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ORTHOdontics
PGI/II
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PEDIATRIC ORTHODONTICS
INCLUDES PRINCIPLES AND APPLICATIONS OF:
EARLY TREATMENT
WITH FOCUS ON CLASS II, DIVISION 1 MALOCCLUSION
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FACULTY:
Joseph Ghafari
, DMD.
Goals: This series of lectures should enable the resident to:
1. Define early treatment in reference to chronological and biological ages.
2. Understand the normal development of the occlusion and how to intercept
interferences with that development.
3. Understand the potential and limitations of early treatment of various
malocclusions.
4. Understand the principles of diagnosis and treatment planning of occlusal
problems as well as the types of mechanotherapy that can be utilized for their
correction.
Objectives: The resident should know:
1. The interferences that may affect normal development of the dentition in its arch
and occlusal components.
2. The types of sagittal (Class I anterior protrusion, Class II, Class III -pseudo vs.
true)
vertical (deep bite, open bite) and transverse (midline deviation, posterior
crossbite) that may benefit from early treatment.
3. When to prevent, intercept, or correct a developing problem, and determine the
limitations of intervention.
4. Know the consequence of early treatment or delayed treatment.
5. The evidence available for modalities of early treatment and its timing in the
primary, transitional (early/mid versus late), and permanent dentition.
6. The findings from available key clinical trials on Class II division 1 malocclusion.
7. The mechanotherapy involved, with in dept-knowledge of selected modalities.
8. How habits help develop and/or maintain certain malocclusions, and ways to
manage these habits.
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COURSE DURATION AND SCOPE: This course is part of the Early Treatment series that includes
research studies on Class II treatment. The course is scheduled in the Spring of the first year and/or the Fall
of the second year. It is given at a 2-hour session on a weekly basis for at least 5 sessions. A prerequisite
to this course is the course on Development of the Dentition.
POLICY ON EXAMINATIONS: At least 2 biannual examinations (progress and final) are given for all
courses, if a course spans the entire year. If classes terminate before the end of a semester, the final
examination is given at the semi-annual examination that is closest to the end of the course, unless the
course director schedules the final examination earlier. During a course, any number of progress tests or
assignments may be given. Their cumulative weight in proportion to the final grade may not exceed 50%.
PEDIATRIC ORTHODONTICS
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SUMMARY OUTLINE
INTRODUCTION
-
- CONCEPTS ON MODALITIES OF TREATMENT
AND
OF TREATMENT
TIMING
- CLINICAL TRIALS
- GENERAL TRENDS AND INDIVIDUAL
VARIATIONS
- IMPLICATIONS OF RESEARCH FINDINGS ON
OF CLASS II AND CLASS I
TREATMENT
MALOCCLUSIONS
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COURSE OUTLINE
Introduction
Goals of early treatment of malocclusion
- Prevent the development of malocclusion: avoid potential interferences with normal
development
- Intercept the development of malocclusion: remove existing interferences [already
developing malocclusion].
- Correct an already developed malocclusion: before the cessation of facial growth
Underlying Assumptions
- Dealing with bite problems at one or various times during a child’s growth: Issue of
timing treatment
-Knowledge of normal growth of jaws (relation to somatic growth), teeth, and
developing relation between occlusion and jaws
-Coordinating time of treatment with optimal time of growth: Issue of growth
prediction.
1.
EARLY ORTHODONTIC TREATMENT OF OCCLUSAL
PROBLEMS
CONCEPTS ON MODALITIES AND TIMING OF TREATMENT
1.
MANAGEMENT OF SAGITTAL OCCLUSAL PROBLEMS
A.
Class I, anterior protrusion
Condition
Treatment
B.
Distoclusions
a.
Class II, anterior protrusion (Class II, Division 1).
Condition:
-association with oral habits
-existence of an underlying skeletal problem. In this instance, early treatment is
almost invariably the initial phase in a series of two or more therapeutic phases ending
with the
use of full or partial fixed orthdontic appliances in the permanent
dentition.
