Silabus Eng

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The Ohio State UniversityCollege of Dentistry

Division of Pediatric Dentistry and Community OralHealth

Pediatric Dentistry

6551

__________________________________________________________________________________________

Course SyllabusSummer 2012


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Pediatric Dentistryis an age-defined specialty thatprovides both primary and specialty comprehensivepreventive and therapeutic oral health care for infantsand children through adolescence, including those with

special health care needs.


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PEDIATRIC DENTISTRY 6551

INTRODUCTION TO PEDIATRIC DENTISTRY

July 5, 20128:30-9:20 Introduction/ Prevention and Oral Hygiene Dr. Griffen9:30-10:20 Fluorides I Dr. Griffen10:30-11:20 Fluorides II Dr. Griffen

Pediatric Dentistry: Ch. 14: 220-233Ch.19: 313-323; Ch.31: 513-519; Ch.38: 690-694

July 6, 20127:30-8:20 Restorations in the Primary Dentition I Dr. Griffen

Pediatric Dentistry: pages 341-356

8:30-11:30 LAB: Resins12:30-1:20 Restorations in the Primary Dentition II Dr. GriffenPediatric Dentistry: pages 357-363

1:30-4:30 LAB: Stainless Steel Crowns

July 13, 20127:30-8:20 Pulp Therapy in the Primary Dentition Dr. Gosnell

Pediatric Dentistry: pages 381-3918:30-12:00 LAB: Pulpotomy12:10-12:50 Clinic Orientation *LUNCH PROVIDED* Dr. Gosnell1:00-4:30 LAB: Practical

July 16, 20124:30-5:30 PM Final ExamRoom 1187


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Pediatric Dentistry 6551Introduction to Pediatric Dentistry

Summer 2012

Course Director: E. Gosnell, DMD, MSOffice: 4126 Postle HallTelephone: 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 andyoung permanent dentition. The course includes lectures and laboratory sessions on restorativetechniques 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 steelcrowns.

Course Format

The course will consist of seven one-hour sessions with assigned reading for each lecture. Inaddition there will be 4 laboratory sessions with reading material in the syllabus assigned foreach laboratory session. Finally, there is a final exam and will be held on Monday, July 164:30-5:30 in Postle Hall Room 1187. The final exam may consist of multiple choicematching, short answer, and/or identification.

Course Textbook

Each student is expected to purchase a copy of the course textbook. There will be assignedreadings 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 DJand Nowak AJ., Elsevier Co.

Evaluation

Grading is based 95% on the final exam, but also requires successful completion of allaboratory 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 (StudentEvaluation of Instruction online).

AbsencesDue 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 directlywith Dr.Gosnell these are limited to; birth, death or illness requiring medical attention) will begiven a tentative grade of I until deficient portion of the course is completed througharrangements with Dr. Gosnell directly.


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B. Any student missing a portion of lab for an unexcused reason will be given a final gradeof I and will be required to take the entire course (lecture and laboratory) in July 2013 toreceive full credit.

Academic Misconduct

Students are reminded that all graded work is to be solely their own. Academic misconduct is avery serious offense. Faculty Rule 3335-5-54 will be followed for this course which states "Eachinstructor shall report to the committee on academic misconduct all instances of what he/shebelieves may be academic misconduct." Students are expected to adhere to the College ofDentistry Code of Professional Conduct.

Laboratory Safety and Infection Control Protocol

Proper infection control and safety protocols to be followed in the pre-clinical laboratoryinclude the following: wearing protective eyewear when working with any hazardous chemicalsor laboratory equipment that could cause eye injuries, wearing masks (and using ventilationsystem) during any procedure that involves generation of dust or an aerosol, wearing gloveswhile handling any hazardous materials and following the OSU dress code policy in the pre-clinical laboratory as stated in the Colleges Dress Code. This protocol will be monitored andenforced by course faculty to ensure compliance.


