durable.

***Success rate in class II composite resin in primary molars=

40%, because of that we prefer to place a SSC .

method for cavity design:Now, the

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it need to be modified from that for amalgam, you just follow

the caries and remove it, it doesn’t has to have a specific design

you just need to bevel the enamel all around and you need to

place a liner on dentine.

So the outline should follow the extension of the caries we

don’t have extension for prevention, small occlusal dovetail not

usually necessary so the dovetail should be very small just to

help in retention.

Then remove the soft caries with the round bur, place the

matrix band.

Composite should placed incrementally, place bonding agent to

protect from post-operative sensitivity ..y3ne after you done

with composite you should place a layer of bonding agent and

cure it and then you check the occlusion.

Now, the problems with these restorations:

*integrity of bond at depth of the box y3ne ymkn el bond ma

yw9al mnee7 5a99a 3l gingival floor so in this case you place a

liner like GIC over dentine to ensure good bond and to reduce

microleakage and induce F release, the other thing is that you

have excellent bond between the composite and the vitrebond

,it is better than the bond between the composite and dentine

so you have a more retentive restoration which will work well

against microleakage which caused by polymerization

.sandwich techniqueshrinkage, and this is called

*placement of composite is also difficult because of moisture

sensitivity so you should place a rubber dam.

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* you should place composite in increment, because when

you place it incrementally you minimize the polymerization

shrinkage problem and get more retentive restoration.

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GLASS INOMERS:

: Advantages

*adhesive.

*aesthetic.

*fluoride leaching.

:Disadvantages

*brittle, not strong as composite.

*susceptible to erosion & wear.

Basic chemistry:

*a conventional GIC comprises a powder and liquid

component, when mixed together an acid-base reaction occur,

of coarse first I have something which called gelation and then

it is harden.

*polyalkeonic acid such as polyacrylic acid+ glass component

that is usually a F-Al-silicate.

*as the metallic polyalkeonic salt begins to precipitate,

gelation begins and proceeds until the cement sets hard.

Now, the characteristics:

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It able to chemically bond to enamel and dentine with

insignificant heat formation or shrinkage, this is important, we

don’t want too much heat to form because this will cause

damage to the pulp which mean that GIC is biocompatible.

Another thing is that composite is excellent to bind with

enamel better than dentin, but in GIC the opposite is true, GIC

binds to dentin better than enamel.

GIC is fluoride release but it is prelimited in time, so it leach the

greatest within the first 2 hours after placement of the

restoration up to the next 24 hours, some studies shows that

afterward GIC material is able to absorb any fluoride from the

environment and leach it whenever it needed, so this means

that if you have consistent intake of fluoride to tooth brushing

or mouth rinsing you get a continuous source of fluoride for

this restoration, and then it can delivered to the underlining

dentine.

GIC has a very low volumetric setting contraction (the opposite

of what happen to composite) the composite shrink more than

GIC which doesn't contract.

ALSO, GIC has a similar coefficient of thermal expansion to

tooth structure, it means that, you now the teeth are subjected

to hot liquid and then to cold liquid and then to hot liquid…etc,

the tooth will be affected by this temperature so any material

in nature has coefficient of thermal expansion which indicate

how much it will expand and contract, the tooth has a certain

coefficient of thermal expansion, now the good thing is that

GIC has a very similar coefficient of thermal expansion of

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dentine so that when you have a filling inside the tooth and you

drink something hot, the filling will expand and the tooth will

expand also.

GI disadvantages:

*physical strength.

*water sensitivity but it is less sensitive than composite.

the success rate: Now,

*failure rate of GIC is higher than amalgam :33% vs 20%.

* the average survival time for GIC = 33 months, or 3 years

ta8reban, it is ok in patient who is uncooperative like when you

have 1 or 2 or 3 years old child and he is not cooperative with

you so you cant place a proper composite filling on his anterior

tooth, it 's ok to place a GI or RMGI, it is will last for 2 or 3 years

then when the child become older you can just place your

composite restoration, you can reline on this GI filling as abase

and just place your composite on top of it if there is no

recurrent caries, SO you have limited caries, this is how we

work in pediatric dentistry.

In other situations where we don’t have local anesthesia, y3ni

we can't place the local anesthesia because the child is not

cooperative, you can excavate and place GI, this is not a proper

filling, it's just to arrest the caries.

