12/6/2010 1 Orthodontics IV: Orthodontics IV: Management of the Developing Occlusion Management of the Developing Occlusion- Problems We Commonly Face & How to Solve Problems We Commonly Face & How to Solve Them Them Paul K. Chu, DDS Paul K. Chu, DDS St. Barnabas Hospital St. Barnabas Hospital 02 December 2010 02 December 2010 Review Review • A 3 ½ year old girl A 3 ½ year old girl living in an area living in an area where water is where water is fluoridated at 0 10 fluoridated at 0 10 fluoridated at 0.10 fluoridated at 0.10 ppm will receive what ppm will receive what strength fluoride strength fluoride supplement? (Halo supplement? (Halo effect effect notwithstanding) notwithstanding) Review McDonald & Avery Review McDonald & Avery • Is milk cariogenic? Is milk cariogenic? • What type of caries is breast milk What type of caries is breast milk associated with? associated with? associated with? associated with? • What is the CERTAIN LETHAL dose of What is the CERTAIN LETHAL dose of fluoride in children? fluoride in children? • Is milk cariogenic? NO (remember casein) Is milk cariogenic? NO (remember casein) • What type of caries is breast milk What type of caries is breast milk associated with? (Dentinal) associated with? (Dentinal) associated with? (Dentinal) associated with? (Dentinal) • What is the CERTAIN LETHAL dose of What is the CERTAIN LETHAL dose of fluoride in children? (32 fluoride in children? (32-64mg/kg) 64mg/kg) Review Lecture Review Lecture Central Incisor (#a) 14 weeks in utero First Molar (#d) 15 weeks in utero First Molar (#d) 15 weeks in utero Lateral Incisor (#b) 16 weeks in utero Cuspid (#c) 17 weeks in utero Second Molar (#e) 18 weeks in utero Sella Porion Orbitale Nasion Lecture 3: Lecture 3: Standard Cephalometric Landmarks Standard Cephalometric Landmarks Gonion PNS Menton Gnathion Pogonion B Point A Point ANS Articulare
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Orthodontics IV:Orthodontics IV:Management of the Developing OcclusionManagement of the Developing Occlusion--
Problems We Commonly Face & How to Solve Problems We Commonly Face & How to Solve ThemThem
Paul K. Chu, DDSPaul K. Chu, DDSSt. Barnabas HospitalSt. Barnabas Hospital02 December 201002 December 2010
ReviewReview
•• A 3 ½ year old girl A 3 ½ year old girl living in an area living in an area where water is where water is fluoridated at 0 10fluoridated at 0 10fluoridated at 0.10 fluoridated at 0.10 ppm will receive what ppm will receive what strength fluoride strength fluoride supplement? (Halo supplement? (Halo effect effect notwithstanding) notwithstanding)
Review McDonald & AveryReview McDonald & Avery
•• Is milk cariogenic?Is milk cariogenic?•• What type of caries is breast milk What type of caries is breast milk
associated with?associated with?associated with?associated with?•• What is the CERTAIN LETHAL dose of What is the CERTAIN LETHAL dose of
fluoride in children?fluoride in children?
•• Is milk cariogenic? NO (remember casein)Is milk cariogenic? NO (remember casein)•• What type of caries is breast milk What type of caries is breast milk
associated with? (Dentinal)associated with? (Dentinal)associated with? (Dentinal)associated with? (Dentinal)•• What is the CERTAIN LETHAL dose of What is the CERTAIN LETHAL dose of
fluoride in children? (32fluoride in children? (32--64mg/kg)64mg/kg)
Review Lecture Review Lecture
Central Incisor (#a) 14 weeks in utero
First Molar (#d) 15 weeks in uteroFirst Molar (#d) 15 weeks in utero
Where? Draw a PERPENDICULARline from A point to occlusal plane; B point
l l l
Norm: -1, 0, +1
to occlusal plane
Wits Measures?sagittal discrepancy between the upper and lower jaw
Similar to what?
