Clinical aspects of restorative dentistry in children and adolescents
1. Objectives:
– functional (chewing, swallowing, phonation);
– space maintainer;
– eruption guide;
– growth (organization of inter-arch relationships); aesthetics.
2. Principles: 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 anatomical contours and reliefs
3. Cavity preparation:
The principles of cavity preparation are the same as those applied to permanent teeth and depend on the type of material chosen. However, it is necessary to remember the anatomo-histological peculiarities of the temporary tooth: prominence of the pulp horns and low tissue thickness .
4. Criteria for choosing restorative material in pediatric dentistry:
The choice of coronal restoration material in children must take into account a certain number of related elements:
To the child:
– his age,
– the level of its caries risk,
– his behavior and cooperation which are not always compatible with certain clinical protocols.
To the tooth:
- – the site of the carious lesion,
- – the stage of development of the lesion,
- – the fragility of the residual walls of healthy tissues,
- – the residual time of the temporary tooth on the arch.
To the practitioner:
– knowledge and mastery of different techniques,
– the possibility of taking charge of the child,
– the availability of the necessary equipment.
To the properties of the biomaterial:
– its intrinsic properties (physical, chemical, biological qualities),
– its handling.
5/ Restoration materials :
Composite – Adhesive
Benefits
– Tissue economy
– Good mechanical properties
– Can be used for microcavities
– Aesthetic
Disadvantages
Long operating protocol
– Protocol sensitive to saliva contamination.
Clinical aspects of restorative dentistry in children and adolescents
| hybrid microphone | Adhesive, aesthetic, interesting mechanical properties. | Protocol sensitive to any contamination, point of contact difficult to obtain. | |
| Condensable | Adhesive, aesthetic, firm consistency. | Difficult to obtain contact point, no long-term clinical evaluation, sensitive to any contamination. | |
| Fluid | Adhesive, microcavities. | High viscosity, sensitive to any contamination. |
| Biomaterials | Benefits | Disadvantages |
| Amalgam | Simple and quick to use, low cost, sustainable and bioactive. | Unsightly, non-adhesive, slow setting, mercury controversy. |
| Glass ionomer cement (hybrid by addition of resin or condensable) | Fluoride release (bioactive), easy to use. | Very limited durability (less than three years), very low mechanical quality, minor restoration only. |
| Compomer | Adhesive system (without prior etching), aesthetic. | Lower mechanical quality compared to composite resin |
| Preformed pedodontic cap | Effective in the long term, protection in major dilapidations, conservation of space. | Unsightly, mutilating preparation, child cooperation. |
Clinical aspects of restorative dentistry in children and adolescents
I- Preventive dentistry of temporary teeth
1- fluoride varnishes:
These are vehicles for topical fluoride delivery that are easy and quick to use; they allow prolonged contact between the fluorides contained in the solution and tooth enamel.
Contraindications:
- impossibility of regular monitoring;
- systemic fluoride intake;
- context of high individual caries risk which does not evolve favorably during subsequent control visits.
Operating protocol:
- teeth cleaning;
- teeth drying;
- application using a mini brush;
- drying the product for 2 to 3 minutes;
The patient should avoid brushing teeth and chewing hard foods.
2- Sealants:
Are used for the prevention of
caries in teeth (permanent molars and premolars and temporary molars) without caries but at risk.
Sealant installation protocol
- Clinical and radiographic examination of the tooth;
- Placement of a dam or other method of isolating the tooth;
- Tooth preparation;
- Recheck for the presence or absence of cavities;
- Clean the cracks with a brush, with or without pumice stone;
- Rinse thoroughly;
- Etch the surface with phosphoric acid for 15 to 20 seconds (both permanent and primary teeth);
- Rinse well for 15 seconds;
- Dry the surface well so that the enamel is frost or chalk white;
- Apply a drying/adhesive agent (depending on the chosen operating mode) to the required areas
- Re-dry the tooth;
- Apply a thin layer of sealant, working it into the grooves using a brush or Explorer;
- Dry the sealer for 20 to 30 seconds;
- Polymerize
- Check the articulation;
- If necessary, adjust the joint and polish the sealant with a multi-blade finishing bur;
Re-examine the sealant during recall examinations
II- restorative dentistry of temporary teeth:
A/ Conventional techniques:
A1 / Restoration of molars:
1- amalgam restoration:
Although controversial, amalgam is still widely used for restorations of posterior primary teeth.
