Year : 2007 | Volume
: 25 | Issue : 5 | Page : 34--36
Treatment of severely mutilated incisors: A challenge to the pedodontist
M Usha, V Deepak, S Venkat, M Gargi
Department of Pedodontics and Preventive Dentistry, V. S. Dental College and Hospital, V. V. Puram, Bangalore - 560 004, Karnataka, India
Department of Pedodontics and Preventive Dentistry, V. S. Dental College and Hospital, K. R. Road, V. V. Puram, Bangalore - 560 004, Karnataka
Dental caries is the single most common chronic childhood disease. In early childhood caries, there is early carious involvement and gross destruction of the maxillary anterior teeth. This leads to difficulty in speech, decreased masticatory efficiency, development of abnormal tongue habits and subsequent malocclusion and psychological problems if esthetics are compromised. The restoration of severely decayed primary incisors is often a difficult procedure that presents a special challenge to pediatric dentists. This case report documents the restoration of severely mutilated lateral incisors in a patient with early childhood caries.
|How to cite this article:|
Usha M, Deepak V, Venkat S, Gargi M. Treatment of severely mutilated incisors: A challenge to the pedodontist.J Indian Soc Pedod Prev Dent 2007;25:34-36
|How to cite this URL:|
Usha M, Deepak V, Venkat S, Gargi M. Treatment of severely mutilated incisors: A challenge to the pedodontist. J Indian Soc Pedod Prev Dent [serial online] 2007 [cited 2020 Jul 14 ];25:34-36
Available from: http://www.jisppd.com/text.asp?2007/25/5/34/34745
A problem commonly faced in pediatric clinics is the restoration of primary maxillary incisors severely destroyed by trauma or caries. Most cases are observed among children with nursing bottle caries. ,, In early childhood caries, there is early carious involvement of the maxillary anterior teeth.  Premature loss of carious primary incisors may affect the speech by interfering with the pronunciation of consonants and labial sounds, decreased masticatory efficiency, abnormal tongue habits and potentially subsequent malocclusion. The child may also suffer from psychological problems if esthetics are compromised.  The restoration of primary incisors is often a difficult procedure that presents a special challenge to dental surgeons. 
The esthetic restoration of severely mutilated primary anterior teeth has for a long time been a challenge for the pediatric dentist, not only because of the available materials and techniques, but also because the children who require such restorations are usually among the youngest and least manageable group of patients. Added to this, these teeth usually have short and narrow crowns, thus only a small surface is available for bonding, pulp chamber that is relatively large and enamel that is inherently difficult to acid etch due to its aprismatic nature. In many cases, destruction of the whole crown occurs leaving only dentine in the root for bonding. So, in the past and even now, many of these teeth are extracted. 
A restorative technique that is able to provide efficient, durable and functional restorations, that is simple to perform would enhance the management of patients presenting with carious maxillary primary incisors. Such a technique could help to ensure the child's cooperation and reduce the anxiety associated with restorative treatment.  Because of the reduced coronal structure, direct restorative procedures do not always give satisfactory results. Shape, function and esthetics can be better restored by means of prosthodontic techniques. The child's growth and development may be improved. 
This case report describes the challenging task of treating a four-year-old early childhood caries patient with mutilated maxillary incisors with composite resin using a custom made post made with 0.7 mm wire to increase the potential surface area for attachment of the restorative material and consequently increase the long-term stability of an aesthetic restoration.
A four-year-old female patient reported to the Department of Pedodontics and Preventive Dentistry, V. S. Dental College and Hospital, Bangalore with a complaint of severely decayed teeth. The child was shy and withdrawn.
Intra-oral examination revealed a complete set of deciduous dentition in relation to 54,55,53,52,51,61,62,64,65, 85, 84,74,75 were affected by dental caries. Intra-oral periapical radiographs revealed pulp involvement of 54, 51, 61,64,74, 84, 85. 51, 52, 61, 62, 64 were grossly destructed with periapical abscess and mobility in relation to 51, 61 [Figure 1]. 51,61,64 showed root resorption. Diet analysis, counseling and oral prophylaxis were done. Fluoride application after temporization were done. Extraction of 51,61,64, and restoration in relation of 55,53,65,75 with Glass Ionomer Cement were done. Pulpotomy and restoration with stainless steel crown in relation to 54, and pulpectomy and restoration with stainless steel crown for 74, 84, 85 were carried out. Pulpectomy with composite restoration using custom made posts of 52, 62 were done. Band and loop space maintainer in relation to 64 and removable space maintainer for 51,61 were given.
Pulpectomy of 52,62 followed by root canal filling with zinc oxide eugenol was carried out along with the other required treatments. About 4 mm of the cement was removed from the coronal end of the root canal and I mm of zinc polycarboxylate cement was placed. A 0.7 mm stainless steel orthodontic wire was bent using no. 130 orthodontic pliers into a loop in such a way as to allow the ends to be hooked in the entrance of the root canal. The incisal end of the loop of the wire projected 2-3 mm above the remaining root structure [Figure 2],[Figure 3].
