Restorative dentistry for pediatric teeth
State of the art 2001
GORDON J. CHRISTENSEN, D.D.S., M.S.D., Ph.D.
Many changes have occurred in dental restorative materials and techniques since the time when amalgam was the material most used for restoration of pediatric teeth. Amalgam has received criticism for its alleged health challenges since the beginning of its use. For more than 30 years, resin-based composites have been used with varying levels of success in Class II areas of adult teeth and, to some degree, in pediatric teeth. For about 15 of those years, resin-based composites have been relatively successful when the material is used properly and the teeth have only a small or moderate degree of dental caries. More recently, several new materials have been developed and popularized that have significant levels of fluoride release. These materials have the potential for caries-preventive influence not only on the restored teeth but also, because of the fluoride released into the mouth, on other teeth as well.
What are the trends in restorative concepts for pediatric dentistry? This article discusses the various restorative concepts and materials for restoration of pediatric teeth and provides information about the popular trends in pediatric restorative dentistry as I have observed them on the international lecture circuit.
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COMPOMER
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After several years, and generally favorable research reports around the world, compomer is becoming one of the most promising restorative materials for pediatric teeth.1 Compomers are hydrophilic resins containing glass particles that are dissolved somewhat as the fluids of the mouth activate the acid in the material. As a result of the dissolution, fluoride is released. The assumption is that the fluoride provides cario-static activity. Because a layer of bonding agent needs to be applied before the compomer is placed, the possibility for fluoride release into the tooth preparation is reduced.
Is compomer an acceptable material for pediatric teeth? Numerous studies have observed compomer service in the mouths of children, and they have concluded that the materials are acceptable in pediatric teeth.2,3 Of course, the service potential for restorations in posterior pediatric teeth need be only a few years, ranging from about two years of age until about 12 years of age, or a maximum of about 10 years.
Placement of compomer is relatively simple. The material is puttylike in consistency. It is placed easily in tooth preparations, because it is not sticky. Finishing the material also is not difficult, because it can be cut easily with typical finishing instruments. One negative characteristic of compomer is that it cures only with light, which does not allow it to be used in areas of questionable light accessibility.
The long-term service characteristics of compomer are less desirable than those of resin-based composite, because of lower strength and higher wear rates. Example products are Compoglass F (Ivoclar-Vivadent), Dyract AP (Dentsply Caulk), F2000 (3M Dental Products) and Elan (Kerr).
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HYBRID IONOMER
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Hybrid ionomer also has received significant use as a pediatric restorative material, but it is not as popular as compomer. However, it has high promise for pediatric teeth.4 Hybrid ionomer’s characteristics are different from those of compomer, a fact that probably leads to the differences in popularity. Hybrid ionomer is a combination of glass ionomer and resin, and its physical characteristics are a blend of those of the latter two materials. The two components must be mixed together either by hand or mechanical trituration. The mix is of relatively low viscosity when compared with compomer. This liquid viscosity makes the material more difficult to place in a tooth preparation than compomer. The strength of hybrid ionomer is comparable with that of compomer, but less than that of resin-based composite.
Why would a practitioner choose to use hybrid ionomer when compomer is easier to use? Hybrid ionomer has three modes of cure. When a restoration is large, or the tooth preparation wraps around the tooth, the ability of light to penetrate through the restorative material and into the preparation is reduced. When these conditions exist, the tricure characteristics of hybrid ionomer are necessary. Hybrid ionomer has a higher level of fluoride release than does compomer. It does not require use of a bonding agent before placement and, therefore, fluoride ion is not blocked from the tooth preparation. In the most caries-active patients, hybrid ionomer is probably the best restorative material choice. Example products are Fuji II LC (GC America Inc.), Vitremer Core Buildup Restorative (3M Dental Products) and Photac-Fil (ESPE America).
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RESIN-BASED COMPOSITE OVER COMPOMER OR HYBRID IONOMER
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When occlusal tooth preparations are wider than desirable in the facial-lingual aspect, it may be necessary to place a layer of resin-based composite over the surface of either of the cariostatic materials to increase the restoration’s wear resistance.
