RGUHS Vatsala N et al.

, RJDS 2021;13(2):60-65

Journal of Dental Sciences

Case Report
Dentin Opaquer: A Pediatric Aesthetic Enhancement Technique
Dr. Vatsala N1, Dr. Reshma Dodwad2, Dr. Priya Nagar3, Dr. Richa Lakhotia4, Dr. Anisha Jenny5
Postgraduate student, Department of Paediatric and Preventive Dentistry, Krishnadevaraya College of
1

Dental Sciences, Hunasamaranahalli, International Airport Road, Bangalore 562157.

Reader, Department of Paediatric and Preventive Dentistry, Krishnadevaraya College of Dental Sciences,
2

Hunasamaranahalli, International Airport Road, Bangalore 562157.

Head of the Department, Department of Paediatric and Preventive Dentistry, Krishnadevaraya College of
3

Dental Sciences, Hunasamaranahalli, International Airport Road, Bangalore 562157

Postgraduate student, Department of Paediatric and Preventive Dentistry, Krishnadevaraya College of
4

Dental Sciences, Hunasamaranahalli, International Airport Road, Bangalore 562157.

Postgraduate student, Department of Paediatric and Preventive Dentistry, Krishnadevaraya College of
5

Dental Sciences, Hunasamaranahalli, International Airport Road, Bangalore 562157.

*Corresponding author:
Dr. Vatsala. N, Postgraduate student, Department of Paediatric and Preventive Dentistry, Krishnadevaraya College of
Dental Sciences. Hunasamaranahalli, International Airport Road, Bangalore 562157, Email: drvatsbds@gmail.com.
Affiliated to RGUHS, Bengaluru, Karnataka
Received date: November 26, 2020; Accepted date: December 11, 2020; Published date: March 31, 2021

Abstract
Introduction: Early childhood caries in young children can be initial dental caries and caries involving most
of the tooth structure resulting in pulpal involvement causing loss of tooth structure. There is a need for tooth
restoration for functional and aesthetic reasons. Dentine opaquer can be used to fulfill both the criteria.
Aim: The aim was to determine the efficacy of dentine opaquer to mask the underlying color of caries treated
with restorative material and omega metal post after pulpectomy.
Methods: A report of 2 cases performed in the Department of Pediatric and Preventive Dentistry in,
Krishnadevaraya College of Dental Sciences and Hospital Bangalore. Two different treatments using dentine
opaquer as the restorative material and as core buildup over glass ionomer cement were performed.
Results: Both the cases showed favorable outcomes and better masking efficiency of dentine opaquer as
restorative material and core build up material over glass ionomer cement.
Conclusions: Dentine opaquer is a composite with a compatible shade and better retention on the tooth
surface, as core build up material and along with omega loop demonstrated adequate retention, was easy to
administer as a chair side technique and resulted in least resistant masticatory forces.
Keywords: Caries, Dentine opaquer, Glass ionomer cement, Omega loop

Introduction structure resulting in involvement of the pulp. According

Dental caries are a major oral health concern involving to the American Academy of Pediatric Dentistry, early
most of the teeth due to its wide range of involvement childhood caries is defined as “the presence of one or
from initial discoloration to loss of most of the tooth more decayed, missing (due to caries), or filled tooth

60
 Vatsala N et al., RJDS 2021;13(2):60-65

surfaces in any primary tooth in a child, 71 months of

age or younger.”1 These 2 case reports aim at reporting
the management of initial caries with dentine opaquer
and deep dental caries restored using glass ionomer
cement (GIC) and dentine opaquer as a core buildup
used in restoration.

Case report 1
A 3-year-old child reported to the Department of
Pediatric and Preventive Dentistry with a chief complaint
of decayed teeth in the upper front region of mouth. Figure 1.2: excavation of caries using number 330 bur
The child displayed positive behavior as per Frankl’s
behavior rating scale. Patient’s history regarding the diet
and details of oral hygiene maintenance was obtained.
Oral examination revealed dental caries in relation
to 51, 52, 61 and 62 without involving pulp (Figure
1.1: Preoperative view). An IOPAR was obtained
to reconfirm the pulpal involvement and periapical
pathology. Parent’s consent was obtained, and treatment
was performed. Initial dental caries was removed
using number 330 round bur and remaining soft caries
was excavated with a spoon excavator (Figure 1.2:
excavation of caries using no 330 bur). A layer of GIC
luting cement was placed as base and the cavity was
etched with 35% phosphoric acid for 20 seconds. The
cavity was rinsed and air dried (Figure1.3: application
of etchant). A dentine bonding agent was applied and Figure-1.3: Etchant applied and air dried.
cured for 20 seconds.2 Dentine opaquer was placed over
it and was cured layer by layer to mask the underlying
discoloration and irregularities for 40 seconds each
(Figure1.4: application of bonding agent and dentine
opaquer). Finally, the composite restoration was done
and cured for 40 seconds (Figure1.5: postoperative
view). Restorations were evaluated clinically by visual
examination for color match and marginal adaptability as
per the criteria for assessment of composite restorations
modified United States Public Health Service (USPHS)
criteria. The color matching and marginal adaptability
was scored as Alfa, accordingly after restoration with
final composite restoration (Table -1).3 Figure-1.4: Application of bonding and dentine opaquer

