Download Dental Malocclusions

Dental Malocclusions
Dr Adriana Da Silveira, DDS, MS, PhD
Chief of Orthodontics
Dell Children’s Craniofacial
and Reconstructive Plastic
Surgery Center
The importance of knowledge of
oral health issues
• Pediatricians play an important role in promoting
oral health care, and your advice regarding
dental procedures or therapies may be solicited.
• A large percentage of the lower socio-economic
population reports not having access to a regular
dentist.
• Pediatricians have frequent contact with families
during routine preventive visits in the childhood
years of life and are in a position to advise
families about the prevention of oral diseases in
their children and to refer them to an adequate
professional.
Disorders easily recognized by
pediatrician and parents with
possible early intervention
• sucking habits and tongue thrusting
persisting beyond 3 years of age
• speech problems caused by malocclusions
• mouth breathing
• sleep apnea and sleep disorders
• significant deviations of teeth eruption
norms (severe crowding and impaction of
teeth)
• early problems with jaw(s) growth
• TMJ dysfunction.
Can lead to
• Tooth decay
• Gum disease
• Tooth loss.
Class I
Teeth are crowded,
irregular or poorly
spaced.
Class II
Overbite.
Class III
Underbite.
A Dental Specialist
• Diagnosis
• Prevention
• Treatment
of dental and
facial irregularities.
About 6% of
dentists are
orthodontists.
No later than
Age 7.
Sucking Habits
• Sucking habits include pacifiers, blankets,
toys and finger sucking as well as nutritive
sucking such as breast and bottle feeding
• sucking habits should be discouraged after
age 3
• If the habit persists, there may be
consequences on the developing orofacial
structures with severity being dependent
on the duration, frequency and intensity of
the habit.
Pacifier Sucking
2 and half years old
3 and half years old
Thumbsucking
Tongue Thrusting
• Tongue is kept between teeth
causing a open bite and malocclusion
• Work with speech therapist to correct
speech issues and for tongue
positioning
Tongue Thrusting
Chronic Mouth Breathing
• The terms “adenoid facies” or “long face
syndrome” have been used extensively in
the literature to describe a person with
nasal obstruction with self proclaimed
mouth breathing, increased lower facial
height, anterior open bite, narrow upper
arch and maxilla and presence of posterior
crossbites.
• Does upper-airway compromise produce
chronic mouth breathing?
Which comes first, the Chicken or
the egg?
• Md hx: hx of ADHD, takes
Focalin RX
• Past hx of orthodontic treatment
with limited results
Chronic Mouth Breathing
• Lip incompetence is not necessarily
associated with obligatory mouth
breathing
• Total nasal obstruction is seen in cases of
choanal atresia that result in the same
characteristics as the long face syndrome.
• There is evidence in the literature of
upper-airway problems can produce
chronic mouth breathing such in cases of
large tonsils and allergies (Zicari et al., Eur J Paediatr
Dent. 2009 Jun;10(2):59-64.)
Chronic Mouth Breathing
• Independent of being obligatory mouth
breathers or not, children with open
mouth posture have a tendency of
increased lower facial height with over
eruption of posterior teeth and constricted
upper arch.
• Preventive measures and active
orthodontic treatment should be
considered in these cases to correct
existent manifestations of craniofacial
problems as well as to prevent worsening
the open bite.
Sleep Disorders and Sleep Apnea
• Sleep disorders in children are often associated
with hyperactivity, inattentiveness, aggressive
behavior, irritability, and mood swings.
• Some of the most severe cases are diagnosed
with obstructive sleep apnea (OSA), a severe
problem of interrupted breathing during sleep,
often many times per night.
• Although this disorder is most commonly
recognized in adults, a growing number of
studies indicate that children are affected as well
but are less diagnosed than adults.
Sleep Disorders
and Sleep Apnea
• The clinical features and treatments for these
conditions differ considerably between adults and
children. A typical presentation of an adult with
obstructive sleep apnea has a history of obesity,
snoring, and prominent daytime somnolence.
Conversely, a child with the condition is more
likely to have normal body weight, tonsillar
hypertrophy, and attention disorder with learning
difficulties.
• Snoring can be an indication of sleep problems
but do not need to be present, making it difficult
for parents to suspect of any problems.
OSA
• Evaluation by an ENT specialist for tonsils and
adenoids is indicated.
• Medical management is primarily done by
continuous positive airway pressure (CPAP) and
is the first line of treatment.