1.1. Class I and II restoration:
The crevices, wide and extensive proximal contact points of the primary molars make these teeth the most susceptible to caries.
The external contour of the cavity must encompass the entire carious surface.
If the child has poor hygiene, all the fissures and areas of plaque retention are also included, but remaining as conservative as possible.
A flat pulp floor is desirable and the angle between the floor and the axial walls should be rounded.
The ideal depth is 0.5 mm into the dentin, or 1.5 mm from the enamel surface. If the pulp is very close, pulp protection must be ensured.
For class II, the extension of the interproximal zones must allow self-cleaning.
Ideally, the width of the isthmus should be approximately one-third to one-half of the intercuspal width.
The use of matrices in Class II restorations serves to reconstruct a normal contour and avoid overflowing fillings.
The major problem with amalgam restorations on baby teeth results from a defect in the preparation of the tooth, due to its small dimensions. Fractures of too narrow Class II isthmuses are frequent.
Clinical aspects of restorative dentistry in children and adolescents
1.2- Composite restorations:
Certain requirements limit their use in children, unlike amalgam, composite:
- requires perfect installation which must respect certain rules (laying of the dam, polymerization in several layers, use of adhesive systems, perfect polishing, etc.) in order to ensure the longevity of the restoration.
- The placement of composite resins requires more time and perfect mastery of the technique.
- On the other hand, the composite has no cariostatic action, a very interesting property for the prevention of secondary caries in children.
- All these reasons reduce the indications for composite restorations on deciduous molars. However, preventive occlusal cavities in composite resin can be made on deciduous molars in calm children.
- The indications and steps are the same as for permanent teeth.
Indications Contraindications:
– Restorations of temporary and permanent teeth of sites 1, 2 and 3 and stage 1 or 2.
– Fluid composites are indicated at the bottom of the cavity in the “sandwich” technique.
2. Contraindications:
– Uncooperative child
– Poor or impossible insulation
– Proximal juxta or subgingival cavitary lesion indicating the use of CVI-based material under the composite.
1.3. Restorations with glass-ionomer cements:
Glass ionomer cements are indicated for:
– In very young children whose cooperation is difficult (shorter working time compared to composite restorations);
– For cervical or low volume lesions;
– When there is a certain residual humidity level (installation of the surgical field is impossible in the event of a problem with patient cooperation or teeth in the process of erupting);
– In pulp protection at the bottom of the cavity, when the cavity is deep in a very young child (“sandwich” technique);
In the sanitation of the oral cavity, allowing the reduction of the risk of caries;
– In protection of 6-year-old teeth, when these are affected by early carious lesions or by molar incisor hypomineralization MIH (Molar Incisor Hypomineralization) but their incomplete eruption prevents the establishment of a correct surgical field to carry out definitive treatment with composite resins. The placement of CVI on these teeth makes it possible to stop the carious progression while the tooth completes its eruption.
The protocol for its implementation is simple. The cavity is prepared minimally by limiting itself to the removal of carious tissues. Its use does not require the prior application of a mordanting acid. Its use must be limited in time.
1.4. “Sandwich” technique:
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 photopolymerization. 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 in order to guarantee a perfect seal.
1.5- Restorations to the compomers:
Due to their ease of use, they are recommended for young patients or unruly children.
In the case of small cavities, CVIs are preferred if the child has average hygiene (better prevention by fluoride release).
It can also be used for aesthetic restorations on anterior temporary teeth.
The operating protocol:
It is very similar to that of composites:
- Isolation (the dam being the best means);
- Minimal shaping of the cavity;
- Installation of the single-component adhesive system (etching is optional);
- Injection of the material by compound;
- Photopolymerization;
- Polishing.
1.6. Restoration by infiltration:
This technique aims to treat early caries confined to the enamel at the proximal and vestibular level in a micro-invasive manner to stop the progression of early caries. It is contraindicated in cases of dentinal or cavitary lesions of the enamel.
Methacrylate resin-based infiltration products are used, which are deposited, after cleaning, etching and drying, using a syringe on the surface of the lesion. For proximal caries, a separator is provided to isolate the tooth to be treated.
The tooth substance is preserved as much as possible since there is no milling.
2. Preformed metal crown
Indications Contraindications:
They are the catering of choice when:
the thickness of the residual tissues, after caries removal, is minimal (stage 3 and/or 4 caries),
the deterioration is significant on pulped or depulped teeth,
the tooth has a severe structural abnormality (amelogenesis imperfecta, dentinogenesis imperfecta),
the risk of caries is high in order to prevent caries recurrences.
