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
Govt. Dental College, Rohtak, Haryana, India
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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
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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
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
Craniofacial Growth
and Development
POSTNATAL GROWTH OF MAXILLA
Fig. 1.1: Primary displacement
Primary displacementGrowth at maxillary tuberosity thus

maxilla is pushed anteriorly.
Mini AtlasPedodontics
Fig. 1.2: Secondary displacement
Secondary displacementGrowth of cranial base pushes the

maxilla in downward and forward direction.
Fig. 1.3: Remodeling
Surface remodeling
+ Deposition
- Resorption
Craniofacial Growth and Development
POSTNATAL GROWTH OF MANDIBLE
Fig. 1.4: Ramal growth
RamusResorption on anterior part and deposition on

posterior.
Fig. 1.5: Growth at body
Body of mandibleLengthens posteriorly as former ramal

bone changes into body.
Fig. 1.6: Tuberosity growth
Lingual tuberosityDeposition on posterior facing surface.
Fig. 1.7: Enlows V. principle
Angle of mandibleLingual: 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
CondyleSecondary bone growth
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.
SCAMMONS CURVES FOR GROWTH

The body tissues namely lymphoid, general, genital and neural
grow at different states at different times. This pattern is
discerned by Scammons curve.
Fig. 1.10: Scammons 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.
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.
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 magnumBasion (Ba) with anterior
point of frontonasal sutureNasion (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
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 incisorpeg 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.
18
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 Hertwigs 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.
24
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.
26
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.
28
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
Eruption and
Shedding
CHRONOLOGY OF ERUPTION
Primary Dentition:
Tooth
Hard tissue
formation
begins
Maxillary
Central Incisor 4 months
in utero
Lateral Incisor 4 months
in utero
Canine
5 months
in utero
1st Molar
5 months
in utero
2nd Molar
6 months
in utero
Mandibular
Central Incisor 4 months
in utero
Lateral Incisor 4 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
7 months 1 year
5 months
9 months
2 years
9 months
18 months
3 years
6 months
14 months
2 years
11 months
24 months
3 years
3 months
6 months
1 year
4 months
7 months
1 year
9 months
16 months
3 years
5 months
12 months
2 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
1-1 year
2-2 years
Birth
2-3 years
7-9 years
4-5 years
4-5 years
6-7 years
5-6 years
6-7 years
2-3 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
1-2 years
2-2 years
Birth
2-3 years
8-10 years
4-5 years
4-5 years
6-7 years
5-6 years
6-7 years
2-3 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.
32
DEVELOPMENT OF TEETH
Fig. 3.2 A: Bud stage
Fig. 3.2 B: Cap stage
Fig. 3.2 C: Bell stage
34
Fig. 3.3: Nollas 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.
38
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
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
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.
50
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 childs 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 childs appropriate behavior is reinforced. If the child
shows negative behavior again the procedure is repeated.
52
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 ones 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 AtlasPedodontics
CHAPTER
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

6 to 8 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
Caries
KEYS CIRCLE
Fig. 7.1: Keys 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
SalivapH, 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 zoneFirst signs of enamel breakdown are seen

in this zone.
Dark zoneDemarks the body of lesion from translucent
zone.
Body of lesionThis is the main bulk of lesion with maximal
mineral loss.
Surface zoneThere 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
Plaque Control
MANUAL TOOTHBRUSH
Fig. 8.1: Manual toothbrush
ADA Specifications
Length1 to 1.25 inches

Width5/16 to 3/8 inches
Surface area2.54 to 3.2 cm
No. of rows2 to 4 rows of brushes
No. of tufts5 to 12 per row
No. of bristles80 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
Doesnt 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...
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 Stillmans
stimulation
method but vibrate Cleaning of
brush and also
interproximal area
move occlusally
Easy to master
Pit and Fissure Sealants 81
CHAPTER
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 toothThe 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 preparationThis 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 surfaceApply 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 surfaceRinse 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 frostedwhite appearance.
86
Apply Sealant in the Etched Pits and Fissures
Fig. 9.6: Sealant application
Step 5: Application of sealantApply 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 manufacturers

