Pedodontic
prostheses
J. F. Walsh, B.D.S., F.D.S.* University of the Witwatersrand, South Africa
School
of
Dentistry,
Johannesburg,
C
hildren with mutilated deciduous arches tend to prefer food on the basis of its physical propertieql often resulting in a diet too rich in carbohydrates (Fig. 1) . The degree to which the development of the permanent dentition is affected by loss of teeth from the deciduous arch will depend upon the teeth extracted and the time at which they are lost. 2, 3 The premature loss of a deciduous incisor rarely results in a significant loss of space, whereas the loss of a second deciduous molar can produce a situation where the first permanent molar drifts mesially to contact the first deciduous molar (Fig. 2). This results in crowding in the buccal segments or vertical impaction of the second premolar. Crowding of the buccal segments causes a predisposition for dental carieq4 and the correlation between malocclusion and a poor periodontal condition has been demonstrated by Buckley.5 The lossof an incisor tooth can embarrass the child. Farrell” has pointed out the psychologic harm which can result. OBJECTIVES
OF TREATMENT
The short-term objectives are to restore the deciduous arch, the appearance of the child, and the peace of mind of the parent. Very important considerations will be to educate the parents regarding dental disease and its prevention and to instruct them in methods of improving the child’s oral hygiene. The long-term objectives include the continued education of the parents and child, interceptive orthodontics to avoid crowding in the buccal segments of the permanent dentition, and developing the habit of regular dental care in both parent and child. TREATMENT
PROCEDURES
The first visit is regarded as purely introductory. An accurate history is elicited from the parent, and a diet record sheet is issued .7 If the patient is cooperative, the mouth should be examined. However, the emphasis of this first visit is on becoming *Senior Lecturer,
Department
of Prosthodontics.
13
J. Prosthet. Dent. July, 1976
Walsh
14
Fig. 1. The mutilated dental arch of the child will require extensive clinical treatment with emphasis on preventive dentistry and patient education. Fig. 2. Note the drifting of the first permanent molar which eliminated the space for the second premolar. Table
I. Outline
Visit
of treatment
plan
Objective
Treatment
carried
out
1
Introductory visit
a. History, examination, diagnosis, and treatment plan b. Diet sheet issued to patient c. Commence operant conditioning
2
Commence active treatment
a. Impressions b. Collect diet sheet
3
Commence dental health education
a. Record vertical and centric relation at which centric occlusion will be established b. Discuss diet sheet analysis
4
Commence oral hygiene instruction
a. Try-in of dentures b. Instruction in oral hygiene procedures c. Review diet discussion
5
Review of dental health education
a. Placement of completed dentures b. Revise dental health instruction C. Instructions for wearing and care of dentures
6
Review
a. Examination and adjustments b. Arrange review
mutually acquainted. At the next visit, alginate (irreversible hydrocolloid) impressions are made using stock metal trays. The required vertical and centric relations are recorded using wax occlusion rims constructed on bases of cold-curing acrylic resin. The mandibular rest position is estimated extraorally, and the upper lip is used as a guide to the location of the incisal edges of the upper anterior teeth. The child’s diet is discussed and appropriate advice given, if it is considered necessary. The diet record is kept for analysis and discussion with a dietitian (Table I). The artificial teeth are set up in centric occlusion on an adjustable articulator. Acrylic resin deciduous anterior teeth and the smallest mold of cusp acrylic resin posterior teeth are used. At the try-in, instruction in oral hygiene should be given
Volume Number
36 1
Pedodontic
Fig.
