Dentin Opaquer: A Pediatric Aesthetic Enhancement Technique

Introduction

Dental caries are a major oral health concern involving most of the teeth due to its wide range of involvement from initial discoloration to loss of most of the tooth structure resulting in involvement of the pulp. According to the American Academy of Pediatric Dentistry, early childhood caries is defined as “the presence of one or more decayed, missing (due to caries), or filled tooth surfaces in any primary tooth in a child, 71 months of age or younger.”¹ These 2 case reports aim at reporting the management of initial caries with dentine opaquer and deep dental caries restored using glass ionomer cement (GIC) and dentine opaquer as a core buildup used in restoration.

Case report 1

A 3-year-old child reported to the Department of Pediatric and Preventive Dentistry with a chief complaint of decayed teeth in the upper front region of mouth. The child displayed positive behavior as per Frankl’s behavior rating scale. Patient’s history regarding the diet and details of oral hygiene maintenance was obtained. Oral examination revealed dental caries in relation to 51, 52, 61 and 62 without involving pulp (Figure 1.1: Preoperative view). An IOPAR was obtained to reconfirm the pulpal involvement and periapical pathology. Parent’s consent was obtained, and treatment was performed. Initial dental caries was removed using number 330 round bur and remaining soft caries was excavated with a spoon excavator (Figure 1.2: excavation of caries using no 330 bur). A layer of GIC luting cement was placed as base and the cavity was etched with 35% phosphoric acid for 20 seconds. The cavity was rinsed and air dried (Figure1.3: application of etchant). A dentine bonding agent was applied and cured for 20 seconds.² Dentine opaquer was placed over it and was cured layer by layer to mask the underlying discoloration and irregularities for 40 seconds each (Figure1.4: application of bonding agent and dentine opaquer). Finally, the composite restoration was done and cured for 40 seconds (Figure1.5: postoperative view). Restorations were evaluated clinically by visual examination for color match and marginal adaptability as per the criteria for assessment of composite restorations modified United States Public Health Service (USPHS) criteria. The color matching and marginal adaptability was scored as Alfa, accordingly after restoration with final composite restoration (Table -1).³

Case report 2

A 4-year-old child reported to the Department of Pediatric and Preventive Dentistry complaining of pain in the upper front region of the mouth. The child exhibited negative behavior as per Frankl’s behavior rating scale. Medical and diet history were evaluated. Oral examination revealed grossly decayed teeth in relation to 51, 52, 61, 62 (Figure 2.1: pre-operative view). Radiographic examination revealed periapical abscess in relation to 51, 52, 61and 62.

Parents were informed about the treatment procedure and consent was obtained. Pulpectomy was performed in relation to 51, 52, 61 and 62 and obturated with zinc oxide eugenol cement. Custom-made omega loop post was prepared using 0.9 mm stainless-steel wire and serrations were made to increase the retention and stability of the post.

After completion of pulpectomy post, space was prepared, a 4 mm length of coronal portion of the root filling was removed (2-3 mm below the CEJ). Postspacewaspreparedwith gates glidden drill. Any excess Zinc oxide eugenol cement on the walls of the root canal was removed. The post-space was air dried & a 1 mm base of glass ionomer cement was placed. The post was placed to a distance of 3 mm into the canal and the length was adjusted, such that it extends 2 mm outside the canal (Figure-2.2: Omega loop post insertion).An intraoral periapical radiograph was obtained to make sure that the end of the post was to the level of interdental crest or just apical to it. The prepared post space was then cleaned with saline and air dried. A light cured bonding agent was applied on the etched surface uniformly and light cured for 20 seconds.² The tip of flowable composites syringe was placed 2 to 3 mm below the cementoenamel junction (CEJ) and the composite was slowly injected.

The omega post was then inserted into the canal with cotton pliers and cured for approximately 40 seconds. GIC was used as the core build up material and dentine opaquer was placed over GIC to mask the color of metal and GIC (Figure 2.3a and Figure 2.3b: application of bonding agent and dentine opaquer).