-skeletal and dentoalveolar components
Treatment
Whether the malocclusion is of a skeletal, dento-alveolar, or combined origin, treatment approaches have
relied on similar rationales, perhaps underlying a practical inability to treat a distoclusion with complete
control of its skeletal and neuromuscular components while the dental system is comparatively easier to
manage.
-mechanotherapy: depending on whether the maxilla alone, or both jaws, are
targeted:
(i) head gear, attached to the molars or to a removable appliance (Thurow
appliance).
Numerous types of headgear: vary in direction of extraoral
traction relative to
occlusal plane, that is, relative to the
center of resistance of the anchoring teeth or
group of teeth.
Three major types:
1.
cervical pull with distal and vertical extrusive force
components and a general
direction of pull below the
occlusal plane;
2.
high pull with distal and intrusive force components and a
direction of pull
above the occlusal plane; and
3.
straight pull headgear with a distal retractive force moving
maxillary teeth
along the occlusal plane.
Distal movement of molars is easier with a cervical
pull
headgear because of the lesser resistance to molar extrusion than
intrusion. Two major effects of headgear therapy: are the direct
influence on
maxillary growth, and the indirect effect on
mandibular position and,
therefore, on
the relationship
between maxillary and mandibular structures.
(ii)
ACCO (Acrylic Cervical Occipital Anchorage) or similarly designed
(Cetlin)
appliances: distalize posterior teeth into
neutroclusion and create space for later
reduction
of
the
anterior protrusion.
(iii)
functional appliance. Many functional appliances have been described,
starting with
the activator and its modifications and including the
bionator, function regulator or
Frankel, and the Herbst appliances
(see separate course on Functional Appliances).
Dentoalveolar changes widely documented. Controversies on mode of
action revolve
mainly around their role in stimulating mandibular growth.
Following possibilities
advanced: 1. the mandible surpasses its
growth potential;
2. mandibular growth is accelerated;
These hypotheses assume that the individual growth
potential can be
predicted
within
reasonable accuracy.
3. mandible is merely positioned forward and
subsequent growth, if
sufficient,
adapts
(“catches up”) to this position.
This hypothesis assumes that (a) occlusal
interdigitation plays an
important role in maintaining the mandible in the forward position, and (b)
the most important effect of a functional appliance is the
distal force on
the maxillary complex.This effect is
achieved through the forces
transferred to the maxillary teeth and bone by the appliance.
(iv) Combinations of headgear and functional appliances.
There is an empirical tendency to maximize the response of each jaw, regardless of the origin of the
problem. This tendency is probably due tor inability to accurately predict and influence growth,
particularly in mandible.
b.
Class II, Division 2
Condition:
-original description by EH Angle.
-variations and classifications (Jarabak: four types including Class I, division 2; Ghafari and
Street:
four basic types of Class II, Division 2 malocclusion, based on the inclination of the
maxillary incisors, the
mandibular plane, and the interincisal angle.).
Treatment
-distoclusion: with headgear, ACCO, or combined therapy if distal movement of maxillary
molars is
needed. A functional appliance, when indicated,
often requires aligning the maxillary
incisors to allow
an adequate mandibular forward positioning.
-overbite:
interception might require early extraction of the maxillary primary canines for
orthodontic
or self-alignment of permanent lateral incisors, with
inhibition of vertical drift of the
permanent central
incisors.
Early treatment of a Class II, Division 2 malocclusion should prevent a worsening of the anterior deep bite
which, in severe cases, may be accompanied by an inhibited vertical drift of the posterior teeth and an
accentuation of the chin (“chin button”).
c.
Observations on the evaluation of the early treatment of distoclusions
Factors influencing evaluation of early treatment summarized as differences in
populations and appliances, and differences in and/or inadequacies of
methodology used
in
clinical studies.
1.
Early treatment of distoclusions mostly transforms a Class II malocclusion to a Class I
malocclusion,
not a Class I normal occlusion.
