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The Ohio State University College of Dentistry Division of Pediatric Dentistry and Community Oral Health Pediatric Dentistry 6551 __________________________________________________________________________________________ Course Syllabus Summer 2012 Pediatric Dentistry is an age-defined specialty that provides both primary and specialty comprehensive preventive and therapeutic oral health care for infants and children through adolescence, including those with special health care needs. PEDIATRIC DENTISTRY 6551 INTRODUCTION TO PEDIATRIC DENTISTRY July 5, 2012 8:30-9:20 Introduction/ Prevention and Oral Hygiene Dr. Griffen 9:30-10:20 Fluorides I Dr. Griffen 10:30-11:20 Fluorides II Dr. Griffen Pediatric Dentistry: Ch. 14: 220-233 Ch.19: 313-323; Ch.31: 513-519; Ch.38: 690-694 July 6, 2012 7:30-8:20 Restorations in the Primary Dentition I Dr. Griffen Pediatric Dentistry: pages 341-356 8:30-11:30 LAB: Resins 12:30-1:20 Restorations in the Primary Dentition II Dr. Griffen Pediatric Dentistry: pages 357-363 1:30-4:30 LAB: Stainless Steel Crowns July 13, 2012 7:30-8:20 Pulp Therapy in the Primary Dentition Dr. Gosnell Pediatric Dentistry: pages 381-391 8:30-12:00 LAB: Pulpotomy 12:10-12:50 Clinic Orientation *LUNCH PROVIDED* Dr. Gosnell 1:00-4:30 LAB: Practical July 16, 2012 4:30-5:30 PM Final Exam Room 1187 Pediatric Dentistry 6551 Introduction to Pediatric Dentistry Summer 2012 Course Director: E. Gosnell, DMD, MS Office: 4126 Postle Hall Telephone: 292-9573 Office Hours: By appointment Course Description Pediatric Dentistry 6551 is an introduction to Pediatric Dentistry. It is a .5 credit hour course. The areas of emphasis are prevention and management of dental caries in the primary and young permanent dentition. The course includes lectures and laboratory sessions on restorative techniques for primary teeth. Course Objectives At the completion of this course, the student should have the basic knowledge necessary to provide restorative dental care to pediatric patients including fluoride therapy, diet counseling, oral hygiene care, sealants, conservative resin and amalgam restorations, and stainless steel crowns. Course Format The course will consist of seven one-hour sessions with assigned reading for each lecture. In addition there will be 4 laboratory sessions with reading material in the syllabus assigned for each laboratory session. Finally, there is a final exam and will be held on Monday, July 16 4:30-5:30 in Postle Hall Room 1187. The final exam may consist of multiple choice, matching, short answer, and/or identification. Course Textbook Each student is expected to purchase a copy of the course textbook. There will be assigned readings and test material will come from these readings. The text is: Pediatric Dentistry: Infancy through Adolescence. 4th Edition, Pinkham JR, Casamassimo PS, Fields HW, McTigue DJ and Nowak AJ., Elsevier Co. Evaluation Grading is based 95% on the final exam, but also requires successful completion of all laboratory exercises. If all of the instruments, supplies and all typodont teeth are not replaced at the end of the laboratory sessions, grades will be lowered 1 full grade (i.e from an “A” to a “B”). The remaining 5% of the final grade is dependent on completion of the course SEI (Student Evaluation of Instruction online). Absences Due to the nature of this course, the following will be enforced; A. Any student missing a portion of lab for an excused reason (to be discussed directly with Dr.Gosnell – these are limited to; birth, death or illness requiring medical attention) will be given a tentative grade of “I” until deficient portion of the course is completed through arrangements with Dr. Gosnell directly. B. Any student missing a portion of lab for an unexcused reason will be given a final grade of “I” and will be required to take the entire course (lecture and laboratory) in July 2013 to receive full credit. Academic Misconduct Students are reminded that all graded work is to be solely their own. Academic misconduct is a very serious offense. Faculty Rule 3335-5-54 will be followed for this course which states "Each instructor shall report to the committee on academic misconduct all instances of what he/she believes may be academic misconduct." Students are expected to adhere to the College of Dentistry Code of Professional Conduct. Laboratory Safety and Infection Control Protocol “Proper infection control and safety protocols to be followed in the pre-clinical laboratory include the following: wearing protective eyewear when working with any hazardous chemicals or laboratory equipment that could cause eye injuries, wearing masks (and using ventilation system) during any procedure that involves generation of dust or an aerosol, wearing gloves while handling any hazardous materials and following the OSU dress code policy in the pre-clinical laboratory as stated in the College’s Dress Code. This protocol will be monitored and enforced by course faculty to ensure compliance.” GENERAL INFORMATION PEDIATRIC CLINICAL DENTISTRY Division of Pediatric Dentistry and Community Oral Health 292-1509 Division Chairman Dr. Paul S. Casamassimo Children's Hospital or 4132 Postle Hall 292-1509 Pre-Doctoral Program Director Dr. E. Gosnell 4126-B Postle Hall 292-9573 Post-Doctoral Program Director Dr. Homa Amini Children's Hospital 722-5651 Faculty - Full Time Dr. Ann Griffen 4126-A Postle Hall 292-1150 Dr. Ashok Kumar Children’s Hospital 722-5649 Dr. Dennis J. McTigue 4140 Postle Hall 292-0898 Dr. Megann Smiley Children’s Hospital 722-5651 Dr. Diego Solis Johnstown/Nisonger 475-0564 Dr. S. Thikkurissy 4126-C Postle Hall 292-1788 Clinical Faculty - Part Time Dr. F. Thomas Hagman Dr. Gerald Kassoy Dr. Kara Morris Dr. Cecilia Moy Office Associate Mrs. Gretchen J. Hollern 4126 Postle Hall 292-1509 Clinical Staff Mrs. Peg Greek Mrs. Dorothy Harold Clinic Phone Number 292-2027 Clinic Hours of Operation M, T, F: 8:30 -11:30 1:00 - 4:30 Th: 9:30 – 11:30; 1- 4:30 W: 1:00 - 4:30 The Ohio State University College of Dentistry Section of Pediatric Dentistry Pediatric Dentistry 6551 (Pre-Clinical Laboratory) ____________________________________________________________________________________________________ Course Syllabus Summer 2012 Course Syllabus Summer 2012 TABLE OF CONTENTS Dentistry 6551 Summer Semester Course Outline Schedule of Laboratory Exercises Instructor and Student Assignments Pediatric Rubber Dam Application Conservative Class I Restorations (Posterior ) Class II Composite Preparations in Primary Molars Pulpotomy and Stainless Steel Crown Procedures for Primary Molars LABORATORY DIRECTOR: E. Gosnell, DMD, MS LAB DESCRIPTION Pediatric Dentistry 6551 includes a preclinical laboratory series emphasizing selected techniques unique to Pediatric Dentistry. The teaching format of the course consists of lecture material, interaction with the laboratory instructor and performance of the techniques on dentoforms. LAB GOALS: 1. To develop knowledge, experience, and technical skills necessary for appropriate restoration and preventive procedures for the child patient. 