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CHAPTER 2
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Self‐Study Answers
1. Severity of the caries (patients with high
caries susceptibility), extension, and caries risk
assessment of the patient; restoration of carious
primary molars where more than two surfaces
are affected following pulpotomy or pulpectomy
procedure; restoration and protection of teeth
with extensive surface loss (attrition, erosion,
abrasion); teeth anomalies; developmental
defects; discoloration; patient’s bite; appropriate
cleaning and frequency of brushing; patient
compliance; use as abutments for certain appliances (space maintainers); children who have
extensive caries and must be treated under
general anesthesia
Bibliography
Donly KJ, Garcia‐Godoy F. 2015. Restoring primary anterior
teeth: update for 2014. Pediatr Dent 37(2):136–43.
Lee JK. 2002. Restoration of primary anterior teeth: review of
the literature. Pediatr Dent 24(5):506–10.
2. Strip, stainless steel, open face stainless steel,
prefabricated resin‐faced stainless steel, acrylic
3. The American Academy of Pediatric Dentistry
recommends that a patient with a transitional
dentition should have a radiographic exam that
includes posterior bitewings (if contacts
between the teeth are present) and a panoramic
radiograph or selective periapical radiographs
4. History, clinical evaluation, and supplemental
professional assessment
5.
To avoid the development of air voids within
the resin
Waggoner WF. 2002. Restoring primary anterior teeth. Pediatr
Dent 24(5):511–16.
Waggoner WF. 2015. Restoring primary anterior teeth: an
update for 2014. Pediatr Dent 37(2):163–70.
70 Clinical Cases inPediatric Dentistry
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AB
Case 8
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Anterior andPosterior Zirconia Crowns
Figure 2.8.1 (A, B) Preoperative views of mandibular primary
right first and second molars.
A. Presenting Patient
• Five‐year‐, eleven‐month‐old Asian female
• Presenting for a new patient visit
B. Chief Complaint andHistory ofPresent
Illness
• Mother states, “My daughter has cavities and needs
treatment”
C. Social History
• Patient is in first grade
• Patient lives with parents and has a four‐year‐old sister
• Parents are married
• Mother is the primary caregiver and does not work.
Father is a professor in the university
• Socioeconomic status is upper‐middle class
D. Medical History
• Review of system reveals no significant findings,
American Society of Anesthesiologists (ASA) I
• No known allergies to any food or medications
RESTORATIVE DENTISTRY
• No routine medications
• No previous hospitalization or surgeries; no emergency
visits
E. Medical Consult
• Not necessary at this time
F. Dental History
• Last dental visit was about one month ago
• Patient had a failed sedation visit (oral medication)
with previous pediatric dentist; no treatment was
performed at the visit
• Patient was very anxious and fearful during the
examination
• Parents did not expect patient to cooperate
• Optimal water fluoridation levels
• Poor oral hygiene
• High cariogenic diet, including two cups of juice and
one to two candies daily
• Brushes teeth without supervision once per day
• Parents deny any trauma history
G. Extraoral Exam
•
Head and neck examination: within normal limits
• Height and weight at 50th percentile, body mass
index at 50th percentile
H. Intraoral Exam
• Early mixed dentition
• Occlusion: bilateral mesial step primary molar relationship;
bilateral class I canines; overjet 3 mm, overbite 20%
• Soft tissues are within normal limits
• Generalized moderate plaque accumulation
• Visible carious lesions on maxillary right primary
lateral incisor, maxillary right primary central incisor,
maxillary left primary central incisor, maxillary left
primary lateral incisor, and mandibular right primary
first molar (Figure2.8.1)
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CHAPTER 2
AB
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• Deep pits and fissures on all permanent first
molars
I. Diagnostic Tools
• Radiographs were taken within one month by child’s
previous dentist, including bilateral bitewing and
anterior maxillary radiographs. Figure2.8.2
andFigure2.8.3A show multiple interproximal
cariouslesions
J. Differential Diagnosis
• Not applicable
K. Diagnosis andProblem List
Diagnosis
• Early childhood caries
Problem List
• High caries risk due to poor oral hygiene, cariogenic
diet, and no dental home
• Fearful and extremely apprehensive patient
L. Comprehensive Treatment Plan
• Establish a regular dental home
• Prevention plan:
Dental prophylaxis
Topical fluoride treatment (5% sodium fluoride
varnish applied)
Sealants on all erupted permanent first molars
Review oral hygiene with parent and child,
recommend brushing under parental supervision
Diet counseling
Three‐month recall schedule
• Restorative plan: (see Fundamental Point 1)
• Due to parental expectation on the need for esthetic
restorations, zirconia crowns were planned for all
maxillary lateral and central incisors, and for the
mandibular right primary first molar. A stainless steel
crown was planned for the mandibular right primary
second molar because it did not pose an esthetic
concern
• Behavioral management: due to severe anxiety,
theamount of restorative treatment necessary,
andthe failed sedation experience, full mouth
dental rehabilitation under general anesthesia was
planned
Figure 2.8.2 Preoperative anterior maxillary radiographs.