Composite of suitable shade was loaded to the strip crown and excess composite was removed and cured. The cured strip crown was then removed (Figure 2.4: postoperative view). Restorations were evaluated clinically by visual examination for color match and marginal adaptability by the criteria for assessment of composite restorations modified United States Public Health Service (USPHS) criteria. The color matching and marginal adaptability was scored as Alfa after restoration with final composite restoration (Table -1).³

Discussion

The aesthetics of dentition is synonymous with facial aesthetics and problems at an early age have a huge influence on the psychological development and social interaction with other children.⁴ Achieving aesthetic composite restorations in the anterior region demands experienced hands and skillful training, but a deeper understanding of the chromatic characteristics of teeth, as well as, optical phenomena such as opalescence, fluorescence, fluorescence counter-opalescence, opacity and translucence.⁵ Dentine opaquer has a significant advantage because it provides better aesthetics as a restorative material. Development of new materials suc has art glass crowns, strip crowns, polycarbonate crowns, veneered stainless steel crown, etc. were introduced to restore the teeth with caries but having adequate tooth structure.⁶

The morphology of primary teeth in contrast with permanent teeth is different because they exhibit large pulp chamber, and a thinner enamel–dentine layer, which decreases the time for caries to reach the pulp and cause pulp necrosis. The primary teeth have less surface area for bonding, relatively large pulp chamber and prismatic enamel which is difficult to etch. Also, destruction of the tooth structure frequently involves the entire crown leaving just the root dentine for bonding of restorative material and thus, increasing the failure rate.⁷

Premature loss of anterior primary teeth may cause problems with eating/biting, difficulties in speech development, and retarded eruption of permanent incisors.⁸ The restoration of such teeth to retain the physiologic space and function is of prime importance.

Omega loop was introduced by Mortada and King as intracanal retainer in 2004. Omega loop can be custommade according to the tooth morphology and retention of function is possible. Normally a total of 5 mm long post is used in case of primary teeth. The free ends of these posts are placed inside the canal, approximately 3mm.⁵ Advantages of using omega posts is that they are cost effective and can be applied quickly, wire does not cause internal stress on the root canal due to its incorporation into the restorative material and it can be performed with minimal chair side time. Also, the coronal extension enhances retention of coronal restoration. There are many advanced post materials available with better aesthetics and retention. In the present case report omega loop was used with minimal time for fabrication, inexpensive, demonstrated adequate retention and good aesthetics were achieved by dentine opaquer to mask its metal tint. In a similar fashion, restorations can be aesthetic by masking the under lying irregularities by dentine opaquer application. Restorations were evaluated clinically by visual examination for color match and marginal adaptability by the criteria for assessment of composite restorations modified USPHS (United States Public Health Service). The color matching and marginal adaptability were scored as Alfa after restoration with composite restoration (Table -1).³

Rajesh Retal reported a case describing a technique to restore severely damaged primary anterior teeth with a modified anchor shaped post. This technique was not only simple and inexpensive but also provided better retention.⁹ Rallan Metal reported that restoration of severely mutilated incisors in a patient with early childhood caries. Snuggly-fitting number 4 metal screw post was selected to avoid any fracture because of stress and (Swiss made dental gold-plated screw posts, Nordin, H, Nordin SA CH-1816 Chailly) was adapted by reducing its post part to 3 mm and trimming its core part so that strip crown restoration can be easily performed. The core length of the post system which was placed inside the canal was equal to the recommended length for deciduous teeth. Three mm occupies only the cervical one-third of the canal to avoid interference with the process of primary tooth root resorption and permanent tooth eruption.10 Advantage of omega post over metal post is that desired length and retentive features can be incorporated according to the residual tooth structure.

Verma Letal reported a case of 4-year-old male with grossly decayed maxillary anterior teeth that were restored with glass fibre-reinforced composite resin posts (GFRC), a new system of fibre posts composed of compactly packed silanated e-glass fibers in a light curing gel matrix. The advantages of using fibre reinforced to prepare an intracanal post include resin composite crown reinforcement, translucence, and relative ease of manipulation.¹¹ Fiber reinforced post is expensive compared to metal post and metal posts provide mechanical retention. Ali et al (2018) reported two case reports, where a simple and effective method which was a slight modification of the technique by Mortada and King was used for reconstruction of severely destroyed primary anterior teeth. In a modification to the conventional method, a double omega loop was used instead of a single omega loop.¹² Subramaniam et al (2008) compared fiberglass post with omega shaped stainless steel wire in primary maxillary anterior teeth. After 1 year, fibre glass posts showed enhanced retention and marginal adaptability when compared to omega shaped stainless steel wire.¹³ The disadvantage of fiber post is its cost where omega loop can be used as an alternative.

Conclusions

Presence and evolution of the latest technologies for restoration of decayed teeth have been a boon but still it is difficult to satisfy patient’s desire with respect to aesthetics. With the incorporation of new technologies, dentistry enters into a new field of awareness where almost all the complex problems of restoration can be addressed along with good retention and aesthetics to the patient’s satisfaction along with cost-effective management. Omega loop post demonstrated adequate retention, easy administration as a chair side technique along with good feature rention and was also costeffective compared to advanced materials. Dentine opaquer is a composite with compatible shade and better retention on the tooth surface and can also be used as a core build up material in the pediatric population.

Conflict of Interest

None.