Figure- 1.5: Post-operative view

Figure 1.1: Pre-operative view

61
 Vatsala N et al., RJDS 2021;13(2):60-65

Case report 2 criteria. The color matching and marginal adaptability

A 4-year-old child reported to the Department of Pediatric was scored as Alfa after restoration with final composite
and Preventive Dentistry complaining of pain in the restoration (Table -1).3
upper front region of the mouth. The child exhibited
negative behavior as per Frankl’s behavior rating
scale. Medical and diet history were evaluated. Oral
examination revealed grossly decayed teeth in relation
to 51, 52, 61, 62 (Figure 2.1: pre-operative view).
Radiographic examination revealed periapical abscess
in relation to 51, 52, 61and 62.
Parents were informed about the treatment procedure
and consent was obtained. Pulpectomy was performed
in relation to 51, 52, 61 and 62 and obturated with
zinc oxide eugenol cement. Custom-made omega loop
post was prepared using 0.9 mm stainless-steel wire
and serrations were made to increase the retention and
Figure 2.1: pre-operative view
stability of the post.
After completion of pulpectomy post, space was
prepared, a 4 mm length of coronal portion of the
root filling was removed (2-3 mm below the CEJ).
Postspacewaspreparedwith gates glidden drill. Any
excess Zinc oxide eugenol cement on the walls of the
root canal was removed. The post-space was air dried
& a 1 mm base of glass ionomer cement was placed.
The post was placed to a distance of 3 mm into the
canal and the length was adjusted, such that it extends Figure 2.2: Omega loop post insertion
2 mm outside the canal (Figure-2.2: Omega loop post
insertion).An intraoral periapical radiograph was
obtained to make sure that the end of the post was to the
level of interdental crest or just apical to it. The prepared
post space was then cleaned with saline and air dried.
A light cured bonding agent was applied on the etched
surface uniformly and light cured for 20 seconds.2 The
tip of flowable composites syringe was placed 2 to 3
mm below the cementoenamel junction (CEJ) and the
composite was slowly injected.
The omega post was then inserted into the canal with
cotton pliers and cured for approximately 40 seconds.
GIC was used as the core build up material and dentine
opaquer was placed over GIC to mask the color of metal
and GIC (Figure 2.3a and Figure 2.3b: application of
bonding agent and dentine opaquer).
Composite of suitable shade was loaded to the strip crown
and excess composite was removed and cured. The cured
strip crown was then removed (Figure 2.4: postoperative
view). Restorations were evaluated clinically by visual
examination for color match and marginal adaptability
by the criteria for assessment of composite restorations Figure 2.3a and 2.3b: application of bonding
modified United States Public Health Service (USPHS) agent and dentin opaquer

