pediatric restorative materials amalgam, composite, temporary restoration, glass ionomar, SSC, Nusmile, porcelain crowns,ZOE

1. Dental Restorative Materials
in Pediatric Dentistry
By:
Hussein Al Harthy
Rahaf Najjar
Supervised by:
Dr. Medhat Abdullah
Dr. Omar Elmeligy

2. Lecture outline
 Factors affect choosing material
 Cavity varnishes
 Bases
 Cements
 Temporary filling
 Intermediate restorations
 Permanent restorations
 Amalgam
 Composite
 Crowns in Pediatric Dentistry.

3. Factors affect choosing material
 The age of the child
 Caries risk
 Cooperation of child
 Type of material
 Type of tooth

4. Age
 What can the child handle?
Rubber dam
Local anesthetic
Length of attention span
 How long will the restoration need to last?

5. Caries Risk
 Number of carious teeth
 Size of lesions
 Likelihood of further acid attack
 Need for caries control first?
 Fluoride-releasing materials desired?
 Motivation and compliance of patient and caregiver
 Oral hygiene
 Diet

6. Cooperation of Child
 Nature of child’s behavior
 Highly technique-sensitive procedures may be
inappropriate in children whose behavior is not
Favorable
 Consideration of caries control procedures (Interim
Therapeutic Restorations or fluoride clinics)

7. Choice of Material
 materials available
 What is the best available option for each clinical
Situation?
 What material will provide the characteristics you want?
 What technique can be completed successfully with
minimal psychological trauma to the child?

8. Cavity varnishes
 Gum (eg. copal) as resin dissolved in organic solvents (eg.
chloroform)
 Also eugenol and recent fluoride composition
 Liner (chemicals)
 Applied onto cavity
 Solvents evaporated
 Leave thin film need twice
 Reduce initial microleakage around amalgam
 Some use dental adhesives instead of varnish (thin)
 Mahler study show no reduction in sensitivity with dental adhesive
 Varnish before dental adhesives ( no adhesion )

9. Cement Bases
 Protect and recovery the injured pulp
 Thermal insulator (sufficient thickness min. 0.5 mm)
 Condensable ( high strength )
 All the following have sufficient strength and the most common
used
 Zinc polycarboxylate
 Hard setting calcium hydroxide
 Z.O.E.
 G.I.Cs
 In cases as class II in deep depression or angle cover calcium
hydroxide base with GICs

10. Cements
 Serve as luting agent
 Provide mechanical retention
 Some used as permanent or temporary
restorations
 Used as bases for other material

11. Cements
 Types
Silicate cement (no longer used)
Zinc phosphate cement (no longer used)
Polycarboxylate cement
Glass ionomer cement
Resin modified glass ionomer cements
 Type I : Luting agent
 Type II : Filling material
 Type III : Base and liner
Zinc oxide-eugenol cement
Resin cements

12. Ideal requirement of cements
 Medium working time
 Short-medium setting time
 Very high compressive strength
 High Bond strength to tooth
 Release of fluoride
 No pulpal response
 Easy to remove excess

13. Polycarboxylate cement
 Polyacrylic acid + zinc oxide powder
 short working time
 Short setting time
 Low-medium compressive strength
 Low-medium Bond strength to tooth
 No Release of fluoride
 No pulpal response
 Medium-difficult remove excess
 Used as luting agent or a base especially cavity close to pulp
 Requirement is clean surface 10-15 sec. by swabbing 10%
polyacrylic acid (to bond)
 Mix requirement (30 sec. , recommended ratio, glossy
appearance)

14. Glass ionomer cement
 HYBRID = Silicate Cement [Powder] + PolyCarboxylate [Liquid]
 Setting reaction
There are three stages:
 Dissolution
 Gelation ( Migration)
 Precipitation and Hardening.
(Water hardening or water setting)

15.  Properties
 Short-Medium working time
 Long setting time
 Low compressive strength
 Bond strength to tooth
 Release of fluoride
 Low pulpal response
 Moderate remove excess
 Film thickness is similar or less than zinc phosphate cement.
 Setting time 6 to 8 minutes from start of mixing.
 Recent studies suggest use of it for caries reduction in
xerostomic patients