2. To develop the ability to objectively self-critique clinical work and determine levels of satisfactory (clinically acceptable) work. LAB OBJECTIVES: 1. Diagnose and formulate a treatment plan for the treatment of incipient to major dental caries. 2. Understand the indications for the techniques used in the prevention of dental caries. 3. Understand the indications for the techniques used in the restorative treatment of dental caries. 4. Diagnose and formulate a treatment plan for the treatment of pulpal pathology. 5. Understand the indications for the techniques used in the treatment of pulpal pathology. LAB SCHEDULE: There will be 4 laboratory sessions which will meet as indicated on the master schedule. A practical examination, consisting of a class II resin preparation and a stainless steel crown preparation and adaptation, will be given as a self-paced practical. You and your row instructor will determine when you are ‘ready to take’ the practical. TEXTBOOK(S) AND READING: Reading assignments for this course will come primarily from this syllabus, but the textbook Pediatric Dentistry: Infancy Through Adolescence, Pinkham et al, 4th Edition, Saunders Co., 2005, is the required textbook for ALL pediatric courses, and there will be some assigned readings. Students are expected to have a copy. EVALUATION AND GRADING: To complete the laboratory portion of the course the student must complete all laboratory work at a satisfactory level as judged by his/her lab instructor's evaluation. The evaluation criteria for all lab work are listed on evaluation forms included in this syllabus. In addition a practical exam will be given at the completion of the lab course. POLICIES AND PROCEDURES: For the exercises that are performed on the typodont, if a student significantly deviates from clinical acceptability (a critical error) with their preparation he/she may be asked to re-do the preparation. There is no grade penalty for repeating a procedure. Lab work may NOT be completed outside of scheduled time. There will be sufficient time in the lab to complete all of the necessary work. Schedule of Laboratory Exercises July 6 7:30-8:20 Lecture Introduction/Restorations in the Primary Dentition I, Room 1187 8:30-11:30 Lab I Class I/ II Resin Restorations # I (DO) # A (MO) #30 (O) 12:30-1:20 Lecture Restorations in the Primary Dentition II, Room 1187 1:30-4:30 Lab II # J (SSC) #S (SSC) July 13 7:30-8:20 Lecture Pulp Therapy in the Primary Dentition, Room 1187 8:30-12:00 Lab III #B (Pulpotomy and SSC) Continue #I,A,30,J,S Self-paced practical** 12:10-1:00 Clinic Orientation: Lunch provided 1:00-4:30 Lab IV Continue #I,A,30,J,S,B Self-paced practical** **Self paced practical as determined by bench instructor** RUBBER DAM PLACEMENT th READING ASSIGNMENT: Pediatric Dentistry: Infancy through Adolescence, 4 Edition, chapter 20, pages 343-345 and syllabus material OBJECTIVES: The student should be able to: 1. State several advantages of the use of the rubber dam in children. 2. State several contraindications for use of the rubber dam. 3. State which rubber dam clamp should be used for: --partially erupted 1st permanent molars --fully erupted 1st permanent molars --second primary molars --first primary molars 4. State how far apart the holes should be punched on a rubber dam, and describe what will happen if holes are too close together. Too far apart? 5. State the number of teeth to be isolated when doing a one surface restoration. A multi-surface restoration? 6. State the appropriate patient/operator positions for placing a rubber dam. 7. Explain the advantages and indications for a slit-technique for rubber dam placement. 8. Be familiar with successful placement criteria of the rubber dam. RUBBER DAM APPLICATION IN PEDIATRIC DENTISTRY The rubber dam is used for virtually all restorative procedures in pediatric dentistry. It is placed prior to cavity preparation and usually left in place until the final restoration has been completed. There are a number of advantages for the use of a rubber dam in children. 1. Great accessibility and visibility: a. retracts soft tissue; b. provides dark contrasting background; 2. Control of moisture; 3. Decreased operating time; 4. Enhances the quality of work; 5. Protects the soft tissues and prevents swallowing of dental instruments; 6. Improved infection control; 7. Improved patient management. Contraindications: 1. Bands on teeth 2. Patients with poor nasal airway exchange 3. Patients with allergy to latex (if non-latex dam is not available) 4. Rubber dam clamp cannot be retained due to eruption state of the tooth Armamentarium: --Dark, medium gauge 6"x6" or 5"x5" dam material --Rubber dam frame --Clamps #14, #7 - for erupted 1st permanent molar #14A, #8A - for partially erupted permanent molars #3 - for second primary molars #2 - for premolars and first primary molars --Rubber dam punch --Rubber dam forceps --Scissors --Waxed floss --Cotton pliers Hole Placement: --Use a template --Dividing the dam in sixths --Holes are placed 3.5 mm apart a. If placed too close together, the dam will leak b. If placed too far apart, the dam will fill the interproximal embrasures Rules for Isolation: 1. Single tooth isolation is permissible for sealants and one surface restorations with one exception. Because first primary molars are difficult to clamp, the second primary molar should be clamped and both molars isolated. 2. When restorations involving proximal surfaces or crowns are to be done, at least one tooth anterior and one tooth posterior to the tooth to be restored should be isolated (when available). 3. Holes for maxillary anterior teeth are punched 1" from the top border of the dam material. Isolate canine to canine. 4. Holes for mandibular anterior teeth are punched 2" from the lower border of the dam material. Isolate canine to canine. 5. A floss safety must always be placed on a rubber dam clamp before trying in onto a tooth. Patient Positioning: The patient should be in a supine position with the operator at the 11 o'clock position. For maxillary teeth, ask the child to "put her or his chin toward the ceiling" for the best visibility. Application Techniques: 1. Placement of clamp, then dam and frame are placed over the clamp. This method is preferred because of the good visibility it allows the operator of the tooth to be clamped and of the gingival tissue. 2. Placement of clamp, dam and frame as a unit. This method may be used, however, visibility of the tooth to be clamped is greatly reduced over method 1. Possibility of soft tissue impingement is most likely with decreased visibility. 