12/6/2010

Review Orthodontics IV: Management of the Developing OcclusionOcclusion-- Problems We Commonly Face & How to Solve • A 3 ½ year old girl Them living in an area where water is fluoridated at 0 .10 ppm will receive what strength fluoride supplement? (Halo effect Paul K. Chu, DDS notwithstanding) St. Barnabas Hospital 02 December 2010

Review McDonald & Avery

• Is milk cariogenic? • Is milk cariogenic? NO (remember casein) • What type of caries is breast milk • What type of caries is breast milk associated with? associated with? (Dentinal) • What is the CERTAIN LETHAL dose of • What is the CERTAIN LETHAL dose of fluoride in children? fluoride in children? (32-(32-64mg/kg)64mg/kg)

Review Lecture Lecture 3: Standard Cephalometric Landmarks

Sella Nasion Central Incisor (#a) 14 weeks in utero Porion Orbitale First Molar (#d) 15 weeks in utero Articulare ANS Lateral Incisor (#b) 16 weeks in utero A Point Cuspid (#c) 17 weeks in utero B Point Gonion Pogonion Second Molar (#e) 18 weeks in utero PNS Menton Gnathion

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Lecture 3: Frequently Used Planes Lecture 3: SN Plane Skeletal Assessment --WitsWits (AO-(AO-BO)BO)

Where? Draw a PERPENDICULAR Palatal Plane line from A point to occlusal plane; B point to occllllusal plane Occlusal Plane Wits Measures? sagittal discrepancy between the upper and Mandibular Plane lower jaw Similar to what? Norm: -1, 0, +1 A- N - B

Lecture 4 Lecture 4

• In order from most common to least • Most common-common-8’s8’s nd nd common….name the teeth most • 2 : Mandibular 2 premolars • 3rd: Maxillary Laterals commonly missing… • 4th: Maxillary 2 nd premolars

Management of the Developing Occlusion-Occlusion- Problems We Commonly Face & How to Solve Them CROSSBITES

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Anterior Crossbites Anterior Crossbites

• Indicates • TRUE • PSEUDO skeletal growth --nono functional shift --functionalfunctional shift problem --retrusiveretrusive maxilla --normalnormal maxilla • Indicates --longlong mandlible --retroclinedretroclined maxillary incors/proclined possible --proclinedproclined maxillary incisors/retroclined mandibular incisors developing mandibular incisors Class III occlusion

Anterior Crossbite Results Anterior Crossbite Causes

• Labially positioned supernumary tooth • Trauma/Caries (necrotic teeth can cause deflection) • Arch length deficiency causes lingual deflection of permanent teeth (esp with maxillary laterals) Stillman’s/Gingival Clefts

Anterior Cross Bites: Solutions Anterior Cross Bites: Solutions

• Tongue Blade • Lingual Bite Plane/ i.e. an Incline Plane – Must be done with – Can fabricate on your erupting teeth own with composite – Cooperative pts – Resin on stone model - cover lower incisors only and possibly canines – Cycle of 5 mins of – Only locked in tooth is each hour in contact with plane ––NotNot always successful due to noncompliance

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Anterior Cross Bites: Solutions Posterior Crossbites

• Palatal Hawley • Common 1/13 kids (Kutin(Kutinet al) with spring • Not self correctingcorrecting-- primary posterior CB will be – Indicated when one or 2 teeth are followed by CB in the mixed dentition in CB • Left untreated, can develop into a true skeletal – Esp with lateral incisors defect – Good to correct • Treatment of CB in primary dentition favors arch irregularties development of normal occlusion in permanent also dentition

Posterior SKELETAL Crossbite Posterior DENTAL Crossbite

• Faulty eruption patternpattern-- erupting lingually • Discrepancy in structure of maxilla or • After eruptioneruption-- occlusion mandible locks th em in to pl ace • In mouth breathers, the • Narrow maxilla or wide mandible is often tongue can assume a associated with buccal CB position in the floor of the mouth, resulting in muscle imbalance and subsequent CB

Posterior FUCTIONAL Crossbite Posterior FUNCTIONAL Crossbite

• Posterior Functional • Results from a shift of the Crossbite mandible into an abnormal but more --teethteeth are in max comfortable position itintercuspa tion (shifts to the side of the XB) --unilateralunilateral --mandmand.. midline shifts to side of XB