This provided better mechanical retention and support for the restorative material. Shade selection of the composite was made in daylight. After polycarboxylate cement set, the canal was prepared to get a space of about 3 mm.  The root canal and the remaining coronal structure was etched with 35% phosphoric acid for 20 sec. Then the bonding agent was placed and cured for 20 seconds. Composite restorative material of the selected shade was placed in the canal. The loop was inserted into the canal with composite. The composite was light cured for 40 sec. A strip crown was used and the crown was reconstructed. The occlusion was checked and after the removal of any interference, final finishing and polishing of the restoration was performed using soflex tips [Figure 4]. The removable space maintainer was placed to replace the maxillary central incisors [Figure 5]. This completed the treatment of the full mouth as shown in [Figure 6],[Figure 7],[Figure 8]. The patient was advised to come for regular checkup.
Restoring primary anterior teeth that are grossly destructed due to caries is very challenging for the pediatric dentist. There is a high rate of failure not only because of absence of tooth structure, poor adhesion of bonding agent to primary teeth, limited availability of materials and techniques, but also because the children who require such restorations are among the youngest and least manageable group of patients. To provide shape, function and esthetics in such teeth, use of intra-canal retainers is necessary. After endodontic treatment and placement of intra-canal retainers, the remaining coronal structure can be restored with direct or indirect technique or with single tooth prostheses such as celluloid strip crowns, stainless steel crowns, metal plastic crowns, porcelain veneers, polycarbonate crowns and acrylic resin crowns. 
Rifkin  described restoring primary anterior teeth with post and crown. But it was not widely accepted because of the potential for interference with physiologic root resorption if the wire extends a long way into the root. In addition, it can increase internal stresses within the root leading to fracture if the post is forcibly fitted into a narrow canal.
Threaded posts used in permanent teeth represent an excessive cost for pediatric dentist because it is bought as a kit, which is never totally utilized. Further more, apical tensions may be created, which may lead to root fracture during installation. 
Rodrigues et al.  have described the use of nickel- chromium cast posts with macro-elements that improved the durability of restorations.
Preformed and cast metal posts have been utilized; however, they are expensive and require an additional lab stage. The use of metal posts need the use of an opaque resin to mask the post and could pose additional problems during the course of natural exfoliation. 
More esthetic option may be the use of a biologic post. The disadvantages of this technique include the need of tooth bank, donor and recipient acceptance and stringent cross-control infection policies. 
Studies have shown that intra-canal retention in primary teeth can be obtained by directly building resin composite posts or preparing an "inverted mushroom shaped" undercut in the root canal prior to the build up of the resin. However, resin composite posts have low strength of loading. 
Motisuki et al.  have restored severely decayed primary teeth using an indirect composite resin restoration using fiberglass post. This technique was expensive and required lab work.
Mortada and King  have shown success with the use of direct composite restoration reinforced with mechanically retained orthodontic wire. This led us to use a custom-made post using an orthodontic wire and composite resin to restore mutilated lateral incisors. This technique was easy to perform and achieved excellent cosmetic results. However, it was technique sensitive and required patient cooperation. Also, there was a chance of loss of restoration due to trauma or biting on hard foods. The child, who was shy and withdrawn earlier, was more forthcoming and the restoration was serving well in the five-month recall [Figure 9].
The direct composite resin restoration using a custom made post with orthodontic wire used in this case report demonstrated good retention and esthetics. It was easy to perform and benefited the child immensely.
Staff And PG's, Department of Pedodontics.
|1||Johnsen DC. Characteristics and background of children with "nursing caries". Pediatr Dent 1982;4:218-24|
|2||Ripa LW. Nursing caries: A comprehensive review. Pediatr Dent 1988;10:268-82|
|3||Yui CK, Wei SH. Management of rampant caries in children. Quintessence Int 1992;23:159-68|
|4||Mcdonald, Avery, Dean. Dental caries in the child and adolescent. In: Dentistry for the child and adolescent. 8 th ed. Mosby: 2005. p. 209-10|
|5||Ngan P, Fields H. Orthodontic diagnosis and treatment planning in the primary dentition. ASDC J Dent Child 1995;62:25-33|
|6||Motisuki C, Santos-Pinto L, Giro EM. Restoration of severely decayed primary incisors using indirect composite resin restoration technique. Int J Pediatr Dent 2005;15:282-6|
|7||Wanderley MT, Ferreira SL, Rodrigues CR, Rodrigues Filho LE. Primary anterior tooth restoration using posts with macroretentive elements. Quintessence Int 1999;30:432-6|
|8||Mortada A, King NM. A simplified technique for the restoration of severely mutilated primary anterior teeth. J Clin Pediatr Dent 2004;28:187-92|
|9||Rifkin A. Composite post crowns in anterior teeth. J Dent Assoc S Afr 1983;38:225-7|
|10||Rodrigues Filho LE, Bianchi J, Santos JF, Oliveira JA. Clinical evaluation of dental reinforcements by means of metallic posts with macroretentions. J Dent Res 1996;75:1095|