Pedodontics III Al Azhar University Palestine Gaza Upload By: Lama El Banna lama1997bana@gmail.com Faculty of oral and dental medicine

1. ‫الرحيم‬ ‫الرحمن‬ ‫هللا‬ ‫بسم‬

2. College of Dentistry
Pedodontic I
Restorative materials for primary teeth
Dr. Hazem El Ajrami

3. • In considering the characteristics of an ideal
restorative material, it is apparent that no single
material can fulfill all of the clinical needs. The
characteristics of the ideal restorative material are
described as fulfilling requirements applying to
the:
Physical and mechanical properties of the
material.
Technical features of the material from the
perspective of the dental professional.
Patient acceptance.
Other clinical aspects that contribute to the
material's effectiveness.

4. • The interaction of these factors determines the
longevity of the dental restoration.
• For many years, amalgam was the material of
choice for restoration of primary molars for its
durability and ease of handling. The physical
properties of amalgam restoration are adequate
for all but very large restoration in clinical
technique and less affected by moisture than other
tooth colored dental restorative materials.
Currently, there are a variety of other materials to
choose from for restoring primary teeth, including
compomer, hybrid ionomer, glass ionomers,
stainless steel crowns, and resin composites.

5. • Resin- modified glass ionomers:
Conventional glass ionomers are derived
from aqueous polyalkeonic acid and a glass
component. When the powder and liquid are
mixed together, an acid base reaction occurs.
Resin modified glass ionomers are glass
ionomer cements to which a resin has been
added for strength. Resin-modified glass
ionomers (RMGI) works by the fundamental
acid-base reaction, which is supplemented by a
second resin polymerization reaction.

6. • Advantages of resin - modified glass ionomers:
1. High strength and mechanical properties.
2. Less sensitive to water contamination.
3. RMGI also releases fluoride. Fluoride is
released from RMGI not only when it is placed,
but also after fluoride treatment and brushing
with fluoride toothpaste. This is because glass
ionomer acts as fluoride reservoir.
4. Better esthetics.
5. Rapid setting since its light activated, so it can
finished immediately.

7. 6. Finally, although the shear bond strength of
RMGI to tooth structure in not high, this
restorative material succeeds because its
coefficient of thermal expansion is very close
to that of a tooth. In other words, when the
expands, the RMGI expands in a like fashion.
7. Resin - modified glass ionomer (RMGI) is a
tooth - colored material that bonds to the tooth.
8. Less tooth enamel needs to be removed by the
dentist when an adhesive - colored restoration
is placed in a tooth.

8. • Uses:
1. Used in restoration of Classes I, II, III, IV
and V in primary teeth.
2. Used in stress bearing areas.
3. Useful in child with previous high caries
experience.
4. When patient cooperation is limited and it is
preferable to simplify operative procedure as
possible.

9. • Composite:
Composites are composed of a resin matrix,
an inorganic filler, and an interfacial phase. The
matrix provides the framework, and the filler
imparts its mechanical properties onto the
composite. Advancements are all focused on
better strength together with better consistency
and esthetics.
Some manufactures added fluoride to the
composite restorative but the long-term
effectiveness of these additives was
questionable.

10. • Occlusal wear is greater in composite than in
amalgam restorations, but this only becomes
significant after several years.
• Indications:
Good patient cooperation (technique sensitive).
Low caries rate patients.
When esthetic is needed.
• Uses:
Used in restoration of Classes I, II, III, IV, and
V in primary teeth but has better strength,
esthetics and stability in oral fluids than RMGI.

11. • Compomer:
Compomers are a mix between composite
and glass ionomer to have the benefits of both
materials in term of biocompability, fluoride
release, strength and esthetics.
Compomers are similar to composite, they
have a wear rate about 3 times that of
composite, however, in addition, compomers
require placement of a bonding agent to ensure
adequate retention to dentine surface.

12. • Compomers is one of the most successful
materials introduced for the treatment of
primary teeth due to:
1. Fluoride releasing potential.
2. Bonding capacity to enamel and dentine.
3. No need for acid etch.
4. Simple handling properties.
• Uses:
It can be used in restoration of primary teeth
as well as permanent teeth and can also be used
as fissure sealant.

