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CHAPTER 2
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Figure 2.2.7 Final restoration.
N. Prognosis andDiscussion
• Prognosis for caries is moderate due to the
patient’s moderate cariogenic diet and non‐ideal
oral hygiene. Prognosis could be improved with
reduction in soda frequency and improved oral
hygiene maintenance. Survival of the class II
restoration is good due to the low to moderate
caries risk and receptive acceptance of oral hygiene
instructions
O.
Complications andAlternative
TreatmentPlan
• If the patient had been classified as high risk, a
stainless steel crown would be considered more
appropriate. Likewise, if caries had extended to the
pulp, requiring pulp therapy, a stainless steel crown
would be the treatment of choice. Conversely, if the
patient had excellent oral hygiene maintenance and
the tooth could be isolated well, a resin‐based
composite could be considered as a restorative
material
40 Clinical Cases inPediatric Dentistry
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Self‐Study Questions
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RESTORATIVE DENTISTRY
1. A resin‐modied restoration would not be
appropriate for:
1. A low‐caries‐risk child
2. A moderate‐caries‐risk child
3. A high‐caries‐risk child
2. The proximal walls of a class II preparation in a
primary molar should:
1. Converge
2. Be parallel
3. Diverge
3. The cavosurface margin of a class II preparation in
a primary molar should:
Be beveled 0.5 mm
1.
2. Be beveled 1 mm
3.
Be beveled 2 mm
4. Not be beveled
4. Placing a primer adhesive prior to the placement
of a resin‐modied GIC:
1. Increases the compressive strength of the GIC
2. Increases the bond strength to tooth structure
3. Decreases the permeability of the GIC
5. A GIC setting reaction occurs over:
1. Five minutes
2. Ten minutes
3. One hour
4. 24 hours
Answers are located at the end of the case
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Self‐Study Answers
1. 3, A high‐caries‐risk child
2. 1, Converge
3. 4, Not be beveled
Bibliography
American Academy of Pediatric Dentistry. 2018–2019a. Prescribing
dental radiographs for infants, children, adolescents, and individuals with special health care needs. In: Clinical Practice
Guidelines and Best Practices (Reference Manual). Pediatr
Dent 40:213–15. https://www.aapd.org/research/oral‐health‐
policies‐‐recommendations/prescribing‐dental‐radiographs‐
for‐infants‐children‐adolescents‐and‐individuals‐with‐special‐
health‐care‐needs
American Academy of Pediatric Dentistry. 2018–2019b. Caries‐
risk assessment and management for infants, children, and
adolescents. In: Clinical Practice Guidelines and Best Practices
(Reference Manual). Pediatr Dent 40:205–12. https://www.
aapd.org/research/oral‐health‐policies‐‐recommendations/
caries‐risk‐assessment‐and‐management‐for‐infants‐children‐
and‐adolescents
4. 2, Increases the bond strength to tooth structure
5. 4, 24 hours
American Academy of Pediatric Dentistry. 2002. Pediatric
restorative dentistry consensus conference. Pediatr Dent
24(5):374–6.
Burgess JO, Walker R, Davidson JM. 2002. Posterior resin‐
based composite: review of the literature. Pediatr Dent
24(5):465–79.
Donly KJ, García‐Godoy F. 2002. The use of resin‐based com-
posite in children. Pediatr Dent 24(5):480–8.
Waggoner WF, Nelson T. 2019. Restorative Dentistry for the
Primary Dentition. In: Pediatric Dentistry: Infancy through
Adolescence, 6th edition. Nowak A, etal. (eds). Philadelphia:
Elsevier.
42 Clinical Cases inPediatric Dentistry
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Case 3
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Class II Resin Restoration
RESTORATIVE DENTISTRY
BA
Figure 2.3.1 (A, B) Facial photographs.
A. Presenting Patient
• Seven‐year‐, six‐month‐old Hispanic male
(Figure2.3.1)
• Presenting for a recall examination
B. Chief Complaint
• Mother stated, “He is here for his check‐up and he
has some cavities”
C. Social History
• Patient is in first grade
• Patient is only child
• Parents are married
• The father owns his own plumbing company; the
mother helps out with the business
• Socioeconomic status is mid‐level
D. Medical History
• Past history of rotovirus in December 2004. Patient
was hospitalized for two days due to dehydration. No
further complications
• Noncontributory medical history
• American Society of Anesthesiologists (ASA) I
classification
E. Medical Consult
• Not necessary
F. Dental History
• Fair oral hygiene (brushes twice a day; supervised
brushing, flossing)
• Tap water is fluoridated, uses fluoridated toothpaste
• High cariogenic diet
• Previous treatment was unable to be completed six
months ago due to uncooperative behavior. Parents
opted to defer treatment at that time
G. Extraoral Exam
• Within normal limits
H. Intraoral Exam
• Soft tissues are within normal limits
• Moderate plaque accumulation
• Oral hygiene is fair
• Early mixed dentition
• Maxillary left permanent lateral incisor is erupting; all
permanent first molars present
• Occlusion: bilateral class I molar relationship; bilateralclass
I canines; good spacing; overjet 1 mm, overbite 10%
FUNDAMENTAL POINT 1
Radiographic Guidelines forTransitional Dentition
• The American Academy of Pediatric Dentistry
(AAPD) recommends that a new patient with a
transitional dentition should have a radiographic
examination that includes posterior bitewings (if
contacts between the teeth are present) and a
panoramic radiograph or selective periapical
radiographs. See the AAPD radiography guidelines:
http://www.aapd.org/media/Policies_Guidelines/
E_Radiographs.pdf (AAPD 2018–2019a)
• The American Dental Association (ADA) also has
radiographic guidelines similar to the AAPD
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A
C
Figure 2.3.2 (A–C) Preoperative radiographs.
