Case 4

History of chief complaint:

Her bottom front tooth is positioned behind the others, so we want to begin braces. She doesn't have any pain.

Prenatal history:

MG's mother was healthy during pregnancy. She took no medications apart from the standard supplements, and her diet was regular. No special diet was followed.

Natal history:

MG was born prematurely. There were no reported neonatal jaundice, birth complications, or injuries, and no congenital abnormalities were reported.

Postnatal history:

MG was breastfed until the age of 2 years. The mother described it as feeding on demand, and she does not recall wiping MG's mouth after feeding. After weaning, MG started to drink from a cup, consuming rooibos tea with added sugar and sugary juices.

Medical history:

MG is a healthy child with no significant childhood illnesses and is up to date with all her vaccinations.

 She is allergic to Penicillin.

Dental history and oral hygiene practice:

MG had her first dental visit when she was four years old. She was experiencing pain while eating due to a loose bottom front tooth. Her mother cannot recall if she had experienced any trauma at that time as MG was staying with her grandparents. The dentist extracted the loose tooth. According to her mother, MG was cooperative during the procedure, given her age. However, she did cry upon seeing the blood.

This was her only visit to the dentist, and she has not undergone any dental treatment under general anaesthesia or sedation. MG has been brushing her teeth independently in a back-and-forth motion using adult toothpaste every morning since she was five years old. She does not floss. Before the age of five, her parents assisted her with brushing.

MG is an intelligent child who displays signs of anxiety and nervousness. Her academic performance is excellent, and she prefers indoor activities over sports. She makes friends easily.

• Molar classification: Right class I, Left class I

The maxillary midline coincides with the midsagittal plane.

Mandibular midline shifting to the left (1mm) at rest and occlusion.

• Overjet: 5 mm

• Overbite: 4 mm

• No Crossbite

• No open bite

• Buccal canine bulges: palpable

• No habit.

MG is in her early mixed dentition. No abnormalities were found in the tongue, frenum, or mucosa. However, visible plaque, mild gingival inflammation, and food impaction were detected in the first and second quadrants (55&54, 46&85).

MG's attitude was rated as negative according to Frankl's Behaviour Rating Scale (Shao et al., 2016).

Behaviour management for MG focused on desensitization due to her previous unpleasant dental experience, which, in my opinion, had caused her to exhibit signs of anxiety and nervousness.

 The tell-show-do technique, distraction, and positive reinforcement were employed to help ease her fears. 

We used the TV to distract her and engaged her in conversation throughout the procedure. This diverted her attention from any discomfort and minimized negative or avoidant behaviours.

We also employed the enhancing control technique. MG was instructed to raise his left arm if he felt uncomfortable or needed a break, and we responded immediately. This gave her a sense of control, reducing her anxiety and contributing to a more positive experience.

Additionally, we continuously monitored her response to treatment and made necessary adjustments to ensure her comfort and cooperation throughout the process. 

Although MG's primary concern was the crowded lower anterior sextant, it was essential to address her immediate oral health needs before considering interceptive appliances, given her current high caries risk and irregular dental visits. The literature emphasized that interceptive appliances could accumulate plaque, exacerbating caries risk if not managed properly (Shabzendedar et al., 2011). Therefore, it was crucial for MG to maintain good oral hygiene and be dentally fit before introducing such appliances. Her caries needed stabilization, and her oral hygiene practices required improvement to ensure she could benefit from interceptive treatment effectively. Furthermore, patients must be reliable and regular dental attenders to monitor the appliances and address any issues promptly (Shabzendedar et al., 2011), which was not the case with MG at that time.

Consequently, our primary focus was on treating her existing caries, reinforcing good oral hygiene habits, and establishing a routine of regular dental visits. Once these goals were achieved, we could reassess her suitability for interceptive treatment, ensuring her long-term oral health. As there was no immediate emergency, we started with the least invasive procedures to build her trust and cooperation before progressing to more complex treatments.

• Preventive Phase:

1/Oral hygiene education.

2/Fluoride application: 4 times per year as MG is a high caries risk child.

3/Diet analysis: A 3-day diary.

4/Fissure sealant: 26,36,46

• Restorative treatment: 16o, 55mo, 54do, 75o possible IPT, 73b, 83b, 85do.

• Orthodontics: Consultation regarding the lingually placed 32.

• First visit:

1/ Diagnosis and Treatment plan

2/ Fissure Sealant: 36 & 46. As MG is a high-caries-risk child and good moisture control was achieved, the resin-based fissure sealant 3M™ Clinpro™ Sealant was selected for its fluoride-releasing, caries-preventive benefits (Simonsen, 2002). 

 26: As the 26 partially erupted, satisfactory moisture control could not be achieved. GIC; GC Fuji TRIAGE® was chosen as it is less sensitive to moisture (Welbury et al., 2004).

3/ Oral hygiene education: Active brushing and flossing were demonstrated using a disclosing agent. MG’s mom was advised to help MG brush and floss because she couldn't do it properly.