16.  Clinical Applications
 Tooth – Colored Filling Materials
 Abrasion & Erosion Lesions
 Class III involving exposed dentin
 Occlusal lesions on deciduous teeth
 Temporary ant. and post. Restoration
 Repair of crown margins
 Cement base under composite and ceramics
 Cavity base and liners
 Orthodontic bands and brackets

17. Resin modified glass ionomer
cements
 Due to the main drawbacks of glass ionomer
which are:
 Short working time and long setting time
 Low strength and toughness
 Cracking and desiccation
 Poor resistance to acid attack
 Moisture sensitivity

18.  Addition of polymerizable function groups
 Both chemical & light curing
 Overcome moisture sensitive & low early strength
 Names:
 Light cured GICs, Dual-cured GICs,
 Tri-cured GICs, Hybrid ionomer,
 Resin-ionomers

19.  Type I : Luting agent
 Type II : Filling material
 Type III : Base and liner
 N.B. concern about use some of its type with ceramic restorations
due to fracture occurrence

20. Zinc oxide-eugenol
 Zinc oxide powder + eugenol liquid
 Long working time
 medium setting time
 Low-medium compressive strength
 No Bond strength to tooth
 No Release of fluoride
 No pulpal response
 Easy to remove excess
 Sedative effect
 Usually used as temporary filling , base , temporary luting cement
 N.B. eugenol is inhibitor for resin ( not used with resin cement ,
restoration and even impression)

21. Resin cements
 Occur later from the direct filling resin
 Become popular because of the improved properties of bonding.
 Resin cement is flowable composite resin
 Very high compressive strength
 High Bond strength to tooth
 No Release of fluoride
 pulpal response
 Used beneath tooth color filling materials
 Luting cements (specially for all-ceramic restoration)

22.  Bonded to etched enamel, ceramics, resins and etched metal
surface
 Available in different shades
 Types according to Setting reaction
Polymerization
–Chemical activation
–Light activation
–Dual activation [chemical and light]
used beneath thick restorations

23. Temporary restorations
 Requirements of temporary restoration
 Good biologic characteristics
 Minimal solubility
 Rigid and strong
 Resistant to abrasion
The need for each of proprieties depend on the permanence desire
e.g. , multiple carious teeth removed caries and for the case
temporary fillings will be placed for several months
(more strength and resistance properties)

24.  Zinc oxide eugenol the most commonly used
 Properties of Z.O.E. improved by mixture with polymer
 Conventional G.I.Cs can be used avoid moisture at the setting
 G.I.Cs type II could be used
 Resin modified G.I.Cs useful as long-term temporary restoratives
 Resin modified G.I.Cs is choice as example in cases of erosion

25. Intermediate Restoration
 Glass Ionomer Restoration.
 Compomer.

26. Classification According to The Use:
I. Luting.
II. Restoration.
III. Liner & bases.
IV. Fissure sealant.
V. As Orthodontic cement.
VI. Core build up.
VII. Fluoride Release.
VIII. ART ( Atraumatic Restorative Technique)
IX. Deciduous Teeth.
1) Glass Ionomer

27. Properties of GI:
Adhesion :
 Bonds chemically to the tooth structure.
 Bonding with enamel is higher than that of dentin ,due to greater inorganic
content.
Esthetics :
 Tooth colored material & available in different shades.
 Inferior to composites: lack of translucency & rough surface texture.
 Potential for discoloration & staining.
Biocompatibility :
Favorable pulpal response .
Anticariogenic properties :
 Fluoride is released from glass ionomer at the time of mixing & lies with in
matrix.
 Fluoride can be released out without affecting the physical properties of
cement.
 Fluoride can be taken up into the restoration during topical fluoride
treatment and released again “fluoride reservoir”

28.  It is also known as “Alternative Restorative Treatment”.
 Procedure based on removing carious tooth tissues using hand
instruments alone and restoring the cavity with an adhesive
restorative material.
Goals of ART are:
i. Preserving the tooth structure.
ii. Reducing infection.
iii. Avoiding discomfort.
Atraumatic Restorative Treatment

30. Advantages of ART
1. Easily available inexpensive hand instruments are used if the
expensive electrically driven dental equipment not availabel.
2. As it is almost a painless procedure the need for local anesthesia
is eliminated or minimized.
3. ART involves the removal of only decalcified tooth tissues, which
results in relatively small cavities and conserves sound tooth
tissues as much as possible.
4. Sound tooth tissue need not be cut for retention of filling material.

