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Aliakbar Bahreman, DDS, MS Clinical Professor Orthodontic and Pediatric Dentistry Programs Eastman Institute for Oral Health University of Rochester Rochester, New York EARLY-AGE ORTHODONTIC TREATMENT Quintessence Publishing Co, Inc Chicago, Berlin, Tokyo, London, Paris, Milan, Barcelona, Beijing, Istanbul, Moscow, New Delhi, Prague, São Paulo, Seoul, Singapore, and Warsaw
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Page 1: ORTHODONTIC TREATMENT - Quintessence Publishing!

Aliakbar Bahreman, DDS, MSClinical Professor

Orthodontic and Pediatric Dentistry ProgramsEastman Institute for Oral Health

University of RochesterRochester, New York

EARLY-AGEORTHODONTIC

TREATMENT

Quintessence Publishing Co, Inc

Chicago, Berlin, Tokyo, London, Paris, Milan, Barcelona, Beijing, Istanbul, Moscow, New Delhi, Prague, São Paulo, Seoul, Singapore,

and Warsaw

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Foreword by J. Daniel Subtelny vii Preface and Acknowledgments viii–ix Introduction x

Part I Clinical and Biologic Principles of Early-Age Orthodontic Treatment 1

1 Rationale for Early-Age Orthodontic Treatment 3

2 Development of the Dentition and Dental Occlusion 15

3 Examination, Early Detection, and Treatment

Planning 41

Part II Early-Age Orthodontic Treatment of Nonskeletal Problems 71

4 Space Management in the Transitional Dentition 73

5 Management of Incisor Crowding 105

6 Management of Deleterious Oral Habits 131

7 Orthodontic Management of Hypodontia 157

8 Orthodontic Management of Supernumerary Teeth 189

9 Diagnosis and Management of Abnormal Frenum

Attachments 205

10 Early Detection and Treatment of Eruption

Problems 225

Contents

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Part III Early-Age Orthodontic Treatment of Dentoskeletal Problems 291

11 Management of Sagittal Problems

(Class II and Class III Malocclusions) 293

12 Management of Transverse Problems

(Posterior Crossbites) 355

13 Management of Vertical Problems

(Open Bites and Deep Bites) 377

Index 417

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This book is a compendium of signifi cant and pertinent in-formation related to early-age orthodontic treatment, a sub-ject that seems to have evolved into one of considerable controversy, with as many orthodontists expressing a nega-tive reaction as a positive reaction to its benefi ts. Dr Bahre-man is a believer in early-age orthodontic treatment, and he expresses some cogent arguments founded in years of ex-perience in practice and teaching to back up his beliefs. In developing his treatise, Dr Bahreman outlines the develop-ment of the occlusion and/or malocclusion from the embry-onic stages, when the foundation of the jaws and thereby the position of the dentition is fi rst established.

Early-age orthodontics is not about the time it takes to orthodontically treat a problem; it is a story of growth, of variation in anatomy, and of muscle function and infl uenc-es, a realization that it is the jaws that contain the teeth and that where the jaws go, the teeth will have to go, and

both undergo varying infl uences as well as grow in varying directions. Early-age orthodontics necessitates recognition of this process and aims to alter and redirect it whenev-er feasible and possible. Dr Bahreman has undertaken a monumental effort in directing efforts along this path. An extensive exploration of the literature is an added bonus, as the mechanical approaches are based on this literature. In fact, the extensive review of the literature and its applica-tion to diagnosis and varying forms of therapy are worth a veritable fortune.

You may or may not agree with the basic premises, but you will have access to important information that will wid-en your scope of vision and thereby widen your treatment horizons. To my mind, an ounce of prevention, if possible, is worth a pound of cure. The reality of prevention can exist at the earliest stages of development.

J. Daniel Subtelny, DDS, MS, DDSc(Hon) Professor Emeritus

Interim Chair and Director of Orthodontic Program

Eastman Institute for Oral Health

University of Rochester

Rochester, New York

Foreword

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After obtaining a master’s degree in orthodontics in 1967, I began my career at a newly founded dental school in Tehran. My responsibilities included teaching and administrative du-ties at the university and maintenance of a very busy private practice. In addition, I established both the orthodontic and pediatric dentistry departments at the university.

Many patients were being referred to the orthodontic de-partment, and there were no qualifi ed faculty members to help me provide care. To rectify the situation, I designed an advanced level, comprehensive curriculum in orthodontics for undergraduate students, including classroom instruction, laboratory research, and clinical demonstrations. Once the students completed the course, they could work in the clinic, thus temporarily solving the issue of the heavy patient load in the orthodontic clinic. With additional staff now available, I could select patients, mostly children in the primary or mixed dentition, for some interceptive treatment.

Despite my diffi culties in performing all of the aforemen-tioned duties, this situation had a fortunate outcome. It helped me to understand and discover the advantages of early-age orthodontic treatment, which was not common in those years. During my more than 40 years of practice and teaching, especially in early orthodontic treatment, I have accumulated a considerable amount of educational data for teaching pur-poses. I would like to share this experience and information with readers.

The public’s growing awareness of and desire for dental services, especially at an early age, have encouraged our pro-fession to treat children earlier. Despite the recommendation by the American Association of Orthodontists that orthodon-tic screening begin by the time a child is 7 years old, many orthodontists still do not treat children prior to the complete eruption of the permanent teeth. I believe that this inconsis-tency is due to the educational background of orthodontists as well as a lack of familiarity with recent technical advance-ments and the various treatment options that are available for young patients.

The therapeutic devices available for this endeavor are not complex, but deciding which ones to use and when to employ them are important steps. As we make these decisions, we should also remember not to treat the symptom but rather to treat the cause. My goal is to present the basic information necessary to understand the problems, to differentiate among various conditions, and to review different treatment options. Case reports are examined to facilitate clinical application of the theory in a rational way.

To understand the morphogenesis of nonskeletal and skel-etal occlusal problems, to detect problems early, and to inter-vene properly, we must look at all areas of occlusal develop-ment, including prenatal, neonatal, and postnatal changes of the dentoskeletal system, and explore all genetic and envi-ronmental factors that can affect occlusion at different stages of development. In other words, we must have a profound understanding of the fundamental basis and morphogenesis of each problem and then apply this knowledge to clinical practice. Thus, the goals of this book are:

• To provide a comprehensive overview of all areas of dental development, from tooth formation to permanent occlu-sion, to refresh the reader’s memory of the fundamentals necessary for diagnosis and treatment planning.

• To emphasize all the important points of the developmen-tal stages that must be recognized during examination of the patient to facilitate differential diagnosis. Each tooth can become anomalous in a number of ways and to different degrees. Occlusion and maxillomandibular relationships can vary in the sagittal, transverse, and vertical directions.

• To discuss the application of basic knowledge to practice by presenting several cases with different problems and differ-ent treatment options.

• To demonstrate the benefi ts of early-age orthodontic treat-ment, achieved by intervention in developing malocclusion and guidance of eruption.

Materials are presented in three parts: In Part I, “Clinical and Biologic Principles of Early-Age Orthodontic Treatment,” three chapters introduce and explain the concept of early-age treat-ment, describe its necessity and advantages, and discuss the controversies surrounding this topic; discuss the basic foun-dation of occlusal development, empowering the practitioner to detect anomalies and intervene as necessary; and illustrate the procedures, tools, and techniques available for diagnosis, emphasizing differential diagnosis and treatment planning for early-age treatment.

Part II, “Early-Age Orthodontic Treatment of Nonskeletal Problems,” consists of seven chapters describing the non-skeletal problems that might develop during the primary and mixed dentitions. The chapters explain the ontogeny, diagno-sis, and early detection of, and intervention for, these prob-lems. Topics include space management, crowding, abnormal oral habits, abnormal frenum attachment, hypodontia, super-numerary teeth, and abnormal eruption problems.

Preface

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Part III, “Early-Age Orthodontic Treatment of Dentoskeletal Problems,” consists of three chapters on early intervention for the dentoskeletal problems that might arise during the pri-mary and mixed dentitions in the three dimensions: sagittal problems (anterior crossbite and Class II and Class III maloc-clusions); transverse problems (posterior crossbites); and ver-tical problems (open bites and deep bites).

This book will provide the reader with a fi rm foundation of the basic science and case examples with various treatment options. It is my hope that the information provided will pro-mote a better understanding of abnormalities and their causes and enable readers to recognize the clues for early detection and intervention.

Acknowledgments

First and foremost, I would like to gratefully acknowledge the valuable opportunity that was afforded me as a student in Dr Daniel Subtelny’s orthodontic program. Between 1964 and 1967, I completed both my orthodontic specialty and master degree programs with Dr Subtelny as my mentor. As chairman and program director, researcher, and mentor, Dr Subtelny has dedicated over 57 years of his life to teaching, personally infl uencing the lives of over 350 students from around the world, myself included. In 1999, after over 32 years of teaching, practicing, and administrating in Tehran, I was fortunate enough to return to the Eastman Institute for Oral Health to work alongside Dr Subtelny as a faculty mem-ber in the Orthodontic and Pediatric Dentistry Programs.

In addition to Dr Subtelny, there are several individuals to whom I would like to express my deep gratitude for their help and encouragement in preparation of this book: the late Dr Estepan Alexanian, head of the Department of His-tology at the Shahid Beheshti University Dental School in

Tehran, whose dedication as an educator and preparation of superb histologic slides is remarkable and who allowed me to use his slides in my publication; Mr Aryan Salimi for scanning some of the slides and radiographs in this book; and Ms Elizabeth Kettle, Program Chair of the Dental Sec-tion of the Medical Library Association, head of Eastman’s library, for her sincere help in editing this publication.

Finally, I wish to acknowledge the constant support of my family: Malahat, Nasreen, Saeid, Alireza, Tannaz, and Peymann Motevalei. Especially high gratitude goes to my wife, Malahat, for her tolerance, support, and encourage-ments. I also want to thank my son Alireza for his technical help and guidance in computer skills and my granddaughter Tannaz Motevalei for drawing some of the illustrations.

This publication is the product of 17 years spent orga-nizing materials derived from my 45 years of practice and teaching as well as reviewing hundreds of articles and books. I herewith dedicate this book to the teachers, practi-tioners, residents, and students who are dedicated to treat-ing malocclusion earlier in children, before it becomes more complicated and costly.

