PortalKota – Restorative Pediatric Dentistry by Mint Kids Dentistry Dr Soo JunWelcome to your 10-minute review on rubber dam, sealant and class 2 restorations for the primary molars first we’re gon na start with rubber Dam.
Do we need to read for ever dam for all patients? Definitely do we need to use it for all procedures, yep, even the sale of silk crown preparation.
This confuses many students because oftentimes with a crown preparation, we don’t use a rubber Dam, but for the child, patient, a rubber Dam is so essential that we do use it.
Even for crown preparations, it’s a great way to protect the patient from aspirating any sort of objects from having to worry about swallowing water.
It also protects the cheek and tongues of our wiggly patients to make sure that everyone is safe.
Restorative Pediatric Dentistry by Mint Kids Dentistry Dr Soo Jun
It’s very important to make sure that we do use a rubber dam. Even when we do crown preparations, we want to prevent the patient from aspirating any material such as our stainless steel crown.
Hopefully, this image stays with you and reminds you for years beyond, UCLA that a rubber dam is essential for the child patient. A common issue that I see with students when we’re using rubber dams in the general clinic as well as in the Pediatric clinic, is they’re.
Not 100 % sure which clamp to use if you use the right, clamp, you’re gon na be more successful. So here are some clinical tips. The 26n is indicated for a fully erupted permanent molar.
Here’s a picture of the 26 end clamp. You can see that it doesn’t dig down into the tissues, which is why it’s indicated for a fully erupted molar.
It’s also a nice blade rather than some sharp points, so it can be very easy on the gingival tissues as well as onto the crown.
So if you’re treating a patient and they have a fully erupted permanent molar such as a nine year old and you’re, treating tooth number 30, this is a great clamp if you’re treating a younger child and you’re planning to clamp a primary molar. The 27 end. Clamp is perfect. This is a very similar clamp to the 26n.
You can see that it’s a nice blade rather than digging down into the gingiva and it’s a Gris, it’s a little bit smaller, so it’s great for primary molars.
So if you’re treating a 4 5 or 6 year old and you’re planning to clamp a primary molar, this is the perfect clamp.
The third clamp that you’re going to have available to you in clinic is the 14 a you can see. The shape is of different. It has some serious four prongs that dig down into the gingiva and the a signifies that it is an angled gingival II.
So a is for angled. That way, you remember, you need to have an angled clamp if you’re gon na be clamping a primary. I’m sorry, a permanent molar, that’s partially erupted.
The reason this is important is that the height of contour is not yet above the gingival margin, so we’re not able to get a clamp like the 26 and on because it doesn’t dig down the 14.
A is a great clamp for a partial erupted molar, because the angled prongs dig down under the gingiva below the height of contour and can hold the clamp onto the tooth.
So if you’re, seeing a patient who’s, seven years old and you’re treating tooth number three you’re gon na get ready a 14-8 clamp.
Alternatively, if you’re treating a 12 or 13 year old, patient and you’re treating a primary or a permanent second molar, then again you’re going to need to use the 14 a so try to think ahead is the tooth, fully erupted or partial erupted that you’re planning to Clamp is it a primary or a permanent molar? All of these will help you decide on the best clamp to use and to get ready before your patient arrives.
Next step is punching the dam whenever you’re, seeing a Pediatric patient, be that a four year old to a 14 year old. Everything needs to be ready before we get started, including the dam being on the frame and punched and ready to go here.
Are some individual steps on how to punch the dam which we did go over in the preclinical lab? And i’m gon na highlight a few very important points for one.
You want to make sure that you use the correct, correct size, hole of the punch for each tooth that you’re putting the rubber dam onto a lot of students tend to use the largest punch hole for every soothe because they remember having a lot of trouble.
Placing a dam in the preclinical lab – this isn’t a good idea, because then, when the holes are too large, the dam does not hold itself in place. It tends to pop off of the teeth, because it’s too big for the tooth in question.
