Paediatric dentistry

5. Review about 2 microscopy analysis. still a problem, the methods

weeks later to check There was early allergy is a possibility. described is
that the patient is concern that There are no unknown. Theories
not experiencing bleaching solutions biological concerns of oxidation, photo-
any sensitivity, and with a low pH would regarding the short- oxidation, and ion
then at 6 weeks by cause term use of car- exchange
which time 80% of demineralization of bamide peroxide. It have been
any colour change enamel when the pH has a similar suggested.
should have fell below the 'critical' cytotoxicity on mouse Conversely, the
occurred. value of 5.2-5.8. fibroblasts to zinc cause of re-
However, no phosphate cement discolouration is also
Carbamide peroxide evidence of this and Crest toothpaste, unknown. This may
gel (10%) breaks process has been and has been used be a combination of
down to 3% hydrogen noted to date in any for a number of years chemical reduction
peroxide and 7% urea clinical trials or in the USA to reduce of the oxidation
in the mouth. Both laboratory tests, plaque and promote products previously
urea and hydrogen possibly because the wound healing. formed, marginal
peroxide have low urea (and However, there are leakage of
molecular weights, subsequently the no long-term studies restorations, allowing
allowing them to ammonia) and of its safety. Labora- ingress of bacterial
diffuse rapidly through carbon dioxide tory studies have and chemical by-
enamel and dentine. released on shown that products, and
This explains the degradation of the carbamide peroxide salivary or tissue
transient pulpal carbamide peroxide has a mutagenic fluid contamination
sensitivity elevate the pH. potential on vascular via permeable tooth
occasionally There is an initial endothelium and structure.
experienced with decrease in bond there may be harmful There is currently,
home bleaching strengths of enamel effects on the and has been for
systems. to composite resins periodontium, some years,
Pulpal histology with immediately after together with delayed continued confusion
regard to these home bleaching, but wound healing. relating to the legal
materials has not this returns to normal Published clinical position of dentists
been assessed, but within 7 days. This studies of 1-2 years' using tooth-
no clinical effect has been duration have shown whitening techniques
significance has been attributed to the that the yellowing of which involve the
attributed to the residual oxygen in ageing responds best use of bleach. The
changes seen with the bleached tooth to this treatment. situation at the time
35% hydrogen surface which inhibits Although this would of publication is that
peroxide over 75 polymerization of the appear to take home it is illegal in the UK
years of usage, composite resin. The bleaching out of the to supply a product
except where teeth home-bleaching remit of paediatric for the purpose of
have been systems do not affect dentistry, it may still tooth-whitening if
overheated or the colour of have a part to play in that product contains
traumatized. By restorative materials. cases of mild or releases more
extrapolation, 3% Any perceived effect fluorosis. Irrespective than 0.1% hydrogen
hydrogen peroxide in is probably due to of the clinical peroxide. When
the home systems superficial cleansing. application, evidence considering such
should be safe. Minor ulceration or suggests that annual products for clinical
Although most irritation may occur re- treatment may be use it is advisable to
carbamide peroxide during the initial necessary to seek medico-legal
materials contain treatment. It is maintain any advice.
trace amounts of important to check effective lightening.
phosphoric and citric that the mouthguard This further highlights
acids as stabilizers does not extend onto the importance of 10.2.5
and preservatives, no the gingivae and that more research into The
indication of etching the edges of the the long-term effects
or a significant inside-
guard are smooth. If of this treatment on
change in the surface ulceration persists, a the teeth, mucosa, outside
morphology of decreased exposure and periodontium. bleaching
enamel has been time may be The exact
demonstrated by technique
necessary. If there is mechanism of An alternative
scanning electron bleaching in any of approach to the
management of the 10.2.6
discoloured endo-
dontically treated Localiz
tooth has been ed
described. Known as compo
the inside-outside
bleaching technique, site
it is essentially a resin
combination of the restorat
walking and vital
bleaching techniques. ions
Tooth preparation is This restorative
the same as technique uses
described for the recent advances in
walking bleach dental materials sci-
technique (Section ence to replace
10.2.2) with particular defective enamel with
attention being paid a restoration that
to removal of the bonds to and blends
