Composite Restorations in Pediatric Dentistry: Clinical Techniques, Applications & Material Selection

Dental composite is widely used in pediatric dentistry because of its aesthetic appearance, adhesive properties, and versatility across a range of restorative and preventive procedures. Its successful application depends on proper tooth preparation, moisture control, bonding, placement, finishing, and appropriate case selection. This section discusses the clinical procedure for composite restorations in children, its interaction with primary teeth, and its major applications in pediatric dentistry.

Clinical Procedure

Enamel Cleaning

Enamel cleaning involves removing deposits from the enamel surface, such as the surface cuticle and stained pellicle (Welbury et al., 2018). Several techniques can be used, including prophylaxis pastes, pumice slurry, fine-grit diamond instruments, and sandblasting discs (AAPD, 2019).

According to the American Academy of Pediatric Dentistry (AAPD, 2019), a rotating prophylaxis brush with a fine-grit paste is recommended before enamel etching. Fluoride-containing prophylaxis pastes should be avoided because they may increase resistance of the enamel surface to etching (Kakaboura & Papagiannoulis, 2005). Grinding of enamel should also be avoided as it can remove the superficial aprismatic enamel layer and compromise the subsequent etching pattern through scratches, debris, and an irregular surface (Kakaboura & Papagiannoulis, 2005).

Enamel Conditioning and Etching

The etching pattern and duration of etching influence resin bond strength (Moore, 2019). Minimal structural changes have been reported when enamel is etched for more than 30 seconds (Moore, 2019). Therefore, the use of 37% phosphoric acid for approximately 30 seconds on enamel and 15 seconds on dentin is recommended for selective etching (AAPD, 2019).

Following etching, excessive drying should be avoided because it can cause collapse of collagen fibrils and desiccation of dentin (AAPD, 2019). Gentle drying for approximately 5 seconds is recommended (Lenzi et al., 2017).

Dental Adhesive and Bonding

The most commonly used adhesive approaches include etch-and-rinse systems, also known as total-etch systems, and self-etch adhesives. These systems function through the application of primers and adhesives to establish a bond between the tooth structure and composite resin (Garcia-Godoy & Donly, 2014).

Etch-and-rinse adhesives are applied after the tooth has been etched and rinsed (Tsujimoto et al., 2017). These systems generally incorporate both primer and bonding components (Tsujimoto et al., 2017).

Self-etch adhesives were introduced as an alternative requiring fewer clinical steps (Tsujimoto et al., 2017). They contain acidic resin components that simultaneously condition and prime the tooth surface without a separate etching and rinsing stage. However, some in-vitro studies have reported lower bond strength, a milder etching effect, and a thinner bond interface with enamel compared with 37% phosphoric acid etch-and-rinse systems (Lenzi et al., 2017).

After adhesive application, gentle air drying for approximately 5 seconds is recommended to remove excess solvent and prevent pooling (Moore, 2019). The adhesive should then be light-cured according to the manufacturer’s instructions (Moore, 2019).

Finishing and Polishing

Finishing is performed to remove excess composite and eliminate areas of premature or high occlusion. Fine diamond finishing burs or 12- and 30-fluted carbide burs can be used for this purpose (AAPD, 2019).

Polishing aims to create a smooth restoration surface and reduce surface roughness, which can otherwise facilitate plaque accumulation (Moore, 2019). Polishing can be performed using abrasive discs, rubber cups, rubber points, or diamond polishing pastes (Moore, 2019).

Composite Resin and Primary Teeth

Composite restorations rely primarily on micromechanical bonding to etched enamel (Berry & Osborne, 2015). However, primary teeth have thinner enamel than permanent teeth, which may contribute to lower retention rates of composite restorations (Berry & Osborne, 2015). Primary dentin also has a lower degree of mineralization compared with permanent dentin (Chay et al., 2014).

Therefore, the etching procedure must be carefully controlled to minimize excessive demineralization and the formation of a weak hybrid layer (Chay et al., 2014). Proper isolation and adhesive technique are particularly important when placing composite restorations in primary teeth.

Clinical Applications of Composite in Pediatric Dentistry

Composite resin has several applications in pediatric dentistry, including:

• Preventive resin restorations (PRR)

• Sandwich restorations

• Strip crowns

• Interceptive dentistry

• Splinting traumatized teeth

• Reattachment of fractured anterior teeth

• Fissure sealants

• Direct restorative dentistry

Preventive Resin Restorations

Preventive resin restorations (PRRs) are suitable for patients with low caries risk and teeth presenting with shallow carious lesions (Waggoner et al., 2002). Flowable composite or sealant restorative materials can be used to restore cavity-prone pits and fissures while preserving unaffected tooth structure (Moore, 2019).

