Case 1: Pedo

REHABILITATIVE AND ESTHETICS DENTISTRY

Presented by:
Tan Teng Teng 160110132009
Ling Pei Cheng 160110132010
Shangeetha 160110132013
IRREVERSIBLE PULPITIS
DEFINITION

•Severe inflammation of the dental pulp that

never change even when the cause is removed
ETIOLOGY
• deep caries,
• bacteria involvement of pulp through caries
SIGN AND SYMPTOMS
• intense, lingering pain to temperature changes
• spontaneous pain and sharp and shooting pain
• pain when bending over pain due to change
• lying down or change of position in intrapulpal
pressure
Mechanism of Irreversible Pulpitis
• Irreversible pulpitis is a persistent inflammatory condition of the pulp
• The post capillary venules become congested, these attract the
polymorph nuclear leukocytes, by chemotaxis and start an acute
inflammatory reaction
• This inflammatory reaction produces micro-abscesses (acute)
• Microscopically one sees area of abscess and a zone of necrotic
tissue, with microorganisms present in the late carious state, along
with lymphocytes, plasma cells and macrophages
Mechanism of Irreversible Pulpitis
• No microorganisms are found in the
center of the abscess because of the
phagocytic activity of the polymorph
nuclear leukocytes
• Then the caries reaches the pulp, the
histological picture changes, then sees
an area of ulceration (chronic), zone of
infiltration of PMNs leukocytes and
zone of proliferating fibroblasts
Treatment for Irreversible Pulpitis
• The main treatment for irreversible pulpitis is to perform an
endodontic treatment, or a root canal, to help relieve the symptoms
and inflammation.
• An endodontist will take an image of the tooth to evaluate the root
and the bones of for signs of disease.
• If infection is present, it can be treated during the root canal.
• However, in some cases, a course of antibiotics may need to be used
to help clear the infection before the root canal can be performed. If
a root canal cannot be done, then the tooth may need to be pulled,
or extracted.
Premature Loss of Deciduous
Teeth
Causes of Premature Loss of Deciduous Teeth
Anterior:
• premature resorption of their roots: ectopic eruption
• Trauma

Posterior:
• decay (caries) followed by extraction.
• Premature resorption of the roots of deciduous incisors and canines is
a symptom of crowding.
• In addition, the distal root of maxillary second deciduous molars can
resorb prematurely if the first permanent molar erupts too far to the
mesial. However, the deciduous molar will not exfoliate, and the
eruption of the permanent molar will be blocked.
Effects of Premature Loss of Deciduous Teeth
1) The occurrence of migrations
• These migrations are greater and happen more quickly in the maxilla
than in the mandible.
• migrations in the maxilla are mainly limited to mesial movement and
rotation of the first permanent molar.
• In the mandible, teeth mesial to the lost tooth have a greater
tendency to move distally.
2) the spatial conditions in the dental arches
• premature loss of deciduous teeth in dental arches with excess space
has no or only little effect on the development of the dentition.
• In the absence of excess space, complications might appear; in cases
of crowding, complications are a certainty.
3) Tongue and buccal musculature and the timing of the loss is
relevant.
• Loss long before the time of emergence of the successor leads to its
delayed emergence.
• loss shortly before emergence has an accelerating effect.
• loss of deciduous teeth at an early age has more negative sequelae
than loss occurring later. Migrations of adjacent teeth take place
mainly in the first 6 months after the premature loss.
Premature loss of deciduous incisors and
canines
• maxillary central deciduous incisors do not play a role in the
mechanism of distal displacement of lateral deciduous incisors and
deciduous canines during the eruption and emergence of the central
permanent incisors.
• With the eruption and emergence of a maxillary central permanent
incisor, the root of the adjacent lateral deciduous incisor can resorb,
and the crown can exfoliate (Fig a&b).
• In unilateral premature loss of a maxillary lateral deciduous incisor,
the deciduous canine on that side will not displace distally and
buccally during the eruption of the central permanent incisor; in
bilateral loss, this phenomenon will occur on both sides.
• Too little space remains for the lateral permanent incisors.(figure
c&d)

Their eruption can lead to premature resorption

and loss of the deciduous canines. (figure e)
• Subsequently, the lateral permanent incisors move labially and
occupy their positions in the dental arch. Too little space remains for
the permanent canines. Sometimes in such cases the deciduous
canines are not lost prematurely; instead, the lateral permanent
incisors emerge palatally.
Effect of premature loss of deciduous anterior
teeth.
• the eruption of maxillary lateral
permanent incisors can lead to premature
loss of deciduous canines.
• A. With unilateral premature loss of a
maxillary deciduous canine, the incisors
will migrate in that direction, and the
midlines of the dental arches will no
longer match. Consequently, insufficient
space remains there for the maxillary
permanent canine, which will emerge A
buccally.
• B. With premature loss of both maxillary deciduous canines, the
midline will not displace. If both deciduous canines are lost
prematurely, both permanent canines will be outside the dental arch.

