BACKGROUNDCleft lip and palate patients present with a variety of clinical presentations that may prevent dentists from completing conventional caries excavation and restorative practices due to lack of access to caries or poor isolation methods. A treatment alternative to arresting caries involves the combined use of Silver Diamine Fluoride (SDF) with Glass Ionomer (GI) or Resin Modified Glass Ionomer (RMGI) in a technique known as Silver Modified Atraumatic Restorative Technique (SMART). The restoration may be definitive or used as an interim therapeutic restoration (ITR) until definitive treatment can be initiated.

INDICATIONS FOR USEThere are several indications for use of SMART technique. The Atraumatic Restorative Technique (ART) is indicated when the patient is unable to return for subsequent dental treatment or may be used as a definitive treatment option.1,2 Interim Therapeutic Restorations (ITR) use the same technique and may be indicated in uncooperative patients, special needs patients, caries control prior to undergoing general anesthesia, or in cases where traditional cavity preparation and/or a traditional dental restoration is not feasible. 2 It is recommended that the restoration be replaced with a definitive restoration within 6 months.2 Definitiverestorations were placed on #8 and #9 as presented in the case report due to extensive treatment time required before orthodontic treatment can be completed.

CLINICAL TREATMENTTreatment was rendered to #8 and #9 using SMART technique in attempts to immediately arrest decay, enhance pulpal vitality, and reduce risk for extraction to prevent loss of bone to the anterior maxilla and palate. Caries control was necessary prior to initiating orthodontic treatment. Treatment was rendered as follows: 1. Isolation obtained using cotton roll (due to

tooth positioning, unable to obtain isolation using rubber dam)

2. Desiccation of the lesion and application of SDF using microbrush for 1 minute

3. Gentle flow of compressed air until dried followed by 10 minutes of tooth isolation

4. Margins prepped to clean tooth structure5. Polyacrylic acid applied to margins and clean

tooth structure for 10 seconds, rinsed, and blotted dry

6. Restored using GC Fuji IX according to manufacturers instructions

CLINICAL PRESENTATIONA 9-year-old male presents to Riley Dental Clinic for treatment of #8 and #9 dental caries prior to undergoing comprehensive orthodontic treatment. Medical history includes repaired bilateral cleft lip and palate. Clinical findings included ectopically erupted #D and #G, anterior crossbite, congenitally missing maxillary lateral incisors, anterior crossbite, and #8 and #9-DFL caries. Patient reported no dental pain or sensitivity despite the extent of caries on #9. Radiographic findings confirmed clinical findings.

INITIAL CLINICAL PHOTOS

REFERENCES1. Alvear Fa B, Jew JA, Wong A, Young D. Silver Modified Atraumatic Restorative

Technique (SMART): an alternative caries prevention tool. StomaEduJ. 2016;3(2):

2. Saber AM, El-Housseiny AA, Alamoudi NM. Atraumatic Restorative Treatment and Interim Therapeutic Restoration: A Review of the Literature. Dent J (Basel). 2019 Mar 7;7(1):28.

3. Use of Silver Diamine Fluoride for Dental Caries Management in Children and Adolescents, Including Those with Special Health Care Needs. Pediatr Dent. 2018 Oct 15;40(6):152-161. PMID: 32074885.

4. Clinical photographs courtesy of IUSD Department of Orthodontics

SMART for Use in the Cleft Lip and Palate PatientBrittany A. Bauer, DMD • Juan F. Yepes, DDS, MD, DrPH, MS

Indiana University School of Dentistry, Indianapolis, Indiana – Riley Hospital for Children