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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_98_библиотеки_им_акад_М_И_Перельмана
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141Comprehensive Care
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FIGURE 10.14 Lower occlusal view showing marginal ridge involvement of 74 and 84 and very extensive lesions in
both 75 and 85.
FIGURE 10.15 Orthopantomogram conrming carious involvement of 55, 54, 64, 65, 75, 74, 84, and 85. It should also be
noted that the rst permanent molars were near to eruption and that there was the possibility that 16 might erupt ectopically.
FIGURE 10.16 Periapical radiograph of 75 and 74 showing no furcation involvement.
Radiographic Assessment
Initial radiographic assessment included an orthopantomogram and a periapical view to assess possible periapical and furcation involvement of 75 (Figures10.15 and 10.16).
Behaviour Assessment
Robert was considered to be fairly cooperative but a little slow at comprehending instructions. It was
decided that behaviour management should include the TSD technique in a form compatible with
Robert’s understanding, using step-by-step instructions and demonstrations. It was also important to
assess the motivation of the family towards dental treatment before embarking on a long and complicated treatment plan.
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Preventive Assessment
As with cases A, Robert had high caries levels, so prevention was a high priority. As before, this would
include oral hygiene, diet analysis, and uoride application.
Treatment Plan
A treatment plan was drawn up as follows.
Visit 1
• Examination, radiographs, oral hygiene assessment, prophylaxis, outline of treatment plan.
• Caries risk assessment.
• Diet history sheet given.
• Application of uoride varnish.
• Treatment and preventive plan discussed with parents.
Visit 2
• Introduction.
• Dressing of open cavities with IRM.
• Prophylaxis.
• Collection of diet history sheet.
Visit 3
• Local analgesia and rubber dam.
• 64 remove caries and place PMC.
• 65 remove caries and place PMC.
• Discussion of diet analysis.
• Fluoride varnish application on early lesions 51 and 61.
Visit 4
• Local analgesia and rubber dam.
• 54 pulpotomy and PMC.
• 55 pulpotomy and PMC.
• Recheck oral hygiene.
Visit 5
• Local analgesia and rubber dam.
• 75 pulpotomy and PMC.
• 74 pulpotomy and PMC.
• Duraphat uoride varnish application on 51 and 61.
Visit 6
• Local analgesia and rubber dam.
• 84 pulpotomy and PMC.
• 85 pulpotomy and PMC.
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143Comprehensive Care
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Visit 7
• Check all restorations.
• Reinforce oral hygiene and prevention programme.
• Arrange three-month recall, with the plan to ssure-seal rst permanent molars on eruption.
The post-operative intra-oral photographs and radiographs are shown in Figures10.17–10.21.
FIGURE 10.17 Anterior view showing improvement of occlusion following placement of PMCs. There has also been
no deterioration of the early lesions in 51 and 61.
FIGURE 10.18 Upper occlusal view showing PMCs on all upper primary molars.
FIGURE 10.19 Lower occlusal view showing PMCs placed on all lower primary molars.
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FIGURE 10.20 (a–d) Fourth-month post-operative periapical radiographs of the primary molars showing normal
periapical and furcation areas.
FIGURE 10.21 (a–d) One-year post-operative periapical radiographs of the primary molars showing no change in
the furcation areas.
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145Comprehensive Care
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Case C
The following case is an example of the use of minimal intervention dentistry in a preschool child
with limited cooperation. The patient was managed with prevention and the use of the Hall technique
PMCs for the carious primary dentition.
Background
Chief Complaint
The parents reported that the child was avoiding eating and drinking liquids which were either hot or
too cold. He never woke up with pain at night and did not have a history of lingering pain.
Past Dental History
The patient was an irregular attender at his general practitioner and always cried during examination.
The dentist had tried to manage the caries with dressings but was unsuccessful due to the limited
cooperation and moisture control.
Medical History
The patient had no relevant medical history.
Intra-Oral Findings
Teeth 55, 75, and 85 were hypomineralized with superimposed caries. The dentine was soft and sensitive to excavation. There was no evidence of caries in other primary molars.
Radiographic Assessment
Left and right bitewing radiographs conrmed the clinical ndings. It was noted that in all three
affected teeth—55, 75, and 85—the lesions were deep; however, there was a clear band of dentine
between the base of the lesions and the pulp.
Behavioural Assessment
This 5-year-old child was reasonably cooperative to examination and short procedures but could not
cope with local analgesia or the ‘noise of the drill’.
Preventive Assessment
The patient’s oral hygiene seamed acceptable; however, the hypomineralization of his primary molars,
coupled with his cariogenic diet, resulted in the development of caries in his hypomineralized molars.
Therefore, dietary analysis, oral hygiene, uoride application, and progress monitoring were needed
to prevent any future caries development.
Treatment Plan
In view of the limited cooperation and short attention span of the child and the clinical and radiographic ndings, the patient was considered as a good candidate to be treated with the use of the Hall
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technique for restoration of the carious teeth. The following treatment was planned and carried out
after the initial visit:
Visit 1
• Examination, radiographs, oral hygiene assessment, prophylaxis, outline of treatment plan.
