1

Contents
Definition of operative Principles of tooth

dentistry Indication for operative treatment Rationale of pediatric treatment General consideration regarding pediatric dentistry Classification of dental caries

preparation Various materials used in pediatric restorations Amalgam Restoration GIC restoration Resin based composites Comparative studies

Definition
Art and science of the DIAGNOSIS, TREATMENT, and

PROGNOSIS of defects of teeth that do not require full coverage restoration for correction. Treatment should result in the restoration of proper tooth form, function, and esthetics, while maintaining the physiologic integrity of the teeth in harmonious relationship with the adjacent hard and soft tissues.
All of which should enhance the general health and

welfare of the patient

3

Indications for Operative Treatment

Caries,
Malformed, discolored, non esthetic, or fractured

teeth, Wearing of teeth (attrition, abrasion, etc.) Restoration replacement or repair.

Basis of pediatric operative dentistry:

Maintenance of arch length preserve primary teeth Maintenance of healthy oral environment transmissible factor Prevention and relief of pain conservative procedure

Maintenance and improvement of appearance

smile care
5

General considerations for Restoration procedure in

Development status of dentition: Stage of root

children

development / resorption
Caries experience of the patient: Caries risk assessment

based on history
Patients oral hygiene Patient cooperation & parent compliance Individually tailored treatment plan

 Difference in tooth morphology-

Primary tooth is small, bulbous, bell shaped Definite cervical constriction Pulpal outline DEJ Pulp horns are highly placed Thin & uniform thick enamel
Symmetry of caries attack

Proximal decalcification in Cl-II lesions

Need for bitewing radiograph, if contacts are closed
7

Consideration for efficient treatment:

Appointments Single arch treatment Positive attitude of the dental team

Four handed dentistry

Use euphemisms

Classification of Cavity Preparation: [Primary & young permanent teeth]

G.V. Blacks Classification
Class I V , Class VI [ Simons modification]

Finns modification
Class I: Cavities involving the pit and fissures of the molar

teeth and the buccal and lingual pits of all teeth.

Class II: Cavities involving proximal surface of molar teeth with

access established from the occlusal surface

Class III: Cavities involving the proximal surfaces of the anterior

teeth which may or may not involve a labial or a lingual extension tooth which involve the incisal angle

Class IV: A restoration of the proximal surface of an anterior Class V: Cavities present on the cervical third of all teeth,

including proximal surface where the marginal ridge is not included in the cavity preparation
10

Sturdevants Classification:
Simple Cavity- One surface Compound Cavity- Two surfaces Complex Cavity- + Two surfaces

11

Baumes Classification:
Pit & Fissure Cavities Smooth Surface Cavities

12

Mount & Hume Classification:

Extent SITE Minimal 1 Moderate 2 Enlarged 3 Extensive 4

Pit & Fissure 1.1 1 Contact Area 2.1 2 Cervical 3.1 3

1.2
2.2

1.3
2.3

1.4
2.4

3.2

3.3

3.4

13

Conventional Concept of Cavity Preparation :

G.V. Blacks concept extension for prevention To prevent the recurrence of caries by placing the margins of

restoration along self cleansing areas.

14

CLASSIFICATION OF TOOTH PREPARATION

According to BLACKS CLASSIFICATION:
1.

Class I :- all pits and fissure restoration are class I , and are assigned to three groups. Restoration on occlusal surface of molars and premolars. Restoration on occlusal two thirds of the facial and lingual surfaces of molars.
15

 Restoration on lingual surface of

maxillary incisors.

2. Class II :Restoration on the proximal surfaces of posterior teeth. 3.Class III :Restoration on the proximal surfaces of anterior teeth that do not involve the incisal angles.
16

4. Class IV :Restoration on the proximal surfaces of anterior teeth that do involve the incisal edges.
5. Class V :Restoration on the gingival third of the facial or lingual surfaces of all teeth.

17

6. Class VI :Restoration on the incisal edge of anterior teeth or the occlusal cusp heights of posterior teeth.

18

INITIAL AND FINAL STAGES OF TOOTH PREPARATION

: in this stage, the mechanical alterations of the tooth extended to sound tooth structure while adhering to a specific , limited pulpal or axial depth.
Final tooth preparation:

this stage includes excavating any remaining ,infected carious dentin,removing old restorative material if indicated,protecting pulp.
19

 The stages and steps in tooth preparation are as

follows: Initial tooth preparation: Step 1. outline form and initial depth Step 2. primary resistance form Step 3. primary retention form Step 4. convenience form
20

Final tooth preparation:

Step 5. removal of any remaining infected dentin or

old restorative material,if indicated. Step 6. pulp protection, if indicated Step 7. secondary resistance and retention form Step 8. final procedures-cleaning , inspecting,sealing.

