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Aesthetic and functional rehabilitation of child using mock-up combined with

stratified technique

Article in European Archives of Paediatric Dentistry. Official Journal of the European Academy of Paediatric Dentistry · July 2014
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R. Garcia Lopes1, M. Mendes Pinto2,
C. H. L. de Godoy3, L. Jansiski Motta4, C. Carvalho
Bortoletto5, S. Olivan5, S. Kalil Bussadori6
Nove de Julho University, São Paulo, SP, Brazil
1
Master’s student in Biophotonics Applied to Health Sciences
2
Professor of Paediatric Dentistry
3
Doctoral’s student in Rehabilitation Sciences
4
Professor of Master's Program in Management of Health Systems
5
Professor of Pediatric Dentistry
6
Professor of Master’s and Doctoral Programs in Biophotonics
Applied to Health Sciences and Rehabilitation Sciences
e-mail: sandra.skb@gmail.com
Aesthetic and functional
rehabilitation of child
using mock-up
combined with
stratified technique
abstract
Background The loss of the vertical dimension of
occlusion in children with quickly progressing early
childhood caries hinders the aesthetic rehabilitation of
primary incisors. Minimally invasive restorations using
chemical-mechanical caries removal methods preserve
sound dental tissue and maintains the health of the pulp.
This is the treatment of choice for children and allows
crown reconstruction of the primary incisors without
the need for endodontic treatment. The resources
employed in the rehabilitation process range from
biological restorations to direct and indirect crowns
with or without the aid of a celluloid matrix.
Case Report The aim of this study was to describe a
case of maxillary incisor rehabilitation in a female patient
aged two years five months using a mock-up combined
with the stratified technique and Planas’ direct tracks.
After a 26-month follow-up period only a little fracture
of the reconstructed incisor had occurred. Clinical
Implications: In the case described, neuro-occlusal and
functional rehabilitation enabled the establishment of
satisfactory aesthetics in the primary incisors.
Keywords Dental aesthetics; Mouth rehabilitation;
Primary teeth.
234 European Journal of Paediatric Dentistry Clinical Supplement to vol. 15/2-2014
Introduction
The loss of vertical dimension of occlusion in children
with quickly progressing early childhood caries hinders
the aesthetic rehabilitation of primary incisors and can
lead to a reduction in chewing capacity, a change in the
swallowing pattern, speech problems, the development
of bad oral habits and emotional problems stemming
from compromised dental aesthetics [Pupo et al., 2011;
Gujjar & Indushekar, 2010; Oliveira et al., 2010].
The extensive loss of dental tissue normally requires
endodontic treatment to enhance the retention of
the restoration and allow prosthetic rehabilitation for
the preservation of primary teeth until eruption of
the permanent successors. However, as prevention
is currently the main focus of paediatric dentistry
[Oliveira et al., 2010], minimally invasive restoration
using a chemical-mechanical caries removal method
for the maximum preservation of sound dental tissue
and the maintenance of pulp health is the treatment of
choice in children. The use of Papacarie® (Formula &
Ação, São Paulo, Brazil) for chemical-mechanical caries
removal is a painless procedure, that allows the dentist
to forgo anaesthesia, and has proven to be effective at
reducing residual cariogenic bacteria [Anegundi et al.,
2012; El-Tekeya et al., 2012; Kochhar et al., 2011].
The resources employed for crown reconstruction on
primary incisors range from biological restorations to
direct and indirect crowns with or without the aid of
a celluloid matrix. A diagnostic wax-up combined with
a silicone mock-up serves as a guide in this process,
allowing predictability in restorative procedures
regarding shape, speed and contour and facilitating the
application of filling increments [Baratieri et al., 2010].
The presence of malocclusion in approximately 73%
of children in the primary dentition phase hinders the
rehabilitation of a large portion of teeth, rendering
functional and esthetic recovery impossible. However,
early diagnosis and treatment can help avoid alterations
in the bone base [Chibinski et al., 2005].
In the 1960s, Pedro Planas developed a functional
orthopedic therapy based on neuro-occlusal
rehabilitation in patients in the primary dentition phase.
Functional jaw orthopaedics proposes the use of Planas’
direct tracks in primary teeth for the correction of
crossbite and functional rehabilitation [Planas, 1988].
This paper describes a case of neuro-occlusal,
functional and aesthetic rehabilitation of primary
incisors using a minimally invasive restoration technique
with the aid of Planas’ direct tracks. The advantages
and disadvantages of the use of a mock-up and the
stratified restoration technique are also discussed.