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GENERAL INFORMATION

PEDIATRIC CLINICAL DENTISTRYDivision of Pediatric Dentistry and Community Oral Health 292-1509

Division Chairman Dr. Paul S. CasamassimoChildren's Hospital or4132 Postle Hall

292-1509

Pre-Doctoral Program Director Dr. E. Gosnell4126-B Postle Hall292-9573

Post-Doctoral Program Director Dr. Homa AminiChildren's Hospital722-5651

Faculty - Full Time Dr. Ann Griffen4126-A Postle Hall292-1150

Dr. Ashok KumarChildrens Hospital722-5649

Dr. Dennis J. McTigue4140 Postle Hall292-0898

Dr. Megann SmileyChildrens Hospital722-5651

Dr. Diego SolisJohnstown/Nisonger475-0564

Dr. S. Thikkurissy4126-C Postle Hall292-1788

Clinical Faculty - Part Time Dr. F. Thomas HagmanDr. Gerald KassoyDr. Kara MorrisDr. Cecilia Moy

Office Associate Mrs. Gretchen J. Hollern4126 Postle Hall292-1509

Clinical Staff Mrs. Peg GreekMrs. Dorothy Harold

Clinic Phone Number 292-2027

Clinic Hours of Operation M, T, F: 8:30 -11:301:00 - 4:30

Th: 9:30 11:30; 1- 4:30W: 1:00 - 4:30


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The Ohio State University

College of DentistrySection of Pediatric Dentistry

Pediatric Dentistry 6551

(Pre-Clinical Laboratory)

____________________________________________________________________________________________________



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TABLE OF CONTENTSDentistry 6551Summer 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 forPrimary Molars


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LABORATORY DIRECTOR: E. Gosnell, DMD, MS

LAB DESCRIPTIONPediatric Dentistry 6551 includes a preclinical laboratory series emphasizing selected techniquesunique to Pediatric Dentistry. The teaching format of the course consists of lecture material,interaction with the laboratory instructor and performance of the techniques on dentoforms.

LAB GOALS:1 . To develop knowledge, experience, and technical skills necessary for appropriate

restoration and preventive procedures for the child patient.2. To develop the ability to objectively self-critique clinical work and determine levels

of satisfactory (clinically acceptable) work.

LAB OBJECTIVES:1. Diagnose and formulate a treatment plan for the treatment of incipient to majordental caries.2. Understand the indications for the techniques used in the prevention of dentalcaries.

3. Understand the indications for the techniques used in the restorative treatment ofdental 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 pulpalpathology.

LAB SCHEDULE:There will be 4 laboratory sessions which will meet as indicated on the master schedule. Apractical examination, consisting of a class II resin preparation and a stainless steel crownpreparation and adaptation, will be given as a self-paced practical. You and your rowinstructor will determine when you are ready to take the practical.

TEXTBOOK(S) AND READING:Reading assignments for this course will come primarily from this syllabus, but thetextbookPediatric Dentistry: Infancy Through Adolescence, Pinkham et al, 4th Edition, SaundersCo., 2005,is the required textbook for ALL pediatric courses, and there will be some assignedreadings. Studentsare expected to have a copy.

EVALUATION AND GRADING:To complete the laboratory portion of the course the student must complete all laboratorywork at a satisfactory level as judged by his/her lab instructor's evaluation. The evaluationcriteria for all lab work are listed on evaluation forms included in this syllabus. In additiona practical exam will be given at the completion of the lab course.

POLICIES AND PROCEDURES:For the exercises that are performed on the typodont, if a student significantly deviatesfrom clinical acceptability (a critical error) with their preparation he/she may be asked tore-do the preparation. There is no grade penalty for repeating a procedure.


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Lab work may NOT be completed outside of scheduled time. There will be sufficient timein thelab to complete all of the necessary work.


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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 LectureRestorations in the Primary Dentition II, Room 11871:30-4:30 Lab II # J (SSC)

#S (SSC)

July 13 7:30-8:20 Lecture Pulp Therapy in the Primary Dentition, Room1187

8:30-12:00 Lab III #B (Pulpotomy and SSC)

Continue #I,A,30,J,SSelf-paced practical**12:10-1:00 Clinic Orientation: Lunch provided1:00-4:30 Lab IV Continue #I,A,30,J,S,B

Self-paced practical**

**Self paced practical as determined bybench instructor**


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RUBBER DAM PLACEMENT

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

OBJECTIVES:

The student should be able to:

1 . State several advantages of the use of the rubber dam in children.

