jaypee gold standard mini atlas series pe-dodontics (2008) [unitedvrg]

8/10/2019 Jaypee Gold Standard Mini Atlas Series Pe-dodontics (2008) [PDF] [UnitedVRG]

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Jaypee Gold Standard M ini Atlas Series

Pedodontics


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Jaypee Gold Standard M ini Atlas Ser ies

Pedodontics

Nikhil Marwah BDS, MDSAssistant Professor

Department of Pedodontics

Govt. Dental College, Rohtak, Haryana, India

JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD

New Delhi Ahmedabad Bengaluru Chennai Hyderabad

Kochi Kolkata Lucknow Mumbai Nagpur

Co-author

Vijaya Prabha K

Postgraduate StudentDepartment of Pedodontics

Govt. Dental College, Rohtak, Haryana, India


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Published by

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Jaypee Gold Standard Mini Atlas Series: Pedodontics

2008,Jaypee Brothers Medical Publishers

All rights reserved. No part of this publication and DVD ROM should be reproduced, stored in a

retrieval system, or transmitted in any form or by any means: electronic,mechanical, photocopying,

recording, or otherwise, without the prior written permission of the author and the publisher.

This book has been published in good faith that the material provided by author is original.

Every effort is made to ensure accuracy of material, but the publisher, printer and author willnot be held responsible for any inadvertent error(s). In case of any dispute, all legal mattersare to be settled under Delhi jurisdiction only.

First Edition:2008

ISBN 81-8448-012-1Typeset at JPBMP typesetting unit

Printed at Paras Press


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Practicing dentists, graduate and postgraduate students ofdentistry seek out for information that will help them stay

abreast of ongoing advances in dental care strategies. This

coloredAtlas of Pedodonticswould be a very valuable and

highly informative tool for identification of various dental

anomalies, common dental disease and various dental

procedures in the scope of Pedodontics.

Samir DuttaSenior Professor and Head

Department of Pedodontics

Government Dental College

Rohtak

Foreword


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Any dental disease common or rare, any dental procedure oreven classroom teaching for that matter is better understood

by students if they are taught with audiovisual aids or

pictographical representations. Moreover in a world where

oral and dental diseases are plenty and on a rise, possessing

only theoretical knowledge is not sufficient for establishing

a definitive diagnosis.

ThisAtlas of Pedodonticswould help all dentists whether

studying or practicing to understand the subject andprocedures in Pedodontics better and apply this visual

knowledge in their routine practice for betterment of patient

care.

Nikhil Marwah

Preface


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1. Craniofacial Growth and Development ................. 1

2. Developmental Anomalies of Teeth ...................... 11

3. Eruption and Shedding ......................................... 29

4. Gingiva .................................................................... 43

5. Behavior Management .......................................... 48

6. Development of Occlusion..................................... 56

7. Caries ...................................................................... 64

8. Plaque Control ....................................................... 76

9. Pit and Fissure Sealants ....................................... 81

10. Pediatric Operative Dentistry .............................. 89

11. Pediatric Endodontics ...........................................114

12. Oral Surgical Procedures in Children............... 131

13. Oral Habits ........................................................... 152

14. Space Management.............................................. 156

15. Pediatric Orthodontics ........................................ 162

16. Traumatology ....................................................... 176

Index ...................................................................... 189

Contents


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POSTNATAL GROWTH OF MAXILLA

CHAPTER

1 Craniofacial Growthand Development

Primary displacementGrowth at maxillary tuberosity thus

maxilla is pushed anteriorly.

Fig. 1.1: Primary displacement


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2 Mini AtlasPedodontics

Secondary displacementGrowth of cranial base pushes the

maxilla in downward and forward direction.

Fig. 1.2: Secondary displacement

Fig. 1.3: Remodeling

Surface remodeling

+ Deposition

- Resorption


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Craniofacial Growth and Development 3

POSTNATAL GROWTH OF MANDIBLE

Fig. 1.4: Ramal growth

RamusResorption on anterior part and deposition on

posterior.

Fig. 1.5: Growth at body

Body of mandibleLengthens posteriorly as former ramal

bone changes into body.


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Lingual tuberosityDeposition on posterior facing surface.

Fig. 1.6: Tuberosity growth

Fig. 1.7: Enlows V. principle

Angle of mandibleLingual: resorption on posterio-inferioraspect, deposition on antero-superior aspect.

Buccal: resorption on antero-superior aspect, deposition on

posterio-superior aspect.


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CondyleSecondary bone growth

Fig. 1.8: Condylar growth


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CEPHALOCAUDAL GRADIENT OF GROWTH

Fig. 1.9: Cephalocaudal growth

In fetal life at about 1/3rd month of intrauterine development,

the head takes up almost 50 percent of total body length. The

cranium is large relative to face and represents more than

half of total head, whereas the limbs are still rudimentary

and the trunk is underdeveloped. By the time of birth, the

trunk and limbs have grown faster than head and face. So

that the proportions of entire body devoted to head has

decreased by 30 percent with the progressive reduction in

relative size of head to about 12 percent the adult. There is

more growth of lower limbs than upper limbs during postnatallife. This means there is an axis of increased growth extending

from head towards feet. This is called cephalocaudal gradient

of growth.


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Fig. 1.10: Scammons growth curve

SCAMMONS CURVES FOR GROWTH

The body tissues namely lymphoid, general, genital and neural

grow at different states at different times. This pattern is

discerned by Scammons curve.

Lymphoid Tissue

It increases rapidly in late childhood and reaches almost 200percent of its adult size. By 18 years the lymphoid tissue

undergoes involution to reach adult size.


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Neural Tissue

This grows very rapidly and reaches adult size by 6-7 years.

Very little growth occurs after that.

Genital Tissue

This shows negligible growth until puberty. But, grows rapidly

reaching puberty till adult level is achieved.

General Tissue

This consists of bones, muscles and other organ systems.

These exhibit an S shaped curve with rapid growth up to

2-3 years of age followed by a slow phase till about 10 years.

Then the growth again enters rapid phase in the 10th year

and continues till terminating about 18-20 years.


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GROWTH PREDICTION

Fig. 1.11: Growth prediction of cranium, maxilla and mandible

Cranial Base Prediction

The cranial base is designated by a line joining the most

anterior point of foramen magnumBasion (Ba) with anterior

point of frontonasal sutureNasion (Na) as seen on the lateral

Cephalometric radiograph. In a normal child cranial base will

grow 2 mm/year. This is expressed by 1 mm forward growth

of Nasion and 1 mm backward growth of Basion, both along

the original cranial base line (red line).

Mandibular Growth Prediction

Condylar axis: This is defined as a line from a point on the

Ba-N line midway between anterior and posterior borders of


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condylar neck (DC point), to the geometric center of

mandibular ramus (Xi point). During 1 year of growth Xi

point will grow downward along condylar axis by 1 mm

(brown line).

Corpus axis: The length of body of mandible is defined by a

line from Xi point to the anterior point on mandibularsymphysis. Each year corpus axis grows 2 mm (green line).

