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-Today we will talk about intracoronal restorations in pediatric dentistry Lecture outline: *intracoronal restorative materials: amalgam, composit, RMGIs, PMCR. *choice of material in pediatric restorations. *anterior restorations. *posterior restorations. Firstly. -intracoronal restorations: are any restoration that placed in the tooth, so you make a cavity and fill it . -extracoronal restoration: is something that we put on cap or around the tooth. *************************************************** Now, we will start talking about amalgam as an intracoronal restorative materials.. the advantages of using amalgam are: *simple-ease of manipulation *quick. *cheap. *technique insensitive. *durable.
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Disadvantages: *not adhesive. *not esthetic. *require mechanical retention in cavity. *environmental & occupational hazards, which regard to toxicity from mercury. * public concerns. Now, why is it not being adhesive?? Why this is a disadvantage?? . They see that when we deal with an adhesive restorative material like composit or GI I dont have to have a certain cavity design (a certain depth and a certain width) I just follow the caries, but with amalgam because it is not adhesive I need to have mechanical retentive properties of the cavity, this mean that we have to remove extra tooth structure in order to get the kind of design thats mean that it is not conservative to the tooth structure. clinical uses: *class I restorations in primary and permanent teeth. * 2-surface class II restorations in primary molars where the preparation does not extend beyond the proximal line angle, it means a very small class II. *class II restorations in permanent molars and premolars. *class IV restorations in primary and permanent teeth.

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_INDICATIONS: *patient at moderate risk for caries. *patient uncooperative (poor moisture control).

Now,the success rate for: class I amalgam is 93%. class II amalgam is 71%. all primary molar amalgams are 79%. When you compare amalgam with SSC's, you have a 92% success rate, thats why when we do treatment planning usually we have a class II, we put a crown. Now, the method for interproximal class II amalgam restoration in primary molars : 1 ) LA, RD 2)small bur in order to remove the caries, and you need to include an isthmus & dovetail for retention and you need to break the contact point , with the slow speed bur you need to remove the deep caries and then you place liners,(in pediatric dentistry we always place liners), why?? . Because we have a very big pulps, high pulp horns, & wide dentinal tubules, so you have to protect the pulp. 3) place matrix band,wedge,amalgam,condense,carve,burnish. 4)then you check the contact point with floss. 5)remove the rubber dam and check the occlusion.
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Now,this is an example of single tooth isolation by rubber dam..

You punch a hall on each tooth in the dam.. the dam is a sheet of rubber and you use a puncher and you just make a hall for each tooth, this is called single tooth isolation. Here .. we have a quadrant isolation, you make a hall for a group of teeth

Now, the modified outline for primary molars is where the occlusal outline shouldnt extend into all the fissures but needs to incorporate a small isthmus and dovetail for retention. The fracture in class II amalgam occur in the isthmus (the isthmus is the narrowest part in the dovetail occlusaly ) so after the fracture microorganism will go inside the tooth and cause abscess formation, so specially in small teeth the SSC is better because class II is quite wide and extend beyond the line angle. ****************************************************

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COMPOSITE : Advantages: *adhesive. *aesthetic. *reasonable wear properties. *command set, once you done you can cure. Disadvantages: *technique sensitive. * rubber dam is required. *expensive, (more expensive than amalgam but it's not that expensive) . *polymerization shrinkage is one of the chemical properties that can happen, but we can minimize it. Basic chemistry: *monomer/resin:Bis-GMA or UDMA. *filler: quartz or glass *silane coupling agent. *photo-initiator. *stabilizer. *pigments. *radioactive agent like <yttrium tri-fluoride>
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Now, the bonding agent why do we need it?? It bond the primer and the composite resin together, in the past they used a primer then a bonding agent then the composite, so after acid etching we put a primer and this will form a layer with the collagen fiber in the dentine, then the bond will bind to the primer, then the composite will bind to the bond .

Most modern bonding systems use an intermediary priming agent which allows a hydrophobic bonding agent to bond to the wet surface of dentine below and create a superficial bond to the hydrophobic composite. << the idea is the composite is hydrophobic and the bonding is hydrophobic also, but the primer is hydrophilic so it can binds to the dentine then allow the others to bind consequently >> A mechanical interlocking is achieved after the acid etching because they have a porous area. In the fifth-generation we dont have all 3 layers, we have a bottle of bonding agent which contain the primer and the bonding agent together, the most recently one is the seventh generation in which you have an acid etch, the primer and the bonding agent in one bottle, you just place it, then dry it and finally light cure it. But most of the studies done comparing between the fifth and the seventh generation shows that the fifth-generation has better retentive coat, because when we do each step alone you guarantee that everything is done properly. The filler content:
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*anything which unfilled has no resin in it. *anything with a sealant or bonding agent has 50%. * a flowable composite from 50% - 70% . *composite resin has from 70% - 85%. Now according the filler size: we have..