3. The
patient
is wearing
complete
upper
and lower
prostheses
15
dentures.
and the importance of proper diet re-emphasized. The parent is asked to supervise the child’s oral hygiene and to bring the child’s toothbrush along at all subsequent visits. When completed, the child is allowed to becomefamiliar with the dentures before they are inserted. The dentures are then placed in the mouth (Fig. 3)) and the child is allowed to see how he looks. Verbal and written instructions are given to the parent and patient with respect to wearing, cleaning, ,and care of the dentures when out of the mouth. At the next visit, any difficulties are investigated, adjustments are made, and oral hygiene procedures are checked by asking the child to demonstrate cleaning his dentures. For the child of 2 to 5 years of age, subsequent appointments are arranged at intervals of 6 months to check on the comfort and fit of the dentures and to establish the pattern of regular visits. For the child 5 years of age or older, review appointments are arranged at 3 month intervals. The goal is to establishthe habit of regular dental care when the permanent dentition has developed. Decisions can be made concerning possible orthodontic treatment, and dentures may need to be modified or replaced to allow unrestricted development of the jaws and eruption and alignment of the permanent dentition. During treatment, problems have been encountered when making impressions, recording centric jaw relation, and making reline impressions. DEVELOPING
RAPPORT
WITH
THE CHILD
PATIENT
The child requiring dentures will probably already have had teeth extracted. His experience of dental treatment might have been frightening, and he will be suspiciousof the dentist. Cooperation of the child during impressionmaking has been
16
J. Prosthet. Dent. July. 1976
Walsh
achieved by the technique which Frank@ terms “operant conditioning.” At the first visit, the patient is given an upper stock tray to take home. The parent, preferably the mother, is instructed to supervise at home while the child inserts the tray into the mouthl. This is repeated at a regular time on successive days for 2 weeks. The importance of giving the child control is emphasized to the mother, who is advised not to take an active part. This approach will minimize difficulty with impression making. When recording centric relation, something similar to a flame is introduced into his mouth. This can be a frightening and unfortunate experience. The problem is better avoided completely. Any adjustment of the occlusion rims should be done out of the child’s sight. When relining dentures, it is better to use a bland impression material, such as silicone, and avoid zinc oxide/eugenol pastes and rubber base materials. Children are unpredictable. The child with a denture may often abuse or break it. Should this happen, it is important that all the fragments are located. Various solutions to this problem have been proposed9 SUMMARY Premature loss of deciduous teeth can result in unsatisfactory dietary habits and crowding in the buccal segments of the permanent dentition. It may also affect the social development of the young child. For these reasons, the prosthetic restoration of the deciduous arch must be considered whenever teeth have been lost prematurely. I would staffs of the the Department
like to thank Professor A. A. Grant for his encouragement and advice and the Department of Dental Prosthetics, the Department of Preventive Dentistry, and of Medical Illustration, University of Manchester, for their assistance.
References 1. Hobson, P.: The Value of an Intact Deciduous Arch, Br. Dent. J. 12% 175, 1970. 2. Carr, L. M.: The Effect of Extraction of Deciduous Molars on the Eruption of Bicuspid Teeth, Aust. Dent. J. 8: 130-136, 1963. 3. Miller, J.: Dentistry for Children, Br. Dent. J. 112: 308-310, 1962. 4. Massler, M., and Savara, B. S.: Relation of Gingivitis to Dental Caries and Malocclusion in Children 14 to 17 Years of Age, J. Periodontol. 22: 87-96, 1951. 5. Buckley, L. A.: The Relationship Between Malocclusion and Periodontal Disease, J. Periodontol. 43: 415417, 1972. 6. Farrell, Jr.: Dentures for Infants, Dent. Pratt. Dent. Rec. 20: 87-91, 1969. Counselling in the Control of 7. Holloway, P. J., Booth, E. M., and Wragg, K. A.: Dietary Dental Caries, Br. Dent. J. 126: 161-165, 1969. 8. Franks, C. M., editor: Conditioning Techniques in Clinical Practice and Research, London, 1964, Tavistock Publications. 9. Combe, E. C.: Studies on Radio-opaque Dental Materials, Dent. Pratt. Dent. Rec. 22: 51-54, 1971. UNIVERSITY