B
I. Diagnostic Tools (see Fundamental Point 1)
• Two bitewing radiographs and a periapical radiograph of
the mandibular right side (to evaluate possible pulpal or
furcation involvement of the mandibular right primary first
molar) showed multiple carious lesions (Figure2.3.2).
• The patient may have a panoramic film taken at a
future recall date
J. Differential Diagnosis
• Not applicable
K. Diagnosis andProblem List
Diagnosis
• Dental caries
Problem List
• High caries risk
• Fair oral hygiene
• Poor diet
• Irregular use of dental home
Comprehensive Treatment Plan
L.
• Establish a dental home
• Implement an at‐home and in‐office prevention plan
• Dental prophylaxis and fluoride treatment
• Treatment plan recommended:
◦ Sealants on all first permanent molars
◦ Maxillary right primary second molar (MO) resin
restoration
◦ Maxillary right primary first molar (DO) resin
restoration
◦ Maxillary left primary first molar (DO) possible
pulpotomy and stainless steel crown
◦ Mandibular right primary first molar (DO) possible
pulpotomy and stainless steel crown
Treatment
M.
Local Anesthesia
• Used 2% xylocaine with 1:100 000 of epinephrine
• Dosage for children is 4.4 mg/kg or 2 mg/lb
Rubber Dam Isolation
• Used a number 14 clamp, placed on the maxillary
right permanent first molar; individual punched
holeswere used to isolate the maxillary right primary
second molar for treatment (Figure2.3.3)
Cavity Preparation
• Cavity preparation is similar to a class II restoration for
amalgam with modifications
• Using a number 330 bur, the cavity was prepared in
the following manner:
◦ Begin preparation of the proximal box, moving the
bur in a pendulum motion from buccal to lingual
◦ Once gingival contact is broken with adjacent tooth,
check to see that the gingival margin is wider than
the occlusal margin
◦ After removing all caries, the axial pulpal line angle
is slightly rounded, and a dovetail extension is made
on the occlusal surface with the cavosurface
margins beveled
◦ The proximal box should not extend past the line
angles; if so, then a stainless steel crown is
indicated
◦ Using a T‐band matrix system, place the band
around the tooth, with a wedge securing the band
interproximally (Figure2.3.4)
Restoration
• After placement of the matrix band and wedge, etch
the tooth for fifteen to thirty seconds with 35–40%
phosphoric acid (Figure2.3.5)
• Rinse thoroughly for twenty seconds and dry
Figure 2.3.3 Rubber dam isolation.
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RESTORATIVE DENTISTRY
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Figure 2.3.4 Cavity preparation and matrix placement.
Figure 2.3.5 Etch with phosphoric acid.
Figure 2.3.6 Placement of dentinal bonding agent.
Figure 2.3.7 Light curing of resin restoration.
• Apply a dentinal bonding agent, carefully following
manufacturer’s instructions (Figure2.3.6)
• Apply resin composite material in increments, preferably no more than 2 mm of composite at a time.
Incremental curing of the composite reduces
polymerization shrinkage and ensures maximum
polymerization (Figure2.3.7)
Figure 2.3.8 Finishing of resin restoration.
Figure 2.3.9 Final restoration.