3. Slit technique. Is used in pediatric dentistry when it is anticipated that the rubber dam interproximal septa will be severed during rotary instrumentation. The most frequent use of this technique will be for preparation for stainless steel crowns. Simply punch the holes, isolating at least three teeth, and cut the dam septa with scissors prior to placement. This allows for fast application of the dam and provides good retraction of cheeks and lips and accessibility and visibility to the operating field. Moisture control is not optimal but this is of little consequence for crown preparations. Stabilization of the anterior extent of the isolation 1 . Use of small piece of rubber dam material "flossed" between the interproximal contacts; 2. Use of a wooden wedge between interproximal contacts; 3. Ligation. Criteria for successful Placement of rubber dam --Material covers the upper lip but not the nose; --Dam is centered on the face; --Clamp is stable and does not impinge on the gingiva; --Dam is stabilized anteriorly with wedge, rubber dam piece, or ligature; --Dam does not leak; --Dam is inverted into gingival sulcus; --Placement is accomplished in 5 minutes or less; --Correct number of teeth are isolated; --Tell-show-do used when applying rubber dam. Removal of the rubber dam 1. Remove all ligatures or other objects used to stabilize; 2. Stretch and cut rubber dam septa; 3. Remove dam, frame and clamp as a unit; 4. Inspect dam for missing pieces; 5. Inspect mouth; CONSERVATIVE CLASS I RESTORATIONS CONSERVATIVE CLASS I COMPOSITE READING ASSIGNMENT: Syllabus material and Assigned reading: Pediatric Dentistry Infancy through Adolescence pages 352-356 OBJECTIVES: The student should be able to: 1. Define what a conservative class I resin restoration is, and when it might be used. 2. Identify and differentiate between a sealant and conservative class I. 3. List and discuss the technique for preparation and applicantion of a conservative class I. 4. Describe how to repair a sealant or conservative class I. 5. Identify the common reason for failure or loss of a sealant/class I composite. Conservative Class I Preparation and Restoration Self-Evaluation CONSERVATIVE CLASS I COMPOSITE 1. Occlusal surface free of plaque and debris. 2. Caries removed. 3. Tooth surface chalky-white after etching, rinsing and drying. 4. Resin placed in cavity preparation. 5. Sealant applied over and to ALL susceptible pits and fissures on the tooth. 6. No voids found in the sealant. 7. Sealant can not be dislodged with an explorer. 8. Occlusion adjusted. What is a CONSERVATIVE CLASS I COMPOSITE? The conservative class I restoration is indicated for small carious lesions that progress into dentin. It is a logical extension of sealant philosophy and technique. The preventive approach of sealing susceptible pits and fissures is combined with conservative cavity preparation of caries occurring on the same occlusal surface. Instead of the traditional amalgam cavity preparation "extension for prevention" beyond the area of decay into the adjacent pits and fissures, this approach limits cavity preparation to the discrete areas of decay. To be considered a restoration the preparation must extend into dentin. These preparations are filled with a flowable or a conventional resin and covered over with a sealant to protect the remaining grooves and pits. This results in a restoration that conserves tooth structure and is both therapeutic and preventive. CRITERIA 1. Questionable carious areas 2. Incipient lesions 3. Well-confined carious lesions 4. Enamel defects LABORATORY SIMULATION Your dentoform contains a plastic tooth (#30) which has been prepared to simulate a caries situation. For the laboratory situation you will need a high speed (330) to remove the darkened ‘carious’ material until you see white tissue. The preparation that results is your conservative Class I composite preparation. You will not be placing a base, but simply restoring the preparation with composite and sealant. CONSERVATIVE RESTORATION (D-E): D. In this diagram the caries extends into the dentin. Again, a 330 bur is used to conservatively remove the decay. E. In this example, a glass ionomer liner (L) is placed over the dentin. This is followed by a bonding agent (BA) and posterior resin (CR) material. Finally, a sealant (S) is placed over all the remaining susceptible pits and fissures. TECHNIQUE CONSERVATIVE CLASS I & SEALANT W/ CARIES EXCAVATION 1. Prepare tooth with an appropriate bur by removing only carious areas and/or those areas suspected of being carious. NOTE: ALL GROOVES DO NOT NEED TO BE OPENED AND NO EXTENSION FOR PREVENTION IS REQUIRED. (For the lab exercise remove only the dark simulated carious material). NOTE: The appropriate ADA billing code is determined by the depth of the preparation. The preparation must extend into dentin to be billed as a composite restoration. 2. Remove all debris from tooth by thoroughly washing and drying. 3. Apply etchant (acid) to the prepared areas and all remaining grooves and developmental defects. A 15 second application of etchant is sufficient for both primary and permanent teeth. 4. Rinse the tooth for 5 seconds with an air-water spray. Remove water by a combination of air and suction. Dry tooth with contaminant-free stream of compressed air. The entire etched surface(s) should have a dull whitish appearance. If it does not, re-etch. Salivary contamination, no matter how slight, at any time during the etching procedure necessitates a 10 second re-etch followed by rinsing and drying. 5. Place appropriate base material on floor of the preparation if needed. 6. Apply very thin layer of bond to prepared areas and entire groove structure using the disposable brush tip provided and air thin. NOTE: DO NOT USE SAME BRUSH TIP THAT WAS USED TO APPLY THE ETCHING AGENT. 7. Cure bonding agent for 10-15 seconds. Larger cavities may require two coats. (Two thin coats are better than one thick and pooled coat.) 8. Using the applicator gun or syringe (for flowable), extrude into the cavity, restoring to surface level enamel. A deep lesion (> 3mm) may need incremental fill and cure to insure adequate polymerization of material. Cure restorative material. 9. Place sealant over remaining grooves and pits and cure again. SEALANT PORTION 1. Slowly “paint” the sealant into the grooves and any development pits with the brush tip on the sealant syringe. 2. Care should be taken to avoid entrapment of air by not trying to force resin material into orifices of the preparation or fissures with tip of brush. Sealant should extend up cuspal inclines to just clear occlusion. A gentle lapping motion is used to feather-edge resin material to enamel. 