Esthetic Preformed Crowns in Pediatric Dentistry

Esthetic preformed crowns are an important option in pediatric dentistry, providing a functional and aesthetic solution for restoring primary teeth. Here’s a detailed overview of various types of esthetic crowns used in children:

i) Polycarbonate Crowns

• Advantages:
  • Save time during the procedure.
  • Easy to trim and adjust with pliers.
• Usage: Often used for anterior teeth due to their aesthetic appearance.

ii) Strip Crowns

• Description: These are crown forms that are filled with composite material and bonded to the tooth. After polymerization, the crown form is removed.
• Advantages:
  • Most commonly used crowns in pediatric dental practice.
  • Easy to repair if damaged.
• Usage: Ideal for anterior teeth restoration.

iii) Pedo Jacket Crowns

• Material: Made of tooth-colored copolyester material filled with resin.
• Characteristics:
  • Left on the tooth after polymerization instead of being removed.
  • Available in only one shade.
  • Cannot be trimmed easily.
• Usage: Suitable for anterior teeth where aesthetics are a priority.

iv) Fuks Crowns

• Description: These crowns consist of a stainless steel shell sized to cover a portion of the tooth, with a polymeric coating made from a polyester/epoxy hybrid composition.
• Advantages: Provide a durable and aesthetic option for restoration.

v) New Millennium Crowns

• Material: Made from laboratory-enhanced composite resin material.
• Characteristics:
  • Bonded to the tooth and can be trimmed easily.
  • Very brittle and more expensive compared to other options.
• Usage: Suitable for anterior teeth requiring esthetic restoration.

vi) Nusmile Crowns

• Indication: Indicated when full coverage restoration is needed.
• Characteristics: Provide a durable and aesthetic solution for primary teeth.

vii) Cheng Crowns

• Description: Crowns with a pure resin facing that makes them stain-resistant.
• Advantages:
  • Less time-consuming and typically requires a single patient visit.
• Usage: Suitable for anterior teeth restoration.

viii) Dura Crowns

• Description: Pre-veneered crowns that can be placed even with poor moisture or hemorrhage control.
• Challenges: Not easy to fit and require a longer learning curve for proper placement.

ix) Pedo Pearls

• Material: Aluminum crown forms coated with a tooth-colored epoxy paint.
• Characteristics:
  • Relatively soft, which may affect long-term durability.
• Usage: Used for primary teeth restoration where aesthetics are important.

Maternal Attitudes and Corresponding Child Behaviors

1. Overprotective:

   • Mother's Behavior: A mother who is overly protective tends to shield her child from potential harm or discomfort, often to the point of being controlling.
   • Child's Behavior: Children raised in an overprotective environment may become shy, submissive, and anxious. They may struggle with independence and exhibit fearfulness in new situations due to a lack of opportunities to explore and take risks.

2. Overindulgent:

   • Mother's Behavior: An overindulgent mother tends to give in to the child's demands and desires, often providing excessive affection and material rewards.
   • Child's Behavior: This can lead to children who are aggressive, demanding, and prone to temper tantrums. They may struggle with boundaries and have difficulty managing frustration when they do not get their way.

3. Under-affectionate:

   • Mother's Behavior: A mother who is under-affectionate may be emotionally distant or neglectful, providing little warmth or support.
   • Child's Behavior: Children in this environment may be generally well-behaved but can struggle with cooperation. They may be shy and cry easily, reflecting their emotional needs that are not being met.

4. Rejecting:

   • Mother's Behavior: A rejecting mother may be dismissive or critical of her child, failing to provide the emotional support and validation that children need.
   • Child's Behavior: This can result in children who are aggressive, overactive, and disobedient. They may act out as a way to seek attention or express their frustration with the lack of nurturing.

5. Authoritarian:

   • Mother's Behavior: An authoritarian mother enforces strict rules and expectations, often without providing warmth or emotional support. Discipline is typically harsh and non-negotiable.
   • Child's Behavior: Children raised in authoritarian environments may become evasive and dawdling, as they may fear making mistakes or facing punishment. They may also struggle with self-esteem and assertiveness.

