Chapter 4: Pediatric Dentistry Introduction



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Performing a Pulpectomy

Introduction


Under certain conditions a vital pulpotomy will not be successful. If hemostasis is not accomplished, if the pulp is necrotic, or if the tooth has irreversible pulp disease, a pulpectomy must be performed, or else the tooth should be extracted.

Partial Pulpectomy


This procedure is actually a variation of the pulpotomy procedure. If hemostasis cannot be achieved, a slow-speed, round bur is advanced 2 to 3 mm down the canal to reach unaffected vital tissue. The procedure then proceeds to step #4 as described previously.

Complete Pulpectomy


When a vital pulpotomy or a partial pulpectomy will not be successful, the canals must then be thoroughly debrided and filled with a resorbable paste. This technique relies heavily on the bactericidal properties of the paste and the recuperative powers of the body. Due to primary molar canal anatomy, all pulp tissue cannot be removed.

Indications for a Complete Pulpectomy


A complete pulpectomy may be indicated in the following situations:

  • a restorable primary tooth with hyperemic or necrotic pulp

  • a history of spontaneous pain

  • clinical or radiographic signs of an infection

Contraindications for a Complete Pulpectomy

A complete pulpectomy may be contraindicated in the following situations:



  • medically compromised patients (i.e. patients requiring SBE prophylaxis, patients with shunts, or immunocompromised patients)

  • pathologic root resorption

  • excessive bone loss or mobility

  • teeth with perforations

Procedures for Performing a Complete Pulpectomy


The following steps should be used to perform a complete pulpectomy on a pediatric patient:

Step

Action

1

Isolate the tooth and perform occlusal reduction.

2

Expose the pulp chamber by removing the roof of the pulp chamber with a high-speed handpiece.

3

Use the preoperative X-ray to determine a length 1 to 2 mm short of the radiographic apex. A precise working length does not need to be determined.

4

Debride the canals using standard endodontic k-files or Hedstrom files (up to at least the size 30 file). An apical stop is required.

5

Irrigate during instrumentation and dry the canals when debridement is complete.

6

If hemostasis cannot be achieved, temporize and reappoint for fill.

7

Fill the canals with ZOE resorbable paste using jiffy tubes, lentulo spiral drills, or the

needle tube tips to the Centrix syringe. Iodoform (Vitapex) or ZOE paste are recommended.



8

Expose a postoperative X-ray to evaluate the fill.

9

Place the ZOE dressing in the chamber and restore appropriately.

Guidelines for Treatment of Trauma to Primary Dentition

Introduction


The highest incidence of pediatric dental trauma occurs at approximately 18 months of age, shortly after the child learns to walk. The treatment of dental trauma in the child begins with asking the what, why, where, when, and how of the injury. Additionally, it is important to assess if the child needs a medical consultation or should be considered a victim of child abuse.

Neurological Assessment


It is not the dentist's responsibility to diagnose neurological status, but to seek a medical opinion if CNS involvement is suspected. Consultation is of primary importance with a history of unconsciousness, seizure, vomiting, severe headache, or prolonged confusion or irritability associated with the trauma. A quick cranial nerve assessment would evaluate smell, hearing, balance, memory, speech, and reactivity of the pupils to light. The patient should have normal gait, be able to follow movement with the eyes, have equally sized pupils, be able to protrude tongue normally, and have symmetrically facial movement.

Determining Treatment for Injuries to Primary Dentition


The following flow diagrams should be considered an aid in determining treatment for the following injuries to the primary dentition:

  • crown fracture (Figure 1: Crown Fracture Ellis Classification)

  • root fracture (Figure 2: Root Fracture)

  • luxation or avulsion injury (Figure 3: Luxation)

  • alveolar fracture (Figure 4: Alveolar Fracture)

Figure 1: Crown Fracture Ellis Classification


Figure 2: Root Fracture



Figure 3: Luxation


Figure 4: Alveolar Fracture


Section G: Management of Developing Dentition

Introduction


The untimely loss of one or more deciduous molars or canines can result in crowding problems, loss of arch length, ectopic eruption, or impaction. Prevention with space maintenance appliances will help the patient avoid some of these difficulties. Please review Chapter 10, Orthodontics, regarding interceptive orthodontic treatment.

