Early Orthodontic Treatment Victoria J Lynskey, DMD, MDS Associate Clinical Professor, UCSF
2. ObjectivesDefine Early TxWhen you should refer a patientWho is (and is not) a good candidate for Early txWhat common problems are addressed in Early txWhat options are available to treat Early PatientsHow to determine success 3. Definitions of Early treatment Phase Therapy: early dental problems that left alone will create anunhealthy environment for the growth and development of the teeth,gums, bone and jaws Preventative/ Prophylactic: Prevent a problem from happening Interceptive Orthodontics: Intercept a developing problem Growth Modification: timing treatment to maximize and guide thegrowth of the jaw bones that support the teeth 4. Treatment Phases for Early/Interceptive Orthodontics Phase I (12-15 months) Maintenance Phase (12-24 mo) Phase II (12-15months)Phase I active treatmentMaintenance Phase II active treatment12-15 months 12-24 months12-18 months The Big Question is When and Who is a candidate forEarly Treatment 5. What is normal in a 7-year oldClass I Dental & SkeletalocclusionUgly-duckling stage(spacing and or minorOB/OJ concernsDuring transitional dentition,perfect tooth alignment isnot to be expected and isnot cause for alarm. 6. Transition from Primary toPermanent Dentition 7. What is NOT Normal Sagital relationshipssuch as Class II, dental andskeletal Class III, dental,skeletal andfunctional shifts 8. Class II Skeletal Relationship 32% of malocclusions are Class II, butthey are 70% of what orthodontists treatThe upper jaw is ahead of the lower jaw(XS OJ or buck teeth)In skeletal Class II, the jaws aremalaligned. Treatment can includeredirecting the eruption of teeth during jawgrowth Extraction Plan + FFA; or HPHGExcessive OJ leads to risk of trauma inprotrusive teeth.The upper jaw may be over developed,but more often, the lower jaw is under-developed.Untreated, skeletal malocclusions mayrequire orthognathic surgery to correct thejaw position after growth is completeGrowth Plan: Herbst/Forsus, HG 9. Class III Skeletal Relationship Mandibular Prognathism usually dx in adult (permanent dentition) Midface deficiencies and maxillaryconstriction is usually dx in the Characterized by anterior crossbite mixed dentitionApproximately 3% of the malocclusionsCan be caused by lack of growth in the upper jaw or excessive growth in the lowerjaw (seen later in development)Early treatment of maxillary sagital problem often includes a transverse componentEarly Class III treatment is best at age 7-10 as it requires significant compliancewith extra-oral headgear 10. Protraction HeadgearEarly Txt for Class III is primarily to affect maxillary growth.Requires RPE plus PHG and often FFA. Class III: Protraction/ reverse Pull(often used with an RPE to aid in skeletal movement) 11. Functional ShiftsThe position of the teeth affect the position of the jaw. When there is apremature contact (see the canine) it can cause the jaw to shift so thatthe teeth can contact. This can be habit forming and may result inunwanted asymmetric growth. 12. Habits, Medical Problems Finger, thumb, Tongue thrust Speech discrepancies Mouth breathing due to airway constriction(tonsils, adenoids) TMJ dysfunction, rheumatoid arthritis, andgrowth hormone abnormalities may causeorthodontic problems 13. Vertical Relationships-Open bites Dental vs Skeletal Habits such as finger/thumb sucking,tongue thrust, or airway obstruction May result in chewing difficulty andspeech problem Tx may require ENT, habit therapyand habit appliances 14. Vertical Relationships- Deep Bites Potential for abnormal toothwear and gingivalimpingements May be skeletal cause:vertical maxillary excess orexcessive curve of Spee This can be one of the mostdamaging of malocclusions 15. Crossbite: Anterior Skeletal vs dental Can result from orthopedic problems or functional shifts All of these may damage the teeth and can cause long term gingivalproblems These need to be corrected early to avoid damage to teeth andgums 16. Crossbite: Posterior Often found in patients with anarrow maxilla A posterior crossbite may alsocause a functional shift It may also appear as aunilateral crossbite These are easily treated in thegrowing child 17. Arch Length - crowding Causes Early loss of primary teeth Decay, genetics Tooth size problems Missing teeth Eruption problems 18. Arch Length-crowding Premature loss of Primary Teeth Missing primary teeth, but adequate spacefor secondary dentition= space maintainer Band and loop Lingual Arch Distal Shoe Nance 19. Arch Length-crowdingIrregular lower incisors Irregular Incisors, no arch-length/space discrepancy. Large