clinical problem solving in dentistry orthodontics and paediatric dentistry

Clinical Problem Solving in Dentistry: Orthodontics and Paediatric Dentistry, 3ed BY D. Millet, P. Day

Clinical Problem Solving in Orthodontics and Paediatric Dentistry, third edition,  provides a unique step-by-step guide to differential diagnosis and treatment planning. The popular 'Clinical Case' format helps readers combine different dental procedures into a rational plan of treatment for patients who may have several dental problems requiring attention.

This is a third edition of a hugely successful practical resource in orthodontics and paediatric dentistry which is ideal for undergraduate dental students and postgraduates preparing for the MJDF and similar exams

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Clinical problem Solving in Orthodontics & Paediatric Dentistry

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Orthodontics &Paediatric Dentistry To my parents (Declan) and to Philly, Izzy, Ollie, Mum and Dad (Peter) or their enduring love and support. For Elsevier Content Strategist: A lison Taylor Content Develop m ent Sp ecialist: Sally Davies Project Manager: Louisa Talbott Designer/ Design Direction: Christian Bilbow Illustration Manager: Lesley Frazier CLINICAL P ROBLEM S OLVIN G IN DENTISTRY SERIES THIRDEDITION Orthodontics &Paediatric Dentistry Declan Millett BDSc DDS FDSRCPS(Glasg) FDSRCSEng DOrthRCSEng MOrthRCSEng FHEA Pro essor o Orthodontics Cork University Dental School and Hospital University College Cork Cork, Ireland Peter Day BDS PhD FDS(Paeds)RCSEng MPaedDent(RCSEng) MFDS(RCSEng) FRCD(Canada) FIADT PGCLTHE FHEA Associate Pro essor and Consultant in Paediatric Dentistry School o Dentistry at the University o Leeds and Brad ord District Care NHS Foundation Trust Salaried Dental Service Leeds, UK With contributions rom Caroline Campbell BDS MSc MPaedDent(Ed) MFDS RCPS(Glasg) FDSPaedDent(Glasg) Consultant in Paediatric Dentistry, Honorary Senior Clinical Lecturer Department o Paediatric Dentistry Glasgow Dental Hospital and School University o Glasgow Glasgow, UK Marie Therese Hosey BDS MSc(MedSci) DDS FDS RCPS(Glas) Pro essor o Paediatric Dentistry Population and Patient Health Division King’s College London Dental Institute London, UK Edinburgh London New York Ox ord Philadelphia St Louis Sydney Toronto 2017 © 2017 Elsevier Ltd . All rights reserved . Previou s ed itions: © 2005, 2010, reprinted 2011 (tw ice) and 2013 Elsevier Ltd . All rights reserved . N o part of this p ublication m ay be rep rod u ced or transm itted in any form or by any m eans, electronic or m echanical, inclu d ing p hotocopying, record ing, or any inform ation storage and retrieval system , w ithou t p erm ission in w riting from the p u blisher. Details on how to seek perm ission, fu rther inform ation about the Pu blisher ’s perm issions p olicies and ou r arrangem ents w ith organizations such as the Cop yright Clearance Center and the Cop yright Licensing Agency, can be fou nd at ou r w ebsite: w w w.elsevier.com / p erm issions. This book and the ind ivid u al contribu tions contained in it are p rotected u nd er cop yright by the Pu blisher (other than as m ay be noted herein). ISBN 978-0-7020-5836-3 N otices Know led ge and best p ractice in this eld are constantly changing. As new research and exp erience broad en ou r und erstand ing, changes in research m ethod s, professional p ractices, or m ed ical treatm ent m ay becom e necessary. Practitioners and researchers m u st alw ays rely on their ow n exp erience and know led ge in evalu ating and using any inform ation, m ethod s, com p ou nd s, or exp erim ents d escribed herein. In u sing su ch inform ation or m ethod s they shou ld be m ind fu l of their ow n safety and the safety of others, includ ing parties for w hom they have a p rofessional resp onsibility. With respect to any d ru g or p harm aceutical prod u cts id enti ed , read ers are ad vised to check the m ost current inform ation provid ed (i) on p roced ures featu red or (ii) by the m anu factu rer of each prod u ct to be ad m inistered , to verify the recom m end ed d ose or form u la, the m ethod and d u ration of ad m inistration, and contraind ications. It is the resp onsibility of practitioners, relying on their ow n exp erience and know led ge of their p atients, to m ake d iagnoses, to d eterm ine d osages and the best treatm ent for each ind ivid u al p atient, and to take all ap p ropriate safety precau tions. To the fullest extent of the law, neither the Pu blisher nor the au thors, contribu tors, or ed itors, assum e any liability for any injury and / or d am age to p ersons or prop erty as a m atter of p rod u cts liability, negligence or otherw ise, or from any use or op eration of any m ethod s, p rod u cts, instru ctions, or id eas contained in the m aterial herein. The publisher’s policy is to use paper manufactured from sustainable forests Printed in China Last d igit is the print num ber: 9 8 7 6 5 4 3 2 1 Contents 1 Median diastema and ectopic eruption o an upper rst permanent molar 2 Unerupted upper central incisor 3 Absent upper lateral incisors 1 24 Pain control and treatment planning or carious primary teeth 140 5 25 Facial swelling and dental abscess 146 26 The uncooperative child and adolescent 149 11 by M arie Therese Hosey 4 Crowding and buccal upper canines 16 5 Severe crowding 25 6 Palatal canines 36 7 More canine problems 46 27 Children with disabilities and learning dif culties 157 by M arie Therese Hosey 28 Common medical problems in children 163 29 The displaced primary incisor 168 8 In raoccluded primary molars 51 9 Increased overjet 55 30 The ractured immature permanent incisor crown 171 175 10 Incisor crossbite 62 11 Reverse overjet 66 31 The root ractured permanent incisor 12 Increased overbite 73 32 The avulsed incisor 179 13 Anterior open bite 81 14 Posterior crossbite 87 33 Disorders o eruption and ex oliation 184 15 Bilateral crossbite 91 34 Poor quality rst permanent molars 187 16 Late lower incisor crowding 99 17 Prominent chin and TMJDS 102 18 Dri ting incisors 109 35 Tooth discoloration, hypomineralization and hypoplasia 191 19 Appliance -related problems 113 36 Mottled teeth 195 37 Multiple missing and abnormally shaped teeth 199 38 Amelogenesis imper ecta 203 39 Dentinogenesis imper ecta 206 20 Tooth movement and related problems 118 21 Cle t lip and palate 125 22 Nursing and early childhood caries 130 40 Dental erosion 209 23 High caries risk adolescents 135 41 Gingival bleeding and enlargement 213 by Caroline Campbell • vi CONTENTS 42 Oral ulceration 216 43 Mind Maps® 219 A4 Implications o some medical problems or orthodontics 269 A5 Lateral cephalometric analysis 271 Appendices A6 A structured dental trauma history orm A1 The index o orthodontic treatment need: dental health component 264 A2 Classi cation and de nitions 265 A3 Orthodontic problems: re erral guide 268 Index 273 275 vii • Pre ace to the third edition The fond ness of stu d ents for this p roblem -solving form at and their encou raging feed back have led u s to being asked by the p u blishers to d o a third ed ition. The passage of tim e has brou ght a new co-au thor, Peter Day, to the Paed iatric Dentistry section and a new contribu ting au thor, MarieTherese H osey. It is w ith great regret that Richard Welbury, w ho co-authored the rst and second ed itions, w as u nable to continue in this role and w e thank him m ost sincerely for his form er involvem ent. We are ind ebted to ou r colleagues w ho have p rovid ed valu able su ggestions regard ing this revision. The stru ctu re of the chap ters rem ains u nchanged , w ith the presentation of a clinical problem follow ed by a step-bystep lead -through assessm ent, d iagnosis and treatm ent planning. All chap ters and related Mind Map s®, w here relevant, have been u p d ated . Ad d itional cases are inclu d ed in several chap ters to re ect the contem p orary and changing face of orthod ontic and p aed iatric d entistry clinical practice. Three new orthod ontic append ices d eal w ith classi cation and d e nitions, im plications of com m on m ed ical problem s and referral gu id elines. In ad d ition, one new paed iatric d entistry append ix provid es a structured d ental trau ma history form . Tw o new chap ters ad d ress m anagem ent of the physically and m ed ically com prom ised child . In p romotion of evid ence-based best p ractice and to d irect further learning, reference lists have been u pd ated throughou t to includ e Cochrane review s, w here these have been d evelop ed . It is ou r hope that this text w ill continu e to be of use to u nd ergrad u ates and to those in the early years of postgrad u ate training. DTM PFD Cork and Leeds 2016 • viii Pre ace to the f rst edition Problem solving is a core skill w hich the d ental und ergrad u ate m u st d evelop and re ne for exam inations and everyd ay clinical p ractice. As orthod ontics and p aed iatric d entistry interface broad ly, com bined clinical teaching and exam inations in these d isciplines are linked increasingly to encourage holistic p roblem solving of d ental and occlu sal p roblem s in the child and ad olescent p atient. This book aim s, therefore, to ad d ress a range of com m on clinical p roblem s encou ntered in orthod ontic and p aed iatric d ental p ractice. The form at p rom otes a logical ap p roach to problem solving throu gh history taking, clinical exam ination and d iagnosis, w hich u nd erp in the princip les of treatm ent p lanning for both d iscip lines. A short reference list is provid ed w ith each chap ter to facilitate fu rther d irected learning. Mind Map s ® are also given for each topic to provid e a focused fram ew ork for learning and revision. Each Mind Map ® links key w ord s, or key points, w hich are highlighted throu ghou t the text, to create an overview of the su bject and is d esigned to trigger inform ation recall. Intend ed p rim arily for the u nd ergrad u ate, w e hope this book w ill be of valu e also to the ju nior postgrad u ate and to those p rep aring for m em bership exam inations. DTM RRW Cork and Glasgow 2004 ix • Acknowledgements We are p articu larly gratefu l to Mrs K Shep herd and Mrs G Drake for their help and su p p ort in the p rep aration of p hotograp hic m aterial. We w ou ld also like to thank especially Dr G McIntyre, Ms R Bryan, Mr J C Aird , Dr A Shaw, Miss D Fu ng, Dr T Ubaya, Dr C Cam p bell, Dr K O’Rourke, Dr P Mu rray, Dr T McSw iney, Dr P Mu rp hy, Dr M Mead e, Dr L Darby, Dr S McMorrow, Dr S Littlew ood , Dr A Garry, Dr E Salloum , Dr D Morris, Dr S Fayle, Dr A Mighell and Cork University Dental School & H ospital for provision of som e of the illu strations. Mr K Evans also kind ly assisted w ith the p rod uction of the app liances show n in Figs 9.4 and 13.8. Ms N Kelly is thanked esp ecially for the ed iting and com p ilation of photograp hic m aterial. Thank you to stud ents and staff w ho have u nd ertaken som e or all of the care on w hich the cases are based on. We are also gratefu l to Buzan Centres Ltd for the style for the Mind Map s ®. Ou r gratitud e is extend ed to the staff of Elsevier w ho have been very help fu l throu ghout. 1 Median diastema and ectopic eruption o an upper frst permanent molar History o complaint Brian’s p rim ary front teeth had a p leasing ap p earance w ith a sm all m id line space in the u pp er arch; the low er p rim ary front teeth w ere not spaced . There is no history of trau m a. The permanent incisors erupted in their p resent positions. Brian’s p erm anent m olars started to eru p t over a year ago and there is no d iscomfort from any of them . Medical history Brian is t and w ell. Dental history Brian attend s his general d ental practitioner every 6 m onths but has not required any treatm ent. Family history Brian’s father had an u p p er m id line sp ace that w as closed w ith a xed ap pliance. Examination Extraoral examination SUMMARY Brian is almost 8 years o age. He presents with a gap between his upper ront teeth and crooked lower ront teeth (Fig. 1.1); an ‘adult’ upper back tooth also does not appear to be coming through properly. What are the causes o these problems and what treatment would you recommend? History Complaint Brian’s m other noticed the gap betw een his u p p er front teeth and the irregu larity of his low er front teeth. She is anxiou s abou t his ap p earance and is keen for treatm ent to be provid ed . Recently she has also noticed that one of his new ‘ad u lt’ u p p er back teeth is not com ing throu gh p rop erly com pared w ith his other u pper back tooth on the opposite sid e. Fig. 1.1 Anterior occlusion at presentation. Brian has a Class I skeletal p attern w ith average FMPA and no facial asym m etry. Lip s are com petent w ith the low er lip resting at the incisal third of the up p er central incisors. There are no tem porom and ibu lar joint signs or sym ptom s. Intraoral examination Soft tissu es are healthy and the d entition is caries-free. The intraoral view s are show n in Figs 1.1 and 1.2. ■ What do you observe? Low-lying maxillary labial renum. The ollowing teeth are visible: 6 E D C B1 1B C D 6 E D C 21 12 C D E 6 (note E6 present, but 6 erupting into E). Mild lower labial segment crowding with distolabial rotations o 1| 1; slight spacing distal o 2 | 2. Upper median diastema with the crowns o 1 1 f ared distally. Class III incisor relationship. Crossbites B| B . C| C Fig. 1.2 Lower occlusal view (note 6 | 6 erupted but not shown). 