A- N - B
Lecture 4Lecture 4
•• In order from most common to least In order from most common to least common….name the teeth most common….name the teeth most commonly missing…commonly missing…
•• Labially positioned supernumary toothLabially positioned supernumary tooth•• Trauma/Caries (necrotic teeth can cause Trauma/Caries (necrotic teeth can cause
•• Palatal Hawley Palatal Hawley with springwith spring–– Indicated when Indicated when
one or 2 teeth are one or 2 teeth are in CBin CBin CBin CB
–– Esp with lateral Esp with lateral incisorsincisors
–– Good to correct Good to correct arch irregularties arch irregularties alsoalso
Posterior CrossbitesPosterior Crossbites
•• Common 1/13 kids (Common 1/13 kids (KutinKutin et al)et al)•• Not self correctingNot self correcting-- primary posterior CB will be primary posterior CB will be
followed by CB in the mixed dentitionfollowed by CB in the mixed dentition•• Left untreated can develop into a true skeletalLeft untreated can develop into a true skeletal•• Left untreated, can develop into a true skeletal Left untreated, can develop into a true skeletal
defectdefect•• Treatment of CB in primary dentition favors Treatment of CB in primary dentition favors
development of normal occlusion in permanent development of normal occlusion in permanent dentitiondentition
•• After eruptionAfter eruption-- occlusion occlusion locks them into placelocks them into placeoc s t e to p aceoc s t e to p ace
•• In mouth breathers, the In mouth breathers, the tongue can assume a tongue can assume a position in the floor of the position in the floor of the mouth, resulting in mouth, resulting in muscle imbalance and muscle imbalance and subsequent CBsubsequent CB
•• Results from a shift of the Results from a shift of the mandible into an mandible into an abnormal but more abnormal but more comfortable position comfortable position (shifts to the side of the (shifts to the side of the XB)XB)
•• CondylarCondylar position & position & length of length of mandibularmandibularskeletal structures skeletal structures different bilaterally in different bilaterally in children with XB. children with XB.
•• Compensatory growth Compensatory growth occurred after expansion occurred after expansion treatment.treatment.
REMEMBER TO DOCUMENT & REMEMBER TO DOCUMENT & REFER (or TREAT) CROSSBITES!!!REFER (or TREAT) CROSSBITES!!!
Untreated cross bite can lead to:Untreated cross bite can lead to:
--gingival inflammation and recession of the investing gingival inflammation and recession of the investing tissues surrounding the maltissues surrounding the mal--opposed teeth opposed teeth
--occlusal traumaocclusal trauma--enamel abrasion or fractures enamel abrasion or fractures --development of abnormal chewing an swallowing development of abnormal chewing an swallowing
problemsproblems--abnormal growth of the maxilla and the mandibleabnormal growth of the maxilla and the mandible--the development of a permanent Class III dentofacial the development of a permanent Class III dentofacial
abnormalityabnormality--asymmetric growth of the mandibleasymmetric growth of the mandible--temporomandibular joint dysfunction temporomandibular joint dysfunction
PROBLEMS WITH ERUPTIONPROBLEMS WITH ERUPTIONand how to handle themand how to handle them
PROBLEMS WITH ERUPTION OF TEETHPROBLEMS WITH ERUPTION OF TEETH--PERMANENT LATERAL INCISORSPERMANENT LATERAL INCISORS
•• Ectopic Ectopic EruptionEruption-- due due to excessive to excessive mass ormass ormass or mass or inadequate inadequate arch lengtharch length
•• Be prepared if Be prepared if early loss of early loss of canine occurs!canine occurs!
PROBLEMS WITH ERUPTION OF TEETHPROBLEMS WITH ERUPTION OF TEETH--PERMANENT LATERAL INCISORSPERMANENT LATERAL INCISORS
•• Ectopic Ectopic eruption of eruption of laterallateral-- causing causing exfolliation ofexfolliation ofexfolliation of exfolliation of primary canine primary canine & 1& 1stst molar molar may cause may cause transposition transposition of canine! of canine!
PROBLEMS WITH ERUPTION OF TEETHPROBLEMS WITH ERUPTION OF TEETH--PERMANENT LATERAL INCISORSPERMANENT LATERAL INCISORS
•• If ectopic erution If ectopic erution occurs with lateral, occurs with lateral, and no midline shift is and no midline shift is seen, place LLHA seen, place LLHA , p, pwith spurwith spur to prevent to prevent midline shiftmidline shift
PROBLEMS WITH ERUPTION OF TEETHPROBLEMS WITH ERUPTION OF TEETH--PERMANENT LATERAL INCISORSPERMANENT LATERAL INCISORS
•• If ectopic If ectopic erution occurs erution occurs with lateral, with lateral, and midlineand midlineand midline and midline shift IS seen, shift IS seen, extract extract contralateral contralateral primary canine primary canine to prevent to prevent midline shift! midline shift!