Maxillary Growth Prediction

Point A on maxilla grows forward same as Nasion. Therefore

the N-A angle remains the same during growth. Skeletal

convexity of a patient is determined by the relationship

between point A and facial plane (blue line).


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Developmental Anomalies of Teeth 11

CHAPTER

2 DevelopmentalAnomalies of Teeth

MICRODONTIA

It is a condition of unknown etiology in which teeth are

comparatively smaller. Microdontia can be generalized,relative or may affect only a single tooth. It is usually seen in

permanent dentition and the most commonly affected tooth

is maxillary lateral incisorpeg lateral.

Fig. 2.1: Microdontia


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MACRODONTIA

Anomaly of size where the tooth is larger as compared to its

normal counterpart. The above picture demonstrates a single

tooth macrodontia.

Fig. 2.2: Large teeth


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OLIGODONTIA

Anodontia refers to congenital absence of teeth, which may

be partial or complete. Oligodontia is a term to describe

multiple (more than 6) missing teeth. The etiology of this

may be genetic or environmental.

Fig. 2.3: Multiple missing teeth


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HYPODONTIA

It is defined as missing teeth as a result of failure of

development. It is mostly seen in permanent dentition. The

central incisor is the least common missing tooth and the third

molar is the most common missing tooth.

Fig. 2.4: Single missing teeth


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HYPERDONTIA

This refers to more number of teeth as compared to normal

dentition. It may be as a result of hyperactivity of the dental

lamina and is mostly associated with some syndrome.

Depending on their appearance in arch they are called as

supernumerary, supplemental, paramolar, distomolar or

mesiodens.

Fig. 2.5: Extra lateral incisor


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FUSION

Tooth fusion is defined as union between the dentin and/or

enamel of two or more separate developing teeth. The fusion

may be partial or total depending upon the stage of tooth

development at the time of union. Fusion can occur between

two normal teeth or between normal and supernumerary teeth

also. The characteristic appearance is fused crowns with two

separate non-fused root canals.

Fig. 2.6: A.Fusion of incisors, B.Fused roots, C.Bilateral fusion


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GEMINATION

Geminated teeth are developmental anomalies of the tooth

shape that arise from an abortive attempt by the single toothbud to divide, resulting in a bifid crown. It appears that

gemination is caused by complex interactions among a variety

of genetic and environmental factors with recessive mode of

inheritance. The clinical presentation of gemination is two

separate crowns with one large root canal.

Fig. 2.7: Radiograph of geminated tooth


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CONCRESCENCE

It is a form of fusion in which the teeth are joined by cementum

only. This usually occurs after root formation has taken place

but can be either before or after eruption of teeth. Traumatic

injury is most often the causative factor, which leads to fusion

of roots following resorption of interdental bone. These areusually asymptomatic and are left as such unless they interfere

with occlusion or eruption of succedaneous teeth.

Fig. 2.8: A.Concrescence, B.Hypercementosis


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DILACERATIONS

Fig. 2.9: Root dilacerations

Abnormally sharp bend or angulation in the root or crown

surface due to trauma during formation of tooth. The trauma

causes displacement of calcified portion of tooth and theremaining portion grows at a separate angle.


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DENS IN DENTE

It occurs due to invagination of Hertwigs root sheath before

crown calcification that gives an appearance of tooth within

a tooth. It is most frequently seen in maxillary lateral incisors

and mostly warrants prophylactic treatment.

Fig. 2.10: Tooth in a tooth appearance


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DENS EVAGINATUS

It is a tubercle projecting from the occlusal surface of the

teeth, which occurs as a result of proliferation of a part of

inner enamel epithelial cells into stellate reticulum of enamel

organ. When on posterior teeth it may interfere with occlusion

and therefore has to be reduced but one must be careful about

any pulpal extensions. It is also called as occlusal enamel

pearl.

Fig. 2.11: A.Crown evaginatus, B.Root enamel pearl


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TALON CUSP

An accessory cusp like structure projecting from the cingulum

area or CEJ of anterior teeth or supernumerary teeth, which

may or may not include the normal dental tissues. It occurs

due to folding of inner enamel epithelial cells and transient

focal hyperplasia of peripheral cells of mesenchyme during

morphodifferentiation. The treatment options vary from mild

occlusal grinding to pulpal therapy depending upon the size

of talon and its contents.

Fig. 2.12: A.Talon, B.Talon on supernumerary, C.Extra cusp


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SUPERNUMERARY TOOTH

Supernumerary teeth develop as a consequence of

proliferation of epithelial cells from dental lamina with theincidence ranging from 0.5 to 3.8 percent and maxillary

anterior region in males being more affected. The above

photograph shows an extracted mesiodens.

Fig. 2.13: A.Extracted supernumerary tooth, B.Mesiodens deciduous

dentition, C.Multilobed supernumerary


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SUPERNUMERARY ROOTS

Presence of more than normal number of roots in a tooth.This condition has unknown etiology and is of minimal

concern unless an endodontic treatment or extraction has to

be done, wherein the number and position of roots is needed.

Fig. 2.14: Multiple roots


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ANKYLOGLOSSIA

Ankyloglossia is the fusion of tongue to the floor of mouth.

This may be complete or partial depending on the extent of

fusion. The above picture shows partial ankyloglossia or

tongue-tie as a result of short lingual frenum. The most

common problem associated with tongue-tie is difficulty in

speech. This condition is sometimes selfcorrective but mostly

requires surgical intervention in the form of frenectomy.

Fig. 2.15A:Tongue-tie


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Benign Migratory Glossitis

Fig. 2.15C: Cleft tongue

Fig. 2.15B:Geographic tongue

Multiple area of desquamations of fill form papillae is an

circinate pattern. These areas often heal spontaneously and

re-appear at another spot.

Cleft/Bifil Tongue

Rare condition due to lack of fusion of lateral swellings and

failure of groove obliteration by underlying mesenchymal

proliferations.


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Fig. 2.16: A.Internal resorption, B.External root resorption

INTERNAL RESORPTION

It refers to an unusual form of tooth resorption that begins

internally in a tooth, apparently initiated by inflammatory

hyperplasia of pulp. The squeal of this is usually perforation

and extraction but it can also be treated endodontically if

diagnosed early.

Common form of root resorption due to periapical

inflammation, cysts, pathologies impaction or may even be

idiopathic.


