Year : 2010 | Volume
: 28 | Issue : 1 | Page : 42--44
Rehabilitation of severely mutilated teeth under general anesthesia in an emotionally immature child
S Navit, A Katiyar, F Samadi, JN Jaiswal
Department of Pedodontics and Preventive Dentistry, Sardar Patel Postgraduate Institute of Dental and Medical Sciences, Lucknow, India
Department of Pedodontics and Preventive Dentistry, Sardar Patel Postgraduate Institute of Dental and Medical Sciences, Utrathia, Rai Barelli Road, Lucknow
Dental caries is the single most common chronic childhood disease. In rampant caries, there is early pulp involvement and gross destruction of the maxillary anterior teeth as well as posterior teeth. This leads to decreased masticatory efficiency, difficulty in speech, compromised esthetics, development of abnormal tongue habits and subsequent malocclusion and psychological problems. The restoration of severely decayed primary incisors is often a procedure that presents a special challenge to dentists, particularly in an uncooperative child. This case report documents the restoration of severely mutilated deciduous teeth in an emotionally immature patient under general anesthesia.
|How to cite this article:|
Navit S, Katiyar A, Samadi F, Jaiswal J N. Rehabilitation of severely mutilated teeth under general anesthesia in an emotionally immature child.J Indian Soc Pedod Prev Dent 2010;28:42-44
|How to cite this URL:|
Navit S, Katiyar A, Samadi F, Jaiswal J N. Rehabilitation of severely mutilated teeth under general anesthesia in an emotionally immature child. J Indian Soc Pedod Prev Dent [serial online] 2010 [cited 2021 May 8 ];28:42-44
Available from: https://www.jisppd.com/text.asp?2010/28/1/42/60476
Nonpharmacologic behavior-management techniques are primary techniques for treating children in the dental chair. Alternative methods such as conscious sedation and other forms of sedation are also widely used.  However, in some circumstances these techniques may fail and the use of general anesthesia (GA) becomes the only resource to provide dental treatment for children in a safe and effective way.
The esthetic restoration of severely mutilated primary anterior teeth had been a challenge for the dentist for a long time, 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. 
This case report describes the challenging task of treating a 3-year-old rampant 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 esthetic restoration, as well as pulpotomy, pulpectomy and other restorative procedures in the needful teeth.
A 3-year-old female patient reported with a complaint of severely decayed teeth. The child was emotionally immature and highly uncooperative. Intraoral examination revealed multiple carious lesions, and 52, 61, 62, 64, 74, 84, showed pulp involvement. Crown portions of maxillary incisors were grossly destructed [Figure 1] and [Figure 2]. It was decided to do pulpectomy in relation to 52, 61, 62, 84, Post and core in 52, 61, 62 followed by strip crown in 51, 52, 61 and 62, pulpotomy in relation to 74, glass ionomer cement (GIC) restoration in relation to 54, 64, 65, 83, light cure composite restoration in relation to 71, 81.
Consent was taken from the parents. After due appointment, the patient was admitted to SPPGIDMS, Lucknow, and was given general anesthesia. Under GA, pulpectomy followed by composite restoration (strip crown) using custom-made posts, pulpotomy and restoration were performed; all procedures were carried out along with the other required treatments. For building core in deciduous anterior teeth, about 4 mm of cement was removed from the coronal end of the root canal, and 1 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 structure [Figure 3]. The loop was inserted into the canal with composite. The composite was light cured for 40 seconds. A strip crown was used and the crown was reconstructed [Figure 4].
This provided better mechanical retention and support for the restorative material. The occlusion was checked; and after the removal of any interference, final finishing and polishing of the restoration was performed using soflex tips. After completion of the procedure, a post operative photograph [Figure 5] and Orthopantomogram [Figure 6] was made. Home care instructions, including oral hygiene measures and diet counseling, were given to the parents. Recall checkup was scheduled after a period of 1 week, followed by recall checkup after every 6 months to assess the maintenance status of oral hygiene and for performing checkup procedures in the child's mouth.
Dental treatment under GA is an expensive alternative but on certain occasions the method of choice for treating unmanageable children. It is indicated for very young children who require extensive conservative dentistry and are unable to accept treatment in the dental chair, for children who are medically compromised, or for children who require oral surgical procedures.  An important consideration for children who are unable to cooperate due to fear, anxiety or young age is their subsequent acceptance of care using other methods with low risk and low impact.  The aim of GA is to restore the child's oral health in a single visit, allowing behavior-modification methods to be introduced more readily afterwards.  In this case, custom-made post was used in anterior teeth; other available options such as threaded posts, nickel-chromium cast posts, preformed and cast metal posts have been utilized;  however, they are expensive and require an additional lab stage. The use of metal posts needs 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 disadvantage of this technique is 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 buildup of the resin.  However, resin composite posts have low strength of loading. Ushamohan Das et al. also used a custom-made post using an orthodontic wire followed by strip crowns and achieved excellent cosmetic results in a child patient.  This led us to use the technique to do the complete oral rehabilitation of the patient. However, it was technique sensitive and required parent's cooperation. Also there was a chance of loss of restoration due to trauma or biting on hard foods, so the parents were advised that the child should avoid hard food. The child was very happy and satisfied regarding all functions of teeth, viz., mastication, speech, cosmetic function, etc. Restoration was found to be serving well at the 3-month recall.
In this study, authors take the view that full-mouth rehabilitation under GA can enable children to cope with future dental care and leave them in a position where they may be more amenable to dental care.
This approach offers the advantage of providing extensive complete oral rehabilitation in a short period of time and in a single visit, allowing immediate relief of pain, even with little or no cooperation from the child. However, it has little effect in promoting oral health and acceptance of routine dental care.
We would like to thank the entire teaching and nonteaching staff of the Department of Pedodontics and Preventive Dentistry, Sardar Patel Postgraduate Institute of Dental and Medical Sciences, Lucknow, and also the patient and her guardian for their continued support during the course of the case.
|1||Enger DJ, Mourino AP. A survey of 200 paediatric dental general anesthesia cases. J Dent Child 1985;52:36-41.|
|2||Johnsen DC. Characteristics and background of children with "nursing caries". Pediatr Dent 1982;4:218-24|
|3||Harrison MG, Roberts GJ. Comprehensive dental treatment of healthy and chronically sick children under intubation general anaesthesia during a 5-year period. Br Dent J 1998;184:503-6.|
|4||El-Bialy WB, Al-Rashid BA, El-Tanani H. Extraction of teeth under general anaesthesia for outpatient children and mentally retarded patients in Kuwait. Egyp Dent J 1992;4:257-62.|
|5||Ripa LW. Nursing Caries: A comprehensive review. Pediatr Dent 1988;10:268-82.|
|6||Mortada A, King NM. A simplified technique for the restoration of severely mutilated primary anterior teeth. J Clin Pediatr Dent 2004;28:187-92.|
|7||Rifkin A. Composite post crowns in anterior teeth. J Dent Assoc S Afr 1983;38:225-7.|
|8||Usha M, Deepak V, Venkat S, Gargi M. Treatment of severely mutilated incisors: Challenge to the pedodontist. J Indian Soc Pedod Prevent Dent 2007;25: S34-6.|