If you use the occur, echt size hole for the tooth that you’re planning to put the rubber dam onto then once the dam goes over the tooth, it will snap down below the cej and hold itself in place. So that’s one reason to use the correct size.
Punch for each tooth that you’re rubber damming. The other reason is that you want to have ideal isolation. If the hole is too big for the tooth, then you have gingiva popping through everywhere.
You’Re really, not isolating. The other important point is the distance between the holes. If you put the holes too close together, you’re gon na have a lot of stretching and a lot of leakage.
If you put the holes too far apart, you’re gon na get a lot of excessive dam and wrinkles, and it’s definitely harder to put on so a good rule of thumb is about two to three millimeters.
Apart for each hole and you’re gon na direct those holes in a 45 degree angle, we only need to punch that tooth that were clamping as well as one to two teeth in front.
So we usually clamp with the permanent first molar and isolate all the way to the canine. Next, we’re gon na have a moment of how to punch the dam first place the rubber dam frame onto the dam at the top of the dam.
That way, you’re not closing on the dam over the patient’s nose. Let’s go ahead and pause here.
So, as you saw, I took the rubber dam and I quartered it into quadrants just the way that we treat a patient, we always treat by quadrants after you figure out which quadrant you’re working in you’re gon na go ahead and place.
The clamp punch a 1/2 inch in from the frame and I’m sorry one and a half inch in from the frame and a half inch down from the midline.
So let’s go ahead and continue watching so again about an inch and a half in from the side of the frame and a half inch down from the midline.
That’s our first punch! That’s where the clamp, then all of our holes need to stay within that quadrant. We’Re gon na punch the dam at a 45 degree angle with about two to three millimeters of space between each punch, using the correct sized hole for each tooth.
You and there’s our dam in a nice 45 degree angle for each tooth: permanent molar up to canine. Okay, so you might be thinking to yourself.
Okay, I got the right clamp. I got my dam ready and punched, but don’t kids hate the rubber dam? They really don’t.
If you give them profound anesthesia as well as great tell show do remember.
The rubber dam is a raincoat; it keeps all the water on the outside, protects them from any sort of extra rain or any extra water show them the tooth ring before you get started.
This is the ring, that’s going to go on to their tooth and it slides right on just like it does on your finger, and you can show them that with the bow of the clamp, you can even put it on to the patient’s finger.
If you want to – but I usually put it on my own – explain that when the ring goes on, it’s a nice tight fit. So it’s gon na give a tight squeezing hug, but not a pinch if they feel a hug.
We want a thumbs up, but that’s good if they feel a pinch. We want a thumbs down and we can go ahead and give them some more local anesthetic.
If we don’t tell patients about the tight hug, they tend to interpret that as pain, and they want to get the damn off.
So proper preparation prevents the patient from being upset with the tight hug reassure the child also that they can breathe and swallow with the dam on they’re actually going to be able to breathe and swallow better because they’re not going to have any water in their mouth. A couple of clinical tips make sure you always tie floss around the bow of the clamp prior to placement.
Never leave a child with the rubber dam unattended and never leave anything in the mouth. That’s not visible, such as cotton rolls underneath it down.
Here’s a moment of placing the rubber dam on a dental patient. We want to make sure that we place the clamp first and check stability and also check for a thumbs up that we’re having a nice tight snug.
But no pinching you’ll see that I’m using a 26n for a fully erupted permanent molar, and I keep my finger on the clamp to make sure that I have good stability and the clamp doesn’t pop off next step check your stability stability good now go with your Rubber dam notice that the dam is already on the frame, which is my cheapest assistant, it’s going to keep the dam out of my way, so I can see well stretch the hole for the bow.
The first part of a clamp – that’s gon na go through, is just the boat, don’t focus on anything else. After the rubber dam goes over, the bow, relax, relax behind the bow to decrease. The pressure, prevents your rubber dam clamp from popping off.
