Powerpoint Presentation on Central Incisor - PDF

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					                                                                                    Outline
                                                          I. Definitions and Terms:
                                                               Early Treatment
      Early Treatment in                                       Preventive, Interceptive, Corrective
                                                               Phase I, Phase II
           Orthodontics                                   II. Specific goals of early treatment

                         Dr. Suzan Ekim                   III. Non skeletal orthodontic issues:
                                                               Crowding
                    ekimx001@umn.edu                           Eruption Disturbances
                 Division of Orthodontics                      Anterior Crossbites
                 University of Minnesota                  IV. Skeletal orthodontic issues:
                                    2007                       Transverse problems
                                                               Vertical problems
                                                               Growth Modification

                                                          V. Summary and Cases




I. Definitions and Terms                                  I. Definitions and Terms
                                                           Preventive early treatment:
                                                           Patient education and maintenance of a favorable orthodontic
                                                           condition.
    Early Treatment:                                          e.g. patient education of stopping digit sucking habits, space
                                                              maintenance appliances.
      Treatment initiated during the primary or mixed
      dentition with the purpose to prevent, intercept     Interceptive early treatment:
      or correct a specific orthodontic problem or         Improvement of an orthodontic problem.
      problems, also known as, Phase I treatment.             e.g. Primary tooth guidance extractions, reduction of excessive overjet,
                                                              growth modification appliances, space redistribution, space creation,
                                                              deep bite reduction, habit appliances.

                                                           Corrective:
                                                           Complete or nearly complete correction of an orthodontic problem.
                                                              e.g. Expansion appliances, growth modification appliances, alignment
                                                              of anterior teeth.




                                                          II. Specific Goals of
I. Definitions and Terms                                  Early Treatment
 Phase I
                                                          Overall goal of early treatment:
   Treatment initiated during the primary or mixed
   dentition with the purpose to prevent, intercept or     To improve or correct orthodontic problems
   correct an orthodontic problem, also known as, early    that would result in:
   treatment.
                                                              Irreversible damage to the dentition and
 Phase II                                                     supporting structures
   Treatment initiated during the permanent dentition         Progression into a more severe orthodontic
   with a comprehensive approach to correcting the            problem that would be more difficult to treatment
   orthodontic problems, also known as, comprehensive         in Phase II.
   treatment.




                                                                                                                                         1
II. Specific Goals of                          II. Specific Goals of
Early Treatment                                Early Treatment
                                               1.   Improved Psychosocial Development
Specific goals of early treatment                               Self-Esteem, esthetics
 Clearly defined endpoints of phase I          2.   Improved Occlusal Function
 orthodontic treatment.                                        Symmetry, shifts/slides, attrition
                                               3.   Manage potential for damage to dentition
                                                               Trauma, attrition, recession, injury, primary
Why is this important?                                         tooth extractions.
                                               4.   Phase II simplification
 To prevent extended Phase I treatment times                     Growth modification, space
     Patient cooperation anticipated                             management, primary tooth extractions
                                               5. Improved or corrected skeletal discrepancies
     Damage to unerupted teeth
                                                              Symmetry, reduce skeletal discrepancies,
  Phase II is still likely for most cases                     transverse problems.




II. Specific Goals of                          Benefits                            Risks
Early Treatment                                 Improved patient                     Misdiagnosis
                                                socialization                        Extended
Consider the 4 factors in the development of    Better patient                       treatment time
the dentition:                                  cooperation                          Greater cost (time
1. Eruption                    Guidance         Earlier correction                   and money)
                                                Sometimes                            Patient burnout
2. Growth                      Orthopedics      fewer extractions                    Increased caries
3. Drift                       Space Control    required                             risk
4. Equilibrium                 Habit Control    Sometimes less
                                                orthognathic
                                                surgery required




I. Definitions and Terms:
     Early Treatment
     Preventive, Interceptive, Corrective
     Phase I, Phase II
                                                   III. NON SKELETAL
II. Specific goals of early treatment           ORTHODONTIC ISSUES
III. Non skeletal orthodontic issues:
      Crowding                                      Crowding
      Anterior Crossbites
      Eruption Disturbances                         Anterior Crossbites
                                                    Eruption
IV. Skeletal orthodontic issues:                    Disturbances
     Transverse problems
     Vertical problems
     Growth Modification