31. 5. The leaching of fluoride from glass ionomer probably
remineralizes sterile demineralized dentin and prevents
development of secondary caries.
6. The combined preventing and curative treatment can be done in
one appointment.
7. Repairing of defects in the restoration can be easily done
8. It is less expensive and less time consuming.
9. It enables to oral health workers to reach people who never would
have received any oral health service.

32. Disadvantages of ART
1. Not long lasting. The average life is two years .
2. Because of the low wear resistance and low strength of the
existing glass ionomer materials their use is limited.
3. A relatively unstandardized mix of glass ionomer may be
produced due to hand mixing.
4. The continuous use of hand instruments over long period of time
may result in hand fatigue.
5. As fundamental principles of cavity preparation are not followed
all oral health workers may not accept it.

33. 2) Compomer
 “Poly acid modified composite”
 Combination of composition between: composite and Glass
Iononmer.
 Advantages:
1. more water resistance.
2. Fluoride release.

34. Indication:
suitable for high caries risk patient.
Contraindication:
Stress baring area like large class II and class IV.
Properties:
1) Hydrophilic expansion , by water uptake from saliva.
2) No loss of mechanical properties >> continuous acid base
reaction.
3) Increased marginal integrity >> less post operative sensitivity.
4) Reduced secondary caries >> Fluoride release.

35. Permanent Restoration
 Amalgam Restoration.
 Restorative Resin.
 Glass Ionomar.
 Full coverage in Pediatric Dentistry.

36. Requirement of an Ideal Restorative
Material
1) Restoration of esthetic.
2) Maintenance of the crown strength.
3) Preserve the anatomy of occlusal surface. Thus preserving
interarch relations.
4) Long working time and short sitting time.
5) Long term adhesion between tooth and restoration to ensure
complete isolation.

37. 1) Amalgam Restoration:
 Selection of alloy.
 Trituration.
 Condensation.
 Marginal breakdown and bulk fracture.
 Bonded Amalgam Restoration.
 Mercury Toxicity.

38. Selection of Alloy
 Rate of hardening, smoothness of the mix, and ease of
condensation and finishing vary with the alloy.
1) High copper alloy: When significantly more copper is available,
improved laboratory properties and clinical performance have been
demonstrated.
Advantage:
Have low creep. Creep is the tendency of a material to deform
continuously under a constant applied stress >> marginal breakdown
(ditching) commonly noted with amalgam restoration.
2) zinc-free, high-copper alloy should be used when the dentist
operates in a field where moisture control is difficult.

39. Trituration
 The most serious error in amalgamation is undertrituration.
Undertriturated mix:
1. Appears dry and sandy and does not cohere into a single mass.
2. Amalgam will set too rapidly, which results in a high residual mercury
content.
3. Reduced strength.
4. Increased the likelihood of fracture or marginal breakdown

40. Condensation
purpose of condensation
To adapt the amalgam to the walls of the cavity preparation as closely
as possible, to minimize the formation of internal voids

41. Marginal breakdown and bulk fracture
 A commonly observed type of amalgam failure which the marginal
areas become severely chipped.
 Athin ledge of amalgam may be left that extends slightly over the
enamel at the margins >> cannot support the forces of mastication
>> fracture, leaving an opening at the margins.
 Bulk fracture of amalgam is much less common with high copper
amalgam alloys.

42. Causes:
 Poor cavity design resulting in an insufficient bulk of material across
the isthmus.
 Premature loading of the restoration >> amalgam gains strength
slowly over the first 24 hours.