2.
Criteria to note success often lacking, for success must be evaluated at different levels
within the same occlusion. Often, correction of molar occlusion temporally separate from achievement of
canine neutroclusion and/or overjet.
3.
Malocclusion must be clearly defined, to eliminate any “noise” in the selection process of
a study’s
population. (Class II malocclusion refers to Class II molar relationship regardless of the
canine occlusion?
Existence of a skeletal problem?).
C.
Anterior Crossbite
a.
Dental crossbite
Condition usually affects one or two incisors in otherwise normal occlusion.
Treatment: correct inclination of involved tooth/teeth; two essential
considerations: space requirements and overbite. Prerequisite: provide space for
alignment.
-mechanotherapy: removable plates with finger springs; fixed and removable inclined planes.
b.
Dento-alveolar crossbite
Condition involves crossbite of a group of teeth, usually all four incisors, in a
seemingly
Class III or “super Class I” occlusion (also known as a pseudo-Class III or
functional
anterior crossbite).
Treatment considerations include proper positioning of affected teeth, and
disocclusion of
anterior teeth if deep overbite.
Early correction of this crossbite is important to prevent its stabilization in the
permanent dentition and avoid hindrance of anterior maxillary alveolar growth.
-mechanotherapy: fixed orthodontic appliances; inclined planes; “sagittal” removable appliances
(procline maxillary anterior teeth by periodic activation of jackscrew built into plate); functional
appliances
(effect seems limited; chin cup (success seems contingent on severity of crossbite, depth
of the bite, and patient’s cooperation.
d.
Anterior crossbite with underlying skeletal discrepancy.
Condition: “True” Class III malocclusion: rarely, if ever, resolved by orthodontic
means, and in
most cases surgical correction is required, normally after or towards the end of
mandibular growth (skeletal
ages of 16-18 years in females, 18-20 years in males).
Treatment: Treatment approaches include the extended use of a chincup, the
“Delaire
mask” or reverse headgear, or both.
Major problem with early treatment: ability to forecast malocclusion’s development. Yet early treatment
may reduce the severity of the malocclusion by minimizing associated problems such as crowding of the
maxillary arch. If left uncorrected, problem may have to be treated later by tooth extractions (usually
premolars) that contract a maxillary arch already constricted relative to the mandibular arch. The use of a
palatal expander is often indicated, after accurate diagnosis of transverse occlusal relationships is
necessary.
2.
MANAGEMENT OF VERTICAL OCCLUSAL PROBLEMS
A.
Deep overbite
Condition: dentoalveolar.
Treatment: correction leads to an increased overjet; aims at enhancing eruption
of posterior teeth, while maintaining height of incisors, especially if underlying
skeletal hypodivergency.
-mechanotherapy:
a-removable appliance with anterior bite plate; retraction of incisors to reduce overjet
with same appliance (stretching elastics against incisors).
b-fixed appliances: partial banding/bonding of permanent first molars and incisors;
“intrusive” arch promotes extrusion of molars (easier achieved) and intrusion of the
incisors (consider increasing posterior anchorage e.g. with palatal bar or headgear,
particularly when tendency to skeletal vertical hyperdivergency.
True intrusion is difficult to achieve; however, in a growing individual, stabilization of the incisors is
considered a relative intrusion since their vertical movement is impeded relative to the other teeth.
B.
Anterior open bite
Condition: usually associated with a habit (digit sucking or tongue thrust).
Treatment:
1- correct habit
2- treatment rationales:
-increase overbite (“close” bite) by favoring extrusion or proper eruption of
anterior teeth.
-stabilize or depress posterior teeth (particularly in skeletal hyperdivergent
patterns).
-mechanotherapy: appliance, such as tongue crib, may eliminate associated habit
while effecting bite closure; fixed appliances; high-pull headgear; bite block (hard –
acrylic- or soft
–rubber); incorporated magnets; vertical pull chin cup (no definite
evidence).
