UMA

RESTORATIVE TREATMENT
SUMMARY

Main focus:
1. Prevention (Diet, Brushing, Preventive material)
2. Conservative treatment
3. Esthetic where applicable

Oral hygiene

CARIES
Opportunistic bacteria metabolizes sugar → acid → breakdown of enamel and dentine

Sucrose (glycolysis ) → fructose + glycan ( glucose variant ) → lactic acid and adhesion of S.
Mutans + adhesion and creation of acidic environment

Oral flora = most dangerous bacteria

Reason = cause in many diseases when immunity down ( corona patients died from pneumonia
caused by oral flora )

Indications

White spots

Restoration in 3 year old patients ( high caries risk )

Caries management (according to ICDAS CLASSIFICATION)

1. Microbial control ( salivary control ( preventive ) )

2. re-mineralization, resin infiltration, SDF ( initial caries )
3. MI restoration, defect specific GI or resin ( moderate caries )
4. Traditional operative dentistry ( sever caries )
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Carious teeth:

Caries classification:

Active caries= NO intervention only preventive measures

Active caries + cavitation = Micro invasive (intervention according to classification)
1. Type 1 classification = Clinically uncertain
2. Type 2 classification (CLINICALLY UNCLEAR)

E1 = OUTER HALF OF ENAMEL

E2 = INNER HALF OF ENAMEL

3. Type 3 classification (clinically certain)

D1 = DEJ involvement (mixed intervention (preventive and restorative))
D2 = OUTER DENTINAL HALF
D3 = INNER DENTINAL HALF

Dentine situation:

INFECTED DENTINE AFFECTED DENTINE

 Weak soft structure  Inner affected dentine vital
 High moisture content  Re-mineralization
 High level of bacteria  Low level of bacteria
 MMP enzyme active  Sensitive
 No sensation  Can be used for inter-dentine
diffusion
 Bacterial invasion  Help In creation of reactionary
dentine
 Not useful dentine  Salvageable
 No mineralization  Help prevent recurrence of caries
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Dentine types:

Reactionary sclerotic

Moderate caries Sever caries

Deposits of Odontoblasts deposit of Odontoblast like structures

Not pulp involved pulp involved

Discontinuity in tubular Dentine no tubular dentine present in area → no permeability

→ lower permeability

Affected Dentine: prevents composite adhesion to walls hence walls are cleared of all
carious lesion (affected dentine and infected all removed)(clean sound walls) for resin tags and
composite adhesion.

Cavity floor: affected dentine left for the development of reactionary dentine.

MMP:
MATRIX METALLOPROTEINASES ENZYMES

 Cause of degradation of dentine

 Present in dentine inactivated
 Activated by acid from demineralization of enamel reaching dentine or acid etchin used
in restoration reaching the dentine.
 Can be Deactivated by Chloro-Hexidine / Sodium Hypochlorite

NOTE FOR SUGAR

MOST DANGEROUS ADDICTIVE SUBSTANCE DUE TO HIGH RELEASE OF DOPAMINE COMPARED

TO (COCAIN)

Addiction begins neonatal

Fructose ↑= vitamin D ↓ Cause fatty liver in kids (liver cirrhosis (drinker’s liver) in adult)
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SOLUTIONS :
1. Preventive:
 Saliva Flush (Bacteria)

1. High buffering capacity (neutralize acid)

2. Re-mineralization

Action

While sleeping, action of washing occurs.

Also

Warning: while sleeping, insoluble glycan formed (production of extracellular polysacch.

Forming enhanced De-mineralization.

 Brushing

1. Remove insoluble glycan cover

2. Massage gingiva (better for gingiva health)

 Application of fluoride varnish or sealants

1. Protection of teeth from caries via Fluorapatite crystals formation

2. Sealants prevent impaction of food and formation of acids

2. MECHANICAL (INTERVENTIVE)

Restorative treatment
 SSC ( WETHER FOR PREPARATION OR HALL TECHNIQUE )
 GI CEMENT
 RESIN MODIFIED GI CEMENT
 VERITISE FLOW
 BIOACTIVE GIOMERE
 SDF
 AMALGAM
 MONOCALCIUM PHOSPHATE
 RENEWAL MI
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TO ACQUIRE OPTIMUM RESULTS IN EPDIATRIC DENTISTY:

