Reemplazo estético de dientes anteriores superiores primarios

IJCDC Abstract A problem commonly faced in pediatric dental clinic is the esthetic rehabilitation of a young toddler who has suffered multiple tooth loss subsequent to rampant early childhood caries or extensive dental trauma.

Restorative options available to the practitioner include, both removable and fixed appliances .The fixed appliances include bonded appliances and soldered wire and crowns \bands appliances. The most decisive factor for placing an anterior esthetic appliance is parental desire. Other considerations include: space maintenance, masticatory function, speech development, and tongue habits. This paper discusses one type of fixed anterior esthetic appliance and considerations to be made while placing the appliance.

JULY-DEC 2011 • VOL 1 • ISSUE 1

Indian Journal of Comprehensive Dental Care

1. Professor, Department of Pedodontics and Preventive Dentistry, Sri Guru Ram Dass Institue of Dental Sciences and Research , Amritsar 2. Senior Lecturer, Department of Pedodontics and Preventive Dentistry, Sri Guru Ram Dass Institue of Dental Sciences And Research , Amritsar 3. Senior Lecturer, Department of Pedodontics And Preventive Dentistry, Sri Guru Ram Dass Institue Of Dental Sciences And Research , Amritsar 4. Professor and Head, Department of Pedodontics and Preventive Dentistry, Sri Guru Ram Dass Institue of Dental Sciences and Research , Amritsar

Keywords esthetics, stainless steel crowns, appliance.

Introduction One of the pediatric dentist's greatest restorative challenges is the esthetic rehabilitation of a young toddler who has suffered multiple tooth loss subsequent to rampant early childhood caries or extensive dental trauma. The implications of this situation include neuromuscular imbalance with decreased masticatory efficacy, speech disturbances, development of parafunctional buccal habits and psychological problems 1.

Restorative options available to the practitioner for treatment of premature anterior tooth loss include, both removable and fixed appliances. The fixed appliances include bonded appliances and soldered wire and crowns \bands appliances.

Whenever there is premature loss of maxillary primary anteriors, many parents will seek an esthetic solution to replace the lost teeth. For the clinician seeking to construct and place an esthetic appliance in a preschooler there is very little information in the dental literature which addresses the need or indications for these appliances. A few articles have been published which describe a particular appliance

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design 2, but there is a scarcity of information available to aid the clinician in appliance design, placement, and counseling of parents. This paper discusses one type of fixed anterior esthetic appliance and considerations to be made while placing the appliance. Two case reports are presented here to describe the procedure.

Appliance design There are many types of appliances that can be fabricated.

However, the authors have had the most success with the design of the Groper appliance 3. This appliance is similar to a Nance holding arch, but with plastic teeth processed onto the wire instead of a palatal acrylic button in the rugae area.

The round wire should be 0.036 to 0.040 inch in diameter and is attached to either the first or second primary molars with either stainless steel crowns (SSC) or prefabricated stainless steel bands.

Steps in fabrication First appointment: 1. Prepare the molars for SSCs. If pulpotomies are indicated, perform them at this time. If the abutment teeth have

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Fig 1: Maxillary occlusal view showing loss of primary anterior plus loss of primary first molar on right side.

Fig 2: Stainless steel crowns on primary first and second molars.

minimal or no caries, minimal tooth preparation is required and local anesthesia may not be required. If bands are to be used, no tooth preparation is necessary.

2. Fit the SSC; do not expect a “snap” fit. Seat SSC with direct downward pressure, not lingual to buccal seating. Reduce buccal bulge if necessary. If needed, trim the lingual of the SSC. Remember that the draw of the finished appliance must allow for a seating, which is directly downward.

3. Take an alginate impression with the SSCs\band on teeth.

Remove the impression, place and secure the crowns in the impression pour up with dental stone. If cooperation allows, take a mandibular alginate impression and wax bite registration.

LABORATORY PROCEDURE 1. A .036”or .040” wire was formed to the palatal arch and soldered to the molar stainless steel crown or orthodontic band 2. Before the first appointment, irreversible hydrocolloid impression was obtained from another child who had a full complement of teeth and the resultant cast was to serve as a template for a set of “donor denture teeth” 3. Donor upper cast was duplicated in heavy body vinyl siloxane impression material, and the number of teeth required was poured with autopolymerizing acrylic resin .The resultant teeth will serve as final artificial denture teeth.

4.Pink color autopolymerizing acrylic resin was applied to retain the artificial teeth onto the wire Second appointment: 1. Try in the appliance. Adjust as needed with 3-prong pliers and crown crimpers 2. Cement the appliance with glass ionomer cement or resin-modified glass ionomer cement.