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Posterior FUNCTIONAL Crossbite Posterior FUCTIONAL Crossbite • May be corrected • Lining up the midlines by simple canine reveals true incisal or inclined inadequacy… a plane adjustment constricted maxillary • Best to treat during arch! mixed dentition

Posterior Crossbite Treatment - Posterior Crossbite Treatment - DENTAL DENTAL • WW--ArchArch Expander • i.e Porter Appliance • You can expand the arm to also tip anteriors for XB • Un equal W-W-ArchArch Expander • Opened 3-3-44 mm wider than • Longer arm is the bracing passive wi dth arm • Tipping only • Usually require 22--33 mos of • Shorter arm is in CB active treatment and 3 mos of retention

Posterior Crossbite Treatment - Posterior Crossbite TreatmentTreatment-- DENTAL DENTAL • Quad helix • Extra wire gives this greater range of action than w archarch-- but equivalent force to w arch • Crossbite Elastics • Anterior helices can stop • Link lingual clasp of thumb habit • Weakened anterior segment-segment- maxillary molar to kids can break or distort buccal tube on • Widen appliance 3-3-88 mm mandibular molar • Tipping only

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Posterior Crossbite TreatmentTreatment-- Posterior Crossbite Treatment SKELETAL • RPE • RPE • Rapid Palatal Expander • Key • i.e: Haas, Hyrax, Minne Expander, Cap Splint • Make sure pt keeps up hygiene! • TkTurn key as per orthodontists Rx

Posterior Crossbite Treatment Posterior Crossbite Treatment

• Condylar position & • Headache is length of mandibular common skeletal structures different bilaterally in • Suture will open children with XB. • Compensatory growth freely within 22--33 occurred after expansion weeks treatment. • Treatment eliminated assymetries observed before treatment!

REMEMBER TO DOCUMENT & REFER (or TREAT) CROSSBITES!!! Untreated cross bite can lead to: PROBLEMS WITH ERUPTION --gingivalgingival inflammation and recession of the investing tissues surrounding the mal-mal-opposedopposed teeth and how to handle them --occlusalocclusal trauma --enamelenamel abrasion or fractures --developmentdevelopment of abnormal chewing an swallowing problems 1st Permanent Molars --abnormalabnormal growth of the maxilla and the mandible 2nd Permanent Molars --thethe development of a permanent Class III dentofacial abnormality Permanent Laterals --asymmetricasymmetric growth of the mandible --temporomandibulartemporomandibular joint dysfunction

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PROBLEMS WITH ERUPTION OF PROBLEMS WITH ERUPTION OF TEETHTEETH-- PERMANENT FIRST MOLARS TEETHTEETH-- PERMANENT FIRST MOLARS

• Ectopically Erupting • Halterman Teeth: • Distalizes • Most common 3% of ectopic the time permanent molar • Molars= self correct • Change power 66% of the time chain every 22-- 3 weeks

PROBLEMS WITH ERUPTION OF PROBLEMS WITH ERUPTION OF TEETHTEETH-- PERMANENT FIRST MOLARS TEETHTEETH-- PERMANENT FIRST MOLARS

PROBLEMS WITH ERUPTION OF PROBLEMS WITH ERUPTION OF TEETHTEETH-- PERMANENT FIRST MOLARS TEETHTEETH-- PERMANENT FIRST MOLARS

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PROBLEMS WITH ERUPTION OF PROBLEMS WITH ERUPTION OF TEETHTEETH-- TEETHTEETH-- SECOND PERMANENT PERMANENT LATERAL INCISORS MOLARS • DeDe--ImpactorImpactor • Ectopic • Distalizes ectopic EruptionEruption--duedue permanent molar to excessive mass or inadequate arch length • Be prepared if early loss of Activate canine occurs!

PROBLEMS WITH ERUPTION OF TEETHTEETH-- PROBLEMS WITH ERUPTION OF TEETHTEETH-- PERMANENT LATERAL INCISORS PERMANENT LATERAL INCISORS

• Ectopic • If ectopic erution eruption of occurs with lateral, laterallateral--causingcausing and no midline shift is seen,,p place LLHA exfolliation of with spur to prevent primary canine midline shift & 1st molar may cause transposition of canine!

PROBLEMS WITH ERUPTION OF TEETHTEETH-- PROBLEMS WITH ERUPTION OF TEETHTEETH-- PERMANENT LATERAL INCISORS PERMANENT CANINES

• If ectopic Normal Eruption of Canine erution occurs • It starts out lingual to the arch with lateral, and mesially directed • Changes to a more vertical and midline orientation when it engages the distal aspect of the lateral shift IS seen, incisor root extract • Continues to erupt into the oral cavity labial to the contralateral resorbing deciduous cuspid • Often see simultaneous closure primary canine of a maxillary central incisor to prevent diastema midline shift!