Eruption Gingivitis

• Eruption gingivitis is a transitory form of gingivitis observed in young children during the eruption of primary teeth. It is characterized by localized inflammation of the gingiva that typically subsides once the teeth have fully emerged into the oral cavity.

Characteristics

• Age Group:

  • Eruption gingivitis is most commonly seen in young children, particularly during the eruption of primary teeth. However, a significant increase in the incidence of gingivitis is often noted in the 6-7 year age group when permanent teeth begin to erupt.

• Mechanism:

  • The increase in gingivitis during this period is attributed to several factors:
    • Lack of Protection: During the early stages of active eruption, the gingival margin does not receive protection from the coronal contour of the tooth, making it more susceptible to irritation and inflammation.
    • Food Impingement: The continual impingement of food on the gingiva can exacerbate the inflammatory process, leading to gingival irritation.

Contributing Factors

• Accumulation of Debris:
  • Food debris, material alba, and bacterial plaque often accumulate around and beneath the free gingival tissue. This accumulation can partially cover the crown of the erupting tooth, contributing to inflammation.
• Common Associations:
  • Eruption gingivitis is most frequently associated with the eruption of the first and second permanent molars. The inflammation can be painful and may lead to complications such as:
    • Pericoronitis: Inflammation of the soft tissue surrounding the crown of a partially erupted tooth.
    • Pericoronal Abscess: A localized collection of pus in the pericoronal area, which can result from the inflammatory process.

Clinical Management

• Oral Hygiene:

  • Emphasizing the importance of good oral hygiene practices is crucial during this period. Parents should be encouraged to assist their children in maintaining proper brushing and flossing techniques to minimize plaque accumulation.

• Professional Care:

  • Regular dental check-ups are important to monitor the eruption process and manage any signs of gingivitis or associated complications. Professional cleanings may be necessary to remove plaque and debris.

• Symptomatic Relief:

  • If the child experiences pain or discomfort, topical analgesics or anti-inflammatory medications may be recommended to alleviate symptoms.

Wright's Classification of Child Behavior

1. Hysterical/Uncontrolled

   • Description: This behavior is often seen in preschool children during their first dental visit. These children may exhibit temper tantrums, crying, and an inability to control their emotions. Their reactions can be intense and overwhelming, making it challenging for dental professionals to proceed with treatment.

2. Defiant/Obstinate

   • Description: Children displaying defiant behavior may refuse to cooperate or follow instructions. They may argue or resist the dental team's efforts, making it difficult to conduct examinations or procedures.

3. Timid/Shy

   • Description: Timid or shy children may be hesitant to engage with the dental team. They might avoid eye contact, speak softly, or cling to their parents. This behavior can stem from anxiety or fear of the unfamiliar dental environment.

4. Stoic

   • Description: Stoic children may not outwardly express their feelings, even in uncomfortable situations. This behavior can be seen in spoiled or stubborn children, where their crying may be characterized by a "siren-like" quality. They may appear calm but are internally distressed.

5. Overprotective Child

   • Description: These children may exhibit clinginess or anxiety, often due to overprotective parenting. They may be overly reliant on their parents for comfort and reassurance, which can complicate the dental visit.

6. Physically Abused Child

   • Description: Children who have experienced physical abuse may display heightened anxiety, fear, or aggression in the dental setting. Their behavior may be unpredictable, and they may react strongly to perceived threats.

7. Whining Type

   • Description: Whining children may express discomfort or displeasure through persistent complaints or whining. This behavior can be a way to seek attention or express anxiety about the dental visit.

8. Complaining Type

   • Description: Similar to whining, complaining children vocalize their discomfort or dissatisfaction. They may frequently express concerns about the procedure or the dental environment.