CASE 1 A four and a half year old boy was referred to our dental

Indian Journal of Comprehensive Dental Care

Fig 3: Pink color autopoly merizing acrylic resin is applied to retain artificial teeth onto the wire

Fig 4: Frontal view showing patient with the esthetic appliance

department with chief complaint of missing teeth. A dental record was made for the child, in order to register his medical as well as his dental history with a proper extra and intra oral examination. His mother told us he lost all his upper anterior primary teeth at school while playing with his friends. The teeth could not be found and the child was taken to the school clinic to take the necessary measures for controlling the bleeding and sterilizing the area. Two weeks later, his mother brought him to our department asking for teeth replacement because she was very anxious about the appearance of her son, and she insisted on having a fixed appliance as teeth replacement. Intra-oral examination revealed a healthy gingival tissue with sound remaining primary teeth(maxillary second primary molar of both sides and maxillary first molar of left side ) and the sockets of the lost teeth were about to heal (Fig. 1). An appointment was given to the mother to construct the fixed appliance as described above with SSC on the entire primary maxillary molar (Fig.2). After one week, the appliance was fitted in the child's mouth (Fig. 3) .Both the child and the parents were pleased with the new look of the child, which gave him a normal appearance. Some instructions were given to his mother to maintain a good oral hygiene for the child and recall visits to make any necessary adjustments for the appliance if needed (Fig. 4).

CASE 2 A three and a half year old boy was referred with chief complaint of missing teeth.Intra -oral examination revealed missing maxillary central incisors. The procedure was followed as described earlier with orthodontic band on primary maxillary second molars (Figures 5 to 7).

Discussion When considering the need for an anterior appliance to replace missing primary anteriors, the following points should be discussed with the parents. First, the strongest factor for placing an anterior esthetic appliance is parental desire. While space maintenance, masticatory function,

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Fig 5: Anterior view demonstrating missing maxillary centrals

Fig 6: This appliance, replacing two maxillary centrals, was attached to second primary molars with orthodontic bands

Fig 7: Frontal view showing patient with the esthetic appliance

speech development, and tongue habits may be of some consideration, there is no strong evidence that early loss of maxillary incisors will have any significant, long-lasting effect on the growth and development of the child.

consider appliances for children under 3 years of age who have not yet developed their speech skills. Children over 4 years will usually compensate for the tooth loss and not exhibit any long-term speech disorders 9.

Space maintenance

Esthetic appearance

While space maintenance in the posterior region is an important consideration when there is early loss of primary molars, the anterior segment, from canine to canine, appears to be stable, even with the early loss of several incisors, with no net loss of space from canine to canine4.

One of the most important and valid reasons for replacing missing incisors is to restore a natural and pleasing appearance and thus provide an opportunity for normal psychological development. As children grow and develop, they continually formulate a mental image about their bodies. However, body image alterations bear little significance in the very young 10. Most children are highly adaptable and preponderantly positive in mood. Children under 5 are seldom affected socially to any great extent due to their limited exposure to peers, unlike school-age children. However, it is possible that children who regularly attend daycare or preschool programs may become more aware of their image and lack of teeth and be affected by their appearance. As these children approach school age, they may have a lesser problem fitting into groups of children who are in the mixed dentition and actively exfoliating the primary incisors 5.

Masticatory function Parents may express concern about their child's ability to eat without anterior teeth. They need to be reassured that feeding is generally not a problem 4. In a survey of parents whose children had all anterior extracted or lost due to trauma, parents reported that their child adapted to the lack of their anterior teeth and had no difficulty in eating and chewing 5.

Speech Yet another consideration is the child's speech development following loss of maxillary anteriors. This issue remains somewhat controversial. Many sounds are made with the tongue touching the lingual side of the maxillary incisors and inappropriate speech compensations can develop if the teeth are missing. Speech articulations and sounds that are most frequently in error due to dentition are: /S/ as in soap, /Z/ as in zebra, and /th/ as in think 6. One study demonstrated that children who had worn dentures from early childhood exhibited no articulation errors, while those who did not exhibited articulation errors directly related to dentition. This study concluded that patients who received prosthetic dental appliances (two years is optimal as related to speech) develop better articulation skills 6. Another study,

by Riekman and El Badrawy 7, found that loss of all maxillary primary incisors before age 3 years resulted in some speech problems in some children. Another study by Gable 8, et al found that early loss of incisors had no long-term effect on speech .While the data is incomplete, it may be prudent to Indian Journal of Comprehensive Dental Care

The possibilities of caries and growth interference are two other topics that should be discussed with parents considering a maxillary esthetic appliance. Plaque and food debris accumulation is increased with the fixed anterior appliance. A comprehensive caries prevention program must be initiated with a frequent recall schedule. Adequate measures of oral hygiene and a modified low cariogenic diet should be achieved before placing any appliance in the mouth. At the present time there is no evidence that prosthetic appliances might restrict a child's oral growth 11.

