Chapter 4: Pediatric Dentistry Introduction



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Section E: Restorative Dentistry for Children

Introduction


Restorative dentistry in children may require the use of alternative techniques and materials. Since success may be limited by behavior, speed and efficiency are important.

Rubber Dam Technique

Introduction


The use of the rubber dam in pediatric dentistry is considered to be the standard of care. A rubber dam should be used for operative procedures, whenever possible.

Advantages


The rubber dam offers the following advantages:

  • improves child management; enhances the delivery of nitrous oxide sedation

  • decreases gag response from water spray

  • prevents aspiration of small objects

  • protects soft tissues from abrasive and chemical trauma

Tips for Using The Rubber Dam Technique


The following are some tips for using the rubber dam technique:

  • Keep the rubber dam clamp ligated at all times with dental floss.

  • Use age appropriate vocabulary; i.e., the clamp is a "tooth button" and the rubber dam is a “raincoat.” Explain why you are using it. (The raincoat keeps the sugar bugs from going in your tummy)

  • The W8A, 14, and 26N are the most commonly used clamps. The 26N is helpful for clamping maxillary molars without palatal anesthesia. Weak or old clamps may fracture during use and become swallowed or aspirated. Discard suspect clamps.

  • Sequential placement of first, the clamp, and secondly, the dam, decreases fear. Allow the child to see and feel the dam.

Restoring Primary Incisors and Cuspids

Introduction


Carious primary anterior teeth are to be thought of as reservoirs of cariogenic bacteria. They should not be ignored because the patient risks the following:

  • additional caries

  • pain and infection

  • damage to the developing tooth

  • deflection of the permanent teeth

Materials


The following materials are recommended for restoring primary anterior teeth:

  • Glass ionomers. Small lesions can be restored with visible, light-cured glass ionomer restorative material (resin modified glass ionomers, not compomers).

  • Composites. Hybrid composites work well, look good, and have adequate durability. Composites are very technique sensitive so patient cooperation is required. Strip crowns work well for the larger composite fillings. Composites are not indicated with large lesions involving many surfaces, or when decay extends subgingivally.

  • Stainless steel crowns (SSCs). SSCs can be placed on incisors with large lesions on patients whose lack of cooperation could compromise the quality of a composite restoration. The main advantage of a SSC is durability. Because they are not esthetic, it is imperative that the parent be fully informed prior to placing the SSCs. Esthetics can be improved by cutting a window in the labial surface of the crown; and filling with a composite.

  • Prefabricated aesthetic crowns. Ceramic or veneered stainless steel crowns are available from several different vendors. Before planning to use any of these, a pediatric dentist should be consulted. Currently, all available veneered crowns demonstrate veneer failures. Repairs are difficult.

Restoring Primary Molars

Introduction


Posterior teeth in the primary dentition can be restored using the same materials as the posterior teeth of the permanent dentition except that the stainless steel crown is used instead of cast restorations.

Materials


Sealant, composites, glass ionomer, amalgam, and SSCs can all be indicated for carious primary molars.

  • Sealant. Sealants, including invasive sealants, are often used in children with deep pits and fissures, or incipient decay. Sealant material can also be used in developmental pits in incisors and cuspids.

  • Glass ionomer. Visible, light-cured glass ionomer is actually a glass ionomer-composite hybrid. It bonds to teeth and releases fluoride. It is suitable for use in caries control, in all restorations, and as a base replacing composite in preventive resin restorations. Glass ionomer restorations leech fluoride, and inhibit recurrent decay.

  • Composite. Composite restorations may be indicated in the individual with a low caries rate and minimal pit and fissure caries. The preventive resin restoration technique (PRR) is an acceptable clinical restorative procedure. Class II composites are usually contraindicated.

  • Amalgam. Amalgam is used often in occlusal restoration. Class II restorations before the full eruption of the first permanent molars have a high failure rate.

  • Stainless steel crowns. When Class II carious lesions in molars need to be restored, the SSC is the restoration of choice. Full coverage is also required following any pulp therapy.

Using Stainless Steel Crowns (SSCs)

Introduction


Stainless steel crowns (SSCs) can be used in restoring any primary tooth. They are used extensively in the IHS because of the high caries rate of the population, the durability of the SSC, and the lack of adequate recall programs.

