1. Dental Restorative Materials in Pediatric Dentistry By: Hussein Al Harthy Rahaf Najjar Supervised by: Dr. Medhat Abdullah Dr. Omar Elmeligy 2. Lecture outline Factors affect choosing material Cavity varnishes Bases Cements Temporary filling Intermediate restorations Permanent restorations Amalgam Composite Crowns in Pediatric Dentistry. 3. Factors affect choosing material The age of the child Caries risk Cooperation of child Type of material Type of tooth 4. Age What can the child handle? Rubber dam Local anesthetic Length of attention span How long will the restoration need to last? 5. Caries Risk Number of carious teeth Size of lesions Likelihood of further acid attack Need for caries control first? Fluoride-releasing materials desired? Motivation and compliance of patient and caregiver Oral hygiene Diet 6. Cooperation of Child Nature of childs behavior Highly technique-sensitive procedures may be inappropriate in children whose behavior is not Favorable Consideration of caries control procedures (Interim Therapeutic Restorations or fluoride clinics) 7. Choice of Material materials available What is the best available option for each clinical Situation? What material will provide the characteristics you want? What technique can be completed successfully with minimal psychological trauma to the child? 8. Cavity varnishes Gum (eg. copal) as resin dissolved in organic solvents (eg. chloroform) Also eugenol and recent fluoride composition Liner (chemicals) Applied onto cavity Solvents evaporated Leave thin film need twice Reduce initial microleakage around amalgam Some use dental adhesives instead of varnish (thin) Mahler study show no reduction in sensitivity with dental adhesive Varnish before dental adhesives ( no adhesion ) 9. Cement Bases Protect and recovery the injured pulp Thermal insulator (sufficient thickness min. 0.5 mm) Condensable ( high strength ) All the following have sufficient strength and the most common used Zinc polycarboxylate Hard setting calcium hydroxide Z.O.E. G.I.Cs In cases as class II in deep depression or angle cover calcium hydroxide base with GICs 10. Cements Serve as luting agent Provide mechanical retention Some used as permanent or temporary restorations Used as bases for other material 11. Cements Types Silicate cement (no longer used) Zinc phosphate cement (no longer used) Polycarboxylate cement Glass ionomer cement Resin modified glass ionomer cements Type I : Luting agent Type II : Filling material Type III : Base and liner Zinc oxide-eugenol cement Resin cements 12. Ideal requirement of cements Medium working time Short-medium setting time Very high compressive strength High Bond strength to tooth Release of fluoride No pulpal response Easy to remove excess 13. Polycarboxylate cement Polyacrylic acid + zinc oxide powder short working time Short setting time Low-medium compressive strength Low-medium Bond strength to tooth No Release of fluoride No pulpal response Medium-difficult remove excess Used as luting agent or a base especially cavity close to pulp Requirement is clean surface 10-15 sec. by swabbing 10% polyacrylic acid (to bond) Mix requirement (30 sec. , recommended ratio, glossy appearance) 14. Glass ionomer cement HYBRID = Silicate Cement [Powder] + PolyCarboxylate [Liquid] Setting reaction There are three stages: Dissolution Gelation ( Migration) Precipitation and Hardening. (Water hardening or water setting) 15. Properties Short-Medium working time Long setting time Low compressive strength Bond strength to tooth Release of fluoride Low pulpal response Moderate remove excess Film thickness is similar or less than zinc phosphate cement. Setting time 6 to 8 minutes from start of mixing. Recent studies suggest use of it for caries reduction in xerostomic patients 16. Clinical Applications Tooth Colored Filling Materials Abrasion & Erosion Lesions Class III involving exposed dentin Occlusal lesions on deciduous teeth Temporary ant. and post. Restoration Repair of crown margins Cement base under composite and ceramics Cavity base and liners Orthodontic bands and brackets 17. Resin modified glass ionomer cements Due to the main drawbacks of glass ionomer which are: Short working time and long setting time Low strength and toughness Cracking and desiccation Poor resistance to acid attack Moisture sensitivity 18. Addition of polymerizable function groups Both chemical & light curing Overcome moisture sensitive & low early strength Names: Light cured GICs, Dual-cured GICs, Tri-cured GICs, Hybrid ionomer, Resin-ionomers 19. Type I : Luting agent Type II : Filling material Type III : Base and liner N.B. concern about use some of its type with ceramic restorations due to fracture occurrence 20. Zinc oxide-eugenol Zinc oxide powder + eugenol liquid Long working time medium setting time Low-medium compressive strength No Bond strength to tooth No