Jaypee Gold Standard Mini Atlas Series Pe-dodontics (2008) [PDF] [UnitedVRG]

Jaypee Gold Standard Mini Atlas Series®

Pedodontics

Jaypee Gold Standard Mini Atlas Series®

Pedodontics Nikhil Marwah BDS, MDS Assistant Professor Department of Pedodontics Govt. Dental College, Rohtak, Haryana, India

Co-author Vijaya Prabha K Postgraduate Student Department of Pedodontics Govt. Dental College, Rohtak, Haryana, India ®

JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD New Delhi • Ahmedabad • Bengaluru • Chennai • Hyderabad Kochi • Kolkata • Lucknow • Mumbai • Nagpur

Published by Jitendar P Vij Jaypee Brothers Medical Publishers (P) Ltd B-3 EMCA House, 23/23B Ansari Road, Daryaganj,New Delhi 110 002 India Phones: +91-11-23272143, +91-11-23272703, +91-11-23282021, +91-11-23245672 Rel: +91-11-32558559 Fax: +91-11-23276490 +91-11-23245683 e-mail: [email protected], Visit our website: www.jaypeebrothers.com Branches  2/B, Akruti Society, Jodhpur Gam Road Satellite, Ahmedabad 380 015 Phones: +91-79-26926233, Rel: +91-79-32988717, Fax: +91-79-26927094 e-mail: [email protected]  202 Batavia Chambers, 8 Kumara Krupa Road, Kumara Park East, Bengaluru 560 001 Phones: +91-80-22285971, +91-80-22382956, +91-80-22372664, Rel: +91-80-32714073 Fax: +91-80-22281761, e-mail: [email protected]  282 IIIrd Floor, Khaleel Shirazi Estate, Fountain Plaza, Pantheon Road, Chennai 600 008 Phones: +91-44-28193265, +91-44-28194897, Rel: +91-44-32972089 Fax: +91-44-28193231, e-mail:[email protected]  4-2-1067/1-3, 1st Floor, Balaji Building, Ramkote, Cross Road , Hyderabad 500 095 Phones: +91-40-66610020, +91-40-24758498, Rel: +91-40-32940929 Fax:+91-40-24758499, e-mail: [email protected]  Kuruvi Building, 1st Floor, Plot/Door No. 41/3098, B & B1, St. Vincent Road Kochi 682 018 Kerala, Phones: +91-484-4036109, +91-484-2395739 Fax: +91-484-2395740, e-mail: [email protected]  1-A Indian Mirror Street, Wellington Square Kolkata 700 013 Phones: +91-33-22651926, +91-33-22276404, +91-33-22276415, Rel: +91-33-32901926 Fax: +91-33-22656075 e-mail: [email protected]  Lekhraj Market III, B-2, Sector-4, Faizabad Road, Indira Nagar, Lucknow 226 016 Phones: +91-522-3040553, +91-522-3040554, e-mail: [email protected]  106 Amit Industrial Estate, 61 Dr SS Rao Road, Near MGM Hospital, Parel, Mumbai 400 012 Phones: +91-22-24124863, +91-22-24104532, Rel: +91-22-32926896 Fax: +91-22-24160828, e-mail: [email protected]  “KAMALPUSHPA” 38, Reshimbag, Opp. Mohota Science College Umred Road, Nagpur 440 009 Phone: Rel: +91-712-3245220 Fax: +91-712-2704275 e-mail: [email protected] Jaypee Gold Standard Mini Atlas Series®: Pedodontics © 2008, Jaypee Brothers Medical Publishers All rights reserved. No part of this publication and DVD ROM should be reproduced, stored in a retrieval system, or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the author and the publisher. This book has been published in good faith that the material provided by author is original. Every effort is made to ensure accuracy of material, but the publisher, printer and author will not be held responsible for any inadvertent error(s). In case of any dispute, all legal matters are to be settled under Delhi jurisdiction only. First Edition: 2008 ISBN 81-8448-012-1 Typeset at JPBMP typesetting unit Printed at Paras Press

Foreword Practicing dentists, graduate and postgraduate students of dentistry seek out for information that will help them stay abreast of ongoing advances in dental care strategies. This colored Atlas of Pedodontics would be a very valuable and highly informative tool for identification of various dental anomalies, common dental disease and various dental procedures in the scope of Pedodontics. Samir Dutta Senior Professor and Head Department of Pedodontics Government Dental College Rohtak

Preface Any dental disease common or rare, any dental procedure or even classroom teaching for that matter is better understood by students if they are taught with audiovisual aids or pictographical representations. Moreover in a world where oral and dental diseases are plenty and on a rise, possessing only theoretical knowledge is not sufficient for establishing a definitive diagnosis. This Atlas of Pedodontics would help all dentists whether studying or practicing to understand the subject and procedures in Pedodontics better and apply this visual knowledge in their routine practice for betterment of patient care. Nikhil Marwah

Contents 1. Craniofacial Growth and Development ................. 1 2. Developmental Anomalies of Teeth ...................... 11 3. Eruption and Shedding ......................................... 29 4. Gingiva .................................................................... 43 5. Behavior Management .......................................... 48 6. Development of Occlusion ..................................... 56 7. Caries ...................................................................... 64 8. Plaque Control ....................................................... 76 9. Pit and Fissure Sealants ....................................... 81 10. Pediatric Operative Dentistry .............................. 89 11. Pediatric Endodontics ........................................... 114 12. Oral Surgical Procedures in Children ............... 131 13. Oral Habits ........................................................... 152 14. Space Management.............................................. 156 15. Pediatric Orthodontics ........................................ 162 16. Traumatology ....................................................... 176 Index ...................................................................... 189

CHAPTER

1

Craniofacial Growth and Development

POSTNATAL GROWTH OF MAXILLA

Fig. 1.1: Primary displacement

Primary displacement—Growth at maxillary tuberosity thus maxilla is pushed anteriorly.

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Mini Atlas—Pedodontics

Fig. 1.2: Secondary displacement

Secondary displacement—Growth of cranial base pushes the maxilla in downward and forward direction.

Fig. 1.3: Remodeling

Surface remodeling + Deposition - Resorption


3

POSTNATAL GROWTH OF MANDIBLE

Fig. 1.4: Ramal growth

Ramus—Resorption on anterior part and deposition on posterior.

Fig. 1.5: Growth at body

Body of mandible—Lengthens posteriorly as former ramal bone changes into body.

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Fig. 1.6: Tuberosity growth

Lingual tuberosity—Deposition on posterior facing surface.

Fig. 1.7: Enlow’s V. principle

Angle of mandible—Lingual: resorption on posterio-inferior aspect, deposition on antero-superior aspect. Buccal: resorption on antero-superior aspect, deposition on posterio-superior aspect.


Fig. 1.8: Condylar growth

Condyle—Secondary bone growth

5

6


CEPHALOCAUDAL GRADIENT OF GROWTH

Fig. 1.9: Cephalocaudal growth

In fetal life at about 1/3rd month of intrauterine development, the head takes up almost 50 percent of total body length. The cranium is large relative to face and represents more than half of total head, whereas the limbs are still rudimentary and the trunk is underdeveloped. By the time of birth, the trunk and limbs have grown faster than head and face. So that the proportions of entire body devoted to head has decreased by 30 percent with the progressive reduction in relative size of head to about 12 percent the adult. There is more growth of lower limbs than upper limbs during postnatal life. This means there is an axis of increased growth extending from head towards feet. This is called cephalocaudal gradient of growth.


7

SCAMMON’S CURVES FOR GROWTH The body tissues namely lymphoid, general, genital and neural grow at different states at different times. This pattern is discerned by Scammon’s curve.

Fig. 1.10: Scammon’s growth curve

Lymphoid Tissue It increases rapidly in late childhood and reaches almost 200 percent of its adult size. By 18 years the lymphoid tissue undergoes involution to reach adult size.

8


Neural Tissue This grows very rapidly and reaches adult size by 6-7 years. Very little growth occurs after that. Genital Tissue This shows negligible growth until puberty. But, grows rapidly reaching puberty till adult level is achieved. General Tissue This consists of bones, muscles and other organ systems. These exhibit an ‘S’ shaped curve with rapid growth up to 2-3 years of age followed by a slow phase till about 10 years. Then the growth again enters rapid phase in the 10th year and continues till terminating about 18-20 years.