Case Report
A female patient aged two years five months

fig. 1 fig. 2
fig. 4 fig. 5
visited the paediatric dental clinic of Nove de Julho
University (Brazil) with complaints of pain during
meals and problems with socialisation at school. The
patient history revealed a cariogenic diet with an
irregular schedule and inadequate oral hygiene. The
clinical exam revealed a considerable loss of vertical
dimension, anterior crossbite, angular cheilitis, carious
lesions on the mandibular molars and maxillary incisors
with extensive crown destruction, but without pulp
involvement (Fig. 1).
The first phase of rehabilitation involved minimally
invasive treatment with the application of Papacarie®
(Formula&Ação, São Paulo, Brazil) for chemical-
mechanical caries removal without anesthesia and Riva
Light Cure glass ionomer cement (SDI Ltda, Australia). In
the second step, casting was performed to obtain the
mock-up, on which Planas’ direct tracks were created
in the primary mandibular right second molar, primary
mandibular right first molar, primary mandibular left
second molar and primary mandibular left first molar
(teeth 74, 75, 84 and 85), which were cemented with
Tetric flow resin (Ivoclar Vivadent, Brazil), and the
wax-up diagnosis on the primary maxillary right and
left incisors and primary maxillary right and left lateral
incisors (teeth 52, 51, 61 and 62) (Fig. 2). For the mock-
up wax casting with added silicone were used. The cast
was cut, maintaining the crowns of the affected teeth,
which were filled with acrylic resin, color Dencor® A1
(Classico, São Paulo, Brazil), and then adapted to the
upper arch until partial polymerization. The procedure
was finalised with adjustments and mild wear on the four
maxillary incisors (Fig. 3). To finalise the rehabilitation,
European Journal of Paediatric Dentistry Clinical Supplement to vol. 15/2-2014
Mock-up in paediatric dentistry
fig. 3
fig. 6
the stratified restoration technique was employed with
resin compound. After 40 days, a silicone guide was
created based on the mock-up installed in the upper
arch. The mock-up was then removed and the affected
teeth were cleaned with pumice stone and a rubber cup,
conditioned with phosphoric acid 37% for 15 seconds,
rinsed and dried gently. The Ambar bonding system
(FGM, Joinville, Brazil) was applied with the aid of a
disposable Cavibrush micro-applicator (FGM, Joinville,
Brazil) in two layers for 10 seconds each. A mild jet of
air was applied for 10 seconds for evaporation of the
solvent. The bonding system was then photoactivated for
10 seconds, following the manufacturer’s instructions.
An extra-thin layer of Opallis® T-neutral resin (FGM,
Joinville, Brazil) was placed on the palatal face of the four
teeth of the guide, which was positioned and adapted
to the upper arch for photoactivation of the resin for 20
seconds. With the palatal enamel reproduced, the teeth
were reconstructed in layers using the Opallis resin kit in
colors DA1, EA1 and A0.5. Polishing and finishing were
performed with the 8 mm Diamond pro sanding kit
(FGM, Joinville, Brazil) and Diamond excel paste with a
Diamond flex disc (FGM, Joinville, Brazil) (Fig. 4, 5, 6, 7).
After 1-year follow-up period no event was detected,
just a piece of the primary right maxillary incisor had
broken after 26 months (Fig. 8).
Discussion
Compromised aesthetics of the smile can have a
direct impact on a child’s self-esteem. Aesthetics
235
 Garcia Lopes R. et al.
fig. 7
fig. 8
can be further compromised by a loss of the vertical
dimension of occlusion and subsequent reduction
in neuro-occlusal function. The recovery of shape,
function and aesthetics of teeth affected by extensive
carious lesions is only possible with the reestablishment
of the vertical dimension through either orthopaedic or
prosthodontic treatment.
In the case described here, the recovery of the vertical
dimension of occlusion was achieved with Planas’ direct
tracks on the primary mandibular molars, after which
the anterior region had free functional space for the
minimally invasive aesthetic rehabilitation of the four
maxillary incisors with no risk of facture to the root or
new crown. However, follow-up is needed to evaluate
the adaptation of the restorations and perform any
necessary functional and/or aesthetic adjustments
[Pupo et al., 2011; Oliveira et al., 2010].
Planas’ neuro-occlusal rehabilitation allowed the
adaptation of the tissue and bone bases during therapy
with direct tracks and the initial installation of the
crown [Planas, 1988].
The use of Papacarie® on extensive, deep carious
lesions helps the atraumatic removal of the carious
tissue without the need for anaesthesia and preserves
the sound dental tissue. In comparison to other
products or techniques, Papacarie® offers greater
efficiency in the treatment of the dental surface prior
to restoration [Arora et al., 2012; Bussadori et al.,
2005; Anegundi et al., 2012; El-Tekeya et al., 2012]. In
the present case, chemical-mechanical caries removal
led to the avoidance of endodontic treatment, which
made the patient more cooperative throughout the
rehabilitation process.