3. Once the sealant material has been placed to operator's satisfaction, it is exposed to a suitable visible light source for 40 seconds on each surface keeping end of light tip 1-2 mm from surface. If area to be polymerized is larger than tip of light, tip should be moved slowly over entire surface. The time should be increased proportionally to ensure that all areas are equally exposed to light. 4. Before removing rubber dam, restoration should be checked for (1) voids by gently passing an explorer over it and (2) retention by trying todislodge it. If a void is encountered, a small amount of material can be added provided no salivary contamination has occurred. Retention failures are usually caused by moisture contamination and necessitate repeating application procedure beginning with etching. 5. Check for presence of sealant material on the proximal surfaces. 6. Check the occlusion and make any necessary adjustments with light strokes of appropriate stones or finishing burs. CLASS II COMPOSITE RESTORATIONS IN PRIMARY MOLARS CLASS II COMPOSITE PREPARATION FOR PRIMARY TEETH READING ASSIGNMENT: Pediatric Dentistry: Infancy through Adolescence, 4th edition, Pages 355-357, syllabus material OBJECTIVES: The student should be able to: 1. List several anatomic considerations to be made when restoring primary teeth. 2. Draw the outline form of class II composite preparations on primary teeth. 3. State the appropriate pulpal, axial and gingival depths of a primary class II composite preparation. 4. Discuss or list several principles regarding the occlusal outline of primary class II compsite preparations. 5. Discuss the absence of a requirement for retentive grooves in the proximal box. 6. Discuss or list several principles regarding the proximal box of primary class II preparations. 7. Be familiar with evaluative criteria for class II composite preparations (See self-evaluation form). 8. State the preferred bur for preparing a class II composite. 9. State where the retention and resistance form is found in class II composite preparation. 10. Be familiar with the use of a matrix band. 11. State how 2 back-to-back composites should be condensed and restored. 12. Be familiar with some common errors of class II preparations. 13. Describe what can happen and why if the gingival floor of the proximal box is placed too far gingivally. CLASS II COMPOSITE PRIMARY TEETH SELF EVALUATION FORM 1. Occlusal outline form: curved, continuous, fluid. 2. Occlusal outline form: parallels the mesial - distal axis. 3. Occlusal width 1.0 - 2.0 mm. 4. Occlusal depth > 1.0mm but not more than 2.0 mm. 5. Pulpal floor perpendicular to the long axis, flat, and level. 6. Isthmus width 1/3 of the occlusal table, or 1.0-1.5 mm of enamel surrounding the preparation. 7. Proximal box cervical depth just below contact. 8. Axial wall depth 1.0-1.5 mm from contact area. 9. Buccal and lingual proximal walls parallel to the external surface. 10. Buccal and lingual proximal margins can be explored with explorer tip. 11. Gingival - axial line angle 90o 12. Axial - pulpal line angle beveled. Anatomic Considerations of Primary Teeth Although some primary teeth show resemblance to their permanent successors, they are not miniature permanent teeth. Several anatomic differences must be distinguished before restorative procedures are begun. 1. Primary teeth have thinner enamel and dentin thickness than permanent teeth. 2. The pulps of primary teeth are larger in relation to crown size than permanent pulps. 3. The pulp horns of primary teeth are closer to the outer surface of the tooth than permanent pulps. The mesio-buccal pulp horn is the most prominent. 4. In primary teeth, the enamel rods of the gingival third of the crown extend in an occlusal direction from the dentino-enamel junction. This is in contrast to the permanent dentition in which the rods extend in a cervical direction. 5. Primary teeth demonstrate greater constriction of the crown and have a more prominent cervical contour than permanent teeth. 6. Primary teeth have broad, flat proximal contact areas. 7. Primary teeth are whiter in color than their permanent successors. 8. Primary teeth have relatively narrow occlusal surfaces compared to their permanent successors. The principles of class II composite preparation for primary teeth are essentially the same as that taught in restorative dentistry with a few modifications because of some of the morphological features of primary molars. In this course, the student will learn to prepare primary molars for composite restorations with an understanding of the modifications required and the anatomical reasons for the modifications. General Considerations The outline form for several class II composite preparations can be seen below. The occlusal outline form should: Include all carious areas andt should be as conservative as possible. Ideal pulpal floor depth is 0.5 mm into dentin (approximately 1.5 mm from the enamel surface). The length of the cutting end of the No. 330 bur is 1.5 mm, so this becomes a good tool for gauging cavity depth. The cavosurface margin should be placed out of stress-bearing areas, with no bevel. To help prevent stress concentration, the outline form should be composed of smooth, flowing arcs and curves, and all internal angles should be rounded slightly. When a dovetail is placed in the second primary molars, its bucco-lingual width should be greater than the width of the isthmus to produce a locking form to provide resistance against occlusal torque, which may displace the restoration mesially or distally. The isthmus should be one third of the intercuspal width, and the bucco-lingual walls should converge slightly in an occlusal direction. The mesial and distal walls should flare at the marginal ridge so as not to undercut ridges. Oblique ridges should not be crossed unless they are undermined with caries or are deeply fissured. The proximal box should be: Broader at the cervical than at the occlusal. The buccal, lingual, and gingival walls should all break contact with the adjacent tooth, just enough to allow the tip of an explorer to pass The buccal and lingual walls should create a 90 degree angle with the enamel. The gingival wall should be flat, not beveled, and all unsupported enamel should be removed. Ideally, the axial wall of the proximal box should be 0.5 mm into dentin and should follow the same contour as the outer proximal contour of the tooth. Since occlusal forces may permit a concentration of stress within the amalgam around sharp angles, the axio-pulpal line angle is routinely beveled or rounded. NO BUCCAL OR LINGUAL RETENTIVE GROOVES SHOULD BE PLACED IN THE PROXIMAL BOX. The mesio-distal width of the gingival floor should be 1 mm, which is approximately equal to the width of a No. 330 bur. In primary teeth many practitioners limit class II composite restorations to relatively small two surface restorations. Three surface (MOD) restorations may be done, but studies have shown that stainless steel crowns are a more durable and predictable restoration for large and multisurface caries restorations. Class II Cavity Preparation MESIO-OCCLUSAL CAVITY OF MANDIBULAR RIGHT SECOND PRIMARY MOLAR Methods of cavity preparation described in this handout are applicable to the student using the high- speed handpiece. On occasions it may be necessary to use the slow speed handpiece for gross removal of deep decay, for accessibility and for use in cavity preparation for hyperactive children. Consequently the slow speed handpiece should be mounted and ready for use prior to an operative appointment for children. A rubber dam and wedge are placed before the preparation is started. 