9

GROWTH PREDICTION

Fig. 1.11: Growth prediction of cranium, maxilla and mandible

Cranial Base Prediction The cranial base is designated by a line joining the most anterior point of foramen magnum—Basion (Ba) with anterior point of frontonasal suture—Nasion (Na) as seen on the lateral Cephalometric radiograph. In a normal child cranial base will grow 2 mm/year. This is expressed by 1 mm forward growth of Nasion and 1 mm backward growth of Basion, both along the original cranial base line (red line). Mandibular Growth Prediction Condylar axis: This is defined as a line from a point on the Ba-N line midway between anterior and posterior borders of

10


condylar neck (DC point), to the geometric center of mandibular ramus (Xi point). During 1 year of growth Xi point will grow downward along condylar axis by 1 mm (brown line). Corpus axis: The length of body of mandible is defined by a line from Xi point to the anterior point on mandibular symphysis. Each year corpus axis grows 2 mm (green line). Maxillary Growth Prediction Point A on maxilla grows forward same as Nasion. Therefore the N-A angle remains the same during growth. Skeletal convexity of a patient is determined by the relationship between point A and facial plane (blue line).

Developmental Anomalies of Teeth 11

CHAPTER

2

Developmental Anomalies of Teeth

MICRODONTIA

Fig. 2.1: Microdontia

It is a condition of unknown etiology in which teeth are comparatively smaller. Microdontia can be generalized, relative or may affect only a single tooth. It is usually seen in permanent dentition and the most commonly affected tooth is maxillary lateral incisor—peg lateral.

12


MACRODONTIA

Fig. 2.2: Large teeth

Anomaly of size where the tooth is larger as compared to its normal counterpart. The above picture demonstrates a single tooth macrodontia.


OLIGODONTIA

Fig. 2.3: Multiple missing teeth

Anodontia refers to congenital absence of teeth, which may be partial or complete. Oligodontia is a term to describe multiple (more than 6) missing teeth. The etiology of this may be genetic or environmental.

14


HYPODONTIA

Fig. 2.4: Single missing teeth

It is defined as missing teeth as a result of failure of development. It is mostly seen in permanent dentition. The central incisor is the least common missing tooth and the third molar is the most common missing tooth.


HYPERDONTIA

Fig. 2.5: Extra lateral incisor

This refers to more number of teeth as compared to normal dentition. It may be as a result of hyperactivity of the dental lamina and is mostly associated with some syndrome. Depending on their appearance in arch they are called as supernumerary, supplemental, paramolar, distomolar or mesiodens.

16


FUSION

Fig. 2.6: A. Fusion of incisors, B. Fused roots, C. Bilateral fusion

Tooth fusion is defined as union between the dentin and/or enamel of two or more separate developing teeth. The fusion may be partial or total depending upon the stage of tooth development at the time of union. Fusion can occur between two normal teeth or between normal and supernumerary teeth also. The characteristic appearance is fused crowns with two separate non-fused root canals.


GEMINATION

Fig. 2.7: Radiograph of geminated tooth

Geminated teeth are developmental anomalies of the tooth shape that arise from an abortive attempt by the single tooth bud to divide, resulting in a bifid crown. It appears that gemination is caused by complex interactions among a variety of genetic and environmental factors with recessive mode of inheritance. The clinical presentation of gemination is two separate crowns with one large root canal.

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CONCRESCENCE

Fig. 2.8: A. Concrescence, B. Hypercementosis

It is a form of fusion in which the teeth are joined by cementum only. This usually occurs after root formation has taken place but can be either before or after eruption of teeth. Traumatic injury is most often the causative factor, which leads to fusion of roots following resorption of interdental bone. These are usually asymptomatic and are left as such unless they interfere with occlusion or eruption of succedaneous teeth.


DILACERATIONS

Fig. 2.9: Root dilacerations

Abnormally sharp bend or angulation in the root or crown surface due to trauma during formation of tooth. The trauma causes displacement of calcified portion of tooth and the remaining portion grows at a separate angle.

20


DENS IN DENTE

Fig. 2.10: Tooth in a tooth appearance

It occurs due to invagination of Hertwig’s root sheath before crown calcification that gives an appearance of tooth within a tooth. It is most frequently seen in maxillary lateral incisors and mostly warrants prophylactic treatment.


DENS EVAGINATUS

Fig. 2.11: A. Crown evaginatus, B. Root enamel pearl

It is a tubercle projecting from the occlusal surface of the teeth, which occurs as a result of proliferation of a part of inner enamel epithelial cells into stellate reticulum of enamel organ. When on posterior teeth it may interfere with occlusion and therefore has to be reduced but one must be careful about any pulpal extensions. It is also called as occlusal enamel pearl.

22


TALON CUSP

Fig. 2.12: A. Talon, B. Talon on supernumerary, C. Extra cusp

An accessory cusp like structure projecting from the cingulum area or CEJ of anterior teeth or supernumerary teeth, which may or may not include the normal dental tissues. It occurs due to folding of inner enamel epithelial cells and transient focal hyperplasia of peripheral cells of mesenchyme during morphodifferentiation. The treatment options vary from mild occlusal grinding to pulpal therapy depending upon the size of talon and its contents.


SUPERNUMERARY TOOTH

Fig. 2.13: A. Extracted supernumerary tooth, B. Mesiodens deciduous dentition, C. Multilobed supernumerary

Supernumerary teeth develop as a consequence of proliferation of epithelial cells from dental lamina with the incidence ranging from 0.5 to 3.8 percent and maxillary anterior region in males being more affected. The above photograph shows an extracted mesiodens.

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SUPERNUMERARY ROOTS

Fig. 2.14: Multiple roots

Presence of more than normal number of roots in a tooth. This condition has unknown etiology and is of minimal concern unless an endodontic treatment or extraction has to be done, wherein the number and position of roots is needed.


ANKYLOGLOSSIA

Fig. 2.15A: Tongue-tie

Ankyloglossia is the fusion of tongue to the floor of mouth. This may be complete or partial depending on the extent of fusion. The above picture shows partial ankyloglossia or tongue-tie as a result of short lingual frenum. The most common problem associated with tongue-tie is difficulty in speech. This condition is sometimes selfcorrective but mostly requires surgical intervention in the form of frenectomy.

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Benign Migratory Glossitis

Fig. 2.15B: Geographic tongue

Multiple area of desquamations of fill form papillae is an circinate pattern. These areas often heal spontaneously and re-appear at another spot. Cleft /Bifil Tongue

Fig. 2.15C: Cleft tongue

Rare condition due to lack of fusion of lateral swellings and failure of groove obliteration by underlying mesenchymal proliferations.


INTERNAL RESORPTION

Fig. 2.16: A. Internal resorption, B. External root resorption

It refers to an unusual form of tooth resorption that begins internally in a tooth, apparently initiated by inflammatory hyperplasia of pulp. The squeal of this is usually perforation and extraction but it can also be treated endodontically if diagnosed early. Common form of root resorption due to periapical inflammation, cysts, pathologies impaction or may even be idiopathic.

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ENAMEL HYPOPLASIA

Fig. 2.17: A. Fluorosis in deciduous dentition, B. Permanent dentition fluorosis, C. Acid erosion, D. Tetracycline staining

Eruption and Shedding 29

CHAPTER

3

Eruption and Shedding

CHRONOLOGY OF ERUPTION Primary Dentition: Tooth Hard tissue formation begins Maxillary Central Incisor 4 months in utero Lateral Incisor 4½ months in utero Canine 5 months in utero 1st Molar 5 months in utero 2nd Molar 6 months in utero Mandibular Central Incisor 4½ months in utero Lateral Incisor 4½ months in utero Canine 5 months in utero 1st Molar 5 months in utero 2nd Molar 6 months in utero

Crown completed

Eruption

Root completed

4 months

7½ months 1½ year

5 months

9 months

2 years

9 months

18 months

3 ¼ years

6 months

14 months

2½ years

11 months

24 months

3 years

3½ months

6 months

1½ year

4 months

7 months

1½ year

9 months

16 months

3 years

5½ months

12 months

2¼ years

10 months

20 months

3 years Contd...