PRRs are particularly appropriate for lesions limited to enamel and pits and fissures without significant cavitation or dentinal involvement (Garcia-Godoy & Donly, 2015).

Sandwich Technique

The sandwich technique combines the fluoride-releasing properties and dentin-like modulus of elasticity of glass ionomer cement (GIC) with the strength and aesthetic properties of composite resin (Lindberg, 2005).

It can be classified into open and closed sandwich techniques (Fabianelli et al., 2009). The open sandwich technique may be used in Class II restorations, where GIC is placed below the contact point to reduce the risk of material washout and subsequent open contacts (Lindberg, 2005; Sidu et al., 2011). Van Dijken et al. (1999) reported a similar 3-year success rate between open sandwich restorations and amalgam Class II restorations.

The closed sandwich technique involves placing GIC as a base beneath the composite restoration, commonly in Class I restorations (Darsan et al., 2018). The similar modulus of elasticity between GIC and dentin may help reduce stress at the dentin-restoration interface (Loguercio et al., 2002).

Strip Crowns

Strip crowns are highly aesthetic restorations used for extensively decayed primary anterior teeth (Kupietzky et al., 2003). Appropriate crown form selection and accurate measurement of the mesiodistal tooth width are essential for successful treatment (Welbury et al., 2018).

Indications include multiple carious lesions involving the incisal edge, extensive cervical lesions or erosions, and teeth following pulp therapy (Moore, 2019). Resin composite strip crowns have demonstrated good clinical performance in primary incisors with extensive or multisurface caries, with reported retention rates of approximately 80% over periods exceeding three years (Kupietzky et al., 2005).

However, strip crowns are technique-sensitive, particularly in the presence of moisture contamination (Kupietzky, 2002; Mittal et al., 2016). They are therefore contraindicated in uncooperative patients, teeth with only small single-surface caries lesions, and anterior crossbite cases (Waggoner et al., 2002).

Composite in Interceptive Dentistry

Fiber-reinforced composite has been investigated as an aesthetic and potentially less invasive alternative to conventional metal band-and-loop space maintainers in the mixed dentition (Yuleri et al., 2012).

However, composite band-and-loop space maintainers have demonstrated inadequate success rates, mainly because of loop fracture and loosening of the band under masticatory forces (Potgieter et al., 2018).

Fiber-reinforced composite can also be used for temporary stabilization of luxated and avulsed teeth. Reinforced ribbons are bondable, biocompatible, translucent, aesthetic, and relatively easy to use (Yuleri et al., 2012). However, evidence regarding their long-term success and longevity remains limited, and further randomized clinical trials are required.

Splinting of Traumatized Teeth

Composite splints have historically been used for stabilization following dental trauma. However, rigid composite splints may be brittle and susceptible to fracture and can cause gingival irritation during removal (Kahler et al., 2016).

Flexible splinting using composite and orthodontic wire, commonly with a wire diameter of approximately 0.3–0.4 mm, is frequently used for traumatized teeth (Kahler et al., 2016). Resin-modified glass ionomer cement (RMGIC) has also been suggested because it can be relatively easy to apply and remove while causing minimal iatrogenic damage to enamel (Kahler et al., 2016).

Reattachment of Fractured Anterior Teeth

Reattachment of a fractured tooth fragment provides a conservative and aesthetic treatment option when the original fragment is available following dental trauma (Garcia et al., 2018).

The fractured fragment and remaining tooth structure can be minimally prepared with a bevel, followed by the application of flowable composite to adapt and bond the fragment to the remaining tooth structure (Garcia et al., 2018). The use of flowable composite has demonstrated a reported success rate of 88.9% after five years of follow-up (Sarapultsev, 2019).

Fissure Sealants

The success of pit and fissure sealants depends largely on achieving an adequate bond between the sealant and tooth structure (Dhillon et al., 2012). Flowable composite has been suggested as a possible alternative sealant material (Asefi et al., 2016; Bagherian et al., 2018).

However, flowable composite may have a greater risk of microleakage (Singh & Pandey, 2011). Resin-based sealants may also demonstrate reduced retention in moisture-contaminated environments compared with glass ionomer-based sealants (Gray et al., 1994). Therefore, GIC-based sealants may be a more practical and cost-effective option in situations where moisture control is difficult (Joshi et al., 2019).

Composite in Restorative Dentistry

Composite resin can be successfully used for different cavity classes in primary and permanent teeth, provided that appropriate case selection and moisture control are achieved.

Class I restorations: There is strong evidence supporting the use of composite restorations in Class I cavities (AAPD, 2016). An 8-year observation period reported a 79% success rate for Class I composite restorations in primary teeth (Bücher et al., 2015). Secondary caries associated with polymerization shrinkage has been reported as one of the common causes of restoration failure (Puckett et al., 2007).