• Caries risk assessment.
• Diet history sheet given.
• Application of uoride varnish.
• Treatment and preventive plan discussed with parents.
Visit 2
• Placement of ssure sealant on 65 for acclimatization.
• Reinforcement of oral hygiene.
• Collection and analysis of diet sheet.
• Application of uoride varnish.
Visit 3
• Detailed dietary advice and reinforcement of oral hygiene.
• Placement of PMC on 55 and 75 using the Hall technique.
Visit 4
• Placement of PMC on 85 using the Hall technique.
• Reinforcement of oral hygiene and dietary advice.
• Schedule for review in four months for diet analysis, uoride application, and restoration
assessment.
FIGURE 10.22 (a, b) Upper and lower intra-oral views showing hypomineralized and carious 55, 75, and 85.
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147Comprehensive Care
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FIGURE 10.23 (a, b) Right and left bitewing radiographs conrming clinical diagnosis and showing a clear band of
dentine between the base of the carious lesions and the pulp horn in all three affected primary molars.
FIGURE 10.24 (a, b) Showing PMC restorations on 55, 75, and 85 placed with PMC using Hall technique.
Case D
Background
Past Dental History
A 2½ -year-old boy presented with frequent episodes of pain which was associated with eating. The
parents reported generalized loss of tooth structure and expressed concerns with the deterioration of
their son’s dental condition.
Past Medical History
The parents reported no relevant medical conditions or allergies.
Intra-Oral Findings
Apart from the second primary molars, the remaining primary teeth were present. Teeth presented
with variable degrees of dental caries, suggestive of severe early childhood caries (Figures10.25a, b,
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and c). The remaining sound enamel appeared hypomineralized, which is possibly suggestive of an
underlying enamel defect.
Radiographic Assessment
Due to patient’s age and cooperation level, radiographic examination was not possible.
Behaviour Assessment
The patient was very uncooperative; therefore, treatment under general anaesthesia was decided after
discussion with the parents.
Treatment Plan
Due to the patient’s high caries risk, the multisurface nature of the dental caries, and the parents’
request of aesthetic restorations, a decision was made to restore the carious teeth using full coverage
zirconia crowns. Risks and benets of treatment, including GA length, cost, and alternative treatment
modalities (use of strip crowns anteriorly and prefabricated metal crowns on posterior teeth), were
discussed with the parents, who decided to proceed with full coverage white zirconia restorations.
FIGURE 10.25 (a) Pre-operative upper arch occlusal view showing gross decay affecting all teeth, with possible
underlying enamel defect. (b) Pre-operative lower arch occlusal view showing gross decay affecting all teeth, with
possible underlying enamel defect. (c) Anterior view showing gross decay affecting all teeth, with possible underlying
enamel defect.
Treatment Plan
A treatment plan was drawn up as follows.
Visit 1
• Examination, radiographs, oral hygiene assessment, prophylaxis, outline of treatment plan.
• Caries risk assessment.
• Diet history sheet given.
• Application of uoride varnish.
• Treatment and preventive plan discussed with parents.
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Visit 2
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• Comprehensive treatment under general anaesthesia. All teeth were prepared to receive
zirconia crowns (Figure 10.26a). After trial tness and bite assessment (Figure 10.26b),
crowns were cemented using glass ionomer cement (Figures10.27a, b). No pulp therapy was
required on any of the prepared teeth.
149Comprehensive Care
FIGURE 10.26 (a) Upper occlusal view showing immediate post-operative preparation of upper teeth. (b) Right-side
view showing pre-cementation occlusal assessment of temporary crowns on 54, 83, and 84.
FIGURE 10.27 (a) Anterior view showing crowns post-cementation with well-aligned teeth and good occlusion.
Minimal gingival trauma is evident immediately after cementation. (b) Upper occlusal view showing cemented crowns
post-cementation, showing well-aligned teeth.
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150 Restorative Techniques in Paediatric Dentistry
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FIGURE 10.28 (a) One-year follow-up upper occlusal view showing well-retained restoration and erupted upper sec-
ond primary molar. (b) One-year follow-up lower occlusal view showing well-retained restoration and erupted upper
second primary molars. (c) One-year follow-up anterior view showing well-retained crowns in good occlusion.
Visit 3 (One Week Post-Operatively)
• Check all restorations.
• Reinforce oral hygiene and prevention programme.
• Arrange regular recall sessions.
The patient was reviewed on regular basis, with last review at 3.5years, showing retention of all
zirconia crowns, however with calculus build-up (Figure10.29a). Plaque removal was done, and oral
hygiene instructions were given.
FIGURE 10.29 (a) Three-and-a-half-year follow-up anterior view of upper teeth showing gingival inammation
and plaque accumulation. (b) Three-and-a-half-year follow-up anterior view showing well-retained crowns in good
occlusion.
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