30


Contd... Permanent Dentition: Tooth Hard tissue formation begins

Crown completed

Eruption

Root completed

Maxillary Central Incisor Lateral Incisor Canine 1st Premolar 2nd Premolar 1st Molar 2nd Molar 3rd Molar

3-4 months 10-12 months 4-5 months 1½-1¾ year 2-2¼ years Birth 2½-3 years 7-9 years

4-5 years 4-5 years 6-7 years 5-6 years 6-7 years 2½-3 years 7-8 years 12-16 years

7-8 years 8-9 years 11-12 years 10-11 years 10-12 years 6-7 years 12-15 years 17-24 years

10 years 11 years 13-15 years 12-13 years 12-14 years 9-10 years 14-16 years 18-25 years

Mandibular Central Incisor Lateral Incisor Canine 1st Premolar 2nd Premolar 1st Molar 2nd Molar 3rd Molar

3-4 months 3-4 months 4-5 months 1¾-2 years 2¼-2½ years Birth 2½-3 years 8-10 years

4-5 years 4-5 years 6-7 years 5-6 years 6-7 years 2½-3 years 7-8 years 12-16 years

6-7 years 7-8 years 9-10 years 10-11 years 11-12 years 6-7 years 11-13 years 17-21 years

9 years 10 years 12-14 years 12-13 years 13-14 years 9-10 years 14-15 years 18-25 years


DENTAL AGE ASSESSMENT

Fig. 3.1: Dental age

Gron. A and Moorees CF helped formulate what is to date the most commonly used method of determining dental age. This method involved scoring of to permanent teeth according to crown and root formation using standard dental films.

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DEVELOPMENT OF TEETH

Fig. 3.2 A: Bud stage

Fig. 3.2 B: Cap stage


Fig. 3.2 C: Bell stage

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Fig. 3.3: Nolla’s stages of tooth development


PRE-ERUPTIVE TOOTH MOVEMENT

Fig. 3.4: Tooth movement

The pre-eruptive phase of tooth movement is preparatory to the eruptive phase. It consists of the movement of the developing and growing tooth germs within the alveolar processes prior to root formation. Bodily movement is a shift of the entire tooth germs, which causes bone resorption in the direction of tooth movement and bone apposition behind it. Eccentric growth refers to relative growth in one part of the tooth while the rest of the tooth remains constant.

36


GUBERNACULAR CORD

Fig. 3.5: Gubernacular cord

The future eruption pathway appears as a zone in which connective tissue fibers have disappeared, cells have degenerated and decreased in number, blood vessels become fewer and terminal nerves break up and degenerate. An altered tissue space overlying the tooth becomes visible as an inverted funnel shaped area. In the periphery of this zone, the follicle fibers direct themselves toward the mucosa and are defined as the gubernacular cord. This structure guides the tooth in its eruptive movements.


STAGES OF TOOTH ERUPTION

Fig. 3.6: Eruption stages

Eruption is defined as a process whereby the forming tooth migrates from its intraosseous location in the jaws to its functional position within the oral cavity. Anatomic Stages in the Eruption of the Teeth Stage I: Preparatory stage. Stage II: Migration of the tooth towards the oral epithelium. Stage III: Emergence of crown tip into the oral cavity. Stage IV: First occlusal contact. Stage V: Full occlusal contact. Stage VI: Continuous eruption.

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ERUPTION HEMATOMA

Fig. 3.7: Eruption hematoma

A bluish purple, elevate area of tissue, commonly called eruption hematoma, occasionally develops few weeks before the eruption of primary or permanent tooth. The blood filled cyst is most frequently seen in the primary second molar or the first permanent molar region. This condition develops as a result of trauma to the soft tissue during function and is self-limiting.


ERUPTION BULGE

Fig. 3.8: Eruption bulge

This is an auto correcting swelling in the region of erupting tooth, usually associated with trauma to the surrounding soft tissue.

40


NATAL TEETH

Fig. 3.9: Isolated natal tooth

Natal teeth are the teeth that are present at birth; Neonatal teeth are those that erupt within one month after birth. They are mostly seen in mandibular incisor region and are attributed to superficial positioning of the developing of the tooth germ, which predisposes the tooth to erupt early. They may resemble normal primary teeth, but in many instances they are poorly developed with failure of the development of the roots.


RETAINED TEETH

Fig. 3.10: Retained deciduous

The term, retained teeth refers to the teeth that are over retained in the oral cavity even after their succedaneous tooth has erupted. These have to be extracted as soon as possible as they may cause crowding and malocclusion.

42


ECTOPIC ERUPTION

Fig. 3.11: Defected central incison

Arch length inadequacy or a variety of local factors may influence a tooth to erupt in a position other than normal, this is called as ectopic eruption. The above photograph depicts an ectopically erupting central incisor due to lack of space.

Gingiva 43

CHAPTER

4

Gingiva

GINGIVA

Fig. 4.1: Child gingiva

Fig. 4.2: Adult gingiva

44


Characteristic

Children

Adult

Color

Pale pink

Coral pink

Surface

Smooth

Stippled

Gingiva

Thick and round

Knife edged

Free gingiva

Keratinized saddle (area)

Non-keratinized interdental col

Interdental gingiva

Interdental clefts

Not present

Attached gingiva

Retrocuspid papilla

Not present

Sulcus depth

2.1-2.3 mm

2-3 mm

Alveolar mucosa

Red, thin, vascular

Pink

Periodontal ligament

Wide

Narrow

Collagen bundles

More hydrated, less differentiated

More differentiated

Polypeptide chains

Normal cross-linking

Tight cross-linked

Ground substance

Low ratio of collagen to ground substance

Ground substance to collagen ratio normal

Fibers

Gingival fibers are immature

Mature and organized

Trabeculae

Thick trabeculae with large marrow spaces

More trabeculae with less marrow spaces

Gingiva 45

Fig. 4.3: Pigmentation of gingiva

Fig. 4.4: Gingival recession due to crossbite

46


Fig. 4.5: Chronic generalized gingivitis

Fig. 4.6: Localized gingivitis due to local irritants

Gingiva 47

Fig. 4.7: Polyp in relation to molar

48


CHAPTER

5

Behavior Management

TELL SHOW DO

Fig. 5.1: Explanation of method

Tell Verbal explanations of procedures in phrases appropriate to the developmental level of the child.

Behavior Management 49

Fig. 5.2: Demonstration

Show Demonstration for the patient of visual, auditory, olfactory and tactile aspects of the procedure in a carefully defined, non-threatening setting. The dentist can either demonstrate on himself or on an inanimate object.

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Fig. 5.3: Performing

Do Without deviating from the explanation and demonstration the dentist proceeds directly to perform the previewed operation.


HAND OVER MOUTH EXERCISE

Fig. 5.4: HOM being carried out

When indicated, a hand is placed over child’s mouth and behavioral expectations are calmly explained. Child is told that the hand will be removed as soon as the appropriate behavior begins. When child responds the hand is removed and child’s appropriate behavior is reinforced. If the child shows negative behavior again the procedure is repeated.

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Fig. 5.5: HOM modification with airway restricted

Fig. 5.6: HOM modification tower over mouth airway restricted


Fig. 5.7: Modification tower over mouth airway unrestricted

MODELING It is based on the theory, which states that one’s learning or behavior acquisition occurs through observation of suitable model performing a specific behavior. The picture shows live modeling by sibling.

Fig. 5.8: Sibling modeling

54


PARENTAL PRESENCE

Fig. 5.9: Parental presence

This is seen in very young patients. But has to be used sometimes even in older uncooperative patients for supporting and communicating with the child.


MOUTH PROP

Fig. 5.10: Adjunct for mouth opening

PARENTAL RESTRAINT

Fig. 5.11: Seen is very young children suffering from material anxiety

56 Mini Atlas—Pedodontics

CHAPTER

6

Development of Occlusion

PHYSIOLOGIC SPACING

Fig. 6.1: Spacing in deciduous teeth

These are present in between the primary teeth and play an important role in normal development of the permanent dentition. The total space present may vary from 0 to 8 mm with the average 4 mm in the maxillary arch and 1 to 7 mm with the average of 3 mm in the mandibular arch.