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Fig. 2.17: A.Fluorosis in deciduous dentition, B. Permanent dentition

fluorosis, C.Acid erosion, D.Tetracycline staining

ENAMEL HYPOPLASIA


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Eruption and Shedding 29

CHAPTER

3 Eruption andShedding

CHRONOLOGY OF ERUPTION

Primary Dentition:

Tooth H ard tissue Crown Eruption Root formation completed completed begins

MaxillaryCentral Incisor 4 months 4 months 7 months 1 year

in uteroLateral Incisor 4 months 5 months 9 months 2 years

in uteroCanine 5 months 9 months 18 months 3 years

in utero1st Molar 5 months 6 months 14 months 2 years

in utero2nd Molar 6 months 11 months 24 months 3 years

in uteroMandibular

Central Incisor 4 months 3 months 6 months 1 year in utero

Lateral Incisor 4 months 4 months 7 months 1 year

in uteroCanine 5 months 9 months 16 months 3 yearsin utero

1st Molar 5 months 5 months 12 months 2 yearsin utero

2nd Molar 6 months 10 months 20 months 3 yearsin utero Contd...


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Tooth Hard tissue Crown Eruption Root formation completed completed

begins

Maxillary

Central Incisor 3-4 months 4-5 years 7-8 years 10 yearsLateral Incisor 10-12 months 4-5 years 8-9 years 11 years

Canine 4-5 months 6-7 years 11-12 years 13-15 years

1st Premolar 1-1 year 5-6 years 10-11 years 12-13 years

2nd Premolar 2-2 years 6-7 years 10-12 years 12-14 years

1st Molar Birth 2-3 years 6-7 years 9-10 years

2nd Molar 2-3 years 7-8 years 12-15 years 14-16 years

3rd Molar 7-9 years 12-16 years 17-24 years 18-25 years

Mandibular

Central Incisor 3-4 months 4-5 years 6-7 years 9 years

Lateral Incisor 3-4 months 4-5 years 7-8 years 10 years

Canine 4-5 months 6-7 years 9-10 years 12-14 years

1st Premolar 1-2 years 5-6 years 10-11 years 12-13 years

2nd Premolar 2-2 years 6-7 years 11-12 years 13-14 years

1st Molar Birth 2-3 years 6-7 years 9-10 years

2nd Molar 2-3 years 7-8 years 11-13 years 14-15 years

3rd Molar 8-10 years 12-16 years 17-21 years 18-25 years

Contd...

Permanent Dentition:


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Fig. 3.1: Dental age

DENTAL AGE ASSESSMENT

Gron. A and Moorees CFhelped formulate what is to date

the most commonly used method of determining dental age.

This method involved scoring of to permanent teeth according

to crown and root formation using standard dental films.


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DEVELOPMENT OF TEETH

Fig. 3.2 A:Bud stage

Fig. 3.2 B: Cap stage


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Fig. 3.2 C: Bell stage


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Fig. 3.3: Nollas stages of tooth development


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PRE-ERUPTIVE TOOTH MOVEMENT

The pre-eruptive phase of tooth movement is preparatory to

the eruptive phase. It consists of the movement of the

developing and growing tooth germs within the alveolar

processes prior to root formation. Bodily movement is a shift

of the entire tooth germs, which causes bone resorption in

the direction of tooth movement and bone apposition behind

it. Eccentric growth refers to relative growth in one part of

the tooth while the rest of the tooth remains constant.

Fig. 3.4: Tooth movement


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The future eruption pathway appears as a zone in which

connective tissue fibers have disappeared, cells have

degenerated and decreased in number, blood vessels become

fewer and terminal nerves break up and degenerate. An altered

tissue space overlying the tooth becomes visible as an inverted

funnel shaped area. In the periphery of this zone, the follicle

fibers direct themselves toward the mucosa and are defined

as the gubernacular cord. This structure guides the tooth in

its eruptive movements.

Fig. 3.5:Gubernacular cord

GUBERNACULAR CORD


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STAGES OF TOOTH ERUPTION

Eruption is defined as a process whereby the forming tooth

migrates from its intraosseous location in the jaws to itsfunctional position within the oral cavity.

Anatomic Stages in the Eruption of the Teeth

Stage I: Preparatory stage.

Stage II:Migration of the tooth towards the oral epithelium.

Stage III:Emergence of crown tip into the oral cavity.

Stage IV:First occlusal contact.

Stage V:Full occlusal contact.

Stage VI:Continuous eruption.

Fig. 3.6:Eruption stages


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ERUPTION HEMATOMA

Fig. 3.7: Eruption hematoma

A bluish purple, elevate area of tissue, commonly called

eruption hematoma, occasionally develops few weeks before

the eruption of primary or permanent tooth. The blood filled

cyst is most frequently seen in the primary second molar or

the first permanent molar region. This condition develops as

a result of trauma to the soft tissue during function and is

self-limiting.


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Fig. 3.8:Eruption bulge

ERUPTION BULGE

This is an auto correcting swelling in the region of erupting

tooth, usually associated with trauma to the surrounding soft

tissue.


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NATAL TEETH

Natal teeth are the teeth that are present at birth; Neonatal

teeth are those that erupt within one month after birth. They

are mostly seen in mandibular incisor region and are attributed

to superficial positioning of the developing of the tooth germ,which predisposes the tooth to erupt early. They may resemble

normal primary teeth, but in many instances they are poorly

developed with failure of the development of the roots.

Fig. 3.9: Isolated natal tooth


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RETAINED TEETH

The term, retained teeth refers to the teeth that are over

retained in the oral cavity even after their succedaneous tooth

has erupted. These have to be extracted as soon as possible

as they may cause crowding and malocclusion.

Fig. 3.10: Retained deciduous


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ECTOPIC ERUPTION

Arch length inadequacy or a variety of local factors may

influence a tooth to erupt in a position other than normal, this

is called as ectopic eruption. The above photograph depicts

an ectopically erupting central incisor due to lack of space.

Fig. 3.11:Defected central incison


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Gingiva 43

CHAPTER

4Gingiva

GINGIVA

Fig. 4.1:Child gingiva

Fig. 4.2:Adult gingiva


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Char acter i sti c Chi l dr en A dul t

Color Pale pink Coral pink

Surface Smooth Stippled

Gingiva Thick and round Knife edged

Free gingiva Keratinized saddle Non-keratinized

(area) interdental colInterdental Interdental clefts Not present

gingiva

Attached Retrocuspid papilla Not present

gingiva

Sulcus depth 2.1-2.3 mm 2-3 mm

Alveolar Red, thin, vascular Pink

mucosa

Periodontal Wide Narrow

ligament

Collagen More hydrated, More differentiated

bundles less differentiated

Polypeptide Normal cross-linking Tight cross-linked

chains

Ground Low ratio of collagen to Ground substance to

substance ground substance collagen ratio normal

Fibers Gingival fibers are Mature and organized

immature

Trabeculae Thick trabeculae with More trabeculae with less

large marrow spaces marrow spaces


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Gingiva 45

Fig. 4.4: Gingival recession due to crossbite

Fig. 4.3: Pigmentation of gingiva


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Fig. 4.6: Localized gingivitis due to local irritants

Fig. 4.5: Chronic generalized gingivitis


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Gingiva 47

Fig. 4.7: Polyp in relation to molar


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CHAPTER

5 BehaviorManagement

TELL SHOW DO

Tell

Verbal explanations of procedures in phrases appropriate to

the developmental level of the child.

