Case Report

Rehabilitation of severely mutilated teeth

under general anesthesia in an emotionally
immature child
Navit S, Katiyar A, Samadi F, Jaiswal JN

Abstract
Dental caries is the single most common chronic childhood
disease. In rampant caries, there is early pulp involvement
and gross destruction of the maxillary anterior teeth as well as
posterior teeth. This leads to decreased masticatory efficiency,
difficulty in speech, compromised esthetics, development of
abnormal tongue habits and subsequent malocclusion and
psychological problems. The restoration of severely decayed
primary incisors is often a procedure that presents a special
challenge to dentists, particularly in an uncooperative child.
This case report documents the restoration of severely
mutilated deciduous teeth in an emotionally immature patient
under general anesthesia.

Key words
Composite resin, rampant caries, post, primary anterior teeth
DOI: 10.4103/0970-4388.60476

Department of Pedodontics and Preventive Dentistry, Sardar

Patel Postgraduate Institute of Dental and Medical Sciences,
Lucknow, India
Correspondence:
Dr. Ashish Katiyar, Department of Pedodontics and Preventive
Dentistry, Sardar Patel Postgraduate Institute of Dental and
Medical Sciences, Utrathia, Rai Barelli Road, Lucknow, India.
E-mail: ashkar1981@gmail.com

This case report describes the challenging task of treating

a 3-year-old rampant caries patient with mutilated
maxillary incisors with composite resin using a custommade post made with 0.7-mm wire to increase the potential
surface area for attachment of the restorative material
and consequently increase the long-term stability of an
esthetic restoration, as well as pulpotomy, pulpectomy and
other restorative procedures in the needful teeth.

PMID: ***

Case Report
Introduction
Nonpharmacologic behavior-management techniques
are primary techniques for treating children in the
dental chair. Alternative methods such as conscious
sedation and other forms of sedation are also widely
used. [1] However, in some circumstances these
techniques may fail and the use of general anesthesia
(GA) becomes the only resource to provide dental
treatment for children in a safe and effective way.

A 3-year-old female patient reported with a complaint

of severely decayed teeth. The child was emotionally
immature and highly uncooperative. Intraoral examination
revealed multiple carious lesions, and 52, 61, 62, 64, 74, 84,
showed pulp involvement. Crown portions of maxillary
incisors were grossly destructed [Figures 1 and 2]. It was
decided to do pulpectomy in relation to 52, 61, 62, 84, Post
and core in 52, 61, 62 followed by strip crown in 51, 52, 61
and 62, pulpotomy in relation to 74, glass ionomer cement
(GIC) restoration in relation to 54, 64, 65, 83, light cure
composite restoration in relation to 71, 81.

The esthetic restoration of severely mutilated primary

anterior teeth had been a challenge for the dentist
for a long time, not only because of the available
materials and techniques but also because the children
who require such restorations are usually among the
youngest and least manageable group of patients.[2]

Consent was taken from the parents. After due

appointment, the patient was admitted to SPPGIDMS,
Lucknow, and was given general anesthesia. Under
GA, pulpectomy followed by composite restoration
(strip crown) using custom-made posts, pulpotomy and
restoration were performed; all procedures were carried

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Navit, et al.: Rehabilitation under general anesthesia

out along with the other required treatments. For

building core in deciduous anterior teeth, about 4mm
of cement was removed from the coronal end of the
root canal, and 1mm of zinc polycarboxylate cement
was placed. A 0.7-mm stainless steel orthodontic wire

Figure 1: Intraoral view of the patient

was bent using no. 130 orthodontic pliers into a loop

in such a way as to allow the ends to be hooked in the
entrance of the root canal. The incisal end of the loop
of the wire projected 2-3mm above the remaining
structure [Figure 3]. The loop was inserted into the
canal with composite. The composite was light cured
for 40 seconds. A strip crown was used and the crown
was reconstructed [Figure 4].
This provided better mechanical retention and
support for the restorative material. The occlusion
was checked; and after the removal of any interference,
final finishing and polishing of the restoration was
performed using soflex tips. After completion of the
procedure, a post operative photograph [Figure 5] and
Orthopantomogram [Figure 6] was made. Home care
instructions, including oral hygiene measures and diet
counseling, were given to the parents. Recall checkup
was scheduled after a period of 1 week, followed by
recall checkup after every 6 months to assess the
maintenance status of oral hygiene and for performing
checkup procedures in the childs mouth.