Finishing
•
A finishing carbide bur may be used to adapt the
occlusal anatomy, if needed (Figure2.3.8)
• Polishing can be completed with the use of enhancement points
• Use a sealant material to reduce occlusal wear and
seal the restoration. The additional light curing will
also help to obtain maximum polymerization of the
resin restoration (Figure2.3.9)
N. Prognosis andDiscussion
• Ideally, a sealant on the maxillary right first permanent
molar and a resin restoration on the maxillary right
primary first molar would have also been provided
during the same visit, but the patient’s level of
cooperation did not allow for further treatment
In this case, a resin restoration was performed instead of
•
a stainless steel crown, because of the small size of the
lesion and the fair patient cooperation. This patient is
considered a high caries risk. However, having effectively
instilled the importance of oral hygiene, recall examinations, good diet, and establishment of a dental home for
this patient, resin restorations were determined to be the
treatment of choice (see Fundamental Points 1, 2 and 3)
O. Complications andAlternative
TreatmentPlan
• If the behavior of the patient would have been poor,
making it difficult to isolate the tooth for a class II
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resin restoration, the alternative treatment would be a
stainless steel crown or a glass ionomer cement (GIC)
restoration
FUNDAMENTAL POINT 2
Guidelines fortheSelection ofRestorative
Materials
• The AAPD has recommendations regarding
theindications and contraindications of restorations
using resin‐based composites (AAPD 2018–2019b)
Indications
• Small pit‐and‐fissure caries in which conservative
preventive resin restorations are indicated in
both primary and permanent dentition
• Occlusal surface caries extending into dentin
• Class II restorations in primary teeth that do not
extend beyond the proximal line angles
• Class II restorations in permanent teeth that
extend approximately one‐third to one‐half the
buccolingual width of the tooth
• Class III, IV, V restorations in primary and
permanent teeth
• Strip crowns in primary and permanent dentition
FUNDAMENTAL POINT 3
Rationale forMaterial Selection
• The mesio‐occlusal lesion in this patient was
restored with a class II resin‐based composite
restoration. If there was difculty in isolating the
tooth, with the moderate caries risk status of the
child, a resin‐modied GIC would be chosen
rather than a resin‐based composite. Saliva
contamination causes the tooth/resin interface
bond to be compromised, with subsequent
restoration failure with resin‐based composite
restorations. GIC can still chemically cure in the
presence of minimal contamination. The uoride
release from the GIC can aid in inhibiting tooth
demineralization at restoration margins in this
moderate‐caries‐risk patient. According to the
Pediatric Restorative Dentistry Consensus
Conference, primary teeth can be effectively
restored with resin‐modied GIC Class II restorations (AAPD 2002)
Contraindications
• In cases in which a tooth cannot be isolated to
obtain moisture control
• In individuals who need large multiple surface
restorations in the posterior primary dentition
• In high‐risk patients with multiple caries and/or tooth
demineralization and who exhibit poor oral hygiene,
and when maintenance is considered unlikely
46 Clinical Cases inPediatric Dentistry
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Self‐Study Questions
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RESTORATIVE DENTISTRY
1. In the cavity preparation for primary teeth, is the
cavosurface margin beveled?
2. Are retention grooves placed in a class II
preparation for primary teeth?
3. If the cavity preparation extends past the line
angles, what type of restoration should be placed?
4. How long should primary teeth be etched?
5. Should the class II resin restoration receive
additional light curing after polishing?
Answers are located at the end of the case
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Self‐Study Answers
1. Yes
2. No
3. Stainless steel crown
Bibliography
American Academy of Pediatric Dentistry. 2002. Pediatric
restorative dentistry consensus conference. Pediatr Dent
24:374–6.
American Academy of Pediatric Dentistry. 2018–2019a. Prescribing
dental radiographs for infants, children, adolescents, and individuals with special health care needs. In: Clinical Practice
Guidelines and Best Practices (Reference Manual). Pediatr
Dent 40:213–15. https://www.aapd.org/research/oral‐health‐
policies‐‐recommendations/prescribing‐dental‐radiographs‐for‐
infants‐children‐adolescents‐and‐individuals‐with‐special‐
health‐care‐needs
4. Fifteen to twenty seconds
5. Yes
American Academy of Pediatric Dentistry. 2018–2019b. Caries‐risk
assessment and management for infants, children, and adolescents. In: Clinical Practice Guidelines and Best Practices
(Reference Manual). Pediatr Dent 40:205–12. https://www.
aapd.org/research/oral‐health‐policies‐‐recommendations/
caries‐risk‐assessment‐and‐management‐for‐infants‐children‐
and‐adolescents
48 Clinical Cases inPediatric Dentistry
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Case 4
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Class V Glass Ionomer Restoration
Social History
A
C.
• Patient attends preschool
• Enjoys playing with his friends and younger sister
•
Parents are married and both work
D. Medical History
• Not contributory
RESTORATIVE DENTISTRY
B
Figure 2.4.1 (A, B) Facial photographs.
E. Medical Consult
• Not applicable
F. Dental History
• First dental visit
• Optimal water fluoridation levels (0.7 ppm)
• Brushes teeth by himself
• High cariogenic diet
• Parent does not expect patient to be cooperative
G. Extraoral Examination
• Within normal limits
H. Intraoral Examination (Figure2.4.2)
• Moderate plaque accumulation
• Mild gingivitis
A. Presenting Patient
• Three‐year‐, eight‐month‐old male (Figure2.4.1)
• New patient dental examination
B. Chief Complaint
• Parent states, “I am concerned the stains on his front
teeth may be cavities”
Figure 2.4.2 Preoperative photograph.
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