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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

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Jaypee Gold Standard Mini Atlas Series: Pedodontics
2008, Jaypee Brothers Medical Publishers
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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

Craniofacial Growth
and Development

POSTNATAL GROWTH OF MAXILLA

Fig. 1.1: Primary displacement

Primary displacementGrowth at maxillary tuberosity thus


maxilla is pushed anteriorly.

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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.

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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.

Craniofacial Growth and Development

Fig. 1.8: Condylar growth

CondyleSecondary bone growth

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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.

Craniofacial Growth and Development

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.

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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.

Craniofacial Growth and Development

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

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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.

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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.

Developmental Anomalies of Teeth 13

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.

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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.

Developmental Anomalies of Teeth 15

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.

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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.

Developmental Anomalies of Teeth 17

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.

Developmental Anomalies of Teeth 19

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.

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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.

Developmental Anomalies of Teeth 21

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.

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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.

Developmental Anomalies of Teeth 23

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.

Developmental Anomalies of Teeth 25

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.

Developmental Anomalies of Teeth 27

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

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...

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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

Eruption and Shedding 31

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

Eruption and Shedding 33

Fig. 3.2 C: Bell stage

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Fig. 3.3: Nollas stages of tooth development

Eruption and Shedding 35

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.

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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.

Eruption and Shedding 37

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 and Shedding 39

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.

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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.

Eruption and Shedding 41

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.

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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

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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

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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

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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.

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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.

Behavior Management 51

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.

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Fig. 5.5: HOM modification with airway restricted

Fig. 5.6: HOM modification tower over mouth airway restricted

Behavior Management 53

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

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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.

Behavior Management 55

MOUTH PROP

Fig. 5.10: Adjunct for mouth opening

PARENTAL RESTRAINT

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

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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.

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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.

Development of Occlusion 59

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.

60 Mini AtlasPedodontics

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.

Development of Occlusion 61

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.

62 Mini AtlasPedodontics

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.

Development of Occlusion 63

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.

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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

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Mini AtlasPedodontics

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.

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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

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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.

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Mini AtlasPedodontics

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.

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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.

76 Mini AtlasPedodontics

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.

78 Mini AtlasPedodontics

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...

80 Mini AtlasPedodontics
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:

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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.

Pit and Fissure Sealants 83

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.

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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.

Pit and Fissure Sealants 85

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.

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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.

Pit and Fissure Sealants 87

Curing the Sealant

Fig. 9.7: Light curing

Step 6: Light cure the sealant according to the manufacturers


recommended time for curing.

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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.

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Mini AtlasPedodontics

Fig. 10.2: Class 2

Cavities on the proximal surfaces of posterior teeth with


access established from occlusal surface.

Pediatric Operative Dentistry 91

Fig. 10.3: Class 3

Cavities on the proximal surfaces of anterior teeth that may


or may not involve the labial or lingual extension.

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Mini AtlasPedodontics

Fig. 10.4: Class 4

Restorations on the proximal surfaces of anterior teeth that


involve the incisal edge.

Pediatric Operative Dentistry 93

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.

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MODIFICATION TO INCLUDE
CARIOUS GROOVES

Fig. 10.6: Occlusofacial

Fig. 10.7: Occlusolingual

Pediatric Operative Dentistry 95

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

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Mini AtlasPedodontics

RUBBER DAM KIT

Fig. 10.11: RD Kit

Pediatric Operative Dentistry 97

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.

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Mini AtlasPedodontics

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.

Pediatric Operative Dentistry 99

RUBBER DAM RETAINING FORCEP

Fig. 10.14: Forcep

Used for placement and removal of clamps.

100 Mini AtlasPedodontics

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.

Pediatric Operative Dentistry 101

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.

102 Mini AtlasPedodontics

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

Pediatric Operative Dentistry 103

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

104 Mini AtlasPedodontics

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.

Pediatric Operative Dentistry 105

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.

106 Mini AtlasPedodontics

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.

Pediatric Operative Dentistry 107

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.

108 Mini AtlasPedodontics

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.

Pediatric Operative Dentistry 109

Composite Veneering

Fig. 10.28: Preoperative

Preoperative presentation of the patient exhibiting moderate


enamel hypoplasia.

Fig. 10.29: Postoperative

Photograph after composite veneering.

110 Mini AtlasPedodontics

Composite Restoration

Fig. 10.30: Class I feature of incisor

Enamel fracture in central incisor.