2. State several contraindications for use of the rubber dam.

3. State which rubber dam clamp should be used for:--partially erupted 1st permanent molars--fully erupted 1st permanent molars--second primary molars

--first primary molars

4. State how far apart the holes should be punched on a rubber dam, and describe what will happen ifholes are too close together. Too far apart?

5. State the number of teeth to be isolated when doing a one surface restoration. A multi-surfacerestoration?

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.


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RUBBER DAM APPLICATION IN PEDIATRIC DENTISTRY

The rubber dam is used for virtually all restorative procedures in pediatric dentistry. It is placed prior to cavitypreparation and usually left in place until the final restoration has been completed.

There are a number ofadvantages for the use of a rubber dam in children.

1. Great accessibility and visibility:a. retracts soft tissue;b. provides dark contrasting background;

2. Control of moisture;3. Decreased operating time;4. Enhances the quality of work;5. Protects the soft tissues and prevents swallowing of dental instruments;6. Improved infection control;7. Improved patient management.

Contraindications:

1. Bands on teeth2. Patients with poor nasal airway exchange3. Patients with allergy to latex (if non-latex dam is not available)4. Rubber dam clamp cannot be retained due to eruption state of the tooth

Armamentarium:

--Dark, medium gauge 6"x6" or 5"x5" dam material--Rubber dam frame--Clamps #14, #7 - for erupted 1st permanent molar

#14A, #8A - for partially erupted permanent molars#3 - for second primary molars#2 - for premolars and first primary molars

--Rubber dam punch--Rubber dam forceps--Scissors--Waxed floss--Cotton pliers

Hole Placement:

--Use a template--Dividing the dam in sixths--Holes are placed 3.5 mm apart


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a. If placed too close together, the dam will leakb. 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 andboth 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. Formaxillary teeth, ask the child to "put her or his chin toward the ceiling" for the best visibility.


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Application Techniques:

1. Placement of clamp, then dam and frame are placed over the clamp. This method is preferredbecause of the good visibility it allows the operator of the tooth to be clamped and of the gingivaltissue.

2. Placement of clamp, dam and frame as a unit. This method may be used, however, visibility of thetooth 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 interproximalsepta will be severed during rotary instrumentation. The most frequent use of this technique will be forpreparation 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 accessibilityand visibility to the operating field. Moisture control is not optimal but this is of little consequence for crownpreparations.

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;


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CONSERVATIVE CLASS I

RESTORATIONS

CONSERVATIVECLASS I COMPOSITE


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READING ASSIGNMENT: Syllabus material and Assigned reading: Pediatric Dentistry Infancy throughAdolescence pages 352-356

OBJECTIVES:


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.


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Conservative Class I Preparation and RestorationSelf -Evaluation

CONSERVATIVE CLASS I COMPOSITE

1 . Occlusal surface free of plaque and debris.

2. Caries removed.

3. Tooth surface chalky-white after etching, rinsing and drying.

4. Resin placed in cavity preparation.

5. Sealant applied over and to ALL susceptible pits andfissures on the tooth.

6. No voids found in the sealant.

7. Sealant can not be dislodged with an explorer.

8. Occlusion adjusted.


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What is a CONSERVATIVE CLASS I COMPOSITE?

The conservative class I restoration is indicated for small carious lesions that progress into dentin. It is alogical extension of sealant philosophy and technique. The preventive approach of sealing susceptible pitsand fissures is combined with conservative cavity preparation of caries occurring on the same occlusalsurface. Instead of the traditional amalgam cavity preparation "extension for prevention" beyond the area ofdecay 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 arefilled with a flowable or a conventional resin and covered over with a sealant to protect the remaining groovesand pits. This results in a restoration that conserves tooth structure and is both therapeutic and preventive.

CRITERIA

1 . Questionable carious areas2. Incipient lesions3. Well-confined carious lesions4. Enamel defects

LABORATORY SIMULATION

Your dentoform contains a plastic tooth (#30) which has been prepared to simulate a caries situation. For thelaboratory situation you will need a high speed (330) to remove the darkened carious material until you seewhite tissue. The preparation that results is your conservative Class I composite preparation. You will not beplacing a base, but simply restoring the preparation with composite and sealant.


