CLINICAL ASPECTS OF RESTORATIVE DENTISTRY IN CHILDREN AND ADOLESCENTS

CLINICAL ASPECTS OF RESTORATIVE DENTISTRY IN CHILDREN AND ADOLESCENTS

Pediatric restorative dentistry aims to reconstruct the temporary tooth in its anatomical integrity so that it can fulfill its roles:

• functional (chewing, swallowing, phonation);
• Space maintainer;
• From eruption guide;
• Growth (organization of inter-arcade relationships);
• aesthetic.

The practitioner must prevent pain, infections and their spread to the underlying permanent tooth germs, promote oral health, allow the eruption of permanent teeth in a healthy environment to avoid early caries and, finally, prevent malocclusions.

2. Restoration of temporary teeth:

The objective of a restoration is to allow the temporary tooth to recover its anatomical integrity in order to ensure its functional role, maintaining space and guiding the eruption of the underlying permanent tooth.

The principles of restoration are as follows:

• total removal of carious tissue;
• protection of underlying tissues;
• preparation of the cavity to receive the filling material;
• implementation of the restoration with reconstruction of the anatomical contours and reliefs

Diagnostic approach:

The diagnostic approach must make it possible to define the restoration choices which are essentially linked to the pathology (severity of the caries) and its location; to the resulting risk of recurrence at the level of the tooth (value of the residual tissues) and the patient (individual caries risk [ICR] and behavior). Finally, it must take into account extrinsic parameters (linked to the

practitioner). This diagnosis is of course based on a careful clinical examination after carrying out prophylactic brushing and if possible using optical aids. It is supplemented by suitable radiographic examinations (retrocoronary radiographs or bite-wings ) and a laser fluorescence examination (DIAGNOdent® or DIAGNOdent Pen®).

1. Parameters related to the temporary tooth:

The anatomy of the temporary tooth is characterized in particular by a thin enamel layer and a voluminous pulp chamber with very marked pulp horns at the level of the molars.

Thus, an initial lesion will quickly evolve into an irreversible lesion. Once the dentin tissue is reached, the radiographically visible limit of the lesion will quickly approach the pulp and often require preventive pulpotomy.

Furthermore, its coronal shape and its relationship with adjacent teeth can cause difficulties in setting up the operating field, resulting in problems of isolation and therefore

sealing. Its physiological stage allows us to understand the residual time on the arch. For a temporary molar, the lifespan from its emergence in the oral cavity until its exfoliation is approximately 8-9 years.

There are three physiological periods that will mark its evolution: maturation, stability, resorption. The latter is the longest (around 4 years) and is manifested by the rhizalysis of the root.

More than the child’s civil age, it is the root anatomy that allows us to evaluate the remaining time of the tooth on the arch.

2. Size and location of the carious lesion in relation to the pulp:

At the level of the temporary tooth, the modified Mount and Hume classification refers to three sites – occlusal, proximal and cervical – and determines three main stages of development of the carious lesion. The first stage concerns involvement of the enamel or the outer third of the dentin. It essentially calls for techniques of either remineralization (enamel involvement) or microdentistry. Stage 2 concerns involvement of the middle third of the dentin and stage 3 of the deep third of the dentin. These last two stages call for techniques known as “macrodentistry” with (stage 3) or without (stage 2) preventive pulpotomy.

3. Child-related settings:

The child’s age should be considered to get an initial idea of ​​their behavior. Their compliance and ability to accept treatment sessions are major elements in our therapeutic choices. The assessment of RCI is another determining parameter for the therapeutic choice but also for its implementation over time because its correction must be the subject of our full attention as a first step. The identification of more or less recent progressive caries activity is important.

All children with an initial lesion or active irreversible dentin caries are considered to be at high RCI. In contrast, a child previously treated for early childhood caries (high cod or DMFT), who is now caries-free and has changed poor eating and hygiene habits, is at low risk. Once a high RCI is identified, a second

parameter that must be taken into consideration when choosing the material(s) to be favored is the number of cavities present in the mouth. Thus, the use of classic filling materials (amalgam, preformed pedodontic cap [PPC]) is recommended for children with multiple cavities while the use of adhesive materials is possible for children with one or two cavities.