Fig. 10.31: Restored central incisor

Postrestorative photograph.

Pediatric Operative Dentistry 111

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.

112 Mini AtlasPedodontics

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

Pediatric Operative Dentistry 113

Fig. 10.36: Photograph depicting crown reduction,


i.e. occlusal and proximal

Fig. 10.37: Fully adapted stainless steel crown

114 Mini AtlasPedodontics

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.

116 Mini AtlasPedodontics

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

Pediatric Endodontics 117

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

118 Mini AtlasPedodontics

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

Pediatric Endodontics 119

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.

120 Mini AtlasPedodontics

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.

Pediatric Endodontics 121

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.

122 Mini AtlasPedodontics

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.

Pediatric Endodontics 123

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.

124 Mini AtlasPedodontics

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).

Pediatric Endodontics 125

Fig. 11.13: Appearance of tooth after complete


BMP and irrigation

Fig. 11.14: Dry the canals using paper points to


prepare for obturation

126 Mini AtlasPedodontics

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.

Pediatric Endodontics 127

Fig. 11.17: Carious 2nd molar

Preoperative radiograph showing carious pulp exposure.

Fig. 11.18: Endodontically restored

Postpulpectomy radiograph showing visibly obturated root


canals.

128 Mini AtlasPedodontics

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.

Pediatric Endodontics 129

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.

130 Mini AtlasPedodontics

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

132 Mini AtlasPedodontics

Fig. 12.2: Lingual nerve anesthesia

Fig. 12.3: Long buccal nerve anesthesia

Oral Surgical Procedures in Children 133

Fig. 12.4: Greater palatine nerve block

Fig. 12.5: Nasopalatine nerve block

134 Mini AtlasPedodontics

Fig. 12.6: Posterosuperior alveolar nerve block

Fig. 12.7: Middle superior alveolar nerve block

Oral Surgical Procedures in Children 135

Fig. 12.8: Anterosuperior alveolar nerve block

Fig. 12.9: Infiltration anesthesia

136 Mini AtlasPedodontics

PERIAPICAL SURGERY

Fig. 12.10: Preoperative photo showing the periapical lesion

Fig. 12.11: Curettage of the defect in periapical


region after raising flap

Oral Surgical Procedures in Children 137

Fig. 12.12: Re-suturing of the flap

Fig. 12.13: Postoperative view after one weekcompletely


healed periapical lesion

138 Mini AtlasPedodontics

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

Oral Surgical Procedures in Children 139

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

140 Mini AtlasPedodontics

Fig. 12.17: Postoperative suturing

Oral Surgical Procedures in Children 141

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

142 Mini AtlasPedodontics

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

Fig. 12.21: Post surgical suturing

Oral Surgical Procedures in Children 143

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

144 Mini AtlasPedodontics

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

Fig. 12.24: Clipping of frenum

Oral Surgical Procedures in Children 145

Fig. 12.25: Post frenectomy

REMOVAL OF SUPERNUMERARY TEETH

Fig. 12.26: Preoperative view exhibiting the supernumerary tooth

146 Mini AtlasPedodontics

Fig. 12.27: Removal of visible supernumerary tooth

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


supernumerary tooth

Oral Surgical Procedures in Children 147

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.

148 Mini AtlasPedodontics

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.

Oral Surgical Procedures in Children 149

Fig. 12.33: Upper arch bar fixation on hot

Fig. 12.34: Lower arch bar fixation

150 Mini AtlasPedodontics

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.

Oral Surgical Procedures in Children 151

Fig. 12.36: Epulis

Fig. 12.37: Mucocele

152 Mini AtlasPedodontics

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.

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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.

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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.

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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.

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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

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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.

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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.

Pediatric Orthodontics 165

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.

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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.

Pediatric Orthodontics 167

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.

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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.

Pediatric Orthodontics 169

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

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Fig. 15.13: Postcross bite correction

CROSS BITE CORRECTION USING SPRING

Fig. 15.14: Single tooth cross bite

Pediatric Orthodontics 171

Fig. 15.15: Correction of cross bite using removable appliance


with Z-spring and posterior bite plane

Fig. 15.16: Postoperative view

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TREATMENT OF MIDLINE DIASTEMA

Fig. 15.17: Preoperative view

Fig. 15.18: Correction of midline diastema using elastics

Pediatric Orthodontics 173

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.

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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.

Pediatric Orthodontics 175

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.

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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.

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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.

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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.

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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.

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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.

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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

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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

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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