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CONSERVATIVE RESTORATION (D-E):

D. In this diagram the caries extends into the dentin. Again, a 330 bur is used to conservatively removethe decay.

E. In this example, a glass ionomer liner (L) is placed over the dentin. This is followed by a bondingagent (BA) and posterior resin (CR) material. Finally, a sealant (S) is placed over all the remaining

susceptible pits and fissures.


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TECHNIQUE

CONSERVATIVE CLASS I & SEALANT W/ CARIES EXCAVATION

1. Prepare tooth with an appropriate bur by removing only carious areas and/or those areas suspectedof being carious. NOTE: ALL GROOVES DO NOT NEED TO BE OPENED AND NO EXTENSIONFOR 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. A15 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 andsuction. 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 howslight, at any time during the etching procedure necessitates a 10 second re-etch followed by rinsingand 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 disposablebrush tip provided and air thin. NOTE: DO NOT USE SAME BRUSH TIP THAT WAS USED TO

APPLY THE ETCHING AGENT.

7. Cure bonding agent for 10-15 seconds. Larger cavities may require two coats. (Two thin coats arebetter than one thick and pooled coat.)

8. Using the applicator gun or syringe (for flowable), extrude into the cavity, restoring to surface levelenamel. 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


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1. Slowly paint the sealant into the grooves and any development pits with the brush tip on the sealantsyringe.

2. Care should be taken to avoid entrapment of air by not trying to force resin material into orifices of thepreparation or fissures with tip of brush. Sealant should extend up cuspal inclines to just clearocclusion. 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 visiblelight source for 40 seconds on each surface keeping end of light tip 1-2 mm from surface. If area to bepolymerized is larger than tip of light, tip should be moved slowly over entire surface. The time shouldbe 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 anexplorer over it and (2) retention by trying todislodge it. If a void is encountered, a small amount ofmaterial can be added provided no salivary contamination has occurred. Retention failures areusually caused by moisture contamination and necessitate repeating application procedurebeginning 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 orfinishing burs.


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CLASS II COMPOSITE RESTORATIONS

IN PRIMARY MOLARS


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CLASS II COMPOSITE PREPARATION FOR PRIMARY TEETH

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

OBJECTIVES:


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 IIcompsite 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 toofar gingivally.


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CLASS II COMPOSITEPRIMARY 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 enamelsurrounding 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 externalsurface.

10. Buccal and lingual proximal margins can be explored withexplorer tip.

11. Gingival - axial line angle 90o

12. Axial - pulpal line angle beveled.


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Anatomic Considerations of Primary Teeth

Although some primary teeth show resemblance to their permanent successors, they are not miniaturepermanent teeth. Several anatomic differences must be distinguished before restorative procedures arebegun.

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 thanpermanent 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 anocclusal direction from the dentino-enamel junction. This is in contrast to thepermanent dentition in which the rods extend in a cervical direction.

5. Primary teeth demonstrate greater constriction of the crown and have a moreprominent cervical contour than permanent teeth.

6. Primary teeth have broad, flat proximal contact areas.7. Primary teeth are whiter in color than their permanent successors.8. Primary teeth have relatively narrow occlusal surfaces compared to their permanent

successors.

The principles of class II composite preparation for primary teeth are essentially the same as that taughtin restorative dentistry with a few modifications because of some of the morphologicalfeatures of primary molars.

In this course, the student will learn to prepare primary molars for composite restorations with anunderstanding 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.


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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 enamelsurface). The length of the cutting end of the No. 330 bur is 1.5 mm, so this becomes agood 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 shouldbe greater than the width of the isthmus to produce a locking form to provide resistanceagainst occlusal torque, which may displace the restoration mesially or distally.

The isthmus should be one third of the intercuspal width, and the bucco-lingual wallsshould converge slightly in an occlusal direction.

The mesial and distal walls should flare at the marginal ridge so as not to undercutridges.

Oblique ridges should not be crossed unless they are undermined with caries or aredeeply 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 beremoved.

Ideally, the axial wall of the proximal box should be 0.5 mm into dentin and shouldfollowthe same contour as the outer proximal contour of the tooth.