Fig. 5.1: Explanation of method


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Behavior Management 49

ShowDemonstration for the patient of visual, auditory, olfactory

and tactile aspects of the procedure in a carefully defined,

non-threatening setting. The dentist can either demonstrate

on himself or on an inanimate object.

Fig. 5.2: Demonstration


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Do

Without deviating from the explanation and demonstration

the dentist proceeds directly to perform the previewed

operation.

Fig. 5.3: Performing


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HAND OVER MOUTH EXERCISE

When indicated, a hand is placed over childs mouth and

behavioral expectations are calmly explained. Child is told

that the hand will be removed as soon as the appropriate

behavior begins. When child responds the hand is removed

and childs appropriate behavior is reinforced. If the child

shows negative behavior again the procedure is repeated.

Fig. 5.4: HOM being carried out


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Fig. 5.5: HOM modification with airway restricted

Fig. 5.6: HOM modification tower over mouth airway restricted


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Fig. 5.7: Modification tower over mouth airway unrestricted

MODELING

It is based on the theory,which states that ones learning or

behavior acquisition occurs through observation of suitable

model performing a specific behavior. The picture shows livemodeling by sibling.

Fig. 5.8: Sibling modeling


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PARENTAL PRESENCE

This is seen in very young patients. But has to be used

sometimes even in older uncooperative patients for supporting

and communicating with the child.

Fig. 5.9: Parental presence


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Fig. 5.10:Adjunct for mouth opening

Fig. 5.11: Seen is very young children suffering from material anxiety

MOUTH PROP

PARENTAL RESTRAINT


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CHAPTER

6 Developmentof Occlusion

PHYSIOLOGIC SPACING

These are present in between the primary teeth and play an

important role in normal development of the permanentdentition. The total space present may vary from 0 to 8 mm

with the average 4 mm in the maxillary arch and 1 to 7 mm

with the average of 3 mm in the mandibular arch.

Fig. 6.1: Spacing in deciduous teeth


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Development of Occlusion 57

PRIMATE SPACING

These between the upper lateral incisors and the canines

(present mesial to maxillary deciduous canines) and lower

canines and first deciduous molars (present distal to

mandibular deciduous canines). These spaces are also called

as anthropoid or simian spaces.

Fig. 6.2: Primate spaces


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TERMINAL PLANES

The mesio-distal relation between the distal surfaces of

maxillary and mandibular 2nd deciduous molars is called as

terminal plane.

FLUSH TERMINAL

The distal surfaces of the upper and lower teeth are in a

straight plane (flush) and therefore situated on the samevertical plane. Usually it is a favorable relationship to guide

the permanent molars.

Fig. 6.3: Flush relation


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MESIAL STEP

The distal surface of the lower molar is more mesial to that

of the upper. Invariably, it is favorable to guide the permanent

molars into a class 1 relationship.

Fig. 6.4: Mesial step relation


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DISTAL STEP

The distal surface of the lower molar is more distal to that of

the upper. This relationship is unfavorable as it guides the

permanent molars into distal occlusion.

Fig. 6.5: Distal step relation


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LEEWAY SPACE OF NANCE

This takes place around 9 to 10 years of age and is charac-

terized by replacement of deciduous molars and canines by

premolars and permanent cuspids. The combined mesio-

distal width of permanent canine and premolars is less than

deciduous canine and molars. This is called Leeway Space

of Nance. It is 1.8 mm (0.9 mm on each side) in maxillaryarch and 3.4 mm (1.7 mm on each side) in mandibular arch.

This excess space is utilized by mandibular molars to establish

class I relationship.

Fig. 6.7: Leeway space


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UGLY DUCKLING

This is a self-correcting malocclusion seen around 9 to 11

years of age or during eruption of canines. As the permanent

canines erupt they displace the roots of lateral incisors

mesially. This force is transmitted to the central incisors and

their roots are also displaced mesially. Thus, the resultant

force causes the distal divergence of the crown in an opposite

direction. This leads to midline spacing and ugly appearance

of the child and so it is called ugly duckling stage. This

condition corrects itself after the canines have erupted. The

canines after eruption apply pressure on the crowns of

incisors thereby causing them to shift back to original posi-

tions.

Fig. 6.8: Broadbent phenomenon


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CHAPTER

7Caries

KEYS CIRCLE

Caries is due to interplay of three factors viz. host, agent and

environmental influences.

Fig. 7.1: Keys triad


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Caries 65

NEWBRUN CIRCLE

Caries is caused by interplay of primary and secondary factors.

Primary Secondary

Plaque Oral hygiene

SalivapH, composition, buffer, flow

Diet

Substrate Type of carbohydrate

Composition of food

Oral clearanceFrequency of eating

Tooth Fluoride contents

Morphology

Nutrition

Fig. 7.2: Newbrun modification


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HISTOPATHOGENESIS OF ENAMEL CARIES

Translucent zoneFirst signs of enamel breakdown are seen

in this zone.

Dark zoneDemarks the body of lesion from translucent

zone.

Body of lesionThis is the main bulk of lesion with maximal

mineral loss.

Surface zoneThere is partial loss of minerals due to

subsurface demineralization.

Fig. 7.3: Histology of enamel caries


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Caries 67

HISTOPATHOGENESIS OF DENTINAL CARIES

a. Zone of decomposed dentin

b. Zone of bacterial invasion

c. Zone of demineralization

d. Zone of dentinal sclerosis

e. Zone of fatty degeneration.

Fig. 7.4: Histology of dentinal caries


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FOOD GUIDE PYRAMID

Fig. 7.5: Food guide pyramid


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Caries 69

DIFFERENT TYPES OF CARIES

Initial Caries

Fig. 7.6:Incipient caries on incisors

Occlusal Caries

Fig. 7.7: Occlusal caries in first molar


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Proximal Caries

Fig. 7.8: Proximal caries in first molar

Deep Caries

Fig. 7.9: Grossly caries in multiple teeth

Caries is defined as microbial disease of the calcified tissues

of teeth that is demineralization of inorganic components and

subsequent breakdown of organic moieties of enamel and

dentin.


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Caries 71

EARLY CHILDHOOD CARIES

Presence of one or more decayed (non-cavitated, cavitated)

missing (due to caries) or filled tooth surface in any primary

tooth in a child of 71 months or younger.

Fig. 7.10:Stage 1

Initial reversible stage from 10 to 18 months, with cervical

and interproximal areas of chalky white demineralization.


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Damaged carious stage from 18 to 24 months. Lesion in

maxillary anterior teeth, may spread to dentin and show

yellowish brown discoloration, pain on having cold food

items.

Fig. 7.11: Stage 2

Fig. 7.12: Stage 3

Deep lesion from 24 to 36 months. Frequent complain of

pain with pulpal involvement in maxillary incisors and

carious involvement of molars.


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Caries 73

Traumatic stage lasts from 30 to 48 months. Teeth become so

weakened by caries that relatively small forces can fracture

them. Molars are now associated with pulpal problems

whereas, the maxillary incisors become non-vital.