V. Summary and Cases




                                                                                                               2
Classification of Mixed                                   Classification of Mixed
Dentition Crowding                                        Dentition Crowding
 Incisor Liability – mild amount of transitional            Moderate Transitional
 crowding of the permanent incisors in a                    Crowding
 mixed dentition (~2-3mm).                                ~ 4mm of anterior crowding

  Permanent Mn incisor
widths = interdental spaces
of primary teeth + primate
   spaces + permanent                                       Severe Transitional
     incisor inclination                                    Crowding
                                                          ~ >4mm of anterior crowding




Crowding Management                                       Leeway Space

                                                           Moyers –
Treatment options for moderate and severe                    2.5mm per side in Mn
crowding in a mixed dentition depends on:                    2.0mm per side in Mx
  Preventing irreversible damage
  Promoting eruption of teeth into attached gingiva        Proffit –
                                                             1.7mm per side in Mn
  Class I, II or III dental and skeletal growth pattern
                                                             0.9mm per side in Mx
  Incisor proclination
  Midline shifted or centered                              Used for:
  Esthetics                                                  Crowding
  Leeway space available for crowding or molar               Molar drift
  correction.




Crowding Management                                       Lower Lingual Holding Arch
Options:                                                                            LLHA
  No treatment and monitor
                                           Maintains
  Space Maintainers                       current arch
  Extract primary canines ±                                                         Holds arch
                                           perimeter
  LLHA                                                                              perimeter as the
                                                                                    permanent teeth
  Arch width expansion                                                              erupt.
  Incisor proclination                  Increases arch
  Distalizers – lip bumpers,               perimeter
  headgear etc.




                                                                                                       3
Severe Transitional Crowding                     Serial Extraction
Signs:                                           Definition:
                                                   A planned sequence of tooth removal during the
  Lack of interdental spaces in                    transition from primary to permanent dentition to promote
  primary dentition.                               eruption of teeth through attached gingiva (keratinized
  >4mm of crowding of                              tissue) and reduce the severity of crowding.
  permanent incisors.
  Early loss of primary canine                   Eruption sequence of the permanent dentition:
  by ectopic eruption of lateral                 Maxilla:     61245378
  incisor.                                       Mandible:    6 1 2 (3 4) 5 7 8
  Ectopic eruption of upper
  first permanent molars.




                                                 Serial Extraction
Serial Extraction

   Ideal Case Selection Requirements:
     1.   No skeletal disproportions; balanced
          AP, V, T dimensions
     2.   Class I molar
     3.   Non-retrusive lip profile              Timing of extraction:
     4.   Normal overbite                              ½ to ¾ root development
                                                       of 1st PMs to accelerate
     5.   Coincident midlines                          eruption.
     6.   Severe crowding warranting                   Phase II full braces for
          extractions.                                 alignment, bite and root
                                                       parallelism.




                                                 Anterior Crossbites
   III. NON SKELETAL
                                                    Lingual eruption of a
ORTHODONTIC ISSUES                                  maxillary incisor
                                                    relative to the
  Crowding                                          mandibular incisor.
  Anterior Crossbites                               With or without a shift
  Eruption Disturbances                             Traumatic occlusion
    Ectopic eruption of maxillary first             possible
    permanent molars
                                                    Lower anterior
    Mesiodens
                                                    recession possible
    Ankylosed primary molars




                                                                                                               4
                                           Ectopic Eruption of Maxillary
                                           First Molar
   III. NON SKELETAL
ORTHODONTIC ISSUES                          Ectopic eruption is a
                                            developmental disturbance
                                            in the eruption of the
  Crowding
                                            permanent dentition where
  Anterior Crossbites                       the first permanent molar
  Eruption Disturbances                     erupts with a mesial
     Ectopic eruption of maxillary first    angulation and resorbs the
     permanent molars                       distal root aspect of the
     Mesiodens                              primary second molar.
     Ankylosed primary molars




Ectopic Eruption of Maxillary
First Molar                                Ectopic Molar Appliance

  Reversible                                Usually in young
    Spontaneous correction                  children
  Irreversible                              Treatment sometimes
    Without treatment will continue to      not possible due to
    resorb the primary molar towards        cooperation or
    early exfoliation and compete for
    arch space with the second              compliance.
    premolar.
                                            Effective if molar is
  Prevalence of 4%                          accessible




Mesiodens                                  What is happening here?