21

OUTLINE FORM AND INITIAL DEPTH

Definition:

it is the placement of the preparation margins in the position they will occupy in the final preparation, except for finishing the enamel walls and margins.it also includes preparing an initial depth of 0.20.5 mm pulpally beyond the DEJ.
22

 PRINCIPLES:
1)

Remove all friable or weakened enamel.

2) Include all faults 3) Place margins such that good finishing of the margins of the restoration is possible.

23

 FACTORS:

Certain factors affect the decision regarding the extent of the outline form . they are: Extent of the carious lesion, defect or faulty old

restoration.
Esthetic requirements which may affect the choice of

the restorative material and modify the cavity design.

24

 FEATURES:

Generally proper outline form may be established if the following features are incorporated: 1)Preserve cuspal strength. 2)Preserve marginal ridge strength. 3)Minimize faciolingual extension. 4)Use enameloplasty wherever possible.
25

5)Connect two close faults or tooth preparation(less than 0.5 mm apart)

6)Restrict the depth of the preparation into dentin to a maximum of 0.2-0.5mm.

26

 RESTRICTED AND INCREASED EXTENSIONS:

Condition that may warrant consideration of restricted

extensions for smooth surface caries are as follows:

i. ii.

Proximal contours and root proximity Esthetic requirements

iii. The use of some tooth preparations for composite

restoration.
27

 Condition that may necessitates increased extensions for

smooth surface caries are as follows

i. ii.

Mental or physical handicaps Advanced patient age

iii. Restoration of teeth as partial abutments or as units of

splints.
iv. Need to adjust tooth contours.
28

STEP 2: FORM.

PRIMARY

RESISTANCE

It may be defined as

the shape and placement of the preparation wall that best enables the restoration and the tooth to withstand, without fracture, masticatory forces delivered principally in the long axis of the tooth.

29

 PRINCIPLES:
THE FUNDAMENTAL PRINCIPLES INVOLVED IN

PRIMARY RESISTANCE FORM ARE AS FOLLOWS:

1.

To use box shape or mortise form with relatively flat floors.

2.
3.

Restrict the extension of the external walls.

To have slightly rounded angles.
30

4. To cap weak cusps and envelope or include enough of a weakened tooth with in the restration.
5. To provide enough thickness of restorative material

to prevent its fracture under load.

6. To bond the material to tooth structure when

appropriate.

31

Restorative material thickness Amalgam Cast gold Porcelain Composite

minimal

1.5mm 1-2mm 2.0mm 1-2mm

32

 FACTORS:
Certain factors affect the resistance form of

the preparation:

1)

Amount of occlusal contact

2) Amount of remaining tooth structure

3) Type of restorative material
33

 FEATURES:
The following features enhance primary resistance form: 1) Relatively flat floors 2) Box shape 3) Including all weakened tooth structure 4) Preservation of tooth and marginal ridges
34

5) Rounded internal line angles

6) Adequate thickness of the restorative material 7) Reduction of cusp for capping when indicated.

35

STEP 3. FORM
IT is

PRIMARY

RETENTION

the shape or form of the conventional preparation that resists displacement or removal of the restoration by tipping or lifting forces.
PRINCIPLES: the principles of primary retention form

varies according to the restorative material used

36

 For amalgam:

Occlusal convergence 2. Occlusal dovetail

1.

For composite resin: 1. Acid etching and bonding 2. Enamel bevels

37

 For cast metal

Close parallelism of opposing walls with a slight degree of occlusal divergence. 2. Occlusal dovetail
1. 1.

For direct filling gold: Elastic compression of dentin during condensation.

38

STEP 4.CONVENIENCE FORM:

It is

the shape or form of the preparation that provides for adequate observation , and ease of operation in preparing and restoring the tooth.

39

 FEATURES:
1.

Providing adequate width and lateral extensions for tooth preparation for all restorative materials. Refining line and point angles.

2.

3.

Providing proximal clearance from the adjacent tooth.

4. Occlusal divergence for cast gold inlays.

40

FINAL TOOTH PREPARATION STAGE

When the extensions and wall designs have fulfilled

the objectives of initial tooth preparation, the preparation is inspected carefully for other needs.
For most conservative restoration at this stage itself

may be complete except for final procedures.

However in case of extensive destruction additional

steps required.
41

STEP 5.REMOVAL OF ANY REMAINING ENAMEL PIT OR FISSURE,INFECTED DENTIN, OR OLD RESTORATIVE MATERIAL IF INDICATED
the elimination of any infected

carious tooth structure or faulty restorative material left in the tooth after initial tooth preparation.

42

 PRINCIPLES:

The deeper portion of carious dentin may generally exhibit two distinct areas:
1.