Contraindications: The contraindications to the installation of pedodontic caps are:
– exfoliation close to the temporary tooth,
Patients unable to cooperate during treatment.
– severe subgingival involvement.
Advantages & Disadvantages:
Speed of execution and ease of use compared to usual methods,
Maintaining space in the mesio-distal and occlusal direction,
Maintaining pulp vitality,
Low cost,
Sustainability.
Disadvantages:
– Color (unsightly appearance),
– Difficult adaptation with atypical morphologies or in the presence of root caries.
Operating protocol:
Choosing, trying on and adjusting the headdress:
Choice of preformed crown according to the mesiodistal diameter of the tooth,
Adjust the crown with a roller clamp,
Remove the subgingival parts with a bur or crown scissors, remembering to polish all the retouched areas.
Tooth preparation:
Reduce the occlusal surface following a vestibulo-lingual V with a pear bur mounted on a turbine,
Clean clearance of the proximal faces with a diamond flame cutter on a turbine,
Round the proximal axes,
The preparation should always be juxta- or supra-gingival.
The operating protocol follows the following steps:
Tooth preparation
1- Elimination of mesial and distal contact points (stay at the gingival limit, no fillet or shoulder) diamond bur, turbine;
2- Homothetic reduction of the occlusal face by approximately 1.5 mm (to make room for the sealing cement) diamond bur, turbine;
The mesio-distal space to be restored is measured using a caliper.
Choice of cap: temporary molar box.
To insert the crown on the
prepared tooth, place it on the lingual side and pass it over the preparation to the vestibular limit
A crown will often make a “click” sound as it passes past the cervical undercut area. Firm pressure will usually be required to
put the crown in place.
It is advisable to prepare a larger quantity of cement
larger than normal.
When the crown is placed on the tooth, excess cement should flow out at the edges.
If this is not the case, the volume of cement is insufficient. This may lead to loosening of the crown.
Clinical aspects of restorative dentistry in children and adolescents
Clinical aspects of restorative dentistry in children and adolescents
Clinical aspects of restorative dentistry in children and adolescents
Clinical aspects of restorative dentistry in children and adolescents
Remove excess cement, then go under the area of the dental floss contact point to remove excess cement from this area.
Finally, check the occlusion of the crown.
The patient should be aware that temporary gum pain may occur as the anesthesia wears off.
A.2/Restoration of anterior teeth
Restoration with transparent molds:
The indication for restoration on deciduous incisors and canines is often the consequence of caries, trauma or failure of hard tissue development.
The operating protocol follows the following steps:
Choice of mold size based on the mesio-distal diameter of the tooth,
– Laying the operating field,
– Removal of decayed tissue with a round bur on a contra-angle,
– Tooth preparation: this consists first of all in reducing the incisal edge (1 mm) then the proximal faces (proximal slices) using diamond burs mounted on turbines. 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.
Cutting and adjusting the mold using scissors,
– Testing the mold,
– Perforation of the mold: 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 on the dental stump,
– Filling the mold with composite, which is hollowed out in the center to leave room for the dental stump,
– Insertion of the mold,
– Elimination of excess,
– Photo-polymerization on all sides,
– Removal of the mold using a probe, a mouth spatula or an excavator,
– Polishing the tooth,
– removal of the operating field,
– occlusion check.
B/Unconventional techniques:
B.1. ART (Atraumatic Restorative Treatment): ART uses only manual instrumentation to remove carious tissue, followed as for other therapies by a restoration with an adhesive material.
Rotary instrumentation may sometimes be used early in the procedure to widen a caries cavity that does not allow passage of hand instruments, hence the name “modified Atraumatic Restorative Treatment – mART.”
To successfully achieve this therapy, it is essential to isolate the bacteria that remain after manual excavation by a waterproof restoration preferably using a biomaterial with cariostatic properties.
It is an easy technique, not very painful and less anxiety-provoking than conventional techniques.
Indications:
– Class I and V caries cavities (for class I, if the tooth is subjected to masticatory forces, this restoration will be considered temporary because the CVIs do not resist masticatory forces).
– Small or medium sized Class II caries cavities.
Contraindications:
– Class III and IV caries cavities.
– Class II caries cavities of large size.
– Limited or difficult access to hand instruments.
– Irreversible pulp damage.
– Large caries cavities.
– In a very young patient (in this case, restorations that last until the normal date of physiological tooth loss are preferred).