43. Bonded Amalgam Restoration
 dental amalgam does not adhere to tooth structure, it must be
retained mechanically by the design of the cavity preparation
and/or mechanical devices such as pins.
 “ Bonded amalgam restoration” chemically activated dentin-
bonding systems over which the amalgam is condensed before the
resin adhesive has hardened.

44. Mercury Toxicity
 The amount of mercury released from the amalgam in service is
small compared with other sources of mercury from air, water, and
food.
 Amalgam Alternative: Gallium Alloy
1. Mercury free metallic.
2. Early setting  can polished in the same visit.
3. Better marginal Seal.
4. More costly.

45. What about dental office personnel?
 A potential hazard exists from long-term
inhalation of mercury vapor in the dental
clinic.
 The dental clinic should be well ventilated.
 All mercury waste and amalgam scrap
removed during placement or removal of
amalgam restorations should be collected
and stored in well-sealed containers.
• When amalgam is cut, water spray and high-speed
evacuation should be used.
• Biologically contaminated wastes containing mercury,
including extracted teeth, should be cold sterilized with
a chemical agent before disposal.

46. 2) Restorative Resin
 Conventional Composite.
 Micro-filled Composite.
 Small particles, Hybrid and Nanohybrid composite.
 Flowable Composite.
 Posterior composite.
 Acid etching Technique.
 Bonding Agent.

47.  The term composite material refers to a combination of at least two
chemically different materials with a distinct interface separating the
components. Its provides properties that could not be obtained with
any of the components alone.
 In a resin composite dental restorative material, an inorganic filler
has been added to a resin matrix in such a way that the properties
of the matrix have been improved.
 The resin matrix of many currently available composite materials is
bisphenol A–glycidyldimethacrylate (bis-GMA) or urethane
dimethacrylate resin.
 Fillers are ground particles of fused silica, crystalline quartz, and
soft glasses such as barium, strontium, and zirconium silicate
glass.

48.  The filler and the resin matrix must be chemically bonded together
with a coupling agent on the surface of the filler. If this is not done,
the particles may be easily dislodged, water sorption at the filler-
matrix interface may take place, and stress transfer between matrix
and filler may not occur.
 The filler particles are coated with a reactive silane product.
Classification based on method of curing:
1) Chemical cure.
2) Light cure.
3) Dual cure.

49. 1. Esthetic.
2. Conservative cavity.
3. Low thermal conductivity.
4. Quite resistance to microleakage.
5. No corrosion.
6. Strengthening of the remaining tooth
structure.
1. Polymerization shrinkage.
2. High coefficient of thermal expansion.
3. Pulp irritation due to residual
monomer .
4. Low wear resistance.
5. Technique sensitive.
Advantages
Disadvantages
Resin Restoration

50. Classification based on size of partials:
1. Conventional (Macro-filled) Composite
 The fillers in conventional composites is in the 8 to 12 µm range.
 wear resistance + surface roughness .
2. Micro-filled Composite
 Use of an extremely small silica filler particle, whose size is 0.02 to
0.04 µm.
 microfine, microfilled, or polishable resins.
 Improve the surface smoothness and polishability of composite
resins
 Softer composite and have a slightly higher coefficient of thermal
expansion, a higher water absorption, more polymerization
shrinkage, and lower mechanical properties.
 Use: 1) Esthetic Area 2) stress free areas (class III or class V ).

51. 3. Small-particle composites
 have an average filler size of 1 to 5 µm, with a broad distribution of
sizes.
 Best combination of physical properties of all the currently available
composites.
 Use: stress-bearing applications such as class IV and class II
restorations.
4. Hybrid composites
 The most recent step toward smaller particle size.
 They contain filler with an average size of 0.6 to 1.0 µm in addition
to 10% to 20% colloidal silica.
 Use: 1) anterior teeth if carefully polished.
2) Material that could compare favorably with dental amalgam
in wear resistance in class I and II.