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 occlusionEvaluate 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-evaluationRecall 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
FINNS 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
SIMONS 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

typesmetallic (Youngs frame) and plastic (Nygaard Ostby
frame).
RUBBER DAM NAPKIN
It is placed between rubber dam and patients skin. It has the
following uses:
Prevents allergy
Acts as a cushion
Prevents pressure marks on patients cheeks
Convenient method for wiping the patients 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
patients 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 weekcompletely

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: psychotherapybeta hypothesis, reminder
therapythumb home concept, chemotherapyfemite and
mechanotherapyblue 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 therapyelastic
exercise, lip exercise, subconscious therapy and mechanotherapyHay 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: Gerbers appliance
161
CHAPTER
15
Pediatric
Orthodontics
REMOVABLE RETENTION APPLIANCES
Fig. 15.1: Hawleys 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: Beggs brackets
The Beggs 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 treatmentPlace Ca(OH)2 on the
exposed dentin and restore.
Permanent treatmentReattachment 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 thirdExtraction.
2. When fracture is in apical thirdObturation till the
possible working length and apical surgery to remove the
fragment.
3. When fracture is near to gingival marginOrthodontic
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 infarctionNo treatment.
2. Enamel fractureRestoration with composite, selective
grinding.
3. Enamel and dentin fractureCa(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. IntrusionIf 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. ExtrusionExtrusion injuries, interfere with the
occlusion; therefore extraction is often indicated.
8. AvulsionReimplantation 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

stainless steel crowns 112
strip crowns 107
F
Finns 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
Scammons curves for growth 7
general tissue 8
genital tissue 8
lymphoid tissue 7
neural tissue 8
Simons 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

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

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POSTNATAL GROWTH OF MAXILLA

Fig. 1.1: Primary displacement

Primary displacementGrowth at maxillary tuberosity thus

Fig. 1.2: Secondary displacement

Secondary displacementGrowth of cranial base pushes the

Fig. 1.3: Remodeling

Craniofacial Growth and Development

POSTNATAL GROWTH OF MANDIBLE

Fig. 1.4: Ramal growth

RamusResorption on anterior part and deposition on

Fig. 1.5: Growth at body

Body of mandibleLengthens posteriorly as former ramal

Fig. 1.6: Tuberosity growth

Lingual tuberosityDeposition on posterior facing surface.

Fig. 1.7: Enlows V. principle

Angle of mandibleLingual: resorption on posterio-inferior

Craniofacial Growth and Development

Fig. 1.8: Condylar growth

CondyleSecondary bone growth

CEPHALOCAUDAL GRADIENT OF GROWTH

Fig. 1.9: Cephalocaudal growth

In fetal life at about 1/3rd month of intrauterine development,

Craniofacial Growth and Development

SCAMMONS CURVES FOR GROWTH

Fig. 1.10: Scammons growth curve

Craniofacial Growth and Development

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

Cranial Base Prediction

condylar neck (DC point), to the geometric center of

Developmental Anomalies of Teeth 11

Fig. 2.1: Microdontia

It is a condition of unknown etiology in which teeth are

Fig. 2.2: Large teeth

Anomaly of size where the tooth is larger as compared to its

Developmental Anomalies of Teeth 13

Fig. 2.3: Multiple missing teeth

Anodontia refers to congenital absence of teeth, which may

Fig. 2.4: Single missing teeth

It is defined as missing teeth as a result of failure of

Developmental Anomalies of Teeth 15

Fig. 2.5: Extra lateral incisor

This refers to more number of teeth as compared to normal

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

Tooth fusion is defined as union between the dentin and/or

Developmental Anomalies of Teeth 17

Fig. 2.7: Radiograph of geminated tooth

Geminated teeth are developmental anomalies of the tooth

Fig. 2.8: A. Concrescence, B. Hypercementosis

It is a form of fusion in which the teeth are joined by cementum

Developmental Anomalies of Teeth 19

Fig. 2.9: Root dilacerations

Abnormally sharp bend or angulation in the root or crown

Fig. 2.10: Tooth in a tooth appearance

It occurs due to invagination of Hertwigs root sheath before

Developmental Anomalies of Teeth 21

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

It is a tubercle projecting from the occlusal surface of the

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

An accessory cusp like structure projecting from the cingulum

Developmental Anomalies of Teeth 23