4. Practitioner-related parameters:

The “practitioner” parameter certainly plays a role, particularly in the understanding and knowledge of different restoration techniques, without forgetting their ability to understand the care of the child.

This entire approach should enable us to make our therapeutic choices, retaining only the best, often associated with a greater number of clinical procedures.

For children who are uncooperative or uncooperative, and while waiting for better care, restorative techniques are limited, resulting in significant risks of caries recurrence. They should therefore be considered temporary or transitional solutions, rarely definitive.

This is particularly true of the Hall technique, which involves covering temporary teeth with PPCs without preparation. In practice, the success of this technique is highly dependent on the

diagnosis of the pulp condition which is sometimes difficult to assess in young children. The second is atraumatic restorative treatment (ART). This is a minimal treatment approach to the carious lesion by manual curettage of removal and the placement of a glass ionomer cement to look for a fluoride release effect.

For children whose caries severity does not allow the above-mentioned treatments, treatment must be carried out under conscious sedation or general anesthesia. Therefore, the choice of material is limited because the installation of a watertight surgical field is often impossible, which limits posterior composite adhesive restorations. On the other hand, the number of clinical steps

for this type of restoration is often incompatible with the duration of treatment under conscious sedation or general anesthesia in polycarious subjects. Thus, treatment under general anesthesia is generally more conventional and uses amalgams or CPP on the most damaged teeth.

For cooperative children, all therapeutic options can be considered.

We must distinguish between micro- and macrodentistry, which do not correspond to the same clinical protocols, and restorations on posterior teeth from restorations on anterior teeth, because they do not meet the same mechanical and aesthetic requirements. Indeed, depending on the stage

of the development of dental caries, we use different surgical techniques: microdentistry (stage 1) or macrodentistry (stages 2 and 3).

Different materials for coronal restorations in children:

Pediatric dentistry has not escaped the evolution of restorative materials.

There are temporary and permanent materials that have different properties and implementation protocols. On the other hand, restoration on posterior teeth can involve variable therapeutic steps depending on the cavitation and the techniques used can then be different and the material used as well. The preparation forms therefore depend both on the surgical technique and the material used.

1. Amalgam:

Dental amalgams contain approximately 50% mercury, which forms an intermetallic compound with copper, silver, and tin. They have been used for nearly 150 years and are still used in pediatric dentistry, and no proven toxicity has been demonstrated to date (FDI). They are reliable restorations over time.

2. Glass ionomer cements:

Glass ionomer cements (GICs) are formed from a powder (aluminosilicate glass) and a liquid (polyacrylic acid based) forming a matrix where the glass particles come together in a continuous phase. If the acidity of the cement allows for spontaneous chemical bonding with the

mineralized structures of the tooth, it is strongly recommended to use a conditioner that partially removes the smear layer and thus increases adhesion for all types of CVI.

Their setting reaction is long and even the so-called fast commercial versions need to be protected from saliva. Thus, all these materials are sensitive to water exchange (water absorption and desiccation). Surface protection with a photopolymerizable varnish is therefore recommended. It also contributes to the improvement of the surface condition, the quality of which is much lower than that of composite resins. Finally, some CVI have greater mechanical properties thanks to an increased powder/liquid ratio; these are the so-called condensable CVI (CVIc).

3. Cements modified by the addition of resin:

Other IVCs contain small amounts of photopolymerizable resin: resin-modified cements (CVIMAR). Their setting reaction is therefore twofold: acid-base reaction and photopolymerization reaction. Their adhesion is superior to traditional IVCs and their appearance is more aesthetic. CVIMARs remain sensitive to water contamination and their mechanical qualities are poor. For all commercial forms, pre-dosed capsules should be preferred for better homogeneity and shorter working time compared to manual mixing.

Nanoionomers are CVIMARs combining nanofillers. They are photopolymerizable and

are used with an acid primer that is also photopolymerizable (without rinsing). Their aesthetic appearance and mechanical properties are improved.