Release of fluoride No pulpal response Easy to remove excess Sedative effect Usually used as temporary filling , base , temporary luting cement N.B. eugenol is inhibitor for resin ( not used with resin cement , restoration and even impression) 21. Resin cements Occur later from the direct filling resin Become popular because of the improved properties of bonding. Resin cement is flowable composite resin Very high compressive strength High Bond strength to tooth No Release of fluoride pulpal response Used beneath tooth color filling materials Luting cements (specially for all-ceramic restoration) 22. Bonded to etched enamel, ceramics, resins and etched metal surface Available in different shades Types according to Setting reaction Polymerization Chemical activation Light activation Dual activation [chemical and light] used beneath thick restorations 23. Temporary restorations Requirements of temporary restoration Good biologic characteristics Minimal solubility Rigid and strong Resistant to abrasion The need for each of proprieties depend on the permanence desire e.g. , multiple carious teeth removed caries and for the case temporary fillings will be placed for several months (more strength and resistance properties) 24. Zinc oxide eugenol the most commonly used Properties of Z.O.E. improved by mixture with polymer Conventional G.I.Cs can be used avoid moisture at the setting G.I.Cs type II could be used Resin modified G.I.Cs useful as long-term temporary restoratives Resin modified G.I.Cs is choice as example in cases of erosion 25. Intermediate Restoration Glass Ionomer Restoration. Compomer. 26. Classification According to The Use: I. Luting. II. Restoration. III. Liner & bases. IV. Fissure sealant. V. As Orthodontic cement. VI. Core build up. VII. Fluoride Release. VIII. ART ( Atraumatic Restorative Technique) IX. Deciduous Teeth. 1) Glass Ionomer 27. Properties of GI: Adhesion : Bonds chemically to the tooth structure. Bonding with enamel is higher than that of dentin ,due to greater inorganic content. Esthetics : Tooth colored material & available in different shades. Inferior to composites: lack of translucency & rough surface texture. Potential for discoloration & staining. Biocompatibility : Favorable pulpal response . Anticariogenic properties : Fluoride is released from glass ionomer at the time of mixing & lies with in matrix. Fluoride can be released out without affecting the physical properties of cement. Fluoride can be taken up into the restoration during topical fluoride treatment and released again fluoride reservoir 28. It is also known as Alternative Restorative Treatment. Procedure based on removing carious tooth tissues using hand instruments alone and restoring the cavity with an adhesive restorative material. Goals of ART are: i. Preserving the tooth structure. ii. Reducing infection. iii. Avoiding discomfort. Atraumatic Restorative Treatment 29. Advantages of ART 1. Easily available inexpensive hand instruments are used if the expensive electrically driven dental equipment not availabel. 2. As it is almost a painless procedure the need for local anesthesia is eliminated or minimized. 3. ART involves the removal of only decalcified tooth tissues, which results in relatively small cavities and conserves sound tooth tissues as much as possible. 4. Sound tooth tissue need not be cut for retention of filling material. 30. 5. The leaching of fluoride from glass ionomer probably remineralizes sterile demineralized dentin and prevents development of secondary caries. 6. The combined preventing and curative treatment can be done in one appointment. 7. Repairing of defects in the restoration can be easily done 8. It is less expensive and less time consuming. 9. It enables to oral health workers to reach people who never would have received any oral health service. 31. Disadvantages of ART 1. Not long lasting. The average life is two years . 2. Because of the low wear resistance and low strength of the existing glass ionomer materials their use is limited. 3. A relatively unstandardized mix of glass ionomer may be produced due to hand mixing. 4. The continuous use of hand instruments over long period of time may result in hand fatigue. 5. As fundamental principles of cavity preparation are not followed all oral health workers may not accept it. 32. 2) Compomer Poly acid modified composite Combination of composition between: composite and Glass Iononmer. Advantages: 1. more water resistance. 2. Fluoride release. 33. Indication: suitable for high caries risk patient. Contraindication: Stress baring area like large class II and class IV. Properties: 1) Hydrophilic expansion , by water uptake from saliva. 2) No loss of mechanical properties >> continuous acid base reaction. 3) Increased marginal integrity >> less post operative sensitivity. 4) Reduced secondary caries >> Fluoride release. 