In the most caries-active patients, hybrid ionomer is probably the best restorative material choice.
The technique is simple. Depending on practitioner choice and the need for cario-static activity in the restoration, either compomer or hybrid ionomer is placed in the deepest portion of the tooth preparation. The material is cured, and a layer of any low-wear resin-based composite is placed over the cured preventive material. There is no need to place a bonding agent on the preventive material before placing the resin-based composite, because there is a layer of uncured resin left on the restoration surface if you have not washed it off. This technique provides a lower rate of wear for the pediatric patient than either of the two preventive materials alone.
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ENHANCED-STRENGTH GLASS IONOMER
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When rapid placement is necessary, such as in the event of an uncooperative patient, another material choice may be in order. Several improved versions of conventional glass ionomer are available for such situations. These products provide the tooth color of conventional glass ionomer and greater strength than conventional glass ionomer. These materials must be mixed, either by hand or on a triturator. The enhanced-strength glass ionomer is applied to the tooth preparation in a putty mass and contoured into place. The material sets by a typical acid-base reaction, and it does not require light curing. It is easy to finish, and clinicians report that the restorations serve for several years. Example products are Fuji IX GP (GC America Inc.) and Ketac-Molar Quick (ESPE America). Both of these products are available in quicksetting forms.
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AMALGAM
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Yes, amalgam is still around, and it has served for many years. Most practitioners know the good and bad characteristics of amalgam when used in primary teeth. A typical small amalgam restoration in a child’s tooth usually will serve for the needed life of that tooth. Larger amalgam restorations tend to chip out around the margins in pediatric teeth, and the enamel also chips out around the margins in the child’s tooth. In my opinion, the several alternatives to amalgam, described in the preceding portion of this column, challenge the continued use of amalgam in children.
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STAINLESS STEEL CROWNS
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For many years, clinicians have placed stainless steel crowns on children’s teeth that have been greatly destroyed by dental caries. The concept has worked well and has saved many teeth that otherwise would have been removed. However, the continued use of nickel in dentistry is being challenged by both dentists and patients because of its alleged allergenic potential. In my opinion, alternatives for the use of stainless steel crowns should be devised as soon as possible—such as titanium-alloy crowns made in similar molds.
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RESIN-BASED COMPOSITE
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Dentists have used resin-based composites in children for many years, but they are difficult to place and have little or no caries-preventive properties. It appears to be more logical to place a fluoride-releasing material first.
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SUMMARY
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As reported to me by practicing dentists in continuing education courses, amalgam use in pediatric dentistry has diminished significantly during the past few years. Compomer has become the most popular restorative material for posterior pediatric tooth restorations. Hybrid ionomer also is popular, and it probably is the best choice for teeth that are highly carious. When excessive wear is expected, resin-based composite can be placed over the occlusal surface of larger pediatric restorations.
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Dr. Christensen is co-founder and senior consultant of Clinical Research Associates, 3707 N. Canyon Road, Suite No. 7A, Provo, Utah 84604, and is a member of JADA’s editorial board. He has a master’s degree in restorative dentistry and a doctorate in education and psychology. He is board-certified in prosthodontics. Address reprint requests to Dr. Christensen.
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FOOTNOTES
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The views expressed are those of the author and do not necessarily reflect the opinions or official policies of the American Dental Association.
Educational information on topics discussed by Dr. Christensen in this article is available through Practical Clinical Courses and can be obtained by calling 1-800-223-6569.
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REFERENCES
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- Croll TP. Using the 3M F2000 compomer restorative system in pediatric dentistry. Perspect Esthet Dent 1998; 3(2):1–3.
- Hativobic-Kofman S, White T, Ali A. Microleakage and fracture resistance of compomers and amalgam (abstract 208). J Dent Res 1998;77(special issue B):657.
- Peters T, Roeters J, Frankenmolen F. Clinical evaluation of Dyract in primary molars: 1-year results. Am J Dent 1996;9;(2): 83–8.[Medline]
- Croll TP. Restorative dentistry for preschool children. Dent Clin North Am 1995;39(4):737–70.[Medline]
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COMPOMER
HYBRID IONOMER