Fig. 7.13: Stage 4


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POST CARIES REHABILITATION

Preoperative view exhibiting initial proximal caries in central

incisors and canine, occlusal caries in both second molars,

deep caries in left first molar and grossly decayed right first

molar.

Fig. 7.14: Preoparative photograph


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Caries 75

Postoperative picture showing a completely rehabilitated

patient; GIC restoration of canines and right second molar,composite restoration of central incisors, amalgam restoration

of left maxillary molar, pulp therapy and stainless steel crown

for left first molar and band and loop space maintainer

following extraction of right first molar.

Fig. 7.15: Postoperative photograph


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CHAPTER

8Plaque Control

MANUAL TOOTHBRUSH

ADA Specifications

Length1 to 1.25 inches

Width5/16 to 3/8 inches

Surface area2.54 to 3.2 cm

No. of rows2 to 4 rows of brushes

No. of tufts5 to 12 per row

No. of bristles80 to 85 per tuft.

Fig. 8.1: Manual toothbrush


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Plaque Control 77

POWERED TOOTHBRUSH

They have 3 motions back and forth, circular and elliptical

and are mostly recommended for individual lacking motor

skill, handicapped patients, patients who have orthodontic

appliances.

Fig. 8.2: Powered brush


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Fig. 8.3: Multiple methods of brushing


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Plaque Control 79

TECHNIQUES OF TOOTH BRUSHING

Method Bristle placement Motion Advantage/

Disadvantage

Scrub Horizontal, on Scrub in anterior- Easy to learngingival margin posterior direction Best suited for

keeping brush children

horizontalBass Apical, towards Short back and Remove plaque

gingival into forth vibratory from cervical areasulcus at 45, to motion while and sulcustooth surface bristles remain Easily learned

in sulcus Good gingivalstimulation

Charters Coronally, 45, Small circular Hard to learn andsides of bristles motions with position brushhalf on teeth and apical movement Clears inter-half on gingiva towards gingival proximal

margin Gingival stimu-lation

Fones Perpendicular to With teeth in Easy to learnthe tooth occlusion, move Interproximal areas

brush in rotary not cleanedmotion over both May cause traumaarches and gingivalmargin

Roll Apically, parallel On buccal and Doesnt cleanto tooth and then lingual inward sulcus areaover tooth surface pressure, then Easy to learn

rolling of head Good gingivalto sweep bristle stimulationover gingiva and

tooth

Contd...


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Stillman On buccal and On buccal and Excellent gingival

lingual, apically lingual slight stimulation

at an oblique angle rotary motions Moderate dexterity

to long axis of with bristle ends requiredtooth. Ends rest stationary Moderate cleaning

on gingiva and of interproximal

cervical part area

Modified Pointing apically Apply pressure as Good gingival

Stillman at an angle of in Stillmans stimulation

45 to tooth method but vibrate Cleaning of

surface brush and also interproximal area

move occlusally Easy to master

Method Bristle placement Motion Advantage/

Disadvantage

Contd...


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Pit and Fissure Sealants 81

CHAPTER

9 Pit and FissureSealants

TYPES OF PIT AND FISSURE

Fig. 9.1: Pits and fissure in molars

The fissure contains organic plug composed of reduced

enamel epithelium, microorganism forming dental plaque and

oral debris. There are 5 types of pits and fissures:


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V type (34%)

U type (14%)

I type (19%)

IK type (26%)

Inverted Y type (7%).

STEPS OF SEALANT APPLICATION

Deep Stained Fissures

Step 1:Isolation of toothThe tooth should be isolated from

salivary contamination by use of cotton rolls and suctioning.

This procedure is very technique sensitive and so moisture

control is essential to achieve optimum bond strength.

Fig. 9.2:Preoperative photograph


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Minimal Tooth Preparation Using

Tapering Fissure Bur

Step 2:Tooth preparationThis can be achieved by multiple

methods like treat the surface with slurry of pumice and water,

air abrasion with aluminum oxide particles and enameloplasty.

Fig. 9.3: Fissures are enlarged


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Application of Etchant Gel in Fissures

Step 3:Acid etch tooth surfaceApply the etching agent to

the tooth surface using a fine brush. Gently rub the etchant

applicator over tooth surface including 2-3 mm of cuspal

inclines and reaching into any buccal or lingual pits and

grooves that are present. The recommended etching time is

15 sec.

Fig. 9.4: Application of gel


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White Frosted Appearance after Etching

Step 4:Rinse and dry etched tooth surfaceRinse the etched

tooth surface with air water sprang for 30 seconds. This

removes the etching agent and reaction products from etched

enamel surface. Dry the tooth for 15 seconds with unconta-

minated compressed air. The dried etched enamel should have

a frostedwhite appearance.

Fig. 9.5: Post gel application


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Apply Sealant in the Etched Pits and Fissures

Step 5:Application of sealantApply the material and allow

it to flow into pits and fissures. In mandibular teeth, apply

the sealant distally and allow it to flow mesially with the

converse being true for the maxillary teeth. Allow the sealant

to flow in the etched pits and fissures to avoid incorporating

air into material and creating voids. Using a fine brush or

applicator carry a thin layer of up the cuspal inclines to sealsecondary and supplemental fissures.

Fig. 9.6: Sealant application


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Curing the Sealant

Step 6: Light cure the sealant according to the manufacturers

recommended time for curing.

Fig. 9.7:Light curing


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Postoperative View Following

Curing of Pit and Fissure Sealant

Step 7:Explore the sealed tooth surface for pits and voids

that may have not been sealed.

Step 8:Evaluate the occlusionEvaluate occlusion of sealed

tooth surface with articulating paper to determine if any

excessive sealant is present and needs to be removed.

Step 9:Recall and re-evaluationRecall and check the patient

at subsequent visits. It is necessary to re-evaluate sealed toothsurface for loss of material, exposure of voids and caries

development especially in the first 6-month of placement.

Fig. 9.8: Sealed pit and fissure surface


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Pediatric Operative Dentistry 89

CHAPTER

10 PediatricOperative Dentistry

FINNS CLASSIFICATION OF

CAVITY PREPARATION

Pit and fissure cavities on occlusal surface of molars and the

buccal and lingual pits of all teeth.

Fig. 10.1:Class 1


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Cavities on the proximal surfaces of posterior teeth with

access established from occlusal surface.

Fig. 10.2: Class 2


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Restorations on the proximal surfaces of anterior teeth that

involve the incisal edge.

Fig. 10.4: Class 4


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Cavities on the cervical third of all teeth, including proximal

surfaces where the marginal ridge is not included in cavity

preparation.

Fig. 10.5: Class 5


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MODIFICATION TO INCLUDE

CARIOUS GROOVES

Fig. 10.6: Occlusofacial

Fig. 10.7: Occlusolingual


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SIMONS MODIFICATION

Restorations on the incisal edge of anterior teeth or theocclusal cusp tips of posterior teeth.