The intercanine growth between the age of 2-4 years is minimal (< 0.5mm) and is clinically insignificant 12. Changes in arch length with tooth migration generally occur after the eruption of the first permanent molar. At that time, the fixed appliance may be removed as this represents the time that the incisors would normally be exfoliating.

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Potential loosening of bands or SSC resulting from continual torquing of bands or SSC by the movement of wire during normal chewing not only necessitates frequent recementation,but may cause decalcification or decay on the abutment teeth. Jenny Z.C.Chang 13 use double SSC on the abutment teeth which lessen the possibility of secondary caries due to the fact that loosening often occurs from disintegration of cement in between the two SSC that snapped together. So the abutment tooth is still protected by the smaller size SSC. The timing of placement is somewhat controversial.

Historically, it was suggested to allow 6-8 weeks following tooth loss, before fabrication. This delay was thought to allow good healing and gingival shrinking to occur, which would result in a better fitting, more esthetically pleasing appliance. However, personal experience has found that delay is not necessary and immediate placement is possible.

Perhaps, one reason to delay treatment is to ascertain when the parents' concern of esthetics is a real one. Many parents who contemplated an appliance will opt to change their decision and not place it after they observe how well their child adapts to their post-extraction situation. They may observe during this waiting period that no negative change in their child's functioning, eating, or speech has occurred.

Esthetically, many parents' image of their child improves within the delay period and their esthetic concern will dissipate.

To summarize, if parents do not indicate a desire to replace missing anterior teeth, no treatment is usually required. But, if the parents do wish to replace missing teeth, they should not be discouraged from their decision.

This paper has offered several considerations for the clinician to make when considering the placement of a fixed prosthetic appliance to replace missing incisors in preschool children. A simple technique for appliance placement was also discussed. These appliances are almost always considered an elective appliance and their placement is usually dictated by the wishes of the parent.

3. Jasmin JR, Groper JN. Fabrication of a more durable fixed anterior esthetic appliance. J Dent Child 51(2):124-127, 1984.

4. Christensen JR, Fields HW. Space maintenance in the primary dentition. : Infancy through Adolescence. Pinkham JR ed. 2nd ed. Philadelphia: W.B. Saunders Company; 1994:358-363 5. Koroluk LD, Riekman GA. Parental perceptions of the effects of maxillary incisor extractions in children with nursing caries. J Dent Child 58:233-236, 1991.

6. Coston GN, Salinas CF. Speech characteristics in patients with hypohidrotic ectodermal dysplasia in Birth defects: Original article series. 24:229-34, 1988.

7. Riekman GA, El Badrawy HE. Effect of premature loss of primary maxillary incisors on speech. Ped Dent 7:119-122, 1985.

8. Gable, TO, Kummer AW, Lee L, Creaghead NA, Moore LJ. Premature loss of the maxillary primary incisors: Effect on speech production. J Dent Child 62(3):173-179, 1995 9. William F. Waggoner, MS Ari Kupietzky . Anterior esthetic fixed appliances for the preschooler: considerations and a technique for placement. Pediatric Dentistry 23(2), 147150,2001 10. Lynch M. Special children, special needs: the ectodermal dysplasias. Pediatric Nursing 18:212-216, 1992.

11. Dyson JE. Prosthodontics for children: Total Patient Care.

Pediatric Dentistry: 259-274, 1988.

12. Scures CC. Report of the increase in bicanine diameter in 2 to 4 -year-old children. J Dent Child 34:332-335, 1967.

13. Jenny Z.C.Chang, Peter H.C.Chen .An appliance to replace prematurely lost maxillary anterior teeth using double stainless steel crowns on the abutment teeth. Clin Pediatr Dent 23(4):285-288,1999

References 1. Ripa L.W. Nursing caries - A comprehensive review. Pediatr Dent 10: 268- 282, 1988.

2. Klapper BJ, Strizak-Sherwin R. Esthetic anterior space maintenance. Ped Dent 5(2):121-123, 1983.

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