62
 Vatsala N et al., RJDS 2021;13(2):60-65

The morphology of primary teeth in contrast with

Figure 2.4: Post -operative view
Discussion
The aesthetics of dentition is synonymous with facial
aesthetics and problems at an early age have a huge
influence on the psychological development and social
interaction with other children.4 Achieving aesthetic
composite restorations in the anterior region demands
experienced hands and skillful training, but a deeper
understanding of the chromatic characteristics of teeth,
as well as, optical phenomena such as opalescence,
fluorescence, fluorescence counter-opalescence, opacity
and translucence.5 Dentine opaquer has a significant
advantage because it provides better aesthetics as a
restorative material. Development of new materials suc
has art glass crowns, strip crowns, polycarbonate crowns,
veneered stainless steel crown, etc. were introduced to
restore the teeth with caries but having adequate tooth
structure.6
permanent teeth is different because they exhibit large
pulp chamber, and a thinner enamel–dentine layer, which
decreases the time for caries to reach the pulp and cause
pulp necrosis. The primary teeth have less surface area
for bonding, relatively large pulp chamber and prismatic
enamel which is difficult to etch. Also, destruction of
the tooth structure frequently involves the entire crown
leaving just the root dentine for bonding of restorative
material and thus, increasing the failure rate.7
Premature loss of anterior primary teeth may cause
problems with eating/biting, difficulties in speech
development, and retarded eruption of permanent
incisors.8 The restoration of such teeth to retain the
physiologic space and function is of prime importance.
Omega loop was introduced by Mortada and King as
intracanal retainer in 2004. Omega loop can be custom-
made according to the tooth morphology and retention of
function is possible. Normally a total of 5 mm long post
is used in case of primary teeth. The free ends of these
posts are placed inside the canal, approximately 3mm.5
Advantages of using omega posts is that they are cost
effective and can be applied quickly, wire does not cause
internal stress on the root canal due to its incorporation
into the restorative material and it can be performed with
minimal chair side time. Also, the coronal extension
enhances retention of coronal restoration. There are

Table 1 Criteria for assessment of composite restorations (modified USPHS).3

Criteria Score Description

The restoration appears to match the shade and translucency of adjacent tooth tissues.
Alfa
The restoration does not match the shade and translucency of adjacent tooth tissues, but the
Color match Bravo mismatch is within the normal range of tooth shades.

Charlie The restoration does not match the shade and translucency of adjacent tooth structure, and
the mismatch is outside the normal range of tooth shades and translucency.

There is no visual evidence of marginal discoloration different from the color of the restor-
Alfa ative material and from the color of the adjacent tooth structure.
There is visual evidence of marginal discoloration at the junction of the tooth structure and
Marginal
the restorations, but the discoloration has not penetrated along the restoration in a pulpal
staining Bravo direction.
Charlie There is visual evidence of marginal discoloration at the junction of the tooth structure and
the restorations that has penetrated along the restoration in a pulpal direction.

Alfa Surface texture is similar to enamel.

Surface Bravo Surface texture is similar to conventional composite resin or to white mounted stone.
roughness
Charlie Surface has porosities, impairing the continuous movement of the Explorer.

63
 Vatsala N et al., RJDS 2021;13(2):60-65

Alfa The restoration appeared to adapt closely to the tooth. There are no catch or crevice at any
point on the margin. There is no retention of the explorer on the margin.

Marginal The explorer catches and there is visible evidence of a crevice, which the explorer
adaptation Bravo penetrates, indicating that the edge of the restoration does not adapt closely to the tooth
structure. The dentine and/or the base are not exposed, and the restoration is not mobile.
Charlie The explorer penetrates crevice defect extended to the dento-enamel junction.
Alfa The restorations were continuous with existing anatomic form.

Bravo The restoration was discontinuous with the existing anatomic form, but the missing
Anatomic form
material was insufficient to expose base or dentine.
Charlie Sufficient material has been lost to expose dentine or base.
Alfa Absence of secondary caries.
Secondary caries
Bravo Presence of secondary caries.