1. Establish the occlusal outline form of the preparation with a #330 bur. (Fig C) The occlusal portion is cut through the enamel just into the dentin. The preparation should be parallel to the long axis of the tooth. The walls are made parallel or slightly divergent to each other to prevent pulpal exposure and weakening of the cusps by undermining. 2. Establish the width of the isthmus approximately one-third the distance between the cusps or 1.0 to 1.5 mm wide (Fig C) 3. To start the proximal box of the preparation, move the #330 bur in a gingival direction at the dentino-enamel junction (Fig. 4). Proximal view which illustrates the movement of the #330 bur toward the gingival. 4. Move the bur bucco-lingually with a pendulum motion so that the widest bucco-lingual width of the box is at the gingival margin. Do not increase the width of the isthmus. The proximal box-outline will look like an inverted cone (Fig. 5). Proximal view which illustrates the angulation of the handpiece and the #330 bur when cutting the proximal box. 5. The proximal box is extended gingivally to break contact with the adjacent tooth and to a depth where the tip of an explorer can be passed through (Fig. 6). The mesio-distal depth of the gingival floor would be approximately 1.0 mm. The bucco-lingual outline of the axial wall should conform to the curvature of the proximal form of the tooth to reduce the possibility of encroachment of the pulp (Fig. 7). Figure 6: Tip of the explorer passed through the interproximal at the gingival, buccal and lingual margins. Figure 7: The axial wall of the proximal box should conform to the proximal outline of the tooth. 6. The buccal and lingual margins of the proximal box are extended only to a cleansable area. Do not place retention grooves or points. 7. Use the #330 bur to bevel the pulpo-axial line angle (Fig. 9). Illustrates the rounding of the pulpo-axial anglewith a #330 bur. Figure 10: Occlusal view of completed Class II preparation on a Second Primary Molar. REMEMBER! The retention of a class II composite comes primarily from the slight undercuts of the occlusal portion and the divergence of the proximal box walls. RESTORATION OF CLASS II Matrix Application Matrices must be placed for interproximal restorations to aid in restoring normal contour and normal contact areas and to prevent extrusion of restorative materials into gingival tissues. Two major types of matrix bands are available for use in pediatric dentistry. 1 . T-band: allows for multiple matrices; no special equipment is needed 2. Tofflemire matrix: can be difficult to place as multiple matrices Steps of Restoration of Class II Composite Restorations 1. Place pulp protection as necessary. (not in lab situation) 2. Place a matrix band. 3. While holding the matrix band in place, forcefully insert a wedge between the matrix band and the adjacent tooth, beneath the gingival seat of the preparation. The wedge is placed with a pair of Howe pliers or cotton forceps from the widest embrasure. The wedge should hold the band tightly against the tooth but should not push the band into the proximal box. It may be necessary to trim the wedge slightly to achieve a proper fit, because of spacing in the dentoform. 4. Using the composite carrier, add the composite to the preparation in single increments, beginning in the proximal box. 5. Using a small condenser, condense the composite into the corners of the proximal box and against the matrix band to ensure the re-establishment of a tight proximal contact. Continue filling and condensing until the entire cavity is overfilled. 6. Carving of the occlusal portion is performed with a small cleoid-discoid carver, as in Class I restorations. 7. Carefully remove the wedge and the matrix band. 8. Remove excess composite at the buccal, lingual, and gingival margins with an explorer. Check to see that the height of the newly restored marginal ridge is approximately equal to the adjacent marginal ridge. 9. Gently floss the interproximal contact to check the tightness of the contact, to check for gingival overhang, and to remove any loose resin particles from the interproximal region. 10. Remove the rubber dam carefully. 11. Check the occlusion for irregularities with articulating paper, and adjust as needed. LABORATORY SIMULATION Some technical problems inherent in the lab situation due to the rubberized gingiva and varying tooth size include: 1. Difficulty getting the matrix placed gingivally. 2. Difficulty wedging due to space between the teeth. Two wedges may be needed. 3. Over-contouring of the interproximal box (you should carve the box with normal contour and not attempt to establish contact there before you prepare the tooth.) 4. Remember these teeth rotate in the sockets, so before you prep and during the preparation be sure to check on the mesial-distal orientation of the tooth. Otherwise, you may find the preparation is too wide interproximally. SOME COMMON ERRORS OF CLASS II PREPARATIONS Restorative Dentistry for Children / The Class II Figure 14: The flare of the proximal box is too wide. The divergence of the buccal and lingual walls is lost because of improper angulation of the bur resulting in relatively thin and unsupported cusp areas. Figure 14 Figure 15 Figure 16 Figures 15 and 16: The flare of the proximal box is carried too wide. Figure 17: The axial wall and pulpal floor are too deep, resulting in pulp involvement. Figure 17 Figure 18: Because of the prominent cervical bulge of primary molars, increasing the depth of the gingival floor can result in penetration of the tooth at the constriction. Figure 18 PULPOTOMY AND STAINLESS STEEL CROWN PROCEDURES FOR PRIMARY MOLARS PULPOTOMY TREATMENT READING ASSIGNMENT: Pediatric Dentistry: Infancy through Adolescence, 4th Edition pp 379-387 and syllabus material OBJECTIVES: The student should be able to: 1. List several findings which contraindicate pulpotomy treatment on a primary molar. 2. Identify the vitality of the pulp of a tooth indicated for a pulpotomy. 