PROBLEMS WITH ERUPTION OF TEETHPROBLEMS WITH ERUPTION OF TEETH--PERMANENT CANINESPERMANENT CANINES
Normal Eruption of Normal Eruption of CanineCanine
•• It starts out lingual to the arch It starts out lingual to the arch and mesially directedand mesially directed
•• Changes to a more verticalChanges to a more verticalChanges to a more vertical Changes to a more vertical orientation when it engages orientation when it engages the distal aspect of the lateral the distal aspect of the lateral incisor rootincisor root
•• Continues to erupt into the Continues to erupt into the oral cavity labial to the oral cavity labial to the resorbing deciduous cuspidresorbing deciduous cuspid
•• Often see simultaneous closure Often see simultaneous closure of a maxillary central incisor of a maxillary central incisor diastemadiastema
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PROBLEMS WITH ERUPTION OF TEETHPROBLEMS WITH ERUPTION OF TEETH--PERMANENT CANINESPERMANENT CANINES
•• 33rdrd Molars Molars most most commonly commonly impactedimpacted-- thenthenimpactedimpacted then then caninescanines
•• Why?Why?
PROBLEMS WITH ERUPTION OF TEETHPROBLEMS WITH ERUPTION OF TEETH--PERMANENT CANINESPERMANENT CANINES
Why?Why?•• Tooth has longest period of Tooth has longest period of
developmentdevelopment•• Follows dubious course of Follows dubious course of
developmentdevelopmentdevelopmentdevelopment•• Occupies several Occupies several
developmental positions in developmental positions in successionsuccession
PROBLEMS WITH ERUPTION OF TEETHPROBLEMS WITH ERUPTION OF TEETH--PERMANENT CANINESPERMANENT CANINES
Treatment optionsTreatment options•• Extract primary canines Extract primary canines •• Refer to ortho for chain/ button Refer to ortho for chain/ button
placement by OMFSplacement by OMFS
SPACE REGAININGSPACE REGAINING
SPACE REGAININGSPACE REGAINING
Halterman ApplianceHalterman ApplianceR b !!R b !!•• Remember!!Remember!!
SPACE REGAININGSPACE REGAINING
Penguin/ Penguin/ PendulumPendulum
•• RegainRegain•• Regain Regain maxillary spacemaxillary space
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SPACE REGAININGSPACE REGAINING
Distal JetDistal JetR iR i•• Regain Regain maxillary maxillary spacespace
SPACE REGAININGSPACE REGAINING
Williams Williams ApplianceApplianceApplianceAppliance
•• Mandibular Mandibular ExpansionExpansion
SERIAL EXTRACTIONSERIAL EXTRACTION
SERIAL EXTRACTIONSERIAL EXTRACTION
•• INDICATIONSINDICATIONS•• --only when dental arches are structurally only when dental arches are structurally
inadequate for developing teethinadequate for developing teethinadequate for developing teethinadequate for developing teeth•• --little of no hope of attaining little of no hope of attaining •• --**CLASS I DENTITION ONLY!!!!!!!** **CLASS I DENTITION ONLY!!!!!!!**
SERIAL EXTRACTIONSERIAL EXTRACTION SERIAL EXTRACTIONSERIAL EXTRACTION•• FIRST: Extract Primary Canine (wait 6 FIRST: Extract Primary Canine (wait 6 mosmos, ,
then..)then..)-- usually incisors will self correctusually incisors will self correct•• SECOND: Extract Primary First Molar (wait 6 SECOND: Extract Primary First Molar (wait 6
allows for normal canine eruption)allows for normal canine eruption)
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Functional AppliancesFunctional Appliances
Functional AppliancesFunctional Appliances•• AOA: AOA: “Functional appliances are designed to “Functional appliances are designed to
alleviate skeletal and neuromuscular imbalances. “alleviate skeletal and neuromuscular imbalances. “•• Ideal placement: Early Mixed DentitionIdeal placement: Early Mixed Dentition•• Via changing jaw position, or muscular forces.Via changing jaw position, or muscular forces.