-special consideration for skeletal hyperdivergency: blocked airways must be
examined may
need removal.
In many patients with underlying skeletal problems, early treatment with orthodontic appliances is
compensatory at best, and surgical correction would be considered later. If early therapy is successful,
retention of results through the end of active facial growth is indicated.
3.
MANAGEMENT OF TRANSVERSE OCCLUSAL PROBLEMS
A.
Posterior crossbite
a.
A single tooth crossbite
-Condition: buccal or lingual, involves a tipping of the affected maxillary or mandibular
tooth.
-Treatment: correct inclination of malaligned maxillary, mandibular or both teeth (not
indicated for a single primary molar in crossbite).
-mechanotherapy: crosssbite elastics; removable appliance with finger spring or jack
screw; fixed appliances.
b.
posterior segment of an arch is in crossbite.
-Condition: unilateral and bilateral crossbites.
-if unilateral: differentiate between true or anatomic (occlusion similar in IC=RC)
unilateral crossbite and functional crossbite (mandible shifts laterally to side of crossbite
from IC to RC); therefore bilateral component in RC, an indication for bilateral
treatment).
-Treatment: depending on severity dental buccal tipping, dentoalveolar, or palatal
expansion.
-mechanotherapy: Porter or W appliance, Quad helix, a removable plate with expansion
jack screw, fixed appliances with a springor a jack screw ( Haas or Hyrax types),
expanded archwires in banded orthodontic appliance.
Uncorrected, the mandibular lateral shift may become permanent: an asymmetry of the corpus and the
condyle might follow (not definitively proven). The shift often is caused by an occlusal interference of the
primary canines for a more convenient occlusion with the posterior crossbite. Reduction of the occlusal
interference may eliminate the mandibular deviation and should be attempted prior to the expansion,
particularly in cases of mild constriction of the maxillary arch.
c.
Bilateral crossbites can also be anatomic (CO=CR) or have an additional
functional component (mandibular shift to the side of the crossbite). But differentiation
is academic since bilateral expansion required in both cases.
d.
posterior crossbite where maxillary molars are in full buccal position relative to
the mandibular opposing teeth (Brodie syndrome).
-Condition: Rare and difficult to manage.
-Treatment: often implies constricting maxillary arch, rather than expanding mandibular
arch, but sometimes both. Constriction of the maxillary arch may require a later
extraction of permanent teeth (usually premolars), or in case of distoclusion, additional
space may be provided by distal movement of the molars.
B.
Midline deviation
Between the dental arches are discussed.
-diagnosis: establish whether a skeletal deviation exists, if so, whether it is true or
functional. Functional deviation associated with posterior crossbite and corrected
simultaneously. If true skeletal midline discrepancies, rule out any pathology within the
mandible or of the condyles.
4-
CONTROVERSIES ON TIMING TREATMENT
Opinions of orthodontists on early treatment vary widely:
1- start therapy as early as the developing malocclusion is identified as natural forces
brought to normal function.
2no advantage to be gained.
3justified if orthodontist can achieve either definite interception of malocclusion or
meaningful reduction of severity to affect outcome and/or length of later complete
correction.
Problem: predicting facial development. Insofar as the individual patient deviates
significantly from the average, success can be limited. Limitations increase with
malocclusions involving skeletal discrepancies.
Timing of treatment:
Value of early treatment versus waiting until permanent dentition erupted demonstrated.
Controversy as to how early.
Primary dentition: controversial, no evidence, but demonstrated for limited types of
malocclusion.
Mixed dentition: two-phase treatment versus one stage two-phase-treatment. See clinical
trials section.
2.
CLINICAL TRIALS: DESIGN, SET-UP, AND FINDINGS
1.
DESIGN OF TRIALS
2.
FINDINGS
-Retrospective versus retrospective.
-Inclusion and exclusion criteria
-Protocol
-Facial changes.