Since occlusal forces may permit a concentration of stress within the amalgam aroundsharp angles, the axio-pulpal line angle is routinely beveled or rounded.

NO BUCCAL OR LINGUAL RETENTIVE GROOVES SHOULD BE PLACED IN THE

PROXIMAL BOX.

The mesio-distal width of the gingival floor should be 1 mm, which is approximatelyequal to the width of a No. 330 bur.

In primary teeth many practitioners limit class II composite restorations to relatively small two surfacerestorations. Three surface (MOD) restorations may be done, but studies have shown that stainless steelcrowns are a more durable and predictable restoration for large and multisurface caries restorations.


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Class II Cavity Preparation

MESIO-OCCLUSAL CAVITY OF MANDIBULAR RIGHT SECOND PRIMARY MOLAR

Methods of cavity preparation described in this handout are applicable to the student using the high-speed handpiece. On occasions it may be necessary to use the slow speed handpiece for gross removal

of deep decay, for accessibility and for use in cavity preparation for hyperactive children. Consequentlythe slow speed handpiece should be mounted and ready for use prior to an operative appointmentfor 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 cutthrough 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

ofthe cusps by undermining.

2. Establish the width of the isthmus approximately one-third the distance between the cuspsor 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 thedentino-enamel junction (Fig. 4).

Proximal view which illustrates the movement of the #330 bur toward the gingival.


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4. Move the bur bucco-lingually with a pendulum motion so that the widest bucco-lingual width of thebox is at the gingival margin. Do not increase the width of the isthmus. The proximal box-outline willlook like an inverted cone (Fig. 5).

Proximal view which illustrates the angulation of the handpiece and the #330 bur when cutting theproximal box.

5. The proximal box is extended gingivally to break contact with the adjacent tooth and to a depth wherethe 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 thecurvature 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 lingualmargins.

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.


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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 theocclusal portion and the divergence of the proximal box walls.

RESTORATION OF CLASS II

Matrix ApplicationMatrices 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 typesofmatrix bands are available for use in pediatric dentistry.1 . T-band: allows for multiple matrices; no special equipment is needed2. Tofflemire matrix: can be difficult to place as multiple matrices


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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 theadjacent tooth, beneath the gingival seat of the preparation. The wedge is placed with a pair of Howepliers or cotton forceps from the widest embrasure. The wedge should hold the band tightly againstthe tooth but should not push the band into the proximal box. It may be necessary to trim the wedgeslightly 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 inthe proximal box.

5. Using a small condenser, condense the composite into the corners of the proximal box and againstthe matrix band to ensure the re-establishment of a tight proximal contact. Continue filling andcondensing until the entire cavity is overfilled.

6. Carving of the occlusal portion is performed with a small cleoid-discoid carver, as in Class Irestorations.

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 seethat the height of the newly restored marginal ridge is approximately equal to the adjacent marginalridge.

9. Gently floss the interproximal contact to check the tightness of the contact, to check for gingivaloverhang, and to remove any loose resin particles from the interproximal region.

10. Remove the rubber dam carefully.

11. Check the occlusion for irregularities with articulating paper, and adjust as needed.

LABORATORY SIMULATIONSome technical problems inherent in the lab situation due to the rubberized gingiva and varying tooth sizeinclude:

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 attemptto 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 tocheck on the mesial-distal orientation of the tooth. Otherwise, you may find the preparation is too wideinterproximally.


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SOME COMMON ERRORS OF CLASS II PREPARATIONS


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Restorative Dentistry for Children / The Class II

Figure 14: The flare of the proximal box is too wide. The divergence of the buccaland lingual walls is lost because of improper angulation of the burresulting 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 toodeep, resulting in pulp involvement.

Figure17


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Figure 18: Because of the prominent cervical bulge of primary molars, increasing the depthof the gingival floor can result in penetration of the tooth at the constriction.

Figure 18


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PULPOTOMY AND

STAINLESS STEEL CROWN

PROCEDURES

FOR PRIMARY MOLARS


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PULPOTOMY TREATMENT

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

OBJECTIVES:


1. List several findings which contraindicate pulpotomy treatment on aprimary 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.