Fig. 10.8: Buccal groove extension

Fig. 10.9: Cusp coverage Fig. 10.8: Cusp coverage with

class I cavity


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RUBBER DAM KIT

Fig. 10.11:RD Kit


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RUBBER DAM SHEETS

Available sizes are 5" 5" or 6" 6"

Available thickness are

Thin 0.15 mm

Medium 0.2 mm

Heavy 0.25 mm

Extra heavy 0.30 mm

Special heavy 0.35 mm

Available colors are green, blue, black, pink and burgundy. Also available in different flavors like mint, banana and

strawberry.

Fig. 10.12: Sheet


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RETAINERS

It has 4 prongs, 2 jaws that are connected by a bow as

shown

Various types and sizes are present for each tooth

Its use is to anchor the most posterior tooth to be isolated

and also to retract gingival tissue

Can be classified as wingless or winged. Later provide

more retention.

Fig. 10.13: Rubber dam clamps


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RUBBER DAM RETAINING FORCEP

Used for placement and removal of clamps.

Fig. 10.14: Forcep


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RUBBER DAM PUNCH

It is a precision instrument having a rotating metal table with

six holes of varying sizes and a tapered, sharp, pointed

plunger. The largest hole being for molars and the smallest

for mandibular incisors.

Fig. 10.15: Rubber dam punch


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RUBBER DAM FRAME

It holds and positions the border of rubber dam. It is of twotypesmetallic (Youngs frame) and plastic (Nygaard Ostby

frame).

RUBBER DAM NAPKIN

It is placed between rubber dam and patients skin. It has the

following uses:

Prevents allergy

Acts as a cushion Prevents pressure marks on patients cheeks

Convenient method for wiping the patients lips on

removal of dam.

Fig. 10.16: Plastic rubber dam frame


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LUBRICANT

It facilitates passing of dam through posterior contacts and

also help the dam to pass over clamps. It is also applied over

patients tissues to prevent injury and dryness. Commonly

used lubricants are soap solution, petroleum jelly and cocoa

butter.

DENTAL FLOSS

To secure the rubber dam.

RUBBER DAM TEMPLATE

To punch holes for accurate placement of rubber dam

according to quadrants.

Fig. 10.17: Template for hole placement


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PROCEDURE FOR PLACEMENT

OF RUBBER DAM

Fig. 10.18: Administration of local anesthesia and selection of clamp

Fig. 10.19: Selection of rubber dam sheet and punching

holes with rubber dam punch


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Secure the floss on the clamp by wrapping it all around the

bow and passing it from both the holes in wings and place

the clamp on the tooth with the help of retainer forceps and

check for stability.

Fig. 10.20: Secured rubber dam clamp


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Now lubricate the punched hole in the sheet and also apply

lubricant on the gingival tissues and lips of the patient. Enlarge

the hole in the sheet with the help of retaining forceps and

gradually adapt it on the retainer.

Fig. 10.21:Application of RD sheet


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Apply the frame and stretch the dam over it and cut if there is

any excess in nasal area.

QUICK DAM

Fig. 10.22: Final fitting of rubber dam

This type of rubber dam has a pre-attached frame and is easy

to place as it has minimal instrument requirement.

Fig. 10.23:Hardy dam placed


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ESTHETIC DENTISTRY

Strip Crowns

Preoperative view of carious central incisors.

Fig. 10.24:Carious incisor

Fig. 10.25: Restored incisor

Strip crowns placed on central incisors.


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Bleaching

Photograph depicting enamel hypoplasia.

Fig. 10.26: Preoperative

Presentation after bleaching with a mixture of hydrochloric

acid, ether and hydrogen peroxide.

Fig. 10.27: Postoperative


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Composite Veneering

Preoperative presentation of the patient exhibiting moderate

enamel hypoplasia.

Fig. 10.28: Preoperative

Fig. 10.29: Postoperative

Photograph after composite veneering.


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Composite Restoration

Enamel fracture in central incisor.

Fig. 10.30: Class I feature of incisor

Fig. 10.31: Restored central incisor

Postrestorative photograph.


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Fragment Reattachment

Complicated crown fracture involving enamel, dentin, pulp.

Fig. 10.32: Trauma to central incisor

Broken fragment of the central incisor.

Fig. 10.33: Fragment

Attachment of the fragment to the tooth with composite resin

following endodontic therapy.

Fig. 10.34: Re-attached fragment


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Stainless Steel Crowns

It is indicated in caries involving three or more surfaces,

rampant caries, recurrent caries around existing restoration,

after pulp therapy, acquired enamel defects, severe bruxism.

Fig. 10.35:Endodontically treated molar prior to crown cutting


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Fig. 10.36: Photograph depicting crown reduction,

i.e. occlusal and proximal

Fig. 10.37: Fully adapted stainless steel crown


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CHAPTER

11 PediatricEndodontics

Fig. 11.1: Procedure of IPC

INDIRECT PULP CAPPING

Defined as a procedure where in small amount of carious

dentin is retained in deep areas of cavity to avoid exposure


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Pediatric Endodontics 115

of pulp, followed by placement of a suitable medicament and

restorative material that seals of the carious dentin and

encourages pulp recovery.

Use local anesthesia and isolation and

establish cavity outline

Remove the superficial debris and majority of

the soft necrotic dentin

Stop the excavation as soon as the firm

resistance of sound dentin is felt

Peripheral carious dentin is removed with a sharp spoon

shaped excavators on the cavity floor

Cavity flushed with saline and dried with cotton pellet

Site is covered with Ca (OH)2. Remainder cavity isfilled with reinforced ZOE cement

During the second appointment, 6-8 weeks later;

carefully remove all temporary filling material

Previous remaining carious dentin will have become

dried out, flaky and easily removed

The cavity preparation is washed out and dried gently

and covered with Ca(OH)2

Base is built up with Reinforced ZOE cement /GIC

and final restoration is then placed.


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DIRECT PULP CAPPING

It is defined as the placement of a medicament or non-

medicated material on a pulp that has been exposed in course

of excavating the last portions of deep dentinal caries or as a

result of trauma.

Isolate and avoid manipulation of pulp

Cavity should be irrigated with saline and

hemorrhage is arrested with light pressure

from sterile cotton pellets

Place the pulp capping material, on the exposed pulp with

application of minimal pressure

Final restoration

HISTOLOGICAL CHANGES

AFTER PULP CAPPING

Fig. 11.2A:After 24 hours:Necrotic zone adjacent to Ca(OH)2 paste is

separated from healthy pulp tissue by a deep staining basophilic layer


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Fig. 11.2B:After 7 days:Increase in cellular and fibroblastic activity

Fig. 11.2C: After 14 days: Partly calcified fibrous tissue lined by

odontoblastic cells is seen below the calcium proteinate zone;

disappearance of necrotic zone


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Fig. 11.2D:After 28 days:Zone of new dentin


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PULPOTOMY

Defined as the amputation of affected, infected coronal

portion of the dental pulp preserving the vitality and function

of the remaining part of radicular pulp.