Functional AppliancesFunctional Appliances
•• Class II: Bionator I & 2; Herbst; Frankel; Class II: Bionator I & 2; Herbst; Frankel; T i Bl kT i Bl kTwin BlockTwin Block
•• Class III: Twin Block; FrankelClass III: Twin Block; Frankel
AppliancesAppliances-- FrankelFrankel
The Frankel appliances are removable designs 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
•• Class II correction (growth and Class II correction (growth and forward movement of forward movement of mandible) mandible)
•• Wax bite is usually taken Wax bite is usually taken forward in a Class I position (if forward in a Class I position (if comfortable for patient) with comfortable for patient) with co o tab e o pat e t) tco o tab e o pat e t) t22--3mm vertical opening 3mm vertical opening between posterior teeth. between posterior teeth.
•• Initially, the appliance is used Initially, the appliance is used to encourage forward growth to encourage forward growth or advancement of the or advancement of the mandible. Later, the appliance mandible. Later, the appliance can be further utilized to open can be further utilized to open the bite by removing the the bite by removing the posterior bite pads; or, by posterior bite pads; or, by removing the anterior cap, it removing the anterior cap, it can close the bite. can close the bite.
AppliancesAppliances-- Twin BlockTwin Block•• Indicated for : Class II Division Indicated for : Class II Division
I; Class II Division 2; Class I I; Class II Division 2; Class I open bites; Class I closed bites; open bites; Class I closed bites; Class III occlusions.Class III occlusions.
•• Unlike bulky, oneUnlike bulky, one--piece piece functional appliances, the Twin functional appliances, the Twin Block has separate, unattached Block has separate, unattached upper and lower bite blockupper and lower bite blockupper and lower bite block upper and lower bite block components components -- actually two actually two appliances which work together appliances which work together as one. as one.
•• In function, these two In function, these two appliances interlock at the 70 appliances interlock at the 70 degree angle set into the bite degree angle set into the bite blocks and posture the mandible blocks and posture the mandible forward into the ideal Class I forward into the ideal Class I position preset by your wax position preset by your wax registration.registration.
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AppliancesAppliances-- HerbstHerbst
The Herbst appliance-positions mandible anteriorly
•• High Pull HeadgearHigh Pull Headgear•• Will deepen biteWill deepen bite-- for for
use in clockwise use in clockwise rotating patientsrotating patientsrotating patients rotating patients (i.e. Class II (i.e. Class II openbite)openbite)
Headgear AppliancesHeadgear Appliances
•• Cervical Pull HeadgearCervical Pull Headgear•• Will open biteWill open bite-- for use for use
in counterclockwise in counterclockwise t ti ti t (it ti ti t (irotating patients (i.e. rotating patients (i.e.
--for Class III Occlusionfor Class III OcclusionRemember, patient compliance is Remember, patient compliance is
key in headgear success!key in headgear success!key in headgear success!key in headgear success!
Ok so what do we do with all this Ok so what do we do with all this knowledge???knowledge???knowledge???knowledge???
OrhtodonticsOrhtodontics-- when?when?
•• Best to get a screening by Age 7 (AAO)Best to get a screening by Age 7 (AAO)
OrhtodonticsOrhtodontics-- early treatment early treatment indications? (indications? (DugoniDugoni 1995)1995)
•• Dental/skeletal Class Dental/skeletal Class II or IIIII or III
•• Ant/Post XBAnt/Post XB
•• Periodontal Periodontal compromisecompromise
•• Ant OB > 3mmAnt OB > 3mm•• More than 6mm OJMore than 6mm OJ•• Max midface defMax midface def•• Mod incisor crowdingMod incisor crowding•• Ectopic erutpionsEctopic erutpions
•• Severe deepbite w/ Severe deepbite w/ palatal impingmentpalatal impingment
Orhtodontic AppliancesOrhtodontic Appliances--Mixed Dentition Phase IMixed Dentition Phase I
•• Purpose: To establish Purpose: To establish normal, vertical, normal, vertical, transverse, & sagittal transverse, & sagittal dental & skeletaldental & skeletaldental & skeletal dental & skeletal relationships relationships –– NOT NOT necessarily to prevent necessarily to prevent the need for full, fixed the need for full, fixed appliances. appliances.