9. Tense Cooperative

   • Description: These children are on the borderline between positive and negative behavior. They may show some willingness to cooperate but are visibly tense or anxious. Their cooperation may be conditional, and they may require additional reassurance and support.

Causes:
The primary cause of CP is any factor that leads to decreased oxygen supply (hypoxia) to the developing brain. This can occur due to various reasons, including complications during pregnancy, childbirth, or immediately after birth.

Classification of Cerebral Palsy:

1. Based on Anatomical Involvement:

   • Monoplegia: One limb is affected.
   • Hemiplegia: One side of the body is affected.
   • Paraplegia: Both legs are affected.
   • Quadriplegia: All four limbs are affected.

2. Based on Neuromuscular Involvement:

   • Spasticity: Characterized by stiff and tight muscles; this is the most common type, seen in 70% of cases. Affected individuals may have limited head movement and a limp gait.
   • Athetosis: Involves involuntary, writhing movements, seen in 15% of cases. Symptoms include excessive head movement and drooling.
   • Ataxia: Affects balance and coordination, seen in 5% of cases. Individuals may exhibit a staggering gait and slow tremor-like movements.
   • Mixed: A combination of more than one type of cerebral palsy, seen in about 10% of cases.

1. Spastic Cerebral Palsy (70% of cases)

Characteristics:

• Limited Head Movement: Individuals have restrictions in moving their head due to increased muscle tone.
• Involvement of Cerebral Cortex: Indicates that the motor control areas of the brain (especially those concerning voluntary movement) are affected.
• Limping Gait with Circumduction of the Affected Leg: When walking, the patient often swings the affected leg around instead of lifting it normally, due to spasticity.
• Hypertonicity of Facial Muscles: Increased muscle tension in the facial region, contributing to a fixed or tense facial expression.
• Unilateral or Bilateral Manifestations: Symptoms can occur on one side of the body (hemiplegia) or affect both sides (diplegia or quadriplegia).
• Slow Jaw Movement: Reduced speed in moving the jaw, potentially leading to functional difficulties.
• Hypertonic Orbicularis Oris Muscles: Increased muscle tone around the mouth, affecting lip closure and movement.
• Mouth Breathing (75%): The individual may breathe through their mouth due to poor control of oral musculature.
• Spastic Tongue Thrust: The tongue pushes forward excessively, which can disrupt swallowing and speech.
• Class II Division II Malocclusion (75%): Dental alignment issue often characterized by a deep overbite and anterior teeth that are retroclined, sometimes accompanied by a unilateral crossbite.
• Speech Involvement: Difficulties with speech articulation due to muscle coordination problems.
• Constricted Mandibular Arch: The lower jaw may have a narrower configuration, complicating dental alignment and oral function.

2. Athetoid Cerebral Palsy (15% of cases)

Characteristics:

• Excessive Head Movement: Involuntary, uncontrolled movements lead to difficulties maintaining a stable head position.
• Involvement of Basal Ganglia: Damage to this area affects muscle tone and coordination, leading to issues like chorea (involuntary movements).
• Bull Neck Appearance: The neck may appear thicker and less defined, owing to abnormal muscle development or tone.
• Lack of Head Balance, Drawn Back: The head may be held in a retracted position, affecting posture and balance.
• Quick Jaw Movement: Involuntary rapid movements can lead to difficulty with oral control.
• Hypotonic Orbicularis Oris Muscles: Reduced muscle tone around the mouth can lead to drooling and lack of control of oral secretions.
• Grimacing and Drooling: Facial expressions may be exaggerated or inappropriate due to muscle tone issues, and there may be problems with managing saliva.
• Continuous Mouth Breathing: Patients may consistently breathe through their mouths rather than their noses.
• Tissue Biting: Increased risk of self-biting due to lack of muscle control.
• Tongue Protruding: The tongue may frequently stick out, complicating speech and intake of food.
• High and Narrow Palatal Vault: Changes in the oral cavity structures can lead to functional difficulties.
• Class II Division I Malocclusion (90%): Characterized by a deep bite and anterior open bite.
• Speech Involvement: Affected due to uncontrolled muscle movements.
• Muscle of Deglutition Involvement: Difficulties with swallowing due to affected muscles.
• Bruxism: Involuntary grinding or clenching of teeth.
• Auditory Organs May be Involved: Hearing impairments can coexist.