4. Composite resins:

Composite resins consist of a matrix of polymers and fillers. The monomers provide the plasticity needed to place and mold the material into the restoration cavity. The presence of fillers limits the shrinkage and exothermic setting inherent in this material.

type of material. Fillers also help reduce the dilatometric gap with the tooth while increasing mechanical performance. Depending on the rate and size of the fillers, we distinguish between microhybrid, condensable, and flowable composites.

All types of composite are suitable for temporary teeth. Composites

are always used with an adhesive system. There are two main families of adhesive systems which

use phosphoric acid or not. These are systems with H3PO4 etching and rinsing and systems without rinsing, self-etching systems (SAM). SAMs are now effective, especially in cavities with large dentin areas. On enamel, it is preferable to use an adhesive system with H3PO4 etching.

5. Preformed pedodontic caps:

They come in the form of nickel-chromium crowns of various sizes for all types of temporary molars (Ion®, 3M/ESPE). They are easy to work with, ductile for shaping, and elastic for insertion. They have high mechanical and corrosion resistance while presenting no biocompatibility problems. They are the ideal material for major coronal decay.

6. Compomers:

Compomers are materials derived from IVC and composite technology. They consist of an organic matrix of polymers containing polyacid groups. Their poor mechanical properties and much more limited fluoride release than IVCs no longer allow them to be indicated as restorative materials for temporary teeth.

Operating protocol:

The typical treatment session takes place as follows:

• contact anesthesia
• local or locoregional infiltration
• laying the surgical field;
• careful plaque removal and descaling;
• removal of carious tissue;
• implementation of a matrix system in case of proximal restoration;
• restoration using the chosen biomaterial;
• installation of a si! Ions seal on the restoration;
• withdrawal of the matrix system where applicable;
• polishing;
• checking the contact point using dental floss;
• Removal of the surgical field.

Note: Cavity preparation depends on the choice of restorative material. However, the anatomo-histological characteristics of the temporary tooth must be remembered: prominence of the pulp horns and low tissue thickness.

The choice of matrix system depends on the anatomy of the temporary molar, the periodontium (large papillae) and the type of carious lesion:

• MacKean crampon + wooden wedge;
• circumferential metal matrix adjusted and stabilized by a wooden wedge;
• transparent matrix for the restoration of anterior teeth.
• The matrix should not exceed the height of the marginal ridges.

1. Anterior teeth:

Anterior tooth restorations concern primary teeth that are decayed, traumatized, or affected by a structural abnormality. For these restorations, the materials of choice are composites and glass ionomer.

1. Interim Therapeutic Restorations:

ITR lies between non-invasive dentistry and restorative dentistry. It consists of:

• to remove, using an excavator or a burr used at low speed, the carious superficial dentin;
• to perform the filling with a glass ionomer, then a fissure sealant. This technique can only be applied if the patient can be regularly monitored, in order to overcome any problems occurring with the restorations considered to be “temporary”.

2. Strip Crown Frasaco®:

The progression of the lesion is rapid, starting from the vestibular surfaces and then encircling the dental crown. It seems impossible to satisfactorily establish a cavity and the only way to perform a durable and aesthetic restoration is to use transparent molds (Strip Crown Frasaco ®).

The preparation consists first of reducing the incisal edge and then the proximal faces (diamond burs on turbine n° 379314018, 8862 314 012). Attention should be paid to the marginal limits so as not to cause gingival bleeding which would make the necessary isolation difficult and which would cause a change in shade (Ram and Fuks, 2006).

After removing the decayed tissue with a round bur on a contra-angle, a transparent mold is chosen, adapted to the size and shape of the tooth. After etching and placing the adhesive on the dental stump, the mold, previously drilled to allow the composite resin to escape, is loaded and then placed on the stump. After light-curing, it is removed using a mouth spatula and the tooth is polished.

The intervention takes place in the following stages:

• local anesthesia;
• laying the surgical field;
• choice of mold size based on the mesiodistal diameter of the tooth;
• carious eviction following the contours of the lesion;
• preparation of the proximal tooth (slices), reduction of the incisal edge (lmm);
• cutting and adjusting the mold using curved scissors;
• mold fitting;
• using a probe, perforation of the mesial and distal corners of the mold to facilitate the escape of excess composite;
• etching and placing the adhesive;
• filling the mold with composite, which is hollowed out in the center to leave room for the dental stump;
• Setting up the mold, removing excess;
• Photopolymerization on all sides;
• removal of the mold using a probe or excavator;
• polishing;
• removal of the operating field;
• occlusion check.