Development of Occlusion 57

PRIMATE SPACING

Fig. 6.2: Primate spaces

These between the upper lateral incisors and the canines (present mesial to maxillary deciduous canines) and lower canines and first deciduous molars (present distal to mandibular deciduous canines). These spaces are also called as anthropoid or simian spaces.


TERMINAL PLANES The mesio-distal relation between the distal surfaces of maxillary and mandibular 2nd deciduous molars is called as terminal plane. FLUSH TERMINAL

Fig. 6.3: Flush relation

The distal surfaces of the upper and lower teeth are in a straight plane (flush) and therefore situated on the same vertical plane. Usually it is a favorable relationship to guide the permanent molars.


MESIAL STEP

Fig. 6.4: Mesial step relation

The distal surface of the lower molar is more mesial to that of the upper. Invariably, it is favorable to guide the permanent molars into a class 1 relationship.


DISTAL STEP

Fig. 6.5: Distal step relation

The distal surface of the lower molar is more distal to that of the upper. This relationship is unfavorable as it guides the permanent molars into distal occlusion.


INCISOR RELATION

Fig. 6.6: Change in incisor angulation

Permanent incisors replace the deciduous incisors during 6½ to 8½ years. The permanent incisors are larger as compared to their primary counterparts and thus require more space for their alignment. This difference between space available and space required is called the incisor liability. This is 7 mm for maxillary arch and 5 mm for mandibular arch.


LEEWAY SPACE OF NANCE

Fig. 6.7: Leeway space

This takes place around 9 to 10 years of age and is characterized by replacement of deciduous molars and canines by premolars and permanent cuspids. The combined mesiodistal width of permanent canine and premolars is less than deciduous canine and molars. This is called Leeway Space of Nance. It is 1.8 mm (0.9 mm on each side) in maxillary arch and 3.4 mm (1.7 mm on each side) in mandibular arch. This excess space is utilized by mandibular molars to establish class I relationship.


UGLY DUCKLING

Fig. 6.8: Broadbent phenomenon

This is a self-correcting malocclusion seen around 9 to 11 years of age or during eruption of canines. As the permanent canines erupt they displace the roots of lateral incisors mesially. This force is transmitted to the central incisors and their roots are also displaced mesially. Thus, the resultant force causes the distal divergence of the crown in an opposite direction. This leads to midline spacing and ugly appearance of the child and so it is called ugly duckling stage. This condition corrects itself after the canines have erupted. The canines after eruption apply pressure on the crowns of incisors thereby causing them to shift back to original positions.

64


CHAPTER

7

Caries

KEYS CIRCLE

Fig. 7.1: Key’s triad

Caries is due to interplay of three factors viz. host, agent and environmental influences.

Caries 65

NEWBRUN CIRCLE

Fig. 7.2: Newbrun modification

Caries is caused by interplay of primary and secondary factors. Primary

Secondary

Plaque

Oral hygiene Saliva—pH, composition, buffer, flow Diet Type of carbohydrate Composition of food Oral clearance Frequency of eating Fluoride contents Morphology Nutrition

Substrate

Tooth

66


HISTOPATHOGENESIS OF ENAMEL CARIES

Fig. 7.3: Histology of enamel caries

Translucent zone—First signs of enamel breakdown are seen in this zone. Dark zone—Demarks the body of lesion from translucent zone. Body of lesion—This is the main bulk of lesion with maximal mineral loss. Surface zone—There is partial loss of minerals due to subsurface demineralization.

Caries 67

HISTOPATHOGENESIS OF DENTINAL CARIES

Fig. 7.4: Histology of dentinal caries

a. b. c. d. e.

Zone of decomposed dentin Zone of bacterial invasion Zone of demineralization Zone of dentinal sclerosis Zone of fatty degeneration.

68


FOOD GUIDE PYRAMID

Fig. 7.5: Food guide pyramid

Caries 69

DIFFERENT TYPES OF CARIES Initial Caries

Fig. 7.6: Incipient caries on incisors

Occlusal Caries

Fig. 7.7: Occlusal caries in first molar

70


Proximal Caries

Fig. 7.8: Proximal caries in first molar

Deep Caries

Fig. 7.9: Grossly caries in multiple teeth

Caries is defined as microbial disease of the calcified tissues of teeth that is demineralization of inorganic components and subsequent breakdown of organic moieties of enamel and dentin.

Caries 71

EARLY CHILDHOOD CARIES Presence of one or more decayed (non-cavitated, cavitated) missing (due to caries) or filled tooth surface in any primary tooth in a child of 71 months or younger.

Fig. 7.10: Stage 1

Initial reversible stage from 10 to 18 months, with cervical and interproximal areas of chalky white demineralization.

72


Fig. 7.11: Stage 2

Damaged carious stage from 18 to 24 months. Lesion in maxillary anterior teeth, may spread to dentin and show yellowish brown discoloration, pain on having cold food items.

Fig. 7.12: Stage 3

Deep lesion from 24 to 36 months. Frequent complain of pain with pulpal involvement in maxillary incisors and carious involvement of molars.

Caries 73

Fig. 7.13: Stage 4

Traumatic stage lasts from 30 to 48 months. Teeth become so weakened by caries that relatively small forces can fracture them. Molars are now associated with pulpal problems whereas, the maxillary incisors become non-vital.

74


POST CARIES REHABILITATION

Fig. 7.14: Preoparative photograph

Preoperative view exhibiting initial proximal caries in central incisors and canine, occlusal caries in both second molars, deep caries in left first molar and grossly decayed right first molar.

Caries 75

Fig. 7.15: Postoperative photograph

Postoperative picture showing a completely rehabilitated patient; GIC restoration of canines and right second molar, composite restoration of central incisors, amalgam restoration of left maxillary molar, pulp therapy and stainless steel crown for left first molar and band and loop space maintainer following extraction of right first molar.


CHAPTER

8

Plaque Control

MANUAL TOOTHBRUSH

Fig. 8.1: Manual toothbrush

ADA Specifications • • • • • •

Length—1 to 1.25 inches Width—5/16 to 3/8 inches Surface area—2.54 to 3.2 cm No. of rows—2 to 4 rows of brushes No. of tufts—5 to 12 per row No. of bristles—80 to 85 per tuft.

Plaque Control 77

POWERED TOOTHBRUSH

Fig. 8.2: Powered brush

They have 3 motions back and forth, circular and elliptical and are mostly recommended for individual lacking motor skill, handicapped patients, patients who have orthodontic appliances.


Fig. 8.3: Multiple methods of brushing

Plaque Control 79

TECHNIQUES OF TOOTH BRUSHING Method Bristle placement

Motion

Advantage/ Disadvantage Scrub Horizontal, on Scrub in anterior- • Easy to learn gingival margin posterior direction • Best suited for keeping brush children horizontal Bass Apical, towards Short back and • Remove plaque gingival into forth vibratory from cervical area sulcus at 45°, to motion while and sulcus tooth surface bristles remain • Easily learned in sulcus • Good gingival stimulation Charters Coronally, 45°, Small circular • Hard to learn and sides of bristles motions with position brush half on teeth and apical movement • Clears interhalf on gingiva towards gingival proximal margin • Gingival stimulation Fones Perpendicular to With teeth in • Easy to learn the tooth occlusion, move • Interproximal areas brush in rotary not cleaned motion over both • May cause trauma arches and gingival margin Roll Apically, parallel On buccal and • Doesn’t clean to tooth and then lingual inward sulcus area over tooth surface pressure, then • Easy to learn rolling of head • Good gingival to sweep bristle stimulation over gingiva and tooth Contd...

80 Mini Atlas—Pedodontics Contd...

Method Bristle placement

Motion

Advantage/ Disadvantage

Stillman On buccal and lingual, apically at an oblique angle to long axis of tooth. Ends rest on gingiva and cervical part

On buccal and lingual slight rotary motions with bristle ends stationary

• Excellent gingival stimulation • Moderate dexterity required • Moderate cleaning of interproximal area

Modified Pointing apically Stillman at an angle of 45° to tooth surface

Apply pressure as • Good gingival in Stillman’s stimulation method but vibrate • Cleaning of brush and also interproximal area move occlusally • Easy to master

Pit and Fissure Sealants 81

CHAPTER

9

Pit and Fissure Sealants

TYPES OF PIT AND FISSURE

Fig. 9.1: Pits and fissure in molars

The fissure contains organic plug composed of reduced enamel epithelium, microorganism forming dental plaque and oral debris. There are 5 types of pits and fissures:

82


V – type (34%) U – type (14%) I – type (19%) IK – type (26%) Inverted Y – type (7%). STEPS OF SEALANT APPLICATION Deep Stained Fissures Step 1: Isolation of tooth—The tooth should be isolated from salivary contamination by use of cotton rolls and suctioning.