34. Permanent Restoration Amalgam Restoration. Restorative Resin. Glass Ionomar. Full coverage in Pediatric Dentistry. 35. Requirement of an Ideal Restorative Material 1) Restoration of esthetic. 2) Maintenance of the crown strength. 3) Preserve the anatomy of occlusal surface. Thus preserving interarch relations. 4) Long working time and short sitting time. 5) Long term adhesion between tooth and restoration to ensure complete isolation. 36. 1) Amalgam Restoration: Selection of alloy. Trituration. Condensation. Marginal breakdown and bulk fracture. Bonded Amalgam Restoration. Mercury Toxicity. 37. Selection of Alloy Rate of hardening, smoothness of the mix, and ease of condensation and finishing vary with the alloy. 1) High copper alloy: When significantly more copper is available, improved laboratory properties and clinical performance have been demonstrated. Advantage: Have low creep. Creep is the tendency of a material to deform continuously under a constant applied stress >> marginal breakdown (ditching) commonly noted with amalgam restoration. 2) zinc-free, high-copper alloy should be used when the dentist operates in a field where moisture control is difficult. 38. Trituration The most serious error in amalgamation is undertrituration. Undertriturated mix: 1. Appears dry and sandy and does not cohere into a single mass. 2. Amalgam will set too rapidly, which results in a high residual mercury content. 3. Reduced strength. 4. Increased the likelihood of fracture or marginal breakdown 39. Condensation purpose of condensation To adapt the amalgam to the walls of the cavity preparation as closely as possible, to minimize the formation of internal voids 40. Marginal breakdown and bulk fracture A commonly observed type of amalgam failure which the marginal areas become severely chipped. Athin ledge of amalgam may be left that extends slightly over the enamel at the margins >> cannot support the forces of mastication >> fracture, leaving an opening at the margins. Bulk fracture of amalgam is much less common with high copper amalgam alloys. 41. Causes: Poor cavity design resulting in an insufficient bulk of material across the isthmus. Premature loading of the restoration >> amalgam gains strength slowly over the first 24 hours. 42. Bonded Amalgam Restoration dental amalgam does not adhere to tooth structure, it must be retained mechanically by the design of the cavity preparation and/or mechanical devices such as pins. Bonded amalgam restoration chemically activated dentin- bonding systems over which the amalgam is condensed before the resin adhesive has hardened. 43. Mercury Toxicity The amount of mercury released from the amalgam in service is small compared with other sources of mercury from air, water, and food. Amalgam Alternative: Gallium Alloy 1. Mercury free metallic. 2. Early setting can polished in the same visit. 3. Better marginal Seal. 4. More costly. 44. What about dental office personnel? A potential hazard exists from long-term inhalation of mercury vapor in the dental clinic. The dental clinic should be well ventilated. All mercury waste and amalgam scrap removed during placement or removal of amalgam restorations should be collected and stored in well-sealed containers. When amalgam is cut, water spray and high-speed evacuation should be used. Biologically contaminated wastes containing mercury, including extracted teeth, should be cold sterilized with a chemical agent before disposal. 45. 2) Restorative Resin Conventional Composite. Micro-filled Composite. Small particles, Hybrid and Nanohybrid composite. Flowable Composite. Posterior composite. Acid etching Technique. Bonding Agent. 46. The term composite material refers to a combination of at least two chemically different materials with a distinct interface separating the components. Its provides properties that could not be obtained with any of the components alone. In a resin composite dental restorative material, an inorganic filler has been added to a resin matrix in such a way that the properties of the matrix have been improved. The resin matrix of many currently available composite materials is bisphenol Aglycidyldimethacrylate (bis-GMA) or urethane dimethacrylate resin. Fillers are ground particles of fused silica, crystalline quartz, and soft glasses such as barium, strontium, and zirconium silicate glass. 47. The filler and the resin matrix must be chemically bonded together with a coupling agent on the surface of the filler. If this is not done, the particles may be easily dislodged, water sorption at the filler- matrix interface may take place, and stress transfer between matrix and filler may not occur. The filler particles are coated with a reactive silane product. Classification based on method of curing: 1) Chemical cure. 2) Light cure. 3) Dual cure. 48. 1. Esthetic. 2. Conservative cavity. 