1 •2 MEDIANDIASTEMAANDECTOPICERUPTIONOFANUPPERFIRSTPERMANENTMOLAR ■ Wha t is the aetiology o the 1 | 1 rotations? Incisor rotations are usu ally a m anifestation of inherent crow d ing in the arch, w hich is genetic in origin. The lack of primary low er incisor sp acing rep orted by the child ’s m other is p red ictive of likely crow d ing of the p erm anent successors. Incisor rotations may also resu lt from ectopic position of the tooth germ s or from the p resence of a su p ernu merary tooth. ■ Wha t are the possible causes o the upper median dia stema? These are listed in Table 1.1. ■ Is the dental and occlusal development normal? Dental d evelopm ent is norm al. Erup tion d ates of the prim ary and p erm anent d entition are given in Table 1.2. It is com m on for som e crow d ing to be present as the low er incisors eru pt, w hich u su ally m anifests itself as slight lingual p lacem ent and / or rotation of the teeth, bu t the slight Table 1.1 Causes o an upper median diastema Key point Causes Comments Developmental Due to pressure o 2 2 on 1 1 roots ( ormerlyre erred to as‘uglyduckling’stage); tends to resolve bythe time 3 3 erupt Dentoalveolar disproportion Small teeth in a large arch Absent or peg shaped 2’s upper permanent incisor teeth? Proclination o 21 12 Maybe due to a digit sucking habit Prominent labial renum Implicated where there is blanching o the incisive papilla on stretching the renumand notching between 1 1 is seen on radiograph Pathological Cyst/tumour Juvenile periodontitis Table 1.2 Eruption dates or primary and permanent teeth Months Upper Permanent Years Upper Central incisor 6–7 Central incisor 7–8 Lateral incisor 7–8 Lateral incisor 8–9 Canine 18–20 Canine 11–12 First molar 12–15 First premolar 10–11 Second molar 24–36 Second premolar 10–12 First molar Lower On eruption: • Some crowding o 21| 12 is usual. • A median diastema between 1 1 is normal. ■ In the developing dentition, how is space created or the Supernumerarytooth/teeth in midline Primary d istal tilt and rotations of 1| 1 m ay ind icate inherent crow d ing. Also, there is no low er prim ate (anthropoid ) sp ace betw een the p rim ary canines and rst p rim ary m olars. Spacing betw een the up per perm anent central incisors ( ared d istally and form erly d escribed as the ‘u gly d u ckling’ stage, term s best avoid ed w ith concerned p arents) is also norm al at this stage, but generalized sp acing of the up p er prim ary teeth inclu d ing the u p per prim ate spaces (located betw een the u p p er p rim ary lateral incisors and the up p er prim ary canines) shou ld exist. Although the prim ary incisor relationship is com m only ed ge-to-ed ge at 5–6 years w ith incisor attrition, it is not usu al for the perm anent incisor relationship to be sim ilar. Rather a Class I incisor relationship should be present. B B A crossbite shou ld not exist on || . C C The rst perm anent m olars shou ld norm ally be in a halfunit Class II relationship d u e to the ‘ ush term inal p lanes’ relationship of the second p rim ary m olars. 6–7 Second molar 12–13 Third molar 17–21 Lower Central incisor 6–7 Central incisor 6–7 Lateral incisor 7–8 Lateral incisor 7–8 9–10 Canine 18–20 Canine First molar 12–15 First premolar 10–12 Second molar 24–36 Second premolar 11–12 First molar 5–6 Second molar 12–13 Third molar 17–21 Space is obtained from three sources: the spacing w hich should exist betw een the prim ary incisors; an increase in intercanine w id th; and by the p erm anent u p p er incisors eru p ting m ore labially and p roclined com p ared w ith their p red ecessors. On average, the u p per and low er intercanine w id th increases by abou t 1–2 m m in the prim ary d entition; a further increase of around 3 m m occu rs d u ring the m ixed d entition but is generally comp lete by abou t 9 years w hen the u pper and low er perm anent lateral incisors are fu lly erup ted although som e m inor increase occu rs u ntil 13 years. Key point Intercanine width: • Increases ~1 2 mm during primary dentition. • Increases ~3 mm in mixed dentition. • Is generally complete by ~9 years, with minor increase to ~13 years. Investigations ■ What investigations would you undertake? Explain why. Clinical • Gently pull the upper lip upwards and observe i there is blanching o the incisive papilla rom the renal attachment. This may implicate the renum in the possible aetiology o the upper median diastema. In Brian’s case, slight blanching o the incisive papilla was detected. 3• MEDIANDIASTEMAANDECTOPICERUPTIONOFANUPPERFIRSTPERMANENTMOLAR • Check i there is a mandibular displacement associated with BB the crossbites on . I a displacement is detected, CC early crossbite correction is indicated. Brian, however, did not have a mandibular displacement, which was con rmed by the absence o a lower centreline shi t. Radiographic A left bitew ing rad iograp h cou ld be taken to assess 6 p osition/ statu s of any root resorp tion of E and an u p p er anterior occlu sal rad iograp h to assess p resence/ absence of an u p p er m id line su p ernu m erary. Alternatively, a d ental p anoram ic tom ogram , w hich is easier for the child to cooperate w ith, cou ld be taken initially, w hich w ill also allow you to ascertain the p resence, p osition and form of all u neru pted teeth. If a supernu m erary tooth/ teeth or other pathology is observed or su sp ected on the d ental p anoram ic tom ogram in the anterior p rem axilla, an u p p er anterior occlusal rad iograp h should be taken. ■ The dental panora mic tomogram is shown in Fig. 1.3. What do you notice? Normal alveolar bone levels. A normally developing dentition, which is consistent with the patient’s chronological age. Resorption o the distal root o E E. Impaction o 6. Diagnosis ■ What is the dia gnosis? the sm all existing spaces d istal to them (Fig. 1.4). Further im p rovem ent in the low er incisor crow d ing is also likely u ntil about 9 years of age as the intercanine w id th increases. The up per med ian d iastem a is likely to red u ce as the m axillary p erm anent lateral incisors and canines erupt. Brian’s m other should be reassu red abou t this. The attachm ent of the m axillary labial frenu m, althou gh initially to the incisive papilla d u ring the p rim ary d entition, m oves to the labial attached m u cosa as the p ermanent lateral incisors eru p t and ap p roxim ate the p erm anent central incisors (Fig. 1.5). In a sp aced arch, this m igration of the frenum is less likely. In contrast, w here the u pp er arch is potentially crow d ed and the d iastem a is less than 4 m m, recession of the frenum and closu re of the m ed ian d iastem a m ay be forthcom ing eventu ally. H ow ever, in the p resent case, as Brian’s father had an u pp er m ed ian d iastem a, there may be a tend ency for the sp ace to persist. ■ How common is impaction o 6? This anom aly of erup tion occurs in about 2–6% of child ren bu t has been rep orted in 20–25% of child ren w ith cleft lip and / or p alate. ■ Wha t are the ca uses o impaction o 6? Impaction o 6 is indicative o crowding. Both local and hereditary actors have been implicated (Table 1.3). A multi actorial mode o inheritance has been identi ed where both genetic and local actors act in combination. ■ Describe the clinica l eatures o ectopic eruption o 6 and cla ssif cation o this anomaly. Ectopic erup tion of 6 is m anifested by eru ption m esial of its norm al path. Com plete eru p tion of 6 is initially blocked by Mild Class III malocclusion in the early mixed dentition on a Class I skeletal base with average FMPA. Mild lower labial segment crowding; upper median diastema. BB Crossbites || with no mandibular displacement. CC Impacted 6. ■ What is the IOTN DHC gra de (see Appendix 1, p. 264)? Expla in why. 4t – d u e to a p artially eru p ted and im pacted 6. ■ What trea tment would you advise or the labial segment problems? Explain why. N o treatm ent is ind icated at p resent. The m ild low er labial segm ent crow d ing m ay red u ce slightly by d rift of 2| 2 into Fig. 1.4 Lower occlusal view 1 year a ter presentation. Fig. 1.3 Dental panoramic tomogram. 1 Fig. 1.5 Anterior occlusion ollowing eruption o 2’s. 1 •4 MEDIANDIASTEMAANDECTOPICERUPTIONOFANUPPERFIRSTPERMANENTMOLAR Table 1.3 Causes o impaction (ectopic eruption) o 6 Factor Cause Local Signifcantlylarger 6 and more pronounced mesial angle o eruption o 6 Hereditary Familial tendency Small maxilla the d istal su rface of E, w hich then, in resp onse to tooth contact, u nd ergoes resorp tion. Ectop ic erup tion of 6 is d escribed as ‘reversible’ if d isim paction and fu ll eru p tion ensu e spontaneou sly. After 8 years of age, this occu rs rarely. If 6 rem ains im pacted u ntil treated or p rem ature loss of E hap p ens spontaneou sly, ectop ic eru ption of 6 is d escribed as ‘irreversible’. Treatment ■ What treatment options a re there or irreversible ectopic eruption o 6? Without extraction o E Where im p action of 6 is m ild , a brass w ire separator m ay be tightened arou nd the contact area of E and 6 over several visits; this w ill release 6 by d isplacing it d istally. Discing the d istal surface of E and the u se of a separating sp ring have also been p roposed . If 6 exhibits marked m esial tip p ing, more active d istal m ovem ent is requ ired . This may be achieved by a sp ring sold ered to a transp alatal bar u niting the D’s. The spring acts against a com posite stop bond ed to the occlu sal su rface of 6. With extraction o E If there is m arked resorption or abscess formation of E, or if 6 cannot be d isim p acted w ith a sep arating sp ring, or if 6 is cariou s and p oor access im p ed es restoration, extraction of E is u navoid able. As 6 erup ts w ith a m esial inclination, sp ace loss occu rs rap id ly follow ing loss of E. Consid eration shou ld be given to regaining sp ace by d istalizing 6 w ith a sp ring on an u p p er rem ovable ap pliance in cases of u nilateral loss of E. Where bilateral loss of E occu rs, d istal m ovem ent of 6’s m ay be achieved by sp rings sold ered to a transp alatal arch connecting both D’s or by cervical traction to band s on 6’s. Alternatively, m anagem ent of the sp ace loss resu lting from extraction of E’s can be d eferred u ntil the p erm anent d entition. Key point For impacted 6 consider: • Brass wire separator. • Discing distal sur ace o E. • Move 6 distally. • Extract E. Fig. 1.6 Upper occlusal view ollowing extraction o E. ■ How will the orthodontist manage impaction o 6 in this case? The variou s op tions regard ing d isim p action of 6 shou ld be d iscu ssed w ith Brian and his p arents. It shou ld then be exp lained that if E becom es abscessed , or attem pts to d isim p act 6 are u nsu ccessfu l, extraction of E w ill be required . Treatm ent to d eal w ith the resu ltant space loss w ill be required thereafter. Brian w as not keen for any orthod ontic treatm ent and , therefore, it w as d ecid ed to extract E in view of the caries risk to 6. The consequent u p p er buccal segm ent crow d ing (Fig. 1.6) w ill be d ealt w ith in the p erm anent d entition. Im p ressions and a w ax registration for stu d y m od els shou ld be record ed of the d evelop ing Class III m alocclu sion. This shou ld then be monitored u ntil the perm anent d entition is fu lly established w hen treatm ent p lanning can be com pleted . Primary resources and recommended reading Bjerklin K, Ku rol J, Valentin J 1992 Ectopic eru p tion of m axillary rst p erm anent m olars and association w ith other tooth and d evelop m ental d istu rbances. Eu r J Orthod 14:369–375. Foster TD, Gru nd y MC 1986 Occlu sal changes from p rim ary to p erm anent d entitions. Br J Orthod 13:187–193. H u ang WJ, Creath CJ 1995 The m id line d iastem a: a review of its aetiology and treatm ent. Ped iatr Dent 17:171–179. Ku rol J, Bjerklin K 1986 Ectop ic eru p tion of m axillary rst p erm anent m olars: a review. ASDC J Dent Child 53:209–214. For revision, see Mind Maps 1a and 1b, pages 220 221, and Appendices 2 and 3 pages 265 268. 2 Unerupted upper central incisor Medical history N eil is t and w ell. Examination Extraoral examination N eil has a m ild Class II skeletal p attern w ith slightly increased FMPA. H is lip s are com p etent. N o facial asym m etry or abnorm al tem p orom and ibu lar joint signs or sym p tom s w ere d etected . Intraoral examination ■ The appearance o the mouth is shown in Figs 2.1 and 2.2. What do you notice? Oral hygiene is air calculus is visible on the buccal aspect o 6. SUMMARY Neil, a 9-year-old boy, presents with 1 unerupted (Fig. 2.1). What are the possible causes and how would you manage the problem? History Complaint N eil’s m other is very concerned abou t the u neru p ted 1 as he is 9 years old and the tooth has not yet ap peared ; 2 is also eru p ting over B, and she d islikes the ap p earance. History o complaint A w as lost at abou t 6 years of age, and 1 eru p ted norm ally at 6.5 years of age. Unfortu nately, N eil fell over w hile playing soccer w ith his class team 4 m onths ago and fractu red 1, exp osing the p u lp, w hich w as treated by a coronal pu lp otomy and p lacem ent of calciu m hyd roxid e. A ■ Is there anything else you would wish to elicit rom the history? N eil’s m other shou ld be asked abou t any history of trau m a to the prim ary incisors, p articu larly intru sion of BA . There is no history of traum a to the prim ary d entition. B C Fig. 2.1 Upper labial segment at presentation. Fig. 2.2 (A) Right buccal occlusion. (B) Anterior occlusion. (C) Le t buccal occlusion. 