Figure 2.8.3 (A, B) Preoperative bitewing radiographs.
FUNDAMENTAL POINT 1
Full Coronal Restoration forAnterior Teeth
• Indication for full coronal restoration of carious
primary incisors:
Multiple surfaces are involved either due to
caries or trauma
The incisal edge is involved
There is extensive cervical decalcification
Pulpal therapy is indicated
Caries may be minor, but oral hygiene is
verypoor
The child’s behavior makes moisture or
bleeding control very difficult
(American Academy of Pediatric Dentistry
2018–2019)
• For primary anterior teeth, the types of esthetic
crowns currently available are: open‐faced
stainless steel crowns, preveneered stainless
steel crowns, strip crowns, polycarbonate crowns,
and zirconia crowns (Waggoner 2002, 2015)
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M. Treatment (see Fundamental Point 2)
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• Since the patient was treated under general
anesthesia, local anesthesia was not used to avoid
postoperative self‐inflicted soft tissue injury
• Occlusal reduction, under rubber dam isolation,
1–1.5 mm, using a wheel diamond bur in a high‐speed
handpiece (Figure2.8.4):
Interproximal reduction 1–1.5 mm, using a flame‐
shaped diamond bur to break contact (Figure2.8.5)
Buccal–lingual reduction 1–1.5 mm
Using a flamed‐shaped diamond to prepare subgingivally 1–2 mm to produce a feathered margin
Select appropriate try‐in crown size, where the
correct crown size has a passive fit
Control the hemorrhage of the prepared tooth with
pressure or ViscoStat® (Ultradent Products, South
Jordan, Utah, USA) (see Fundamental Point 3)
Select the appropriate zirconia crown size and
cement with BioCem® (NuSmile Pediatric Crowns,
Houston, Texas, USA) (see Fundamental Point 3)
Remove the excess cement before light curing
(Figure2.8.6)
Follow‐up at two weeks postoperatively shows
crowns on the maxillary incisors and the mandibular
right primary first molar all in good repair
(Figure2.8.7)
RESTORATIVE DENTISTRY
Figure 2.8.5 Interproximal and subgingival reduction on
mandibular primary right first molar.
Figure 2.8.4 Rubber dam isolation and occlusal reduction of
mandibular primary right first molar.
Figure 2.8.6 Zirconia crown (arrow) completed.
Prognosis andDiscussion
N.