Incisors + large primary molars +small premolars=no space issues, but transient crowding & rotations ofthe permanent incisors Up to 2mm of crowding may resolve spontaneously For 3-4mm of anterior crowding, IPR lower Cs andplace lingual arch ** 20. Arch length-Crowding: Delayed/blocked premolar development Aligned Incisors, no arch-length/space discrepancy. Erupting canine width+ erupting 1stPM width + largeprimary 2nd molar width=transient crowding & rotations ofthe erupting canines and premolars For posterior arch crowding, IPR lower Es, hemi-sectionor extract and place lingual arch 21. Arch Length-crowdingLocalized space loss Localized space loss (3mm or less); Space Regaining Maxillary Regaining: tipping vs bodily movement Headgear or intra-oral appliance FFA 22. Arch Length-crowdingLocalized space loss Localized space loss (3mm or less); Space Regaining Mandibular Regaining FFA or lip bumper 23. Arch Length-crowding Midline discrepancy Premature loss of a primary tooth resultsin a midline shift Tx with fingerspring or FFA 24. Arch Length-crowding Severe Serial/Guided eruption (>10mm) No skeletal abnormality exists (Class I) >10mm crowding Influence first premolars to erupt prior to canines. For mandible this means ext Ds at to 2/3 root formation on 4s. Overbite might increase during guidance but can be tx after eruption of all permanent teeth in a comprehensive phase. 25. Arch Length - Spacing Maxillary Midline Diastema Normal diastema = ugly duckling stage Larger diastema: >2mm =FFA Supernumeraries Missing permanent lateral incisors Tooth size discrepancy Tongue thrust Excessive tissue in the frenum Tx indicated for 1) when the centrals inhibit eruption of the laterals or canines, or 2) esthetic issues (behavioral), 3) protrusion and trauma risk Studies prove that stability of the end result is improved if a large diastema is corrected before the full eruption of the permanent dentition 26. Abnormal eruption sequenceEctopically-erupting teeth Lateral incisor/canine First molar 27. Congenitally missingpermanent teeth 28. Congenitally missingpermanent teeth Mandibular second premolars: Retention Ankylosis Delayed eruption Manage until it interferes with eruption or drift of other teeth, then extracting and placing space maintainer if necessary Monitor 1) tipping of molars over distal marginal ridges of the ankylosed teeth 2) super-eruption of opposing teeth 29. Ankylosed TeethAnkylosis: Fusion of the tooth to the bonePrimary Failure of eruption: Failure of permanent teeth to grow normallyResult: 1) Adjacent teeth continue to erupt & can tip forward, over theprimary teeth resulting in space loss; 2) the primary molars appear to sinkas the rest of the teeth and jaws continue to grow and develop. This willcause a significant discrepancy in the alveolar bone height, an issue duringreplacement when permanent teeth are missing 30. Early Treatment Rationale Phase I (12-15 months) Maintenance Phase (12-24 mo) Phase II (12-15months)Phase I active treatmentMaintenance Phase II active treatment12-15 months 12-24 months12-18 months The Big Question is When and Who is a candidate forEarly Treatment 31. Crossbite: Posterior Skeletal vs Dental Unilateral/ bilateral 32. Orthodontic Terminology Sagital Dimension (AP) Dental (Angle Classification): Overjet(OJ): distance between the upper & lower front teeth(mm) Molar position Canine position Skeletal: relation of maxilla and/or mandibleto the skull Goal: to affect mandibular growth or dentalcompensation. OJ Class II, Div 1 Class II, Div.2 33. Jaw Deformities Class II: Growth modificationExtraction Plan + FFA Growth Plan: Herbst/Forsus, HG 34. Craniofacial Anomalies Cleft Lip & Palate Syndromes: Hemifacial Microsomia, Craniosynostosis,Crouzons, Treacher-Collins, etc. 35. Benefits of Early Treatment Young patients may be more cooperative andfollow instructions Increased stability Habit modification Reduce extractions Reduced risk of tooth trauma (protruded teeth) Reduced periodontal trauma (crossbites andguiding eruption into attached gingiva) Growth modification (sagitally, transverse,asymmetric jaw growth) 36. Benefits of Early Treatment 37. Benefits of Early Treatment RPE + FFA to create space for U2s and LR2 38. Benefits of Early Treatment 39. Benefits of Early Treatment 40. Disadvantages Time: most patients that require a phase I formoderate to severe dental or jaw growthmodification will require a second phase. Money: increased cost to staging treatment into2 phases is approximately $600 OHI: poor motor skills may require more parentalinvolvement. Emergencies: higher risk of working on theweekend 41. Questions 42. Thank You!