Then I go with each side of the clamp individually first sided buckle, then lingual now the clamp is secured and inside the dam. Now it’s time to pull the rubber dam forward for the individual teeth, really not taking your hands off the dam at any time, because you’re keeping that gingival pressure, okay, our dams on you – can see.
I continue to relax the dam behind the rubber dam, clamp to prevent it from popping off and then your great technique, floss down, then floss again with the same piece of floss, without pulling it out.
This keeps the dam, nice and secure and then pull out the floss, alright, very good nice inversion and we’re almost ready to go okay, so we’ve covered rubber dam for the child patient, let’s go ahead and cover a clasp to prep for the primary molar.
I know that you guys have done class to your props before so. This is just a quick reminder. Remember that we, the you know, ideal outline forms to be done first, so we don’t want to be excavating caries, the first step.
What we really want to do is an ideal classic class to preparation it’s fairly similar for both an amalgam as well as composite the main difference between amalgam and composite.
Is we don’t have to go to the Popol depth of 1.5 millimeters for composite, usually we’re at about 1 millimeter or still with an enamel, but definitely the depth of 1 millimeter? So that would be the main difference between the two.
We want to make sure that our isthmus width is wide enough, so about one millimeter to 1.5, and then we want to have our proximal walls that clear the adjacent tooth, both gingival II as well as bucco lingually, and that’s the same for composite as well as Amalgam, our axial depth of the proximal box, should be about one millimeter to 1.25. This is the danger zone.
This is where the pulp horns are, so we want to make sure that we’re using our 330 bird and doing a nice ideal class to box rather than going too deep axially the birds that I recommend are really very classic: 33 Burr for the clues I’ll prep. As well as starting the box, and then I like to use a 245 burr to create my proximal walls and you’ll, see why, in the next couple of slides, a really important component of the class to preparation for a primary molar is convergence of the box.
And this applies to both composite as well as amalgam, we’re not using this convergent to have hold the restoration in we’re using the convergence to make sure we don’t have undermined enamel.
The convergent walls of the proximal box box should parallel the buckle and the lingual surfaces at the expense of the gingival. What that means is every box needs to be convergent, so we don’t have undermined enamel. How do we do it? Well?
This is where the 245 burr comes in. It’s a nice fur for sweeping back and forth within the box, creating a wider gingival floor and a narrower occlusal surface.
That way, we have good 90-degree exit angles that parallel the buckle and the lingual walls, as well as a converging box at the expense of the gingival. So again, our gingival floor is always wider than our occlusal portion of the box. In the clinic.
I tend to see students who really flare the box, because they’re trying to clear both buccal and lingual e and gingival e by bringing all the walls out so remember you want to converge in box by sweeping the 245 burr, both buccal and lingual, all right next Step is sealants one of my favorite procedures for our pit and fissure sealants.
The first step is always to clean the two surface: you’re going to use a toothbrush any or a pro Fingal with pumice either.
One is good I like to use a toothbrush, because it’s a great time to do oral hygiene instruction and get that in for the patient so that when they leave, they really have a good tooth, brushing Ohi and their sealants. Then you’re going to decide on a resin or glass ionomer sealant. Do you remember how we choose between one or the other right?
A glass ionomer sealant is for a partially erupted tooth. That really needs a sealant such as it has demineralized surface at the grooves of the tooth, but it’s partially erupted, so we want to seal it, so it doesn’t become a cavity, but we can’t use a resin sealant because it’s not fully erupted.
The next step is to isolate the quadrant and utilize a bite block just to review we’re going to pumice the tooth or use a toothbrush to get all the plaque off the buccal, lingual and occlusal surfaces.
Then we’re gon na go ahead and isolate the tooth using cotton rolls a dry angle as well as a bite Bach. The next step is before you get started, verify that your isolation is ideal and give your patient some instructions about staying nice and still maybe being frozen for the next 60 seconds so that you have a great working field.
You’Re gon na always keep your eyes on the tooth. This is really important. You, as the operator have to verify that the tooth is never contaminated by saliva.