3. State the medicament and filling materials for primary tooth pulpotomies at OSU. 4. State the number of root canals in each primary molar and name them. 5. Identify the instruments used to excise coronal pulpal tissue. 6. Discuss the use of hemostatic agents to control pulpal bleeding. 7. Identify the appropriate restoration to be placed over a tooth with a pulpotomy. 8. Draw and describe access openings for primary molars. PULPOTOMY PROCEDURE SELF EVALUATION FORM PULPOTOMY PROCEDURE 1 Create access opening and de-roof chamber. 2 Remove all red from chamber without perforating. 3. Fill chamber with ZOE B&T (Zinc Oxide Eugenol Base and Temporary Filling Material). PULPOTOMY PROCEDURES FOR PRIMARY MOLARS Pulpotomy is indicated for vital primary teeth whose pulps have been exposed. It is the treatment of choice when there is no sign of the following: (1) spontaneous pain, (2) swelling, (3) tenderness to percussion, (4) abnormal mobility, (5) fistulas, (6) sulcular drainage, (7) internal resorption, (8) pulpal calcifications, (9) pathologic external root resorption, (10) periapical radiolucency, (11) inter-radicular radiolucency, or (12) excessive pulpal bleeding or a putrescent odor. The Division of Pediatric Dentistry and Community Oral Health at The Ohio State University recommends the use of ferric sulfate for the vital pulpotomy procedure in primary molars. Many other dental schools teach the use of formocresol for primary teeth pulpotomy’s and this material is commonly used in dental practice today. Formocresol puplotomies have demonstrated a high rate of clinical success; however concern is mounting over its safety. Formocresol induces a chronic inflammatory response and is potentially immumogenic,mutagenic and even carcinogenic. While the likelihood of these events occuring may be low with a low concentration of formocresol, we have elected to switch to ferric sulfate because recent research indicates that it’s success approaches that of formocresol without its potential toxicity concern. Technique for a ferric sulfate pulpotomy is as follows: 1. Access and caries removal Using local anesthesia and with a rubber dam in place, remove all dental caries except that over the exposure site. Prepare an access opening that is sufficiently large by connecting the pulp horns, and then remove the entire roof of the pulp. PULPOTOMY TREATMENT 2. Coronal pulp amputation Using a large sterile, large spoon excavator, incise and remove all pulp tissue within the coronal chamber. A large, round bur in a slow speed handpiece is preferred by most dentists, but for the inexperienced, extreme care must be taken to avoid perforating the pulpal floor. The operator should be able to locate and visualize all of the pulpal canals. NOTE: Maxillary primary molars have 3 canals (mesiobuccal, distobuccal, lingual); Mandibular molars have 2 canals (mesial, distal) 3. Hemorrhage control and evaluation One or more sterile cotton pellets should be placed over each pulp amputation site (canal orifice), and pressure should be applied for several minutes. When the pellet is removed, hemostasis should have been gained and be apparent, even though a minor amount of wound bleeding may be evident. A deep purple hemorrhage or an excessive amount of bleeding that persists in spite of cotton pellet pressure is indicative of inflammatory pulp changes that have extended into the radicular pulp. Such changes preclude the tooth from remaining a good candidate for the pulpotomy procedure and pulpectomy or extraction is indicated. It should be noted that no intrapulpal local anesthesia should be used in attempting to minimize the hemorrhage, since bleeding behavior is a clinical evaluation that is critical to judging the radicular pulp status. Be certain to remove the entire roof of the pulp chamber as small tissue tags remaining under the roof may cause the continued bleeding. 4. Ferric sulfate application A cotton pellet soaked in ferric sulfate should be placed over the radicular pulp stumps for approximately 15 seconds with a rubbing motion. The pulp stumps are then blotted dry with cotton pellets. 5. Zinc oxide and eugenol base and final restoration PLEASE NOTE: ALL COTTON PELLETS ARE REMOVED FROM THE TOOTH PRIOR TO FILLING WITH ZOE MATERIAL. ZOE IS PLACED IN DIRECT CONTACT WITH THE PULPAL STUMPS. A regular mix of zinc oxide and eugenol (or a reinforced product such as IRM) should be placed at the base of the coronal pulp chamber directly on the amputation sites and should be lightly condensed so as to fill the access opening completely. The final restoration should be a stainless steel crown and, should be placed at the same appointment as the ferric sulfate pulpotomy. STAINLESS STEEL CROWN (SSC) (Chrome Steel Crown) READING ASSIGNMENT: Pediatric Dentistry: Infancy through Adolesence pages 357-363 and Syllabus material OBJECTIVES: The student should be able to: 1. Describe indications, contraindications, advantages and disadvantages of the SSC restoration for primary and young permanent teeth. 2. Identify the difference between a "3M Ion" crown and a "Unitek" crown. 3. List the bur(s) used in the preparation of a SSC. 4. State the appropriate amount of reduction on each surface for a SSC: - occlusal - proximal - buccal - lingual 5. State the type of finish line desired for a SSC preparation. 6. State several reasons why an SSC may not seat completely during try-on. 7. State the appropriate gingival length of a SSC. 8. Describe the difference between "contouring" and "crimping" an SSC. 9. State 3 advantages of a tight marginal fit for a SSC. 10. State or illustrate the appropriate contour and shape to the gingival margins of 1st and 2nd primary molars. 11. Be familiar with several evaluative criteria for SSCs. (See Self-Evaluation Form). At the completion of this laboratory exercise the students should be able to: 1. Prepare and adapt a stainless steel crown on a primary molar. CHROME STEEL CROWN PREPARATION SELF-EVALUATION 1. Occlusal surface is reduced 1-1.5 mm and follows cusp form. 2. Proximal cut; contact is cleared, reduction not greater than 1 mm. 3. Proximal walls are parallel or slightly convergent to occlusal. 4. Proximal cuts end cervically without chamfer or ledge. 5. Proximal walls are straight when viewed from occlusal and perpendicular to arch perimeter. 6. Cervical bulge remains, there is minimal or no buccal or lingual reduction. 7. All line angles are gently rounded. CHROME STEEL CROWN ADAPTATION SELF-EVALUATION 1. Crown is trimmed to 1 mm below gingival margin (for the Unitek crown only), and crown margin is fluid in form and follows contour of gingiva. 2. Surface is contoured in gingival 1/3 of buccal, lingual, mesial and distal (for the Unitek crown only). 3. Crown is crimped at gingival margin and tightly adapted to tooth surface on buccal, mesial, lingual and distal. 