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Occlusal development is a long process starting around the sixth week of intrauterine life and concluding around the age of 20 years. This long developmental process is a sequence of events that occur in an orderly and timely fashion under the control of genetic and environmental factors. Dental oc-clusion is an integral part of craniofacial structure and coordi-nation of skeletal growth changes. Occlusal development is essential for establishing a normal and harmonious arrange-ment of the occlusal system.

As we learn about craniofacial growth changes, the poten-tial infl uences of function on the developing dentition, and the relationships of basal jawbones and head structure, we acquire a better understanding of when and how to inter-vene in the treatment guidance for each patient. It is more effective to intervene during the primary or mixed dentition period to reduce or, in some instances, avoid the need for multibanded mechanotherapy at a later age.

Untreated malocclusions can result in a variety of prob-lems, including susceptibility to dental caries, periodontal disease, bone loss, temporomandibular disorders, and un-desirable craniofacial growth changes. Moreover, the child’s appearance may be harmed, which can be a social handicap. The benefi ts of improving a child’s appearance at an early age should not be undervalued. The goals of many clinicians who provide early treatment are not only to reduce the time and complexity of comprehensive fi xed appliance therapy but also to eliminate or reduce the damage to the dentition and supporting structures that can result from tooth irregu-larity at a later age. In short, early intervention of skeletal and dental malocclusions during the primary and mixed dentition stages can enable the greatest possible control over growth changes and occlusal development, improving the function, esthetics, and psychologic well-being of children.

For many decades, orthodontists have debated about the best age for children to start orthodontic treatment. While we agree on the results of high-quality orthodontic treatment, we often differ in our opinions as to how and when to treat the patient. Some practitioners contend that starting treat-ment in the primary dentition is the most effective means of orthodontic care. Others prefer to begin the treatment in the mixed dentition. There is also controversy about whether the early, middle, or late mixed dentition is preferable.

Despite the fact that the American Association of Ortho-dontists recommends that orthodontic screening be started by the age of 7 years, many orthodontists do not treat chil-dren prior to the eruption of permanent teeth, and some postpone the treatment until the full permanent dentition

has erupted, at approximately 12 years. The controversy sur-rounding early versus late treatment is often confusing to the dental community; therefore, clinicians must decide on a case-by-case basis when to provide orthodontic treatment. Indeed, there are occasions when delaying treatment until a later age may be advisable.

The long-term benefi ts of early treatment are also con-troversial. The majority of debates seem to revolve around early or late treatment of Class II malocclusions. There is less controversy regarding many other services that can be per-formed for the benefi t of young patients during the primary or mixed dentition, such as treatment of anterior and poste-rior crossbite, habit control, elimination of crowding, space management, and management of eruption problems.

Practitioners who are in favor of early treatment of Class II problems contend that early intervention is the best choice for growth modifi cation when the problem is skeletal and especially when it results from mandibular retrusion. On the other hand, opponents believe that there is no difference in the fi nal result and that a single-phase treatment approach is preferable because of the advantages that accompany the reduced treatment time.

Unfortunately, some practitioners, without a profound evaluation of the indications for early treatment, conclude that late treatment is always preferable. However, broad conclusions drawn from narrowly focused research can be misleading. One cannot conclude that no birds can fl y by considering the fl ight characteristics of the ostrich.

To evaluate and demonstrate the benefi ts of early treat-ment, I aim to discuss and clarify available treatments and services and discuss cases with different problems and dif-ferent treatment options. An understanding of all aspects of early treatment requires a thorough knowledge of the basics of embryology, physiology, and growth and development. This includes development of the dentition, tooth formation, eruption, exfoliation, and all transitional changes. Therefore, my other goal is to integrate the basic science and the clini-cal, in order to refresh the reader’s memory on important points about the bases of nonskeletal and skeletal problems that can arise during the transitional stages of occlusion.

Each patient who enters our practice represents a new chapter and a new lesson that we can learn from. A thorough knowledge of the basis for early-age orthodontic treatment, an understanding of the proper treatment techniques, and a willingness to consider their appropriateness for each in-dividual patient will allow us to intervene in ways that will provide the maximum benefi t for a young and growing child.

Introduction

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CLINICAL AND BIOLOGIC PRINCIPLES OF EARLY-AGE ORTHODONTIC TREATMENT

IPART

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Rationale for Early-Age Orthodontic Treatment1

3

In the past, orthodontic treatment has been focused mainly on juvenile and adult treatment. Treatment options for patients in these age groups often are limited by complex dental and orthodontic problems and the lack of suffi cient future cranio-facial growth.

During the later part of the 18th century, orthodontic treatment of Class II malocclusion was limited primarily to retrac-tion of the maxillary anterior teeth to decrease excessive overjet. In 1880, Norman Kingsley1 published a description of techniques for addressing protrusion. He was among the fi rst to use extraoral force to retract the maxillary anterior teeth after extraction of the maxillary fi rst premolars; the extraoral force was applied with headgear. Later, Case2 continued to refi ne these methods.

Angle’s classifi cation3 of malocclusion, published in the 1890s, provided a simple defi nition of normal occlusion and was an important step in the development of orthodontic treatment. Angle opposed the extraction of teeth and favored the preservation of the full dentition. His position against tooth extraction led him to depend on extraoral force for the expan-sion of crowded dental arches and retraction of the anterior segment. Later he discontinued the use of extraoral force and advocated the use of intraoral elastics to treat sagittal jaw discrepancies.

Because of Angle’s dominating belief that treatment with Class II elastics was just as effective as extraoral force, the use of headgear was abandoned by the 1920s. Then, in 1936, Oppenheim4 reintroduced the concept of extraoral anchorage, employing extraoral traction to treat maxillary protrusion. Accepting the position of the mandible in Class II malocclusions, Oppenheim attempted to move the maxillary dentition distally by employing a combination of occipital anchorage and an E-arch, allowing the mandible to continue its growth. This resulted in an improved relationship with the opposing jaw. In 1947, Silas Kloehn5 reintroduced extraoral force, in the form of cervical headgear, for the treatment of skeletal Class II relationships.

In 1944, another student of Angle’s, Charles Tweed,6 was discouraged by the prevalence of relapse in many of his pa-tients treated without extraction, so he decided to oppose the conventional wisdom of nonextraction.

In the early part of the 20th century, there was optimism about the infl uence of orthopedic force on skeletal growth. An almost universal belief was that orthodontic forces, if applied to the growing face, could alter the morphologic outcome. In the United States, headgear was the principal appliance used for facial orthopedic treatment, whereas in Europe the functional appliance was predominantly used.

In 1941, Alan Brodie,7 one of Angle’s students, concluded that the growing face could not be signifi cantly altered from its genetically predetermined form and that the only option for the orthodontist in cases of skeletal malocclusion would be dental camoufl age, or the movement of teeth within their jaws. This idea led to tooth extraction.

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Examination, Early Detection, and Treatment Planning3

60

Panoramic radiographs

The panoramic radiograph is a common diagnostic tool in today’s dental practice. It is a kind of radiograph that pro-vides a full picture of the dentition and the complete maxilla and mandible.

Panoramic radiographs do not show the fi ne detail captured on intraoral radiographs and are not as specifi c as other intraoral radiographs, but in a single radiograph it provides a useful general view of all dentition, the maxilla and mandible, the sinuses, and both TMJs. This type of radiograph is very useful, especially during the mixed dentition, for early detection and prevention of all problems disturbing the normal development of occlusion.

Especially during the mixed dentition as a diagnostic tool for early-age orthodontic treatment, the following are important aspects that should be carefully evaluated on a panoramic radiograph before any orthodontic treatment:

• Position and pattern of fully emerged as well as emerging permanent teeth

• Sequence of permanent tooth eruption• Asymmetric eruption• Comparison of crown height levels on the left and right

sides• Obstacles preventing eruption• Abnormal tooth malformations (gemination, fusion, dens

in dente, or dilaceration)• Exfoliation and pattern of primary teeth root resorption• Tooth number and supernumerary teeth or congenitally

missing teeth• Eruption problems, such as impaction, ectopic, transposi-

tion, or ankylosis• Bone density and trabeculation• Cysts, odontomas, tumors, and other bone defects or

pathologic lesions• Third and second molar positions, inclinations, and rela-

tionships to the fi rst molars and ramus edge• Shape of the condylar head and ramus height• Comparison of the left and right condylar heads and rami

The characteristics and management of these problems are discussed in their related chapters in part 2 of this book. Chapter 10 introduces a simple and practical technique for application of panoramic radiographs to assess canine im-paction.

Longitudinal Panoramic

Radiograph Monitoring

Over many years of teaching and practice, in both pediat-ric dentistry and orthodontic departments, the author be-came interested in conducting a retrospective evaluation of patients who were referred for some type of orthodontic problem and who had previous panoramic radiographs avail-able. This retrospective evaluation led to the conclusion that the longitudinal monitoring of panoramic radiographs dur-ing the mixed dentition is a very valuable, easy technique that enables detection of developmental anomalies during the transitional dentition. Today the author strongly recom-mends this easy and very useful technique to all practitio-ners, especially pediatric dentists and orthodontists.

The transitional dentition is one of the most critical stages of the dentition, and many eruption problems, whether hereditary or environmental, emerge during this stage. Longitudinal panoramic radiograph monitoring is a careful serial monitoring technique that any practitioner can perform for young patients during transitional dentition to watch for developmental anomalies that may arise at these ages.

The technique the author recommends is to take one panoramic radiograph when the patient is around the age of 6 years (during the eruption of the permanent fi rst molar) and then two more panoramic radiographs at 8 and 10 years of age. Careful comparison of two or three consecutive radiographs of a patient at this stage of the dentition can easily reveal any abnormal developmental processes emerging between radiographs and therefore can enable early detection and intervention. The following three cases illustrate the advantages of longitudinal monitoring of panoramic radiographs and proper intervention.

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Longitudinal Panoramic Radiograph Monitoring

This case confi rms the importance of longitudinal radiographic evaluation, indicating how early interven-tion could have helped this little girl. Figures 3-23a to 3-23c are three consecutive radiographs found in her record. A periapical radiograph reveals the fi rst sign of a problem, that is, asymmetric eruption of the central incisors at age 7 years. A panoramic radiograph taken about 15 months later shows the eruption of both central incisors and the asymmetric position of the lateral incisors. A third radiograph, a panoramic radiograph taken about 7 months later, reveals that the left lateral incisor had erupted while the right lateral incisor remained unerupted.