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PULPOTOMY PROCEDURESELF 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).


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PULPOTOMY PROCEDURES FOR PRIMARY MOLARS

Pulpotomy is indicated for vital primary teeth whose pulps have been exposed. It is the treatmentof choice when there is no sign of the following: (1) spontaneous pain, (2) swelling, (3) tendernessto 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 Universityrecommends the use of ferric sulfate for the vital pulpotomy procedure in primary molars. Many otherdental schools teach the use of formocresol for primary teeth pulpotomys and this material iscommonly used in dental practice today. Formocresol puplotomies have demonstrated a high rate ofclinical success; however concern is mounting over its safety. Formocresol induces a chronicinflammatory response and is potentially immumogenic,mutagenic and even carcinogenic. While thelikelihood of these events occuring may be low with a low concentration of formocresol, we haveelected to switch to ferric sulfate because recent research indicates that its success approaches thatof 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 theexposure site. Prepare an access opening that is sufficiently large by connecting the pulp horns, andthen remove the entire roof of the pulp.


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PULPOTOMY TREATMENT


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2. Coronal pulp amputation

Using a large sterile, large spoon excavator, incise and remove all pulp tissue within the coronachamber. A large, round bur in a slow speed handpiece is preferred by most dentists, but for theinexperienced, extreme care must be taken to avoid perforating the pulpal floor. The operator shouldbe able to locate and visualize all of the pulpal canals.

NOTE: Maxillary primary molars have 3 canals (mesiobuccal, distobuccal, lingual); Mandibular molarshave 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 shouldhave 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 pelletpressure is indicative of inflammatory pulp changes that have extended into the radicular pulp. Suchchanges preclude the tooth from remaining a good candidate for the pulpotomy procedure andpulpectomy or extraction is indicated. It should be noted that no intrapulpal local anesthesia should beused in attempting to minimize the hemorrhage, since bleeding behavior is a clinical evaluation that iscritical to judging the radicular pulp status. Be certain to remove the entire roof of the pulp chamber assmall 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 forapproximately 15 seconds with a rubbing motion. The pulp stumps are then blotted dry with cottonpellets.

5. Zinc oxide and eugenol base and final restoration

PLEASE NOTE:

ALL COTTON PELLETS ARE REMOVED FROM THE TOOTH PRIOR TO FILLING WITHZOE MATERIAL. ZOE IS PLACED IN DIRECT CONTACT WITH THE PULPAL STUMPS.

A regular mix of zinc oxide and eugenol (or a reinforced product such as IRM) should be placed at thebase of the coronal pulp chamber directly on the amputation sites and should be lightly condensedso as to fill the access opening completely. The final restoration should be a stainless steel crownand,should be placed at the same appointment as the ferric sulfate pulpotomy.


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STAINLESS STEEL CROWN (SSC)(Chrome Steel Crown)

READING ASSIGNMENT: Pediatric Dentistry: Infancy through Adolesence pages 357-363 and Syllabusmaterial

OBJECTIVES:


1. Describe indications, contraindications, advantages and disadvantages of theSSC 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 1stand 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.


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CHROME STEEL CROWN PREPARATIONSELF-EVALUATION

1. Occlusal surface is reduced 1-1.5 mm and follows cusp form.

2. Proximal cut; contact is cleared, reduction not greater than 1 mm.

3. Proximal walls are parallel or slightly convergent to occlusal.

4. Proximal cuts end cervically without chamfer or ledge.

5. Proximal walls are straight when viewed from occlusal and perpendicular to arch perimeter.

6. Cervical bulge remains, there is minimal or no buccal or lingual reduction.

7. All line angles are gently rounded.

CHROME STEEL CROWN ADAPTATIONSELF-EVALUATION

1. Crown is trimmed to 1 mm below gingival margin (for the Unitek crown only), and crown margin is fluidin 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 anddistal.

4. The aim of the stainless steel crown is to restore:OcclusionContact (if present before procedure)Gingival health


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Indications for Stainless Steel Crowns on Primary Teeth

1. To restore carious primary teeth that would otherwise require largeamalgam 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 highdecay rates where recurrent caries is expected.