Fig. 11.3: Preoperative carious tooth

Anesthetize the tooth and remove all caries using high-speed

straight fissure bur without entering the pulp chamber. Enlarge

the exposed area and deroof the pulp chamber.


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Clean the pulp chamber with saline and remove all debris.

Place a cotton pellet over the pulp stumps to achieve

hemostasis.

Fig. 11.5: Clean pulp chamber

Fig. 11.4: Excavation of pulp

Remove any ledges or overhanging enamel with slow speed

round bur and use sharp spoon excavators to scoop out coronal

pulp and pulpal remnants.


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Using a cotton pellet apply diluted formocresol to the pulp

for 4 min. Remove cotton pellets and check for fixation,

brownish discoloration of the pellet as well as the pulp stump

is an indicator of fixation.

Fig. 11.7: Restored tooth

Fig. 11.6: Fixed pulp tissue

Place ZOE cement in the pulp chamber.


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Post pulpotomy radiograph showing the extent of the pulp

medicament.

Fig. 11.9: Pulpoloyed 2nd molar

Fig. 11.8:Deep caries in 2nd molar

Preoperative radiograph showing deep caries in close

approximation to pulp.


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PULPECTOMY

Defined as the complete removal of the necrotic pulp from

the root canals of primary teeth and filling them with an inert

resorbable material so as to maintain the tooth in the dental

arch.

Fig. 11.10: Preoperative view

Fig. 11.11:Access opening

Tooth is anesthetized, isolated and access cavity is prepared.

Pulp chamber is deroofed and all accessible coronal and

radicular pulp tissue is removed with broaches.


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Determine the working length and file the canals,progressively increasing the file diameter and complete the

biomechanical preparation (BMP).

Fig. 11.12: Working length and bio-mechanical preparation


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Fig. 11.13:Appearance of tooth after complete

BMP and irrigation

Fig. 11.14: Dry the canals using paper points to

prepare for obturation


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Coat the walls of canals with thin watery mix of cement with

the help of a reamer

Fig. 11.15: Obturation

Use thick mix and fill the canals using lentulospiral. Keep on

adding fresh mix till no further cement can be incorporated

in canals. Now seal the pulp chamber.

Fig. 11.16: Completion of obturation


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Preoperative radiograph showing carious pulp exposure.

Fig. 11.17: Carious 2nd molar

Fig. 11.18: Endodontically restored

Postpulpectomy radiograph showing visibly obturated root

canals.


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APEXIFICATION

It is a method of inducing apical closure by formation of a

mineralized tissue in the apical region of a non-vital

permanent tooth with an incompletely formed root apex.

Fig. 11.19: Tooth exhibiting open apex

Access gained the pulp chamber and all debris and necrotic

pulp tissue is removed from the canal.


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Working length is determined and BMP to remove infecteddentin from the canal walls. Ca(OH)2is used to fill the entire

root canal.

Fig. 11.20:Calcium hydroxide dressing


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Fig. 11.21:Tooth is re-entered after 6 months to

check for apical barrier

Fig. 11.22: Post obturation

Complete obturation with gutta-percha is done.


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Oral Surgical Procedures in Children 131

CHAPTER

12 Oral SurgicalProcedures in Children

SITE AND TYPE OF LOCAL

ANESTHESIA IN CHILDREN

Fig. 12.1:Inferior alveolar nerve block


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Fig. 12.2: Lingual nerve anesthesia

Fig. 12.3: Long buccal nerve anesthesia


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Fig. 12.4:Greater palatine nerve block

Fig. 12.5: Nasopalatine nerve block


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Fig. 12.6: Posterosuperior alveolar nerve block

Fig. 12.7:Middle superior alveolar nerve block


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Fig. 12.8:Anterosuperior alveolar nerve block

Fig. 12.9: Infiltration anesthesia


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146/200


Fig. 12.12: Re-suturing of the flap

Fig. 12.13: Postoperative view after one weekcompletely

healed periapical lesion


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ENUCLEATION

It is complete removal of cyst along with its cystic contents

and lining. This space is filled with a blood clot, which

reorganizes to form normal bone. Mostly indicated for cysts

that have a high recurrence rate.

Fig. 12.14:Intraoral view of the cyst


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Fig. 12.15: Removal of overlying bone and enucleation of cyst

followed by complete removal of lining

Fig. 12.16: View of the cyst after removal


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Fig. 12.17: Postoperative suturing


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Fig. 12.18: Preoperative view of the cyst

Fig. 12.19:Removal of primary tooth overlying the cyst after

administration of local anesthesia

MARSUPIALIZATION

This refers to creating a surgical window in the cyst so, as to

remove the cystic contents, promote shrinkage and enhance

bone fill. It is mostly indicated in young children when cyst

is close to developing tooth germ.


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Fig. 12.20: Removal of cystic contents and irrigation of the cavity

Fig. 12.21: Post surgical suturing


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FRENECTOMY

Frenal attachment is a thin band of fibrous tissue and muscle

covered by mucous membrane. If the lingual frenum is

attached too near to mandibular incisors, this is called tongue-

tie and the procedure to relieve the attachment is called as

lingual frenectomy.

Fig. 12.22:Photograph depicting close lingual frenal attachment


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Fig. 12.23: Lifting of tongue with traction sutures post anesthesia

Fig. 12.24: Clipping of frenum


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Fig. 12.25: Post frenectomy

Fig. 12.26: Preoperative view exhibiting the supernumerary tooth

REMOVAL OF SUPERNUMERARY TEETH


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Fig. 12.27: Removal of visible supernumerary tooth

Fig. 12.28: Raising of palatal flap to uncover palatally placed

supernumerary tooth


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Fig. 12.29:Mesiodens post removal

Fig. 12.30: Wire splint and composite

DENTOALVEOLAR FRACTURES

Splinting with the help of stainless steel wire and composite

is done in cases where the injury to the dentoalveolar tissues

is minimum and main focus is stabilization of teeth.


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Fig. 12.31:Eyelet wiring

Fig. 12.32: Gunning splint

Eyelet wiring is indicated when teeth are present in pairs.

The advantage of this method is that in case of wire

breakdown only the respective eyelet has to be changed.

Acrylic splint is made for stabilization in mandibular arch

and mainly indicated in children where mixed dentition and

developing tooth buds contraindicate the use of direct fixation.


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Fig. 12.33:Upper arch bar fixation on hot

Fig. 12.34:Lower arch bar fixation


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Fig. 12.35: Intra-arch elastics after arch bar fixation

ASYMPTOMATIC ORAL LESIONS

Arch bars are the most effective, quick and inexpensive

method of fixation. In case of maxillary segment the hooks

are directed upwards and in mandible, downwards. The arch

bar is then cut according to arch form and adapted buccally.Wires are then made to pass interdentally and attached to the

hooks and tightened clockwise.