13. • Stainless steel crown:
Stainless steel crown provide strong durable
restoration for primary teeth.
It is indicated in restoration of badly
decayed deciduous teeth, pulpotomized
molars, also can be used as a temporary
restoration for decayed permanent molars.

14. • MANAGEMENT OF DEEP CARIOUS
LESIONS IN CHILDREN
Pulp exposure is caused most commonly by
caries but may also occur during cavity
preparation or by fracture of the crown. Pulp
exposures caused by caries occur more
frequently in primary than in permanent teeth
because primary teeth have relatively large pulp
chambers, more prominent pulp horns and
thinner enamel and dentine. In primary molars
with proximal cavities, pulp involvement occurs
in about 85 % of those with broken marginal
ridges.

15. • Exposure of the pulp by caries is invariably
accompanied by infection of the pulp. The
infected pulp becomes inflamed and necrosis
may result. If infection spreads to the alveolar
bone, the developing permanent tooth may be
affected. For these reasons, a primary tooth
with a pulp exposure should not be left
untreated. When these carious exposures could
be treated with consistently good results,
several problems in dentistry would be solved.
The clinical condition of the carious tooth and
its surrounding tissues is an important
diagnostic factor.

16. • Diagnostic aids in selection of teeth for vital
pulp therapy:
1. History of pain:
The history of either presence or absence of
pain may not be as reliable in the differential
diagnosis of the condition of the exposed
primary pulp as it is in permanent teeth but it
should be taken into consideration in selection
of the teeth for vital pulp therapy. Information
may be taken from the parents and history may
be helpful in determining the status of a
painful tooth.

17. • The dentist should distinguish between two
types of pain: provoked and spontaneous pain
(unprovoked).
• Provoked pain is precipitated by stimulus
(thermal, chemical or mechanical irritants) and
disappear after removal of the stimulus, this
denotes that the pulp is vital and protected by a
thin layer of dentine and can be treated
successfully with good prognosis (e.g. pain after
hot or cold drink, pain immediately after eating).

18. • Spontaneous pain is a throbbing constant pain
that may keep the patient awake at night. It
indicates advanced pulp damage, which means
that involvement of the pulp has progressed
too far for treatment preserving pulp vitality or
with even a successful pulpotomy.

19. 2. Clinical examination:
A careful intraoral examination is of extreme
importance in detecting the presence of a
pulpally involved tooth.
A. Tooth mobility:
Abnormal tooth mobility is a clinical sign
that may indicate a severely diseased pulp or
involvement of periodontal ligaments
(pathological mobility must be distinguished
from normal mobility in primary teeth near
exfoliation).

20. B. Sensitivity to percussion:
Percussion should start with a very gentle
and careful tap by the tip of the finger to
prevent exposing the child to uncomfortable
stimuli. If the tooth is sensitive to percussion,
this indicates' apical or pulpal inflammation or
both.
C. Examination of mucobuccal fold:
Presence of swelling, sinus, draining fistula
or chronic abscess associated with a deep
carious lesion is a sign of an irreversibly
diseased pulp (non vital pulp).

21. D. Size of exposure and amount of pulpal
bleeding:
Size of exposure, appearance of the pulp and
amount of bleeding are the most valuable
observation in diagnosing the condition of the
primary pulp. The most favorable condition for
vital pulp therapy is the small pinpoint
exposure surrounded by sound dentine. If the
exposure is large and associated with watery
exudate or pus, the tooth is not suitable for
vital pulp therapy.

22. 3. Radiographic interpretation:
The clinical examination should be followed
by a high quality periapical and bite-wing
radiograph to examine periapical area and
supporting bone. Pulp exposure cannot be
accurately detected from an xray film.

23. • Radiographic interpretation in children is more
difficult than adults due to:
 Young permanent teeth with incompletely
formed root ends giving the impression of
periapical radiolucency.
 The roots of primary molars undergoing
normal physiologic resorption often present
a misleading picture or one suggestive of
pathologic change.
 Permanent teeth are superimposed on the
primary teeth.

24. • Radiographs are valuable for determining the
following:
• Periapical changes such as thickening or
widening of periodontal membrane space.
• Rarefaction in supporting bone.
• Presence of calcified masses within the pulp
chamber and root canals.
• Periapical and interradicular radiolucencies of
bone.