• Due to the patient’s caries risk, and caries involved in
multiple surfaces, full coronal restorations were planned
for carious primary incisors and primary molars instead
of resin‐based restorations. The full coronal restoration
will also reduce the risk of recurrent decay
• Prognosis for the crowns is good since they were
placed in the well‐controlled setting of the
operatingroom
• The risk of future carious lesions will remain high
unless an aggressive caries prevention plan is put in
place and the family show good compliance
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Clinical Cases inPediatric Dentistry 73
CHAPTER 2
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A
B
FUNDAMENTAL POINT 2
Zirconia Crowns
• Zirconia is a type of bioceramic material used to
make preformed biocompatible crowns that are
very durable and esthetic
• Zirconia crowns have become popular because of
the natural color option. Zirconia crowns were rst
introduced in 2010. They are available in various sizes
and shades for anterior and posterior primaryteeth:
Zirconia crowns require a feathered margin as
in other crown preparations; however, these
crowns require more tooth reduction when
compared withstrip crowns and stainless
steel crowns (Clarketal. 2016)
Zirconia crowns require a passive fit and can only be
placed without resistance. The ceramic crowns do
not flex, so the tooth is prepared to fit the crowns
rather than adjusting the crowns to fit a tooth
Unlike stainless steel crowns, zirconia crowns
cannot be crimped. The retention is reliant on the
different internal surface designs and cementation
◦ Although more esthetic, the cost of zirconia
crowns is higher than other types of crowns
C
Figure 2.8.7 (A–C) Two‐week postoperative photographs.
O. Common Complications andAlternative
Treatment Plans
• An anterior crossbite could alter the plan to use
anterior zirconia crowns
• Inability to control bleeding might affect the
placement of zirconia crowns by interfering with
adequate bonding from the cement and poor
esthetics
FUNDAMENTAL POINT 3
Cementation forZirconia Crowns
• Most of the manufacturers of zirconia crowns
recommend glass ionomer cement or
resin‐modied glass ionomer cement
• A new BioActive cement (BioCem®, NuSmile
Pediatric Crowns, Houston, Texas, USA) was
introduced to cement zirconia crowns. BioCem
forms hydroxyapatite to integrate into tooth
structure and releases phosphate, calcium, and
uoride ions. BioCem is a dual cured resin‐ modied
glass ionomer cement and provides a superior
bond to zirconia surfaces (Waggoner 2015)
• Hemorrhage control is very important to prevent
contamination of the crowns and achieve
adequate bonding from cement
• Thorough cleaning of crowns with alcohol is
necessary before cementation
• Try‐in crowns allow for sizing. The actual crown
can then be cemented free of contamination
prior to cementation
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Self‐Study Questions
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RESTORATIVE DENTISTRY
1. What are the indications for full coronal
restoration of carious primary incisors?
2. What are the options for esthetic crowns in
anterior teeth?
3. What kinds of cement can be used for zirconia
crowns?
4. List three differences between zirconia crowns
and stainless steel crowns?
5. What important factor can interfere with
cementation of zirconia crowns?
Answers are located at the end of the case
Clinical Cases inPediatric Dentistry 75
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CHAPTER 2
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Self‐Study Answers
1. Caries present on multiple surfaces, the incisal
edge is involved, extensive cervical decalcification,
pulpal therapy is indicated, caries may be minor but
with poor oral hygiene, difficult to control moisture
or bleeding due to child’s behavior
2. Open‐faced stainless steel crowns, preveneered
stainless steel crowns, strip crowns, polycarbonate
crowns, and zirconia crowns
3. Glass ionomer cement, resin‐modified glass
ionomer cement, BioCem
Bibliography
American Academy of Pediatric Dentistry. 2018–2019. Pediatric
restorative dentistry. In: Clinical Practice Guidelines and
Best Practices (Reference Manual). Pediatr Dent 40:330–42.
https://www.aapd.org/research/oral‐health‐policies‐‐
recommendations/pediatric‐restorative‐dentistry
Clark L, Wells MH, Harris EF, Lou J. 2016. Comparison of
amount of primary tooth reduction required for anterior and
posterior zirconia and stainless steel crowns. Pediatr Dent
38(1):42–6.