The important, detectable abnormal sign in this radiograph is the abnormal position of the maxillary permanent right canine in relation to the unerupted lateral incisor; unfortunately, no intervention was performed at this point, and the patient did not return until 3 years later. Figures 3-23d and 3-23e present the last panoramic and occlusal views, showing the complete resorption of the permanent lateral incisor root.

Possible intervention:Assessment of the available serial radiographs indicates that the best treatment option was early inter-vention and extraction of the maxillary primary right canine when the fi rst (see Fig 3-23b), or even the second (see Fig 3-23c), panoramic radiograph was taken. Extraction of the maxillary primary right canine would have facilitated and accelerated eruption of the permanent lateral incisor, moving this tooth away from the canine forces and preventing root resorption (see Figs 3-23d and 3-23e).

Fig 3-23 (a) Periapical radiograph showing asymmetric eruption of the maxillary central incisors. (b) Panoramic radiograph taken about 15 months later, showing the eruption of both central incisors and the asymmetric position of the lateral incisors. (c) Panoramic radiograph taken 7 months after the fi rst panoramic radio-graph, revealing that the right lateral incisor remains unerupted. Panoramic (d) and occlusal (e) radiographs taken 3 years later. In the absence of treatment, the permanent lateral incisor has undergone complete root resorption.

a

c

b

d

e

Case 3-1

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Space Management in the Transitional Dentition4

88

This type of unilateral regainer is recommended in cases where the force is to be directed only to the molar in the maxillary dentition.

Sliding loop and lingual arch. This appliance is designed similarly to the sliding loop regainer, but it includes a lingual holding arch connected to the opposite molar band to pro-vide anchorage and prevent adverse effects on the anterior component (Fig 4-21).

Pendulum appliance (molar distalizer). The pendulum appliance is a fi xed bilateral or unilateral molar distalizer. It is designed with two bands cemented to the primary fi rst molars or the premolars and an acrylic resin button touch-ing the palate to provide good anchorage. One end of a β-titanium spring is embedded in acrylic and the other end

is inserted in the palatal tube, making the spring removable (Fig 4-22). The appliance can be activated at each appoint-ment. This type of distalizer is indicated for the permanent dentition, in cases of space loss or Class II molar correc-tion.

Distal jet appliance. The distal jet appliance is also a fi xed unilateral or bilateral distalizer with an acrylic resin button for anchorage. Bands are cemented to the anterior abut-ment, and two bars with open coil spring slide to embed-ded tubes for activation. The bars connected to the molar palatal tube can be removed, and the push coil can be re-activated (Fig 4-23).

2 × 4 bonding. Molar distalization and space regaining can be achieved as a part of 2 × 4 bonding in patients who need

Fig 4-17 Fixed unilateral sliding loop space regainer.

Fig 4-18 Gurin lock space regainer. Fig 4-19 Band and U-loop space regainer. (Courtesy of Great Lakes Orthodontics.)

Fig 4-20 Molar distalizer with Nance anchorage. (a) Space loss at the time of appliance placement. (b) Space regained at the end of treatment.

a b

Fig 4-21 Mandibular molar distalizer. (Courtesy of Great Lakes Orthodontics.)

Fig 4-23 Distal jet appliance for molar distal-ization. (Courtesy of Great Lakes Ortho-dontics.)

Fig 4-22 Pendulum distalizer with spring activation on the right molar. The distalizer in this image also includes a screw for expansion.

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Space Regaining

incisor alignment (such as space closure, crossbite correc-tion, or midline shift) during the early or middle mixed denti-tion. A light force can be applied to molars by a push coil inserted between lased incisors and the permanent molar tube (Fig 4-24).

Sectional bracketing. In patients with normal occlusion and space loss in one quadrant, minor tooth movement and space regaining can be achieved by sectional bracketing. Figure 4-25 shows a patient with a good Class I mandibular and maxillary left dentition. The problem is space loss at the maxillary right second premolar site that has resulted from mesial tipping of the molar and distal tipping of the fi rst pre-

molar. Sectional bracketing of this segment, leveling with a sectional archwire, and placement of a push coil between the tipped molar and premolar can open space and upright the adjacent teeth.

Removable space regainers

Removable appliances can also be used for space regaining as well as space maintenance. This can be accomplished by incorporating different springs or screws in the appliance, either unilaterally or bilaterally. A Hawley appliance with different modifi cations is a simple, effective appliance that can be used for all of these purposes (Fig 4-26).

Fig 4-24 (a to d) Push coil and 2 × 4 bonding to regain space for the maxillary second premolars.

a b

c d

Fig 4-25 Sectional bracketing to open space for the maxillary right premolar.

Fig 4-26 Hawley removable space regainers with jackscrews. (a and b) Bilateral removable regainers for the maxilla. (c) Bilateral removable regainer for the mandible. (d) Unilateral removable regainer for the maxilla.

a b

dc

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Orthodontic Management of Supernumerary Teeth8

196

Fig 8-7 (a) Parapremolar supernumerary teeth preventing eruption of mandibular premo-lars. (b) Paramolar supernumerary teeth damaging the permanent fi rst molar roots.

Fig 8-6 Supplemental mandibular supernu-merary tooth (arrow) causing crowding, mid-line shift, and arch asymmetry.

a b

Early Recognition and

Clinical Signs of Hyperdontia

Development of supernumerary teeth can occur any time during the primary dentition, mixed dentition, and the per-manent dentition. They are almost always harmful to adja-cent teeth and to the occlusion. Most cases of supernumer-ary teeth are asymptomatic and are usually found during routine clinical or radiologic investigations. Therefore, early recognition of and treatment planning for supernumerary teeth are important components of the preliminary assess-ment of a child’s occlusal status and oral health, which is based on careful clinical and paraclinical examinations.

Clinical examination

Clinical examination of children during the primary or mixed dentition is discussed in detail in chapter 3. When assess-ing supernumerary teeth in the developing occlusion of a child, the clinician must consider the number, size, and form of teeth, the eruption time, the sequence of eruption, the position of each tooth, and local and general factors that can affect occlusion during transitional changes. The following are clinical signs of the presence of supernumer-ary teeth:

• Abnormal pattern and abnormal sequence of eruption• Delayed eruption• Absence of eruption

Fig 8-5 (a to h) Various supernumerary teeth, affecting occlusion in many different ways.

a

d f

b

e

g

c

h

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Diagnosis and Management of Abnormal Frenum Attachments9

218

Case 9-2

A 10-year, 8-month-old girl exhibited a Class II division 1 malocclusion and maxillary and mandibular incisor protrusion. In addition, an invasive frenum attachment caused severe maxillary incisor crowding, displacement, and cystic formation (Figs 9-19a to 9-19e).

Treatment:The treatment plan included removal of the frenum, the cyst, and all abnormal soft tissue attachment and extrac-tion of the four fi rst premolars, carried out as a serial step-by-step extraction.

After the surgical procedure and tissue healing, a removable maxillary Hawley appliance was inserted to achieve slow, minor incisor alignment, and use of a lower holding arch for about 1 year was followed by step 1 of the extraction series: removal of the maxillary primary canines, both maxillary primary fi rst molars, and both mandibular primary fi rst molars. Figure 9-19f shows alignment of the maxillary incisors and the canine bulges before serial extraction.

Step 2 was extraction of all four fi rst premolars. Maxillary anchorage was prepared with a Nance appliance, and the lower holding arch was removed as reciprocal anchorage.

Step 3 of the extraction sequence was removal of the remaining primary second molars. This was followed by maxillary and mandibular bonding to start maxillary canine retraction. Then mandibular and later anterior retrac-tion and space closure were accomplished. Some mesial movement of the mandibular molars was allowed, in order to achieve a Class I molar relationship (Figs 9-19g to 9-19k).

a

f

i

d

b

g

j

e

c

h

k

Fig 9-19 Treatment of a 10-year, 8-month-old girl with a Class II division 1 malocclusion and maxillary and mandibular protru-sion. An invasive frenum attachment has caused tooth displacement, maxillary incisor crowding, and formation of a cyst. (a to c) Pretreatment occlusion. (d) Pretreatment panoramic radiograph. (e) Pretreatment cephalometric radiograph. (f) Tissue heal-ing and some incisor alignment. The arrows show canine bulge. (g to i) Posttreatment occlusion. (j) Posttreatment panoramic radiograph. (k) Posttreatment cephalometric radiograph.

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Early Detection and Treatment of Eruption Problems10

244

Fig 10-18 Management of an ectopic maxillary canine that has caused resorption of the permanent central incisor root and subsequent exfoliation. (a to c) Pretreatment occlusion. (d) Pretreatment panoramic radiograph. (e to h) Occlusion during active treatment and level-ing. The canine bracket has a higher K distance to achieve elongation. (i to l) Posttreatment occlusion, after end of active treatment and reshaping of the canine to mimic the central incisor. 1—permanent central incisor; 2—permanent lateral incisor; 3—permanent canine; C—primary canine.

a

d

g

j

b

e

h

k

c

f

i

l

Tooth Transposition

Another kind of eruption disturbance is tooth transposition, or positional interchange of two adjacent teeth, especially their roots. Tooth transposition is a rare but clinically diffi -cult developmental anomaly. Depending on the transposed teeth and their position, normal eruption of adjacent teeth can be affected, root anatomy can be damaged, and erup-tion of the affected teeth can be delayed. This eruption disturbance was fi rst defi ned in 1849 by Harris,50 who de-scribed tooth transposition as an “aberration in the position of the teeth.”

Transposed teeth are classifi ed into two types of tooth displacement: complete transposition and incomplete

transposition (Fig 10-19). In complete transposition, both the crowns and the entire root structures of the involved teeth are displaced to abnormal positions. In incomplete transposition, only the crown of the involved tooth is trans-posed, and the root apices remain in place.

Transposition is sometimes accompanied by other dental anomalies, such as peg-shaped lateral incisors, congenitally missing teeth, crowding, overretained primary teeth, dilac-erations, and rotation of adjacent teeth.

Displacement of one tooth from one quadrant across the midline to the other side of the arch has very rarely been re-ported, but according to Shapira and Kuftinec51 these types of anomalies should be considered ectopically erupted teeth, not transposed teeth.

C 2

3

1

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Simple Dental Crossbite

Case 11-9: Anterior dental crossbite

A 10-year-old girl in the middle mixed dentition presented with a Class III molar relationship on the right side because of space loss, 0- to 1-mm overbite and overjet, and three maxillary incisors in crossbite. Treatment had been delayed, causing severe crowding of the mandibular incisors and ectopic eruption of the mandibular right lateral incisor (Figs 11-18a to 11-18f).

