March 16, 2016
by Carla Cohn, DMD
For those of us that take care of children all of the time, most of the time, or some of the time, we know that we must have good behavioral management skills as well as good technical dental skills. When it comes to kids in our practice, there is no doubt that we can have some challenges from time to time. Our child patients can be described in one of two ways: the easy to care for dandelion child1, or the higher maintenance orchid child.
Consider that people, adults, or children have different “sensitivity thresholds”. Dr. Bruce Ellis and Dr. Thomas Boyce have described this in their studies of reactivity to stress. They have described certain children as “dandelion children” and others as “orchid children”. The dandelion children, like the dandelion flower, are hardier, and can thrive in almost any environment in the same way that dandelions proliferate in many types of fields and harsher climates. Orchid children, on the other hand, require more care and attention to thrive. They need kinder climates and conditions, as does the orchid, to flower. What does this analogy mean to us as dental professionals? Take for example the restorative dental appointment scenario. Our young patient comes in for a filling. We recline the dental chair and position our overhead light. The dandelion child goes for the ride with us, and the orchid child has difficulty relaxing. Next, we place some topical anesthetic and perhaps give the child’s tooth a rinse with our air water syringe and saliva ejector. Again, we have differences in reactions. The dandelion child is calm and cool, readily accepting our ‘tell, show, and do’ as we go along with the appointment. The orchid child becomes shy, resistant to our talk, or perhaps even uncooperative. We can look at our patient and parent pool as a veritable bouquet of flowers; some who can adapt easily to what we ask of them as patients and others who require more guidance and care. We in turn must be able to recognize the different types of personalities that we meet each day. We must be the ones to modify our behaviour in order to give our children and their parents what they need to survive and flourish. As dental professionals, we can be intimidated, sometimes terrified, when we have a child patient. Is that child a dandelion, or an orchid? For this reason alone, it is imperative to have fast and easy restorative routines to rely upon when treatment is required. We must have excellent materials, and established procedures, so that even when our child’s behavior is unpredictable, our results will be proven.
Resin composites are arguably the most common restorative material used by North American dentists. The advent of excellent resin composites with superior wear and handling allow us to restore teeth aesthetically, functionally, and with the ability to preserve healthy tooth structure. According to the American Academy of Pediatric Dentistry (AAPD) guidelines on restorative dentistry, strong evidence exists for success of composite class I restorations in primary and permanent molars as well as class II restorations in permanent molars. There is more limited evidence of success of composite class II restorations in primary molars. Caution is recommended when isolation and/or patient cooperation are not ideal.2 It is clear that although our materials continue to improve in strength and aesthetics that we remain diligent in our techniques, and in particular maintenance of a dry field.
We strive to make our procedures faster and simpler. We can achieve these goals with the introduction of bulk fill composites. I will describe a modified snowplow technique for composite restorations using bulk fill materials.
1) Tooth Preparation:
Care must be taken in preparation to maintain a conservative approach. Remember that there are key differences in tooth morphology between primary and permanent teeth.3
• Primary teeth have a thinner enamel and dentin than permanent teeth.
• The size of the pulp in relation to the crown is much greater for a primary tooth than for a permanent tooth.
• The interproximal contact is broader and flatter than in permanent teeth.
• Crowns of primary teeth are relatively short.
Given these facts, it is imperative to maintain as much tooth structure as possible, be aware of the proximity of the pulp as well as to incorporate retention into the preparation.
The self-etch adhesives, such as Futurabond U (VOCO) (Fig. 7), have been a great advantage for use in children for many reasons. It is fast, simple and reliable. Futurabond U (VOCO) single dose is a choice product due to its ease of application and its ability to be used as a self-etch, total-etch or selective-etch. It has a hydrophilic component making a dry field not absolutely necessary, and its dual-cure feature allows for a complete cure even after placement of the composite. My technique of choice is to use the product with a selective-etch technique. Phosphoric acid is used to etch only the enamel surfaces of the preparation and then use the product over the entire preparation. The use of a selective-etch technique with a one-step, self-etch system has been shown to increase the bonding effectiveness to both primary and permanent teeth.4
III) Flowable Composite:
The flowable composite acts as a layer of “caulking”. It flows easily into areas that are too small for the heavy composite paste to reach. The flowable placement has been shown to reduce the marginal microleakage.5,6,7 Since flowables have the ability to adapt to the restoration and flex with the tooth, microleakage is reportedly decreased.8 X-tra base (VOCO) (Fig. 11) is a highly filled (75%) flowable composite. The high fill content attributes to its excellent strength as well as its low shrinkage. It is a bulk fill, available in a universal shade, which is ideal for pediatric applications due to the speed that this allows. It has the benefit of curing to a depth of 4 mm in ten seconds. X-tra base will self-level upon application, ensuring a layer of even depth. Additional excellent properties include a radiopacity of 350% AI, which is critical to viewing on post-operative radiographs. The flowable composite must be placed in a thin layer on the gingival floor and in the area of the interproximal box. Care must be taken to place a thin layer, as a too thick layer will compromise the strength of the entire restoration. The goal is to have the flowable make up approximately 10% of the total volume of composite in the restoration. Critical to this technique is to leave the layer of flowable uncured, which is not a recommendation of the manufacturer, but is paramount to the technique.