4/ Fluoride application: Because of the controlled swallowing reflex at her age, and she could understand the instructions. Acidulated phosphate fluoride gel ([APF]; 1.23% F, 12,300 ppm F) 4 times per year as she is a high-risk child.

Professionally applied topical fluoride treatments are efficacious in reducing the prevalence of dental caries. APF has a low pH, enabling it to deliver fluoride at a faster rate into enamel (AAPD).

5/ Diet analysis: A 3-day diary was given to the parent.

16: Sealant restoration was performed using composite on the distal part and resin-based sealant (Clipro) to seal the occlusal table.

73 & 83: Flowable composite was applied to the labial surfaces. This material was chosen due to ease of handling, MG's cooperation, satisfactory moisture control, and availability.

75o. Topical anaesthesia gel was administered, followed by local anaesthesia with 2% lidocaine containing 1:100,000 epinephrine, using one ampule with the STA system. As the caries was limited to the first third of the dentine (D1), complete removal did not pose a threat of pulp exposure. Complete caries removal was achieved. 3M™ Vitremer Core Buildup was used according to the manufacturer's instructions. The occlusion was checked.

Motivation for using Vitremer:

•Command set(light cured) saves time

•Fluoride release equals that of GIC

•Higher fracture resistance and fracture toughness  than GIC 

•High moisture resistance

•Good handling properties Less technique sensitive than conventional GIC and Dyract.

Another option is Dyract XP, both with similar failure rates (Pummeret, 2019).

• Upon leaving the clinic, MG's lower lip appeared in good condition, although I observed her biting on it. As a precautionary measure, I instructed both MG and her mother to refrain from biting on the lip to avoid any potential damage.

55do, 54mo.

Topical anaesthesia (labial and palatal) was administered, followed by local anaesthesia with 2% lidocaine containing 1:100,000 epinephrine, using a 1/4 ampule infiltration with the STA system to facilitate the matrix band placement. Complete caries removal was achieved as the caries were in the D1 stage in both 55DO and 54MO. Sectional matrix bands were applied first on tooth 55, followed by tooth 54. Both cavities were filled with compomer Dyract XP, chosen due to MG's cooperation and the good isolation achieved. Given that both cavities were in high-stress-bearing areas and MG is a high caries risk child, the fluoride-releasing properties of compomer Dyract XP made it the material of choice. Other options included Vitremer, both with similar failure rates (Pummeret, 2019).

MG experienced slight pain upon the administration of palatal anaesthesia. However, after reassurance, the session proceeded normally.

85od. MG refused to take local anaesthesia this time, probably due to her feeling slight pain in the last appointment.

As the caries were at D2 level and no local anaesthesia was administrated, we decided to selectively remove caries to firm dentine. In this approach, various criteria are used to determine the removal of carious tissue, both at the edges of the cavity and near the pulp. The main objective is to create an environment that is conducive to the best adhesive seal for restoration. To achieve this goal, it is crucial to have intact enamel and hard dentin at the edges of the cavity, which promotes the longevity of the restoration. However, near the pulp, a different criterion is applied, which aims to preserve firm dentin to prevent pulp exposure. This method is recommended for shallow or moderately deep lesions because the depth of the cavity must be sufficient to ensure adequate sound enamel and dentin around the edges, facilitating effective bonding and a complete peripheral seal (Innes et al., 2016), (Schwendicke, 2018a), (Barrett & O'Sullivan, 2021).

Material used: 3M™ Vitremer™ Core Buildup/Restorative B2. (same motivation as above).

Three months follow-up: MG’s oral hygiene has improved since the initial visit, though there is still room for further improvement. Oral hygiene instructions were reinforced. Topical fluoride was applied using 5% sodium fluoride varnish (2.26% fluoride, 22,600 ppm F).

After consulting with the orthodontic department, the plan for managing lower incisor crowding is to use a lower lingual arch. However, as previously mentioned, it is essential to stabilize MG's caries and improve her oral hygiene practices to ensure she can fully benefit from the interceptive treatment.

 Preserving leeway space during the mixed dentition phase is a well-established method for managing space, particularly in the mandibular arch, where it can address minor anterior crowding using a passive lower lingual arch (LLA) as the dentition transitions to permanent teeth (Hudson et al., 2013). Gianelly's study found that 4.5 mm of crowding could be resolved in 77% of cases using this approach (Gianelly, 1994).

However, clinicians must monitor the intermaxillary first molar relationships. Maintaining mandibular arch length can lead to unfavourable molar relationships if the upper molars drift mesially into the leeway space while lower molars are held back. In such cases, distalizing the upper molars with headgear or interarch elastics may be necessary to achieve proper occlusion (Hudson et al., 2013, Ngan et al., 1999). Notably, the upper leeway space is generally larger than the lower space. 

We will continue to monitor MG's oral hygiene every three months; however, according to her current oral hygiene level, she is not a candidate for intermittent appliance; this has been communicated to MG and her parents, and the ball is in their hands, so to speak.