52.  5.Nanohybrid composites:
 They have superior esthetic and wear resistance, high polishability,
and superior handling characteristics.
 They are marketed as universal composites.
 Because their handling and esthetic qualities make them suitable
for anterior buildups, while their micro sized particles gives them
very acceptable wear resistance.

53.  6. Flowable composites : This material has made it possible to fill
small cavities on occlusal surfaces.
 Often used to seal the dentin of a tooth prior to placing the filling
material.
 Due to the low level of filler particles, flowable composites are
more prone to shrinkage and wear, so they are generally not used
in bulk to fill large cavities.

54.  Resin Infeltrate:
 A new minimally invasive technique on smooth surface white spot lesions.
HOW DOES CARIES INFILTRATION WORK?
 Caries infiltration works by capillary action, whereas sealants only cover
incipient caries lesions at the surface of the tooth (and eventually wear
off).
 With this technique, the unique low viscosity resin is drawn deep into the
pore system of a lesion like a sponge draws up liquid.
 The resin completely fills the pores within the tooth, replacing lost tooth
structure and stopping caries progression by blocking further introduction
of any nutrients into the pore system.
 Carious lesions are stabilized while the anatomical shape and color of the
tooth are not altered at all.

55. Posterior composite.
 The improved strength, hardness, and modulus of elasticity of
some of the newer composite resins, with their low thermal
conductivity and superior esthetics, indicate that they may serve as
alternatives for amalgam.
 Disadvantages
 Posterior class II restorations often have gingival margins in dentin
or cementum >> No direct access to light cure >> physical
properties and colure changes >> management by increment
curing.
 Curing shrinkage >> microleakage .
 It compromised by moisture contamination during placement.

56.  Pits and fissure sealant
 Types: 1. Opaque materials are available in tooth color or white.
2. Transparent sealants are clear, pink, or amber.
 The clear and tooth-colored sealants are esthetic but are difficult to
detect by examiner.
 The cariostatic properties of sealants:
1) The physical obstruction of the pits and grooves.
2) Prevents colonization of the pits and fissures with new bacteria
3) prevents the penetration of fermentable carbohydrates to any
bacteria remaining in the pits and fissures.

57.  Indications :
1) Deep retentive fissures.
2) No evidence clinically / radiographicaly of proximal caries.
3) High caries risk patient.
4) Stained pits and fissures with appearance of declassification.
5) Tooth in the mouth less than 3 years.
• Contraindications:
1) Well coalesced , self cleansing pits and fissure.
2) Clinically / radiographically evidence of proximal caries.
3) Tooth not fully erupted.
4) Isolation not possible.
5) Dental caries
6) Tooth in the mouth 3 years and more.

58. Acid Etching Technique
 One of the most satisfactory methods for mechanical bonding of
resin to enamel .
 The enamel is etched with a solution of phosphoric acid (usually
about 35%) for approximately 15 to 20 seconds.
 Use a water rinse to remove the debris produced during etching. A
minimum wash time of 30 seconds .
 The acid cleans the enamel to provide better wetting of the resin
and creates pores into which the resin flows to produce “tags” that
greatly increase retention.

59. Bonding Agent
 Enamel bonding >> mechanical bonding to tooth structure.
 The dentin-bonding systems >> removal of the dentin smear layer
and decalcification of the outer layer of intact dentin with an acid
(primer).
 It is important that the etched dentin surface not be desiccated
before application of the primer when systems with hydrophilic
primers are used.
 systems combine the primer and the resin adhesive into one
component.
 systems mix together the acid, primer and resin adhesive before
they are placed on the tooth surface (self etching).

60. GENERATION TIME
PERIOD
DEVELOPMENT
1 1950-1970 Experimentation with mineral acids for bonding acrylic
to enamel, concern about etching of dentin, bonding
agents not utilized with composites.
2 Early 1970s Acid etching of enamel, enamel bonding agents
3 Late 1970s Hydrophobic enamel bonding agents, hydrophilic
dentin bonding agents, light cured components.
4 Mid to late
1980s
Removal of dentin smear layer, acidic monomers and
acidic pretreatments,, reduction of steps in bonding
technique, multiuse bonding agents.
5 Early 1990s Etching to achieve hybrid layer in dentin, hydrophilic
agents for both enamel and dentin, bonding to moist
tooth structure, single bottle primer adhesives.
6 Mid to late
1990s
Self etching primers and primer adhesives, light and
dual cured options
7 Early 2000s No mix, self etching adhesives.

