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CHP 11: Moderate Nonskeletal Problems in

Preadolescent Children: Preventive Interceptive


Treatment Family Practice
OUTLINE
1. Orthodontic Triage: Distinguishing Moderate from
Complex Treatment Problems
Step 1: Syndromes and Developmental Anomalies
Step 2: Facial Profile Analysis
Step 3: Dental Development
Step 4: Space Problems
Step 5: Other Occlusal Discrepancies
2. Management of Occlusal Relationship Problems
Posterior Crossbite
Anterior Crossbite
Anterior Open Bite
3. Management of Eruption Problems
Overretained Primary Teeth
Ectopic Eruption
Supernumerary Teeth
Delayed Incisor Eruption
Ankylosed Primary Teeth
4. Management of Space Problems
Space Analysis: Quantification of Space Problems
5. Treatment of Space Problems
Premature Tooth loss with adequate space: Space
Maintenance
Localized Space Loss (3mm or Less): Space
Regaining
Mild-to-Moderate Crowding of Incisors with Adequate
Space
Generalized Moderate Crowding
Other Tooth Displacements

Orthodontic Triage
1. Step 1: Syndromes and Developmental Anomalies
a First step is to identify facial syndromes and complex
anomalies for combined care with specialists/referral
b Look for abnormal physical appearance,
medical history and developmental disorders,
significant asymmetry
i.
Physical: Crouzons, Treacher Collins, hemifacial
microsomia, cleft lip and palate
ii.
Med hx: radiation, bisphosphonates and growth
hormones
iii.
Developmental disorders:<3%til or >97%tile
iv.
Significant asymmetry: developmental/trauma
2. Step 2: Analyze Facial Profile (diagnose problems visually
to judge intervention)
a AP and Vertical Dimension Problems
i.
AP skeletal:
1. Class 2: tx can be deferred until near
adolescence. Prognosis is same early or late
2. Class 3: Maxillary deficiency: treat early!
Mandibular excess: doesnt matter,
prognosis is bad either early or late
ii.
Vertical dimension problems:
1. Long face and short face: both defer until
adolescence after growth finishes.
b Excessive Dental Protrusion or Retrusion
i.
Dental (incisor) protrusion:
1. If patient has good skeletal proportion,
usually space analysis will indicate small or
nonexistent discrepancy because of incisor
compensation
2. Bimaxillary protrusion (not excessive
overjet): treat by premolar extraction and
retraction of protruding incisors. but
extraction not performed until late in

3.

mixed dentition or early permanent


dentition
Step 3: Dental Development
a Problems involving dental development often need
treatment as soon as they are discovered, typically
during early mixed dentition.
b Severe problems: asymmetric tooth development
sequence, missing permanent teeth, ankylosed
permanent teeth, primary failure eof eruption, and
supernumerary teeth
c Moderate problems: single supernumerary with
uncomplicated position, retained/ankylosed primary
teeth, ectopic eruption, transposition
d Asymmetric Sequence of Dental Development
i.
Criteria to diagnose asymmetric eruption: one
side ahead by 6 months or more.
ii.
Must identify etiology before treatment!
1. No obvious etiology: monitor or treat early
by selective extraction of primary or
permanent teeth.
2. History of head and neck radiation
therapy/trauma: treat by timed surgical
removal or tooth reorientation.
e Missing Permanent Teeth
i.
Most likely to be congenitally missing: maxillary
lateral incisors and mandibular second
premolars.
ii.
Posterior teeth treatment options:
1. Maintain primary tooth
2. Extract overlying primary teeth and allow
adjacent permanent teeth to drift
3. Extract primary teeth followed by
immediate ortho treatment
4. Protho replacement/ transplantation/
implant.
iii.
Anterior teeth: refer to chapter 12? @@
f Ankylosed permanent teeth
i.
Technically categorized into the same problem
as missing permanent teeth, but Im writing this
in a different point so it wont be confusing

ii.

4.

5.