*microfilled ( .01-.1) *macrofilled. (>5.0-50) *hybrid < micro and macro filled mixture> (.05-5.0) Clinical uses of composite: -In primary molars, composite is a satisfactory restorative material, providing that the child is cooperative because it is a technique sensitive . And we can use it in pits a fissure caries , we just use a small round bur , remove the caries from different areas and we just placed composite and then fissure seal the all surface.. the idea is that we dont have to open all the fissures together y3ne we dont have to make them as one cavity, so this is a very conservative of the tooth structure. But if we have a deep caries which reach the pulp, upon caries removal we do pulpatomy and then we place a SSC. NOW, let's go back to the clinical uses of composite which is : *small pit and fissure caries-PRR in bothe primary and permanent dentition.
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*occlusal surface caries extending into dentine. *class II restorations in primary teeth that do not extend beyond the proximal line angles. *class II restoration in permanent teeth that extend approximately one-third to one-half of the buccolingual intercuspal width of the tooth.

*class V restorations in primary and permanent teeth . *class III restorations in primary and permanent teeth. *class IV restorations in primary and permanent teeth. *strip crown in the primary and permanent dentition. Composite resin contraindications: *where a tooth cannot be isolated to obtain moisture control. *individual needing large multiple surface restorations in the posterior primary dentition. *high risk patient that have multiple caries and tooth demineralization, exhibit poor oral hygiene and compliance with daily oral hygiene we need something more durable.

***Success rate in class II composite resin in primary molars= 40%, because of that we prefer to place a SSC . Now, the method for cavity design:

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it need to be modified from that for amalgam, you just follow the caries and remove it, it doesnt has to have a specific design you just need to bevel the enamel all around and you need to place a liner on dentine. So the outline should follow the extension of the caries we dont have extension for prevention, small occlusal dovetail not usually necessary so the dovetail should be very small just to help in retention. Then remove the soft caries with the round bur, place the matrix band. Composite should placed incrementally, place bonding agent to protect from post-operative sensitivity ..y3ne after you done with composite you should place a layer of bonding agent and cure it and then you check the occlusion.

Now, the problems with these restorations: *integrity of bond at depth of the box y3ne ymkn el bond ma yw9al mnee7 5a99a 3l gingival floor so in this case you place a liner like GIC over dentine to ensure good bond and to reduce microleakage and induce F release, the other thing is that you have excellent bond between the composite and the vitrebond ,it is better than the bond between the composite and dentine so you have a more retentive restoration which will work well against microleakage which caused by polymerization shrinkage, and this is called sandwich technique. *placement of composite is also difficult because of moisture sensitivity so you should place a rubber dam.
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* you should place composite in increment, because when you place it incrementally you minimize the polymerization shrinkage problem and get more retentive restoration. ****************************************************

GLASS INOMERS: Advantages: *adhesive. *aesthetic. *fluoride leaching. Disadvantages: *brittle, not strong as composite. *susceptible to erosion & wear. Basic chemistry: *a conventional GIC comprises a powder and liquid component, when mixed together an acid-base reaction occur, of coarse first I have something which called gelation and then it is harden. *polyalkeonic acid such as polyacrylic acid+ glass component that is usually a F-Al-silicate. *as the metallic polyalkeonic salt begins to precipitate, gelation begins and proceeds until the cement sets hard. Now, the characteristics:
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It able to chemically bond to enamel and dentine with insignificant heat formation or shrinkage, this is important, we dont want too much heat to form because this will cause damage to the pulp which mean that GIC is biocompatible. Another thing is that composite is excellent to bind with enamel better than dentin, but in GIC the opposite is true, GIC binds to dentin better than enamel. GIC is fluoride release but it is prelimited in time, so it leach the greatest within the first 2 hours after placement of the restoration up to the next 24 hours, some studies shows that