Treatment:Because of the severe crowding and displacement of incisors, the treatment plan incorporated fi xed appliances with maxillary and mandibular 2 × 6 bonding. The fi rst step in treatment was 2 × 4 maxillary bonding, mandibu-lar fi rst molar occlusal bonding to disocclude the anterior segment, and placement of 0.016-inch nickel-titanium maxillary arches (cinched back) for leveling and release of abnormal anterior contact. The second step was placement of 0.016-inch stainless steel maxillary arches with an open U-loop mesial to the molar tube (extended arch length) to procline the maxillary incisors out of crossbite. The third step was mandibular 2 × 4 bonding: fi rst with 0.014-inch nickel-titanium archwire because of severe crowding and later with 0.016-inch nickel-titanium archwire for further leveling.

The fourth step was use of an open U-loop to place an extended-length stainless steel archwire against the mandibular molar tube to achieve minor mandibular incisor proclination in order to gain space and align the man-dibular incisors. The fi nal step was bonding the permanent canines after eruption for fi nal anterior alignment. Figures 11-18g to 11-18k show the treatment outcome.

a

d

g

j

b

e

h

k

c

f

i

Fig 11-18 Management of incisor cross-bite in a 10-year-old girl. The locked oc-clusion has resulted in severe displace-ment and crowding of the mandibular incisors as well as ectopic eruption of the mandibular right central incisor. (a to e) Pretreatment occlusion. (f) Pretreat-ment panoramic radiograph. (g to j) Post-treatment occlusion. (k) Posttreatment panoramic radiograph.

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417

AAcellular cementum, 23Achondrodysplasia, 230Acrodynia, 236Active holding arch, 82, 83fActive lingual arch, 92Adenoid facial type, 146Age of patient

midline diastema and, 210for orthodontic screening, 7serial extraction considerations,

117space loss affected by, 76

Agranulocytosis, 236Alginate, 51Alkaline phosphatase, 20, 235Allergies

hypodontia and, 162mouth breathing and, 147

Alveolar bone, 24Alveolar process

development of, 225function of, 26growth of, 26maxilla and mandible relationship

to, 37Alveolar ridge, 233Ameloblasts, 18, 19f, 20Amelogenesis, 20Amelogenesis imperfecta, 19Amelogenin, 21Anchored space regainers, 87–89, 88fAngle’s classifi cation of

malocclusion, 3, 150Ankyloglossia, 215f, 215–216Ankylosis

case studies of, 285f–286fdefi nition of, 281dentition effects of, 282, 282f–283fdiagnosis of, 283etiology of, 281–282lateral tongue thrust and, 141management of, 283–284permanent teeth, 31prevalence of, 281primary teeth, 31, 165, 281treatment of, 283–284

Anodontia, 158

Anterior Bolton discrepancy, 209Anterior crossbite

case studies of, 320f–322fcephalometric evaluation of, 316Class III malocclusion and, 316clinical examination of, 316differential diagnosis of, 316Hawley appliance for, 319illustration of, 49f, 257fincisor, 317, 318f, 321fmaxillary canine impaction and,

257fin mixed dentition, 321fsimple

defi nition of, 316etiology of, 317, 318fincidence of, 316signs of, 317

single-incisor, 320ftreatment of, 319, 347f–351f

Anterior open biteanterior tongue thrust and, 142illustration of, 49flisping caused by, 50thumb sucking as cause of, 133, 134f

Anterior provisional partial denture, 84–85, 85f

Anterior teethearly loss of, 84protrusion of, 90

Anterior tongue thrust, 141, 141fApposition, 21Arch

collapse of, 6, 6f, 339, 344fcrowding in, 52dental cast evaluation of, 52development of, 28form of, 52length of

defi nition of, 53incisor proclination for

increasing, 91loss of, 282palatal canine impaction and, 255primary dentition’s role in, 30reduction of, during transitional

dentition, 115

tooth size and, discrepancy between, 106–107

transitional dentition changes in, 38

physiologic changes in, 29required space in, 53symmetry of, 52, 53f

Arnold expander, 363, 363fAsymmetric tooth eruption, 240–241Atavism theory, 192Autotransplantation

canine impaction treated with, 265disadvantages of, 171lateral incisor hypodontia treated

with, 171mandibular second premolar

hypodontia treated with, 174

BBand and loop space maintainer, 82,

83fBand and occlusal bar, 84, 84fBand and pontic, 84, 84fBand and U-loop space regainer, 87,

88fBehavioral evaluation, 43Behavioral modifi cation, for non-

nutritive sucking, 135Bipupillary plane, 56Bite guards, 152Bite plate, 403–404, 404fBitewing radiographs, 58Blanching test, 211, 211fBluegrass appliance, 136, 137fBolton analysis, 54, 78, 79fBolton discrepancy, 115, 127, 128f,

209Bone morphogenetic protein 2, 23Bone remodeling, 228Brachycephalic head shape, 45Brodie syndrome, 360f, 360–361,

372f–373fBruxism, 151–152Buccal canine impaction, 254, 257f,

263–264Buccal crossbite, 360, 372f–374fBud stage, 17f–18f, 17–18

Page numbers with “t” denote tables; those with “f” denote fi gures; those with “b” denote boxes

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418

D

CCalcospherites, 21Camoufl age treatment

for Class II malocclusion, 297for open bite, 380

Caninescrescent moon–shaped root

resorption of, 118, 119feruption of

ectopic, 165, 243, 244fbefore premolar eruption,

239–240mandibular. See Mandibular

canines.maxillary. See Maxillary canines.permanent

ectopic eruption of, 165, 243, 244feruption of, 37, 38b

primaryearly loss of, 403extraction of, 261–262overretained, 246premature exfoliation of, 118serial extraction of, 120

transposition of, 245–246, 255unerupted, bulging of, 118

Cap stage, 18, 18fCartilage calcifi cation, 21Casts, dental, 51–54Cellular cementum, 23Cementoblasts, 22f, 23Cementogenesis, 23Cementum

acellular, 23cellular, 23formation of, 23

Central diastema, 36Central incisors

eruption of, before maxillary lateral incisor eruption, 240

maxillaryanterior crossbite caused by, 317,

318fdiastema between, 205

overretained, 317supernumerary, 199f–200f

Cephalometric radiographs, 66–67, 68b, 101f, 116–117, 258, 296

Cervical headgear, 3Cervical loop, 22, 22fChemotherapy, 162–163Chin cap with spurs, 332, 332fClark’s rule, 258Class I malocclusions, serial

extraction in, 119–122, 121f, 124f–126f

Class II malocclusioncase studies of, 302f–315fcephalometric analysis of, 296characteristics of, 294diagnosis of, 295–296division 1, 301–302, 407fdivision 2, 302, 410fearly treatment of, 9, 294facial height effects on, 294growth patterns, 294historical background of, 3jaw characteristics in, 295bmorphologic characteristics of,

295, 295bpanoramic radiograph of, 62fprevalence of, 294serial extraction in, 122–123transverse dimension

considerations, 294

treatment ofcamoufl age, 297early, 294extraoral traction, 298–299functional appliances, 298growth modifi cation and occlusal

guidance, 297–299headgear, 298–300HLH technique, 299–302,

308f–309f, 314flip bumper, 300–301, 301fmodifi ed Hawley appliance, 300,

300fone-phase, 302, 310f–315forthognathic surgery, 297two-phase, 301–302, 302f–309f

variations of, 295fClass III malocclusion

anterior crossbite and, 316case studies of, 333f–351fcauses of, 329classifi cation of, 331crossbite and, comparisons

between, 331bdentofacial characteristics of, 329hereditary, 334f, 342f–343fmandibular prognathism with,

330, 341f, 346fpretreatment evaluation of, 329prevalence of, 329–330pseudo–

case studies of, 325f–329fdefi nition of, 323delayed treatment of, 324, 330multiple incisor involvement in,

323removable appliances for, 324,

324fsigns of, 323treatment of, 323–324, 324f

serial extraction in, 123skeletal, 329–330treatment of

after incisor eruption, 338, 338f–346f

chin cap with spurs, 332, 332fin early mixed dentition, 333early strategies for, 331–332face mask–chin cap combination,

332, 332ffactors that affect, 331binterceptive, 335f–336fin late mixed dentition, 344fin primary dentition, 333, 334f

Cleft lip and palate, 163Cleidocranial dysostosis, 231Clinical examination

ankylosed primary molars, 283anterior crossbite, 316delayed tooth eruption, 232description of, 44differential diagnosis of, 142–143hyperdontia, 196–197posterior crossbite, 361before serial extraction, 116tongue thrust, 142–143

Closing the drawbridge, 383, 383fComputed tomography scans, 59,

59f, 258–259Concave profi le, 47, 47fConcomitant hypodontia and

hyperdontia, 165Condylar hypertrophy, 361, 361fCondylar hypotrophy, 361Congenital hypothyroidism, 230

Convex facial profi le, 47f, 117Coronoid process, 26Corrective orthodontic treatment, 4Craniofacial growth

dentition development and, 15, 25–27

description of, 5, 116genetic infl uences on, 5mouth breathing effects on, 148occlusion affected by, 116

Crossbiteanterior. See Anterior crossbite.central incisor, 179ffunctional. See Pseudo–Class III

malocclusion.posterior. See Posterior crossbite.skeletal Class III malocclusion and,

comparisons between, 331bthumb sucking as cause of, 133,

134funilateral, 6, 7f

Crowdingarch, 52degree of

space analysis and, 79space loss affected by, 76

of incisors. See Incisor(s), crowding of.

of mandibular incisors, 38–39of molars, 91f

Crownepithelial coverage of, 24permanent, primary root

resorption and, 32Crown and bar, 84, 84fCrown and pontic, 84, 84fCurve of Spee, 53–54, 79, 404Curve of Wilson, 361Cuspal height, 400Cusps, enamel knot’s role in

formation of, 20Cyst formation, 18

DDeep bite

case studies of, 405f–413fcuspal height effects on, 400defi nition of, 397degree of, 397dental, 397–398, 402–403development of, 397differential diagnosis of, 399–400etiology of, 397–399factors that affect, 400impinging, 6, 6f, 202f, 206, 209,

310f, 314f, 405fmandibular forward growth and,

397morphologic characteristics of, 399periodontal disease and, 401relapse of, 399reverse, 336fskeletal, 398–399, 403–404treatment of

appliances for, 404–405delayed, 400early, 401in mixed dentition, 403–404, 412fin permanent dentition, 401–402in primary dentition, 403strategies for, 402–405