2 •6 UNERUPTEDUPPERCENTRALINCISOR Mild plaque deposits on most teeth associated with marginal gingival erythema. Box 2.1 Causes o unerupted or missing upper permanent central incisor 6 ED C 2 BA 1 2 C D E6 Early mixed dentition with present. 6 ED C 2 1 1 2 C E6 Missing Restored incisal edge o 1, which also appears to be darker than the other incisors. • Avulsed. Class I malocclusion with mild lower and moderate upper labial segment crowding. Present but unerupted Upper centreline to the right; lower centreline to the le t. • Dilaceration and/or displacement due to trauma. Potential crowding lower le t quadrant. • Scar tissue. Buccal segment relationship Class I bilaterally. • Supernumerary tooth. ■ Why are the centrelines displa ced? An im balance of u pper anterior tooth size (the retained A is consid erably sm aller than an 1 ) has p rom oted the u p p er centreline shift, bu t this has been aggravated by inherent u pper arch crow d ing. The low er centreline shift is d u e to early u nbalanced loss of D in a p otentially crow d ed arch. ■ Could the lower centreline shi t have been prevented? Follow ing rem oval of D the low er centreline shou ld have been m onitored at review visits. D shou ld have been extracted to balance for loss of D w hen the centreline appeared to be m igrating. ■ With unilatera l loss o what other primary tooth, would you consider a balancing extraction to prevent a centerline shi t? Where u nilateral loss of a p rim ary canine has occu rred (or is planned as in the case of a p alatally ectop ic canine; see Chap ter 6) and the contralateral tooth is not m obile, consid eration should be given to its rem oval to prevent loss of the centreline. A balancing extraction of another second primary m olar to p revent a potential centerline shift is u nnecessary. Key point Always balance or unilateral loss/extraction o a primary canine. ■ Wha t are the possible causes o the unerupted 1 ? These are listed in Box 2.1. ■ How would you ra te the likelihood in this case o each o the potential causes o unerupted 1 listed in Box 2.1? Congenital absence o 1 is highly unlikely. It would be very rare or 1 to be absent without other congenitally missing teeth. Avulsion o 1 can be excluded as there is no history o 1 having erupted or o incisor trauma. Extraction o 1 can be excluded also. Ectopic position o the tooth germ is a possibility but is more likely to be secondary to some pathological cause or the presence o a supernumerary tooth. • Congenitally absent. • Extracted. • Ectopic position o the tooth germ. • Crowding. • Pathology, e.g. cyst, odontogenic tumour. Box 2.2 Classifcation o supernumerary teeth (s/n) by morphology and e ects on the dentition • Conical or peg-shaped – most o ten lies between 1 1 and mayproduce no e ect, a median diastema, incisor rotation or ailure o 1 eruption (Fig. 2.3A); 75–78%o s/n. • Tuberculate or barrel-shaped – most usually associated with unerupted 1; ~12% o s/n. • Supplemental – resembles and lies adjacent to the last tooth o a series (2’s, 5’s, 8’s); likely to produce crowding, centreline shi t (Fig. 2.3B). • Odontome – may be either compound or complex; compound is more common in the anterior maxilla; complexis more common in the premolar and molar areas; associated with unerupted/displaced teeth. Dilaceration and/or displacement due to trauma can be excluded due to the absence o a relevant history. Scar tissue can be excluded also as this would result rom trauma. A supernumerary tooth (Box 2.2) is the most likely cause o unerupted 1. With an incidence o 1 3% in the premaxilla, supernumerary teeth (particularly the late- orming tuberculate type) are associated with delay or noneruption o an upper permanent central incisor. Crow d ing is an unlikely cau se. Althou gh the u pp er labial segm ent is crow d ed , only very severe crow d ing w ou ld prevent 1 eru pting 2 years follow ing its expected eru ption tim e. Pathology is also an u nlikely cau se. There is no evid ence of alveolar exp ansion in the p rem axilla, w hich w ou ld m ost likely be d u e to cyst form ation p ossibly arising from 1, a sup ernu m erary or od ontom e. Other rarer lesions w ou ld need to be exclud ed . Key point A supernumerary tooth is the most common cause o ailure o eruption o 1. 7• UNERUPTEDUPPERCENTRALINCISOR A 2 Radiographic The follow ing view s are required to d eterm ine the p resence/ absence of 1 and / or p ossible su p ernu m erary teeth: • Dental panoramic tomogram gives a general screen o the developing dentition allowing detection o the presence/absence o unerupted teeth. • Upper anterior occlusal or periapical views provide greater detail o the anterior maxilla. In particular, the ollowing can be assessed: the crown and root morphology o unerupted 1, the presence o supernumerary teeth and/ or other pathology and their relation to the incisor roots, the root and periapical status o traumatized 1. On a panoramic radiograph these structures may be poorly de ned due to superimposition o other anatomical eatures or by lying outside the ocal trough o the tomogram. Periapical radiographs should include the roots o adjacent teeth to determine i they were damaged during previous trauma to 1. Used in com bination and em ploying the principle of vertical parallax, the d ental panoram ic tom ogram and the u pper anterior occlu sal or periapical view s can be u sed to localize the p osition of any u neru p ted tooth and / or su p ernu m erary relative to the d ental arch. Key point B Fig. 2.3 (A) Two conical supernumerary teeth between 1 1. (B) Supplemental 2. ■ What is the aetiology o supernumerary teeth? Althou gh not entirely know n, genetic factors seem to p lay a part w ith a m ale p red ilection. The cleft area is also frequ ently affected w here the alveolu s is involved . Dichotom y of the tooth bu d and localized ind ep end ent hyp eractivity or fragm entation of the d ental lam ina have also been su ggested ; the latter is esp ecially relevant to cleft lip and palate. Mu ltip le su p ernu merary teeth rarely occu r bu t are associated w ith cleid ocranial d ysp lasia, Gard ner synd rom e and cleft lip and p alate. • Two radiographic views are required to localize an unerupted tooth in the premaxilla using parallax. • A lateral view may be required to aid localization o a dilaceration, i visible on either the dental panoramic tomogram or on the upper anterior occlusal/periapical views. ■ How would you determine the position o an unerupted tooth in the anterior premaxilla using vertica l paralla x? If the tooth m oves in the sam e d irection as the tu be shift, it lies p alatal to the arch; if it m oves in the op p osite d irection to the tu be shift, it lies buccal to the arch. Where there is no app arent shift in its position betw een the lm s, it lies in the line of the arch. ■ Neil’s radiographs a re shown in Fig. 2.4. Wha t do Key point Supernumerary teeth are more common in males. Investigation ■ What investigations are required? Expla in why. Clinical Palpation of the labial and p alatal m u cosae in the 1 area to d etect if the uneru p ted 1 is p resent. Sensibility testing of 1 to assess p u lp al statu s. 1 w as vital on sensibility testing to all stim u li, bu t as 1 w as u neru pted , it w as not p ossible to com p are resp onses to that tooth. Com parison w ith the 2’s ind icated that 1 had a d im inished response to electric pu lp testing. these show? The panoram ic tom ograp h show s all perm anent teeth to be p resent, includ ing third m olars. Dental d evelopm ent ap pears reasonably aligned w ith chronological age. There is a supernu m erary tooth overlying 1 . Root resorption of the remaining rst prim ary m olars is ad vanced , and caries is D evid ent in . Bitew ing rad iographs w ou ld be requ ired ED E for m ore accu rate assessm ent of the extent of cariou s involvem ent of the p rim ary m olars. The u pp er anterior occlusal view show s that root resorption of BA is ad vanced . 1 has a norm al crow n and root form , and the root canal ap p ears w id e w ith an ap ical calci c brid ge. A tu bercu late su pernum erary overlies the crow n of 1 . The com posite tip rep air to 1 is visible, and root form ation is incom plete w ith apical narrow ing. 2 •8 UNERUPTEDUPPERCENTRALINCISOR Upper centreline shi t to the right; lower centreline shi t to the le t. Buccal segment relationship Class I bilaterally. ■ What is the IOTN DHC grade (see p. 264)? Explain why. 5i – d ue to im ped ed eru ption of 1 cau sed by the presence of a su p ernu m erary tooth. Treatment ■ What a re your aims o treatment? A • • • • Restore gingival and dental health. Relie o crowding. Correction o centrelines. Alignment o 1. De nitive restoration o 1. ■ What is your treatment plan? B Fig. 2.4 (A) Dental panoramic tomogram. (B) Upper anterior occlusal radiograph. Application of vertical p arallax to these rad iographs ind icates that 1 and the sup ernum erary tooth are palatally p ositioned . ■ Is there any other a lternative radiographic investigation you might consider? I so, why? Althou gh a cone beam com puted tom ographic (CBCT) view m ay be consid ered in the assessm ent of u neru pted tooth p osition, and if a su p ernu m erary tooth, or teeth, is present, a risk/ bene t analysis need s to be u nd ertaken on a case-by-case basis. Only w hen conventional rad iograp hic view s fail to provid e suf cient d iagnostic inform ation shou ld CBCT be requested . In this case it w as reckoned to be u nnecessary based on the view show n in Fig. 2.3. Diagnosis ■ Wha t is your diagnosis? Class I malocclusion on a mild Class II skeletal base with slightly increased FMPA. For treatment planning, you shou ld make arrangements for N eil to be referred for joint consu ltation by an orthod ontist, oral surgeon and paed iatric d entistry colleague regard ing management of unerupted 1 , associated su pernu merary, the prognosis of 1 and the cariou s molars. The plan agreed w as: 1. Oral hygiene instruction. 2. Dietary advice with the aid o a diet diary. 3. Provision o a custom-made mouthguard or soccer practice. The t may need to be modi ed with regard to some aspects o the treatment given below. 4. Determine the prognosis o 1. The likelihood o apical closure was deemed to be good, and 1 was to be monitored radiographically at 3-month intervals. 5. Determine the prognosis o the second primary molars rom bitewing radiographs. E’s were deemed to be o reasonable prognosis, but E’s require ormocresol pulpotomy and stainless steel crowns or extraction in view o the pulpal carious involvement. More than hal the root length o E| E remains, and in view o the space loss that already exists in the lower arch, it would be wise to minimize any urther extractions except in an attempt to correct the centreline shi t. 6. Open space or 1 and correct the upper centreline. D 7. Taking the poor prognosis o into account, and to D allow relie o upper arch crowding at this stage, to create space or centreline correction and or 1 to be accommodated, the ollowing extractions are D C BA C D indicated . D Removal o D is required to balance the extraction o D. Extraction o D will balance the loss o D and tend to encourage correction o the lower centreline shi t. 8. Generalized mild marginal gingivitis. Caries in D ; trauma to 1 involving the pulp. ED E Upper and lower arch crowding. BA retained; 2 erupting labially; 1 unerupted with associated tuberculate supernumerary. 9. The supernumerary tooth will also need to be surgically removed and an attachment with a length o gold chain should be bonded to 1, ollowed by f ap replacement (closed technique). 1 should not be surgically exposed with an open technique. In this case it will be necessary to await urther eruption o 2 ollowing removal o BA be ore moving 2 and 12 distally to create space or 1. 