Class II restorations: Compared with RMGIC, composite resin demonstrates greater wear resistance and microhardness, contributing to good functional performance (Van Dijken et al., 1999). However, RMGIC may demonstrate lower rates of secondary caries because of its fluoride release (Jones & Taylor, 2018). Reported survival rates for Class II composite restorations vary considerably, ranging from approximately 59% to 95%, with cavity size being an important factor affecting longevity (Jones & Taylor, 2018; Zhou et al., 2019).

Class III, IV and V restorations: Interproximal restorations in primary teeth can be challenging because of the close proximity of the pulp horns to the interproximal surfaces and the relatively small clinical crowns (Waggoner et al., 2002). Tooth-coloured bonded restorative materials are therefore advantageous because they allow conservative preparation (Waggoner et al., 2002).

The aesthetic properties of composite resin further support its use for Class III, IV, and V restorations in both primary and permanent teeth, particularly when the patient is cooperative and adequate moisture control can be achieved (AAPD, 2019).

Choosing Between RMGIC, Compomer, Composite and Amalgam

Table.1 below discuss the bottom line of this paper, where the major advantages and disadvantages of the different dental materials are compared:-

	Advantages	Disadvantages
RMGIC	Adhesive Aesthetics> > GIC Simple to handle Release Fluoride	Water absorption Significant wear Technique sensitive
C OMPOMER	Adhesive Aesthetic Simple to handle Fluoride > release	Technique sensitive Less aesthetics than > composite Less flouride release > than RMGIC & GIC. Less wear resistance > than composite
CO MPOSITE	Adhesive Most Aesthetic Reasonable wear > resistance	Technique sensitive Rubberdam is required Expensive
AMALGAM	Technique > insensitive Durable Cheap Quick & simple	Non-Adhesive Require mechanical > retentive preperation Environmental, Public > hazards Unaesthetic

The success of composite restorations in pediatric dentistry is multifactorial and depends on understanding the material’s physical and chemical properties, selecting the appropriate clinical application, and following a precise restorative technique. Adequate caries excavation, isolation, bonding, placement, finishing, and polishing are essential for restoration longevity. In addition, appropriate patient selection and effective management of caries risk factors are necessary to maintain the restoration and achieve predictable long-term clinical outcomes.

References

• American Academy of Pediatric Dentistry. (2019). Pediatric restorative dentistry. Chicago. Available at: https://www.aapd.org/research/oral-health-policies–recommendations/pediatric-restorative-dentistry/. Last accessed: 13/08/2020.

• Darsan, J., Pai, V.S., Gowda, V.B., Krishnakumar, G.R. and Nadig, R.R., 2018. Evaluation of gingival microleakage in deep Class II closed sandwich composite restoration: An in vitro study. Journal of Clinical & Diagnostic Research, 12(1).

• Garcia, F.C.P., Poubel, D.L., Almeida, J.C.F., Toledo, I.P., Poi, W.R., Guerra, E.N. and Rezende, L.V., 2018. Tooth fragment reattachment techniques—A systematic review. Dental Traumatology, 34(3), pp.135-143.

• Jones, G. and Taylor, G., 2018. Glass ionomer or composite resin for primary molars. Evidence-Based Dentistry, 19(3), p.86.

• Joshi, S., Sandhu, M., Sogi, H.P., Garg, S. and Dhindsa, A., 2019. Split-mouth randomised clinical trial on the efficacy of GIC sealant on occlusal surfaces of primary second molar. Oral Health & Preventive Dentistry, 17(1), pp.17-24.

• Kahler, B., Hu, J.Y., Marriott-Smith, C.S. and Heithersay, G.S., 2016. Splinting of teeth following trauma: A review and a new splinting recommendation. Australian Dental Journal, 61, pp.59-73.

• Puckett, A.D., Fitchie, J.G., Kirk, P.C. and Gamblin, J., 2007. Direct composite restorative materials. Dental Clinics of North America, 51(3), pp.659-675.

• Tsujimoto, A., Barkmeier, W.W., Takamizawa, T., Watanabe, H., Johnson, W.W., Latta, M.A. and Miyazaki, M., 2017. Comparison between universal adhesives and two-step self-etch adhesives in terms of dentin bond fatigue durability in self-etch mode. European Journal of Oral Sciences, 125(3), pp.215-222.

• Van Dijken, J.W.V., Kieri, C. and Carlen, M., 1999. Longevity of extensive Class II open-sandwich restorations with a resin-modified glass-ionomer cement. Journal of Dental Research, 78(7), pp.1319-1325.

• Welbury, R., Duggal, M.S. and Hosey, M.T. eds., 2018. Paediatric Dentistry. Oxford University Press.