Deep overbite, 303fDeglutition, 139–140De-impactor spring, 242, 243f

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Delayed exfoliation, of primary dentition, 31

Dental caries, 31Dental casts

arch form and symmetry evaluations using, 52

description of, 51–52occlusion evaluations using, 52before serial extraction, 116

Dental follicleanatomy of, 22–23fi broblasts of, 24permanent, congenital absence

of, 31tooth eruption affected by, 227

Dental history, 43–44Dental lamina

development of, 16f, 16–17magnifi cation of, 16f

Dental occlusion. See Occlusion.Dental retrusion, 56Dentigerous cyst, 193, 194fDentin

apposition of, 21formation of, 20hypoplasia of, 21interglobular, 21mineralization of, 20–21, 23

Dentin fl uorosis, 21Dentin matrix protein-2, 23Dentinogenesis, 20Dentinogenesis imperfecta, 19Dentition

ankylosis effects on, 282, 282f–283fbruxism effects on, 152intraoral examination of, 48–49, 49fmonitoring of, during early-age

orthodontic treatment, 9Dentition development

craniofacial growth and, 15, 25–27description of, 15neonatal, 27f, 27–28permanent, 19postnatal, 28primary. See also Primary

dentition.bud stage of, 17f–18f, 17–18calcifi cation stage of, 20–21cap stage of, 18, 18fcrown stage of, 21, 21fearly bell stage of, 18f, 18–19initiation stage of, 16f–17f, 16–17late bell stage of, 19f–20f, 19–20molecular level of, 22–23morphodifferentiation stage of,

19f–20f, 19–21root formation, 22, 22fstudies of, 22–23

retarded, 238–239Dentogingival junction

development of, 24tissues of, 24

Desmosomes, 18Developmental spaces, 28–29Diagnostic database, 42Diagnostic process

description of, 51goal of, 41interview, 42–44questionnaire, 42–44schematic diagram of, 42, 42fsteps involved in, 42

Diastema, 36, 94, 179fcentral, 94, 179fmidline. See Midline diastema.

Dichotomy theory, 192Digit sucking, 132–136, 134fDigital imaging, 59Distal drift, 76–77Distal jet appliance, 88, 88fDistal shoe, 82Distal step terminal plane, 29f, 29–30,

33fDistraction osteogenesis, 360Divergence of the face, 47Dolichocephalic head shape, 45, 146fDown syndrome, 163, 231, 245Drift, 26, 76–77“Dual bite,” 51Dwarfi sm, 230

EE space, 110, 110fEarly exfoliation, of primary

dentition, 31Early-age orthodontic treatment

advantages of, 66benefi ts of, 11–12clinical evidence about, 10controversy associated with, 9–11costs of, 11current interest in, 6–7defi nition of, 4dentition monitoring during, 9goals of, 8growth patterns and, 10–11lack of training in, 12misconceptions about, 10–11modern views on, 41objectives of, 4one-phase, 8patient benefi ts, 11phases of, 8–9practitioner benefi ts, 12professional encouragement of, 12rationale for, 7reasons for, 4–7results with, 11–12single phase of, 8, 10strategy of, 4, 8timing of, 7–8, 298two-phase, 9–10

Ectoderm, 22Ectodermal dysplasia, 163Ectomesenchymal cells, 19–20, 23–24Ectomesenchyme, 16–17Ectopic eruption

defi nition of, 241permanent canines, 243, 244fpermanent fi rst molars, 241–242,

242fprevalence of, 241

Ectopic impacted canines, 260Ellis lingual arch, 82, 83fEmbryonic period, 15Enamel

apposition of, 21formation of, 20mineralization of, 20–21tetracycline discoloration of, 21

Enamel hypoplasia, 21Enamel knot

in cusp formation, 20defi nition of, 17illustration of, 18f

Enamel matrix, 20–21Enamel organ, 18, 18fEpithelial cuff, 24Epithelial thickening, 16, 16fExamination(s)

clinical. See Clinical examination.extraoral. See Extraoral

examination.photographic evaluation. See

Photographic evaluation.radiographic. See Radiographs.

Exfoliation, of primary dentitiondescription of, 30–32, 229early, 235–236

External enamel epithelium, 18Extraction. See also Serial extraction.

early-age orthodontic treatment effects on need for, 11–12

space creation through, 90Extraoral anchorage, 3Extraoral examination

elements of, 44–45frontal facial evaluation, 45–46, 46flateral facial evaluation, 46–47

Extraoral photographyfacial esthetics, 55–56, 57ffrontal view, 54–57, 55flateral view, 55–56oblique view, 55

Extraoral radiographs, 58–59Extraoral traction, for Class II

malocclusion, 298–299

FFace

description of, 131embryologic development of, 15vertical growth of, 380

Face mask–chin cap combination, 332, 332f

Facial asymmetry, 56, 57f, 361fFacial esthetics

composition of, 45early-age orthodontic treatment

benefi ts for, 11evaluation of, 44malocclusion effects on, 9photographic evaluation of, 55–56,

57fprimary dentition’s role in, 30

Facial evaluationfrontal, 45–46, 46flateral, 46–47

Facial form, 44Facial height, 294Facial profi les, 47, 47fFacial proportion

evaluation of, 46, 46ffrontal, 56, 57fhead posture and, 148lateral, 56, 57f

Facial symmetry, 45–46, 46fFacial trauma, 162Facial typing, 45Family medical history, 43–44Fiber-reinforced composite resin

fi xed partial denture, 170Fibroblast growth factors, 23Fibroblasts, 228Finger sucking, 132–136, 134b, 134f,

378, 378f, 381–382

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420

I

First molarsdistalization of, 91, 91fectopic eruption of, 241–242, 242fmandibular

maxillary fi rst molar and, 37mesial shift of, 38permanent, 32

maxillaryectopic eruption of, 119, 119f, 243fmandibular fi rst molar and, 37vertical palisading of, 119, 119f, 124

Fixed expanders, 93–94, 94f, 362–364, 363f–364f

Fixed orthodontic appliances, 136, 137fFluorosis, dentin, 21Flush terminal plane, 29f, 29–30, 33,

33fFourth germ layer, 22Frenectomy, 214, 215f, 217fFrenotomy, 216Frenum

maxillary labial, 207morphogenesis of, 206–207structure of, 206–207

Frenum attachment abnormalitiesankyloglossia, 215–216case studies of, 216f–222fdifferential diagnosis of, 210–211in infants, 214management of

in adults, 211–212delayed, 212frenectomy, 214, 215f, 217fin infants, 214in mixed dentition, 212–213, 213fin primary dentition, 213–214results of, 213ftwo-phase, 213

midline diastema. See Midline diastema.

occlusion affected by, 210radiographs of, 211, 211fsigns of, 211, 211f

Frontal cephalometric radiographs, 67Frontal view, 54–55, 55fFunctional crossbite, 359–360.

See also Pseudo–Class III malocclusion.

Functional matrix, 6, 131

GGenetic theory, of maxillary canine

impaction, 255–256Gingival groove, 27Glossectomy, 49Glycosaminoglycans, 18Groper fi xed anterior prosthesis, 85Growth modifi cation techniques

Class II malocclusion treated with, 297–299

open bite treated with, 382–383, 383f

Growth patternsClass II malocclusion, 294early-age orthodontic treatment

and, 10–11incisor position and crowding

affected by, 111mixed dentition space analysis, 53sagittal expansion and, 90–91serial extraction considerations,

117–118space analysis and, 79

Growth status evaluation, 43

Gubernaculum dentis, 227Guidance theory, of maxillary canine

impaction, 254–255Gum pads, 27, 27f, 140Gurin lock regainer, 87, 88f

HHaas expander, 93, 94f, 363, 363fHalterman appliance, 242, 243fHand-wrist radiographs, 59Hard tissues. See Dentin; Enamel.Hawley appliance

anterior crossbite treated with, 319bruxism treated with, 152Class II malocclusion treated with,

299–300as habit breaker, 136, 137fmodifi ed, 300, 300f, 324f, 406fas removable distalizer, 92space maintenance using, 86, 86fspace regaining using, 89, 89ftongue thrust treated with, 145f

HeadgearClass II malocclusion treated with,

298–300high-pull, 299historical background of, 3J-hook, 299patient’s cooperation in using, 299sagittal expansion using, 92

Hemifacial microsomia, 163Hereditary crowding, of incisors,

118–119, 119fHertwig’s epithelial root sheath, 22,

22f, 24Histodifferentiation

description of, 18, 19fdeveloping abnormalities during, 19

Holoprosencephaly, 207Homeobox genes, 22, 161Hyperactivity theory, 192Hyperdontia. See also

Supernumerary teeth.case studies of, 198f–202fclinical examination of, 196–197defi nition of, 17hypodontia and, 165–166, 192management of, 197–198occlusion affected by, 196, 197fprevalence of, 189–190, 190t–191tradiographic examination of, 197

Hypodontiaautotransplantation for, 171, 174case studies of, 174f–185fcentral incisors, 180f–181fclefts associated with, 163clinical signs of, 167defi nition of, 17, 158dental anomalies associated with,

164–165dentoskeletal patterns affected by,

166description of, 157distribution of, 160tin Down syndrome, 163early recognition of, 167environmental factors, 161–163ethnicity and, 159t–160tetiology of, 160–163sex and, 159t–160tgenetic factors, 160–161in hemifacial microsomia, 163hyperdontia and, 165–166, 192

lateral incisorsautotransplantation for, 171canine substitution for space

closure, 168–169case studies of, 176f–178f,

184f–185fimpaction caused by, 274management of, 168–171maxillary, 208fmidline diastema caused by, 208,

208fprosthesis for, 169–171, 171f

management of, 167–168mandibular second premolars,

172–174, 180f–181fmicrodontia and, 164occlusion affected by, 157, 166partial, 163prevalence of, 158, 159t, 162soft tissue affected by, 166space closure, 168–169, 173syndromes associated with,

163–164systemic diseases associated with,

162treatment of, 167–168

Hypophosphatasia, 235–236Hypopituitarism, 230Hypoplasia

dentin, 21enamel. See Enamel hypoplasia.