Fig. 9.2: Preoperative photograph

This procedure is very technique sensitive and so moisture control is essential to achieve optimum bond strength.


Minimal Tooth Preparation Using Tapering Fissure Bur

Fig. 9.3: Fissures are enlarged

Step 2: Tooth preparation—This can be achieved by multiple methods like treat the surface with slurry of pumice and water, air abrasion with aluminum oxide particles and enameloplasty.

84


Application of Etchant Gel in Fissures

Fig. 9.4: Application of gel

Step 3: Acid etch tooth surface—Apply the etching agent to the tooth surface using a fine brush. Gently rub the etchant applicator over tooth surface including 2-3 mm of cuspal inclines and reaching into any buccal or lingual pits and grooves that are present. The recommended etching time is 15 sec.


White Frosted Appearance after Etching

Fig. 9.5: Post gel application

Step 4: Rinse and dry etched tooth surface—Rinse the etched tooth surface with air water sprang for 30 seconds. This removes the etching agent and reaction products from etched enamel surface. Dry the tooth for 15 seconds with uncontaminated compressed air. The dried etched enamel should have a frosted—white appearance.

86


Apply Sealant in the Etched Pits and Fissures

Fig. 9.6: Sealant application

Step 5: Application of sealant—Apply the material and allow it to flow into pits and fissures. In mandibular teeth, apply the sealant distally and allow it to flow mesially with the converse being true for the maxillary teeth. Allow the sealant to flow in the etched pits and fissures to avoid incorporating air into material and creating voids. Using a fine brush or applicator carry a thin layer of up the cuspal inclines to seal secondary and supplemental fissures.


Curing the Sealant

Fig. 9.7: Light curing

Step 6: Light cure the sealant according to the manufacturer’s recommended time for curing.

88


Postoperative View Following Curing of Pit and Fissure Sealant

Fig. 9.8: Sealed pit and fissure surface

Step 7: Explore the sealed tooth surface for pits and voids that may have not been sealed. Step 8: Evaluate the occlusion—Evaluate occlusion of sealed tooth surface with articulating paper to determine if any excessive sealant is present and needs to be removed. Step 9: Recall and re-evaluation—Recall and check the patient at subsequent visits. It is necessary to re-evaluate sealed tooth surface for loss of material, exposure of voids and caries development especially in the first 6-month of placement.

Pediatric Operative Dentistry 89

CHAPTER

10

Pediatric Operative Dentistry

FINN’S CLASSIFICATION OF CAVITY PREPARATION

Fig. 10.1: Class 1

Pit and fissure cavities on occlusal surface of molars and the buccal and lingual pits of all teeth.

90


Fig. 10.2: Class 2

Cavities on the proximal surfaces of posterior teeth with access established from occlusal surface.


Fig. 10.3: Class 3

Cavities on the proximal surfaces of anterior teeth that may or may not involve the labial or lingual extension.

92


Fig. 10.4: Class 4

Restorations on the proximal surfaces of anterior teeth that involve the incisal edge.


Fig. 10.5: Class 5

Cavities on the cervical third of all teeth, including proximal surfaces where the marginal ridge is not included in cavity preparation.

94


MODIFICATION TO INCLUDE CARIOUS GROOVES

Fig. 10.6: Occlusofacial

Fig. 10.7: Occlusolingual


Fig. 10.8: Buccal groove extension

SIMON’S MODIFICATION Restorations on the incisal edge of anterior teeth or the occlusal cusp tips of posterior teeth.

Fig. 10.9: Cusp coverage

Fig. 10.8: Cusp coverage with class I cavity

96


RUBBER DAM KIT

Fig. 10.11: RD Kit


RUBBER DAM SHEETS

Fig. 10.12: Sheet

• •

• •

Available sizes are 5" × 5" or 6" × 6" Available thickness are – Thin – 0.15 mm – Medium – 0.2 mm – Heavy – 0.25 mm – Extra heavy – 0.30 mm – Special heavy – 0.35 mm Available colors are green, blue, black, pink and burgundy. Also available in different flavors like mint, banana and strawberry.

98


RETAINERS

Fig. 10.13: Rubber dam clamps

• • • •

It has 4 prongs, 2 jaws that are connected by a bow as shown Various types and sizes are present for each tooth Its use is to anchor the most posterior tooth to be isolated and also to retract gingival tissue Can be classified as wingless or winged. Later provide more retention.


RUBBER DAM RETAINING FORCEP

Fig. 10.14: Forcep

Used for placement and removal of clamps.


RUBBER DAM PUNCH

Fig. 10.15: Rubber dam punch

It is a precision instrument having a rotating metal table with six holes of varying sizes and a tapered, sharp, pointed plunger. The largest hole being for molars and the smallest for mandibular incisors.


RUBBER DAM FRAME

Fig. 10.16: Plastic rubber dam frame

It holds and positions the border of rubber dam. It is of two types—metallic (Young’s frame) and plastic (Nygaard Ostby frame). RUBBER DAM NAPKIN It is placed between rubber dam and patient’s skin. It has the following uses: • Prevents allergy • Acts as a cushion • Prevents pressure marks on patient’s cheeks • Convenient method for wiping the patient’s lips on removal of dam.


LUBRICANT It facilitates passing of dam through posterior contacts and also help the dam to pass over clamps. It is also applied over patient’s tissues to prevent injury and dryness. Commonly used lubricants are soap solution, petroleum jelly and cocoa butter. DENTAL FLOSS To secure the rubber dam. RUBBER DAM TEMPLATE To punch holes for accurate placement of rubber dam according to quadrants.

Fig. 10.17: Template for hole placement


PROCEDURE FOR PLACEMENT OF RUBBER DAM

Fig. 10.18: Administration of local anesthesia and selection of clamp

Fig. 10.19: Selection of rubber dam sheet and punching holes with rubber dam punch


Fig. 10.20: Secured rubber dam clamp

Secure the floss on the clamp by wrapping it all around the bow and passing it from both the holes in wings and place the clamp on the tooth with the help of retainer forceps and check for stability.


Fig. 10.21: Application of RD sheet

Now lubricate the punched hole in the sheet and also apply lubricant on the gingival tissues and lips of the patient. Enlarge the hole in the sheet with the help of retaining forceps and gradually adapt it on the retainer.


Fig. 10.22: Final fitting of rubber dam

Apply the frame and stretch the dam over it and cut if there is any excess in nasal area. QUICK DAM

Fig. 10.23: Hardy dam placed

This type of rubber dam has a pre-attached frame and is easy to place as it has minimal instrument requirement.


ESTHETIC DENTISTRY Strip Crowns

Fig. 10.24: Carious incisor

Preoperative view of carious central incisors.

Fig. 10.25: Restored incisor

Strip crowns placed on central incisors.


Bleaching

Fig. 10.26: Preoperative

Photograph depicting enamel hypoplasia.

Fig. 10.27: Postoperative

Presentation after bleaching with a mixture of hydrochloric acid, ether and hydrogen peroxide.


Composite Veneering

Fig. 10.28: Preoperative

Preoperative presentation of the patient exhibiting moderate enamel hypoplasia.

Fig. 10.29: Postoperative

Photograph after composite veneering.


Composite Restoration

Fig. 10.30: Class I feature of incisor

Enamel fracture in central incisor.

Fig. 10.31: Restored central incisor

Postrestorative photograph.


Fragment Reattachment

Fig. 10.32: Trauma to central incisor

Complicated crown fracture involving enamel, dentin, pulp.

Fig. 10.33: Fragment

Broken fragment of the central incisor.

Fig. 10.34: Re-attached fragment

Attachment of the fragment to the tooth with composite resin following endodontic therapy.


Stainless Steel Crowns It is indicated in caries involving three or more surfaces, rampant caries, recurrent caries around existing restoration, after pulp therapy, acquired enamel defects, severe bruxism.