Maintaining Space in Developing Dentition

Introduction


Space management and space supervision represents one of the most critical aspects of orthodontic treatment for children. Space maintenance techniques may be employed from the early mixed dentition to the early permanent dentition. Maintenance of arch circumference will eliminate many developing crowding situations.

Indications for Space Maintenance


A space maintainer appliance may be indicated as follows

  • when a deciduous first or second molar is lost prior to the eruption of the permanent first molar

  • to preserve leeway space when all of the posterior primary teeth are present but the dentition is slightly crowded

Contraindications for Space Maintenance


A space maintainer may not be indicated under the following situations:

  • The premolars are due to erupt within 6 months. The dental age of the patient should be evaluated. The following may serve as a guide:

  • Root length 3/4 formed indicates eruption in approximately 6 months.

  • With 1/2 root formation present, it takes 4 to 5 months for the succedaneous tooth to move through 1 mm of overlying bone (as measured on a bite-wing radiograph).

  • There is poor compliance, poor oral hygiene, or uncontrolled rampant caries.

  • Space has already been lost.

  • Severe crowding already exists.

  • There is no recall program available

Tips for Using Space Maintainers

When deciding to place a space maintainer it is important to address the following factors:



  • Placement of an appliance should be done as soon as possible after the loss of a primary tooth. Do not wait until the final appointment to evaluate for space maintenance.

  • The dental age of the patient should be evaluated to judge stability of the appliance through the mixed dentition.

  • Cement all appliances with glass ionomer cement to resist enamel demineralization.

  • All patients with space maintainers should be recalled at least every 6 months to evaluate for loose or distorted appliances, decalcification, soft tissue irritation, and eruption of permanent teeth.

Types of Space Maintainer Appliances


The following space maintainer appliances may be used to maintain space in mixed dentition:

  • band and loop or crown and loop

  • distal shoe

  • Nance appliance

  • transpalatal arch (TPA)

  • lower lingual arch (LLA)

Indications for Specific Space Maintainers

Tooth Prematurely Lost

Type of space maintainer to use if loss occurred...


during eruption of 1st permanent molar

after eruption of 1st permanent molar

mandibular primary 1st molar

  • unilateral loss: band & loop/crown & loop

  • bilateral loss: LLA or two unilateral appliances

maxillary primary 1st molar

  • unilateral loss: band & loop/crown & loop

  • bilateral loss: Nance or two unilateral appliances

  • unilateral loss: band & loop/crown & loop

  • bilateral loss: Nance or two unilateral appliances

mandibular primary 2nd molar

Distal shoe

  • unilateral loss: band & loop

  • bilateral loss: LLA

maxillary primary 2nd molar

Distal shoe

  • unilateral loss:

    • band and loop

    • bilateral loss:

    • Nance

both 1st and 2nd mandibular primary molars

Nothing

LLA, if no space loss has occurred

both 1st and 2nd maxillary primary molars

Nothing

Nance, if no space loss has occurred

primary cuspids

Maintain arch symmetry, extract opposite primary cuspid, and place appropriate bilateral appliance.

Maintain arch symmetry, extract opposite primary cuspid, and place appropriate bilateral appliance.

Band and Loop

The band and loop appliance (Figure 5: Band and Loop Appliance) is a unilateral space maintainer that is used in edentulous areas to prevent the drifting of adjacent teeth. It should be used in the primary dentition when a primary second molar is available for banding to hold space for the first premolar. A stainless steel crown may be substituted for the orthodontic band on primary molars. A .030 or.036 inch wire is soldered to the band or crown.