Hypothyroidism, 230Hyrax expander, 93–94, 94f, 363, 363f

IImage shift principle, 258Impinging deep bite, 6, 6f, 202f, 206,

209, 310f, 314f, 405fImplant-supported restorations, 173–174

Incisor(s)anterior crossbite, 317, 318f, 321fcrowding of

acquired, 118Bolton discrepancy, 115, 127, 128fcauses of, 106–107characteristics of, 107–108in Class I malocclusions, 119–122,

121f, 124f–126fin Class II malocclusions, 122–123in Class III malocclusions, 123classifi cation of, 107–108description of, 95, 105environmental, 118hereditary, 118–119, 119fintervention for, 107measurement of, 117minor, 108in mixed dentition, 95, 105–106moderate, 108–114, 109f–114fprediction of, 106prevention of, 107serial extraction for. See Serial

extraction.severe, 115, 117, 120, 121f, 264tooth size–arch length

discrepancy as cause of, 106–107, 123

in transitional dentition, 110transverse expansion for, 93

eruption ofasymmetric, 36central diastema persistence

during, 36

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Class III malocclusion treatment after, 338, 338f–346f

mandibular central incisors, 34, 34fmandibular lateral incisors, 34, 34fmaxillary central incisors, 35, 35fmaxillary lateral incisors, 35–36, 36fpermanent, 34f–36f, 34–36problems during, 36, 36b

impaction ofcase studies of, 275f–280fearly detection and diagnosis of,

273etiology of, 273interceptive treatment of, 274odontoma as cause of, 273supernumerary teeth as cause of,

273, 274f, 279ftrauma as cause of, 273

inclination of, 53, 56, 79, 91, 117intrusion of, 402labial movement of, 91lateral

mandibular, 34, 34fmaxillary, 35–36, 36fsplaying of, 118, 119f

lip position and, 53mandibular

crowding ofBolton discrepancy as cause

of, 127, 128fdescription of, 38–39, 91, 105,

107, 114f, 207, 406feruption of, 34, 34fgingival recession at, 118

maxillaryeruption of, 35–36, 36fspace closure with, 94

overretained, 32fperiodontal condition of, 91primary

early loss of, 81f, 85overretained, 274, 317, 318froots, delayed resorption of, 109fsequential stripping of, 109spaces between, 28

proclination of, 34f, 91–92root resorption of

delayed, 34f, 109fdescription of, 256

splaying of, 118, 119fIncisor liability, 33–34, 36Inconstant swallowing, 142Infantile swallowing, 140, 142Initiation stage, 16f–17f, 16–17Intercanine arch width, 34Interceptive treatment

defi nition of, 4of incisor impaction, 275of maxillary canine impaction,

260–262patient expectations about, 43

Interdental fi bers, 207Interdental spacing, 79Interglobular dentin, 21Interincisal angle, 400Intermolar width, 92Interproximal wedging technique,

242, 242fIntertransitional periods, 28Interview, 42–44Intraoral examination

components of, 116dentition, 48–49, 49f

description of, 47, 116paraclinical evaluation, 51soft tissues, 49–51temporomandibular joint function,

51tongue, 49–51, 50f

Intraoral photography, 58Intraoral radiographs, 58Irradiation, 162–163

JJaw

fracture of, 246ontogenesis of, 25, 25f

Jaw muscles, 26J-hook headgear, 299Jumping the bite, 298Juvenile hypothyroidism, 230Juvenile rheumatoid arthritis, 26

LLasers, 214Lateral cephalometric radiographs,

4, 258Lateral expansion, 93Lateral facial evaluation, 46–47Lateral facial proportion, 56, 57fLateral incisors

hypodontia ofautotransplantation for, 171canine substitution for space

closure, 168–169case studies of, 176f–178fmanagement of, 168–171palatally displaced maxillary

canines associated with, 255prosthesis for, 169–171, 171f

mandibulareruption of, 34, 34ftransposition of, 245, 249f

maxillaryeruption of, 35–36, 36f, 240microdontia of, 208, 208fsupernumerary, 194ftransposition of, 250f

microdontia of, 208, 208fpeg-shaped, 274proclination of, 36, 36fsupernumerary, 198ftransposition of, 245, 249f–250f,

252f–253fLateral jaw radiographs, 58–59Lateral tongue thrust, 141f, 141–142Lateral view, 55–56Leeway space, 78, 80, 95, 276fLigand for receptor activator for

nuclear factor κB, 30Lingual crossbite, 360, 360fLip bumper, 91–92, 92f, 299, 300–301,

301fLip dysfunction, 209, 209f, 398Lip line, 169Lip position, 56, 57fLip proportion, 56, 57fLip seal, 382Lip strain, 55fLisping, 50Locked occlusions, 6f, 6–7, 113fLongitudinal panoramic radiographs,

60, 61f–65f, 116Lower holding arch, 82, 83f, 109fLower lip dysfunction, 403

MMacroglossia

description of, 49, 49ftongue thrust associated with, 141,

141fMalocclusions

Angle’s classifi cation of, 3, 150Class I, 119–122, 121f, 124f–126fClass II. See Class II malocclusion.Class III. See Class III malocclusion.environmental factors associated

with, 293etiology of, 42facial esthetics affected by, 9speech problems and, 50, 150–151thumb/fi nger sucking as cause of,

133, 134f, 137ftreatment of, 115untreated, problems secondary to, 9

Mandibleanatomy of, 25, 25fanterior shift of, 325f–326fdisplacement of, 247masticatory muscle attachment

to, 26normal closure pattern of, 400positions of, 297retrusion of, 412f

Mandibular arch, 49fMandibular canines

eruption of, 37impaction of, 265permanent, eruption of, 37primary

early extraction of, 36premature loss of, 35, 98f, 102f

Mandibular condyleankylosis of, 26growth of, 26–27

Mandibular fi rst molarsextraction of, 247fmaxillary fi rst molar and, 37mesial shift of, 38permanent, 32

Mandibular fi rst premolar eruptionbefore canine eruption, 239–240description of, 37

Mandibular growthasymmetric, 7f, 25, 46fdirection of, 26impinging deep bite effects on, 6insuffi cient, 19malocclusions caused by problems

with, 25at mandibular condyle, 26occlusion affected by, 106temporomandibular joint-related

factors that affect, 26Mandibular incisors. See also

Incisor(s).central, 34, 34fcrowding of

Bolton discrepancy as cause of, 127, 128f

description of, 38–39, 49, 91, 105, 107, 114f, 207

inclination of, 79lateral, 34, 34fproclination of, 350frelative position of, 397

Mandibular molar distalizer, 88, 88fMandibular plane–occlusal plane

angle, 400

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N

Mandibular prognathism, 330, 341f, 346f

Mandibular second molarseruption of, maxillary second

molar eruption before, 240impaction of, 119, 119fterminal plane, 32, 33f

Mandibular second premolars, 172–174, 180f–181f

Mastication, 30Masticatory muscles, 26Maternal rubella, 162Maxillary arch

collapse of, 6, 6f, 339, 344fconstriction of, 355, 357, 359

Maxillary bone, 25Maxillary canines. See also Canines.

displacement of, 266f–267feruption before premolars, 239impaction of

autotransplantation of, 265buccal, 254, 257f, 263–264case studies of, 266f–272fclinical examination of, 257–258consequences of, 256–257early detection of, 257–260ectopic, 260, 262f, 268fetiology of, 254–256interceptive treatment of, 260–262labial, 256odontoma as cause of, 269f–271forthodontic procedures for, 264palatal, 254–256, 263panoramic radiographs of, 259f,

259–260position of, 262prevalence of, 254proximity of, to adjacent teeth, 259radiographic evaluation of,

258f–259f, 258–260signs of, 258space defi ciency as cause of,

266f–267fstep-by-step management of, 264bsurgical exposure of, 262–264, 263ftreatment of, 260–265

Maxillary fi rst molarsectopic eruption of, 119, 119f, 243fmandibular fi rst molar and, 37vertical palisading of, 119, 119f, 124

Maxillary incisors. See also Incisor(s).

central, 35, 35fdelayed treatment of midline

diastema until complete eruption of, 212

fl aring of, 133labial migration of, 401lateral

description of, 35–36, 36feruption of, 35–36, 36f, 240microdontia of, 208, 208fsupernumerary, 194f

liability, 36permanent, 319protrusion of, 36fsecondary spacing, 36, 36f

Maxillary intercanine distance, 29Maxillary second molars

eruption of, before mandibular second molar eruption, 240

terminal plane, 32, 33f

Mechanotherapyincisor impaction treated with, 277fwith selective extraction, for open

bite, 383tongue thrust treated with, 143, 143f

Meckel’s cartilage, 25Medical history, 43–44Mentolabial sulcus, 56, 57fMerrifi eld analysis, of space, 78Mesial drift, 26, 76–77Mesial occlusion. See Class III

malocclusion, skeletal.Mesial shift, 38, 347fMesial step terminal plane, 29f,

29–30, 33, 33fMesiodens, 194, 208, 208fMesocephalic head shape, 45Microdontia

hypodontia and, 164illustration of, 163flateral incisors, 208, 208f

Midline diastemacase studies of, 216f–222fcauses of, 207–210

anterior Bolton discrepancy, 209impinging deep bite, 209lateral incisor hypodontia, 208,

208flip dysfunction, 209, 209fmesiodens, 208, 208fodontoma, 208overview of, 207–208pathologic tooth migration, 210,

210fdefi nition of, 205differential diagnosis of, 210–211etiology of, 206–210sex and, 206management of

in adults, 211–212delayed, 212in infants, 214in mixed dentition, 212–213, 213fin primary dentition, 213–214results of, 213ftwo-phase, 213

occlusion affected by, 210prevalence of, 206radiographs of, 211, 211fshape of, 211, 211f

Mineralization, of hard tissues, 20–21, 23

Mixed dentitionanterior crossbite in, 317, 318f, 321fdeep bite in, 403–404, 412fearly, Class III malocclusion

treatment in, 333frenum attachment abnormalities

in, 212–213, 213fincisor crowding in

description of, 95, 105–106serial extraction for, 115. See also

Serial extraction.Moyers analysis of, 78open bite management in, 382posterior crossbite in, 367fspace analysis of, 52–54, 78transverse expansion during, 93

Modifi ed Hawley appliance, 406fMolar(s)

distalization of, 91fi rst. See First molars.mesially tipped, 91

permanent, 53primary

ankylosis of, 165, 281, 282f, 285fextraction of, 74, 120–121, 121f,

173long-term retention of, 172submerged, 285f

second. See Second molars.Molar distalizer

with Nance anchorage, 87–88, 88fpendulum appliance as, 92, 92f

Morphodifferentiation stage, 19f–20f, 19–21

Mouth breathingadenoid tissue location

evaluations, 150clinical examination of, 149–150dentofacial characteristics of, 146,