INFFECTED DENTIN: this is more superficial layer which is soft and leathery. High concentration of irreversibly denatured. Must be removed.
43

bacteria

and

collagen

is

2. AFFECTED DENTIN: this is the deeper layer,hard in consistency.

It does not contain bacteria and is reversibly denatured. Therefore this layer must be preserved.

44

 Removal of any old-restoration is indicated

if:

1) It would affect the esthetics of the new restoration 2) It may compromise the retention of new restoration 3) There is evidence of secondary caries

45

5) The pulp is symptomatic

6) There is marginal deterioration of the old restoration.
This may be done with a round carbide bur in

an airotar handpiece with air water spray at low speed

46

STEP6.PULP PROTECTION, IF INDICATED

This

is actually not a step in tooth preparation in the strict sense but since it is a step in adapting the preparation for receiving the final restoration it s considered under final tooth preparation.
step is achieved by the use varnish,liners,bases or bonding agents. of cavity

This

47

 The choice of the pulp protection agent is based on:

1)Extent of tooth destruction and preparation to the pulp. 2) Type of restorative material to be used

proximity of

48

 Liners and bases are applied without pressure in

exposure areas. It is recommended to have approximately a 1mm thickness of calcium hyroxide over near or actual exposure areas.
The varnish prevents penetration of material into

the dentin and helps to prevent micro leakage.

49

STEP 7. SECONDARY RESISTANCE AND RETENTION FORM

This step is necessary in case of compound and

complex cavity preparation where additional preparational features are required to improve resistance and retention form.

Secondary resistance and retention form features are of two

types:
1. Mechanical features 2. Conditioning procedures
50

1)

Mechanical features: these include the following:Retention grooves and coves

Groove extention
Skirts

beveled enamel margins

Pins, slots, steps and amalgam pins
51

2) conditioning procedures:
These include etching and bonding. These are employed for bonded restoration like glass

ionomers, composite or ceramic restoration.

52

STEP 8.FINISHING THE EXTERNAL WALLS OF THE PREPARATION

Finishing

the preparation walls is the further development, when indicated, of a specific cavosurface design and degree of smoothness or roughness that produces the maximum effectiveness of the restorative material being used.

53

 OBJECTIVES:
1.

To allow a smooth marginal junction between the restoration and the tooth. To provide close adaptation between the restoration and the tooth structure so that marginal seal is maintained. To provide maximum strength for both the tooth and the restorative material at and near the margins.
54

2.

3.

 FACTORS:

Certain factors decide the type of finishing necessary for the external walls:

1) The direction of the enamel walls 2) Support of enamel rods at the DEJ and at preparation

side
55

3) Choice of the restorative material

4) Location of the margin 5) Degree of smoothness desired.

56

 FEATURES: this vary according to the type of restorative

material employed:
1)design of the cavosurface angle For amalgam:- cavosurface or butt joint recommended.

For composite:- bevels are indicated.

.
57

2)Degree of smoothness or roughness of the wallthis also vary with the type of restorative material used

58

59

Morphologic considerations for pediatric operative dentistry

Shape of crown

60

 Enamel and dentin thickness

61

 Contact area between primary teeth

62

 Inclination of enamel rods

63

 Location of pulp horns

64

Class I Restorations
All pit-and-fissure restorations are Class I, and they are

assigned to three groups, as follows. Restorations on Occlusal Surface of Premolars and Molars Restorations on Occlusal Two Thirds of the Facial and Lingual Surfaces of Molars Restorations on Lingual Surface of Maxillary Incisors.

65

AAPD, 2008
Dental amalgam is recommended for:

1. Class I restorations in primary and permanent teeth; 2. Class II restorations in primary molars where the preparation does not extend beyond the proximal line angles; 3. Class II restorations in permanent molars and pre- molars; 4. Class V restorations in primary and permanent poste- rior teeth.
66

AAPD, 2008
Glass ionomers can be recommended as: 1. luting cements; 2. cavity base and liner; 3. Class I, II, III, and V restorations in primary teeth; 4. Class III and V restorations in permanent teeth in high risk patients or teeth that cannot be isolated; 5. caries control with:
a. high-risk patients; b. restoration repair; c. ITR; d. ART.
67

AAPD,2008
Resin-based composites are indicated for: 1. Class I pit-and-fissure caries where conservative pre- ventive resin restorations are appropriate; 2. Class I caries extending into dentin; 3. Class II restorations in primary teeth that do not ex- tend beyond the proximal line angles; 4. Class II restorations in permanent teeth that extend approximately one third to one half the buccolingual intercuspal width of the tooth; 5. Class III, IV, V restorations in primary and permanent teeth; 6. strip crowns in the primary and permanent dentitions. Contraindications: Resin-based composites are not the restorations of choice in the following situations: 1. where a tooth cannot be isolated to obtain moisture control; 2. in individuals needing large multiple surface restora- tions in the posterior primary dentition
68