61. Ideal Requirements for Bonding Agent:
 Biocompatible.
 Non toxic, non irritant, non poisonous.
 Low film thickness, low viscosity.
 Form strong permanent bond.
 Good dimensional stability.
 Low thermal conductivity.
 Good shelf life.
 Prevent micro leakage.
Indications:
 All direct composite resin restoration, both anterior& posterior.
 For bonding indirect composite resin inlays, onlays and veneers.
 For bonding indirect ceramic veneers , inlays and onlays.
 Bonded amalgam restorations.
 Management of dentin hypersensitivity.

62. “ You Have Ferrari in Cars,
Harley Davidson in Bikes
And Stainless Steel Crowns in Pediatric
Dentistry”
Dr. MUTHU MS
Crowns in Pediatric Dentistry
1. Stainless Steel Crown

63.  Indications:
1. Restorations for primary or young permanent teeth with extensive
and/or multiple carious lesions .
2. Restorations for hypoplastic primary or permanent teeth that
cannot be adequately restored with bonded restorations.
3. Restorations for teeth with anomalies.
4. Restorations for pulpotomized or pulpectomized primary or young
permanent teeth .
5. Restorations for fractured teeth.
6. Restorations for primary teeth to be used as abutments for
appliances.
7. Attachments for habit-breaking and orthodontic appliances.

64. Stainless Steel Crowns for Anterior Teeth

65. 2. Open-face stainless steel crown: crown of appropriate size is
selected, contoured at the cervical margin, polished, and
cemented into place. labial metal cut away, leaving a labial
“window” that is then restored with composite.

66. 3. Alginate impression be made before the restorative appointment.
The crown preparations can then be simulated on a stone model.
 This procedure enables the clinician to cement the crowns at the
same appointment at which the preparations are made.

67. 4. Resin celluloid strip crown technique wherein the tooth is restored
with composite resin using a celluloid crown ( Strip Crown) form
as a matrix.
Very little finishing of the restoration is required when the celluloid
crown has been properly fitted.

68. 5. stainless steel crowns with esthetic facings pre-veneered
 Available in anterior and posterior versions.
 Primary crowns are anatomically correct, stainless-steel crowns with
natural-looking tooth-colored facing.
 Such crowns are available for direct adaptation to the teeth and
have had a significant amount of success.

69. 6. Zirconia Crown:
 It is the next generation in pediatric restorative
technology and represents the perfect balance of
art and science.
 Made from zirconia ceramic.
 Anterior and posterior primary teeth.
Indications:
1) Caries.
2) Tooth surface loss.
3) Inherited defect.
4) Trauma.

70.  Advantages of Zerconia Crown:
1) Esthetic.
2) Strength.
3) Biocompatible.
4) Decreased Chair time.
5) No impression: only 1 visit.
• Disadvantages:
1) No crimping, tooth must prepared to fit the
crown.
2) Saliva an hemorrhage must be controlled.
3) Limited colure.
4) Cost .

74. Referances
 Dentistry for Child and Adolescent, Mcdonalds; 9th edition, chapter 16,17 and
18.
 Pediatric Dentistry: Infancy through Adolescence, Paul S.
Casamassimo , Henry W., Jr. Fields , Dennis J. McTigue , Arthur Nowak ; 5th
edition.
 Aesthetic and Cosmetic Dentistry Made Easy , P. B. Mathur, Sanjay Bansi
Mathur; 1st edition chapter 19.
 Textbook of Pediatric Dentistry , Nikhil Marwah ; 3rd edition.
 http://www.nusmilecrowns.com/
 http://www.kinderkrowns.com/
 Dr. Sung-Ki Kim developed ZIRKIZ crowns(Ready-made primary
anterior crowns) 2013 Qualified instructor of NuSmile crowns.