gutta percha below with enamel.
the cemento-enamel Indications
junction followed by Well-demarcated
the placement of a white, yellow, or
barrier (usually a brown
glass ionomer cement hypomineralized
or IRM cement) to enamel; such as
seal the root canal those seen in MIH
from the oral cavity. A (see Section 10.6
custom-made tray and Fig. 10.25(c))
(see Fig. 10.5(b)) is
constructed as a Armamentarium
vehicle for the Rubber
bleaching gel. dam/contoured
However, rather than
creating space labially matrix strips
as in the vital Round and fissure
bleaching technique, diamond burs
a small reservoir is Enamel-dentine
created palatal to the bonding kit
affected tooth only.
The gel (10% New-generation
carbamide peroxide) highly polishable
is placed by the hybrid composite
patient into both the resin
access cavity of the
non-vital tooth and Soflex discs (3M)
the tray. The tray is and interproximal
then worn full time for polishing strips.
up to 4 days, with the
gel being replaced
every 2-4 hours.
Once an aesthetically
acceptable result is
achieved, the access
cavity is refilled
appropriately. Long-
term results for this
approach are not yet
available, but relapse
is as likely as for any
of the other bleaching
techniques.
 Technique
1. Take preoperative
photographs and
select the shade
(Fig. 10.6(a)).
2. Apply rubber dam
and contoured matrix
strips if required.
3. Remove full extent
of demarcated lesion
with a round
diamond bur down to '9mm
the amelodentinal
HK:mjflna
'
junction (ADJ).
4. Chamfer the no significant may offer not just a
enamel margins with sensitivity and bonding and resin temporary solution,
a diamond fissure therefore no need technology make but a satisfactory
bur to increase the for local these restorations long-term alternative
surface area anaesthesia. If the simple and obviate to the PJC. Most
hypo- I plastic the need for a full composite veneers
available for enamel has become
retention if required. labial veneer. placed in children
5. Etch the resultant carious and this Disadvantages are and adolescents are
cavity margins. extends into marginal staining, of the 'direct' type,
Wash and dry. dentine, I
6. Apply the prime accurate colour as these can be
administration of match, and placed in a single
and bonding agent local anaesthesia suboptimal visit and outcomes
as per the will be necessary. aesthetics if the full for both techniques
manufacturer's Advances in extent of the are equivocal.
instructions. demarcated lesion is Before proceeding
7. Apply the chosen
not removed to the with any veneering
shade of composite, ADJ. technique, the
use a brush decision must be
lubricated with the made as to whether
bonding agent to 10.2.7 Composite to reduce the
smooth and shape, resin veneers thickness of labial
and light-cure for the enamel before
recommended time. Although the placing the veneer.
8. Remove the matrix porcelain jacket Certain factors
strip/rubber dam. crown (PJC) may be should be
9. Polish with graded the most satisfactory considered.
Soflex discs (3M), long-term restoration 1. Increased
finishing burs, and for a severely labiopalatal
interproximal strips if hypoplastic or makes it harderbulk to
required. Add discoloured tooth, it maintain good oral
characterization to is not an appropriate hygiene. This may
the surface of the solution for children be courting disaster
composite. for two reasons: the in the adolescent
10.Take postoperative large size of the with a dubious oral
photographs (Fig. young pulp horns hygiene technique.
10.6(b)).
and chamber, and 2. Composite resin
I The localized the immature
el has a better bond
Hi mm-mm gingival contour.
Composite veneers strength to enamel
restoration is quick may be direct when a surface
and easy to (placed at the initial layer of 200-300mm
complete. Despite appointment) or is removed.
the (b)removal of indirect (placed at a 3. If a tooth is very
defective subsequent discoloured, some
figure 10.6 Well-demarcated white appointment having sort of reduction
opacities on the upper central incisors been fabricated in and/or use of an
(a) treated by localized composite the laboratory). opaqueing agent
restorations (b). Conservative may be desirable as
enamel down to the veneering methods a thicker layer of
ADJ, there is often composite will
otherwise be
required to mask the Advanced restorative dentistry 11
intense stain.
4. If a tooth is already
instanding or rotated,
its appearance can
be enhanced by a
thicker labial veneer.
However, this may
not be appropriate in
cases where
orthodontic treatment
is planned as the
natural anatomy of
the tooth will be
changed.
New-generation
highly polishable
hybrid composite
resins can replace
relatively large
amounts of missing
tooth tissue as well
as being used in thin
sections as a veneer.
Combinations of
shades can be used
to simulate natural
colour gradations
and hues.
Indications
Discolouration
Enamel defects
Diastemata
Malpositioned teeth
Large restorations