Treatment modalities for Pit and fissure caries

69

Prophylactic odontomy
Recommended by Hyatt (1923)

70

Pit and fissure selants and PRR

71

Conventional cavity preparation

Amalgam Primary and permanent Composite restorations
Glass ionomer restoration

72

73

 Outline form: Include all carious pits

and fissures Include deep susceptible pits and fissures Overdestruction of cusps not acceptable Isthmus- to 1/3
Resistance form-Class I- atleast 0.5 mm

below DEJ Flat pupal floor when ever possible Rounded internal line angles Cavo surface margin- 90o
74

Cavity preparation for 1st primary molar-conservative amalgam Cavity Preserve central ridge
Try not to enter dentin untill

involved Slightly convergent walls Mesial pulp horns approximating DEJ

75

nd 2

primary molar- Mandibular

Occlusolingual or occlusobuccal cavity

may be formed

Preserve if possible- separate buccal and

lingual restorations

If buccal /lingual extension made-

converging occlusally with square external line angles dentin

Extension should be cut 0.5 mm into Include buccal developmental groove

76

2nd maxillary primary molaramalgam

Usually carious attack limited to central pit, distal pit,

mesial pit and grooves seperating them. Avoid crossing oblique ridge

77

78

79

Occlusal lesions in enamel onlyIncipient caries

Incipient pit & fissure

lesions can be prepared by using a no. 2 small, round or a no.330 bur to carefully remove the carious enamel. , 1/8 or 1/16 size according to the size of carious lesionFor enameloplasy Air abrasion can also be used

80

 Conditioning of enamel Gel/liquid etchant placed Washed with air water spray Enamel dried throughly (moist for acetone based adhesive) Primer and adhesive placed Placement of resin based composite: flowable

composite preferred over pit and fissure sealant Pit in centric occlusion restored with resin based composite

81

Occlusal lesion involving superficial to middle third of dentin depth

Preparation design: Outline- extent of lesion Carious dentin at base of lesion should be visible-convenience form Underlying enamel can be preserved
Carious dentin removed using round

bur and spoon excavator Sharp line angles avoided Flat ended fissure burs contraindicated Disclosing agents might be used
82

Choice of material
GIC- indicated in active lesions
Primary focus towards removal of soft caries Fluoride releasing properties considered

Minimal tooth destruction

RMGI or composite resin restorations indicated-

Larger lesions

83

 Conditioning of enamel Enamel should be dried- frosty white appearence Complete dehydration of dentin not recommended GIC base might be used as dentin replacement- to be place immediately after etchant befor bonding agent is placed Bonding agent- thin film, avoid pooling at base Placement of composite or compomer 2mm increment- 20 sec curing

84

Occlusal lesion Involving deep dentin

Indirect pulp capping might be required Calcium hydroxide base placed confined to

near exposure site phosphoric acid

If GIC used- Enamel conditioned using Dentin conditioned using polyacrylic acid Final bevel placed after GIC base placement

85

 Resin based Composite or compomer placed

86

Rebonding ofany remaining pits and restoration After polymerization

fissures might be filled using sealants or flowable composites.

Resin based composites and compomers in primary molars-DCNA 2000

87

Rationale for use of various material

88

Conclsion
Therefore , since the form of cavity preparation in

primary teeth is partly governed by their anatomy , newer materials with better adhesive properties are recommended so that minimal destruction of the tooth structure is required.
The more ideal materials are expected to have better

fluoride releasing properties , better aesthetics and a more functionally appropriate stress bearing strength

89

References
Pediatric Dentistry: A Clinical Approach by Goran Koch

Kennedy's paediatric operative dentistry by Martin E. J.

Curzon, J. F. Roberts, David Bernard Kennedy 4th ed

http://www.aapd.org/media/Policies_Guidelines/P_CariesRis

kAssess.pdf FDI statement. Minimal intervention in the management of dental caries. FDI general assembly 1 October 2002 Kreulen CM, van Amerngen et al. Two yeas results with box only resin compposite restorations.J Dent Child 1995;NovDec:395-39 Murdoch-Kinch C A, McLean M E. Minimally invasive 90 dentistry. J Am Dent Assoc 2003(Jan); 134:87-95

Mount GJ and Hume WR: Preservation and restoration of tooth structure. Mosby 1998; 121-154 Mount GJ, Hume WR. A revised classification of carious lesions by site and size. Quintessence Int 1997;28:301-303 Mount GJ. Minimal intervention dentistry: rationale of cavity design. Operative dent 2003;28:92-99 Mount GJ. Minimal treatment of the carious lesion. Int Dent J 1991;41:55-59

91

92