– Children with immunodeficiencies or at risk of infective endocarditis.
Operating protocol:
Isolation of the tooth to be treated,
Widening the cavity opening (if access is limited) using the dental hatchet,
Remove all soft tissue (carious enamel and infected dentin) with excavators of different sizes,
Removal of unsupported enamel using the dental hatchet,
Application of a dentin conditioner for the removal of smear layer and optimization of adhesion,
Rinse and dry,
Application of the CVI,
Elimination of excess and polymerization if a CVIMAR was used,
Checking the occlusion.
B.2. Hall technique:
Hall’s technique. It consists of sealing the crown on the tooth without having performed local anesthesia, caries removal or tooth preparation beforehand.
A retrospective study showed that this technique has results comparable to those observed after using conventional restorative techniques.
This technique is indicated in children who are difficult to treat with conventional therapies without sedation because it is less painful and less anxiety-provoking.
Benefits :
– Simple,
– Fast (on average 12 minutes) compared to conventional restorations (amalgams and adhesive restorations).
– Easy to put in place (even for those who have never put in place preformed metal crowns).
– Non-painful and non-stressful (no anesthesia, no preparation).
– Very well accepted by children, parents and practitioners.
Disadvantages:
– The unsightly appearance of the crowns.
– Temporary disocclusion of teeth.
B.3. Interim Therapeutic Restorations (ITR):
It consists of:
to remove the carious superficial dentin using an excavator or a bur used at low speed;
to perform the obturation with a glass ionomer, then
a furrow seal.
This technique can only be applied to living teeth without pulp symptoms and if the patient can be regularly monitored, in order to overcome any problems occurring with restorations considered to be “temporary”.
B.4. Non-restorative therapies “NRCT – Non Restorative Caries Treatment”:
These therapies do not restore the loss of substance but only attack the causes of these lesions in order to prevent their progression.
Their effectiveness is essentially based on the use of preventive methods by the patient (balanced diet low in sugar and regular brushing with fluoride toothpaste) but sometimes requires certain clinical steps beforehand (widening of the caries cavity using rotating instruments to make it accessible for brushing).
Regular check-ups are necessary
contraindicated in the following situations:
Irreversible pulp damage,
Patients with immunodeficiencies or at risk of infective endocarditis,
Extensive carious lesions,
A patient with a high caries risk,
Uncooperative child and/or parent, as this technique requires multiple monitoring sessions.
Young children (3 to 5 years), this technique should be considered as a temporary measure, the teeth should be restored after the child’s cooperation has improved in order to play their roles until the normal date of their physiological loss.
Restoration of permanent teeth:
Sealing of pits and fissures : These seals constitute a means of prevention
Restoration of anterior teeth:
When the carious lesion is non-cavitated (stage 0), treatment based on topical application of fluoride may be sufficient to remineralize the surface.
In the face of a cavitary lesion, minimal caries removal under the surgical field, followed by restoration using a composite resin, is necessary.
In the case of deep lesions, it is advisable to carry out a layer-by-layer reconstruction “stratification” with dentine and enamel shades for an optimal aesthetic result.
Restoration of posterior teeth:
The restoration of choice for stage 1, 2 and 3 lesions is that of composite resins placed under the surgical field.
For stage 4 lesions, the restoration depends on the age of the child, the stage of maturation of the root and the state of the pulp.
Anomalies and Hypomineralization of the Incisor Molar: fitting a glass ionomer as a temporary measure is a good solution while waiting for the end of eruption .
There are many catering options available:
Sealing of grooves when the enamel is intact,
Restoration with composite resins if there is a cavity,
Installation of preformed caps when the deterioration is significant.
Clinical aspects of restorative dentistry in children and adolescents
CONCLUSION
The practitioner currently has a wide choice of restorative materials that direct conservative dentistry towards preventive dentistry; the current evolution is towards so-called bioactive materials that play a role in preventing caries. We are thus witnessing a real revolution in restorative dentistry that should make it possible to preserve the child’s dental capital as best as possible.
Clinical aspects of restorative dentistry in children and adolescents
Sensitive teeth react to hot, cold or sweet.
Sensitive teeth react to hot, cold or sweet.
Ceramic crowns perfectly imitate the appearance of natural teeth.
Regular dental care reduces the risk of serious problems.
Impacted teeth can cause pain and require intervention.
Antiseptic mouthwashes help reduce plaque.
Fractured teeth can be repaired with modern techniques.
A balanced diet promotes healthy teeth and gums.