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PROBLEMS WITH ERUPTION OF TEETHTEETH-- PROBLEMS WITH ERUPTION OF TEETHTEETH-- PERMANENT CANINES PERMANENT CANINES • 3rd Molars Why? • Tooth has longest period of most development commonly • Follows dubious course of impacted- then development canines • Occupies several developmental positions in • Why? succession

PROBLEMS WITH ERUPTION OF TEETHTEETH-- PERMANENT CANINES

Treatment options • Extract primary canines SPACE REGAINING • Refer to ortho for chain/ button placement by OMFS

SPACE REGAINING SPACE REGAINING

Penguin/ Halterman Appliance Pendulum • Rb!!Remember!! • Regain maxillary space

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SPACE REGAINING SPACE REGAINING

Distal Jet Williams • RiRegain Appliance maxillary • Mandibular space Expansion

SERIAL EXTRACTION

• INDICATIONS • --onlyonly when dental arches are structurally SERIAL EXTRACTION inadequate for developing teeth • --littlelittle of no hope of attaining • --**CLASS**CLASS I DENTITION ONLY!!!!!!!**

SERIAL EXTRACTION SERIAL EXTRACTION • FIRST: Extract Primary Canine (wait 6 mos,mos, then..)then..)-- usually incisors will self correct • SECOND: Extract Primary First Molar (wait 6 mosmos,, then…) • THIRD: Extract Permanent 1st Premolar (whoch(whoch allows for normal canine eruption)

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Functional Appliances

• AOA: “Functional appliances are designed to alleviate skeletal and neuromuscular imbalances. “ • Ideal placement: Early Mixed Dentition Functional Appliances • Via changing jaw position, or muscular forces.

Functional Appliances AppliancesAppliances--FrankelFrankel

• Class II: Bionator I & 2; Herbst; Frankel;

TTiBlkwin Block The Frankel appliances are removable designs • Class III: Twin Block; Frankel invented by Professor Rolf Frankel.

The Frankel philosophy uses the vestibules to enhance favorable growth in developing dentition and restrict undesireable muscle forces.

AppliancesAppliances--BionatorBionator AppliancesAppliances--TwinTwin Block • Indicated for : Class II Division I; Class II Division 2; Class I • Class II correction (growth and open bites; Class I closed bites; forward movement of Class III occlusions. mandible) • Unlike bulky, oneone--piecepiece • Wax bite is usually taken functional appliances, the Twin forward in a Class I position (if Block has separate, unattached comf or tabl e f or pati en t) wi th upper and lower bite block 22--3mm3mm vertical opening components - actually two between posterior teeth. appliances which work together • Initially, the appliance is used as one. to encourage forward growth • In function, these two or advancement of the appliances interlock at the 70 mandible. Later, the appliance degree angle set into the bite can be further utilized to open blocks and posture the mandible the bite by removing the forward into the ideal Class I posterior bite pads; or, by position preset by your wax removing the anterior cap, it can close the bite. registration.

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AppliancesAppliances--HerbstHerbst

Headgear Appliances

The Herbst appliance- positions mandible anteriorly

From Lecture 3 Headgear Appliances

• Clockwise & Class II Openbite= Clockwise • High Pull Headgear Counterclockwise • Will deepen bitebite--forfor mandibular rotation use in clockwise rotating patients (i.e. Class II openbite)

Class III= Counterclockwise

Headgear Appliances Headgear Appliances

• Cervical Pull Headgear • CombiCombi-- Headgear • Will open bitebite--forfor use --maximizesmaximizes molar in counterclockwise retraction while rottitating pa tittients (i.e. controlling molar Class III deepbite) extrusion --forfor Class II molars w/ favorable chin position

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Headgear Appliances

• Reverse Pull Headgear/ Facemask Remember, patient compliance is --forfor Class III Occlusion key in headgear success!

OrhtodonticsOrhtodontics-- when?

• Best to get a screening by Age 7 (AAO) Ok so what do we do with all this knowledge???