9• UNERUPTEDUPPERCENTRALINCISOR 2 ■ How ma y space be created or 1? Space m ay be created u sing an u pper rem ovable appliance or by a xed ap p liance. ■ Are there any adva ntages to use o an upper removable appliance over a f xed a ppliance in this case and at this stage? A rem ovable ap p liance has the follow ing ad vantages in this case at this stage: There are few p erm anent teeth eru p ted , and m any of the prim ary teeth are to be extracted ; this leaves very few teeth on w hich the ap p liance m ay be anchored . Althou gh a xed ap pliance cou ld be bond ed to the p erm anent incisors and band s p laced on the rst p erm anent m olars, anchorage w ou ld need to be reinforced by m eans of linking the rst m olars on either sid e of the arch by m eans of a N ance transpalatal arch w ith an acrylic bu tton w hich contacts the anterior vau lt of the p alate. There w ill be long sp ans of the archw ire u nsu p p orted and liable to d istortion. As the baseplate covers the p alate, anchorage is better w ith a rem ovable ap pliance for the tooth m ovem ents requ ired . If d esired , a p rosthetic tooth cou ld also be ad d ed w hen BA have been rem oved and colou r-m atched to 1; this w ou ld enhance app liance aesthetics. It cou ld be progressively trimm ed as 1 is brou ght into alignm ent. The appliance m ay also be rem oved for cleaning and for sp orts. ■ What design o upper remova ble a ppliance would you use to achieve the desired tooth movements? The ap p liance shou ld be d esigned w ith the aid of the acronym ARAB (activation, retention, anchorage, baseplate) w hile the p atient is still in the d ental chair, so that nothing is overlooked . • Activation: Palatal nger springs (0.5 mm stainless steel wire) to 2 12. • Retention: Adams clasps (0.7 mm stainless steel wire) to 6 6 . Recurved labial bow (0.7 mm stainless steel wire) rom mesial o each E. • Anchorage: From baseplate. • Baseplate: Full palatal acrylic coverage (Fig. 2.5). When sp ace for 1 has been created , a hook m ay be sold ered to the labial bow to allow attachm ent of the gold chain for 1 extru sion or the bow m ay be m od i ed to create a bu ccal arm for this p u rp ose. Key point Sequence in design o an upper removable appliance: ARAB acronym • Activation. • Retention. • Anchorage. • Baseplate. ■ Will an upper removable applia nce achieve a ll the treatment objectives? An up per rem ovable ap pliance w ill achieve the simp le tooth m ovem ents (tipp ing and extrusion) requ ired in this Fig. 2.5 Upper removable appliance to open space or 1 . Fig. 2.6 Following extraction o our rst premolars, xed appliance therapy and urther restorative treatment to 1. case at this stage. It is likely that fu rther treatm ent, p robably loss of a p rem olar u nit from each qu ad rant and xed ap p liance therap y, w ill be required at a later d ate, and then d etailing of 1 p osition can be u nd ertaken (Fig. 2.6). ■ Wha t is the recommended root f lling ma terial or 1 during orthodontic tooth movement? When ap ical closu re is evid ent on 1, no root canal treatm ent is requ ired as the tooth has vital p u lp tissu e. ■ Does orthodontic tooth movement pose any risk to 1? There is an increased risk of root resorp tion. N eil and his m other shou ld be w arned abou t this d u ring the inform ed consent p rocess. 1 m ay also becom e non-vital and requ ire end od ontic treatm ent. ■ Are there any precautions you would take during orthodontic treatment to minimize this risk? As w ith all orthod ontic tooth m ovem ent, excessive forces should be avoid ed . Sensibility testing and a periapical rad iograph shou ld be taken p rior to starting treatm ent and subsequ ently, for m onitoring, at 6 m onths into treatm ent. N eil and his m other should be inform ed of this also d uring the consent p rocess. N eil shou ld be ad vised to w ear the m ou thgu ard provid ed d uring contact sports to m inim ize the risk of repeat trau m a. 1 becam e non-vital nearing com pletion of 1 alignm ent and required end od ontic treatm ent w ith gu tta percha. This w as com pleted uneventfully. 2 • 10 UNERUPTEDUPPERCENTRALINCISOR ■ How would you ensure long-term stability o 1 ollowing alignment? Bond ed p alatal retention w ill be requ ired to gu arantee longterm alignm ent of 1 . Labial gingivoplasty m ay be requ ired at a later stage in relation to 1 to obtain coincid ence of the gingival m argins of 1 1. Key point Sequence in management o unerupted 1: • Obtain oral surgical/orthodontic opinion (and possibly paediatric dental opinion); i prognosis or 1 alignment judged satis actory then, • Open space or unerupted 1 (may involve extractions o primary teeth). • Remove supernumerary. • Bond attachment to 1. • Do not surgically expose 1. • Align 1 with appropriate appliance. • Maintain 1 correction with bonded retainer. • Reassess malocclusion regarding urther treatment needs. Primary resources and recommended reading Becker A, Brin I, Ben-Bassat Y et al 2002 Closed -eru p tion su rgical techniqu e for im p acted m axillary incisors: a postorthod ontic p eriod ontal evalu ation. Am J Orthod Dentofacial Orthop 122:9–14. Flem ing PS, Xavier GM, DiBiase AT et al 2010 Revisiting the su p ernu m erary: the ep id em iological and m olecu lar basis of extra teeth. Br Dent J 208:25–30. Kap ila S, Conley RS, H arrell WE Jr 2011 The cu rrent status of cone beam com p u ted tom ograp hy im aging in orthod ontics. Dentom axillofac Rad iol 40:24–34. Kind elan SA, Day PF, Kind elan JD et al 2008 Dental trau m a: an overview of its in uence on the m anagem ent of orthod ontic treatm ent. Part 1. J Orthod 35:68–78. Mason C, Azam N , H olt RD et al 2000 A retrosp ective stud y of u neru p ted m axillary incisors associated w ith su p ernu m erary teeth. Br J Oral Maxillofac Su rg 38:62–65. Yaqoob O, O’N eill J, Gregg T et al 2010 Managem ent of Uneru pted Maxillary Incisors. Facu lty of Dental Su rgery of the Royal College of Su rgeons of England . Available at: http :/ / w w w.rcseng.ac.u k/ fd s/ p u blications-clinical -gu id elines/ clinical_gu id elines/ d ocu m ents/ ManMaxIncisors2010p d f. For revision, see Mind Map 2, page 222. 3 Absent upper lateral incisors SUMMARY Sa rah, aged 12 years, presents with spacing o her upper anterior teeth (Fig. 3.1). What are the possible causes, and how may it be treated? History Complaint Sarah d oes not like the gap s betw een her u p p er front teeth. She has ju st m oved to a new school and feels self-consciou s abou t the ap pearance of her teeth. History o complaint Family history Sarah’s m other also has a sm all space betw een her upp er front teeth d u e to one m issing tooth (2 ). Social history Sarah is a keen clarinet player and is not m otivated to w ear a xed ap pliance. ■ How will her instrument pla ying impa ct on orthodontic treatment? Wearing an orthod ontic ap p liance w ill tem p orarily affect her m u sical p erform ance, but w ith p ractice and m otivation, m ost w ind instru m ent players ad ju st. With a w ood w ind instru m ent su ch as a clarinet, it is likely that Sarah w ill ad ju st very qu ickly to w earing an orthod ontic appliance and that p laying w ill retu rn to norm al w ithin a few w eeks. It w ould , how ever, be ad visable to avoid tting an ap pliance close to d ates of m u sic exam s, au d itions or p erform ances. Any orthod ontic ap pliance, p articularly xed app liances, m ay ru b the insid e of the lips and cheeks w hen tted , bu t w ax m ay be app lied to m inim ize this. As Sarah is not keen for a xed appliance and provid ed treatm ent is possible w ith a rem ovable ap p liance, this could be removed w hile p laying. In ad vance of any orthod ontic treatm ent, it w ould be u sefu l for the orthod ontist to ascertain how m any hou rs Sarah p ractises per d ay, as leaving the app liance out for long period s is likely to imp ed e treatm ent progress. Examination Extraoral All p rim ary teeth w ere p resent and w ere lost norm ally. When her u p p er p erm anent front teeth eru p ted , there w as consid erable sp acing betw een them , and this has not altered m u ch since then. The p erm anent teeth eru p ted at a normal age, and none have been extracted or avu lsed . Sarah has a Class I skeletal pattern w ith average FMPA; there is no facial asym m etry. H er lips are com petent w ith the low er lip covering the incisal third of the u p per incisors. The tem porom and ibular joints are sym ptom -free. Medical history Intraoral Sarah is t and w ell. Dental history Sarah attend s her general d ental practitioner regu larly but has had no intervention other than p lacem ent of ssu re sealants to her rst p erm anent m olars. ■ The intraoral views are shown in Figs 3.1 and 3.2. Wha t do these show? The so t tissues appear healthy and overall oral hygiene seems good, although there are small plaque deposits labially on the lower incisors. All teeth are o good quality, and no caries is evident. The ollowing teeth are present: 7 6 5 4 3 1 1 3 C4 5 6 7 . 76543211234567 There is a retained ragment o E . There is mild imbrication o the lower incisors; the upper arch is spaced. The incisor relationship is Class I with a complete overbite. The lower centreline is shi ted slightly to the le t. Fig. 3.1 Anterior occlusion at presentation. The buccal segment relationship is hal unit Class II bilaterally. 3 • 12 ABSENTUPPERLATERALINCISORS A B C D Fig. 3.2 (A) Lower occlusal view. (B) Upper occlusal view. (C) Right buccal occlusion. (D) Le t buccal occlusion. ■ Wha t other clinic assessment would you undertake? The labial and palatal m u cosae in the 2 area shou ld be palpated for the p resence of an u neru p ted tooth or any pathology. Key point Congenital absence o 2’s is more common in emales. ■ Wha t are the possible ca uses o the upper labial segment spa cing? These are listed in Table 3.1. ■ Wha t is the most likely cause in this case? Congenital absence of 2 2 is m ost likely. This is m ore comm on in fem ales than m ales. The genetic linkage is ind icated by Sarah’s m other, w ho has absence of 2 . Investigations ■ What urther investigations would you undertake? Clinical • Mobility testing o the retained upper primary canine ( C) is required. Grade 1 mobility was detected. Radiographic Table 3.1 Possible causes o the upper labial segment spacing Cause Aetiology Absence o 2 2 Hypodontia (a ects ~2%o Caucasians) – also associated with cle t lip and palate, Down syndrome and ectodermal dysplasia Avulsion Extraction Failure o /delayed eruption o 2’s Crowding Ectopicposition Supernumerarytooth Scar tissue Dilaceration Cyst/tumour • A dental panoramic tomogram is required to determine the presence/absence o 2’s, 8’s, supernumerary teeth or any pathology. Sarah’s dental panoramic tomogram showed: • • • Normal alveolar bone height. Absence o 2 2 and third molars; short root on C. No pathology associated with any erupted or unerupted teeth. Occlusal • Impressions and a wax registration should be taken or study models to allow urther assessment o the occlusion. 13 • ABSENTUPPERLATERALINCISORS ■ Wha t genes have been linked to hypodontia ? MSX1 and PAX9 have been linked . ■ How would you ra te the severity o the hypodontia? Sarah has m issing 2’s and thu s has m ild hyp od ontia (one or tw o teeth m issing). Mod erate or severe hypod ontia ind icates three to ve or m ore than six teeth m issing, respectively. ■ Are there other acial/dental/occlusal eatures associated with hypodontia? Red u ced low er facial height, d elayed d ental d evelop m ent, retained p rimary teeth, sm all teeth and an increased overbite have been associated . Thinning of the hair and absence of palm ar sw eat gland s are featu res of anhid rotic ectod erm al d ysp lasia, w hich is associated w ith severe hyp od ontia (see Chap ter 37). Diagnosis ■ What is your diagnosis? Class I m alocclu sion on a Class I skeletal base w ith average FMPA. Well cared for mou th. Mild ly im bricated low er incisors bu t otherw ise u ncrow d ed low er arch; sp aced u p p er arch w ith absent 2 2 and retained C. Bu ccal segm ent relationship is half-unit Class II bilaterally. ■ What is the IOTN DHC gra de (see p. 264)? Explain why. 4h – d ue to absence of 2 2 . Treatment ■ What are the trea tment options? These are: 1. Accept the spacing not a realistic option as Sarah is concerned by it. 2. Build up the mesiodistal width o 1’s and 3’s with composite or by veneering to reduce the spacing, but not to close it completely. The median diastema is too large or restorative build up o 1 1 to look aesthetic. Some recontouring o the cusp tips o 3’s would also be required to improve the nal appearance. 3. Orthodontic space closure. This would require a considerable amount o tooth movement along with C extraction, the wearing o a xed appliance and reverse headgear or the placement o TADs may be considered to assist space closure. 4. Orthodontic space opening (this would require extraction o C) or replacement o 2’s on resin-retained bridges, by xed bridgework or by implants in late teenage years. Replacement o 2’s by autotransplantation o lower premolars (see Chapter 2) is not a viable consideration as (i) the lower arch does not warrant premolar extractions and (ii) root ormation on lower premolars is in advance o the ideal stage (two-thirds to three-quarters complete). As op tion 2 w ill only partly ad d ress Sarah’s concerns it has to be ru led ou t. The choice then is betw een the tw o orthod ontic op tions. 