• At this point, the patient would benefit from an
evaluation by an orthodontist for review of
possible skeletal and dental malocclusions.
• Moderate to severe mandibular hypoplasia and
retrusion contribute to reduced airway space and
is commonly observed in some patients with
OSA. Marino et al (2009) demonstrated that OSA
preschool children have a skeletal Class II
pattern with retrognathic mandible and increased
skeletal divergency in their sample (Marino et al. Eur J
Paediatr Dent. 2009 Dec;10(4):181-4.)
Obstructive Sleep Apnea
• Severely autistic
• OSA
• Initial sleep study done in 2006:
Apnea-hypopnea index of 54.8
events/hr (mild 5-15, moderate 1530, and severe > 30)
• Surgery for tonsils and adenoids
removal after first sleep study
• Non complaint with use of CPAP
• Severe crowding of teeth
• Class II malocclusion with mandibular
hypoplasia
Ct Scan views
Treatment Plan
• Seen by the Craniofacial Team
• Tracheostomy to stabilize airway
• Surgical assisted expansion of the
maxilla, distraction of mandible to
widen jaws
• Orthodontic treatment to coordinate
teeth and arches for jaw surgery
• Lower jaw advancement
After SARPE and Distraction
Post Op Ct Scan
After treatment
• Sleep study done in 2/2010 with trach:
Apnea-hypopnea index of 1.3 events/hr
(mild 5-15, moderate 15-30, and severe >
30)
• Mandibular hypoplasia corrected with
surgery
• Increased airway space
• Currently being planned for removal of
braces with removal of tracheostomy and
full dental cleaning in a surgical setting
OSA
•
•
•
•
Hx of asthma
Initial sleep study demonstrated OSA in 2007
Tonsils and adenoids surgically removed in 2007
OSA continued (additional sleep study done in 2008– CPAP
initiated)
• Did not tolerate CPAP
• Referred by his ENT to the Craniofacial team – diagnosed with
Cl II malocclusion with mandibular hypoplasia
Treatment Plan
• Fabricate a forward mandibular positioning
appliance for sleep
• enlarging the airway space and potentially
improving the respiratory function
• Appliance should be worn at night only
and should be carefully monitored for
possible side effects such as TMJ problems
• Temporary solution until he is ready for
orthodontic treatment in preparation for
jaw surgery
After treatment
• Sleep study taken with appliance in place
demonstrate improvement: Apnea-hypopnea index
of 0.6 events/hr, reduction of OSA to URS
• Use of appliance is well tolerated by patient
• Patient is observed until ready for orthodontic
treatment in preparation for jaw surgery
Other sleep disorders
• There is a growing body of evidence that
palatal expansion may increase nasal
cavity volume thus improving nasal
breathing.
• Patients with certain sleep problems
(nocturnal enuresis) and upper airway
resistance syndrome (UARS) may benefit
from these orthodontic treatments (SchützFransson and Kurol. Angle Orthod. 2008 Mar;78(2):201-8.; De
Felippe, Da Silveira et al. Am J Orthod Dentofacial Orthop. 2009
Oct;136(4):490.e1-8; discussion 490-1.)
Jaw Growth Problems
• Problems with craniofacial growth
can result in functional impairments
of the masticatory system and
esthetic concerns.
• When detected early, growth
modification may be a possibility.
Jaw Growth Problems
• Because facial growth is the result of the
interaction of genetic and environmental
factors (some of which are functional and
others are habits).
• A functional shift resulting from a
crossbite should be optimally corrected
early, so that asymmetric growth of the
mandible can be reduced or even
prevented.
• Some problems may be camouflaged or
treated by a combined approach of
surgical and orthodontic means.
Examples of Growth Modification
Types of Orthodontic Treatment
Jaw Growth Problems
Jaw Growth Problems
Jaw Growth Problems
Jaw Growth Problems
Jaw Growth Problems Asymmetries
Jaw Growth Problems
9/08
1/10
Jaw Growth Problems
TMJ Dysfunction
• Rare in children
• Associated with RA or craniofacial
syndromes
• Affects females more than males
Summary
• Discourage sucking habits after 3
years old, refer to a pediatric dentist
or orthodontist if habit persists.
• Breathing and sleep problems are
best managed by a group of different
specialists that may involve
pediatricians, ENT, surgeons,
pulmonologists and orthodontists.
• When seeing jaw growth problems,
refer to an orthodontist.