OF THE
WITWATERSRAND
SCHOOL OF DENTISTRY JAN SMUTS AVE. JOHANNESBURG, SOUTH
AFRICA
prostheses
J. F. Walsh, B.D.S., F.D.S.* University of the Witwatersrand, South Africa
School
of
Dentistry,
Johannesburg,
C
hildren with mutilated deciduous arches tend to prefer food on the basis of its physical propertieql often resulting in a diet too rich in carbohydrates (Fig. 1) . The degree to which the development of the permanent dentition is affected by loss of teeth from the deciduous arch will depend upon the teeth extracted and the time at which they are lost. 2, 3 The premature loss of a deciduous incisor rarely results in a significant loss of space, whereas the loss of a second deciduous molar can produce a situation where the first permanent molar drifts mesially to contact the first deciduous molar (Fig. 2). This results in crowding in the buccal segments or vertical impaction of the second premolar. Crowding of the buccal segments causes a predisposition for dental carieq4 and the correlation between malocclusion and a poor periodontal condition has been demonstrated by Buckley.5 The lossof an incisor tooth can embarrass the child. Farrell” has pointed out the psychologic harm which can result. OBJECTIVES
OF TREATMENT
The short-term objectives are to restore the deciduous arch, the appearance of the child, and the peace of mind of the parent. Very important considerations will be to educate the parents regarding dental disease and its prevention and to instruct them in methods of improving the child’s oral hygiene. The long-term objectives include the continued education of the parents and child, interceptive orthodontics to avoid crowding in the buccal segments of the permanent dentition, and developing the habit of regular dental care in both parent and child. TREATMENT
PROCEDURES
The first visit is regarded as purely introductory. An accurate history is elicited from the parent, and a diet record sheet is issued .7 If the patient is cooperative, the mouth should be examined. However, the emphasis of this first visit is on becoming *Senior Lecturer,
Department
of Prosthodontics.
13
J. Prosthet. Dent. July, 1976
Walsh
14
Fig. 1. The mutilated dental arch of the child will require extensive clinical treatment with emphasis on preventive dentistry and patient education. Fig. 2. Note the drifting of the first permanent molar which eliminated the space for the second premolar. Table
I. Outline
Visit
of treatment
plan
Objective
Treatment
carried
out
1
Introductory visit
a. History, examination, diagnosis, and treatment plan b. Diet sheet issued to patient c. Commence operant conditioning
2
Commence active treatment
a. Impressions b. Collect diet sheet
3
Commence dental health education
a. Record vertical and centric relation at which centric occlusion will be established b. Discuss diet sheet analysis
4
Commence oral hygiene instruction
a. Try-in of dentures b. Instruction in oral hygiene procedures c. Review diet discussion
5
Review of dental health education
a. Placement of completed dentures b. Revise dental health instruction C. Instructions for wearing and care of dentures
6
Review
a. Examination and adjustments b. Arrange review
mutually acquainted. At the next visit, alginate (irreversible hydrocolloid) impressions are made using stock metal trays. The required vertical and centric relations are recorded using wax occlusion rims constructed on bases of cold-curing acrylic resin. The mandibular rest position is estimated extraorally, and the upper lip is used as a guide to the location of the incisal edges of the upper anterior teeth. The child’s diet is discussed and appropriate advice given, if it is considered necessary. The diet record is kept for analysis and discussion with a dietitian (Table I). The artificial teeth are set up in centric occlusion on an adjustable articulator. Acrylic resin deciduous anterior teeth and the smallest mold of cusp acrylic resin posterior teeth are used. At the try-in, instruction in oral hygiene should be given
Volume Number
36 1
Pedodontic
Fig.