3 Key point Management options with absent 2’s are to • Maintain or close 2 space. • Open space or 2 replacement. ■ What a ctors would you consider in deciding between space closure or space opening? Sarah should be seen w ith a restorative colleagu e w ho w ill provid e inp u t regard ing the restorative im plications of each treatm ent op tion. Then, it is often w ise to u nd ertake a trial set-u p of the optim al treatm ent option using d u plicate stud y m od els and to show this to the patient, to allow a fu ller ap p reciation of the likely treatm ent ou tcom e. The follow ing factors should be consid ered : The patient’s attitude to orthodontic treatment. I the patient is not keen to wear xed appliances, it may necessitate a change in treatment plan. The anteroposterior and vertical skeletal relationships. In Class II cases with an increased overjet, space closure is desirable as it will eliminate the overjet, whereas in Class III cases this would tend to worsen the incisor relationship. Space opening is optimal in Class III cases where proclination o the incisors is likely to correct an anterior crossbite. Where the FMPA is reduced, space opening is pre erable to space closure, and the converse is true where an increased FMPA exists. The colour, size, shape and angulation o the canine and incisor teeth. Where the maxillary canine is considerably darker than the incisors and/or it has a marked canine orm, space closure is not advisable as considerable recontouring o 3’s will be required to enable them to resemble 2’s. Where the canine and incisor teeth are so angulated that it is possible to reposition them into their desired locations by tipping movements, a removable rather than a xed appliance may be used. Whether the arches are spaced or crowded, and the buccal segment occlusion. In uncrowded or mildly crowded arches, where the buccal segment occlusion is Class I or at most hal -unit Class II, space opening is best. Space closure is pre erable where more crowding exists and the buccal segment relationship is a ull-unit Class II. In this case it w as d ecid ed to p roceed w ith sp ace op ening for rep lacem ent of 2 2 , u ltim ately on resin-retained brid ges. This requ ired an initial phase of d istal m ovem ent of the u pper bu ccal segm ents to achieve a Class I m olar relationship, extraction of C, follow ed by retraction of 3’s to a Class I relationship w ith 3’s and space op ening for 2’s replacem ent. Im p ortantly, overbite red u ction w as also u nd ertaken in conju nction w ith these tooth m ovem ents to p rovid e sp ace for the m etal fram ew ork of the resin-retained brid ges. Id eally, a xed ap pliance w ould be ind icated to achieve these objectives, bu t as Sarah w as not keen for this form of treatm ent, an accep table thou gh not op tim al outcom e w as d eem ed achievable by u p p er rem ovable ap p liance therap y. ■ Could treatment time ha ve been shortened by an earlier interceptive measure? Rem oval of C’s is a u sefu l intercep tive m easu re in the early m ixed d entition w hen sp ace closu re is p lanned as it 3 • 14 ABSENTUPPERLATERALINCISORS encou rages 3’s to eru p t m ore m esially. In this case, how ever, space op ening for 2’s rep lacem ent w as p lanned . H ence rem oval of C at age 10 is likely to have allow ed 3 to erupt in a m ore d istal p osition than it is now bu t w ou ld also have encou raged m esial d rift of the u p p er left buccal segm ent. So on balance, this extraction at an earlier stage is u nlikely to have shortened treatm ent tim e. Key point With absent 2’s consider: • Patient’s attitude to orthodontic treatment. • Skeletal relationships. • Colour, size, shape and angulation o 3 and 1. • Crowding/spacing. • Buccal segment occlusion. ■ How could the upper buccal segments be moved dista lly using a removable appliance to achieve a Class I molar relationship? An u pper rem ovable ap pliance w ith bilateral screw s to m ove 6 5 4 and 4 5 6 d istally is an op tion. Anchorage need s to be reinforced by allow ing provision for head gear to be attached to the ap pliance. The app liance shou ld also incorp orate: • Adams clasps (0.7 mm stainless steel wire) with headgear tubes soldered to 6’s clasp bridges; Adams clasps (0.7 mm stainless steel wire) to 4’s also. • Short labial bow 3 to 3 (0.7 mm stainless steel wire). • Flat anterior biteplane to hal the crown height o 1 1 and extended 3 mm urther palatally than the maximum overjet measurement. When there is evid ence of fu ll-tim e ap p liance w ear, head gear should be tted for anchorage w ith an up w ard d irection of p ull to prevent the appliance becom ing d islod ged w hen the head gear is being w orn. ■ Wha t orce and dura tion o headgear wear is required or anchorage? A force of 250–350g p er sid e for 8–10 hou rs p er d ay is requ ired . ■ Wha t precautions must be adhered to when prescribing hea dgea r? Tw o safety m echanism s m u st be tted to the head gear assem bly, p referably a safety release sp ring m echanism attached to the head cap and a facebow w ith a locking d evice. Verbal and w ritten safety instru ctions m ust be issued to both p atient and p arent(s)/ gu ard ian. The head gear should be checked at each visit. When com p liance w ith head gear w ear is evid ent, then Sarah shou ld be instru cted to turn each screw once per w eek. C shou ld be extracted and acrylic relieved to allow for p otential d istal d rift of 3 as the bu ccal segm ents are retracted to Class I. Som e over-retraction is ad visable to allow for any slight anchorage slip d u ring the next p hase of treatm ent w hen 3’s w ill be retracted to a Class I relationship w ith 3’s ; 1’s w ill be ap p roxim ated and overbite red u ction w ill be m aintained . ■ What design o upper removable applia nce would you consider or these tooth movements? Palatal nger springs to 31|13 (0.5 mm stainless steel wire). Adams clasps 6 6 (0.7 mm stainless steel wire) with headgear tubes soldered to the clasp bridges. Long labial bow with ‘U’loops (0.7 mm stainless steel wire) rom 4 to 4 . Flat anterior biteplane to hal the crown height o 1 1 and extended 3 mm urther palatally than the maximum overjet measurement. This is an important component o the appliance to ensure that overbite reduction is maintained, creating su cient interocclusal clearance or placement o the metal ramework on the resin-bonded bridges. ■ When space has been created or 2 2 , what should be done? The p atient shou ld be seen again w ith a restorative colleagu e to ensure that the tooth m ovements achieved w ill allow restorative treatm ent to proceed as planned . Then a removable retainer shou ld be tted for 6 m onths carrying replacem ent 2 2 and ensu ring that space for them is maintained by p lacing w ire sp u rs in contact w ith the ad joining teeth (Fig. 3.3). Key point • Always place wire spurs on the removable retainer, to the teeth adjoining the 2 space a ter space opening. • Retain or 6 months be ore replacing 2 on resin-retained bridge (underline 2). ■ What design o resin-retained bridge is required? Maintenance of closu re of the m ed ian d iastem a requ ires perm anent retention. A bond ed p alatal retainer fram ew ork linking 1 1 together is ind icated along w ith resin-retained brid ges w ith single w ing, off 3 3 . It is better that 1 1 are retained as a sep arate u nit rather than risk the retention integrity and su ccess of the brid ges by incorporating 1 1 retention in the brid ge d esign. Im p lant rep lacem ent of 2 2 later is u nlikely as the roots of 31 13 are tipp ed tow ard the 2 2 sp ace, com p rom ising access for im plant p ositioning. The nal resu lt w ith 2 2 replaced on ad hesive brid gew ork is show n in Fig. 3.4. Fig. 3.3 Upper removable appliance retainer with replacement 2’s. 15 • ABSENTUPPERLATERALINCISORS Carter N E, Gillgrass TJ, H obson RS et al 2003 The interd iscip linary m anagem ent of hyp od ontia: orthod ontics. Br Dent J 194:361–366. H arrison JE, Bow d en DE 1992 The orthod ontic/ restorative interface. Restorative p roced ures to aid orthod ontic treatm ent. Br J Orthod 19:143–152. Khalaf K, Miskelly J, Voge E, et al 2014 Prevalence of hypod ontia and associated factors: a system atic review and m eta-analysis. J Orthod 41:299–316. Fig. 3.4 Final restorations. ■ What additional actors would need to have been considered i replacement o 2’s by implants was the pre erred pla n? It w ould be necessary to w ait u ntil facial grow th has red u ced to ad u lt levels. In a girl, grow th of the m axilla is com p lete by abou t 15 years of age and m and ibu lar grow th u su ally 2 years later, w hereas in boys m axillary grow th u su ally continues to about 17 years of age and m and ibu lar grow th until 19 years or later. This is esp ecially im p ortant as an im plant has no eruptive potential and w ill be left behind if erup tion of ad jacent teeth is still continu ing, com p rom ising aesthetics. Asid e from su f cient d istance betw een the roots of the ad jacent teeth, sp ace m u st also exist betw een the tooth crow ns w ith su f cient interocclu sal clearance. Ad d itionally, am p le bu ccopalatal w id th and height of the alveolar bone is requ ired in the 2 area. Primary resources and recommended reading British Orthod ontic Society 2007 Ad vice for m u sicians. Available at: w w w.bos.org.uk/ orthod onticsand you / orthod onticsforschools/ ad viceform u sicians.htm . Kohich KO Jr, Kinzer GA, Janakievski J, 2011 Congenitally m issing m axillary lateral incisors: restorative rep lacem ent. Am J Orthod Dentofac Orthop 139:435–445. Mossey PA 1999 The heritability of m alocclu sion: p art 2. The in u ence of genetics in m alocclu sion. Br J Orthod 26:195–203. Qad ri S, Parkin N A, Benson PE 2016 Sp ace closing versu s sp ace opening for bilateral m issing up per laterals - aesthetic ju d gm ents of layp eop le: a w eb-based su rvey. J Orthod 43 (2):137–146. Robertsson S, Mohlin B 2000 The congenitally m issing u p per lateral incisor. A retrosp ective stu d y of orthod ontic space closu re versu s restorative treatm ent. Eu r J Orthod 22:697–710. Silveira GS, De Alm eid a N V, Pereira DMT et al 2016 Prosthetic rep lacem ent vs sp ace closu re for m axillary lateral incisor agenesis: A system atic review. Am J Orthod 150, 228–237. Zachrisson BU, Rosa M, Toreskog S 2011 Congenitally m issing m axillary lateral incisors: canine su bstitu tion. Am J Orthod Dentofac Orthop 139:434–444. For revision, see Mind Map 3, page 223. 3 4 Crowding and buccal upper canines Medical history Gem m a has had asthm a since she w as 5 years of age and uses a salbu tam ol (Ventolin) inhaler; otherw ise she is t and w ell. ■ What a re the implications or orthodontic trea tment with a sthma? These are sum m arized in Ap pend ix 4. Dental history Gem m a has attend ed for rou tine d ental exam inations since she w as 3 years old bu t has not u nd ergone any active d ental treatm ent. Examination CASE1 SUMMARY Gemma, an 11-year-old girl, attends or a 6-month dental assessment at your practice with both upper permanent canines erupting buccally (Fig. 4.1). What is the cause, and how may it be treated? History Complaint Gem m a d oes not like the ‘squint’ ap pearance of her top and bottom teeth, in p articular the p osition of the u p p er eye teeth, w hich she says ‘look like fangs’. History o complaint The crooked ness of Gem m a’s teeth has been getting w orse for the p ast year. The ap p earance of her u p p er teeth has becom e of m ore concern to her in recent m onths w hen both u pper eye teeth started to eru p t. She is now teased at school and called ‘Fangs’, w hich annoys her. Gem m a’s m other rep orts that her d au ghter ’s baby teeth w ere also slightly crooked . Both she and Gem m a are very keen for treatm ent. Extraoral Gem m a has a Class I skeletal p attern w ith average FMPA. There ap p ears to be slight facial asym m etry w ith the chin point d eviated m ild ly to the right. The lips are com petent. N o temp orom and ibu lar signs or sym p tom s w ere d etected or rep orted . Gem m a and her m other w ere u naw are of Gem m a’s slight facial asym m etry and have noticed no change in her facial ap p earance over recent years. ■ Would you be concerned by the mild acial asymmetry? A mild d egree of facial asym m etry is norm al, and as facial appearance is rep orted ly u naltered for several years, there is no cau se for concern. Intraoral ■ Gemma’s intraoral views are shown in Figs 4.1 and 4.2. What do you notice? Generalized marginal gingival erythema. Plaque deposits visible on several teeth, notably both 3’s. There are no restorations, and there is no obvious caries. Gemma is in the late mixed dentition stage with the 6 5 4 C3 2 1 1 2 3 4 5 6 ollowing teeth present: (note 5 7 6 5 4 3 2 1 1 2 3 4 E6 7 and 7 7 are partially erupted). The lower labial segment is moderately crowded with 2 | 2 bodily displaced lingually and 1| 1 slightly mesiolabially rotated. 3 is distally angulated; 3 is mesially angulated. The lower right buccal segment is also crowded with insu cient space or 5 ; the lower le t buccal segment is uncrowded with E present. The upper labial segment is moderately crowded with 1 1 slightly mesiolabially rotated and 3 3 erupting buccally; C is present. 3 is upright and 3 is slightly distally angulated. The upper buccal segments are aligned. In occlusion, there is a Class I incisor relationship. The overbite is average and complete. Fig. 4.1 Anterior occlusion at presentation. The lower centreline is slightly to the right. 