25. 4. Vitality tests:
• The vitality tests are not reliable in the child
dental patient in diagnosing a deep carious
lesion but it should be taken into
consideration. It gives an indication of
whether the pulp is vital but it does not give
reliable evidence about the extent of the pulp
disease.
• Pulp vitality tests may be used either thermal
or electrical.

26. • Thermal pulp vitality test:
The thermal test includes the application of
heat (hot gutta percha or hot instrument) or cold
(ethyl chloride or ice cone). The reaction of a
normal tooth with vital pulp is tested first
(Normal response: pain on application of hot or
cold stimulus, which disappears after removal of
the stimulus.) If the pain persists, this indicates
pulpitis. If the pulp does not respond to thermal
stimuli, (the child does not feel any pain) this is
an indication of non vital pulp.

27. • Electric pulp tester:
It is an apparatus used to test pulp vitality.
Record the reading of a normal tooth with vital
pulp first, then record the reading of the
carious one , If the pulp of the affected tooth
responds at lower reading than normal this
denotes hyperemia or pulpitis. If it responds at
a higher reading than normal this is an
indication of pulp degeneration.

28. • Disadvantages of electric pulp tester:
Electric irritation to the pulp.
False positive result when content of pulp is
liquid in case of liquefaction necrosis (the
pulp is non vital although it responds at a
lower degree).
The child might be apprehensive and the
dentist lose child's confidence causing
disruptive behavior.

29. 5. Physical condition of the patient:
Successful pulp therapy is dependent in
some measures at least upon the absence of
systemic disturbance that might exert a
deleterious effect on the pulp. Seriously ill
children, suffering from heart disease, nephritis,
leukemia, tumors, cyclic neutropenia should
not be subjected to the possibility of acute
infection resulting from pulp therapy aside
from the fact that pulp might not possess
normal regeneration power. Extraction of the
involved tooth after proper premedication with
antibiotics is the treatment of choice in such
serious diseases.

30. Vital pulp therapy
• Pulp capping:
The aim of pulp capping is to maintain pulp
vitality by placing a suitable dressing either
directly on the exposed pulp (direct pulp
capping) or on a thin residual layer of slightly
soft dentine (indirect pulp capping).

31. I. Indirect pulp capping:
 Indications:
Indirect pulp capping is used when the tooth
has a deep carious lesion in which case the
total removal of all carious dentine would most
certainly result in large pulp exposure
necessitating complex and expensive
treatment. This procedure may be considered
successful provided that there is no root
resorption and absence of mobility or
periapical inflammation radiographically.

32.  Procedure:
 First visit:
1. Without local anesthesia nor rubber dam
application, excavation of the superficial layer
of caries is done up to the last thin leathery
dentine layer.

33. 2. The remaining carious dentine is dried (the
capping material will not adhere on wet
surface) and a layer of zinc oxide- eugenol is
applied on the dentine surface. Zinc oxide-
eugenol is a germicidal agent which kills
bacteria present in carious lesions and prevent
progression of caries toward the pulp i.e. arrests
carious process. This gives the chance to the
pulp for healing and regeneration.

34. 3. The overhanging walls of enamel should be
left as such because it provides retention for
the dressing.
4. The cavity is filled with zinc phosphate
cement or fortified zinc oxideeugenol and
left as such for 6-8 weeks.

35. • Treatment can be judged successful if:
 The restoration was intact.
 The tooth was not sensitive to percussion.
 No history of pain after treatment.
 No radiographic evidence of radicular
diseases.
 No radiographic evidence of root
resorption.
 No clinical evidence of direct pulp exposure
when the tooth was reentered and the
residual carious dentine was examined or
excavated.

36.  Second visit: 6-8 weeks
During the waiting period, the caries process
in the deep layer will become arrested and soft
caries is hardened. A protective layer of
reparative dentine has been formed.
A. The tooth is anesthetized and isolated with
rubber dam.
B. Carefully remove remaining carious dentine,
which is somewhat hardened and the cavity
preparation is completed in the conventional
manner and the tooth is restored as usual.

37. Thank You