2. Posterior teeth:
   1. Site 1:

When the caries affects only the occlusal surface without pulpal proximity and without weakening the proximal surfaces, the treatment of choice is a restoration using at least composite resin. One-stage light-curing is sufficient.

For deeper lesions (stage 2), it is done in two stages to minimize polymerization shrinkage. When the lesion is very deep (stage 3), the placement of a layer of glass ionomer cement at the bottom of the cavity protects the pulp from the irritants contained in the etching agents and adhesives. The shape of the cavity is always determined by the extent of the lesion. The systematic placement of fissure sealants makes it possible to seal the treatment.

NB: Important! In a child with multiple caries and in the presence of very deep grooves, it is advisable to carry out a prophylactic extension or to fill the groove with a groove sealant.

2. Site 2:

First of all, it is worth remembering the coronal anatomy of temporary molars.

• significant inclination of the vestibular faces in the occlusal direction;
• regular curvature of the lingual or palatal surfaces;
• very marked constriction of the anatomical neck;
• variation in the situation of the physiological collar;
• existence of contact surfaces between molars rather than contact points.

The treatment of choice is composite restoration when the caries reaches one-third or two-thirds of the coronal surface away from the pulp chamber. However, even if adhesive materials are used, it is preferable, for the proximal part, to make some mechanical retentions. The caries are generally at or below the point of contact, never above. Care must obviously be taken not to damage the neighboring proximal surface.

1. Cavity preparation Access to the cavity:

It is always done through the marginal ridge (H7 006 or 009 burs on turbine) and its cleaning is carried out using a round ball bur on a blue contra-angle at slow speed. The contact point must first be eliminated. The extension is done following the limits of the carious lesion in a convergent manner in order to promote the mechanical retention of the material. It is also advisable to make a slight chamfer at the limits of the cavity for better integration of the restoration.

Angles at the cervical level should be avoided, the vestibular and lingual walls should converge slightly towards the occlusal table. The cervical limit should be below the contact point, at or just below the gingival limit without a bevel. All angles should be slightly softened. Some authors recommend making a bevel of 0.5 mm. It is essential, during the restoration, to place a matrix system in order to reestablish a correct contact point allowing the passage of dental floss. Two proximal cavities can be filled in the same session: disto-occlusal on the first molar and mesio-occlusal on the second molar. Two matrices are adjusted and contoured using a matrix holder around

each molar and a wooden wedge is forced into the interproximal space. Filling begins with the proximal cavity and ends with the occlusal part. If the cavity is deep, light-curing is done in two stages. The composite is then sculpted (burs 8390 314 016, EF 016, UF 016). A fissure sealant is placed lastly, to seal the restoration and fill the crevices on the occlusal surface.

After polymerization and removal of the matrix and the operating field, it is advisable to check the occlusion and the passage of the dental floss at the contact points.

2. Glass ionomer or flowable composite/composite sandwich techniques : When the carious lesion is large and deep, close to the pulp in very young children, it is advisable to protect the pulp using a glass ionomer cement or a flowable composite with low shrinkage during light curing. The chosen product is placed at the bottom of the cavity and must not cover the proximal walls. After polymerization, the composite is placed in increments in the rest of the occlusal cavity and on the proximal walls to ensure a perfect seal.
3. Preformed crowns:
4. Preformed nickel chrome crowns : When the carious lesion is significant, weakens the proximal and/or vestibular and lingual/palatal walls, and endodontic treatment has been previously carried out, the only way to permanently restore the temporary molar is to create a preformed pedodontic cap.

