Pediatric Dentistry is an age defined specialty that by i301aw


									                         The Ohio State University
                           College of Dentistry
   Division of Pediatric Dentistry and Community Oral Health

          Pediatric Dentistry

                                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

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.


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).

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

Division of Pediatric Dentistry and Community Oral Health   292-1509

Division Chairman                                           Dr. Paul S. Casamassimo
                                                            Children's Hospital or
                                                            4132 Postle Hall

Pre-Doctoral Program Director                               Dr. E. Gosnell
                                                            4126-B Postle Hall

Post-Doctoral Program Director                              Dr. Homa Amini
                                                            Children's Hospital

Faculty - Full Time                                         Dr. Ann Griffen
                                                            4126-A Postle Hall

                                                            Dr. Ashok Kumar
                                                            Children’s Hospital

                                                            Dr. Dennis J. McTigue
                                                            4140 Postle Hall

                                                            Dr. Megann Smiley
                                                            Children’s Hospital

                                                            Dr. Diego Solis

                                                            Dr. S. Thikkurissy
                                                            4126-C Postle Hall

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

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

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.

      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.

      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.

      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.

     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.

     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.

      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

READING ASSIGNMENT:          Pediatric Dentistry: Infancy through Adolescence, 4 Edition,
                             chapter 20, pages 343-345 and syllabus material


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

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.

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.


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


--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
--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

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;

                                               CLASS I COMPOSITE
READING ASSIGNMENT: Syllabus material and Assigned reading: Pediatric Dentistry Infancy through
                   Adolescence pages 352-356


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


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.

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.


1.      Questionable carious areas
2.      Incipient lesions
3.      Well-confined carious lesions
4.      Enamel defects


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.

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.


  1. Prepare tooth with an appropriate bur by removing only carious areas and/or those areas suspected of
     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

  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

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.


READING ASSIGNMENT:           Pediatric Dentistry: Infancy through Adolescence, 4th edition,
                              Pages 355-357, syllabus material


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

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

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

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

                     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

                     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.

                      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


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.


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

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

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.

Some technical problems inherent in the lab situation due to the rubberized gingiva and varying tooth size

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
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 TREATMENT

READING ASSIGNMENT:            Pediatric Dentistry: Infancy through Adolescence, 4th Edition
                               pp 379-387 and syllabus material


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 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.
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

5.   Zinc oxide and eugenol base and final restoration


     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


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

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

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

4. The aim of the stainless steel crown is to restore:
          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
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.


     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

     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.


            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.


             A.    Try smaller size.
             B.    Contour and crimp.

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