17 • CROWDINGANDBUCCALUPPERCANINES 4 A Fig. 4.3 Dental panoramic tomogram. • Retention o the primary canine this usually leads to slight buccal displacement o 3. Key point Buccal displacement o 3 is more usual in a crowded arch. Investigations ■ Wha t investigations would you request and why? B A d ental panoram ic tom ogram is requ ired to provid e a general view of the d evelop ing d entition and to con rm the p resence and position of all u neru pted perm anent teeth. ■ Gemma’s dental panoramic tomogram is shown in Fig. 4.3. What do you notice? Alveolar bone level is normal. Presence o a ull complement o developing permanent teeth, including third molars. All teeth appear caries- ree. C Diagnosis ■ Wha t is your diagnosis? Class I malocclusion on a Class I skeletal base with average FMPA, with the chin point displaced slightly to the right. Generalized marginal gingivitis. Moderate upper and lower arch crowding with the lower centreline shi ted slightly to the right. Right molar relationship is Class III; le t molar relationship is Class I. D Fig. 4.2 (A) Lower occlusal view. (B) Upper occlusal view. (C) Right buccal occlusion. (D) Le t buccal occlusion. The right molar relationship is Class III, and the le t molar relationship is Class I. ■ What are the possible reasons or 3’s erupting buccally? • Crowding buccal displacement o 3’s is o ten a mani estation o inherent crowding in the upper arch. A contributory actor is 3 being the last tooth to erupt anterior to the rst permanent molars. ■ What is the IOTN DHC grade and why (see p. 264)? Expla in why. 4d – d ue to severe d isplacements of teeth, greater than 4 mm. Treatment ■ Wha t treatment is likely to be required in this case? Expla in why. Extractions are requ ired to relieve the m od erate crow d ing. Fixed app liance therap y is ind icated in view of the d istal 4 • 18 CROWDINGANDBUCCALUPPERCANINES angu lation of m ost canines, the rotations of the central incisors, the bod ily lingu al d isplacem ent of 2’s and the centreline shift. ■ Wha t would you do now? As Gem m a has m od erate low er labial segm ent crow d ing, sp ace w ill be requ ired to achieve alignm ent. ■ What possible means are there o creating space? Extractions. Explain to the patient the likely plan or correction o her malocclusion. Arrange or several visits o oral hygiene instruction by the practice hygienist, and assuming that oral hygiene improves satis actorily, take upper and lower impressions and a wax registration or study models. Arrange re erral to an orthodontist and enclose the study models and dental panoramic tomogram. Write a re erral letter to the orthodontist (Fig. 4.4). ■ Wha t aims o treatment do you think will be proposed by the orthodontist? Relie o crowding. Upper and lower arch alignment. Correction o lower centreline. Arch expansion (laterally and/or anteroposteriorly). Distal movement o the molars. Enamel stripping. Any combination o the above. Expansion of the low er intercanine w id th is unstable as is forw ard m ovem ent of the low er labial segm ent (w ith a few excep tions w hich w ill be d ealt w ith elsew here); d istal m ovem ent of the low er rst p erm anent m olars is d if cu lt w ithout extraction of low er second perm anent m olars and is und ertaken rarely. Enam el stripp ing is u sually only consid ered in ad u lts to gain 1–2 m m of space in total. In view of these consid erations, extractions are the only realistic op tion of gaining sp ace in Gem m a’s case. Key point Correction o right molar relationship. Always consider the lower arch f rst in treatment planning. Closure o any residual spacing. ■ Describe how you would approach treatment planning. 1. Consider the lower arch f rst and plan the lower labial segment. As the latter is in a narrow zone o so t tissue balance between the lips and the tongue, it is best to consider this sacrosanct. First the alignment o the labial segment must be assessed, and i it is crowded, as in Gemma’s case, the degree o crowding must be assessed to ascertain i this is su cient to warrant extractions. ■ What a ctors govern the choice o extraction? Prognosis o teeth. Site o crowding. Degree o crowding. Individual tooth position, e.g. grossly displaced or ectopic teeth. In this case there are no low er teeth of p oor p rognosis, and in view of the site and d egree of crow d ing, the low er rst p rem olars w ou ld be the teeth of choice for extraction. Practice address Date Dear Re [patient’s name, address, date of birth] I would be grateful if you could see Gemma for orthodontic assessment and treatment. Gemma is very concerned about the crowding of her teeth. Apart from using a salbutamol (Ventolin) inhaler for asthma, she is in good health. Gemma’s oral hygiene is improving following several visits to our hygenist. She has a caries-free dentition. She is very keen for treatment and is prepared to wear fixed appliances. She has a Class I malocclusion on a Class I skeletal base with average FMPA and the chin point slightly to the right. The upper and lower arches are moderately crowded and the lower centreline is slightly to the right. The right molar relationship is Class III; the left molar relationship is Class I. I enclose current study models and a recent dental panoramic tomogram. ■ Why are f rst premolars commonly chosen or extraction? They are in the middle o the arch and, there ore, provide space or relie o moderate labial and buccal segment crowding. The contact point between the canine and second premolar is as good as between the canine and the rst premolar. I a canine is mesially angulated, considerable scope exists or spontaneous alignment o the labial segment as the canine uprights into the extraction space. For maximum spontaneous improvement, it is best to extract the rst premolars as the permanent canines are erupting. Any residual space is not at the ront o the mouth and is likely to close urther with mesial dri t o the buccal segments. 2. Yours sincerely 3. Fig. 4.4 Example o a re erral letter. Imagine the corrected position o 3. 3 is mesially angulated and will upright spontaneously ollowing removal o 4, thereby providing space or labial segment alignment; 3 , however, is distally angulated and will require bodily retraction with a xed appliance. Mentally reposition 3 to be in a Class I relationship with the corrected position o 3. Space is required in Gemma’s case or this. Extraction o both upper rst premolars should provide adequate space or retraction o 3′s. As 19 • CROWDINGANDBUCCALUPPERCANINES 4. 5. 6. 7. 3 is upright and 3 is distally angulated, xed appliance therapy is indicated to e ect this movement. Plan the upper labial segment. The incisors are mildly crowded and slightly rotated, so xed appliance therapy is required to produce ideal alignment. Decide on the f nal molar relationship. As upper and lower rst premolar extractions are planned, the nal molar relationship should be Class I. Closure o residual buccal segment spacing ollowing the extractions will require xed appliance therapy. Assess the anchorage needs. As almost all o the upper rst premolar extraction spaces will be required or relie o upper arch crowding, and retraction o the upright/distally angulated 3′s is needed, anchorage would be best rein orced with a palatal arch attached to bands on 6′s or temporary anchorage devices (TADs). Plan retention. The prognosis is avourable, but bonded retention to the lower labial segment would be wise in view o the bodily lingual displacement o 2 | 2 . Upper and lower vacuum- ormed retainers should also be provided to be worn at night or the rst 12 months ollowing debond; the lower is designed to t over the bonded retainer. Therea ter, retention should continue on a night-only basis, reducing to alternate nights or another year and then to twice weekly. Gemma’s responsibility with regard to retention should be explained be ore treatment starts. 4 A B Fig. 4.5 (A) Post-treatment: right buccal occlusion. (B) Post-treatment: anterior occlusion. ■ Gemma’s f na l occlusion is shown in Fig. 4.5. What Key point • Always plan anchorage at the treatment planning stage. • The amount o space and type o intended tooth movement in uence anchorage demands. • Always consider retention in the treatment plan. ■ What is the f nal orthodontic treatment plan likely to be? N o ap p liance therap y w ou ld be consid ered u ntil Gem m a has d em onstrated that she is cap able of m aintaining a high stand ard of oral hygiene. Then the orthod ontic plan w ou ld be: 8. Fit palatal arch or anchorage or place TADs (see Chapter 5). 9. Extraction o our rst premolars (provided there is satis actory cooperation with wear o the palatal arch). TADs could be placed, instead o the palatal arch, at the time o the upper arch extractions. 10. Upper and lower xed appliance therapy. 11. Lower canine to canine bonded retainer with upper and lower vacuum- ormed retainers. ■ What risks should the patient be wa rned o regarding f xed appliance orthodontic treatment? The p atient shou ld be w arned of the risk of: Enamel demineralization. Root resorption. Loss o tooth vitality. Relapse. undesirable sequelae o treatment are visible? Several teeth are affected by w hite spot lesions or d em ineralization, ind icating early cariou s involvem ent. ■ How common is this with f xed appliance therapy and which teeth are a ected mostly? The reported prevalence is betw een 2% and 96%. Upp er lateral incisors and low er canines are affected m ost comm only. ■ How may the problem be prevented or minimized? Care ul patient selection; ensure a high standard o oral hygiene pre-treatment. Advise the patient that zzy drinks and sugary oods should not be consumed between meals. The teeth should be brushed with a f uoridated denti rice a ter each meal. Regular surveillance o oral hygiene and oral hygiene instruction should be undertaken by a hygienist throughout treatment. Daily use o a f uoride mouthrinse (0.05% sodium f uoride) is recommended during treatment. Moderate quality evidence exists that application o a f uoride (0.1% f uoride) varnish around the brackets on a 6-weekly basis is e ective. ■ How may these ‘white spots’ be managed? Usually, follow ing rem oval of the ap pliances, the w hite spots regress slightly as m aintenance of an im p roved stand ard of oral hygiene is facilitated . App lication of highconcentration u orid e varnish is inad visable at this stage as 4 • 20 CROWDINGANDBUCCALUPPERCANINES it lead s to hyp erm ineralization of the lesions, w hich m akes them m ore obviou s. Where the w hite sp ot lesions are extensive and p ose an obviou s aesthetic insu lt, acid -p u m ice abrasion w ith 0.2% hyd ro u oric acid m ay be carried ou t. In rare severe cases, veneers or com p osite restorations are likely to be required . A Key point Demineralization with f xed appliances: • Is common (2 96% prevalence). • Mostly a ects 2′s and 3 ’s. • Is best prevented by care ul patient selection and dietary advice. CASE2 SUMMARY Aoi e, a 12-year-old girl, presented with crowded upper teeth. Her mother reported a possible nickel allergy. ■ How would you deal with the history o a possible nickel a llergy? Aoife shou ld be referred to a d ermatologist for assessm ent and patch testing. Fortu nately, no allergy to nickel w as rep orted . ■ How common is nickel allergy? N ickel allergy is m ore comm on in fem ales (10–30%) than m ales (~2%), p ossibly d u e to increased contact from nickelcontaining jew ellery. ■ What implica tions does a nickel allergy ha ve or orthodontic mana gement? These are su m m arized in Append ix 4. Key point A suspected nickel allergy: • Should be assessed by a dermatologist. • Is more common in emales. • May require use o nickel- ree appliance components. ■ Wha t do you notice on the radiographs shown in Fig. 4.6? The d ental p anoram ic tom ogram show s: Normal alveolar bone height. 7 6 5 4 C2 1 1 2 3 4 5 6 7 erupted. 76543211234567 Four third molars developing. All permanent teeth o good quality; some root shortening o C but o reasonable length. B Fig. 4.6 (A) Dental panoramic tomogram. (B) Upper anterior occlusal radiograph. The u p p er anterior occlu sal rad iograp h reveals: Tapered roots o the upper incisors. 3 to be in contact with 2 root which is distally angulated. ■ Where is 3 located? Expla in how this assessment is made and your reasoning. 3 is buccally p laced . This assessm ent is m ad e by com paring the p osition of 3 on the panoram ic lm and the occlusal lm using vertical parallax. The x-ray tube has m oved u p betw een the panoram ic (taken at −10° to the occlu sal plane) and the occlu sal (taken at 65–70° to the occlu sal p lane). This w ou ld be a 75–80° tu be shift. The position of 3 relative to the ad jacent 2 is then assessed . An object closer to the x-ray beam (bu ccally p laced ) w ill seem to m ove in the op posite d irection as the tube shift. This is evid ent for 3. ■ What do you notice in Fig. 4.7? Right bu ccal occlusion show ing: Mild marginal gingival erythema with apparent bulge over 2 . No caries. Crowded lower arch with mesially angulated 3 (lower arch was overall moderately crowded). Spacing between 4 and 2 but insu cient or 3 ; 2 distally angulated and mesiopalatally rotated. Class 1 incisor and molar relationship; average overjet; overbite average (1 covers hal lower incisor crown) and complete. ■ What a re the aims o treatment? The aim s of treatm ent are to: Improve oral hygiene. Relieve upper and lower arch crowding with alignment o 3 . Closure o residual spaces. 21 • CROWDINGANDBUCCALUPPERCANINES Fig. 4.7 Right buccal occlusion at presentation. A B Fig. 4.9 (A) Post-treatment: upper occlusal view. (B) Post-treatment: anterior occlusion. Fig. 4.8 Upper occlusal view ollowing extraction 4 4 and closed surgical exposure o 3 . Fou r rst prem olars w ere extracted follow ed by xed ap p liance m echanics. 