3. Ataxic Cerebral Palsy (5% of cases)

Characteristics:

• Slow Tremor-like Head Movement: Unsteady, gradual movements of the head, indicative of coordination issues.
• Involvement of Cerebellum: The cerebellum, which regulates balance and motor control, is impacted.
• Lack of Balance Leading to Staggering Gait: Individuals may have difficulty maintaining equilibrium, leading to a wide-based and unsteady gait.
• Hypotonic Orbicularis Oris Muscles: Reduced muscle tone leading to difficulties with oral closure and control.
• Slow Jaw Movement: The jaw may move slower, affecting chewing and speech.
• Speech Involvement: Communication may be affected due to poor coordination of the speech muscles.
• Visual Organ May be Involved (Nystagmus): Involuntary eye movements may occur, affecting visual stability.
• Varied Type of Malocclusion: Dental alignment issues can vary widely in this population.

4. Mixed:
Mixed cerebral palsy involves a combination of the above types, where the individual may exhibit spasticity, athetosis, and ataxia to varying degrees.

Dental Considerations for Mixed CP:
- Dental care for patients with mixed CP is highly individualized and depends on the specific combination and severity of symptoms.
- The dentist must consider the unique challenges that arise from the combination of muscle tone issues, coordination problems, and potential for involvement of facial muscles.
- A multidisciplinary approach, including occupational therapy and speech therapy, may be necessary to address oral function and hygiene.
- The use of sedation or general anesthesia might be considered for extensive dental treatments due to the difficulty in managing the patient's movements and ensuring safety during procedures.

Associated Symptoms:
Children with CP may exhibit persistent reflexes such as the asymmetric tonic neck reflex, which can influence their dental treatment. Other symptoms may include mental retardation, seizure disorders, speech difficulties, and joint contractures.

Dental Problems:
Children with cerebral palsy often experience specific dental challenges:

• They may have a higher incidence of dental caries (tooth decay) due to difficulty in maintaining oral hygiene and dietary preferences.
• There is a greater likelihood of periodontal disease, often exacerbated by medications like phenytoin, which can lead to gum overgrowth and dental issues.

Dental Treatment Considerations:
When managing dental care for children with cerebral palsy, dentists need to consider:

• Patient Stability: The child’s head should be stabilized, and their back should be elevated to minimize swallowing difficulties.
• Physical Restraints: These can help manage uncontrolled movements during treatment.
• Use of Mouth Props and Finger Splints: These tools can assist in controlling involuntary jaw movements.
• Gentle Handling: Avoid abrupt movements to prevent triggering the startle reflex.
• Local Anesthesia (LA): Administered with caution, ensuring stabilization to prevent sudden movements.
• Premedication: Medications may be given to alleviate muscle hypertonicity, manage anxiety, and reduce involuntary movements.
• General Anesthesia (GA): Reserved for cases that are too challenging to manage with other methods.

Theories of Child Psychology

Child psychology encompasses a variety of theories that explain how children develop emotionally, cognitively, and behaviorally. These theories can be broadly classified into two main groups: psychodynamic theories and theories of learning and development of behavior. Additionally, Margaret S. Mahler's theory of development offers a unique perspective on child development.

I. Psychodynamic Theories

1. Psychosexual Theory / Psychoanalytical Theory (Sigmund Freud, 1905):

   • Overview: Freud's theory posits that childhood experiences significantly influence personality development and behavior. He proposed that children pass through a series of psychosexual stages (oral, anal, phallic, latency, and genital) where the focus of pleasure shifts to different erogenous zones.
   • Key Concepts:
     • Id, Ego, Superego: The id represents primal desires, the ego mediates between the id and reality, and the superego embodies moral standards.
     • Fixation: If a child experiences conflicts during any stage, they may become fixated, leading to specific personality traits in adulthood.

