Management of compromised first permanent molars Flashcards
Name one of the teeth most prone to caries?
First permanent molars (6’s)
Whats the problem of caries in the first permanent molars?
Getting food trapped and pain
What are the treatment options?
Extraction, maintain until ideal time for removal or retain
What 4 factors can extraction depend on?
- Extent of crowding
- Presenting malocclusion
- Stage of dental development
- if maxillary or mandibular
When is the ideal time for extraction of the 6’s?
When the root bifurcation of the 7’s is forming (8-10 years)
What is the goal for extraction?
Mesial migration of the 7’s to replace the 6’s
What are the advantages of extraction (3)?
- Immediate resolution of symptoms or infection
- One off procedure with favourable cost:benefit if timed well
- Space created may be used to alleviate posterior crowding, reduce overjet and create space for eruption of the 8’s
What are the disadvantages of extraction (4)?
- loss of permanent tooth (esp. if no 8’s)
- may need sedation/GA
- consequence of early/late extraction
- may increase ortho treatment time and complexity
What happens if the 6 is extracted too early?
Distal tipping of the 5 (less engaged by primary teeth roots)
What happens if the 6 is extracted too late?
Mesial tipping of the 7 (can be more problematic)
What is balancing extraction?
Extraction on opposite side of arch to prevent unwanted tooth movements (i.e. movement of midline)
What is compensation extraction?
Extraction of tooth on opposing arch to prevent occlusal problems (overeruption) - especially of upper 6’s
n.b.
We rarely balance 6’s but sometimes compensate them especially if its the lower 6’s that have over-erupted
What are the different methods of maintaining a carious tooth?
- RCT
- Indirect pulp capping
- Direct pulp capping
- Partial pulpotomy
What are the issues with RCT treatment?
- open apices
- poor prognosis (36% success)
- needs lifetime management of the tooth
What is the preferred treatment for a compromised first permanent molar?
Indirect pulp capping
What is indirect pulp capping?
Incomplete caries removal (leave in the deepest part), place CaOH then restoration = stimulates production of tertiary dentine
What is direct pulp capping?
CaOH is place directly not exposed pulp after caries removal
What is a partial pulpotomy?
Removal of part of the pulp (just a couple of mm until healthy pulp is reached (usually for larger exposure)
What treatments do we use to maintain a tooth for extraction?
Stainless steel crowns, conventional or resin modified GIC
What different restorative materials can we use on compromised first permanent molars?
- Composite
- Compomer
- Cast onlay
- Amalgam
When are cast onlays especially useful?
Esp. with hypo mineralised teeth affecting the marginal ridge in patches (full cusp coverage helps to protect)
What different things should be taken into consideration when managing compromised first permanent molars?
- Extent of lesion or defect
- Quality of enamel
- Moisture control
- Pt. co-operation
- Dentist choice/experience
- Symptoms/hypersensitivity (needs more than just intracoronal)
- Caries risk
What different patient factors are there?
- Motivation and dental awareness
- Oral hygiene
- Cost
- Pt. preference
- Behavioural/co-operation
- Symptomatic (i.e. pain, sensitivity and pulpal symptoms)
- Medical factors (cardiac problems, immunocompromised, any medical issue that means cannot extract under GA)
What different dental factors are there?
- Extent of lesion and restorability
- Presence and condition of remaining dentition (DPT)
- Enamel defects (prone to further breakdown, extension, colour and position to predict the future)
- Vitality
- Stage of dental development/dental age
What different orthodontic factors are there?
- Need for ortho input (timing to future ortho e.g. elective xla of other 6’s)
- Malocclusion (influences timing of removal)
- Hypodontia
What are the benefits of temporising with GIC?
- Tolerant of moisture contamination
- Fluoride release
- Easy to place
What are the problems with temporising with GIC?
- Poor physical properties
- No full coverage and doesn’t help with sensitivity
What are the benefits of temporising with a stainless steel crown?
- Prevents further breakdown
- Relieves sensitvity
- longevity
- relatively quick and inexpensive
- single visit
What are the problems with temporising with a stainless steel crown?
- Technically more challenging
- LA often required
- Monitor eruption of 7’s (potential impaction risk)
- Occlusion
What is the technique of placing a stainless steel crown?
+/- LA, can place separators (extra appt. but easier), may need some prep (round over line angles and proximal slice), select crown size (n.b. standard size is v. tall, we only want 1 mm subgingivally), trim and crimp gingival part of crown, smooth roughened surface with green stone, isolate and cement with GIC