Fig. 10.35: Endodontically treated molar prior to crown cutting


Fig. 10.36: Photograph depicting crown reduction, i.e. occlusal and proximal

Fig. 10.37: Fully adapted stainless steel crown


CHAPTER

11

Pediatric Endodontics

INDIRECT PULP CAPPING Defined as a procedure where in small amount of carious dentin is retained in deep areas of cavity to avoid exposure

Fig. 11.1: Procedure of IPC

Pediatric Endodontics 115

of pulp, followed by placement of a suitable medicament and restorative material that seals of the carious dentin and encourages pulp recovery. Use local anesthesia and isolation and establish cavity outline ↓ Remove the superficial debris and majority of the soft necrotic dentin ↓ Stop the excavation as soon as the firm resistance of sound dentin is felt ↓ Peripheral carious dentin is removed with a sharp spoon shaped excavators on the cavity floor ↓ Cavity flushed with saline and dried with cotton pellet ↓ Site is covered with Ca (OH)2. Remainder cavity is filled with reinforced ZOE cement ↓ During the second appointment, 6-8 weeks later; carefully remove all temporary filling material ↓ Previous remaining carious dentin will have become dried out, flaky and easily removed ↓ The cavity preparation is washed out and dried gently and covered with Ca(OH)2 ↓ Base is built up with Reinforced ZOE cement /GIC and final restoration is then placed.


DIRECT PULP CAPPING It is defined as the placement of a medicament or nonmedicated material on a pulp that has been exposed in course of excavating the last portions of deep dentinal caries or as a result of trauma. Isolate and avoid manipulation of pulp ↓ Cavity should be irrigated with saline and hemorrhage is arrested with light pressure from sterile cotton pellets ↓ Place the pulp capping material, on the exposed pulp with application of minimal pressure ↓ Final restoration

HISTOLOGICAL CHANGES AFTER PULP CAPPING

Fig. 11.2A: After 24 hours: Necrotic zone adjacent to Ca(OH)2 paste is separated from healthy pulp tissue by a deep staining basophilic layer


Fig. 11.2B: After 7 days: Increase in cellular and fibroblastic activity

Fig. 11.2C: After 14 days: Partly calcified fibrous tissue lined by odontoblastic cells is seen below the calcium proteinate zone; disappearance of necrotic zone


Fig. 11.2D: After 28 days: Zone of new dentin


PULPOTOMY Defined as the amputation of affected, infected coronal portion of the dental pulp preserving the vitality and function of the remaining part of radicular pulp.

Fig. 11.3: Preoperative carious tooth

Anesthetize the tooth and remove all caries using high-speed straight fissure bur without entering the pulp chamber. Enlarge the exposed area and deroof the pulp chamber.


Fig. 11.4: Excavation of pulp

Remove any ledges or overhanging enamel with slow speed round bur and use sharp spoon excavators to scoop out coronal pulp and pulpal remnants.

Fig. 11.5: Clean pulp chamber

Clean the pulp chamber with saline and remove all debris. Place a cotton pellet over the pulp stumps to achieve hemostasis.


Fig. 11.6: Fixed pulp tissue

Using a cotton pellet apply diluted formocresol to the pulp for 4 min. Remove cotton pellets and check for fixation, brownish discoloration of the pellet as well as the pulp stump is an indicator of fixation.

Fig. 11.7: Restored tooth

Place ZOE cement in the pulp chamber.


Fig. 11.8: Deep caries in 2nd molar

Preoperative radiograph showing deep caries in close approximation to pulp.

Fig. 11.9: Pulpoloyed 2nd molar

Post pulpotomy radiograph showing the extent of the pulp medicament.


PULPECTOMY Defined as the complete removal of the necrotic pulp from the root canals of primary teeth and filling them with an inert resorbable material so as to maintain the tooth in the dental arch.

Fig. 11.10: Preoperative view

Fig. 11.11: Access opening

Tooth is anesthetized, isolated and access cavity is prepared. Pulp chamber is deroofed and all accessible coronal and radicular pulp tissue is removed with broaches.


Fig. 11.12: Working length and bio-mechanical preparation

Determine the working length and file the canals, progressively increasing the file diameter and complete the biomechanical preparation (BMP).


Fig. 11.13: Appearance of tooth after complete BMP and irrigation

Fig. 11.14: Dry the canals using paper points to prepare for obturation


Fig. 11.15: Obturation

Coat the walls of canals with thin watery mix of cement with the help of a reamer

Fig. 11.16: Completion of obturation

Use thick mix and fill the canals using lentulospiral. Keep on adding fresh mix till no further cement can be incorporated in canals. Now seal the pulp chamber.


Fig. 11.17: Carious 2nd molar

Preoperative radiograph showing carious pulp exposure.

Fig. 11.18: Endodontically restored

Postpulpectomy radiograph showing visibly obturated root canals.


APEXIFICATION It is a method of inducing apical closure by formation of a mineralized tissue in the apical region of a non-vital permanent tooth with an incompletely formed root apex.

Fig. 11.19: Tooth exhibiting open apex

Access gained the pulp chamber and all debris and necrotic pulp tissue is removed from the canal.


Fig. 11.20: Calcium hydroxide dressing

Working length is determined and BMP to remove infected dentin from the canal walls. Ca(OH)2 is used to fill the entire root canal.


Fig. 11.21: Tooth is re-entered after 6 months to check for apical barrier

Fig. 11.22: Post obturation

Complete obturation with gutta-percha is done.

Oral Surgical Procedures in Children 131

CHAPTER

Surgical 12ProceduresOralin Children

SITE AND TYPE OF LOCAL ANESTHESIA IN CHILDREN

Fig. 12.1: Inferior alveolar nerve block


Fig. 12.2: Lingual nerve anesthesia

Fig. 12.3: Long buccal nerve anesthesia


Fig. 12.4: Greater palatine nerve block

Fig. 12.5: Nasopalatine nerve block


Fig. 12.6: Posterosuperior alveolar nerve block

Fig. 12.7: Middle superior alveolar nerve block


Fig. 12.8: Anterosuperior alveolar nerve block

Fig. 12.9: Infiltration anesthesia


PERIAPICAL SURGERY

Fig. 12.10: Preoperative photo showing the periapical lesion

Fig. 12.11: Curettage of the defect in periapical region after raising flap


Fig. 12.12: Re-suturing of the flap

Fig. 12.13: Postoperative view after one week—completely healed periapical lesion


ENUCLEATION It is complete removal of cyst along with its cystic contents and lining. This space is filled with a blood clot, which reorganizes to form normal bone. Mostly indicated for cysts that have a high recurrence rate.

Fig. 12.14: Intraoral view of the cyst


Fig. 12.15: Removal of overlying bone and enucleation of cyst followed by complete removal of lining

Fig. 12.16: View of the cyst after removal


Fig. 12.17: Postoperative suturing


MARSUPIALIZATION This refers to creating a surgical window in the cyst so, as to remove the cystic contents, promote shrinkage and enhance bone fill. It is mostly indicated in young children when cyst is close to developing tooth germ.

Fig. 12.18: Preoperative view of the cyst

Fig. 12.19: Removal of primary tooth overlying the cyst after administration of local anesthesia


Fig. 12.20: Removal of cystic contents and irrigation of the cavity

Fig. 12.21: Post surgical suturing


FRENECTOMY Frenal attachment is a thin band of fibrous tissue and muscle covered by mucous membrane. If the lingual frenum is attached too near to mandibular incisors, this is called tonguetie and the procedure to relieve the attachment is called as lingual frenectomy.

Fig. 12.22: Photograph depicting close lingual frenal attachment


Fig. 12.23: Lifting of tongue with traction sutures post anesthesia

Fig. 12.24: Clipping of frenum


Fig. 12.25: Post frenectomy

REMOVAL OF SUPERNUMERARY TEETH

Fig. 12.26: Preoperative view exhibiting the supernumerary tooth


Fig. 12.27: Removal of visible supernumerary tooth

Fig. 12.28: Raising of palatal flap to uncover palatally placed supernumerary tooth


Fig. 12.29: Mesiodens post removal

DENTOALVEOLAR FRACTURES

Fig. 12.30: Wire splint and composite

Splinting with the help of stainless steel wire and composite is done in cases where the injury to the dentoalveolar tissues is minimum and main focus is stabilization of teeth.