many advanced post materials available with better
aesthetics and retention. In the present case report
omega loop was used with minimal time for fabrication,
inexpensive, demonstrated adequate retention and good
aesthetics were achieved by dentine opaquer to mask
its metal tint. In a similar fashion, restorations can be
aesthetic by masking the under lying irregularities by
dentine opaquer application. Restorations were evaluated
clinically by visual examination for color match and
marginal adaptability by the criteria for assessment of
composite restorations modified USPHS (United States
Public Health Service). The color matching and marginal
adaptability were scored as Alfa after restoration with
composite restoration (Table -1).3
Rajesh Retal reported a case describing a technique to
restore severely damaged primary anterior teeth with
a modified anchor shaped post. This technique was
not only simple and inexpensive but also provided
better retention.9 Rallan Metal reported that restoration
of severely mutilated incisors in a patient with early
childhood caries. Snuggly-fitting number 4 metal screw
post was selected to avoid any fracture because of
stress and (Swiss made dental gold-plated screw posts,
Nordin, H, Nordin SA CH-1816 Chailly) was adapted by
reducing its post part to 3 mm and trimming its core part
so that strip crown restoration can be easily performed.
The core length of the post system which was placed
inside the canal was equal to the recommended length
for deciduous teeth. Three mm occupies only the cervical
one-third of the canal to avoid interference with the
process of primary tooth root resorption and permanent
tooth eruption.10 Advantage of omega post over metal
post is that desired length and retentive features can be
incorporated according to the residual tooth structure.
Verma Letal reported a case of 4-year-old male with
grossly decayed maxillary anterior teeth that were
restored with glass fibre-reinforced composite resin
posts (GFRC), a new system of fibre posts composed
of compactly packed silanated e-glass fibers in a
light curing gel matrix. The advantages of using fibre
reinforced to prepare an intracanal post include resin
composite crown reinforcement, translucence, and
relative ease of manipulation.11 Fiber reinforced post
is expensive compared to metal post and metal posts
provide mechanical retention. Ali et al (2018) reported
two case reports, where a simple and effective method
which was a slight modification of the technique by
Mortada and King was used for reconstruction of severely
destroyed primary anterior teeth. In a modification to
the conventional method, a double omega loop was
used instead of a single omega loop.12 Subramaniam et
al (2008) compared fiberglass post with omega shaped
stainless steel wire in primary maxillary anterior teeth.
After 1 year, fibre glass posts showed enhanced retention
and marginal adaptability when compared to omega
shaped stainless steel wire.13 The disadvantage of fiber
post is its cost where omega loop can be used as an
alternative.
Conclusions
Presence and evolution of the latest technologies for
restoration of decayed teeth have been a boon but still
it is difficult to satisfy patient’s desire with respect to
aesthetics. With the incorporation of new technologies,
dentistry enters into a new field of awareness where
almost all the complex problems of restoration can be
addressed along with good retention and aesthetics
to the patient’s satisfaction along with cost-effective
management. Omega loop post demonstrated adequate
retention, easy administration as a chair side technique
along with good feature rention and was also cost-
effective compared to advanced materials. Dentine
opaquer is a composite with compatible shade and better

64

retention on the tooth surface and can also be used as a
core build up material in the pediatric population.
Conflict of Interest
None.
References
1. Kumar R, Sinha A. Restoration of primary
anterior teeth affected by early childhood
cariesusingmodifiedomegaloops-Acasereport.Anna
lsofDental.2014Jan1;2(4):24- 6
2. Sensi LG, Webley W. A simplified approach for
layering composite resin restorations. Gen Dent.
2007;55(7):638-645
3. Barnes DM, Blank LW, Gingell JC, Gilner PP.
A clinical evaluation of a resin-modified glass
ionomer restorative material. J Am Dent Assoc
1995;126:1245-1253
4. Chadha T, Yadav G, Tripathi AM, Dhinsa K, Arora
D. Recent trends of Esthetics in Pediatric Dentistry.
Int J Oral Health Med Res.2017;4(4):70-75.
5. Suwarnkar SD, Prasad VN, Khan R, Sirikonda S.
Posts in primary teeth-a literature review. Journal of
Interdisciplinary Dental Sciences. 2017Jul;6(2).
6. AroraK, PatelD. Restoring severely decayed
primary anterior teeth using omega posts and fibre
post systems a case report. Indian Journal of Applied
Basic MedicalS ciences. 2015;17(24):126-34.
Vatsala N et al., RJDS 2021;13(2):60-65
7. Schmoeckel J, Gorseta K, Splieth CH, Juric H. How
to intervene in the caries process: early childhood
caries–a systematic review. Caries Research. 2020
Jan7:1-1.
8. Shah S, Bargale S, Anuradha KVR, Patel N. Posts in
Primary Teeth-A Sile for Better Smile. J Adv Med
Dent Scie Res.2016;4(1):58-64.
9. Rajesh R, Baroudi K, Reddy K, Praveen BH, Kumar
VS, Amit S. Modified anchor shaped post core
design for primary anterior teeth. Case reports in
dentistry. 2014 Jan 1;2014
10. Rallan M, Rallan NS, Navit P, Malhotra G. Modified
intracanal post for severely mutilated primary
anterior teeth. Case Reports. 2013 Apr18;2013.
11. Verma L, Passi S. Glass fibre-reinforced composite
post and core used in decayed primary anterior
teeth: a case report. Case Rep Dent2011;2011.
12. Ali SM, Kiranmayi M, Raju SS. Esthetic
Rehabilitation of Primary Anterior Teeth using
Double Omega Loop Post: A Report of Two Cases.
Indian J Dent Adv. 2018;9(4):231-4.
13. SubramaniamP,GirishBabuK,SunnyR.Glass fiber
reinforced composite resinasan intracanal post–a
clinical study. Journal of Clinical Pediatric Dentistry.
2008 Apr1;32(3)
65