-Occlusion
-Cephalometric changes
-Conclusions on modalities of treatment
-Conclusions on timing of treatment
Findings from a prospective randomized clinical trial indicated that treatment of
Class II, division 1 malocclusion was as effective in late childhood as in midchildhood. Optimal timing of treatment would be in the late mixed dentition before
the loss of the primary second molars. Practical implications of the findings are
emphasized with clinical illustrations, specifically the effect on treatment timing of
saving the leeway space, and taking advantage of differential growth between the
jaws. General guidelines are weighed in consideration of the concept of early
treatment as one-phase treatment, and whether this concept can be generalized in
view of epidemiologic findings and individual variation.
3.
GENERAL TRENDS AND INDIVIDUAL VARIATIONS
IMPLICATIONS OF RESEARCH FINDINGS ON TREATMENT OF CLASS II AND CLASS I
MALOCCLUSIONS
1.
GENERAL TREND
-Treat in late mixed dentition to take advantage of growth events:
-dental: E space
Loss of second primary molars: an indicator of space loss and potential
modification
in molar occlusion
-skeletal: growth (before adolescent spurt).
Adolescent growth spurt: an indicator of the beginning of decrease in the
rate of
growth (not total cessation, but on average, what is left is
comparatively less in
amount and predictability)
2.
EARLIER INTERVENTION
3.
EPIDEMIOLOGIC FINDINGS
-Occlusal and developmental conditions requiring earlier intervention:
-functional crossbite
-trauma (related to severe overjet)
-psychosocial development (related to severe overjet)
-early loss of primary teeth
-discrepancy between requirements of dental age and skeletal age
- support trend in majority of patients
4.
MANAGEMENT OF HABITS ASSOCIATED WITH OCCLUSAL
PROBLEMS
1.
2.
Relation of vertical occlusal problems to sagittal (and transverse) problems.
Differentiation between skeletal, dentoalveolar and dental deep or open bite.
1-
TONGUE THRUST
A.
Swallow Patterns
a.
Infantile swallow pattern
B
b.
Transitional swallow pattern
c.
Adult swallow pattern
Types of tongue thrust
a.
b.
c.
Subtelny'
s classification - (on basis of diagnosis)
Moyer'
s classification - (on basis of etiology)
Ghafari'
s classification- (on basis of treatment)
Analysis by Proffit et al. (1978, 1993)
a.
Transitional swallow patterns from infantile through adult swallow
pattern.
b.
Tongue pressures in speech and swallowing not significantly different in
tongue
thrusters and non-thrusters
c.
In patients with incisor protrusion, the amount of anterior pressure is
inversely
related to the amount of anterior protrusion.
d.
Tongue pressures directed horizontally against the teeth by tongue
thrusters are not
sufficient in force or duration to push teeth into a
new position.
e.
Orthognathic surgery patients adapt tongue pressure and contact patterns
to the
environment created, usually within a one year span.
f.
Tongue and lip pressures never balance during swallowing and tongue
pressures are
always several times higher (Lear and Moorrees, 1969).
g.
Tongue and lip pressures over time do not balance out to create an
"equilibrium".
h.
The functional activities of the tongue are not important determinants in
tooth
position, but an anterior resting tongue position and
associated vertical pressure
against the anterior teeth can
contribute to or maintain an anterior open-bite
malocclusion (Proffit and Mason).
C.
D.
Malocclusions associated with tongue thrust
E.
Treatment
2-
THUMB (FINGER) SUCKING
1.
Prevalence of malocclusion significantly higher in children with sucking habits
than in those without the habits at 3 and 12 years of age (Popovitch and Thompson, A,.
J. Orthod., 1973).
2.
In children in whom thumb or finger sucking ceased before the age of 6 years,
prevalence of malocclusion was not higher than with children with no history of sucking
habits (op. cit.)
3.
Malocclusions associated with digit sucking
4.
Methods for controlling the habit:
a.
Prevention- behavioral approach
b.
Positive reinforcement
c.
Aversive conditioning techniques
3-
RELATION BETWEEN DIGIT SUCKING AND TONGUE THRUST
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