The preparation principles are as follows:

• local anesthesia is performed;
• an operating field is placed, an essential step in young children because it prevents damage to soft tissues or swallowing of the crown during fitting;
• caries removal and possible pulp protection or pulp treatment are carried out;
• the cavity is sealed with a glass ionomer;
• homothetic occlusal reduction (1.5 mm with a “rugby ball” diamond bur n· 379 314 023) and proximal (with a flame diamond bur n8862 314 012) is carried out. The vestibular and lingual surfaces are respected (except for the vestibular bulge of the first lower temporary molar);
• the corners are rounded;
• the limits of the preparation are juxtagingival;
• the crown is chosen according to the mesiodistal diameter;
• the crown height is reduced and adapted: the cervical edges are cut with curved scissors;
• the cap is tried on by clipping it in the linguovestibular direction and ensuring that it does not whiten the gum too much;
• the limits of the cap are 1 mm intrasulcular;
• After fitting and before sealing, the marginal edges are rolled to improve retention (14 cm Johnson forceps), then polished with quartz and rubber wheels.
• an x-ray is taken to check the fit;
• sealing is carried out with glass ionomer cement, the tooth being dried and isolated by means of salivary rolls;
• The excess is removed with a probe and in the interdental spaces using dental floss where a knot has been made.

To improve aesthetics, it is possible to create vestibular “windows” made of composite. Once sealed, the vestibular portion of the crown is cut using a transmetal bur, then the contours are polished. A composite band is then inserted on the vestibular surface. The placement of a cap does not interfere in any way with the physiological exfoliation of the tooth.

2. Preformed ceramic crowns (Nu Smile®):

To overcome the unsightly side of nickel-chromium crowns, preformed ceramic crowns have appeared. While they are more aesthetic, although available in a single, very white shade, they require more tissue breakdown due to the thickness of the metal and ceramic. Their occlusal morphology is not very pronounced and their longevity is much less than metal crowns, as ceramic fractures are common. They can be useful in the case of restoring all four temporary incisors. In this case, there will be no “crown” effect as in the case of restoring a single incisor, which will inevitably be noticed.

3. Restoration of permanent teeth:

Occlusal posteruptive surfaces are porous and irregular, and therefore more susceptible to chemical and bacterial attacks than others. The dentin tubules are wide and permeable, which means that the progression of the carious lesion is faster than in mature teeth. It takes 12 to 18 months for permanent molars to fully mature. During this time, the tooth is very susceptible to bacterial attacks. At 12 years of age, 80% of decayed teeth are first permanent molars.

1. Pit and fissure caries and fissurotomies:

Fissure sealants represent a non-invasive protection, by bonding a resin filling the crevices of the occlusal, vestibular, lingual and palatal surfaces of permanent molars or premolars. These sealants are a means of prevention that has now largely proven its effectiveness. When the teeth have more uncertain crevices, “catching” on the probe, opening the grooves (fissurotomies) is recommended (bur 8392 314 016), followed by their filling using a flowable composite.

2. Cavities in the front teeth:

Prevention of caries on the smooth surfaces of permanent teeth is based on:

– education in oral and dietary hygiene;

-prevention of dystopias making oral hygiene difficult;

– the implementation of prophylactic measures;

-elimination of carious foci on temporary teeth.

Most changes in healthy surfaces occur immediately after eruption in the oral cavity. As the post-eruptive age increases, the risk of caries decreases. When the carious lesion is non-cavitated (stage 0), treatment with topical fluoride may be sufficient to remineralize the surface.

When faced with a cavitary lesion, minimal caries removal under the surgical field, followed by restoration using a composite resin, is necessary. In cases of deep lesions, a “layer by layer” reconstruction with dentin and enamel shades is necessary for an optimal aesthetic result.

3. Caries of posterior teeth:
   1. Occlusal caries and hidden caries:

Any erupting occlusal surface must be evaluated. The therapeutic approach is determined according to the tooth’s risk (age, degree of eruption, accessibility to brushing, anatomy, surface condition) and the patient’s risk (caries in temporary and/or permanent dentition, access to care, hygiene, diet, fluoridation and general condition). Currently, the restoration of choice for stage 1, 2 or 3 lesions is composite resins placed under the surgical field. Due to fluoridation, the enamel of permanent molars is increasingly resistant. This is why the practitioner is increasingly confronted with the management of “hidden caries”. The carious lesion begins in a small enamel opening and spreads rapidly within the dentine in an “ampullary” manner. As the enamel is very resistant, it is not destroyed in the early stages of the disease. However, the radiographic examination reveals a significant globular lesion, often close to the pulp horns.

