Preserving the roots and restoring a young smile: a challenge to the pedodontist

INTRODUCTION

Early childhood caries is a common chronic disease seen in preschool children with primary dentition. According to American Academy of Pediatric Dentistry (2014), Early childhood caries (ECC) is defined as the presence of one or more decayed non cavitated or cavitated lesions, missing due to caries or filled tooth surfaces in any primary tooth in a child under the age of six.¹

Formerly, the treatment of the severely damaged primary anterior teeth was extraction of these teeth. However, the consequences were space loss, alteration in phonetics, loss of vertical dimension, abnormal oral habits and associated psychological effects. This leads to increased treat¬ment costs and time, loss of school days and risk for delayed physical growth and development.^2,3

The revolution in the field of paediatricaesthetic dentistry brought us various materials and techniques like strip crowns, polycarbonate crowns, veneered stainless steel crowns, zirconium crowns and art glass crowns. These all are boon for the treatment of severely mutilated teeth. This has led the treatment modalities to shift from extraction to reconstruction.

Case Report

A 4-year-old male child [Figure 1(a)] accompanied by his parents reported to the Department of Pedodontics and Preventive Dentistry, AME’s Dental College and Hospital, Raichur, with a chief complaint of decayed upper front teeth. Detailed case history was recorded and examination and done. Intra oral examination revealed complete set of deciduous teeth. Clinically tooth number 52, 51, 61, 62, 64, 85 were found to be carious and 54 was found to be restored. Coronal portions of 52, 51, 61 and 62 were severely mutilated and with pulpal involvement [Figure 1(b)]. After complete clinical and radiographic examination, the child was diagnosed as early childhood caries with tongue thrusting habit.

The treatment goal was to remove the infected pulp and restore function and aesthetics by recreating the normal architecture. Teeth 64 and 85 were indicated for caries removal and restoration. The crowns of the teeth were severely destructed so for restoration of proper crown structure 51, 61 were indicated for pulpectomy followed by omega loop post and composite build up using strip crown and 52, 62 were planned to be treated with pulpectomy followed by fibre post and composite build up using strip crown.

After obtaining informed consent from parents and gaining child’s confidence, the carious teeth with no pulpal involvement were restored with Glass Ionomer Cement. Pulpectomy was performed on 52, 51, 61, and 62 under local anaesthesia. Obturation was done with zinc oxide eugenol (ZOE) cement (DPI Bombay). Post space was prepared by removing about 4mm of ZOE cement followed by placement of 1mm of GIC. Etching was done with 37% phosphoric acid for 10 seconds. It was then washed and dried with three way syringe. The bonding agent was applied and cured for 20 seconds.

A 0.7 mm stainless steel wire was bent into a loop in such a way as to allow the ends to be hooked in the entrance of the root canal of teeth 51, 61. The incisal end of the loop of the wire projected 2-3mm above the remaining root structure to receive the crown build up. 52, 62 were treated with fiber reinforced posts [Figure 2]. The remaining canal spaces were filled with composite. Crown reconstruction was done over the incisal ends of omega loops and fiber posts using composite filled strip crowns. Occlusion was checked for any interference and final polishing was done [Figure 3(a, b)]. Patient was advised for regular checkup every 3 months.

DISCUSSION

The successful restoration of primary anterior teeth with severe destruction of coronal structure is a challenging task for the dentists. Loss of coronal structure due to early childhood caries compromises the longevity of the restoration, especially in the primary anterior teeth.

This might cause aesthetic, speech, orthodontic and psychological problems. The child in this case report presented with severely mutilated maxillary primary anterior teeth. The main aim of treatment is to avoid extraction of these teeth and to restore function, aesthetics and psychology of child. It is not always easy to provide restoration in such cases with very minimal tooth structure and also due to the fact that bonding in primary teeth is not satisfactory.⁴ Rifkin described use of post as intracanal retainer in restoring primary anterior teeth.⁵ If the post extends a long way into the root, it may interfere with physiologic root resorption. Therefore it was not widely accepted. An ideal post and core should be resorbable but provide adequate retention and resistance.⁶

Mortada and King introduced a simple technique of using “omega wire extension” which solved most of the problems since it was not inserted deep into the canals. Therefore, there is no risk of interference with physiological root resorption.⁶ Modified omega wire extension is also an efficient technique which improves retention and causes less internal stress. This enhances the clinical applicability and long-term prognosis.⁷

Various other intracanal retainers that have been used are nickel-titanium and other metallic posts, orthodontic wires, biological posts, short composite resin posts, fiber-reinforced composite (FRC) posts such as polyethylene ribbon fiber posts and glass fiber posts.⁸

The use of a short composite resin post is a simple technique to compress the composite into the canal and create a tapered post. A similar technique, called the mushroom-shaped resin post, involves creating an undercut around the root canal walls and building up the composite within the canal.^9,10 Fiber-reinforced composite posts made of polyethylene and glass fiber provide the best aesthetic results. Glass fiber posts are also used to strengthen weakened roots thereby minimizing the likelihood of root fracture. These types of posts have shown to have high tensile strength and modulus of elasticity similar to dentin.^11,12

After endodontic treatment and placement of intracanal retainers, the remaining coronal structure can be restored with direct or indirect technique or with single tooth crown. The crowns include celluloid strip crowns, stainless steel crowns, metal plastic crowns, porcelain veneers, polycarbonate crowns and acrylic resin crowns.⁶

In the present case, omega wire extensions and glass fiber posts are used as intracanal retainers. Celluloid strip crowns were used for restoration of coronal structure as this technique is simple, quick and gives good esthetic results.

The esthetic results of the present case were satisfactory and helped to restore smile of the child. Moreover, the number of appointments was reduced to a great extent. In addition, the technique eliminates laboratory processing and is economical both in time and expenses.