Presentation:
  Delayed eruption of
  incisors
  Diastema
  Severely displaced incisor
  Ectopic or asymmetric
  eruption of central incisors
  Erupted supernumerary
  tooth in midline




                                                                           5
Ankylosed Primary Molars
  Prevalence of 9-13%                                 III. NON SKELETAL
  Presentation:
    Submerging primary molar
                                                   ORTHODONTIC ISSUES
    Primary molar below occlusal plane
                                                     Crowding
  Issues:
     Missing successor                               Anterior Crossbites
     Delayed eruption of successor                   Eruption Disturbances
     Progressive infraocclusion                         Ectopic eruption of maxillary first
     Loss of arch length                                permanent molars
     Difficult extraction with potential
                                                        Mesiodens
     bony defect if no successor.
     Posterior lateral open bite                        Ankylosed primary molars




I. Definitions and Terms:
     Early Treatment
     Preventive, Interceptive, Corrective
     Phase I, Phase II                                    III. SKELETAL
II. Specific goals of early treatment              ORTHODONTIC ISSUES
III. Non skeletal orthodontic issues:
     Crowding                                        Transverse problems
     Anterior Crossbites                             Vertical Problems
     Eruption Disturbances
                                                     Growth Modification
IV. Skeletal orthodontic issues:
     Transverse problems
     Vertical problems
     Growth Modification

V. Summary and Cases




Transverse Problems in the
                                                   Expander Appliances
Mixed Dentition
                                                  How do they work?
                                                    Rapid or slow expansion
Definition: Posterior Crossbite                       Turning frequency
 When the upper teeth bite on the inside of the
                                                    Skeletal expansion: Separates the:
 lower teeth.                                         midpalatal suture
                                                      circumzygomatic and
Classification:                                       circummaxillary sutures.
                                                      Creates a diastema
  Unilateral or Bilateral
  With or without a shift                           Dental expansion:
                                                      Tipping, therefore overcorrection.
  Dental or Skeletal
                                                    Cannot accomplish skeletal expansion once suture is fused.




                                                                                                                 6
Expander Appliances
                                                              Vertical Problems in
                                                               the Mixed Dentition

                                                            • Open Bites
                                                            • Deep Bites


     Hyrax Appliance               Bonded Expander




Open Bites                                                  Habit Reminder Appliances
 Dental open bite
   Related to a digit habit
   Reversibility related to the age the habit is stopped.
     80% spontaneously correct if stopped before 9yo.
     Otherwise, may consider a habit reminder
     appliance.

 Skeletal open bite
   Increased dentoalveolar height
   Supereruption of maxillary teeth
   Phenotype: short posterior face height, long anterior
   face height, high MPA, retruded mandible, maxillary       Anterior Crib Appliance   Blue Grass Appliance
   constriction.




Skeletal Open Bite
early treatment?
  Partial braces (2x4 appliances)
  High Pull Headgear
  Chin Cup
  Transpalatal arch (TPA)
  Lower lingual arch (LLA)
  Tonsillectomy/adenoidnectomy

     Variable results with skeletal early treatments
       Many are case reports
       Long term stability is questionable
     May need to monitor growth and consider                  Lower Lingual Arch       Transpalatal Arch
     orthognathic surgery in the future.




                                                                                                              7
                                               Deep Bites
   Vertical Problems in
    the Mixed Dentition                         Dental deep bite
                                                  Extrusion of anterior teeth
                                                Skeletal deep bite
                                                  Lack of alveolar development
• Open Bites                                      Overclosure

• Deep Bites
                                                Deep bites range from:
                                                  Slightly excessive (50%)
                                                  Palatally impinging (100%)




Deep bite early treatment
                                                      III. SKELETAL
                                               ORTHODONTIC ISSUES
 Anterior bite plate
                                                Transverse problems
 Partial braces
   2x4 appliances
                                                Vertical Problems
                                                Growth Modification