B
 Premature loss of mandibular lateral deciduous incisors and
deciduous canines.
Unilateral loss of a
mandibular lateral
deciduous incisor as can
happen with asymmetric Bilateral loss of
positioning and eruption of mandibular lateral
mandibular central deciduous incisors.
permanent incisors.

Unilateral loss of a
mandibular deciduous Bilateral loss of
canine, followed by mandibular deciduous
migration of the incisors canines, usually without
to that side and shifting deviation of the midline.
of the midline
 Effects of premature loss of deciduous canines on the angulation of
permanent incisors and the position of the midline.

a) Unilateral loss of a (b) Unilateral loss of a

maxillary deciduous mandibular deciduous
canine results in tipping canine has the same
of the permanent results.
incisors and shifting of
the midline.

(d) With the loss of a

(c) Unilateral loss of deciduous canine in the
opposing deciduous mandible on one side and in
canines leads to tipping of the maxilla on the other side,
the incisors in the same the maxillary and mandibular
direction in both jaws. permanent incisors will tip in
opposite directions.
• In the mandible, premature loss of deciduous incisors has
consequences for the increase in intercanine distance.
• Furthermore, premature loss of mandibular deciduous canines can
result in an increase in overjet and overbite.
Effect of Premature loss of deciduous molars
• If the exfoliation sequence of the primary second molars is reversed
and the maxillary molar is lost before the mandibular, a Class II
relationship of the permanent first molars will result. Again, arch
length will be reduced, and crowding will occur in the maxilla.
•
• If the primary mandibular second molar is lost far too early, the
mandibular arch length will be reduced to such an extent that the
normal leeway wiII be exceeded and crowding will occur.
 MESIAL DRIFTING
Definition
 Natural tendency of teeth to drift towards the front, i.e., towards the lips
 Our teeth tend to move forwards.
 This phenomenon can be observed when you loose a tooth
 The normal tooth gap is close by itself after years, depending on the age
of the patient.

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Etiology

1. Lose of tooth in front of the mesial drifted tooth.

2. Abandoned the space between two teeth for too long.

Mechanism of Mesial Drifting

 Teeth have the tendency to move towards the front

 Chewing movements lead to torsions of lower jaw & to
deflections of the teeth in the tooth sockets themselves
 When a tooth is missing, teeth will tilt into the existing
gap due to the mesial drift
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Permanent molar teeth

 Mesial drifting of permanent molar teeth will incline toward mesial and
rotate if there is premature loss of primary molar tooth or canine.
 This causes the lack of space needed for eruption of permanent canine
and premolars.
 If left untreated, crowding  region of canine and premolars.
 This will cause narrowing of the space in that region.
Management

 By adult orthodontic treatment and wearing retainers after treatment

 Once the teeth are straight, will expect to wear a retainer for the rest of our
life to maintain the position of the teeth, which will naturally begin to drift
again if left alone
 Retainers can be a removable clear thin plastic mouth guard type / bonded
wire inside the lower front teeth that stays in long term.
www.pinterest.com
diastema
 definition
• The gap between two teeth
• Usually closes by the time the
maxillary canines erupt.
Causes – 1. frenum
central
the rim of
incisors
bone
erupt
surroundi
widely no bone is V-shaped
ng each
separated deposited bony cleft
tooth may
from one inferior to develops an
not
another the between "abnormal"
extend to
during frenum. two frenum
the
ugly central attachment
median
duckling incisors, results.
suture.
stage

Tmt – classic frenectomy or orthodontic treatment

 Causes and treatments – 2. multifactorial etiology

Dentoalveolar diastema • Ethnic norm for certain races with large

associated with normal dentoalveolar arches, for example, African
growth and development and Mediterranean groups.