Fig. 12.31: Eyelet wiring

Eyelet wiring is indicated when teeth are present in pairs. The advantage of this method is that in case of wire breakdown only the respective eyelet has to be changed.

Fig. 12.32: Gunning splint

Acrylic splint is made for stabilization in mandibular arch and mainly indicated in children where mixed dentition and developing tooth buds contraindicate the use of direct fixation.


Fig. 12.33: Upper arch bar fixation on hot

Fig. 12.34: Lower arch bar fixation


Fig. 12.35: Intra-arch elastics after arch bar fixation

ASYMPTOMATIC ORAL LESIONS Arch bars are the most effective, quick and inexpensive method of fixation. In case of maxillary segment the hooks are directed upwards and in mandible, downwards. The arch bar is then cut according to arch form and adapted buccally. Wires are then made to pass interdentally and attached to the hooks and tightened clockwise.


Fig. 12.36: Epulis

Fig. 12.37: Mucocele


CHAPTER

13

Oral Habits

THUMB SUCKING

Fig. 13.1: Child performing the habit

Fig. 13.2: Blue grass appliance

Thumb sucking is defined as the placement of the thumb in varying depths into the mouth. Some important clinical features may be proclination of the maxillary incisors, high palatal arch, retroclination of mandibular incisors, posterior cross bite, anterior open bite, dishpan thumb. Management strategies include: psychotherapy—beta hypothesis, reminder therapy—thumb home concept, chemotherapy—femite and mechanotherapy—blue grass appliance.

Oral Habits 153

TONGUE THRUSTING

Fig. 13.3: Anterior tongue thrust

Fig. 13.4: Hay rakes

Tongue thrust is the forward movement of the tongue tip between the teeth to meet the lower lip during deglutition and in sounds of speech, so that the tongue lies interdentally. Its causes may include macroglossia, abnormal sleeping habits, genetic, allergy or gap filling tendency. Common manifestations are open bite, cross bite, midline diastema. Management includes: myofunctional therapy—elastic exercise, lip exercise, subconscious therapy and mechanotherapy—Hay rakes.


MOUTH BREATHING

Fig. 13.5: Act of mouth breathing

Fig. 13.6: Oral screen

Mouth breathing is defined as habitual respiration through the mouth instead of nose. This may be anatomic, developmental or habitual. Clinical features include Adenoid facies, upper lip is short, narrow maxillary arch, anterior open bite, increased incidence of caries, chronic keratinized marginal gingivitis.

Oral Habits 155

LIP BITING

Fig. 13.7: Active lip biting

Fig. 13.8: Lip bumper

This is defined as habit that involve manipulation of lips and perioral structures. It can be further classified as lip wetting or lip sucking habit. Protrusion of upper incisors, retrusion of lower incisors, muscular imbalance, lingual crowding, reddened, chapped area below the vermilion border and accentuated mento-labial sulcus are most common features.


CHAPTER

14

Space Management

FIXED SPACE MAINTAINER

Fig. 14.1: Band and loop

It is a unilateral, non-functional, passive, fixed appliance. It is usually indicated for preserving the space created by the premature loss of single primary molar and bilateral loss of single primary molar before eruption of permanent incisors.

Space Management

157

LINGUAL ARCH SPACE MAINTAINER

Fig. 14.2: Lingual arch space maintainer

It is a bilateral, non-functional, passive/active, mandibular fixed appliance. It is the most effective appliance of space maintenance and minor tooth movement in lower arch. The appliance is usually indicated to preserve the space created by multiple loss of primary molars when there is no loss of space in the arch, bilateral loss of primary molars after eruption of lower lateral incisors, unilateral loss of primary molars after eruption of lower lateral incisors and minor space regaining.


Fig. 14.3: Distal shoe space maintainer

Fig. 14.4: Radiograph of distal shoe after cementation

Distal shoe appliance is otherwise known as the intraalveolar appliance. Distal surface of the second primary molar provides a guide for unerupted first permanent molar. When

Space Management

159

the second primary molar is removed prior to the eruption of first permanent molar, the intra-alveolar appliance provides greater control of the path of eruption of the unerupted tooth and prevents undesirable mesial migration. TRANSPALATAL ARCH

Fig. 14.5: Transpalatal arch

Unilateral, non-functional, passive, maxillary fixed appliance. Transpalatal arch has been recommended for stabilizing the maxillary first permanent molars when primary molars require extraction. The best indication for Transpalatal arch is when one side of arch is intact and several primary teeth on the other side are missing.


Fig. 14.6: Nance palatal arch

Bilateral, non-functional, passive, maxillary fixed appliance. The Nance arch is simply a maxillary lingual arch that does not contact the anterior teeth, but approximates the anterior palate via an acrylic button that contacts the palatal tissue, which provides resistance to the anterior movement of posterior teeth in a horizontal direction. Nance palatal arch may be used in maintaining the maxillary 1st permanent molar positioning when there is bilateral premature loss of primary teeth with no loss of space in arch and a favorable mixed dentition analysis.

Space Management

FIXED SPACE REGAINER

Fig. 14.7: Gerber’s appliance

161


CHAPTER

15

Pediatric Orthodontics

REMOVABLE RETENTION APPLIANCES

Fig. 15.1: Hawley’s appliance

Pediatric Orthodontics 163

Fig. 15.2: Mandibular retention appliance

These are appliances, which are used to retain teeth in position following fixed appliance treatment. The components of these are clasps on molars and labial bow. Removable retentive appliances have the advantage that they can be slowly discarded over a period of time, thus allowing the occlusion to settle.


FIXED ORTHODONTIC ACCESSORIES

Fig. 15.3: Separators

These are used in case of tight interdental contacts. Separators are inserted in between the contact for 24 hours to ease the insertion of bands. Lingual Attachments

Fig. 15.4: Lingual cleat

Fig. 15.5: Lingual button

These provide additional points for fixing of elastics or for tying ligatures. These attachments have to be positioned so as not to irritate the soft tissues. Advantage of such appliances include placement on partially erupted or severely displaced teeth.


Fig. 15.6: Buccal tube

These are fitted on the molar teeth to accommodate the distal end of arch wires. The buccal tubes also have a hook for elastic placement. These are also called as molar tubes.


Fig. 15.7: Elastics

Fig. 15.8: E-chains

Commercially produced latex elastic loops available in various sizes for inter and intramaxillary tractions. They are available in different forms like elastic chains, loops, threads and ligature.


ORTHODONTIC BRACKETS

Fig. 15.9: Edgewise

Brackets in which arch wire channel is wide mesiodistally and rectangular in cross-section. The term edgewise refers to the ability of the bracket to accept rectangular cross-section wire with its larger dimension horizontal. These can also be used with round cross-section arch wires.


Fig. 15.10: Begg’s brackets

The Begg’s bracket has a narrow slot into which arc wire is loosely fitted and held by a locking pin. These are used only with round cross-section arch wires.


TREATMENT OF CROSS BITE USING FIXED APPLIANCE

Fig. 15.11: Preoperative photo depicting single tooth cross bite

Fig. 15.12: Application of brackets and Ni-Ti arch wire to align the tooth


Fig. 15.13: Postcross bite correction

CROSS BITE CORRECTION USING SPRING

Fig. 15.14: Single tooth cross bite


Fig. 15.15: Correction of cross bite using removable appliance with Z-spring and posterior bite plane

Fig. 15.16: Postoperative view


TREATMENT OF MIDLINE DIASTEMA

Fig. 15.17: Preoperative view

Fig. 15.18: Correction of midline diastema using elastics


MYOFUNCTIONAL APPLIANCES

Fig. 15.19: Frankel appliance

This is also called functional regulator. This serves as a template for the craniofacial muscles to function and removes abnormal muscular forces to enable skeletal growth.


Fig. 15.20: Bionator

This is of three types and can be used in Class II div 1 malocclusion, Class III malocclusion and open bite.


Fig. 15.21: Activator

It is used in actively growing children with favorable growth pattern. Its prime indications include Class II, Class III malocclusion, deep bite and open bite.