Figure 2: Preoperative Orthopantomogram of the patient

Figure 3: Post inserted in teeth

Figure 4: Reconstructed crown

Figure 5: Postoperative photograph of the patient

J INDIAN SOC PEDOD PREVENT DENT | Jan - Mar 2010 | Issue 1 | Vol 28 |

43

Navit, et al.: Rehabilitation under general anesthesia

the patient. However, it was technique sensitive and

required parents cooperation. Also there was a chance
of loss of restoration due to trauma or biting on hard
foods, so the parents were advised that the child should
avoid hard food. The child was very happy and satisfied
regarding all functions of teeth, viz., mastication,
speech, cosmetic function, etc. Restoration was found
to be serving well at the 3-month recall.
In this study, authors take the view that full-mouth
rehabilitation under GA can enable children to cope
with future dental care and leave them in a position
where they may be more amenable to dental care.
Figure 6: Postoperative OPG of the patient

Conclusion

Discussion

This approach offers the advantage of providing

extensive complete oral rehabilitation in a short period
of time and in a single visit, allowing immediate relief
of pain, even with little or no cooperation from the
child. However, it has little effect in promoting oral
health and acceptance of routine dental care.

Dental treatment under GA is an expensive alternative

but on certain occasions the method of choice for treating
unmanageable children. It is indicated for very young
children who require extensive conservative dentistry
and are unable to accept treatment in the dental chair,
for children who are medically compromised, or for
children who require oral surgical procedures.[3] An
important consideration for children who are unable
to cooperate due to fear, anxiety or young age is their
subsequent acceptance of care using other methods
with low risk and low impact.[4] The aim of GA is to
restore the childs oral health in a single visit, allowing
behavior-modification methods to be introduced more
readily afterwards.[5] In this case, custom-made post was
used in anterior teeth; other available options such as
threaded posts, nickel-chromium cast posts, preformed
and cast metal posts have been utilized;[6] however, they
are expensive and require an additional lab stage. The
use of metal posts needs the use of an opaque resin to
mask the post and could pose additional problems during
the course of natural exfoliation.
More esthetic option may be the use of a biologic post.
The disadvantage of this technique is acceptance and
stringent cross-control infection policies.
Studies have shown that intra-canal retention in
primary teeth can be obtained by directly building
resin composite posts or preparing an inverted
mushroomshaped undercut in the root canal prior to
the buildup of the resin.[7] However, resin composite
posts have low strength of loading. Ushamohan Das
etal. also used a custom-made post using an orthodontic
wire followed by strip crowns and achieved excellent
cosmetic results in a child patient.[8] This led us to use
the technique to do the complete oral rehabilitation of
44

Acknowledgment
We would like to thank the entire teaching and nonteaching staff
of the Department of Pedodontics and Preventive Dentistry,
Sardar Patel Postgraduate Institute of Dental and Medical
Sciences, Lucknow, and also the patient and her guardian for
their continued support during the course of the case.

References
1. Enger DJ, Mourino AP. A survey of 200 paediatric dental general
anesthesia cases. J Dent Child 1985;52:36-41.
2. Johnsen DC. Characteristics and background of children with
nursing caries. Pediatr Dent 1982;4:218-24
3. Harrison MG, Roberts GJ. Comprehensive dental treatment of
healthy and chronically sick children under intubation general
anaesthesia during a 5-year period. Br Dent J 1998;184:503-6.
4. El-Bialy WB, Al-Rashid BA, El-Tanani H. Extraction of teeth
under general anaesthesia for outpatient children and mentally
retarded patients in Kuwait. Egyp Dent J 1992;4:257-62.
5. Ripa LW. Nursing Caries: A comprehensive review. Pediatr
Dent 1988;10:268-82.
6. Mortada A, King NM. A simplified technique for the restoration
of severely mutilated primary anterior teeth. J Clin Pediatr Dent
2004;28:187-92.
7. Rifkin A. Composite post crowns in anterior teeth. J Dent Assoc
S Afr 1983;38:225-7.
8. Usha M, Deepak V, Venkat S, Gargi M. Treatment of severely
mutilated incisors: Challenge to the pedodontist. J Indian Soc
Pedod Prevent Dent 2007;25: S34-6.
Source of Support: Nil, Conflict of Interest: Nil

J INDIAN SOC PEDOD PREVENT DENT | Jan - Mar 2010 | Issue 1 | Vol 28 |

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