Advantages

SSCs offer the following advantages:


  • excellent durability

  • the least frequently replaced restoration

  • full coverage assists in controlling caries progression

  • can be done quickly assuming good patient behavior and operator skill.

Disadvantages


SSCs pose the following disadvantages:

  • parents may object to appearance

  • preformed crowns may be challenging to adapt to tooth

  • transient damage to periodontium

  • may contribute to ectopic eruption of first permanent molars

Indications


The use of SSCs is indicated in the following situations:

Contraindications

The use of SSCs is contraindicated in the following situations:



  • sensitivity to nickel or crown luting cements

  • lack of acceptance by parent or guardian, i.e., no consent

Armamentarium


  1. Rubber dam isolation materials

  2. Crown crimping pliers

  3. Howe pliers

  4. Appropriate burs. Tapered diamond burs are kind to soft tissue and help prevent ledging

  5. Cement , spatula, mixing pad

  6. Band seater (a Tooth Slooth can also be used)

  7. Routine operative set-up

Procedures for Placing SSC on Primary Molar


Perform the following steps to place SSCs on primary molars:

Step

Action

1.

Obtain anesthesia; place rubber dam.

2.

Reduce the occlusal surfaces of the teeth to be crowned.

3.

Complete caries removal. Perform pulp therapy if indicated.

4.

Reduce the distal aspect of the tooth with a tapered diamond. Displace dam if necessary.

5.

Open and round contacts and line angles including occlusal table.

6.

Select size and adapt crown. It should snap into place and fit snugly.

7.

Cement with an appropriate material with the rubber dam in place.

8.

Wipe excess cement with gauze with rubber dame still in place.

9.

Remove the rubber dam and have the patient bite into the occlusion.

10.

Rinse with air-water syringe. Remove excess cement with floss and explorer.



Troubleshooting SSCs


The following table provides possible solutions to problems associated with SSCs:

Problem

Possible Solutions

SSC that fits buccal-lingual is too wide mesial-distal

Squeeze the next smallest size SSC with the Howe pliers in the mesial-distal direction to lengthen it in the buccal-lingual direction.

SSC that fits mesial-distal is too short buccal-lingual

The next largest size SSC can be squeezed as described above. Re-prepare the tooth buccally and lingually.

SSC with good mesial-distal and buccal-lingual coverage will not seat fully

Try either of the following methods:

Refine preparation. Visualization of the inside of the crown will often reveal a sharp bend indicating further reduction in that area. Check for ledges.

Have the patient bite on a stick or a band seater


Contact points of SSCs are off, contact is open

The SSC can be rotated by gently grasping it with the Howe pliers and twisting. Avoid denting the SSC. Use a larger SSC and exaggerate the crimp.

Tooth prep is half way between sizes

Use the crown and bridge scissors and cut off 1 mm of the crimp on smaller sizes. You now have a 1/2 size larger SSC.

Length of SSC is inadequate

Try any of the following methods:

  • Further reduce the tooth if necessary.

  • Round the edge of the occlusal table.

  • Try an un-crimped Unitek SSC. It is longer than the Ion SSC. It will need contouring and crimping.

Size 7 pedo crown is too small

Try any of the following methods:

  • Further reduce the tooth.

  • Trim the margin of the 7 to make the SSC big enough.

  • Use the Ion SSC for another tooth. You may need to use permanent molar crowns.

The SSC is tipped

Have the patient bite on a stick or band seater.

Refine the prep. There is probably a ledge or the contact is unopened.




Notes: The 3M Ion® Ni-CHO primary molar crowns are the most widely used in the IHS. They are pre-crimped, although additional crimping to achieve a better fit is often indicated. If possible, make minor adjustments in your prep rather than the crown preferred

Crimping SSCs is best performed with a 800417 or 800421 crimping pliers from 3M. After crimping, the margins should be smooth and well adapted to the tooth. The 800421 is most useful when crimping anterior crowns.

Anterior crowns are often challenging. Minimum tooth preparation is required. Select the smallest crown possible that fully seats and crimp to fit.

The patient usually tolerates a slight opening of the occlusion. Rarely do you need to retreat because of traumatic occlusion.

Matching your crown prep to the internal contours of the SSC increases efficiency. Sharp line angles and ledges hinder placement.

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