Severe problem, requires combined surgery and


ortho
1. Surgery: extraction/decoronataion
2. Ortho: space closure, transplantation or
prosthetic replacement after surgery.
g Supernumerary Teeth
i.
Mainly anterior part of maxilla.
ii.
Multiple supernumerary: usually part of
syndrome/congenital abnormality.
iii.
Early removal of supernumerary is indicated,
but must be careful to minimize damage to
adjacent teeth
iv.
Single supernumerary that are not malformed
often erupt spontaneously, causing crowding, if
they can be removed before they cause
distortions, extraction may all that is needed
Step 4: Space Problems
a Involves three scenarios: crowding, irregularity or
teeth malpositioning
b Two scenarios may develop in inadequate space:
i.
Incisor upright and well positioned over basal
bone and tip labially or lingually.
ii.
Crowded teeth align completely/partially but tip
lips forward = incompetent lips.
c Management for space deficiencies
i.
Crowding of 3 mm or less: lost space can be
regained
ii.
4 mm or less: reposition incisors labially or
space management during transition
iii.
5 mm or more is considered complex treatment
with or without protrusion
iv.
10 mm or more: careful and complex planning
so permanent teeth are not impacted or
deflected into eruption paths
d Management for midline diastema
i.
Large diastema > 2mm: esthetic concern and
inhibit adjacent teeth from erupting properly
need early tx
Step 5: Other Occlusal Discrepancies
a Severities of these problems is judged by facial form.
When treating these problems during mixed

dentition, must think about whether you should


treat, or if it can be treated.
b Posterior crossbite: skeletal
i.
In preadolescence: considered as a moderate
problem unless no other complicating factors
are present.
1. Treat by palatal expansion
2. Treat early if child shifts laterally from
incisor dental contact position
3. Often better to delay until late mixed
dentition so erupting premolars and second
molars can be guided into position.
ii.
Adolescent: severe problem, widen midpalatal
suture or expand surgically.
c Posterior crossbite: dental
i.
Moderate problem: no other complicating
factors exist, then tipping is enough.
ii.
Severe problem: include in comprehensive
treatment
d Anterior crossbite
i.
Usually reflects jaw discrepancy, but can from
lingual tipping of incisors during eruption or
crowding
ii.
Moderate problem: removable appliance with
tipping
iii.
Severe problem: comprehensive treatment
planning
e Excess overjet
i.
Moderate: considered moderate problem if
adequate vertical clearance present, then can
tip teeth lingually and bring together with
removable appliance at any age,
1. Treatment timing depends on patients
preference.
ii.
Severe: comprehensive evaluation
f Anterior open bite simple
i.
Moderate problem:
1. Primary dentition: good chance of
spontaneous correction with additional
incisor eruption. No treatment needed.
2. Mixed dentition: finger-sucking therapy

g Anterior open bite complex


i.
Considered complex if there is skeletal
involvement or posterior manifestations, or if
open bite is present in older patients.
ii.
Treat by growth modification or jaw surgery
h Deep overbite
i.
Seldomly treated in mixed dentition, but can be
treated by leveling curve of spee or intrusion.
i Traumatic displacement of teeth
i.
Vertical
1. Spontaneous re-eruption with open apex
2. Orthodontic traction
3. Surgical repositioning
ii.
Horizontal
1. Immediately reposition
2. If fixed in new position, then orthodontics
Management of Occlusal Relationship Problems
1. Posterior Crossbite
Intro
i.
Prevalence: common, 7.1% of US children from
8-11
ii.
Etiology: prolonged sucking habit, narrow
maxilla or lingual tipping of maxillary teeth
iii.
Deciding on whether to treat or not
1. Treat: if mandible shifts on closure, or if
constriction is too severe.
2. Dont treat: defer when other problems
suggest comprehensive evaluation
iv.
Differentially diagnosing from other problems:
1. Must determine whether posterior crossbite
is contributed by AP discrepancies rather
than actual transverse discrepancies.
v.
Treatment overview:
1. 1 mm increase in inter-premolar width
increases arch perimeter by 0.7 mm.
2. Relapse is unlikely if there is no skeletal
component.
3. Treatment in early mixed dentition years is
the same regardless of dental or skeletal
etiology.

4.