afterward GIC material is able to absorb any fluoride from the environment and leach it whenever it needed, so this means that if you have consistent intake of fluoride to tooth brushing or mouth rinsing you get a continuous source of fluoride for this restoration, and then it can delivered to the underlining dentine. GIC has a very low volumetric setting contraction (the opposite of what happen to composite) the composite shrink more than GIC which doesn't contract. ALSO, GIC has a similar coefficient of thermal expansion to tooth structure, it means that, you now the teeth are subjected to hot liquid and then to cold liquid and then to hot liquidetc, the tooth will be affected by this temperature so any material in nature has coefficient of thermal expansion which indicate how much it will expand and contract, the tooth has a certain coefficient of thermal expansion, now the good thing is that GIC has a very similar coefficient of thermal expansion of
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dentine so that when you have a filling inside the tooth and you drink something hot, the filling will expand and the tooth will expand also. GI disadvantages: *physical strength. *water sensitivity but it is less sensitive than composite. Now, the success rate: *failure rate of GIC is higher than amalgam :33% vs 20%. * the average survival time for GIC = 33 months, or 3 years ta8reban, it is ok in patient who is uncooperative like when you have 1 or 2 or 3 years old child and he is not cooperative with you so you cant place a proper composite filling on his anterior tooth, it 's ok to place a GI or RMGI, it is will last for 2 or 3 years then when the child become older you can just place your composite restoration, you can reline on this GI filling as abase and just place your composite on top of it if there is no recurrent caries, SO you have limited caries, this is how we work in pediatric dentistry. In other situations where we dont have local anesthesia, y3ni we can't place the local anesthesia because the child is not cooperative, you can excavate and place GI, this is not a proper filling, it's just to arrest the caries. Now, GIC indications: *shouldnt be used in large restorations subject to occlusal load in teeth retained for more than 3 years because the study is showing us that it can last for not more than 3 years, so if you have an adult you cant place it as a permanent restoration for
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adults, never, you might place it temporarily because he has to leave for a weak, and then he comes back and replace with something permanent. *small occlusal and interproximal caries, you can use it but only with a small one in children. *use stronger, packable, chemically cured GIC and avoid use of RMGIs for posterior restoration.

clinical uses of GI: *luting cement in SSC. *orthodontic bands. *orthodontic bracket's. *liner. *class I, II, III restorations in primary teeth. *class III restorations in permanent teeth in high-risk patients, so even if there is a permanent tooth and the patient is high risk to caries you can place it until you arrest the caries in the patient mouth then replace it with composite restoration. *class V in primary and permanent teeth. *caries control: this is a principle which is used to arrest caries in patient who has a multiple carious lesion by excavating the caries and place a fluoride releasing material like GIC or RMGI's, so we place it in:

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- high risk patients. -restoration repair. - Atraumatic restorative treatment.

ART: (Atraumatic restorative treatment) : Is a technique employs the use of hand instruments to remove tooth structure affected by caries and the GI is placed, the technique was first introduced in silent where some dentist

were on a voluntary mission, they found that many third world areas didnt have any electricity so they couldnt use their rotary instruments so they have to use hand instrument, they excavate the caries and place GI, this is the beginning of this technique. Now a days it is used even in developed countries for uncooperative children or patients who have medical problem or for caries control to arrest the caries. The success rate of ART in class I is 89.6% after 2 year follow up, and have indicated its importance in children with behavior problems as being non-painful. Now it's named as (.) therapeutic restoration, the APD recognizes ITR as a beneficial professional technique in temporary pediatric restorative dentistry .

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ITR is used to reduce the level of oral bacteria like streptococci & lactobacilli in the oral cavity. So they can use for: *to restore and prevent of dental caries in young patient and uncooperative patient. *situation in which there is no electricity to use a rotary instruments. *step wise excavation in children with multiple open carious lesions. (Step wise excavation: is a technique that we remove the caries and we restore with GI but the caries is so deep that you

might reach the pulp so we should leave part of it and then we leave it for a month or so then we get back, we remove the GI and we remove more caries because we sure now that there is some of tertiary dentine) *ITR may use as a caries control. Now, the procedure: *remove the caries, now since we have electricity then we can use the slow speed to remove the caries, the size of restoration can be minimize with maximum caries removal especially walls because you want your filling to adhere properly . The great of success is in class I .

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FOLLOW UP CARE is necessary with topical fluoride, tooth brushing and OHI to improve the treatment outcome in high caries risk dental restoration. Now, method for GI restorations: Same thing except you do a conditioning of dentine with 10% polyacrylic acid for 10 sec then wash it and dry it, after that you place GI and protect it by putting a layer of bonding agent on the top of it and cure it, if you dont have a bonding agent at least put place some vasline to protect the final restoration from moisture contamination, and the final step is check the occlusion. ********* a good information to you to ease the using of GIC in the clinic is to put on your plastic instrument some bonding agent before put GIC.

THE DOCTOR START JUST READING THE SLIDES WHICH TALK ABOUT RMGI AND COMPOMERS SO PLZ REFER TO IT. THE END. (Sorry if there Is any mistake & gd luck in your exams ) DONE BY: SAMAR AL-OMARI

SPECIAL HI GO TO MY PERFECT PARTNER AND SIS KAKOOSH thaaaaanx 3la kol she w 5a9a 3ala surprise el a7ad w ALLAH y5alili hek surprise 3la 6oooooooooooooooooooool yaaaaaaaaa rab w ma y7remni mnha ;) wallah ennek 3la rase (a7la abo el z3be wallah) <3 <3 :*

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Nevs,,, miss you ya ba6ee5a w miss el 23deh w el habal tab3on el f9l el made,, w ba6li habalik w tafkerek elli bala 63meh.. :p <3 <3 luv u :* ****************************************

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