2. Psychosocial Theory / Model of Personality Development (Erik Erikson, 1963):

   • Overview: Erikson expanded on Freud's ideas by emphasizing social and cultural influences on development. He proposed eight stages of psychosocial development, each characterized by a central conflict that must be resolved for healthy personality development.
   • Key Stages:
     • Trust vs. Mistrust (Infancy)
     • Autonomy vs. Shame and Doubt (Early Childhood)
     • Initiative vs. Guilt (Preschool Age)
     • Industry vs. Inferiority (School Age)
     • Identity vs. Role Confusion (Adolescence)
     • Intimacy vs. Isolation (Young Adulthood)
     • Generativity vs. Stagnation (Middle Adulthood)
     • Integrity vs. Despair (Late Adulthood)

3. Cognitive Theory (Jean Piaget, 1952):

   • Overview: Piaget's theory focuses on the cognitive development of children, proposing that they actively construct knowledge through interactions with their environment. He identified four stages of cognitive development.
   • Stages:
     • Sensorimotor Stage (0-2 years): Knowledge through sensory experiences and motor actions.
     • Preoperational Stage (2-7 years): Development of language and symbolic thinking, but egocentric and intuitive reasoning.
     • Concrete Operational Stage (7-11 years): Logical thinking about concrete events; understanding of conservation and reversibility.
     • Formal Operational Stage (12 years and up): Abstract reasoning and hypothetical thinking.

II. Theories of Learning and Development of Behavior

1. Hierarchy of Needs (Abraham Maslow, 1954):

   • Overview: Maslow proposed a hierarchy of needs that motivates human behavior. He suggested that individuals must satisfy lower-level needs before addressing higher-level needs.
   • Levels:
     • Physiological Needs (food, water, shelter)
     • Safety Needs (security, stability)
     • Love and Belongingness Needs (relationships, affection)
     • Esteem Needs (self-esteem, recognition)
     • Self-Actualization (realizing personal potential)

2. Social Learning Theory (Albert Bandura, 1963):

   • Overview: Bandura emphasized the role of observational learning, imitation, and modeling in behavior development. He proposed that children learn behaviors by observing others and the consequences of those behaviors.
   • Key Concepts:
     • Reciprocal Determinism: Behavior, personal factors, and environmental influences interact to shape learning.
     • Bobo Doll Experiment: Demonstrated that children imitate aggressive behavior observed in adults.

3. Classical Conditioning (Ivan Pavlov, 1927):

   • Overview: Pavlov's theory focuses on learning through association. He demonstrated that a neutral stimulus, when paired with an unconditioned stimulus, can elicit a conditioned response.
   • Example: Pavlov's dogs learned to salivate at the sound of a bell when it was associated with food.

4. Operant Conditioning (B.F. Skinner, 1938):

   • Overview: Skinner's theory emphasizes learning through consequences. Behaviors followed by reinforcement are more likely to be repeated, while those followed by punishment are less likely to occur.
   • Key Concepts:
     • Reinforcement: Increases the likelihood of a behavior (positive or negative).
     • Punishment: Decreases the likelihood of a behavior (positive or negative).

III. Margaret S. Mahler’s Theory of Development

• Overview: Mahler's theory focuses on the psychological development of infants and young children, particularly the process of separation-individuation. She proposed that children go through stages as they develop a sense of self and differentiate from their primary caregiver.
• Key Stages:
  • Normal Autistic Phase: Birth to 2 months; the infant is primarily focused on internal stimuli.
  • Normal Symbiotic Phase: 2 to 5 months; the infant begins to recognize the caregiver but does not differentiate between self and other.
  • Separation-Individuation Phase: 5 to 24 months; the child starts to separate from the caregiver and develop a sense of individuality through exploration and interaction with the environment.