3. Low thermal conductivity. 4. Quite resistance to microleakage. 5. No corrosion. 6. Strengthening of the remaining tooth structure. 1. Polymerization shrinkage. 2. High coefficient of thermal expansion. 3. Pulp irritation due to residual monomer . 4. Low wear resistance. 5. Technique sensitive. Advantages Disadvantages Resin Restoration 49. Classification based on size of partials: 1. Conventional (Macro-filled) Composite The fillers in conventional composites is in the 8 to 12 m range. wear resistance + surface roughness . 2. Micro-filled Composite Use of an extremely small silica filler particle, whose size is 0.02 to 0.04 m. microfine, microfilled, or polishable resins. Improve the surface smoothness and polishability of composite resins Softer composite and have a slightly higher coefficient of thermal expansion, a higher water absorption, more polymerization shrinkage, and lower mechanical properties. Use: 1) Esthetic Area 2) stress free areas (class III or class V ). 50. 3. Small-particle composites have an average filler size of 1 to 5 m, with a broad distribution of sizes. Best combination of physical properties of all the currently available composites. Use: stress-bearing applications such as class IV and class II restorations. 4. Hybrid composites The most recent step toward smaller particle size. They contain filler with an average size of 0.6 to 1.0 m in addition to 10% to 20% colloidal silica. Use: 1) anterior teeth if carefully polished. 2) Material that could compare favorably with dental amalgam in wear resistance in class I and II. 51. 5.Nanohybrid composites: They have superior esthetic and wear resistance, high polishability, and superior handling characteristics. They are marketed as universal composites. Because their handling and esthetic qualities make them suitable for anterior buildups, while their micro sized particles gives them very acceptable wear resistance. 52. 6. Flowable composites : This material has made it possible to fill small cavities on occlusal surfaces. Often used to seal the dentin of a tooth prior to placing the filling material. Due to the low level of filler particles, flowable composites are more prone to shrinkage and wear, so they are generally not used in bulk to fill large cavities. 53. Resin Infeltrate: A new minimally invasive technique on smooth surface white spot lesions. HOW DOES CARIES INFILTRATION WORK? Caries infiltration works by capillary action, whereas sealants only cover incipient caries lesions at the surface of the tooth (and eventually wear off). With this technique, the unique low viscosity resin is drawn deep into the pore system of a lesion like a sponge draws up liquid. The resin completely fills the pores within the tooth, replacing lost tooth structure and stopping caries progression by blocking further introduction of any nutrients into the pore system. Carious lesions are stabilized while the anatomical shape and color of the tooth are not altered at all. 54. Posterior composite. The improved strength, hardness, and modulus of elasticity of some of the newer composite resins, with their low thermal conductivity and superior esthetics, indicate that they may serve as alternatives for amalgam. Disadvantages Posterior class II restorations often have gingival margins in dentin or cementum >> No direct access to light cure >> physical properties and colure changes >> management by increment curing. Curing shrinkage >> microleakage . It compromised by moisture contamination during placement. 55. Pits and fissure sealant Types: 1. Opaque materials are available in tooth color or white. 2. Transparent sealants are clear, pink, or amber. The clear and tooth-colored sealants are esthetic but are difficult to detect by examiner. The cariostatic properties of sealants: 1) The physical obstruction of the pits and grooves. 2) Prevents colonization of the pits and fissures with new bacteria 3) prevents the penetration of fermentable carbohydrates to any bacteria remaining in the pits and fissures. 56. Indications : 1) Deep retentive fissures. 2) No evidence clinically / radiographicaly of proximal caries. 3) High caries risk patient. 4) Stained pits and fissures with appearance of declassification. 5) Tooth in the mouth less than 3 years. Contraindications: 1) Well coalesced , self cleansing pits and fissure. 2) Clinically / radiographically evidence of proximal caries. 3) Tooth not fully erupted. 4) Isolation not possible. 5) Dental caries 6) Tooth in the mouth 3 years and more. 57. Acid Etching Technique One of the most satisfactory methods for mechanical bonding of resin to enamel . The enamel is etched with a solution of phosphoric acid (usually about 35%) for approximately 15 to 20 seconds. Use a water rinse to remove the debris produced during etching. A minimum wash time of 30 seconds . The acid cleans the enamel to provide better wetting of the resin and creates pores into which the resin flows to produce tags that greatly increase retention. 