3 remained unerupted 9 months a ter extraction o 4 . How would you manage 3 ? It w ou ld be ad visable to assess 3 w ith an oral su rgeon and d iscu ss surgical exp osu re. ■ What types o surgical exposure are there or a buccally positioned ca nine? Open or closed exp osu re are the p ossible su rgical options. With op en exp osu re, an ap ically rep ositioned ap w ou ld be requ ired . With closed exp osu re, a buccal ap is raised and an attachm ent w ith gold chain bond ed to 3 to facilitate traction, follow ed by replacem ent of the ap . Du e to operator preference, a closed exp osu re w as agreed u p on (Fig. 4.8). ■ How may 3 be aligned? Initially, 3 m ay be aligned partially by attaching the gold chain to the base archw ire; a bracket w ill then need to be bond ed to 3 and a light (typ ically 0.012-in or 0.014-in nickel titanium ) archw ire ‘piggy-backed ’ to the base archw ire to im prove alignm ent until 3 can be fu lly engaged in a 0.019 × 0.025-in stainless steel w ire (assu m ing an 0.022 × 0.028-in slot). The nal occlusion is show n in Fig. 4.9. CASE3 SUMMARY Triona, a 13-year-old girl, presents with 3 and 3 erupting buccally. How will you manage the problem? ■ Wha t do you notice in Fig. 4.10? Mild generalized marginal gingiva erythema; caries- ree dentition with ssure sealants in all rst permanent molars. Mild lower arch crowding; severe upper arch crowding with 3 and 3 erupting buccally. (Cusp tip o 3 just visible.) Lower incisors appear slightly retroclined and upper incisors appear upright to retroclined. Class III incisor relationship; with 2 1 1 in crossbite (reverse overjet was 1 mm on 1 ); minimal overbite (~1 mm measured clinically on 1 ). Centreline shi t (upper was 3 mm to the le t clinically). Right molar relationship slightly Class II; le t molar relationship slightly Class III with 5 erupting potentially in crossbite. ■ Is it possible to ma ke a reliable assessment o the incisor inclination to the underlying denta l bases rom intraoral images o the dentition in occlusion? It is not possible to tell the u pper and low er incisor inclination reliably from intraoral clinical im ages as there are no reference p lanes visible (Frankfort or m axillary and 4 4 • 22 CROWDINGANDBUCCALUPPERCANINES B A C D E Fig. 4.10 (A) Right buccal occlusion. (B) Anterior occlusion. (C) Le t buccal occlusion. (D) Upper occlusal. (E) Lower occlusal. m and ibu lar p lanes resp ectively). Only in the broad est sense m ay com m ent be m ad e regard ing how the inclination of the incisors ‘ap p ears’. ■ Wha t clinical assessment should you underta ke o 2? 2 should be checked for m obility in case it is being resorbed by 3. If this is su spected , sensibility tests shou ld also be u nd ertaken. rad iograp hs of 2 to ensu re that the root statu s rem ains unchanged . This w as found to be the case. A lateral cep halom etric rad iograph is required to provid e m ore inform ation abou t the severity of the Class III m alocclu sion and the extent of any d entoalveolar com p ensation. ■ What is your interpretation o the ollowing cephalometric f ndings? Investigations ■ The patient presented with a denta l panoramic radiograph taken 6 months previously by her general dental pra ctitioner. What radiographic investiga tions would you request and why? It is not necessary to rep eat the p anoram ic lm . This revealed all perm anent teeth to be d evelop ing norm ally and to be of good qu ality. The root statu s of 2 also app eared to be sou nd w ith no evid ence of root resorp tion from 3. As 6 m onths has elap sed since the last rad iograp h w as taken of 2, it w ould be sensible to take tw o p eriap ical SN A = 81°; SN B = 79.5°; SN -m axillary p lane = 8°; 1 to m axillary p lane = 105°; 1 to m and ibu lar p lane = 90°; m axillary m and ibu lar p lanes angle (MMPA) = 28°; facial prop ortion = 57%. The skeletal p attern is m ild ly Class III (AN B = 1.5°; SN ASN B) d u e to very slight m and ibu lar p rognathism. Com pared w ith m ean valu es, the u p per and low er incisors are somew hat retroclined , bu t w ithin the norm al range, and the 1 angle is not com p ensating for the MMPA (shou ld be 120−28° = 92°). Both the MMPA and facial proportion are slightly increased from norm al values, but both are w ithin the norm al range. 23 • CROWDINGANDBUCCALUPPERCANINES Diagnosis ■ What is your orthodontic diagnosis? Class III malocclusion on a mild Class III dental base with slightly increased acial proportions. Mild marginal gingivitis. Mild lower arch and severe upper arch crowding with 3 excluded buccally. Upper centreline shi t o 2 mm to the le t. Right molar relationship is slightly Class II, and le t molar relationship is slightly Class III. ■ What is the IOTN DHC grade? Expla in your reasoning. 4d – d u e to severe d isp lacem ent of teeth greater than 4 m m (betw een 2’s and 3’s bilaterally). Treatment ■ What are your aims o treatment? Improve oral hygiene. Relie o upper and lower arch crowding. Establish a positive overjet and overbite. Correction o the upper centreline. Correction o the molar relationships to Class I. Retain the correction. Monitor third molars. ■ What possible options are there to relieve the upper arch crowding and correct the upper centreline? Sp ace is required in ord er to ad d ress these treatm ent aims. Possible m eans to provid e this are: • Extractions removal o a premolar on either side o the upper arch. Removal o 5 5 is usually considered in Class III camouf age, but anchorage would need to be rein orced (with either a palatal arch or TADs) i their removal was considered. Removal o 4 4 , situated right beside where space is needed, would acilitate alignment o 3 3, and although not all the 4 space is required or relie o crowding in the upper right quadrant, the residual space will be utilized or upper centreline correction. With both extraction options, the upper arch would be aligned inside the lower. • Arch expansion both anteroposterior and lateral expansion o the upper arch would correct the anterior crossbites as well as the tendency to buccal crossbite. It will also provide urther space or 3, which may erupt. Care is required as arch expansion may cause the palatal cusps o the maxillary molars to tip buccally, which will compromise the already tenuous overbite. A potential advantage o this approach is that extractions are delayed while urther mandibular growth is observed when it will become more apparent whether orthodontic correction is possible or not. Such a ‘therapeutic diagnosis’approach to treatment is o ten advisable in a Class III malocclusion where the extent o urther mandibular growth is unknown. 4 • Arch expansion and extractions expansion will reduce the need to extract 4 4 , so 5 5 may be considered. • Arch expansion and distal movement o the le t buccal segment the ormer is as previously outlined; the latter may be achieved by placing a TAD between and pushing against it with coil spring on a xed appliance to move 4 5 6 distally. Triona’s m other w as keen to avoid extractions, if p ossible. Follow ing consid eration of all op tions, it w as agreed to p roceed w ith an initial non-extraction ‘therap eutic d iagnosis’ ap proach (Fig. 4.11). ■ What a ppliance is shown in Fig. 4.11A? How is it constructed and how is it activated? This is a qu ad helix ap p liance and has been cu stom -m ad e in the laboratory; p reform ed types, how ever, also exist. The qu ad helix is attached to band s cem ented to a m olar on each sid e of the arch. For a cu stom -m ad e app liance, an im pression m u st be taken w ith the band s in p lace, then the band s are rem oved and located carefu lly in the im pression before being d isinfected and sent to the laboratory. For the p reformed typ es, attachm ents are w eld ed to the palatal surfaces of the band s into w hich slot the arm s of the qu ad helix; this facilitates rem oval for ad ju stm ents. Both ap pliance types are m ad e of 1 m m stainless steel w ire. Typ ically, activation is achieved by ‘expand ing’ the app liance around half a tooth w id th on each sid e. Although activation m ay be achieved intraorally w ith triple-beak p liers, it is d if cu lt to gauge the am ou nt of activation by that m ean; it is u su ally p referable to rem ove the appliance every second visit and activate it extraorally. ■ Wha t is the most likely initial a ligning archwire shown in Fig. 4.11C? What a vourable properties ha s it got or alignment? This is most likely a nickle–titaniu m archw ire of sm all d iam eter, probably 0.012-in. Its p roperties inclu d e exibility w ithout und ergoing d eform ation, and it exerts a light force w hen tied into d isp laced teeth. ■ How would you re-evaluate treatment progress ollowing upper arch expa nsion a nd a lignment? Interim record s should be taken for further treatm ent planning. These are clinical photographs (extraoral and intraoral view s), stu d y m od els, and a lateral cep halom etric rad iograp h. The lateral cephalom etric m easurem ents shou ld be com pared w ith those taken at the start of treatm ent. Any change in SN B, AN B and MMPA shou ld be noted . The incisor inclinations shou ld also be assessed relative to the m axillary and m and ibular planes resp ectively. 1 inclination w ill ind icate how m u ch their inclination has changed d u ring u p p er arch alignm ent, and 1 inclination w hen consid ered w ith the AN B and MMPA angles w ill ind icate if any d entoalveolar com p ensation has occu rred since treatm ent started and w hether fu rther orthod ontic com p ensation is feasible or d esirable. If there has been m inim al/ no change in SN B, AN B and MMPA then the p rospect of orthod ontic correction is good . Otherw ise any attem p t at orthod ontic cam ou age should be consid ered w ith cau tion d u e to the likely guard ed prognosis; 4 • 24 CROWDINGANDBUCCALUPPERCANINES A A B B C Fig. 4.11 (A) Mid-treatment: upper occlusal view; note eruption o 3 . (B) Mid-treatment: initial aligning archwire. (C) Mid-treatment: upper arch alignment. in su ch circu m stances, it w ou ld be w ise to d elay any fu rther intervention and review at a later stage w hen grow th is com p lete. ■ When is mandibular growth completed? C Fig. 4.12 (A) Post-treatment: right buccal occlusion. (B) Posttreatment: anterior occlusion. (C) Post-treatment: upper occlusal view. Primary resources and recommended reading Benson PE, Parkin N , Dyer F et al 2013 Flu orid es for the p revention of early tooth d ecay (d em ineralised w hite lesions) d u ring xed brace treatm ent. Cochrane Database of Syst Rev Issu e 12. Art N o: CD003809. DOI: 10.1002/ 14651858.CD003809.p u b3. Mand ibu lar grow th is u su ally com p lete by abou t 17 years of age in girls and abou t 2 years later in boys. As reassessm ent revealed that grow th had not been ad verse, it w as d ecid ed to p roceed w ith low er xed appliance therap y and orthod ontic cam ou age on a nonextraction basis. The nal occlusion is show n in Fig. 4.12. H afez H S, Shaaraw y SM, Al-Sakiti AA et al 2012 Dental crow d ing as a caries risk factor: a system atic review. Am J Orthod . Dentofacial Orthop 142:443–450. ■ What will determine whether the correction remains sta ble? Mitchell L 1992 Decalci cation d u ring orthod ontic treatm ent w ith xed ap p liances – an overview. Br J Orthod 19:199–205. The am ou nt of overbite and the buccal segm ent interd igitation w ill d eterm ine the stability of the anterior and p osterior crossbites resp ectively, bu t both w ill also be greatly in u enced by the extent and d irection of fu rther m and ibu lar grow th. The latter w ill have the nal say w ith regard to long-term stability. Little RM, Wallen TR, Reid el RA 1981 Stability and relapse of m and ibu lar anterior alignm ent- rst p rem olar extraction cases treated by trad itional ed gew ise orthod ontics. Am J Orthod 80:349–365. Rahilly G, Price N 2003 N ickel allergy and orthod ontics. J Orthod 30:171–174. Stephens CD 1989 The use of natural spontaneous tooth movement in the treatment of malocclusion. Dent Update 16:337–338, 340–342. For revision, see Mind Map 4, page 224. 