146f, 148–149etiology of, 147evaluation of, 149–150general body growth associated

with, 147–148lip incompetence associated with,

150maxillofacial complex affected by,

146–147occlusion effects of, 146–147open bite caused by, 378orthodontic management of, 150posterior crossbite secondary to,

356–357postural changes associated with,

146–148problems associated with, 149, 149tsigns of, 146f, 147–149treatment of, 150

Moyers mixed dentition analysis, 78MSX1, 23MSX2, 23MSX genes, 161Multirooted teeth, 22Muscular dystrophy, 26

NNance analysis, of space, 54, 77–78Nance holding arch, 83, 84fNasal obstruction, 147, 149Nasolabial angle, 56, 57fNasomaxillary complex, 27, 146Natal teeth, 27–28Neonatal dentition

development of, 27f, 27–28gum pads, 27, 27f, 140natal teeth, 27–28

Neural crest cells, 15, 22Non-nutritive sucking

case studies of, 137f–138fclinical examination of, 134defi nitions of, 132etiology of, 132–133fi nger, 132–136, 134b, 134fmidline diastema caused by, 209,

209focclusion effects, 133open bite caused by, 378, 378f,

381–382, 384fpacifi ers, 136, 139posterior crossbite caused by, 356prevalence of, 133thumb, 132–136, 134b, 134ftreatment of

age of intervention, 135behavioral modifi cation

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techniques, 135description of, 135–138, 137f–138forthodontic appliances, 138, 139f

OObstructive sleep apnea syndrome,

148Occlusal bite plate, 152Occlusal development

craniofacial growth effects on, 116environmental factors, 5–6factors that affect, 37form and function in, 6, 24–25genetic factors, 5hypodontia effects on, 157locked occlusions effect on, 6f, 6–7long process of, 5mechanisms that affect, 5–6prenatal stage of, 16–27tongue’s role in, 27

Occlusal interferences, 6, 6f–7fOcclusal radiographs, 58, 258, 258fOcclusal system, 47Occlusion

Class I, 47dental cast evaluation of, 52frenum attachment abnormalities

effect on, 210hyperdontia effects on, 196, 197fhypodontia effects on, 166importance of, 25locked, 6f, 6–7, 113fmandibular growth effects on, 106midline diastema effects on, 210mouth breathing effects on,

146–147normal, 397pacifi er sucking effects on, 139preparation of, for prosthetics, 174sagittal evaluation of, 52serial extraction and, 117space loss and, 76thumb sucking effects on, 133, 134ftype of, 52vertical dimension of, 293

Odontoblastic process, 20Odontoblasts, 18–20, 19f, 30Odontoma

canine impaction caused by, 269f–271f

description of, 18, 192–193, 193f, 200f–201f, 208, 255

incisor impaction caused by, 273midline diastema caused by, 208

Oligodontiacase study of, 182f–183fcomputed tomography of, 59, 59fdefi nition of, 158management of, 167microdontia and, 163f

One-phase orthodontic treatment, 5, 8

Open biteanterior

anterior tongue thrust and, 142illustration of, 49flisping caused by, 50thumb sucking as cause of, 133,

134fcase studies of, 384f–396fcephalometric evaluation of, 380fclassifi cation of, 381dental, 379differential diagnosis of, 379–380

etiology of, 378–380fi nger sucking as cause of, 378,

378f, 381–382, 384fgenetic factors, 378–379morphologic characteristics of, 379mouth breathing as cause of, 378non-nutritive sucking as cause of,

378, 378f, 381–382, 384foverview of, 377–378serial extraction in patients with, 123skeletal, 379tongue force abnormality as cause

of, 378, 379ftongue guards for, 143, 143ftongue thrust and, 140, 141f, 142,

379, 381, 387f. See also Tongue thrust.

treatment ofcamoufl age, 380closing the drawbridge, 383, 383fearly, 380–383growth modifi cation, 382–383, 383flip seal, 382mechanotherapy with selective

extraction, 383in mixed dentition, 382orthognathic surgery, 380posterior facial height–anterior

facial height ratio increase, 383, 383f

strategies for, 380type I, 381, 384f–386ftype II, 381, 387ftype III, 381, 388f–396fvertical growth pattern associated

with, 390fOral cavity, 48Oral drive theory, 132Oral habits, abnormal

arch collapse affected by, 77bruxism, 151–152early-age orthodontic treatment

effects on control of, 12midline diastema caused by, 209,

209fmouth breathing. See Mouth

breathing.non-nutritive sucking. See Non-

nutritive sucking.overview of, 131time of appearance, 132tongue thrust. See Tongue thrust.

Oral infections, 236Orofacial structure, 47Oronasal complex, 24Oronasal functional matrix, 27Orthodontic appliances, for non-

nutritive sucking, 138, 139fOrthodontic forces, 3Orthodontic screening, 7Orthodontic treatment

canine impaction, 264early-age. See Early-age

orthodontic treatment.historical background of, 3one-phase, 5scientifi c evidence regarding, 6two-phase, 5, 9–10

Osteoblasts, 24Osteoclastogenesis, 228, 230Osteogenesis, 228Osteoprotegerin, 30Outer enamel epithelium, 18Overjet, 303f, 310f, 391f

PPacifi ers, 136, 139Palatal appliance, 136, 137fPalatal crossbite, 360Palatal expansion, orthopedic, 93Palatal plane–occlusal plane, 400Panoramic radiographs, 60, 61f–65f,

116, 259f, 259–260Paraclinical evaluation, 51, 116–117Parathyroid hormone receptor 1, 230Parathyroid hormone-related protein,

230Patient chief complaint of, 43

compliance of, 11–12early-age orthodontic treatment

benefi ts for, 11medical history of, 44

Peak height velocity, 59Pedo temporary bridge, 85Pendulum appliance, 88, 88f, 92, 92fPeriapical abscesses, 31, 31fPeriapical radiographs, 58, 211, 211f,

258Periodontal disease, 49, 401Periodontal ligament

collagen fi bers of, 24, 25fdescription of, 22development of, 24, 25fformation of, 23remodeling of, 228tooth eruption affected by, 227–228

Periodontitis, 236Permanent dentition

ankylosis of, 31eruption of, 30formation of, 19nonsyndromic agenesis of, 160premature eruption of, 235–236transposition of, 164

Photographic evaluationapplications of, 54extraoral. See Extraoral

photography.intraoral, 58before serial extraction, 116

Physical growth evaluation, 43Pierre Robin syndrome, 49–50Porter appliance, 93, 94f, 362, 363fPosterior crossbite

Brodie syndrome, 360–361, 372f–373f

buccal, 360, 372f–374fcase studies of, 364f–374fclinical examination of, 361defi nition of, 355delayed treatment of, 357, 358fdifferential diagnosis of, 361–362early treatment of, 359, 362–366etiology of, 356–357functional shift as cause of, 359fillustration of, 49flateral mandibular shift caused

by, 51lingual, 360, 360fmandibular shift and, 365f–366f,

369f–371fmaxillary arch constriction

associated with, 355, 357, 359in mixed dentition, 367fmorphologic characteristics of, 355mouth breathing as cause of,

356–357palatal, 360paraclinical evaluations, 362

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S

prevalence of, 355, 357in primary dentition, 368fscissors bite, 360thumb sucking as cause of, 133,

134ftreatment of

appliances, 362–364, 363f–364fArnold expander, 363, 363fbonded expander, 364, 364fdelayed, 357early, 359, 362–366fi xed expanders, 362–364,

363f–364fHaas expander, 363, 363fHyrax expander, 363, 363fquad helix, 362–363, 363frapid expander with occlusal

coverage, 364, 364fremovable expanders, 364, 364f

variations of, 358–361, 359fW-arch for correction of, 93

Posterior facial height–anterior facial height ratio, 383, 383f

Posterior teethextrusion of, 402mesial migration of, 402

Postnatal development of dentition, 28Preameloblasts, 20Premolars

eruption ofdescription of, 37–38, 38bE space preservation for, 110, 110fmaxillary canine eruption before,

239second molars eruption before,

239mandibular, 238fsecond

ankylosis of, 165, 165fhypodontia of, 172–174,

180f–181ftransposition of, 247f, 282, 283f

supernumerary, 195transposition of, 245

Preventive orthodontic treatment, 4Primary dentition

ankylosis of, 31bud stage of, 17f–18f, 17–18calcifi cation stage of, 20–21canines

early loss of, 403extraction of, 261–262overretained, 246premature exfoliation of, 118serial extraction of, 120

cap stage of, 18, 18fClass III malocclusion treatment in,

333, 334fclassifi cation of, 28crown stage of, 21, 21fdeep bite in, 403delayed exfoliation of, 31dental lamina, 16f, 16–17early bell stage of, 18f, 18–19early exfoliation of, 31eruption of

delayed, 233bdescription of, 28

evaluation of, 48exfoliation of, 30–32, 229, 235–236frenum attachment abnormality

management in, 213–214hypodontia of, 172

importance of, 30initiation stage of, 16f–17f, 16–17late bell stage of, 19f–20f, 19–20life history stages of, 16loss of

premature, 74space lost after, 75

molecular level of, 22–23morphodifferentiation stage of,

19f–20f, 19–21overretained, 172posterior crossbite in, 368fpremature loss of, 74root formation, 22, 22froot resorption of, 32, 282sequential stripping of, 109spacing in, 28, 29fstudies of, 22–23terminal plane of, 29f, 29–30

Primary epithelial band, 16Primary failure of tooth eruption,

236–238, 237fPrimary molars

ankylosis of, 37, 165extraction of, 241

Primate spaces, 28, 29fProfi le

lateral, 55photographic evaluation of, 55space analysis and, 79types of, 47, 47f, 53

Prosthesisfi ber-reinforced composite resin

fi xed partial denture, 170lateral incisor hypodontia

managed with, 169–171removable partial denture, 170

Pseudo–Class III malocclusioncase studies of, 325f–329fdefi nition of, 323delayed treatment of, 324, 330multiple incisor involvement in,

323removable appliances for, 324,

324fsigns of, 323treatment of, 323–324, 324f

Psychologic problems, 11Puberty, 59

QQuad helix, 93, 94f, 136, 137f, 362–

363, 363fQuestionnaire, 42–44

RRadiation therapy, 236Radiographs

ankylosis, 283bitewing, 58canine impaction, 258f–259f,

258–260cephalometric, 66–67, 68b, 101f,

116–117delayed tooth eruption, 234, 234fdigital, 59extraoral, 58–59hand-wrist, 59intraoral, 58lateral jaw, 58–59longitudinal, 60, 61f–65focclusal, 58panoramic, 60, 61f–65f, 116

periapical, 58, 211, 211fbefore serial extraction, 116supernumerary teeth, 197, 197f

RANK. See Receptor activator for nuclear factor κB.