Figure 5: Band and Loop Appliance

Distal Shoe

The distal shoe (Figure 6: Distal Shoe and Figure 7: Band and Loop Appliance) is a variation of the band and loop. It is very important to use this appliance during the eruption of the first permanent molar, when a second primary molar is missing. The length of the distal arm can be determined by measuring a radiograph of the area. The distal extensions should contact the mesial of the erupting permanent molar and extend 1 mm gingival to the mesial marginal ridge. The distal shoe is maintained until the compete eruption of the permanent molar, at which time the distal shoe is removed and a lingual arch or a Nance appliance is placed.



Warning: The distal shoe is contraindicated in patients prone to bacterial endocarditis.

Figure 6: Distal Shoe



Figure 7: Band and Loop Appliance

Nance Appliance

The Nance appliance (Figure 8: Nance Appliance) is an effective appliance when the patient is missing primary molars bilaterally. It prevents mesial drift and molar rotation. The appliance incorporates a passive palatal acrylic button connected to an .036 wire soldered to molar bands.



Figure 8: Nance Appliance


Transpalatal Arch (TPA)


The transpalatal arch (Figure 9: Transpalatal Arch (TPA)) can be used to maintain the position of the upper first molars in the case where there is unilateral primary molar loss. It consists of .036 wire, soldered to the molar bands, with an Omega loop in the midline. This wire should remain 1.5 mm off of the palate.

Figure 9: Transpalatal Arch (TPA)


Lower Lingual Arch (LLA)


The lower lingual arch (Figure 10: Lower Lingual Arch (LLA)) uses primary second molars or permanent first molars for anchorage. It is used when replacing a distal shoe or when bilateral loss of primary molars or canines has occurred and the permanent incisors have erupted. Omega loops directed gingivally just mesial to the molars are incorporated into the appliance which will allow for adjustments when inserting the appliance. A .036 wire soldered to the bands should be stepped in lingually 1 to 2 mm from the primary canines and molars to allow eruption of the permanent teeth. This wire should also contact the cingulum of the incisors and remain approximately 1.5 mm off of the soft tissue. A wire spur soldered to the LLA distal to the lateral incisor can prevent midline shift when a primary cuspid is prematurely lost.

Figure 10: Lower Lingual Arch (LLA)


Space Maintainer Construction Options


All of the previous appliances can be easily constructed with a minimum of materials and time. This is often done if funds are not available for lab fees. If funds are available, commercial orthodontic laboratories provide good services, with only plaster models being required. The direct construction technique for fixed unilateral space maintainers allows immediate construction and insertion minimizing delays and financial considerations.

Caring for Space Maintainers


Instructions for Parents: A space maintainer has been placed in your child's mouth. It is important to follow a few guidelines for care of the appliance.

  • Avoid hard, sticky foods (especially taffy, gum, Jolly Ranchers, etc.).

  • The appliance is held in place with special dental cement. If the appliance should come out or come loose, please come into the office as soon as possible with the appliance and child.

  • It is important to keep the appliance and the teeth clean; brushing twice a day should be adequate. Adult supervision of the brushing is highly recommended.

  • A properly fitted space maintainer should not cause your child any pain. If your child complains of pain, have the dentist check the appliance as soon as conveniently possible.

Your child's space maintainer needs to be checked periodically for stability and for the eruption of the permanent teeth. Be sure to keep these check-up appointments.

Over-retained Primary Teeth

Introduction


The eruption of a permanent tooth can be delayed or displaced abnormally if its primary predecessor is retained too long. When this happens, the obvious treatment is to remove the primary tooth. As a general guideline a permanent tooth should erupt when approximately three fourths of its root is developed. If root formation of the permanent successor has reached this point while a primary tooth still has considerable root remaining, the primary tooth should be extracted. The problem is most likely to arise when the permanent tooth bud is displaced.