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Fig. 12.37: Mucocele

Fig. 12.36: Epulis


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CHAPTER

13Oral Habits

THUMB SUCKING

Thumb sucking is defined as the placement of the thumb in

varying depths into the mouth. Some important clinical

features may be proclination of the maxillary incisors, high

palatal arch, retroclination of mandibular incisors, posterior

cross bite, anterior open bite, dishpan thumb. Management

strategies include: psychotherapybeta hypothesis, reminder

therapythumb home concept, chemotherapyfemite and

mechanotherapyblue grass appliance.

Fig. 13.1: Child performing

the habit

Fig. 13.2: Blue grass appliance


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Oral Habits 153

Tongue thrust is the forward movement of the tongue tip

between the teeth to meet the lower lip during deglutition

and in sounds of speech, so that the tongue lies interdentally.

Its causes may include macroglossia, abnormal sleeping

habits, genetic, allergy or gap filling tendency. Commonmanifestations are open bite, cross bite, midline diastema.

Management includes: myofunctional therapyelastic

exercise, lip exercise, subconscious therapy and mechano-

therapyHay rakes.

Fig. 13.3:Anterior tongue thrust

TONGUE THRUSTING

Fig. 13.4: Hay rakes


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Mouth breathing is defined as habitual respiration through

the mouth instead of nose. This may be anatomic,developmental or habitual. Clinical features include Adenoid

facies, upper lip is short, narrow maxillary arch, anterior open

bite, increased incidence of caries, chronic keratinized

marginal gingivitis.

Fig. 13.6: Oral screen

MOUTH BREATHING

Fig. 13.5:Act of mouth breathing


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Oral Habits 155

LIP BITING

Fig. 13.7:Active lip biting

Fig. 13.8:Lip bumper

This is defined as habit that involve manipulation of lips and

perioral structures. It can be further classified as lip wetting

or lip sucking habit. Protrusion of upper incisors, retrusion

of lower incisors, muscular imbalance, lingual crowding,

reddened, chapped area below the vermilion border and

accentuated mento-labial sulcus are most common features.


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CHAPTER

14 SpaceManagement

FIXED SPACE MAINTAINER

It is a unilateral, non-functional, passive, fixed appliance. It

is usually indicated for preserving the space created by the

premature loss of single primary molar and bilateral loss of

single primary molar before eruption of permanent incisors.

Fig. 14.1: Band and loop


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Space Management 157

LINGUAL ARCH SPACE MAINTAINER

Fig. 14.2: Lingual arch space maintainer

It is a bilateral, non-functional, passive/active, mandibular

fixed appliance. It is the most effective appliance of space

maintenance and minor tooth movement in lower arch. The

appliance is usually indicated to preserve the space created

by multiple loss of primary molars when there is no loss of

space in the arch, bilateral loss of primary molars after

eruption of lower lateral incisors, unilateral loss of primary

molars after eruption of lower lateral incisors and minor space

regaining.


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Distal shoe appliance is otherwise known as the intra-

alveolar appliance. Distal surface of the second primary molar

provides a guide for unerupted first permanent molar. When

Fig. 14.3: Distal shoe space maintainer

Fig. 14.4: Radiograph of distal shoe after cementation


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the second primary molar is removed prior to the eruption of

first permanent molar, the intra-alveolar appliance provides

greater control of the path of eruption of the unerupted tooth

and prevents undesirable mesial migration.

TRANSPALATAL ARCH

Fig. 14.5:Transpalatal arch

Unilateral, non-functional, passive, maxillary fixed appliance.

Transpalatal arch has been recommended for stabilizing the

maxillary first permanent molars when primary molars require

extraction. The best indication for Transpalatal arch is when

one side of arch is intact and several primary teeth on the

other side are missing.


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Bilateral, non-functional, passive, maxillary fixed

appliance. The Nance arch is simply a maxillary lingual arch

that does not contact the anterior teeth, but approximates the

anterior palate via an acrylic button that contacts the palatal

tissue, which provides resistance to the anterior movement

of posterior teeth in a horizontal direction. Nance palatal arch

may be used in maintaining the maxillary 1st permanent molar

positioning when there is bilateral premature loss of primary

teeth with no loss of space in arch and a favorable mixed

dentition analysis.

Fig. 14.6: Nance palatal arch


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FIXED SPACE REGAINER

Fig. 14.7: Gerbers appliance


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CHAPTER

15 PediatricOrthodontics

REMOVABLE RETENTION APPLIANCES

Fig. 15.1: Hawleys appliance


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Pediatric Orthodontics 163

These are appliances, which are used to retain teeth in position

following fixed appliance treatment. The components of theseare clasps on molars and labial bow. Removable retentive

appliances have the advantage that they can be slowly

discarded over a period of time, thus allowing the occlusion

to settle.

Fig. 15.2: Mandibular retention appliance


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Fig. 15.5: Lingual button

FIXED ORTHODONTIC ACCESSORIES

These are used in case of tight interdental contacts. Separators

are inserted in between the contact for 24 hours to ease the

insertion of bands.

Lingual Attachments

Fig. 15.3: Separators

Fig. 15.4: Lingual cleat

These provide additional points for fixing of elastics or fortying ligatures. These attachments have to be positioned so

as not to irritate the soft tissues. Advantage of such appliances

include placement on partially erupted or severely displaced

teeth.


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These are fitted on the molar teeth to accommodate the

distal end of arch wires. The buccal tubes also have a hook

for elastic placement. These are also called as molar tubes.

Fig. 15.6: Buccal tube


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Fig. 15.7:Elastics

Commercially produced latex elastic loops available in

various sizes for inter and intramaxillary tractions. They are

available in different forms like elastic chains, loops, threads

and ligature.

Fig. 15.8: E-chains


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ORTHODONTIC BRACKETS

Brackets in which arch wire channel is wide mesiodistally

and rectangular in cross-section. The term edgewise refers to

the ability of the bracket to accept rectangular cross-section

wire with its larger dimension horizontal. These can also be

used with round cross-section arch wires.

Fig. 15.9: Edgewise


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The Beggs bracket has a narrow slot into which arc wire is

loosely fitted and held by a locking pin. These are used only

with round cross-section arch wires.

Fig. 15.10: Beggs brackets


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TREATMENT OF CROSS BITE USING FIXED

APPLIANCE

Fig. 15.11: Preoperative photo depicting single tooth cross bite

Fig. 15.12:Application of brackets and Ni-Ti arch

wire to align the tooth


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CROSS BITE CORRECTION USING SPRING

Fig. 15.13: Postcross bite correction

Fig. 15.14: Single tooth cross bite


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Fig. 15.15: Correction of cross bite using removable appliance

with Z-spring and posterior bite plane

Fig. 15.16:Postoperative view


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TREATMENT OF MIDLINE DIASTEMA

Fig. 15.17: Preoperative view

Fig. 15.18: Correction of midline diastema using elastics

8/10/2019 Jaypee Gold Stand

jaypee gold standard mini atlas series pe-dodontics (2008) [unitedvrg]

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