RANKL. See Ligand for receptor activator for nuclear factor κB.

Rapid palatal expander, 364, 364fReceptor activator for nuclear factor

κB, 30Reciprocal induction, 20Reduced dental epithelium, 24Reminder therapy, for non-nutritive

sucking, 135Removable bite plate appliance, 403Removable expanders, 94Removable orthodontic appliances,

136, 137f, 243, 298, 324, 324fRemovable partial denture, for lateral

incisor hypodontia, 170Removable space maintainers,

85f–86f, 85–86Removable space regainers, 89f,

89–90Retained infantile swallow, 140Reward therapy, for non-nutritive

sucking, 135Ricketts’ esthetic line, 56Root development, 117Root formation

illustration of, 22, 22ftooth eruption and, 227

Root resorptioncrescent moon–shaped, 118, 119fprimary tooth, 32regulation of, 30

Rule of fi fths, 46, 56, 57f

SSagittal expansion, 90–92, 91f–92f,

99fSchwartz removable slow expander,

94fScissors bite, 360Second molars

eruption of, before premolars, 239mandibular

impaction of, 119, 119fterminal plane, 32, 33f

maxillary, 32, 33fSecond premolars

hypodontia of, 172–174, 180f–181ftransposition of, 247f, 282, 283f

Secondary spaces, 28–29Secondary spacing, 36, 36fSectional bracketing, 89, 89fSequential selective enamel

stripping, 90Sequential stripping of primary

teeth, 109Serial extraction

in Class I malocclusions, 119–122, 121f, 124f–126f

in Class II malocclusions, 122–123in Class III malocclusions, 123clinical examination before, 116crowding measurements before,

117defi nition of, 115description of, 9diagnostic procedures before,

116–117historical background of, 115

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mandible, 122–123maxilla, 122–123occlusal considerations, 117in open bite, 123paraclinical examinations before,

116–117planning for, 117–119sequence of, 120–122skeletal pattern and, 117–118timing of, 120

Single-tooth implant, for lateral incisor hypodontia, 169–170, 171f

Skeletal deep bite, 398–399Skeletal maturation assessment, 59Skeletal maturity, 59Sleep disorders, 148Sliding loop regainer, 87–88, 88fSocial evaluation, 43Soft tissue

evaluation of, 49–51, 66hypodontia effects on, 166

Soft tissue profi le, 91, 117, 312fSomatic swallowing, 142Space analysis

Bolton, 54, 78, 79fconsiderations in, 79–80defi nition of, 77Merrifi eld, 78methods of, 54mixed dentition, 52–54Moyers, 78Nance, 54, 77–78Staley and Kerber, 78study casts for, 52–54Tanaka and Johnston, 78types of, 77–78

Space closurecanine substitution for, 168–169description of, 74–75, 94frenectomy before, 215fmandibular second premolar

hypodontia, 173Space creation

case studies of, 96defi nition of, 90maxillary canine impaction treated

with, 261moderate incisor crowding treated

with, 110sagittal expansion for, 90–92,

91f–92f, 99fsequential selective enamel

stripping, 90, 109tooth extraction for, 90transverse expansion for, 92–94,

94f, 99fSpace maintainers

functional fi xed, 84f, 84–85nonfunctional fi xed

bilateral, 82, 83funilateral, 82

qualities of, 81removable, 85f–86f, 85–86

Space maintenancecontraindications for, 80–81defi nition of, 80indications for, 80space closure as, 74–75, 94space maintainers for. See Space

maintainers.Space management

case studies of, 96–102

diagnostic procedures used in, 77–80

fundamentals of, 73–77planning for, 77–80treatment options for, 80–95

Space regainers, 87–90, 88f–89fSpace regaining, 86–90, 88f–89f, 97f,

102fSpace supervision

case study of, 100f–101fcombination approach, 110–111defi nition of, 95E space preservation, 110, 110fmethods of, 109–111sequential stripping of primary

teeth, 109Speech

development of, 30physiology of, 150

Speech problemsearly incisor loss and, 85malocclusion and, 50, 150–151soft tissue causes of, 151tongue thrust as cause of, 142

Staley and Kerber analysis, of space, 78

Stellate reticulum, 18, 19f, 30Step-type anterior arch, 383, 383fStomion plane, 56Stomodeum, 16f, 16Straight facial profi le, 47fStratum intermedium, 18, 19fSubnasale line, 56Sucking, non-nutritive. See Non-

nutritive sucking.Sudden infant death syndrome, 139,

148“Sunday bite,” 51Supernumerary teeth. See also

Hyperdontia.case studies of, 198f–202fclassifi cation of, 194, 194bdefi nition of, 189early recognition of, 197ectopic eruption of, 194–195ethnicity and, 190, 191tetiology of, 192sex and, 190, 191tgenetic syndromes associated

with, 192incisor impaction caused by, 273,

274f, 279flate development of, 195, 202location of, 190, 191tmanagement of, 197–198maxillary canine impaction and,

255multiple, 190orthodontic considerations after

removal of, 198prevalence of, 189–191, 190t–191tradiographic examination of, 197,

197fSwallowing

physiology of, 50, 139–140, 381types of, 142

TTanaka and Johnston analysis, of

space, 78Taurodontism, 162, 164–165Temporomandibular disorders, 152

Temporomandibular jointfunction assessments, 51malfunction of, 401

Terminal plane, 29f, 29–30, 32, 33fTetracycline-related enamel

discoloration, 21Three-phase treatment plan, 8Thumb sucking, 132–136, 134b, 134f,

209, 209f, 384fTongue

clinical examination of, 142dysfunction of, 142force abnormality of, open bite

caused by, 378, 379ffunctions of, 49–51, 50focclusal development affected by,

27posture of, 50, 50fsize of, 49–50, 142tonsil effects on, 50f

Tongue crib–transpalatal arch appliance, 136, 137f, 382, 383f

Tongue guard, 143, 143fTongue thrust

anterior, 141, 141fbilateral, 141–142case studies of, 138f, 144f–145fclassifi cation of, 140clinical examination of, 142–143complex, 140defi nition of, 139development of, 140etiology of, 140–141lateral, 141f, 141–142macroglossia associated with, 141,

141fmechanotherapy for, 143, 143fmyofunctional therapy for, 143open bite caused by, 140, 141f, 142,

379, 381, 387foral habit training for, 143problems associated with, 142retained infantile, 140simple, 140speech problems secondary to,

142treatment of, 143, 143f–145ftypes of, 141–142

Tongue-tie. See Ankyloglossia.Tooth agenesis. See Hypodontia.Tooth buds, 17, 17f, 19, 25, 28, 225,

246Tooth development. See Dentition

development.Tooth emergence, 75–76, 229. See

also Tooth eruption.Tooth eruption

abnormal sequence of, 239–241ankylosis. See Ankylosis.asymmetric, 48, 240–241bone remodeling effects on, 228cellular bases of, 228characteristics of, 229defi nition of, 28, 225delayed, 48, 232–235, 233b, 233fdental follicle effects on, 227description of, 24disturbances of, 229–231, 231bectopic

defi nition of, 241permanent canines, 243, 244fpermanent fi rst molars, 241–242,

242fprevalence of, 241

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eruptive phase of, 226factors that disturb

achondrodysplasia, 230cleidocranial dysostosis, 231Down syndrome, 231genetic, 230–231hypothyroidism, 230local, 231overview of, 229–230systemic, 230

factors that infl uence, 76failure of, 236–238, 237fgeneral pattern of, 80guidance of, 95hydrostatic pressure and, 227mechanisms of, 226–228molecular bases of, 228periodontal ligament effects on,

227–228phases of, 226posteruptive phase of, 226prediction of, 75–76pre-eruptive phase of, 226primary dentition, 28retarded, 238–239root formation and, 227sequence of, 37stages of, 229timing of, 76tooth transposition. See Tooth

transposition.Tooth germs, 28, 226Tooth grinding. See Bruxism.Tooth impaction

defi nition of, 254ectopic, 260, 262f, 268fincisors. See Incisor(s), impaction

of.mandibular canines, 265maxillary canines. See Maxillary

canines, impaction of.

Tooth migration, 26, 210, 210f, 247Tooth movement

bone support in edentulous areas achieved through, 171

early-age orthodontic treatment effects on need for, 12

Tooth size–arch length discrepancydescription of, 106–107space defi ciency caused by, 123

Tooth transpositioncase studies of, 249f–253fin children, 246fcomplete, 244, 250fdefi nition of, 244dental anomalies associated with,

244description of, 164diagnosis of, 248etiology of, 246–247incidence of, 245incomplete, 244, 248treatment of, 248

Tooth-supported restorationslateral incisor hypodontia

managed with, 169–170mandibular second premolar

hypodontia managed with, 173–174

Tooth-supporting tissues, 22f, 23–24Transcription factors, 23Transitional dentition

defi nition of, 32dimensional arch changes during,

38eruption problems, 60incisor crowding during, 110panoramic radiographs of, 116phase I, 32–34, 33f–34fphase II, 34f–36f, 34–36phase III, 37

Transpalatal arch, 82, 83fTransposition. See Tooth

transposition.Transverse expansion

indications for, 93space creation through, 92–94, 94f,

99fTrauma

ankylosis caused by, 282facial, 162incisor impaction caused by, 273

Treatment planningcephalometric radiography for, 67description of, 41–42serial extraction, 117–119

Trisomy 21. See Down syndrome.2 x 4 bonding, 88–89, 89f, 97, 122,

319, 324Two-phase orthodontic treatment, 5,

9–10

U“Ugly duckling” stage, 35f, 35–36,

205, 257, 258fUpper lip–lower lip height ratio, 46,

47fUtility arch, 404

VVertical dimension of occlusion, 293Vertical drift, 26Vestibular lamina, 17, 17fVisceral swallowing, 142

WW-arch, 93, 94f, 362, 363fWarford analysis, 260, 261fWax bite, 51Weinberger appliance, 242, 243fWiskott-Aldrich syndrome, 236Wnt signaling pathway, 161

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