Relative
contraindications
Insufficient tooth
tissue available for
bonding
Oral habits, e.g.
woodwind musicians
Occlusal factors
 SKii discolouration is gingival area to a
Paediatric intense. lighter I more
dentistry 6. Apply composite translucent incisal
2. Clean the tooth resin of the desired region (Fig.
10.7(c)).
7. Flick
away the
unfilled
resin
holding
the
contour
strip and
removel
the strip.
8. Finish
the
margins
with
diamond
finishing
burs and

(c) with a of (d)shade to the labial

slurry interproximal I
strips, and the
Figure 10.7 (a) A young patient with amelogenesis imperfecta, (b)
Contoured matrix strip in position, (c) Incremental placement of
dentine shade composite, (d) Postoperative view showing final
composite veneers.
pumice in water. surface and labial surface with
Armamentarium Wash and dry, and roughly shape it graded sandpaper
select the shade into all areas with a discs. Characl
Rubber (Fig. 10.7(a)). plastic instrument; terization should
dam/contoured 3. Isolate the tooth then use a brush be added to
with rubber dam lubricated with improve light
matrix strips unfilled resin to reflection
and a contoured
Preparation and matrix strip. Hold 'paddle' and properties! (Fig.
finishing burs this in place by smooth it into the 10.7(d)).
New-generation applying unfilled desired shape.
highly polishable resin to its gingival Cure for 40
hybrid composite
resin side against the seconds gingivally,
40 seconds mesio- The exact design
Soflex discs (3M) gingiva and curing of the composite
and interproximal for 10 seconds l incisally, 40
polishing strips veneer will depend
(Fig. 10.7(b)). seconds disto-
4. Etch the enamel as incisally, and 40 on each diniafl case
Technique per the but will usually be
1. Use a tapered manufacturer's seconds from the
instructions. palatal aspect if one of four types:
diamond bur to 5. Apply a thin layer incisal coverage intra-enamel or
reduce labial of priming and has been used. window prepjl ration,
enamel by 0.3- bonding resin to Different shades of incisal bevel,
0.5mm if the labial surface com-J posite can overlapped incisal
appropriate. Identify with a brush as per be combined to edge, or feathered
the finish line at the manufacturer's achieve good incisal edge] (Fig.
gingival margin and instructions. It may matches with 10.8). Tooth
also mesially and be necessary to adjacent] teeth and preparation will not
distally just labial to use an opaquer at a transition from a normally expose
the contact points. this stage if the relatively dark dentine, but this I will
be unavoidable in
some cases of
localized hypoplasia
or with cariesJ Figure
10.9 shows an
example of
successful composite
veneers thai have
been in place for 5
years. Studies have
shown that
composite! veneers
are durable enough
to last through
adolescence until a
maa aesthetic
porcelain veneer can
be placed. This is
normally only consiq
ered at about the age
of 18-20 years when
the gingival margin
has j matured to an
adult level and the
standard of oral
hygiene and dentajj
motivation are
acceptable.
CHAPTER 39 Aesthetic Restorative Dentistry for the Adolescent
607
 FIGURE 39-17 A, Preoperative view of a patient missing mandibular central incisors. B, Facial view
of metal ceramic appliance that will replace these teeth. C, Lingual view of resin-retained prosthesis
in place. Df Facial view of the completed treatment.
aid resistance, the rubber dam may M et al: 11. Rueggcberg F,
retention, seating, and push the appliance Morphological Caughman W,
aspects of the Curtis J: Factors
longevity of the resto- incisally, resulting in resin-dentin affecting cure at
ration. Shade selection incomplete seating. It interdiffusion depths within
for pontics should be is helpful to remove zone with light-activated
made before excess cement with a different dentin resin composites,
preparation. soft brush or cotton adhesive systems, / Am f Dent 6:91-95,
An impression of pellet whenever access Dent Res 71:1530- 1993.
1540, 1992. 12. Kramer N,
the prepared arch allows. Following 5. Peutzfeldt A: Lohbaucr U,
should be made with cementation, one Resin composites Garcla-Godoy F et
an accurate should carefully cut in dentistry: the al: Light curing of
elastomeric impression the rubber dam with monomer systems, resin-based
material such as vinyl scissors and remove it. Eur f Oral Sci composites in the
105:97-116, 1997. LED era, Am ]
polysiloxane or Remaining excess 6. Van Meerbeek B, Dent 21:135-142,
polyether. Using a cement may be De Munck J, 2008.
sharp red pencil, the removed with a Yoshida Y et al: 13. Ham WT:
extensions of the diamond or carbide Buonocore Ocular
preparations should be bur (Figure 39-17). Memorial Lecture. hazards of
Adhesion to light sources:
outlined on the Retainer loosening enamel and review of
working model. If from an abutment dentin; current current
preparation grooves tooth has been status and future knowledge,;
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appliance. These Should this occur, the and developments etch-and-rinse
in composite adhesives on dry
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