CHAPTER

16

Traumatology

ELLIS AND DAVEY CLASSIFICATION OF TRAUMA TO ANTERIOR TEETH

Fig. 16.1: Class I fracture

• •

Simple fracture of crown involving only enamel with little or no dentin. The treatment of choice for this is restoration with composite resin corrective grinding and removal of sharp edges is also useful.

Traumatology 177

Fig. 16.2: Class II fracture

• • •

Extensive fracture of crown involving considerable dentin but not exposing dental pulp. Immediate provisional treatment—Place Ca(OH)2 on the exposed dentin and restore. Permanent treatment—Reattachment of the crown fragment, restoration with composite resin or full coverage crown.


Fig. 16.3: Class III fracture

• • •

•

Extensive fracture of crown involving considerable dentine and exposing dental pulp. This type of treatment will depend upon the extent and time of pulp exposure. When the exposure is small and pulp has not been exposed for more than 4-5 minutes then it is advisable to do pulp capping. When the exposure is large and pulp has been exposed for more than 5 minutes then it is ideal to do pulpotomy.

Traumatology 179

Fig. 16.4: Class IV fracture

• •

The traumatized tooth that becomes non-vital with or without loss of crown structure. This is usually a asymptomatic condition and is most often discovered on routine examination. RCT on pulpectomy followed by esthetic rehabilitation.


Fig. 16.5: Class V fracture

• • •

•

Tooth lost as a result of trauma. Clinical presentation is of a bleeding socket with missing tooth. Only treatment option is reimplantation. If the extra-alveolar time is short, the tooth is reimplanted and splinted for 2 weeks and then endodontic treatment is done. If extra-alveolar time is long then tooth is treated with NaF, extraoral RCT is done and then tooth is reimplanted.

Traumatology 181

Fig. 16.6: Class VI fracture

• •

Fracture of the root with or without loss of crown structure. The principle of treatment of permanent teeth is reduction of displaced coronal fragments and firm immobilization. • Following treatment modalities are recommended based on the fracture line: 1. When fracture is present in middle third—Extraction. 2. When fracture is in apical third—Obturation till the possible working length and apical surgery to remove the fragment. 3. When fracture is near to gingival margin—Orthodontic or surgical extrusion of the fragment followed by immobilization and later crown fabrication.


Fig. 16.7: Lateral luxation (Class VII)

Displacement of tooth with neither crown or root fracture. Displacement of tooth in any direction other than axial. • Administer local anesthesia if forceful positioning is anticipated. • Reposition the tooth in normal position using digital pressure. • Splint the tooth for 2 weeks and if there is marginal bone breakdown then splint for 6 to 8 weeks.

Traumatology 183

Fig. 16.8: Extrusive luxation (Class VII)

It is also called peripheral displacement or partial avulsion. It is partial displacement of tooth out of its socket. • Administer local anesthesia if forceful positioning is anticipated. • Reposition the tooth in normal position using digital pressure. • Splint the tooth for 2 to 3 weeks.


Fig. 16.9: Intrusive luxation (Class VII)

Term used to describe displacement of tooth into alveolar bone. • Orthodontic or surgical repositioning of tooth. • Suture the gingival laceration. • Splint for 2 to 3 weeks after tooth has come to normal position.

Traumatology 185

Fig. 16.10: Class VIII fracture

Fracture of crown en masse and its displacement. The management of such cases depends on the extent of injury. Most common management of such cases usually includes endodontic therapy followed by prosthodontic rehabilitation by post and core and crown fabrication.


Fig. 16.11: Class IX fracture

Traumatic injuries of primary teeth. 1. Enamel infarction—No treatment. 2. Enamel fracture—Restoration with composite, selective grinding. 3. Enamel and dentin fracture—Ca(OH)2 and restoration. 4. Enamel and dentin fracture with pulp exposure— Pulpotomy, if root resorption is advanced then extraction. 5. Concussion, luxation—(a) If the luxation injury is slight, soft diet and careful oral hygiene instruction given. (b) If the tooth has been luxated palatally it might be possible to gently reposition and splint it manually if the displacement is less than 2 mm. (c) If the tooth has been

Traumatology 187

displaced by more than 2 mm extraction may be more appropriate. 6. Intrusion—If less than three-quarters of the crown is intruded then the tooth can be allowed to re-erupt spontaneously. If more than three-quarters of the crown has intruded, the tooth may cause symptoms such as pain, and the tooth may require extraction. 7. Extrusion—Extrusion injuries, interfere with the occlusion; therefore extraction is often indicated. 8. Avulsion—Reimplantation is contraindicated as ankylosis may take place thus obstructing the eruption of permanent successor.

Index A Ankyloglossia 25 Apexification 128 Asymptomatic oral lesions 150

B Bilateral fusion 16 Bionator 174 Broadbent phenomenon 63

C Cephalocaudal gradient of growth 6 Chronology of eruption 29 Concrescence 18 Cross bite correction using spring 170 Curing of pit and fissure sealant 88

D Dens evaginatus 21 Dens in dente 20

Dental floss 102 Dentoalveolar fractures 147 Development of teeth 32 Different types of caries 69 deep caries 70 initial caries 69 occlusal caries 69 proximal caries 70 Dilacerations 19 Distal step 60

E Early childhood caries 71 Ectopic eruption 42 Ellis and Davey classification of trauma to anterior teeth 176 Enamel hypoplasia 28 Enucleation 138 Eruption bulge 39 Eruption hematoma 38 Esthetic dentistry 107 bleaching 108 composite restoration 110 composite veneering 109 fragment reattachment 111

190 Mini Atlas—Pedodontics stainless steel crowns 112 strip crowns 107

F Finn’s classification of cavity preparation 89 Fixed orthodontic accessories 164 Fixed space maintainer 156 Fixed space regainer 161 Flush terminal 58 Food guide pyramid 68 Frenectomy 143 Fusion 16

G Gemination 17 Gingiva 43 Growth prediction 9 cranial base prediction 9 mandibular growth prediction 9 condylar axis 9 corpus axis 10 maxillary growth prediction 10 Gubernacular cord 36

H Histopathogenesis of dentinal caries 67

Histopathogenesis of enamel caries 66 Hyperdontia 15 Hypodontia 14

I Incisor relation 61 Internal resorption 27

K Key circle 64

L Leeway space of Nance 62 Lingual arch space maintainer 157 Lip biting 155 Lubricant 102

M Macrodontia 12 Manual toothbrush 76 Marsupialization 141 Mesial step 59 Microdontia 11 Mouth breathing 154 Myofunctional appliance 173

N Natal teeth 40 Newbrun circle 65

Index O Oligodontia 13 Orthondontic brackets 167

P Parental presence 54 Parental restraint 55 Periapical surgery 136 Physiologic spacing 56 Pit and fissure 81 types 81 Post caries rehabilitation 74 Postnatal growth of mandible 3 Postnatal growth of maxilla 1 Powered toothbrush 77 Pre-eruptive tooth movement 35 Primate spacing 57 Procedure for placement of rubber dam 103 Pulp capping 114 direct 116 indirect 114 Pulpectomy 123 Pulpotomy 119

Q Quick dam 106

191

R Removable retention appliances 162 Removal of supernumerary teeth 145 Retained teeth 41 Retainers 98 Rubber dam frame 101 Rubber dam kit 96 Rubber dam napkin 101 Rubber dam punch 100 Rubber dam retaining forcep 99 Rubber dam sheets 97 Rubber dam template 102

S Scammon’s curves for growth 7 general tissue 8 genital tissue 8 lymphoid tissue 7 neural tissue 8 Simon’s modification 95 Site and type of local anesthesia in children 131 Stages of tooth eruption 37 Steps of sealant application 82 application of etchant gel in fissures 84

192 Mini Atlas—Pedodontics apply sealant in the etched pits and fissures 86 curing the sealant 87 deep stained fissures 82 minimal tooth preparation using tapering fissure bar 83 postoperative view following curing of pit and fissure sealant 88 Supernumerary roots 24 Supernumerary tooth 23

T Talon cusp 22 Techniques of tooth brushing 79 Terminal planes 58 Thumb sucking 152 Tongue thrusting 153 Transpalatal arch 159 Treatment of cross bite using fixed appliance 169 Treatment of midline diastema 172

U Ugly duckling 63

Jaypee Gold Standard Mini Atlas Series Pe-dodontics (2008) [PDF] [UnitedVRG]

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