                       The Bite Plate Effect




                                               Class II Growth Modification
                                                Class II
  Growth Modification                             Mandibular deficiency, maxillary
                                                  excess or combination
 Class II                                         Profile: retrognathic, convex
 Class III                                        Molar classification: Class II
                                                  Skeletal discrepancy of jaw
                                                  growth
                                                  Commonly measured using the
                                                  ANB angle




                                                                                     8
Class II Growth Modification                                   Class II Growth Modification

 Indications for Phase I treatment:
   For psychosocial benefit (evidence to                       Skeletal/Orthopedic appliances:
   support)                                                     Headgears
   Decreased risk of tooth fracture if
   accident occurs. (evidence to support)                       Functional appliances

   For better cooperation (some evidence
   to support)                                                 Dental appliances:
   To take advantage of an earlier growth                       Pendulum
   spurt (some evidence to support, but
   growth is so variable that it is difficult to                Partial braces
   select cases)




Orthopedic Appliances: HG                                      Orthopedic Appliances: FA




                                                                                    Herbst - Fixed
                                                             Bionator (Removable)




Dental Distalizers

                                                                    Growth Modification
                                                                 Class II
                                                                 Class III


  Pendulum Appliance                      Pendex Appliance




                                                                                                     9
Class III Growth Modification                                        Class III Growth Modification
Findings:                                                             Indications for Phase I treatment:
  Negative ANB angle                                                    For psychosocial benefit
                                                                        Removal of shift
  Mandibular prognathism
                                                                        Pseudo class III
  Maxillary deficient                                                   Incisal wear risk
  Combination
                                                                        For better cooperation
  Negative overjet
                                                                        To avoid future need for surgery?




Treatment Appliances                                                 Protraction facemask ± RME
Skeletal/Orthopedic Options:
 Protraction Facemask ± RME
 Chin cup

Dental options:
 Expansion
                              “Early Class III treatment is one of
 2x4 appliances               the most difficult undertakings
                              mainly due to the uncertainty of
                              the outcome’s stability after active
                              growth.”            Westwood et al.




I. Definitions and Terms:                                            Summary:
     Early Treatment
     Preventive, Interceptive, Corrective                              Anterior Crossbites
     Phase I, Phase II                                                 Primary molar ankylosis
II. Specific goals of early treatment                                  Impinging deep OB
                                                                       Ectopic eruption
III. Non skeletal orthodontic issues:
       Crowding                                                        Severe crowding
       Anterior Crossbites                                             Loss of arch space or symmetry
       Eruption Disturbances
                                                                       Excessive overjets
IV. Skeletal orthodontic issues:                                       Habits
     Transverse problems
                                                                       Open bites
     Vertical problems
     Growth Modification                                               Posterior Crossbites
                                                                       Growth discrepancies
V. Summary and Cases




                                                                                                            10
Milestone appointments:
   7yo – first orthodontic evaluation
     Supernumerary or missing teeth
     Growth pattern, eruption schedule
   8yo –
                                                                                     CASES
                                         Possible need
     Degree of crowding
                                          for Phase I
     Posterior or Anterior Crossbites      treatment
     Class I, II or III
     Deep bite, open bite, habits
   10yo – Look for permanent canine
   position
                                         Possible need for
                                            Phase II or
   11yo – late mixed dentition            comprehensive
                                            treatment




 Open Bites:                                                 Anterior Crossbites:
 What are some differences?                                  What are some differences?




 Deep Bites:                                                 What early treatment issues do you see?
 What would you check next?




                                                                                                       11
What early treatment issues            I. Definitions and Terms:
                                            Early Treatment
do you see?                                 Preventive, Interceptive, Corrective
                                            Phase I, Phase II

                                       II. Specific goals of early treatment

                                       III. Non skeletal orthodontic issues:
                                              Crowding
                                              Eruption Disturbances
                                              Anterior Crossbites

                                       IV. Skeletal orthodontic issues:
                                            Transverse problems
                                            Vertical problems
                                            Growth Modification

                                       V. Summary and Cases




     Early Treatment in
          Orthodontics
                    Dr. Suzan Ekim
               ekimx001@umn.edu
            Division of Orthodontics
            University of Minnesota
                               2007




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