4. Zirconia crowns (i) have a natural color,
(ii)cannot be crimped and (iii) require a passive fit
5. Hemorrhage control is very important to prevent
contamination of the crowns and achieve adequate
bonding from cement and esthetics. Use try‐in
crowns or thorough cleaning of crowns before
cementation
Waggoner WF. 2002. Restoring primary anterior teeth. Pediatr
Dent 24(5):511–6.
Waggoner WF. 2015. Restoring primary anterior teeth: update
for 2014. Pediatr Dent 37(2):163–70.
76 Clinical Cases inPediatric Dentistry
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3
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Complex Pulp Therapy
Anna B. Fuks
Case 1: Selective Caries Removal (Indirect Pulp Treatment) ................................................................................ 78
Anna B. Fuks, Luna Matar Khoury, Qamar Saadi, and Evelyn Mamber
Case 2: Partial Pulpotomy in Traumatized Primary Incisors .................................................................................. 85
Diana Ram and Anna B. Fuks
Case 3: Cervical Pulpotomy in Cariously Exposed Primary Molars ...................................................................... 91
Moti Moskovitz and Anna B. Fuks
Case 4: Root Canal Treatment in a Primary Molar ................................................................................................ 97
Moti Moskovitz
Case 5: Partial Pulpotomy in a Cariously Exposed Young Permanent Molar .......................................................103
Moti Moskovitz and Anna B. Fuks
Case 6: Pulpotomy with Mineral Trioxide Aggregate inan Immature Permanent Molar .....................................109
Anna B. Fuks
Case 7: Root End Closure – Apexification with Calcium Hydroxide ..................................................................... 115
Iris Slutzky‐Goldberg
Case 8: Root End Closure with Mineral Trioxide Aggregate ...................................................................................... 121
Iris Slutzky-Goldberg
Case 9: Revascularization of Necrotic Immature Permanent Tooth with Apical Periodontitis ............................ 127
Eyal Nuni
Clinical Cases in Pediatric Dentistry, Second Edition. Edited by Amr M. Moursi.
© 2020 John Wiley & Sons, Inc. Published 2020 by John Wiley & Sons, Inc.
Companion website: www.wiley.com/go/moursi/pediatrics
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CHAPTER 3
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Case 1
Selective Caries Removal (Indirect Pulp Treatment)
A
Figure 3.1.1 (A, B) Facial photographs.
A. Presenting Patient
• Five‐year‐old female (Figure 3.1.1)
• Patient presenting for check‐up after a failed attempt
at treatment over 1 year ago
B. Chief Complaint
• The patient’s mother reported that her daughter has
no pain presently, but she noticed several severely
decayed teeth
C. Social History
• Middle class
• The youngest of three children (two girls and
oneboy)
• Father is a pediatrician
• Patient is in kindergarten
D. Medical History
• Suffered left hemiparesis after birth, left ventricular
aneurism
• Had no further hospitalizations
• Heart function is stable
• Takes 75 mg aspirin daily
E. Medical Consultation
• Not applicable
B
F. Dental History
• No dental home
• The patient was taken to a dentist over a year ago
butwas not cooperative. Has not been to the
dentistsince
• Cariogenic diet
• Lives with suboptimal water fluoridation, between 0.1
and 0.2 ppm (fluoridation was discontinued at age
oneyear)
• Received no fluoride supplements
• No regular toothbrushing
• No history of dental or oral trauma
G. Extraoral Exam
• No significant findings
H. Intraoral Exam
Soft Tissues
• Generalized plaque‐induced gingivitis
• Fistulae associated with all the maxillary incisors, the
maxillary right first primary molar, and the mandibular
right and left first primary molars
Hard andDental T issues
•
Complete primary dentition
• Considerable plaque accumulation
• Maxillary right and left first primary molars and
mandibular first primary molar have severely
decayedcrowns
• Maxillary central and lateral incisors with extensive
carious lesions and periapical pathology
• Mandibular right second primary molar has a severely
decayed crown and interradicular pathology
Occlusal Evaluation ofPrimary Dentition
• Mesial step molars, class III right canines, class I left
canines
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