In primary/early mixed dentition, expansion


lingual arch is the best. Jackscrew device is
needed only during adolescence can
distort nose in younger children due
to heavy force
Three basic approaches to treatment of moderate
crossbites
i.
Eliminating Mandibular Shift from Occlusal
Interferences
1. This approach is used when crossbite is
caused by occlusal interferences by
primary canines or primary molars in
primary or mixed dentition
2. How to diagnose: check by positioning
mandible in CO. If maxilla size is adequate
but mandible shifts during closure.
3. Treat by equilibration of primary teeth
(usually just reduction of canines)
ii.
Expansion of a Constricted Maxillary Arch
1. General guideline: expand maxillary arch to
prevent shift during diagnosis BUT if
permanent first molars are expected to
erupt in less than 6 months, then wait for
eruption to include them within expansion.
2. Appliances
Split-plate removable: relies on
compliance, longer treatment time,
more expensive than expansion lingual
arch.
W-arch and Quad Helix:
i.
Easy and reliable
ii.
Both can leave imprint on tongue,
but will disappear a year after the
appliance is removed.
iii.
Expansion should continue at a
rate of 2 mm per month ( 1mm
each side) until crossbite is
slightly overcorrected.
iv.
Removal and re-cementation
are recommended at each

treatment visit. Require 2-3


months with 3 months of retention.
W-arch: fixed appliance, 36 mil steel
soldered to molar bands
i.
Activate by opening apices of W
ii.
Anterior > posterior expansion
iii.
Difficult for precise bilateral
expansion, but correction of tooth
position always achieved.

2.

Quad helix: flexible version of W-arch


i.
Made wit 38 mil steel wire reliable
and easy
ii.
Thick anterior helices to stop finger
habit
iii.
Indication: posterior crossbite and
finger sucking habit.
iv.
Greater range of action than Warch, but forces are equivalent.
iii.
Unilateral Repositioning of Teeth
1. Used when there is unilateral crossbite due
to unilateral maxillary constriction.
2. Treatment methods
W-arch/quad helix with different arm
lengths
Use mandibular lingual arch to stabilize
lower teeth and attach cross-elastics to
maxillary teeth
i.
Complicated, requires cooperation
ii.
Latex elastic with 5mm lumen
generating 6 ounces (170 gm) of
force.
iii.
Will extrude posterior teeth and
reduce overbite do not use with
increased lower face height/limited
overbite.
iv.
Should overcorrect and leave
elastics in place for retention.
Anterior Crossbite
Etiology
i.
Nonskeletal: most commonly due to space
deficiency
ii.
Lingually positioned tooth buds
iii.
Supernumerary teeth deflecting eruption
iv.
Overretained primary incisors
v.
Trauma
Treatment of Nonskeletal Anterior Crossbite
i.
Early correction indicated when: severe
mandibular incisor abrasion or mandibular
gingival recession
ii.
Removable appliance

1.

2.

Two options:
Fingersprings: tip maxillary incisors.
Use one 22-mil double-helical cantilever
spring. (picture 2)
Active labial bow: lingual movement
of mandibular incisors.
Adding
Figure 1:
Fingersprings

iii.

anterior/posterior biteplate or posterior bite


turbo during treatment is not needed unless
excessive overbite or grinding/clenching is
present.
3. Usage:
Requires full-time wear
1.5-2mm of lingual finger spring
activation = 1mm tooth movement per
month.
Should be slightly overcorrected.
Need one or 2 monhs of retention
Common problems: poor compliance,
poor design lacking retention, improper
activation.
Fixed appliance
1. Maxillary lingual arch with
fingersprings: indicated in poor
compliance. Picture 3
Springs soldered on opposite side of
arch
Most effective at 15 mm long
Activated each month by advancing
spring 3mm move tooth at 1 mm per
month

3.

Problem: distortion and breakage and


poor hygiene
2. 2x4 appliance ( 2 molar bands, 4
bonded incisors)
Indicated when there is no skeletal
component to the anterior cross bite
and bodily movement is needed to
correct crowding and rotations.
If correcting lateral incisor crossbite
before permanent canines have
erupted, then best to increase mesial
root tip of lateral incisor to prevent
canine
from
resorbing
incisor
root.
Anterior Open Bite
Etiology
i.
In a preadolescent
child with normal
VD has several causes:
1. Could be a normal transition when
primary teeth are replaced by permanent
teeth
2. Finger sucking
3. Skeletal problem: excessive BD and rotation
of jaw producing excessive lower anterior
face.

ii.

Effects of sucking habits


1. Changes:
Affects permanent teeth rather than
primary
F > M
Depends on frequency, intensity, and
duration
Increase overjet, decreased overbite
Decrease maxillary intercanine and
intermolar width = posterior crossbite
2. Digit sucking vs pacifier use
Pacifier leads to more posterior

crossbite, especially greater than 18


months.
Longer breast-feeding leads to fewer
non-nutritive sucking habits
Most children have non-nutritive
sucking habit 24 months, but 40% at 36
months.