History of the main complaint

At around one year old, AJ tripped while running at home and hit his mouth on the floor, causing minor bleeding from the inside of his upper lip. His mother took him to a dentist, who sutured the lip and reassured them that there was no cause for concern. Currently, AJ’s upper front tooth appears to be growing abnormally, positioned just below his nose, although he is not experiencing any pain. 

Prenatal History:

AJ's mother maintained good health during pregnancy, taking only standard prenatal supplements. Her diet was generally balanced, with no dietary restrictions.

Natal History:

AJ was born prematurely at 37 weeks, with doctors noting that he had stopped growing around 34 weeks. There were no birth injuries, but he was born with a missing thumb on his right hand and an undescended testicle.

Postnatal History:

AJ was unable to breastfeed due to a small mouth, so his mother expressed breast milk and fed him via bottle for the first three months. After that, he transitioned to formula until he was 2 years old. He began eating solid foods at 9 months.

Medical History:
AJ has been diagnosed with ADHD and is currently taking Methylphenidate Hydrochloride 36 mg tablets for management. At 18 months, he underwent a Pollicization surgery, which involved transferring his index finger to the thumb position. Additionally, he has a history of a fractured collarbone and was born with an undescended testicle. There are no known allergies.

Dental History and Oral Hygiene Practices:

AJ’s first dental visit occurred after sustaining blunt force trauma at 1 year old, during which his upper lip was sutured. He was uncooperative during the visit; the second visit was when he was 7 years old. He had a filling on the 85, and he was cooperative.

Since age 5, AJ has been brushing his teeth once daily in the morning, unsupervised, using adult toothpaste. Prior to this, his mother was responsible for brushing his teeth.

AJ is a bright, sociable boy who makes friends easily and shows no signs of anxiety or nervousness. He excels academically and enjoys playing rugby. However, he tends to hide his right arm, where he is missing a finger, due to past experiences of being bullied, which makes him self-conscious. On the dental chair, AJ often places his right arm under his body, likely as a means of hiding it from view.

AJ presents with a symmetrical face and large, prominent ears exhibiting characteristic protrusion. There are no palpable lymph nodes. The temporomandibular joint is functioning normally, and the facial muscles are relaxed with no detectable abnormalities.

Occlusal analysis:

Molar classification: Class I on both sides

The maxillary midline: missing 11however, the mesial surface of the 21 is sifting 2mm to the right

The mandibular midline: coincides with the midsagittal plane.

Overjet: 21: 3mm

Overbite: 21: 4mm

No Crossbite

No open bite

Buccal canine bulges: palpable

No habit.

No abnormalities were found in the tongue, frenum, or mucosa. However, there is visible plaque.

16, 15, 14 sound. 55 RR. 53 exfoliated. 12 sound. 11 impacted, can be palpated in the labial vestibule. 21, 22 sound. 63 incisor attrition.

24 sound. 25 partially erupted. 26, 36 sound. 75mo mobility grad 1. 34 sound. 73 incisor attrition. 32, 31, 41, 42 Sound. 43 partially erupted.

44 Sound. 85md filling, secondary caries, mobility G1, no history of pain, more than half of the root is resorbed; Caries control. 46 Sound

The bone and soft tissue anatomy appear normal, and all permanent teeth are accounted for, except for the wisdom teeth. Notably, there is taurodontism affecting teeth 16 and 26, and tooth 11 is horizontally impacted. The eruption sequence in the third and fourth quadrants is unfavourable, with teeth 34 and 44 erupting ahead of teeth 33 and 43. The leeway space in these quadrants is compromised due to interproximal caries in teeth 75 and 85. The estimated dental age is ten years, corresponding to the inter-transitional stage.

The upper occlusal view does not display the entire root of tooth 11.

Maxilla/Mandible

Maxillary midline shift

Molar classification:

•  Right : Class II

•  Left: Class II

According to Frankl's behaviour rating scale, SJ's attitude was positive (Shao et al., 2016). However, he moves a lot, and he gets easily distracted. His mother indicated that he is usually hyperactive in the afternoon.

In children with ADHD, there is a higher chance of increased anxiety levels in both the children and their parents when visiting the dental clinic. This anxiety may lead to overexcited behaviour (Sinha et al., 2018). To effectively manage this situation:

Schedule Morning Appointment: Early morning is ideal when the medication is at its peak.

Multiple Short Visits: Short, frequent visits are more effective than fewer, longer visits, allowing the child to remain focused and cooperative.

Frequent Breaks: Allowing the child to take breaks and engage in a favourite activity during the visit can help maintain focus and reduce anxiety.

Clear and Repeated Instructions: Provide simple, clear instructions repeatedly. Repetition helps build the child's self-confidence.

Tell-Show-Do Method: This behaviour management technique has proven valuable in managing children with ADHD.

Positive reinforcement: Praising and encouraging the child plays a key role and positive behaviour should be reinforced and rewarded (Sinha et al., 2018).