 EARLY DETECTION
 ACCURATE DIAGNOSIS/ CARIES ACTIVITY DETERMINED OVERTIME
 MONITORING BY RADIOGRAPH
 REGULAR CHECKUPS

Requirements of dental materials in Pediatric Dentistry

Dentists:

 No local anesthesia required

 Minimum moisture control (no rubber dam required)
 No sensitive technique involved (easy to place and manipulate)
 Good biocompatibility
 Good seal
 Good bond to dentine (penetration)
 Re-mineralization
 Strengthen tooth (preserve tooth)
 Adequate working time/ short setting time
Note:
Usually dentists promote selective caries removal hence opt for selfetching/
adhesive restorative material
Dentists also have to use good instruments for a successful operation.

Child: (most children get caries at the age of 6 Embarrassing age)

 Acceptable/white
 No water
 No drilling
 Strong filing (no pain/discomfort while eating )
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RESTORATION: (SEAL IS THE DEAL)
AIMS:

1. HARD TISSUE PRESERVATION

2. MAINTAIN FUNCTION
3. RESTORE ESTHETICS WHERE POSSIBLE

DURING RESTORATION:

The following should be considered:

Total Etch > Self Etch (left for 7 seconds in children)

SMEAR LAYER

Etch → Water wash → Light drying → tubules not too dry or wet (water as guide for
penetration) WATER BONDING TECHNIQUE!!!

MINIMAL INVASIVE DENTISTRY

1. USE OF FLUORIDE
2. MAINTAIN ORAL HYGIENE
3. STOP INFECTION OR REDUCE ACTIVITY
4. REDUCE RE-INFECTION

TECHNIQUE OF PREPARATION

1. Step wise technique

2. Complete caries removal
3. Selective caries removal

Selective caries removal technique (leaving affected dentine)

Definition= peripheral enamel and dentine removed to allow tight seal and durable restoration.

Removal of soft dentine, GI at the base, no further tissue removed, followed by a complete
resin restoration.

Reduces pulp exposure risk significantly compared to non-selective removal caries.

GIC fluoride kills bacteria of remaining caries forming fluoride enhanced arrested caries.
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Light cured GIC or warming GIC helps in fast setting.

Phosphoric acid for 5s (37%) removing debris and oil of hand piece improving bond

Indications contraindications

1. Interim measure to manage dentine caries Irreversible pulpitis

2. Mid technique un-restorable teeth
3. ART= Atraumatic restorative treatment

Mechanical removal chemo-mechanical

Burs carisolv(papaya) agent that breaks

Hand excavation down collagen, degrading and

Air abrasion eliminating carious lesion leaving

Affected dentine

Complete caries removal

The removal of all carious lesion from all walls and floor till sound dentine is reached, rarely
used in nowadays dentistry.

Step wise technique

Step wise technique is similar to selective caries removal in everything except that it is done in
two steps and two visits where a secondary excavation of caries occurs on the second visit until
only hard dentine remains.

1.FLUORIDATION

DURAPHAT Material is the only international accredited fluoride varnish.

AGE 0-2 / 1000 PPM / TWICE DAILY / 0.125g / grain of rice

AGE 2-6 / 1000 PPM / TWICE DAILY / 0.25g / pea sized

AGE 6-↑ / 1450 PPM / TWICE DAILY / 0.50g to 1.0g / full brush

2.SEALANTS

Prevention and arresting incipient lesions require charging by brushing to give fluoride to
sealant, doesn’t heal caries but stops progression
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RESIN INFILTRATION = for whiter spots on lateral carious lesions as a type of seal (smooth
surface caries).

Procedure of RESIN INFILTRATION =

1. 15% hydrochloric acid for 90-120 seconds

2. Remove 45 micron from lesion surface
3. Resin infiltration = occluding porosity caused by lesion (prevention)

3.ICON

Applied for 3 minutes

414 micron infiltration into non-cavitated inter-proximal lesion

Bleaching area allows good adaptation (2mm all around)

If lesion colour doesn’t disappear, 4 rounds of etchin can be done, not more to avoid
sensitivity, if till present polishing is advised to remove it.