2. Proximal caries:

Proximal caries in adolescents or young adults are most often the result of an unbalanced diet, poor interdental hygiene and/or the presence of caries on the proximal surfaces of the second temporary molars.

The first measure to be taken is preventive in order to eliminate etiopathogenic factors. In case of failure, restorations using composite resins are done at a minimum.

3. Molar incisor hypomineralization (MIH):

These hypomineralizations characterize a qualitative defect in the mineralization of the enamel. Since the first clinical cases described in the 1970s, the prevalence of this pathology has been constantly increasing (15 to 20% of children are affected today). The severity of the clinical expression varies greatly between patients but also within the same patient. The enamel of the molars disintegrates very quickly, even before the tooth has completed its eruption. The porous structure of the surface of the molars promotes an accumulation of dental plaque and, consequently, the development of caries.

Affected teeth are often subject to dentin hypersensitivity, making oral hygiene deficient, which must be alleviated as quickly as possible (application of fluoride varnish such as Duraphat desensitizing mouthwashes and toothpaste, application of fluoride gels).

Indeed, the main therapeutic difficulties are the establishment of correct anesthesia, access and isolation, especially when the tooth has not yet completed its eruption. The placement of a glass ionomer as a temporary measure is a good indication while waiting for the end of eruption (fig. 4.14).

Many therapeutic possibilities exist, ranging from fluoridation to tooth extraction, including fissure sealants (when the enamel is intact) or restorative care using composite resins (, or even the installation of preformed pedodontic caps. The difficulty with restorations lies in the limits of the preparations.

4. Other alternatives to conventional cavities:

Microdentistry:

The concept of minimal dentistry or microdentistry is based on prevention, interception of initial or reversible lesions and maximum preservation of enamel-dentin tissues within the framework of regular monitoring of the child in order to control their risk of caries.

The restoration of irreversible lesions must prioritize as much as possible the conservation of areas of

tooth resistance (enamel bridge, marginal ridges) and remove only demineralized dentin tissue, regardless of its location. This is due to new devices used in addition to adhesive restorative materials. Thus, the proximal carious lesion limited to the outer third of the dentin and located below the contact point is no longer eliminated by performing a

proximal access box but only eliminating the carious tissue accessible via the vestibular or lingual route: this is the principle of sonoabrasion.

Ozone:

It has been suggested that delivering ozone to a dental lesion for 10 to 20 seconds may reduce the number of cariogenic bacteria, possibly halting the progression of the lesion and, in the presence of fluoride, allowing its remineralization. This would, in time, delay or prevent the need for traditional conservative care by drilling and filling.

Initial results are considered disappointing and more comprehensive studies are needed before ozone therapy can be considered a viable alternative to

usual methods for the management and treatment of dental caries (Rickard and

al., 2004).

The laser:

The lasers used are erbium-YAG lasers which have spray cooling and can therefore be used on hard tissue.

They have a wavelength that is highly absorbed by water and hydroxyapatite. The laser acts preferentially on water-rich carious tissue, preserving healthy tissue. Recent studies show that it can completely eliminate caries and produce high-quality preparations. In addition, it exhibits bactericidal activity.

Sonoabrasion

Sonoabrasion is done using an ultrasonic handpiece with a frequency of 6500 Hz. The latter is equipped with a diamond insert with different shapes (KaVo SONICflex® micro or bevel inserts) depending on the location of the caries and the type of tooth to be treated: thus, the inserts used to create proximal microcavities have the advantage of being diamond-coated on only one side, thus preserving the neighboring tooth. The SF 30 to 33 inserts are spoon-shaped, with only the convex part working (diamond-coated). Driven by elliptical movements with an amplitude of 240 μm under water irrigation, the practitioner must use them while applying light pressure during preparation (0.1 N). This is the microdentistry method to be preferred in the case of lesions

proximal provided that they are directly accessible. In posterior teeth, it is an advantageous substitute for tunnel preparations which are contraindicated due to the size of the pulp of temporary teeth and the numerous failures observed.