• Tmt – In most cases, diastemas will close spontaneously as the canines erupt.

• Diastemas of 2 mm or less will close on their own in the absence of a deep bite.

• Diastema of 3 mm or more may indicate the need for orthodontic closure with removable

and/or fixed appliances prior to canine eruption.

 • Lower lip biting and digit sucking can change
the equilibrium of forces among the lips, cheeks
Pernicious habits and tongue, causing inadequate lip seal,
causing the maxillary incisors to flare out.

Tmt - discontinue the oral habit and patients with persistent

diastemas may require orthodontic treatment to correct the

malocclusion
 • An object can deflect the
eruption patterns. For example,
Physical supernumerary teeth, persistent
impediment enlarged labial frenum, cysts or
fibromas or forms of periodontal
inflammation.

Tmt – removal of obstruction, frenectomy, orthodontic

appliances
 •Abnormal size, shape, or
Dental position of adjacent
anomalies teeth can leave spaces
and other between them or
malocclusions missing teeth, and jaw
size.

Tmt - orthodontic appliance with

cephalometric analysis and tooth size analysis.

Frenectomy
Definition
• A frenectomy (also known as a frenulectomy or frenotomy) is the
surgical detachment and/or excision of a frenum from its attachment
into the mucoperiosteal covering the alveolar process.
Abnormal labial frenum.
There is blanching (to
cause to become pale) of
the free marginal tissue
between the central
incisors and of the
palatine papilla.
Frenectomy is indicated.
Effects

Accumulation of
food particles and
Midline diastema
eventual pocket
formation

May restrict movements

of the lip May produce an
• Interfere with undesirable
speech cosmetic result
Treatment
• Many times, the replacement of the baby teeth with permanent teeth
will naturally close the gap between the two front teeth.

• If the gap doesn’t close, then it can be treated using braces.

• If the teeth begin to drift apart again after braces have moved them
together, then a maxillary labial frenectomy can be considered if it is
determined to be the cause of the gap.
Treatments
FRENECTOMY
A. Abnormal labial frenum observed
in a preschool child
B. A wedge-shaped section of tissue
including the frenum has been
removed.
C. Two sutures have been placed to
approximate the tissue margins.
RESTORATION OF PRIMARY
POSTERIOR TEETH
Dental restorations for children requires the use of
materials and techniques that need to be modified
because a successful treatment for the child is
determined by the
cooperation,efficiency and speed of work that is
considered.
Materials
Sealant
Sealant has been described as a material placed into
the pits and fissures of caries-susceptible teeth that
micromechanically bonds to the tooth.
Glass Ionomer
Glass ionomers have been used as restorative cements,
cavity liner/base, and luting cement.

Glass ionomers have several properties that make them

favorable to use in children:
1. Chemical bonding to both enamel and dentin
2. Thermal expansion similar to that of tooth structure
3. Biocompatibility
4. Uptake and release of fluoride
5. Decreased moisture sensitivity when compared to
resins.
Stainless Steel Crown
Stainless steel crowns are crown forms that are
adapted to individual teeth and cemented with a
biocompatible luting agent.

Children at high risk exhibiting anterior tooth caries

and/or molar caries may be treated with SSCs to
protect the remaining at risk tooth surfaces.
Composite

Composite is an esthetic restorative material used for

posterior and anterior teeth.
Usually given to children who has low caries count.
Amalgam
Amalgam restorations often require removal of healthy
tooth structure to achieve adequate resistance and
retention.

Usually used in the occlusal part of the tooth.

Stainless Steel Crown
• nickel chrome crown
• restoration for large cavities in primary teeth
Indications
• Extensive and/or multiple carious lesions
• Children with rampant caries
• For hypoplastic primary or permanent teeth
• Pulpotomized or pulpectomized primary or young permanent teeth
• Fractured teeth
• Abutment for space maintainers
Contraindications
• Patients allergy to nickel
• Deciduous teeth that exhibits resorption of >1/2 of the root length
Advantages
• Durable
• Retentive
• Low cost
• Easy to trim and contour
• Fast placement time
• Insensitive to hemorrhage or moisture
• Protection from future decay - feature of full coverage
Disadvantages
• Poor aesthetics
• Potential allergenicity
Tools
1) Rubber dam
2) Crown crimping pliers
3) Howe pliers
4) Burs 1 2
5) Cement, spatula, mixing pad
6) Band seater 3 6