5. To restore teeth in patients with hereditary anomalies - amelogenesisimperfecta, 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 arereferred 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 notrimming of the gingival margin is required. Although they have been pre-contoured and pre-crimped, furthercontouring 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.


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Steps of Preparation and Placement of Stainless Steel Crowns

(Note: Several different preparation designs have been advocated over the years. Only one suchpreparation, requiring minimal tooth reduction, is discussed here. Either Unitek or Ni-Chro Ion crownsmay 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 surroundingthe tooth to be crowned are well anesthetized, and place a rubber dam. Because gingival tissuesall around the tooth may be manipulated during crown placement, it is important to obtain lingualor palatal anesthesia, as well as buccal or facial.

3. Establish access with a No. 330 bur in the high speed handpiece, then removedecay with a large, round bur in the slow speed handpiece or with a spoon excavator.

4. Reduction of the occlusalsurface is carried out

with a No. 169L taper fissure buror a thin, tapereddiamond in the high speed handpiece. Make depth cuts bycutting the occlusal grooves to a depth of 1.0-1.5 mm, andextend through the buccal, lingual, and proximal surfaces.

Next, place the buron its side and uniformly reduce theremaining occlusal surface by 1.5 mm, maintaining thecuspal inclines of the crown. Alternatively a number 8 roundburmay be used.

5.Proximal reduction isaccomplished with thetapered fissure buror thin, tapered diamond. Contact with the

adjacent tooth must be broken gingivally andbucco-lingually, maintaining vertical walls with only a slightconvergence in an occlusal direction. The gingival proximalmargin should have a feather-edge finish line. Care must betaken 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 andoccluso-lingual line angles are rounded by holding the bur at a 30-45 degree angle to theocclusal surface and sweeping it in a mesio-distal direction. Bucco-lingual reduction for thestainless steel crown preparation is generally limited to this bevelling and is confined to the

occlusalone third of the crown. If problems are later encountered in selecting an appropriate crownsize or in fitting a crown over a large mesio-buccal bulge, more reduction of the buccal and lingualtooth structure may become necessary. The buccal and lingual proximal line angles arerounded 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 muchas to create a round preparation.


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7. Selection of a crown begins as a trial and-error procedure. The goal is to place the smallestcrown that can be seated on the tooth and to establish pre-existing proximal contacts. Theselected crown is tried onto the preparation by seating the lingual first and applying pressurein 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-betweensize, 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 thesmaller crown size.

After seating a crown, establish a preliminary occlusal relationship by comparing adjacent marginalridge heights. If the crown does not seat to the same level as the adjacent teeth, the occlusalreduction may be inadequate; the crown may be too long; a gingival proximal ledge may exist; orcontact may not have been broken with the adjacent tooth, preventing a complete seating of thecrown. If an extensive area of gingival blanching occurs around the crown, this indicates the crownis too long or is grossly over-contoured. A properly trimmed crown will extend approximately 1 mminto 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 theIon crown.

Contouring: Contouring involves bending the gingival one third of the crown's margins inward torestore anatomic features of the natural crown and to reduce the marginal circumference of thecrown, ensuring a good fit. Contouring is accomplished circumferentially with a No. 114 ball andsocket pliers (Figure 21 A, on next page) or with a No. 137 Gordon pliers. Remember that theIon crown is pre-contoured.

Crimping: Final close adaptation of the margin of the crown to the tooth surface is achieved bycrimping the cervical 1 mm of the margin circumferentially. The No. 137 pliers may be used forthis; 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 beencountered when the crown is seated. After seating the crown, examine the gingival margins withan explorer for areas of poor fit. Observe the gingival tissue for blanching, and examine theproximal contacts. If proximal contact needs to be established, it can be done with a ball andsocket pliers after removal of the crown.


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When removing the crown, a spoon or cleoid-discoid can be used to engage the gingivalmargin and dislodge the crown. A thumb or finger should be kept over the crown during removalso 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 thecrown 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 mouthA 2 X 2 inch gauze pad shouldbeplaced posteriorto the tooth being crowned to act as a safety net toprevent 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 ispreferred. 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 expressedfrom all margins. The handle of a mirror or the flat end of a band pusher may be used to ensurecomplete seating, or the patient may be instructed to bite on a cotton roll. Before the cement setshave 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 partiallyset, will reach a rubbery consistency. Excess cement may be removed at this stage with an explorertip. The interproximal areas can be cleaned by tying a knot in a piece of dental floss and drawing thefloss through the interproximal region. Alternatively the excess cement may be rinsed from the toothbefore initial setting.