4. The aim of the stainless steel crown is to restore: Occlusion Contact (if present before procedure) Gingival health Indications for Stainless Steel Crowns on Primary Teeth 1. To restore carious primary teeth that would otherwise require large amalgam restorations. 2. To restore primary teeth following a pulpotomy or pulpectomy. 3. To restore teeth with hypoplastic enamel. 4. To restore primary teeth with multiple carious lesions in patients with high decay rates where recurrent caries is expected. 5. To restore teeth in patients with hereditary anomalies - amelogenesis imperfecta, dentinogenesis imperfecta. 6. To restore primary teeth as abutments for fixed appliances. 7. To restore primary teeth to provide retention for removable appliances. 8. To provide temporary restoration of permanent molars. 9. To provide temporary restoration for fractured teeth. Procedure for Stainless Steel Crown Preparation Important Note: The stainless steel crowns which are available to the clinician and which will be utilized in the laboratory are referred to as the "3M" (or "Ion") crowns. The "Ion" (or "3M") crown is a pre-trimmed, pre-contoured, and pre-crimped crown. In most instances no trimming of the gingival margin is required. Although they have been pre-contoured and pre-crimped, further contouring and crimping is sometimes necessary. The occlusal anatomy of these crowns is more prominent, with more secondary anatomy than you see on the uncrimped "Unitek" crowns. Steps of Preparation and Placement of Stainless Steel Crowns (Note: Several different preparation designs have been advocated over the years. Only one such preparation, requiring minimal tooth reduction, is discussed here. Either Unitek or Ni-Chro Ion crowns may be used following these steps.) 1. Evaluate the preoperative occlusion. Note the dental midline and the cusp-fossa relationship bilaterally. 2. Administer appropriate local anesthesia, ensuring that all soft tissues surrounding the tooth to be crowned are well anesthetized, and place a rubber dam. Because gingival tissues all around the tooth may be manipulated during crown placement, it is important to obtain lingual or palatal anesthesia, as well as buccal or facial. 3. Establish access with a No. 330 bur in the high speed handpiece, then remove decay with a large, round bur in the slow speed handpiece or with a spoon excavator. 4. Reduction of the occlusal surface is carried out with a No. 169L taper fissure bur or a thin, tapered diamond in the high speed handpiece. Make depth cuts by cutting the occlusal grooves to a depth of 1.0-1.5 mm, and extend through the buccal, lingual, and proximal surfaces. Next, place the bur on its side and uniformly reduce the remaining occlusal surface by 1.5 mm, maintaining the cuspal inclines of the crown. Alternatively a number 8 round bur may be used. 5. Proximal reduction is accomplished with the tapered fissure bur or thin, tapered diamond. Contact with the adjacent tooth must be broken gingivally and bucco-lingually, maintaining vertical walls with only a slight convergence in an occlusal direction. The gingival proximal margin should have a feather-edge finish line. Care must be taken not to damage adjacent tooth structure. Ledges formed by deep caries should not be removed. 6. Round all line angles, using the side of the bur or diamond. The occluso-buccal and occluso-lingual line angles are rounded by holding the bur at a 30-45 degree angle to the occlusal surface and sweeping it in a mesio-distal direction. Bucco-lingual reduction for the stainless steel crown preparation is generally limited to this bevelling and is confined to the occlusal one third of the crown. If problems are later encountered in selecting an appropriate crown size or in fitting a crown over a large mesio-buccal bulge, more reduction of the buccal and lingual tooth structure may become necessary. The buccal and lingual proximal line angles are rounded by holding the bur parallel to the tooth's long axis and blending the surfaces together. All of the angles of the preparation should be rounded to remove corners but not so much as to create a round preparation. 7. Selection of a crown begins as a trial and-error procedure. The goal is to place the smallest crown that can be seated on the tooth and to establish pre-existing proximal contacts. The selected crown is tried onto the preparation by seating the lingual first and applying pressure in a buccal direction so that the crown slides over the buccal surface into the gingival sulcus. Friction should be felt as the crown slips over the buccal bulge. Some teeth are an in-between size, so that one crown size is too small to seat and the next larger size fits very loosely, even after contouring. Further tooth reduction may be necessary in these cases to seat the smaller crown size. After seating a crown, establish a preliminary occlusal relationship by comparing adjacent marginal ridge heights. If the crown does not seat to the same level as the adjacent teeth, the occlusal reduction may be inadequate; the crown may be too long; a gingival proximal ledge may exist; or contact may not have been broken with the adjacent tooth, preventing a complete seating of the crown. If an extensive area of gingival blanching occurs around the crown, this indicates the crown is too long or is grossly over-contoured. A properly trimmed crown will extend approximately 1 mm into the gingival sulcus. (The Ion [3M] pre-contoured crowns do not usually require trimming.) 8. If necessary, contour and crimp the crown so that it fits tightly; this may not be required with the “Ion” crown. Contouring: Contouring involves bending the gingival one third of the crown's margins inward to restore anatomic features of the natural crown and to reduce the marginal circumference of the crown, ensuring a good fit. Contouring is accomplished circumferentially with a No. 114 ball and socket pliers (Figure 21 –A, on next page) or with a No. 137 Gordon pliers. Remember that the “Ion” crown is pre-contoured. Crimping: Final close adaptation of the margin of the crown to the tooth surface is achieved by crimping the cervical 1 mm of the margin circumferentially. The No. 137 pliers may be used for this; a special crimping plier, (Figure B, on next page), is also available. A tight marginal fit aids in (1) mechanical retention of the crown, (2) protection of the cement from exposure to oral fluids, and (3) maintaining gingival health. After contouring and crimping, firm resistance should be encountered when the crown is seated. After seating the crown, examine the gingival margins with an explorer for areas of poor fit. Observe the gingival tissue for blanching, and examine the proximal contacts. If proximal contact needs to be established, it can be done with a ball and socket pliers after removal of the crown. When removing the crown, a spoon or cleoid-discoid can be used to engage the gingival margin and dislodge the crown. A thumb or finger should be kept over the crown during removal so that the movement of the crown is controlled. 