Even though AJ's primary concern was the unerupted 11, given his high caries risk and irregular dental visits, it was essential to address his immediate oral health needs before considering interceptive appliances. The literature emphasized that interceptive appliances can accumulate plaque, exacerbating caries risk if not managed properly (Shabzendedar et al., 2011). Therefore, AJ needed to maintain good oral hygiene and be dentally fit before introducing such appliances. His oral hygiene practices had to be improved to ensure he could benefit from effective interceptive treatment. Additionally, patients needed to be reliable and regular dental attenders to monitor the appliances and address any issues promptly (Shabzendedar et al., 2011), which was not currently the case with AJ. Therefore, our primary focus was on reinforcing good oral hygiene habits and establishing a routine of regular dental visits. Once these goals were achieved, we could reassess his suitability for interceptive treatment, ensuring his long-term oral health. 

Phase 1: Even though AJ's primary concern is the unerupted 11, given AJ's current high caries risk and irregular dental visits, it is essential to address his immediate oral health needs before considering interceptive appliances. Interceptive appliances can accumulate plaque, exacerbating caries risk if not managed properly (Shabzendedar et al., 2011). Therefore, AJ must maintain good oral hygiene and be dentally fit before introducing such appliances. AJ's caries need to be stabilized, and his oral hygiene practices improved to ensure he can benefit from interceptive treatment effectively. Additionally, patients must be reliable and regular dental attenders to monitor the appliances and address any issues promptly (Shabzendedar et al., 2011). Therefore, our primary focus will be on reinforcing good oral hygiene habits and establishing a routine of regular dental visits. 

Phase 2 interceptive orthodontic.

Phase 1:

Preventive Phase:

1/ Oral hygiene education.

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

3/ Diet analysis: A 3-day diary.

4/ Fissure sealant: 16, 26, 36& 46

5/ Caries control: 75&85 They are about to exfoliate.

 Orthodontics: Consultation regarding the impacted 11.

First Visit:

The appointment was scheduled for early morning, as this is when AJ is most likely to remain seated, benefiting from the peak effect of the medication.

1/ Diagnosis and treatment plan.

2/ Oral Hygiene Instruction and Demonstration:

Active brushing and flossing using a disclosing agent. The missing finger on AJ's right arm does not affect his ability to brush effectively; however, his mother noted that he tends to brush quickly, often in less than a minute. I advised AJ to play his favourite song and brush for the entire duration of the song. I also recommended that his mother supervise his brushing routine and remind him to brush twice a day and floss regularly, as individuals with ADHD are prone to forgetfulness.

3/ Fissure sealant: 16, 26, 36& 46. As AJ 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).

4/ Diet analysis: 3 days diary

5/ Fluoride application

Because of the controlled swallowing reflex at his age, and he could understand the instructions. Acidulated phosphate fluoride gel ([APF]; 1.23% F, 12,300 ppm F) 4 times per year as he 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 faster into enamel (AAPD).

6/ Impression for the orthodontic study model.

7/ Positive reinforcement: AJ was rewarded with a balloon.

AJ and his mother were informed that the first phase of the treatment was complete. At the next appointment, scheduled for three months from now, we will reassess his compliance with oral hygiene practices and determine the next phase of the treatment. 

Three months later, AJ’s oral hygiene has significantly improved since the initial visit. His mother reported that he has been following the instructions diligently and is very excited to begin the second phase. 

•Impression for the orthodontic study model

•Fluoride application

•Reinforcement of OHI

• Three months later, AJ maintained good oral hygiene. 

• Reinforcement of oral hygiene instruction

• Fluoride gel application

• CBCT

Treatment Options for the impacted 11:

1/ Surgical exposure, orthodontic space opening, and traction of the impacted central incisor into its proper position.

2/ Extraction of the impacted central incisor, orthodontic space opening, and future restoration with a bridge or an implant when growth had ceased.

3/Extraction and closure of the space by substituting the lateral incisor for the central incisor with subsequent prosthetic restoration.

Summary of the CBCT Report:

• Paranasal Sinuses:

      Aplastic frontal sinus.

      Bilateral maxillary sinus thickening. Ddx: mucositis.

• Nasal Cavities:

      Mild deviated septum to the left.

• Airway:

      NAD.

• Temporomandibular Joints:

      NAD.

• Osseous Structures:

      NAD.

• Dental findings:

      36/35 interradicular area: cone-shaped tooth-like high density with a low-density halo. Ddx: root rest.

      Developing 18, 28, 48, and 38 follicles were not detectable at the time of the acquisition.

      Bifurcation of the 32 pulp canal.

      Hypo taurodontism 16 and 26.

      Mesial tilting of the 12, 13.

• Tooth 11: 

      Horizontal impaction.

      Mild apical third root curvature superiorly; no effect on surrounding structures.

      The crown and root appear intact, with no signs of resorption or demineralization. 

• Proposed treatment by the orthodontic department:

     Regain the space (2x4) appliance.

     Surgical exposure of the 11.

     Orthodontic traction via gold chain.

• The treatment options will be discussed with AJ and his mother in his next follow-up appointment.