Now, GIC indications:

*shouldn’t be used in large restorations subject to occlusal

load in teeth retained for more than 3 years because the study

is showing us that it can last for not more than 3 years, so if you

have an adult you cant place it as a permanent restoration for

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adults, never, you might place it temporarily because he has to

leave for a weak, and then he comes back and replace with

something permanent.

*small occlusal and interproximal caries, you can use it but

only with a small one in children.

*use stronger, packable, chemically cured GIC and avoid use

of RMGIs for posterior restoration.

clinical uses of GI:

*luting cement in SSC.

*orthodontic bands.

*orthodontic bracket's.

*liner.

*class I, II, III restorations in primary teeth.

*class III restorations in permanent teeth in high-risk patients,

so even if there is a permanent tooth and the patient is high

risk to caries you can place it until you arrest the caries in the

patient mouth then replace it with composite restoration.

*class V in primary and permanent teeth.

*caries control: this is a principle which is used to arrest caries

in patient who has a multiple carious lesion by excavating the

caries and place a fluoride releasing material like GIC or RMGI's,

so we place it in:

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- high risk patients.

-restoration repair.

- Atraumatic restorative treatment.

: ART: (Atraumatic restorative treatment)

Is a technique employs the use of hand instruments to remove

tooth structure affected by caries and the GI is placed, the

technique was first introduced in silent where some dentist

were on a voluntary mission, they found that many third world

areas didn’t have any electricity so they couldn’t use their

rotary instruments so they have to use hand instrument, they

excavate the caries and place GI, this is the beginning of this

technique.

Now a days it is used even in developed countries for

uncooperative children or patients who have medical problem

or for caries control to arrest the caries.

The success rate of ART in class I is 89.6% after 2 year follow up,

and have indicated its importance in children with behavior

problems as being non-painful.

Now it's named as (………….) therapeutic restoration, the APD

recognizes ITR as a beneficial professional technique in

temporary pediatric restorative dentistry .

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ITR is used to reduce the level of oral bacteria like streptococci

& lactobacilli in the oral cavity.

So they can use for:

*to restore and prevent of dental caries in young patient and

uncooperative patient.

*situation in which there is no electricity to use a rotary

instruments.

*step wise excavation in children with multiple open carious

lesions.

(Step wise excavation: is a technique that we remove the

caries and we restore with GI but the caries is so deep that you

might reach the pulp so we should leave part of it and then we

leave it for a month or so then we get back, we remove the GI

and we remove more caries because we sure now that there is

some of tertiary dentine)

*ITR may use as a caries control.

Now, the procedure:

*remove the caries, now since we have electricity then we

can use the slow speed to remove the caries, the size of

restoration can be minimize with maximum caries removal

especially walls because you want your filling to adhere

properly .

The great of success is in class I .

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FOLLOW UP CARE is necessary with topical fluoride, tooth

brushing and OHI to improve the treatment outcome in high

caries risk dental restoration.

Now, method for GI restorations:

Same thing except you do a conditioning of dentine with 10%

polyacrylic acid for 10 sec then wash it and dry it, after that you

place GI and protect it by putting a layer of bonding agent on

the top of it and cure it, if you don’t have a bonding agent at

least put place some vasline to protect the final restoration

from moisture contamination, and the final step is check the

occlusion.

********* a good information to you to ease the using of GIC

in the clinic is to put on your plastic instrument some bonding

agent before put GIC.

THE DOCTOR START JUST READING THE SLIDES WHICH TALK

ABOUT RMGI AND COMPOMERS SO PLZ REFER TO IT.

THE END.

(Sorry if there Is any mistake … & gd luck in your exams )

DONE BY: SAMAR AL-OMARI

SPECIAL HI GO TO MY PERFECT PARTNER AND SIS KAKOOSH thaaaaanx 3la

kol she w 5a9a 3ala surprise el a7ad w ALLAH y5alili hek surprise 3la

6oooooooooooooooooooool yaaaaaaaaa rab w ma y7remni mnha ;) wallah

ennek 3la rase (a7la abo el z3be wallah) <3 <3 :*

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Nevs,,, miss you ya ba6ee5a w miss el 23deh w el habal tab3on el f9l el

made,, w ba6li habalik w tafkerek elli bala 63meh.. :p <3 <3 luv u :*

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;) ;) ;)