Treatment Options


Primary molars may present with resorption of just one root. In some instances, the primary tooth might have minimal or no root structure remaining, yet still be relatively firm due to being locked between adjacent teeth. Intervention may reduce or prevent future orthodontic problems for the patient. If the erupting permanent tooth has been deflected, short term space maintenance may be required to allow eruption and self correction.

Minimal crowding during eruption and exfoliation in the mandibular incisor area is often observed but considered normal. Intercanine width is increased due to pressure from eruption as well as lip and tongue molding. The extraction of primary canines is rarely indicated and should be done only if the practitioner is able to manage the mixed dentition orthodontically.

Supernumerary Teeth

Introduction


The most common supernumerary tooth is the mesiodens located in the maxillary midline. Other less common extra teeth are lateral incisors, premolars, and fourth molars. Supernumerary teeth often interfere with the eruption of adjacent teeth resulting in displacement or impaction of them.

Diagnosis of Supernumerary Teeth


Diagnosis is made with a periapical, occlusal, or panoramic radiograph, which should routinely be taken when delayed eruption of a tooth is suspected.

Treatment


In most cases, extraction of the supernumerary is indicated. Removal should be performed as soon as possible without endangering the developing teeth. Care must be taken to avoid damaging the developing permanent teeth during the removal of the supernumerary tooth. At times it is preferable to wait until root development of the permanent teeth is complete before attempting surgery.

Infraoccluded Primary Teeth

Introduction


An ankylosed primary tooth is often termed "submerged tooth." This tooth is not submerging but is remaining in a stationary position while the adjacent teeth are erupting and the alveolar bone is growing. Further diagnosis can be derived from a break in the continuity of the PDL space seen on the radiograph.

Over-retention


Often, the ankylosed tooth may be maintained the same as any other primary tooth as it resorbs and exfoliates naturally. However, over-retention may lead to some problems:

  • It may impede the eruption of its permanent successor or deflect it from its normal path of eruption.

  • The infraocclusion of a primary second molar can cause excessive mesial tipping of the first permanent molars resulting in loss of arch length.

  • Supereruption of opposing teeth may occur.

Treatment

Three treatment options are provided for three of the various situations associated with infraoccluded primary teeth:



  • If the adjacent teeth have not tipped, a SSC or composite buildup can be placed to maintain space and minimize supereruption of the opposing tooth. The patient should be kept on a regular recall to evaluate further difficulties.

  • If maintenance of the ankylosed primary tooth has caused an interference with eruption or significant drift of the adjacent teeth, then extraction and possible placement of a space maintainer is needed. Space-regaining procedures may also be required.

  • If the ankylosed primary tooth has no successor, the primary tooth should be maintained as long as reasonably possible. A stainless steel crown may be placed to restore the vertical space loss due to infraocclusion. These cases must be followed closely. Extraction with prosthodontic replacement or comprehensive orthodontics may be required.

Severely Decayed First Permanent Molars

Introduction


Severely carious first permanent molars frequently pose a difficult treatment decision. Often these teeth are restored with or without pulp treatment only to require further treatment and eventual extraction.

Decision Making


Timing is critical to avoid poor results. The decision to restore or extract first permanent molars should be a proactive one. The "let's wait and see" approach will rarely yield a good clinical result. In most cases, the decision should be made before the age of 10 years. Delayed extraction of the teeth can result in mesially inclined second molars and a posterior bite collapse. Conversely, extraction of the permanent molar too early (before age 8) may lead to distal drifting of the unerupted second premolar, resulting in non-exfoliation of the primary second molar.

  • When a lower molar is extracted, the upper molar may supererupt. A TPA cemented to the maxillary first molars will prevent this.

  • An orthodontic consult should be considered if extractions are contemplated. Good records and informed consent are mandatory.

  • Often more than one permanent molar is involved. In these cases, extracting all four first permanent molars should be an option.

Chapter 4 4-

Pediatric Dentistry July, 2003


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