By keeping your eyes on the tooth, you know when to call it quits and tell your assistant. We got to start over if you look away that could be when the patient whips their little tongue out and touches the two surface.
Without you see noticing, then your sealant will definitely fail. You’Re gon na edge the enamel for 20 to 30, sometimes 40 seconds and rinse, with minimal amount of water.
The reason we use minimal water is, we don’t want to fill all of our cotton rolls and dry angle with tons of water. We want to use just enough water to get the etchant off and then dry the tooth a very very thoroughly, so it appears frosty. The next step is to use a hydrophilic dentin bonding agent.
This is the same type of bonding agent you’re using in the general clinic. The next step.
After placing your bonding agent is to place the sealant. You can cure these together in one step, so you place your hydrophilic bonding agent, you Aerith in it.
You place your sealant right on top of that, and then you polymerize, with your light cure when you’re placing your sealant start on the mesial occlusal surface and drag the sealant into the grooves, with the sealant tip or the sealant brush use gravity to help you.
If you put the sealant right in the middle of the tooth, you’re always going to have too much of the distal surface so start at the mesial and drag it to the distal, make sure you have voids and you don’t have too much sealant.
If you have too much brush it off with a clean brush, don’t just like your otherwise you’re gon na spend all kinds of time polishing it down after you’re happy with the amount of sealant you have and you don’t see any voids or bubbles go ahead and Polymerize, once the tooth has been polymerized, evaluate your sealant for surface coverage and the rich by checking it with an explorer you’re, really gon na try to rip the sealant off with your Explorer.
If you lost isolation anywhere, the sealant area will pop off after you’ve, checked the retention and looked for any voids. You’Re gon na then rinse the tooth for thirty seconds to remove any BPA and floss the contacts. Why do we need a faucet contacts?
You’Ll see in the next photo so again place your resin sealant on the mesial occlusal surface, drag it to the distal, with the tip of the sealant or with a clean brush.
I don’t like to use an explorer because it tends to contain plaque or get some blood from earlier part of the procedure.
So I don’t use an explorer at this step like here check for retention and then rinse the tube to make sure all the bpa is rinsing.
Let’s review, let’s go back to this slide. Here’s our starting procedure, two permanent molars, we’re gon na clean the tooth with a prophy head and pumice or with a toothed budge brush, which is my preferred method, because I like to do Ohi at each visit.
Then you’re gon na isolate really well with your. So I have a ejector with your dry angle, and a bite block place your edge in two to three millimeters beyond the area that you want to seal so that you know everything has been well edged here.
We see some lower molars and you can see that they’ve edged the buccal surface. That’s really important. Sometimes students forget to edge the buccal and the only focus on the occlusal remember there is usually a buccal pit or groove.
Alternatively, in the maxilla, we want to make sure that we etch the entire occlusal lingual groove, because it does tend to be a deep groove. Oh look at these frosty molars that looks great and you can see that our cotton rolls are also not really moist.
They’Re. Very dry still, and that’s because our operator used a small amount of water to rinse off the etchant. Now we’re ready to place the sealant we’re going, go ahead and place the sealant on the mesial occlusal portion drag it to the distal with your brush.
If you have too much take a clean brush and remove any excess look for voids and look for bubbles remove those before you like here, here’s a brush to remove any excess or to spread it around like here and then check your integrity of the sealant.
With an explorer make sure you try to pull the sealant off and look for any voids uh-oh.
This is why we need to floss. Sometimes we get some sealant stuck in between the tooth or some dentin bonding agent go ahead and floss it out or use an explorer to come, underneath the contact and bring out that part of the sealant ok seems pretty simple right.
Well, we’ll do some demos in the clinic and remember your patients a moving target, so this gets a little bit more difficult depending on the patient’s age.
All right, we’ll see you in clinic go ahead to Angel and complete your assessment to see how this review helped. You prepare for your clinical rotation.