13. Rinse the oral cavity well, and re-examine the occlusion and the soft tissues before dismissing thepatient.


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Two Principles for Obtaining Optimal Adaptation of Stainless SteelCrowns to Primary Molars (Spedding, 1984)

With few exceptions most stainless steel crowns look good in the mouth. Except in cases ofbruxism when crowns may be worn and flattened down, the crowns will continue to appearclinically

acceptable for many years. The radiographic appearance of the crowns is usually not asencouraging. Radiographically, margins are noted to be poorly adapted to proximal toothsurfaces. 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 periodontatissues. The deficiencies though can be largely avoided when attention is paid to two keyprinciples: (1) crown length, and (2) shape of the crown's gingival margins. The length of astainless steel crown should allow the crown to fit just into the gingival sulcus, engaging the naturaundercuts. But more importantly, the crown length should extend just slightly apical to the tooth'sheight of contour. For primary teeth the buccal, lingual and proximal heights of contour happen tobe just above the gingival crest. As a stainless steel crown is trimmed in length such that itsgingival margins come closer to the greatest diameters (heights of contour) of the tooth crown, thespaces 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 smalenough so that the metal can be adapted closely to the tooth. In other words, crowns that extendwell 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 asfrom buccal to lingual to proximal. The margins of the trimmed crown should approximate theshape of the gingival crest around the tooth. Figure A, next page, demonstrates the differentgingival contours. As you look at the marginal gingiva around the second primary molar you willnote that the occluso-gingival heights gradually become shorter along the crests of the gingivamargins towards both the mesial and distal surfaces. The outline of buccal and lingual gingivaaround second primary molars resemble smiles. The buccal gingiva of the first primary molar has adifferent outline. Due to the mesio-buccal cervical bulge the gingival margin dips down as it istraced 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 usedto describe the contour. However, the contours of the lingual marginal gingiva of all first primarymolars resemble smiles. The proximal contours of almost all primary teeth frown (Figure B nextpage), because the shortest occluso-cervical heights are about midpoint buccolingually. Bykeeping these shapes in mind when trimming the stainless steel crowns the close adaptation tothe tooth will be made much easier.

The margins of the finished, trimmed steel crown consist of a series of curves or arcs asdetermined by the marginal gingivae of the tooth being restored. There are no corners, jaggedangles, right angles or straight lines found on these margins. Contouring and crimping pliers arenecessary to apply the appropriate gingival adaptation. Keeping the principles of crown length andmarginal shape in mind will ensure optimal adaptation and clinical success of the crown.


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COMMON CLINICAL SITUATIONS AND THEIRSOLUTIONS DURING ADAPTATION OF CHROME STEEL CROWNS

1. DIFFICULTY IN SEATING CROWN

A. Insufficient occlusal reduction

1. Check occlusal reduction

B. Large cervical bulges or unusual contour of buccal or lingual1. Reduce buccal and lingual surfaces. REMEMBER: DO NOT DESTROY THE NATURAL

UNDERCUT AND ALL REDUCTION MUST END WITH NO LEDGE.

C. Ledge on preparation1. 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 cleared1 . Check with explorer, it should pass freely between proximals. Clear contact if indicated.

E. Crown that is too small1. Select larger crown2. If arch length will not permit a larger crown being used, stretch the smaller crown or

reduce overall size of tooth being prepared.3. Crown may be over adapted (made too small), shape crown outward.

F. Impingement (length) or trapping (width) of gingival tissue.

1 . Check to see that crown is fitting properly into cervical sulcus. Adapt as indicated.

2. DIFFICULTY IN REMOVING CROWN DURING ADAPTATION

A. Crown is tightly adapted.Crown is normally removed with a spoon; try removing with a discoid instrument.Normally crown is removed from buccal to lingual. Try removing from lingual.

3. CROWN THAT IS LOOSE

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


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Silabus Eng

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