IV) Packable Composite
The snowplow technique relies upon the packable composite to be placed in bulk and to push the flowable liner occlusaly and gingivally in the same manner. This allows for the flowable to fill in any voids as the packable is being extruded into the preparation. It would be unreasonable to expect success with a very deep preparation, and so depth of the preparation must be taken into consideration when this technique is used. Remember that primary teeth have very short clinical crowns and preparations, and in most cases have the deepest point in the range of 4 mm. In this situation, it is a reasonable technique. It is suggested that bulk placement requires high intensity light curing.9 It is important to inject the paste smoothly with steady pressure and to avoid pullback as the preparation is filled. I prefer placement with the individual compules as this allows for an even pressure upon extruding the composite. Used in this clinical case is x-tra fil (VOCO) (Fig. 15), which is a posterior multi-hybrid composite. It comes in one universal shade and can cure a 4 mm depth in ten seconds, allowing for a reliable, fast and easy fill.
V) Sealing the Restoration
Finally, I will place a sealant over the entire occlusal surface of the tooth. Placement of a sealant has been shown to decrease microleakage and improve the longevity of the restoration.10
A six-year-old girl presented with lesions varying from E1 to D1 radiographically (Fig. 1) on all of her primary molars. The lesions were conservative, and although this child is a high risk for caries risk assessment, the family is motivated and presents regularly for all appointments at the office. Composite was deemed to be the restorative material choice for this child. For this case, we will study quadrant #1; first and second primary molars (Fig. 2). A rubber dam is placed in a slot style extending from the first permanent molar to the mesial of the primary canine. A conservative preparation is created, with a high speed 556 carbide bur. Care is taken to preserve the buccal and palatal tooth structure and not to extend beyond the proximal line angles (Fig. 3). Both lesions are restored simultaneously. A Triodent (Dentsply) matrix system is used to ensure an excellent interproximal contact and gingival margin (Fig. 4). A high viscosity 35% phosphoric acid etchant (Bisco) is used in this case for ten seconds (Fig. 5). The etchant is completely washed and the teeth are air dried, allowing for placement of adhesive, Futurabond U (VOCO). The adhesive is light-cured for ten seconds according to manufacturer’s recommendations (Figs. 6-8). A thin layer of flowable composite is placed at the gingival 10% of the lesion (x-tra base, VOCO). This layer is not light-cured yet (Figs. 9-11). A bulk layer of composite is placed (x-tra fil, VOCO), packed, and shaped (Figs. 12-15). The restoration is light-cured according to manufacturer’s recommendations (Fig. 16). A final layer of flowable (x-tra base, VOCO) is placed over the entire occlusal surface and light-cured to act as a sealant (Figs. 17 & 18). The final restoration is shown at a follow up appointment. Also seen in this post-operative photograph is a sealant (Grandio Seal, VOCO) on the first permanent molar (Fig. 19).
FIGURE 1. Pre operative radiographs
FIGURE 2. Pre operative photo quadrant #1
FIGURE 3. Preparation
FIGURE 4. Matrix placement (Triodent)
FIGURE 5. High viscosity etch (Bisco)
FIGURE 6. Futurabond U application (VOCO)
FIGURE 7. Futurabond U (VOCO)
FIGURE 8. Light cure
FIGURE 9. x-tra base flowable placement (VOCO)
FIGURE 10. x-tra base flowable placement (VOCO)
FIGURE 11. x-tra base (VOCO)
FIGURE 12. x-tra fil placement (VOCO)
FIGURE 13. Shaping of x-tra fil (VOCO)
FIGURE 14. Shaping of x-tra fil (VOCO)
FIGURE 15. x-tra fil compules (VOCO)
FIGURE 16. Light cure
FIGURE 17. X-tra base flowable placement as sealant (VOCO)
FIGURE 18. Light cure
FIGURE 19. Follow up post operative photo
Children and adults are not so different as patients. People all have different needs, different personalities, different abilities to adapt to situations and different thresholds of reactivity. The one difference that makes children refreshing is their honesty in expressing those feelings. It’s that difference that can be intimidating, unless you are prepared to receive that honesty and to react by giving that child what they need to thrive.OH
Dr. Cohn maintains a private practice at Kid’s Dental and at Western Surgery Centre in Winnipeg. She is a clinical instructor, part-time, in the department of Preventive Sciences at the University of Manitoba. Dr. Cohn lectures internationally on children’s dentistry for the general practitioner.
Oral Health welcomes this original article.
1. Ellis B and Boyce T, Biological Sensitivity to Context, Current Directions in Psychological Science Volume 17, Number 3, 2008, pp 183–187.
2. EAAPD Clinical Guidelines, Guideline on Restorative Dentistry, Reference Manual V 36 / NO 6, 14/15.
3. Waggoner WF. Restorative dentistry for the primary dentition. In: Pinkham JR, Casamassimo PS, Fields HW Jr, McTigue DJ, Nowak AJ, eds. Pediatric Dentistry: Infancy through Adolescence. 4th ed. St. Louis, Mo: Elsevier Saunders; 2005:341-374.
4. Larissa Lenzi, Tathiane; de Almeida Brandão Guglielmi, Camila; Balvedi Umakoshi, Cristiane; Prócida Raggio, Daniela One-step Self-etch Adhesive Bonding to Pre-etched Primary and Permanent Enamel, pp. 57-61(5) Journal of Dentistry for Children,Volume 80, Number 2, May-August 2013
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7. Gordan VV, Vargas MA, Cobb DS, Denehy GE. Evaluation of acidic primers in microleakage of Class V composite restorations. Oper Dent 1998;23:244–249.
8. Weiner, R. Liners and Bases in general Dentistry. Aus Dent Journal. 2011; 56:(1 Suppl): 11-22.
9. Ritter, AV. (2008), Posterior Composites Revisited. Journal of Esthetic and Restorative Dentistry, 20: 57–67. doi: 10.1111/j.1708-8240.2008.00150.x
10. dos Santos PH et al, Influence of Surface Sealants on Microleakage of Composite Resin Restorations Journal of Dentistry for Children, Volume 75, Number 1, January-April 2008, pp. 24-28(5)
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