4.CUROLOX (LIKE ICON)(CURODENT)

Indications

White spots

Decalcification

Demineralization

5.KAREX

For cavitated smooth surface caries/ hydroxyapatite/peptide bonding/ calcium & phosphate
deposition

6.SDF (SILVER DIAMINE FLUORIDE)

INDICATIONS CONTRA-INDICATION
CAVITATED DENTINECARIES IRREVERSIBLE PULPITIS
ANTERIOR AND POSTERIOR TEETH ALLERGY TO SILVER OR HEAVY METALS
HIGH CARIES RISK ACTIVE ORAL ULCER
EARLY CHILDHOOD CARIES/UNCO-OPERATIVE STOMATITIS/ MUCOSITIS
CHILD
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FUNCTION

SDF → AG (SILVER) →PROTIEN + MINERAL = SILVER PROTIEN +SILVER PHOSPHATE+

→ F → MINERAL CALCIUM FLUORIDE

EFFECTS OF SDF

 BACTERIOCIDAL
 PLAQUE CONTROL
 ANTI-ENZYMIC (MMP)
 PREVENT DEMINERALISATION
 INCREASE HARDNESS
 OCCLUSION OF TUBULES
 REMINERALISATION
 ADHESIVE OF CEMENT TO TOOTH

Effect of FLUORIDE IN SDF

 Deep penetration
 Fluoride reservoir
 Alkaline environment = ↓for enzyme activation

Mechanism

1. Silver occlude D.T.

PREVENT ACID AND BACTERIA INTO D.T.

DEGRADATION/ DEMINERALIZATION ↓↓

2. SILVER PHOSPHATE
AG3PO4 CLOSE D.T.

Warning: SDF can cause inflammation in GIT = diarrhea, Kidney problems, Vomiting

Nano-particles of silver profuse into bacterial enzymes and promote lysis (cell death)
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Clinical applications of SDF

1. To arrest root caries and prevent secondary caries.

2. To desensitize sensitive teeth
3. To prevent pit and fissure caries
4. Extreme caries risk patients (ecc/xerostomia)
5. Behavioral or medically compromised patients

Restorative materials (interventive)

1. SSC(STAINLESS STEEL CROWNS)

Top restorative choice by success.

Halls technique

INDICATIONS CONTRA-INDICATIONS
NO SUFFICIENT CO-OPERATION FOR CAVITY PULP NECROSIS/ IRREVERSIBLE PULPITIS
PREPARATION
PRIMARY MOLAR UNRESTORABLE TOOTH
SUFFICIENT TOOTH TISSUE TO RETAIN CROWN INSUFFICIENT CO-OPERATION
CLEAN BAND OF DENTINE BETWEEN LESION NICKEL ALLERGY
AND PULP ON RADIOGRAPH
HYPOPLASIA/HYPOCALCIFICATION/
DEVELOPMENTAL DEFECTS
PERMANENT/PRIMARY CARIESOR
DECALCIFICATION
RESTORING PRIMARY TOOTH FOR SPACE
MAINTAINER
FOLLOWING PULPOTOMY/PULPECTOMY
HIGH CARIES RISK PATIENTS

TOOTH SEPERATOR OR ORTHODONTIC BANDS ARE USED PRIOR TO TREATMENT AND

AIRWAY PROTECTED
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GIC
HYDROPHILIC/ Protect, adhere, seal/ dentine replacement materials.

Alone GIC not strong → solution= should be covered by resin for strength and aesthetics

Advantages

Fluoride releasing for protection and prevention

Interim therapeutic restorations and ART (for young uncooperative patients) Bond strength to
tooth in case of good seal.

Good biocompatibility (similar to dentine)

Disadvantages

Inadequate cavity → lack of retention → failure (2 surfaces only)

Moisture sensitivity

Brittle

Poor wear resistance

RESIN-MODIFIED GIC

1 Chemical bonding to enamel

2 Thermal Expansion similar to dentine

3 Bio-compatibility

4 Uptake and release of fluoride

5 Decreased moisture sensitivity

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Steps for success
1. Lesion cleaning
2. 20% polyacrylic acid for 10 seconds
3. Rinse water and dry
4. Matrix ridges if needed
5. Mixing GIC for 10 seconds and application
6. Quick application and remove excess/↑ in temperature → ↓working time
7. Excess manipulation of GIC after crosslinking lose glass
8. Checkup after 6 months maximum 9 months or a year

AMALGAM
USED TO BE THE MOST COMMON USED RESTORATIVE MATERIAL

Now prohibited from use due to mercury especially pregnant woman

Overtime use in pediatric dentistry is not accepted.

