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 1 12/6/2010 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 2 12/6/2010 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 3 12/6/2010 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 t h 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 4 12/6/2010 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 widt h 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 5 12/6/2010 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 6 12/6/2010 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 7 12/6/2010 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! 8 12/6/2010 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 9 12/6/2010 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) 10 12/6/2010