9. The rubber dam must be removed, and the crown replaced so that the occlusion may be checked. Examine the occlusion bilaterally with the patient in centric occlusion. Look for movement of the crown occluso-gingivally with biting pressure, and check for excessive gingival blanching. After the rubber dam is removed, special care must be taken when handling the crown in the mouth. A 2 X 2 inch gauze pad should be placed posterior to the tooth being crowned to act as a safety net to prevent the crown from dropping into the oropharynx. 10. Rinse and dry the crown inside and out, and prepare to cement it. A glass ionomer cement is preferred. The crown is filled approximately two thirds with cement, with all inner surfaces covered. 11. Dry the tooth with compressed air, and seat the crown completely. Cement should be expressed from all margins. The handle of a mirror or the flat end of a band pusher may be used to ensure complete seating, or the patient may be instructed to bite on a cotton roll. Before the cement sets, have the patient close into centric occlusion and confirm that the occlusion has not been altered. 12. Cement must be removed from the gingival sulcus. Glass ionomer cement, after it has partially set, will reach a rubbery consistency. Excess cement may be removed at this stage with an explorer tip. The interproximal areas can be cleaned by tying a knot in a piece of dental floss and drawing the floss through the interproximal region. Alternatively the excess cement may be rinsed from the tooth before initial setting. 13. Rinse the oral cavity well, and re-examine the occlusion and the soft tissues before dismissing the patient. Two Principles for Obtaining Optimal Adaptation of Stainless Steel Crowns to Primary Molars (Spedding, 1984) With few exceptions most stainless steel crowns look good in the mouth. Except in cases of bruxism when crowns may be worn and flattened down, the crowns will continue to appear clinically acceptable for many years. The radiographic appearance of the crowns is usually not as encouraging. Radiographically, margins are noted to be poorly adapted to proximal tooth surfaces. Often they are too long. Proximal contours of crowns are not well reproduced. Fortunately, these deficiencies seem to have little adverse effects on the supporting periodontal tissues. The deficiencies though can be largely avoided when attention is paid to two key principles: (1) crown length, and (2) shape of the crown's gingival margins. The length of a stainless steel crown should allow the crown to fit just into the gingival sulcus, engaging the natural undercuts. But more importantly, the crown length should extend just slightly apical to the tooth's height of contour. For primary teeth the buccal, lingual and proximal heights of contour happen to be just above the gingival crest. As a stainless steel crown is trimmed in length such that its gingival margins come closer to the greatest diameters (heights of contour) of the tooth crown, the spaces between the margins of the crown and tooth surfaces lessen. Thus, when the margins of the metal crown nearly approximate the greatest diameter of the tooth, the spaces are small enough so that the metal can be adapted closely to the tooth. In other words, crowns that extend well beyond a tooth's height of contour are very difficult to adapt closely to the tooth surface. The shape or contour of the gingival margins differ from first to second primary molar, as well as from buccal to lingual to proximal. The margins of the trimmed crown should approximate the shape of the gingival crest around the tooth. Figure A, next page, demonstrates the different gingival contours. As you look at the marginal gingiva around the second primary molar you will note that the occluso-gingival heights gradually become shorter along the crests of the gingival margins towards both the mesial and distal surfaces. The outline of buccal and lingual gingiva around second primary molars resemble smiles. The buccal gingiva of the first primary molar has a different outline. Due to the mesio-buccal cervical bulge the gingival margin dips down as it is traced from distal to mesial. If you can picture the letter S on its side and stretched out somewhat, and if a tooth crown is placed on top of this curved line, the term *stretched-out-S” can be used to describe the contour. However, the contours of the lingual marginal gingiva of all first primary molars resemble smiles. The proximal contours of almost all primary teeth frown (Figure B next page), because the shortest occluso-cervical heights are about midpoint buccolingually. By keeping these shapes in mind when trimming the stainless steel crowns the close adaptation to the tooth will be made much easier. The margins of the finished, trimmed steel crown consist of a series of curves or arcs as determined by the marginal gingivae of the tooth being restored. There are no corners, jagged angles, right angles or straight lines found on these margins. Contouring and crimping pliers are necessary to apply the appropriate gingival adaptation. Keeping the principles of crown length and marginal shape in mind will ensure optimal adaptation and clinical success of the crown. COMMON CLINICAL SITUATIONS AND THEIR SOLUTIONS DURING ADAPTATION OF CHROME STEEL CROWNS 1. DIFFICULTY IN SEATING CROWN A. Insufficient occlusal reduction 1. Check occlusal reduction B. Large cervical bulges or unusual contour of buccal or lingual 1. Reduce buccal and lingual surfaces. REMEMBER: DO NOT DESTROY THE NATURAL UNDERCUT AND ALL REDUCTION MUST END WITH NO LEDGE. C. Ledge on preparation 1. Reduce ledge to feather edge or seat edge of crown below the ledge and "swing" crown to seat it (See Figure- next page). D. Contact not cleared 1. Check with explorer, it should pass freely between proximals. Clear contact if indicated. E. Crown that is too small 1. Select larger crown 2. If arch length will not permit a larger crown being used, stretch the smaller crown or reduce overall size of tooth being prepared. 3. Crown may be over adapted (made too small), shape crown outward. F. Impingement (length) or trapping (width) of gingival tissue. 1. Check to see that crown is fitting properly into cervical sulcus. Adapt as indicated. 2. DIFFICULTY IN REMOVING CROWN DURING ADAPTATION A. Crown is tightly adapted. Crown is normally removed with a spoon; try removing with a discoid instrument. Normally crown is removed from buccal to lingual. Try removing from lingual. 3. CROWN THAT IS LOOSE A. Try smaller size. B. Contour and crimp.
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