7) Wedges
Procedures
1) Obtain recent preoperative radiograph
2) Provide soft tissue anaesthesia (painless procedure), place a rubber dam in position
3) If rubber dam is unable to be placed, wedges is considered and place firmly on mesial and distal
of the tooth, gingival to the contact area. Remove all caries present and perform root canal
treatment if indicated.
4) Reduce the occlusal surface by 1.5mm using the flame shaped diamond bur.
5) Distal portion is reduced with 10-15 degree taper using a tapered diamond bur.
6) Periphery of preparation is bevelled/rounded including the distal table to remove sharp line
angles.
7) An appropriate sized crown is chosen, fitting within gingival crevice is checked by probing.
8) Once contact is achieved, polish the margins with tone or rubber wheel, wash and dry.
9) Place glass ionomer cement, seat the crown from lingual to buccal, pressing down firmly.
10) Remove access cement after it has set by using probe, floss, or gauze.
11) Remove rubber dam and check the occlusion by having the patient to bite into the occlusion.
12) Rinse again if necessary and remove any left over access cement.
Space Maintainer
• Definition
• is an intra-oral appliance used to preserve arch length
following the premature loss of primary teeth/tooth.
• allows permanent teeth to erupt unhindered into
proper alignment and occlusion.
Indication
• Premature loss of teeth.
• Bad habit of children
• (eliminating bad habits - putting in place an empty tongue
or lip sucking)
Contraindication
• Permanent teeth erupting soon.
• First molar erupt in interlocking position and is stable.
• Angle class III relation.
• Lack of space for the eruption of permanent teeth.
• Excessive space for the eruption of permanent teeth.
• No replacement of permanent teeth.
• Patient not cooperative and bad oral hygiene.
Function of Space maintainer
• Maintain arch length, width, and perimeter
• Provide masticatory function
• Prevent over-eruption of opposing teeth
• Improve esthetics (anterior segment)
• Assist in speech (anterior segment)
• Aid in management of oral habits
Factors to be consider
• specific tooth lost prematurely
• period of time passed since the tooth loss
• occlusion and arch
• status of teeth and periodontal tissue
• eruption potential of permanent teeth
CRITERIA OF SPACE MAINTAINER
1. It should maintain the entire mesio-distal space created by a lost
tooth
2. It must restore the function as far as possible and prevent over-
eruption of opposing teeth
3. It should be simple in construction
4. It should be strong enough to withstand the functional forces
5. It should not exert excessive stress on adjoining teeth
6. It must permit maintenance of oral hygiene
7. It must not restrict normal growth and development and natural
adjustments which take place during the transition from deciduous to
permanent dentition.
TYPES OF SPACE MAINTAINER
• 1. Removable space maintainer

• 2. Fixed space maintainer

CLASSIFICATION OF SPACE MAINTAINER
• Class I: Unilateral Maxillary Posterior

• Class II: Unilateral Mandibular Posterior

• Class III: Bilateral Maxillary Posterior

• Class IV: Bilateral Mandibular Posterior

• Class V: Bilateral Maxillary Anterior Posterior
• Class VI: Bilateral Mandibular Anterior Posterior
• Class VII: Loss of one or more anterior tooth
• Class VIII: Loss of all deciduous teeth
 FIXED
Band-and-loop
Made of stainless steel wire , held in place by an
orthodontic-type band around one of the teeth next to
the space.
A wire loop is attached to the band and it sticks out across
the space where just touches the tooth on the other side
of the open space.
The wire loop holds the space open- avoid crowding.
Indication:
 primary molar loss.
Crown and Loop
The same as band and loop but the band is
replaced by a crown that restores largely
decayed abutment tooth.
Used if abutment tooth is decayed.
Removal of appliance for adjustments is
difficult.
• Transpalatal Bar
Indication:
• for bilateral loss of primary maxillary molars.
Advantages:
• Hygenic
Disadvantages
• May not prevent the mesial tipping of teeth
Lingual arch
Uses bands wrapped around a tooth on either side of the mouth
behind the missing teeth.
A wire connected to the bands runs along the inside of the
bottom teeth.
Indication:
• in situations where both primary first molars
bilaterally

Advantages: Disadvantage:

very stable appliance potential for

because of its two permanent incisors to
abutments erupt later behind the
lingual arch wire
Lingual Arch
Nance appliance
Indication:
• for loss of multiple primary teeth (bilaterally)in
the maxillary arch.