The mock-up technique allows reestablishing the
lingual profile, width and incisal edge in a single step
[Dietschi, 2008; Dietschi et al., 2006]. Upon placement
into the oral cavity with acrylic resin, the mock-up
constructed in the laboratory may require adjustments
236 European Journal of Paediatric Dentistry Clinical Supplement to vol. 15/2-2014
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in terms of occlusion and function. In the present
case, the mock-up remained functioning for 40 days,
allowing the adaptation of the adjacent tissues and
occlusion. The stratified restoration technique with the
application of layers of resin is currently widely employed
on permanent teeth, but it requires patient cooperation
as well as a professional experience and knowledge
regarding different products and their characteristics of
opalescence and fluorescence for the reestablishment
of the natural colour and translucence of the tooth. The
silicone key serves as reference for the new contour
during the three-dimensional incremental buildup of
dentin and enamel [Dietschi, 2001; Dietschi et al., 2006].
In the case reported herein, the patient’s cooperation
allowed the use of the stratified technique for the
establishment of the natural structural characteristics
of the teeth, and the loss of space was recovered and
the crossbite was corrected using Planas’ direct tracks
and the mock-up helped in repositioning the tongue,
improved phonation and dental esthetics. However, the
final phase requires considerable cooperation on the
part of the patient as well as dexterity on the part of
the dentist.
In conclusion, the successful aesthetic restoration of
primary maxillary incisors is directly related to neuro-
occlusal and functional rehabilitation. Moreover, a
well-performed mock-up phase is sufficient to meet
the aesthetic, functional and psychosocial needs of the
child.
References
› Anegundi, R.T. et al., 2012. A comparative microbiological study to assess caries
excavation by conventional rotary method and a chemo-mechanical method.
Contemp Clin Dent, 3(4), pp.388–392.
› Arora, R. et al., 2012. Comparative evaluation of effects of chemo-mechanical
and conventional caries removal on dentinal morphology and its bonding
characteristics - an SEM study. European archives of paediatric dentistry : official
journal of the European Academy of Paediatric Dentistry, 13(4), pp.179–84.
› Baratieri, L. et al., 2010. Odontologia Restauradora: Fundamentos & Técnicas 1a
ed., São Paulo: Santos.
› Bussadori, S., LC, C. & Galvão, A., 2005. Papain gel: a new chemo-mechanical
caries removal agent. J Clin Pediatr Dent, 30(2), pp.115–9.
› Chibinski, A.C.R., Czlusniak, G.D. & Melo, M.D., 2005. Pistas diretas Planas :
terapia ortopédica para correção de mordida cruzada funcional. R Clin Ortodon
Dental Press, 4(3), pp.64–72.
› Dietschi, D., 2001. Layering concepts in anterior composite restorations. J Adhes
Dent, 3(1), pp.71–80.
› Dietschi, D., 2008. Optimising aesthetics and facilitating clinical application
of free-hand bonding using the “natural layering concept”. Br Dent J, 204(4),
pp.181–5.
› Dietschi, D., Ardu, S. & Krejci, I., 2006. A new shading concept based on natural
tooth color applied to direct composite restorations. Quintessence Int, 37(2),
pp.91–102.
› El-Tekeya, M. et al., 2012. Effectiveness of 2 chemomechanical caries removal
methods on residual bacteria in dentin of primary teeth. Pediatr Dent, 34(4),
pp.325–30.
› Gujjar, K.R. & Indushekar, K.R., 2010. Comparison of the Retentive Strength of 3
Different Posts in Restoring Badly Broken Primary Maxillary Incisors. J Dent Child
(Chic), 77(1), pp.17–24.
› Kochhar, G. et al., 2011. An evaluation of different caries removal techniques in
primary teeth: a comparitive clinical study. J Clin Pediatr Dent, 36(1), pp.5–9.
› Oliveira, L.B. et al., 2010. Reabilitação de dentes decíduos anteriores com o uso de
pinos de fibra de vidro. J Health Sci Inst, 28(1), pp.89–93.
› Planas, P., 1988. Importancia del diagnostico, tratamiento precoz en ortodoncia y
equilibrio oclusal. Rev Esp Estomatol, 6(6), pp.477–82.
› Pupo, Y.M. et al., 2011. Reabilitação funcional e estética de dentes decíduos
acometidos por cárie de início precoce. Rev Assoc Paul Cir Dent, 65(2), pp.130–4.