•• banded molars & bracketed banded molars & bracketed incisorsincisors-- allows for molar allows for molar derotation/uprighting/incisor derotation/uprighting/incisor levelling, alignment, & levelling, alignment, & g gg gintrusionintrusion
•• creates a more normal creates a more normal relationship between the lips, relationship between the lips, teeth, tongue, and jaws, as teeth, tongue, and jaws, as well as reduces the risk of well as reduces the risk of fracturing the upper incisors fracturing the upper incisors
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2 x 42 x 4•• banded molars & bracketed banded molars & bracketed
incisorsincisors-- allows for molar allows for molar derotation/uprighting/incisor derotation/uprighting/incisor levelling, alignment, & levelling, alignment, & intrusionintrusion
•• A: arch wire is free to slide A: arch wire is free to slide through molar tubethrough molar tube incisorsincisorsthrough molar tubethrough molar tube-- incisors incisors tip anteriorly and extrudetip anteriorly and extrude--corrects anterior XBcorrects anterior XB
•• B: arch wire cinchedB: arch wire cinched--wire wire doesn’t slidedoesn’t slide-- extrudes incisors extrudes incisors due to lingual torque due to lingual torque –– mesial mesial force on molarforce on molar
•• Purpose: to accomplish 6 Purpose: to accomplish 6 keys of occlusionkeys of occlusion
•• Includes both orthopedic Includes both orthopedic (headgear/functional) & (headgear/functional) & ( eadgea / u ct o a ) &( eadgea / u ct o a ) &orthodontic (full, fixed orthodontic (full, fixed edgewise) edgewise)
•• If Phase I completedIf Phase I completed-- 1212--18 mos18 mos
•• Max/Mand Hawley Max/Mand Hawley retainers must be worn retainers must be worn 24hrs/day first 4 mos 24hrs/day first 4 mos yyafter debracketing.after debracketing.
•• Then next 8 mos at Then next 8 mos at nightnight
•• After 1 yearAfter 1 year-- 11--2 nights 2 nights per week.per week.
Complications of Orthodontic Complications of Orthodontic TherapyTherapy
N it l t thN it l t th•• Nonvital teethNonvital teeth•• Root resorptionRoot resorption•• Relapse (2/3 relapse Relapse (2/3 relapse
without some form without some form of retention)***of retention)***
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Does TMD develop with Does TMD develop with orthdontics?orthdontics?
•• May occur coincidentally with May occur coincidentally with t t tt t t b t NOT llb t NOT lltreatmenttreatment-- but NOT usually but NOT usually because of tx.because of tx.
•• No relation has been found No relation has been found between malocclusion & between malocclusion & TMD.TMD.
Do 3Do 3rdrd Molars contribute to Molars contribute to crowding?crowding?
•• No difference in incisor crowding No difference in incisor crowding in pts with impacted, erupted, in pts with impacted, erupted, missing, or extracted 8’s.missing, or extracted 8’s.
•• Indications for exo? Pathology, Indications for exo? Pathology, external root resorption, external root resorption, pericornitis, caries.pericornitis, caries.
•• Predict impaction? If distance Predict impaction? If distance from distal of 7 to anterior from distal of 7 to anterior border of the ramus is greater border of the ramus is greater or equal to length of developing or equal to length of developing 33rdrd molar crown there is a 70% molar crown there is a 70% chance of eruption. chance of eruption.
Journal of Pediatric DentistryJournal of Pediatric Dentistry--Nov/Dec 2005 Nov/Dec 2005
•• Parents’ satisfaction with their child’s Orthodontic Care: A Parents’ satisfaction with their child’s Orthodontic Care: A comparison of Orthodontists & Pediatric Dentistscomparison of Orthodontists & Pediatric Dentists
•• Found parents equally happy with both doctors delivering Found parents equally happy with both doctors delivering treatmenttreatmenttreatment.treatment.
•• Pediatric dentists treated cases 9 mos earlier than Pediatric dentists treated cases 9 mos earlier than orthodontists.orthodontists.
•• Patients treated by the pediatric dentist were more racially Patients treated by the pediatric dentist were more racially diverse.diverse.
•• Orthodontists 3x more likely to extract primary teeth than Orthodontists 3x more likely to extract primary teeth than pediatric dentist.pediatric dentist.
•• Orhtodontists 14x more likely to treat Phase II cases. Orhtodontists 14x more likely to treat Phase II cases.
So, if you are interested in So, if you are interested in Ortho.. PURSUE IT!Ortho.. PURSUE IT!
To doTo do-- Holiday party (gift, small food Holiday party (gift, small food item) if you have time cook item) if you have time cook somethingsomething--Greg’s Greg’s bdaybday-- TannenTannen leaving leaving earlyearly--5:305:30--66