Air abrasion:

Air-abrasion is designated as a non-rotary and pseudomechanical method of removing demineralized tissues by high-speed projection and under water irrigation of alumina powder (aluminum oxide) whose diameter varies from 25 to 50μm. Particularly effective at the level of

demineralized enamel, its use is sometimes supplemented by that of a small diameter round bur mounted on a contra-angle to remove the residual carious dentin. Keeping the nozzle 1 mm away from the lesion limits its indication to direct access caries, most often

occlusal. This method, which requires the use of an operating field, is not recommended for children suffering from respiratory conditions.

Rotary instruments:

There are many rotary instruments to be mounted on a turbine. In this context of minimal dentistry, several sets have been proposed. Whatever they are, they typically include

Red ring diamond burrs whose working part is shaped like a small diameter ball often mounted on a long non-working neck. Others are specially designed to widen grooves.

Generally speaking, they are less economical in dental tissue than the water-air abrasion system and, unlike sonoabrasion, they can damage the neighboring tooth depending on the location of the caries.

Regardless of the cavity preparation method, the preferred restorative material is composite.

Therapeutic approach according to the child’s age:

1. Posterior restorations in children

In the primary dentition, carious lesions develop preferentially on the proximal antagonistic surfaces of the first and second primary molars and on their occlusal surfaces. Before the eruption of the first permanent molars, caries distal to the second molars and mesial to the first primary molars are rarer.

When the cavity reaches the middle third (stage 2) or the deep third (stage 3), the therapeutic choices are variable and all the more numerous if the child is cooperative.

Thus, we have the choice between so-called classic dentistry (amalgams, CPP) or adhesive dentistry. The latter has the advantage of less damaging cavity preparation.

1. Average carious damage:

In children under 5 years of age, a classic amalgam restoration, or even a CPP, should be preferred, depending on the type of cavity, as these are the ones with the fewest failures over time. At a later age, composite-type adhesive restorations may be recommended, if the operating conditions allow it (isolation and compliance of the child). These composite restorations are now finding their place, particularly with self-etching adhesive systems.

These adhesive systems, in one or two steps without rinsing step, allow to reduce

significantly the surgical protocol while having good results both mechanically and aesthetically. The results are clinically superior to those obtained with other types of

adhesive restorations. Thus, compomers no longer really find their place, without however being contraindicated. Finally, the indication of CVIc and CVIMAR must be limited to short-term restorations. Generally speaking, salivary trimming using a waterproof surgical field is recommended because it corresponds to the best method of salivary isolation.

2. Deep carious lesions:

Temporary teeth are treated endodontically. They are restored with an amalgam or with a CVIc as long as it precedes the placement of a CPP. The latter remains the ideal “material” for major deterioration of the temporary tooth, particularly when the lifespan of the temporary tooth on the arch remains significant (5-7 years) but also for hereditary structural anomalies.

So-called “sandwich” techniques (CVI and composite) can also be considered. However, the corresponding surgical protocol, long and complex, limits their “indication” to children and holders of parental authority whose request is essentially aesthetic.

This restoration technique can be an interesting alternative to CPP for a short period (2-3 years).

5. Conclusion :

The evolution of therapeutic concepts and materials technologies have enabled a

paradigm shift in the restorative approach in children to obtain minimally invasive and aesthetic restorations to maintain the temporary tooth on the arch until it falls out and to allow the growth and construction of the permanent tooth.

CLINICAL ASPECTS OF RESTORATIVE DENTISTRY IN CHILDREN AND ADOLESCENTS

  Untreated cavities can cause painful abscesses.
Untreated cavities can cause painful abscesses.
Dental veneers camouflage imperfections such as stains or spaces.
Misaligned teeth can cause digestive problems.
Dental implants restore chewing function and smile aesthetics.
Fluoride mouthwashes strengthen enamel and prevent cavities.
Decayed baby teeth can affect the health of permanent teeth.
A soft-bristled toothbrush protects enamel and sensitive gums.
 

CLINICAL ASPECTS OF RESTORATIVE DENTISTRY IN CHILDREN AND ADOLESCENTS