3. The
patient
is wearing
complete
upper
and lower
prostheses
15
dentures.
and the importance of proper diet re-emphasized. The parent is asked to supervise the child’s oral hygiene and to bring the child’s toothbrush along at all subsequent visits. When completed, the child is allowed to becomefamiliar with the dentures before they are inserted. The dentures are then placed in the mouth (Fig. 3)) and the child is allowed to see how he looks. Verbal and written instructions are given to the parent and patient with respect to wearing, cleaning, ,and care of the dentures when out of the mouth. At the next visit, any difficulties are investigated, adjustments are made, and oral hygiene procedures are checked by asking the child to demonstrate cleaning his dentures. For the child of 2 to 5 years of age, subsequent appointments are arranged at intervals of 6 months to check on the comfort and fit of the dentures and to establish the pattern of regular visits. For the child 5 years of age or older, review appointments are arranged at 3 month intervals. The goal is to establishthe habit of regular dental care when the permanent dentition has developed. Decisions can be made concerning possible orthodontic treatment, and dentures may need to be modified or replaced to allow unrestricted development of the jaws and eruption and alignment of the permanent dentition. During treatment, problems have been encountered when making impressions, recording centric jaw relation, and making reline impressions. DEVELOPING
RAPPORT
WITH
THE CHILD
PATIENT
The child requiring dentures will probably already have had teeth extracted. His experience of dental treatment might have been frightening, and he will be suspiciousof the dentist. Cooperation of the child during impressionmaking has been
16
J. Prosthet. Dent. July. 1976
Walsh
achieved by the technique which Frank@ terms “operant conditioning.” At the first visit, the patient is given an upper stock tray to take home. The parent, preferably the mother, is instructed to supervise at home while the child inserts the tray into the mouthl. This is repeated at a regular time on successive days for 2 weeks. The importance of giving the child control is emphasized to the mother, who is advised not to take an active part. This approach will minimize difficulty with impression making. When recording centric relation, something similar to a flame is introduced into his mouth. This can be a frightening and unfortunate experience. The problem is better avoided completely. Any adjustment of the occlusion rims should be done out of the child’s sight. When relining dentures, it is better to use a bland impression material, such as silicone, and avoid zinc oxide/eugenol pastes and rubber base materials. Children are unpredictable. The child with a denture may often abuse or break it. Should this happen, it is important that all the fragments are located. Various solutions to this problem have been proposed9 SUMMARY Premature loss of deciduous teeth can result in unsatisfactory dietary habits and crowding in the buccal segments of the permanent dentition. It may also affect the social development of the young child. For these reasons, the prosthetic restoration of the deciduous arch must be considered whenever teeth have been lost prematurely. I would staffs of the the Department
like to thank Professor A. A. Grant for his encouragement and advice and the Department of Dental Prosthetics, the Department of Preventive Dentistry, and of Medical Illustration, University of Manchester, for their assistance.
References 1. Hobson, P.: The Value of an Intact Deciduous Arch, Br. Dent. J. 12% 175, 1970. 2. Carr, L. M.: The Effect of Extraction of Deciduous Molars on the Eruption of Bicuspid Teeth, Aust. Dent. J. 8: 130-136, 1963. 3. Miller, J.: Dentistry for Children, Br. Dent. J. 112: 308-310, 1962. 4. Massler, M., and Savara, B. S.: Relation of Gingivitis to Dental Caries and Malocclusion in Children 14 to 17 Years of Age, J. Periodontol. 22: 87-96, 1951. 5. Buckley, L. A.: The Relationship Between Malocclusion and Periodontal Disease, J. Periodontol. 43: 415417, 1972. 6. Farrell, Jr.: Dentures for Infants, Dent. Pratt. Dent. Rec. 20: 87-91, 1969. Counselling in the Control of 7. Holloway, P. J., Booth, E. M., and Wragg, K. A.: Dietary Dental Caries, Br. Dent. J. 126: 161-165, 1969. 8. Franks, C. M., editor: Conditioning Techniques in Clinical Practice and Research, London, 1964, Tavistock Publications. 9. Combe, E. C.: Studies on Radio-opaque Dental Materials, Dent. Pratt. Dent. Rec. 22: 51-54, 1971. UNIVERSITY
OF THE
WITWATERSRAND
SCHOOL OF DENTISTRY JAN SMUTS AVE. JOHANNESBURG, SOUTH
AFRICA