OrhtodonticsOrhtodontics-- early treatment OrhtodonticsOrhtodontics-- early treatment indications? (Dugoni(Dugoni1995) benefits? (Dugoni(Dugoni-- 1995)

• Dental/skeletal Class • Periodontal • Reduced PM exos • Increased stability of II or III compromise • Decreased time or no lower incisor segment Phase II tx • Reduces incidents of root • Ant/Post XB • Ant OB > 3mm • Reduced need for surgical respor pti on • More than 6mm OJ • Severe deepbite w/ orthodontics • Reduces mucogingival • Max midface def palatal impingment • Increased stability of problems • Mod incisor crowding • Harmful oral habits transverese & AP • Reduced incidents of dimension changes with ectopic eruptions • Ectopic erutpions • Craniofacial anomalies Phase I tx • Better patient cooperation

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3 major Developmental Stages 3 Planes of Space

• Transverse • Primary Dentition • Anterior Posterior • Mixed Dentition • Vertical TRANSVERSE • Early Permanent Dentition

ANTERIOR/ POSTERIOR

VERTICAL

Orhtodontic Appliances-Appliances- Primary Orhtodontic Appliances-Appliances- Dentition Mixed Dentition Phase I

• Very Controversial • Purpose: To establish • Functionsl problems normal, vertical, usually treated transverse, & sagittal • Trasnverse XB dental & skeletal • A/P ––antant XB relationships ––NOTNOT • Vertical Deep/open necessarily to prevent bites the need for full, fixed --HeadgearHeadgear appliances. --BiteBite Planes

Mixed Dentition Phase I-I- 2 x 4 Treatment Approaches

• banded molars & bracketed • Active or Passive incisorsincisors-- allows for molar Space Maintenance derotation/uprighting/incisor levellinggg, alignment, & • Fixed o r remo vable intrusion expansion • creates a more normal relationship between the lips, • Fixed Archwires (2x4) teeth, tongue, and jaws, as well as reduces the risk of Headgear fracturing the upper incisors • Functional Appliances

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Mixed Dentition Phase II-II- 2 x 4 Treatment Approach • banded molars & bracketed incisorsincisors-- allows for molar derotation/uprighting/incisor • Purpose: to accomplish 6 levelling, alignment, & keys of occlusion intrusion • Includes both orthopedic • A: arch wire is free to slide through molar tube - incisors (headgea r/ fu nct i on al ) & tip anteriorly and extrude-extrude- orthodontic (full, fixed corrects anterior XB edgewise) • B: arch wire cinched-cinched-wirewire • If Phase I completed-completed-1212-- doesn’t slide-slide- extrudes incisors 18 mos due to lingual torque –mesial force on molar

Mixed Dentition Phase II-II- Mixed Dentition Phase II-II- Treatment Approaches Treatment Approach

1) Space consolidation 2) Sagittal Arch Coordination 3) Root Parallelism 4) Finishing & Detailing 5) Retention

Mixed Dentition Phase II-II- Complications of Orthodontic Retention Therapy

• Decalcification • Max/Mand Hawley • Caries retainers must be worn Periodontal problems 24hrs/day first 4 mos • after debracketing. • NNitltthonvital teeth • Then next 8 mos at • Root resorption night • Relapse (2/3 relapse • After 1 year-year-11--22 nights without some form per week. of retention)***

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Does TMD develop with Do 3rd Molars contribute to orthdontics? crowding?

• No difference in incisor crowding in pts with impacted, erupted, missing, or extracted 8’s. • Indications for exo? Pathology, • May occur coincidentally with external root resorption, tttreatmen t- btNOTbut NOT usua lly pericornitis, caries. because of tx. • Predict impaction? If distance • No relation has been found from distal of 7 to anterior between malocclusion & border of the ramus is greater TMD. or equal to length of developing 3rd molar crown there is a 70% chance of eruption.

Journal of Pediatric DentistryDentistry-- Nov/Dec 2005

• Parents’ satisfaction with their child’s Orthodontic Care: A comparison of Orthodontists & Pediatric Dentists So, if you are interested in

• Found parents equally happy with both doctors delivering Ortho.. PURSUE IT! treatment. • Pediatric dentists treated cases 9 mos earlier than orthodontists. • Patients treated by the pediatric dentist were more racially diverse. • Orthodontists 3x more likely to extract primary teeth than pediatric dentist. • Orhtodontists 14x more likely to treat Phase II cases.

To do - Holiday party (gift, small food item) if you have time cook something --Greg’sGreg’s bdaybday-- Tannen leaving early --5:305:30--66

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