58. Bonding Agent Enamel bonding >> mechanical bonding to tooth structure. The dentin-bonding systems >> removal of the dentin smear layer and decalcification of the outer layer of intact dentin with an acid (primer). It is important that the etched dentin surface not be desiccated before application of the primer when systems with hydrophilic primers are used. systems combine the primer and the resin adhesive into one component. systems mix together the acid, primer and resin adhesive before they are placed on the tooth surface (self etching). 59. GENERATION TIME PERIOD DEVELOPMENT 1 1950-1970 Experimentation with mineral acids for bonding acrylic to enamel, concern about etching of dentin, bonding agents not utilized with composites. 2 Early 1970s Acid etching of enamel, enamel bonding agents 3 Late 1970s Hydrophobic enamel bonding agents, hydrophilic dentin bonding agents, light cured components. 4 Mid to late 1980s Removal of dentin smear layer, acidic monomers and acidic pretreatments,, reduction of steps in bonding technique, multiuse bonding agents. 5 Early 1990s Etching to achieve hybrid layer in dentin, hydrophilic agents for both enamel and dentin, bonding to moist tooth structure, single bottle primer adhesives. 6 Mid to late 1990s Self etching primers and primer adhesives, light and dual cured options 7 Early 2000s No mix, self etching adhesives. 60. Ideal Requirements for Bonding Agent: Biocompatible. Non toxic, non irritant, non poisonous. Low film thickness, low viscosity. Form strong permanent bond. Good dimensional stability. Low thermal conductivity. Good shelf life. Prevent micro leakage. Indications: All direct composite resin restoration, both anterior& posterior. For bonding indirect composite resin inlays, onlays and veneers. For bonding indirect ceramic veneers , inlays and onlays. Bonded amalgam restorations. Management of dentin hypersensitivity. 61. You Have Ferrari in Cars, Harley Davidson in Bikes And Stainless Steel Crowns in Pediatric Dentistry Dr. MUTHU MS Crowns in Pediatric Dentistry 1. Stainless Steel Crown 62. Indications: 1. Restorations for primary or young permanent teeth with extensive and/or multiple carious lesions . 2. Restorations for hypoplastic primary or permanent teeth that cannot be adequately restored with bonded restorations. 3. Restorations for teeth with anomalies. 4. Restorations for pulpotomized or pulpectomized primary or young permanent teeth . 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. 63. Stainless Steel Crowns for Anterior Teeth 64. 2. Open-face stainless steel crown: crown of appropriate size is selected, contoured at the cervical margin, polished, and cemented into place. labial metal cut away, leaving a labial window that is then restored with composite. 65. 3. Alginate impression be made before the restorative appointment. The crown preparations can then be simulated on a stone model. This procedure enables the clinician to cement the crowns at the same appointment at which the preparations are made. 66. 4. Resin celluloid strip crown technique wherein the tooth is restored with composite resin using a celluloid crown ( Strip Crown) form as a matrix. Very little finishing of the restoration is required when the celluloid crown has been properly fitted. 67. 5. stainless steel crowns with esthetic facings pre-veneered Available in anterior and posterior versions. Primary crowns are anatomically correct, stainless-steel crowns with natural-looking tooth-colored facing. Such crowns are available for direct adaptation to the teeth and have had a significant amount of success. 68. 6. Zirconia Crown: It is the next generation in pediatric restorative technology and represents the perfect balance of art and science. Made from zirconia ceramic. Anterior and posterior primary teeth. Indications: 1) Caries. 2) Tooth surface loss. 3) Inherited defect. 4) Trauma. 69. Advantages of Zerconia Crown: 1) Esthetic. 2) Strength. 3) Biocompatible. 4) Decreased Chair time. 5) No impression: only 1 visit. Disadvantages: 1) No crimping, tooth must prepared to fit the crown. 2) Saliva an hemorrhage must be controlled. 3) Limited colure. 4) Cost . 70. Referances Dentistry for Child and Adolescent, Mcdonalds; 9th edition, chapter 16,17 and 18. Pediatric Dentistry: Infancy through Adolescence, Paul S. Casamassimo , Henry W., Jr. Fields , Dennis J. McTigue , Arthur Nowak ; 5th edition. Aesthetic and Cosmetic Dentistry Made Easy , P. B. Mathur, Sanjay Bansi Mathur; 1st edition chapter 19. Textbook of Pediatric Dentistry , Nikhil Marwah ; 3rd edition. http://www.nusmilecrowns.com/ http://www.kinderkrowns.com/ Dr. Sung-Ki Kim developed ZIRKIZ crowns(Ready-made primary anterior crowns) 2013 Qualified instructor of NuSmile crowns.