Advantages: Disadvantages :

Acryllic button provides Acryllic button may cause

increased stability. difficulty in maintaining
hygiene in the rugae area.

Appliance prevents tipping

and rotation of molars.
Nance appliance
Distal shoe appliance
A distal shoe appliance has a metal wire that is inserted under the
gums which keeps the space from closing.
Indication:
• Loss of a primary second molar before the
eruption of the first permanent molar.
Contraindications:
• Poor OH
• medically compromised patients.
Disadvantages:
• incoming tooth can easily become blocked by
the wire and may require adjustment to allow
the tooth to come in properly
 Removable
Looks like a retainer
It uses artificial teeth or acrylic blocks to fill in the
space or spaces that need to stay open
Works well in older children who can care for this
appliance.
Advantages: Disadvantages:

Technically feasible. children are very

unreliable when it comes
to taking care of
removable appliances
(lost or damaged).

removable unilateral
appliance is small so can
be a serious swallowing
or choking hazard.
Space Regainer
Definition
• A fixed or removable appliance which will help for
both regaining the lost space as well as its
maintenance for the eruption of permanent tooth.
Indication

1. Already shows sign of closing

2. Aid or make the future orthodontic treatment less

complicated

3. More space required for tooth eruption

Contraindication

1. Space for permanent tooth eruption already adequate

2. Space shows no sign of closing
3. General lack of sufficient arch length
4. Space regainer will further complicate existing
malocclusion
 Factors to Be Considered In Planning
For Space Regainer
1. Time lapse since loss 5. Presence of oral bad habit

2. Dental age of patient 6. Existing malocclusion

3. Amount of bone covering the 7. Delayed eruption of

unerupted tooth permanent tooth

4. Sequence of eruption of teeth 8. Congenital absence of

permanent tooth
Criteria of space regainer
Prerequisite of Space Regainer
• It can generate space required
• It wouldn’t interfere tooth eruption
• Simple and strong as possible
• Easily adjustable
• Easily cleaned
• Durable and corrosion resistant
• Universal application
• Should not interfere mastication and speech
Type of space regainer

•Fixed Space Regainer

•Removable Space Regainer
Fixed Space Regainer

Advantages
• Does not need patient cooperation.
• Can restore carious teeth adjacent to the space at the same time.
• Can produce drifting movement.
• Easy manipulation.
• Jaw growth is not hampered.
Disadvantages
• May cause discomfort if its break
• May be dislodge by sticky food
• Elaborate instrumentation with expert skills needed.
• Increased risk of caries.
Fixed Space Regainer

1. Gerber Space Regainer

• It consists of a band adapted on the tooth and an open coil inserted
into a U shaped wire.
• The wire is inserted into the molar tube on the band and whole
assembly cemented on the tooth.
• It can be used in unilateral tooth loss
2. Jackscrew Space Regainer
• It is used to recover the loss of space caused by drifting of tooth into
an edentulous area. It consists of two banded adjacent teeth and a
threaded shaft with screw and a locknut. This is activated regularly to
exert a consistence force against the banded teeth. This appliance
shows rapid results.
3. Looped Coil Space Regainer
• Designed to move a bicuspid mesially. It is not recommended for
moving more than one tooth or for moving a molar distally. The
appliance is adjusted in the mouth by flattening the loop
4. Lip Bumper
• This appliance can be used for bilatereal tooth loss. The pressure
exerted by the lips can produce gradual and continous effect to
distalize molars.
5. Halterman Appliance
• This appliance distalize the the molars while its erupting. It generate
space by gradually change the path of eruption.
6.Maxillary Molar Distalizer

• This appliance is a modification of Nance appliance It can be used for

both unilateral or bilateral
Removable Space Regainer
Advantages
• Doesn’t need preparation of adjacent teeth.
• Easy to clean or permit the teeth to be cleaned.
• Used in combination with other preventive procedure.
• Band construction is not necessary.
• Dental check for caries detection can be made easily.
Disadvantages
• Needs patient’s full cooperation.
• Can only produce tilting movement.
• May be lost or broken.
• May restrict jaw growth if clasp is incorporated.
• Irritate the underlying soft tissue
Removable Space Regainer Utilizing Jackscrew