RESIN RESTORATIONS

Resin based composites

Filler content particle size

Filled/unfilled micro filled(esthetic, polish ,below GIC in flowable form,

Interdentine diffusion)

Flowable/packable macro filled(posterior focus due to high wear resistance, low

esthetics/polish)

Anterior/posterior hybrid(combination=↑esthetic+↑wear resistance )

Note: Composites are known to be very dependent on isolation which is difficult in children
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INDICATIONS

Pit and fissure

Class I into dentine

Class II in primary teeth not extending beyond proximal line angles

Class II restorations in permanent teeth extending to ½ or 1/3 or Buccolingual width of teeth

Class III,IV,V in primary and permanent teeth

Strip crowns in both.

CONTRA-INDICATIONS

Tooth isolation impossible

Multiple → surfaces in posterior primary tooth

High risk patients with defects

Multiple caries, tooth demineralization, exhibiting poor hygiene, un-cooperative patient,

maintenance unlikely in composite restorations.

Dis-advantages

Bonding failure

Shrinkage/leak

Poor dentine wetting

Water sorption low monomer ionization

Doesn’t deactivate MMP

Etchin/collagen degradation (risk of MMP activation)

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Solution:
Reinforcing resin with Ribbond
Mesh network

Prevents voids, leakage, sensitivity, defects

Bioactive giomere
Base below giomere is GIC

Fluoride and strontium hydroxyapatite → fluoroapatite and strontium apatite

Has a neutralization effect against acid.

Reinforcing effect due to fluoroapatite effect

Bacteriostatic= prevent bacterial adhesion → less plaque

Sensitivity control

Activia bioactive
Ionic bioactive resin modified GIC

Moisture friendly

Seal

No secondary caries (good seal)

Durability more than composite

Needs etch and bond

Bacteriostatic

Re-mineralization

A very good amalgam alternative

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CENTION N
Alkalsites group

Stronger than GIC

Esthetic ↑ compared to GIC or Amalgam

Time saving (4 steps)

Permanent restoration of class I/II

Restoration primary still in testing not a definitive effect (relatively new)

Vertise flow
Self adhesive (flowable composite)

No bond needed (Also Relatively no incremental packing (first layer then second layer is final)

Initial layer 0.5mm thick.

Post-op sensitivity ↓

5 seconds of air on cavity after normal preparation then applied without tight moisture control
needed

Paint brush used to thin it out

Polishing done afterwards

Renewal MI (SSC ESTHETIC REPLACEMENT)

SINGLE STEP TECHNIQUE(ETCH,BOND,COMPOSITE IN ONE)

IN PRIMARY TEETH

No LA required

No Etch

No Bond

SCR technique
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POLYLYSINE

FDA approved composite

Promote composite penetration

Absorb water

Tag formation

MMP Inhibitor

MONOCALCIUM PHOSPHATE

Added to composite promotes swelling and precipitation of apatite crystals at tooth restoration
interface.

Used in bone cement and food

Self-etching and resin tags

Volume expansion and resin tag formation to seal cracks and gaps

Mineral perception inhibits enzyme

DENTINE BONDING AGENTS

Hydrophilic and hydrophobic component cause positive influence on bond strength

Smear layer,etch

ENAMEL ADHESIVE OR BONDING AGENT

Hydrophobic resin BIS-GMA

HYBRID LAYER – COPOLYMERISED LAYER OF PRIMER, BONDING RESIN AND COLLAGEN

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The operating protocol of diagnosis and prevention
American

Existing lesion prevention

Tooth structure preservation

Conservative

Aims

 Preservation of tooth/conservative caries preperation

 Prevent caries
 Dental health preservation
 Clinical risk
 Caries process lesion activity

British system

4D system

DETERMINE = history/complaint

DETECT = Risk (clinical and radiographic)

Caries experience categories

Plaque/stages

DECIDE = Activity/severity

DO = Caries care plan, tooth preserving, operative care, check-ups and monitoring

Identification of disease

Disease process

Initial caries management

Appropriate preventive measures

Restorative therapy when indicated

Decision to restore (visual Detection)

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Radiographic Detection

Conclusion
Untreated children caries issue.

Current material requires time and skills.