5 She fractured her right w rist in a fall from her m ountain bike 4 m onths ago and has been attend ing for physiotherap y at the local hosp ital since the cast w as rem oved . Mobility is alm ost back to norm al now, bu t she has d if culty w ith som e proced ures, su ch as toothbru shing. Otherw ise she is t and w ell. ■ What implications does the medical history ha ve or any Severe crowding CASE1 SUMMARY Amy, an almost 11-year-old girl, presents with marked space shortage or both unerupted 3′s (Fig. 5.1). What has caused this problem and how may it be treated? History Complaint Am y d oes not like the appearance of the upp er ‘sid e teeth’ being besid e her upp er front teeth; the ‘sid e teeth’ she thinks ‘look like tw o row s of teeth’. She also d oes not like the crooked ness of her low er front teeth. History o complaint Am y has become aw are of the w orsening app earance of her teeth over the p ast year. In that tim e, she has lost som e baby teeth and the new teeth have com e throu gh crooked . Am y’s m other reports that her d aughter ’s baby teeth looked good w ith only mild irregularity of the low er front teeth. Both she and Am y are keen for treatm ent. Medical history Am y’s m other reports that her d au ghter had a heart m u rm ur as a baby and attend ed a card iologist at the local hospital. proposed orthodontic treatment? Amy’s card iologist should be consulted regard ing the card iac statu s and the p ossible need for antibiotic p rop hylaxis for p roced u res likely to p rod u ce bacteraem ia becau se of the potential risk of infective end ocard itis. The N ational Institute for H ealth and Clinical Excellence (N ICE, w hich governs clinical practice in England and Wales) guid elines (2016) d o not recom m end rou tine antibiotic p rophylaxis for those und ergoing d ental p roced ures; the American H eart Association (AH A) recom m end s antibiotic cover only for those at high risk. Am y’s card iologist con rm ed that her card iac m u rm u r had fu lly resolved and that antibiotic p rop hylaxis w as not requ ired prior to any d ental or orthod ontic (separator p lacem ent, tting/ removal of band s) proced u res. As excellent oral hygiene is essential w ith any orthod ontic treatm ent, the im p act of lack of optim al w rist m obility on oral hygiene shou ld be assessed . Assistance w ith toothbrushing by a parent m ay be requ ired until w rist m obility is fully restored ; com p ared w ith m anual bru shes, pow ered brushes w ith a rotation oscillation action provid e better plaque rem oval in the short term and better protection against gingivitis in the short and long term . Am y’s m other is alread y assisting w ith her d au ghter ’s toothbru shing u sing a pow ered toothbrush. Dental history Am y is a regular attend er at her general d ental p ractitioner. She had several of the baby back teeth extracted a few years ago and has som e ssu re sealants placed in the rst perm anent molars. She brushes her teeth tw ice p er d ay, but her m other says that she need s remind ing abou t toothbru shing, w ith w hich her m other cu rrently assists her. Examination Extraoral Am y has a Class I skeletal pattern w ith average FMPA, average low er facial height and no facial asym m etry. H er lip s are com p etent w ith the low er lip resting in the m id labial third of the u pper central incisors. N o abnorm al tem p oromand ibu lar joint signs or sym p tom s w ere d etected . Intraoral ■ The intraoral views are shown in Figs 5.1 and 5.2. Describe what you see. Poor oral hygiene with plaque deposits visible on several teeth and associated generalized marginal gingival erythema. Fig. 5.1 Anterior occlusion at presentation. Stained occlusal ssures in 6 , brown staining on the mesial o 6 and decalci cation at the gingival margin level on the 5 • 26 SEVERECROWDING Table 5.1 Factors a ecting the rate o space loss ollowing early loss o a primary molar A Factor Ef ect* Age at loss The younger the age at loss, the greater the potential or space loss Degree o crowding The more crowded the arch, the more space that will be lost Tooth extracted Earlyloss o an E, rather than o a D,is likelyto lead to more space loss (see belowregarding arch). 5’s mayerupt and be excluded palatally/linguallyor be impacted; 5 maybe in crossbite; centreline shi t i asymmetrical extraction and in case o E, i earlyloss be ore age 7 Arch romwhich tooth is lost Greater loss is likelyin the upper, rather than in the lower arch, as mesial dri t tendencyis greater in the ormer Type o occlusion Less space loss will occur where good buccal interdigitation exists *The e ects listed above are those that are, in general, likelyto result romeach o the actors given. Individual variation with regard to outcome is, however, possible. Mild lower labial segment crowding with 1 distolabially rotated; 3 slightly mesially inclined and 3 upright. Lower right and le t buccal segments exhibit mild crowding. B Overall, summing the labial and buccal segments, the lower arch has moderate to severe crowding. Severe upper labial segment crowding; 2′s very slightly mesiolabially rotated; both 3′s are about to erupt buccal to the line o the arch. Upper buccal segments are not crowded; there is mesiopalatal rotation o 5 and distopalatal rotation o 4 ; small amount o space on either side between the premolar teeth and between the rst premolars and lateral incisors. C Class I incisor relationship; overbite is average and complete; lower centreline shi ted slightly to the right. Class I molar relationship on right and le t. ■ What is the likely cause o the enamel hypoplasia on 5 ? This is m ost likely d u e to p u lpal p athology in the overlying E , affecting am elogenesis, often referred to as a Tu rner ’s tooth or Tu rner ’s hyp op lasia. ■ What a re the likely causes o the severe upper arch crowding? • D Fig. 5.2 (A) Lower occlusal view. (B) Upper occlusal view. (C) Right buccal occlusion. (D) Le t buccal occlusion. • buccal aspects o 6 | 6; ssure sealants are visible in the occlusal sur ace o the rst permanent molars. 5 has a mildly hypoplastic palatal cusp (this was non-carious). All permanent teeth present rom the second permanent molar to the second permanent molar in the lower arch (5’s are partially erupted); in the upper arch, all permanent teeth (except 3’s) erupted rom second permanent molar to second permanent molar. • • Inherent dentoalveolar disproportion this is genetically determined and represents a mismatch in tooth size and the size o the alveolus. Added to this, the maxillary canines are the last permanent teeth to erupt anterior to the rst permanent molars and are o ten squeezed buccally in a crowded arch. Early loss o primary teeth this leads to mesial dri t o the buccal segments and aggravates crowding. Supernumerary teeth and megadont teeth are other causes o crowding but are not relevant in this case. Any combination o the previously mentioned causes. ■ What a ctors in uence the ra te o space loss ollowing early loss o a primary mola r? What are the e ects o ea rly loss o a primary mola r? These are given in Table 5.1. 27 • SEVERECROWDING Key point On average, space loss is greater ollowing extraction o a primary molar: • The younger the age at extraction. • In the upper rather than the lower arch. • In a crowded arch. • Where the second rather than the f rst primary molar is extracted. • Where there is poor occlusal interdigitation. ■ What are the likely causes o the upper premolar rotations? Developmental where the tooth germ is rotated in its crypt, which could be a mani estation o inherent crowding. Acquired due to early loss o the primary predecessor, most likely due to caries, which removes its main guidance into occlusion and allows the premolar to initially rotate in the tooth crypt, and become characteristically mesiopalatally rotated later due to mesial dri t pressure o the rst permanent molars. A retained prim ary m olar or its root fragm ent m ay also ind u ce rotation of the su ccessor if it fails to erup t in the correct p osition. Investigations ■ What investigations would you request and why? A d ental p anoram ic tom ogram is requ ired to d eterm ine the presence and p osition of all u neru p ted teeth. Bitew ing rad iograp hs w ou ld be ad visable in view of the ssu re and m esial su rface staining observed related to 6 and 6, resp ectively. These w ill also allow the statu s of 5 to be assessed . The presence of all perm anent teeth inclu d ing third m olars w as con rm ed ; enam el caries w as d etected in 6 and 6 (this had not p rogressed throu gh to d entin). Diagnosis ■ What is your diagnosis? Class I malocclusion on a Class I skeletal base with average FMPA. 5 To correct the lower centreline. To close residual buccal segment spacing, maintaining Class I incisor and molar relationships. ■ Wha t is your treatment plan? 1. 2. 3. 4. Provide oral hygiene instruction and dietary advice. Topical f uoride (Duraphat) application to early enamel lesions on lower rst permanent molars. Composite restoration o the palatal aspect o 5 . Re erral, with the recently taken radiographs, to an orthodontist or urther assessment and management o the severe crowding. ■ Explain the treatment options or Amy’s severe upper arch crowding and modera te to severe lower arch crowding. What are the implica tions o ea ch option? Althou gh Am y’s principal concern relates to her u pper arch crow d ing, it is essential that treatm ent planning begins in the low er arch. (See p. 18 for an exp lanation of this and options for relief of crow d ing.) Based on the assessm ent of the overall severity of the low er arch crow d ing, extraction of rst prem olars w ill be requ ired . This w ill relieve im paction of the second prem olars and provid e space for the canines to m ove d istally to facilitate labial segm ent alignm ent. The latter is m ore likely to occur sp ontaneously on the right sid e d ue to the uprighting of the slightly m esially angu lated 3 . Provid ed oral hygiene has im proved suf ciently, xed app liances w ill then be requ ired because of the angu lation of 3, rotation of 1, the need for centreline correction and space closure. Follow ing on the sam e schem e given on p ages 18–19 for treatm ent planning, after you : Imagine the corrected position o 3 (in this case taking the need to move the lower centreline to the le t), the next step is to Mentally reposition 3 to be in a Class I relationship with the corrected position o 3. For Amy, space is required to achieve this. ■ How would you assess the spa ce required in the upper arch? As sp ace is at a p remium , the d istance from the d istal of the lateral incisor to the m esial of the rst p erm anent m olar should be m easured w ith ne pointed stainless steel d ivid ers. This m easured 16 m m on the right and left sid es. Generalized marginal gingivitis; enamel caries in 6 | 6. ■ Is this su cient to achieve the trea tment objectives? Moderate to severe lower arch crowding; severe upper arch crowding with 3′s unerupted but positioned buccally; lower centreline displaced slightly to the right. Rem oval of both u p p er rst p rem olars w ill p rovid e sp ace for alignm ent of 3′s, bu t it w ill be insu f cient to achieve this comp letely and obtain a Class I canine relationship w ith the 3| 3 p ositions corrected u nless all the space from the u p per arch extractions is m aintained . N o space loss is perm issible. Anchorage reinforcem ent is requ ired . It is im p ortant to realize that rem oval of an u pper rst p rem olar creates u sually 7 m m of sp ace, bu t the average m esiod istal w id th of the perm anent m axillary canine is 8 m m – so generally, on average, 15 m m of space is required to accom m od ate 3 and 5. Fortu nately, in Am y’s case, there is a sm all am ount of sp ace present in the u pp er prem olar areas w hich w ill assist correct p ositioning of 3’s w ith the aligned 3’s . Rem oval of both u p p er canines is another p ossibility; if they eru pt bu ccal to the line of the arch in a few m onths’ Class I molar relationship on right and le t. ■ What is the IOTN DHC gra de (see p. 264)? Explain why. 5i – d u e to the im p acted m axillary canines. Treatment ■ What are the aims o treatment? To improve oral hygiene and restore dental health. To relieve crowding. To align upper and lower arches. 5 • 28 SEVERECROWDING tim e, they cou ld be extracted , or if not, su rgical rem oval cou ld be u nd ertaken. Up p er xed app liance therap y w ou ld then be required to rotate the rst prem olars slightly m esiopalatally to hid e the p alatal cu sp and occu p y a greater m esiod istal w id th akin to that of the extracted canine; the palatal cusp of 4′s shou ld also be grou nd to avoid interferences in lateral excu rsions. Bond ed retention w ould also be need ed to m aintain the nal p osition of 4′s. Rem oval of u pp er 4’s ad d resses Amy’s concern and is likely to give the better nal ap p earance. ■ I a n upper removable a ppliance spa ce mainta iner were to be considered, what would be your design? What instructions would you issue regarding appliance wear? Activation: there are no active components. Retention: Adams clasps 6|6 (0.7 mm stainless steel wire) with headgear tubes soldered to the 6′s clasp bridges; f at stops distal o 2|2. Anchorage: ull palatal acrylic coverage; also headgear to be added to t into the molar clasp tubes. Baseplate: ull palatal acrylic coverage. Key point An upper f rst premolar extraction space will not accommodate an upper permanent canine. The u p p er rem ovable ap p liance shou ld be w orn fu ll-tim e except for contact sports and after m eals w hen it shou ld be removed for cleaning. Sticky and hard food s as w ell as zzy d rinks shou ld be avoid ed w hen the ap pliance is w orn. Details regard ing head gear force and w ear for anchorage reinforcem ent as w ell as safety p recau tions necessary are given on page 14. ■ Finalize your treatment planning. ■ Describe the alternatives to this appliance. The next step s are: Sp ace cou ld be m aintained w ith head gear alone tted to band s on the up per rst p erm anent m olars, w ith a force of 200–250 g per sid e, w orn 10–12 hou rs per d ay. Shou ld the head gear not be w orn as requ ired in this case, then m esial d rift of the second p rem olar and rst p erm anent m olar w ill comp rom ise sp ace requ ired for 3′s. A N ance bu tton p alatal arch sold ered to band s on the up per rst p erm anent m olars is an alternative (Fig. 5.3), bu t as space is critical in this case, sold ering a transpalatal arch also to the m olar band s m ay su pp ort anchorage further (Fig. 5.11). The N ance bu tton palatal arch provid es anchorage throu gh m ucosal contact of the acrylic bu tton w ith the anterior vau lt of the p alate w hile the p alatal arch m aintains the interm olar d istance, p reventing m esial d rift and m olar tipp ing. This is assisted fu rther by the ad d ition of a transp alatal arch, straight across the p alate, linking 6 to 6. Another op tion is to place a TAD d istal to the 6’s on either Plan the upper labial segment. The mild rotation o 2’s is best dealt with by xed appliance therapy. Decide on the f nal molar relationship. With our rst premolar extractions, this should be Class I; residual space closure in the lower arch will necessitate xed appliance therapy. Assess the anchorage needs. The high anchorage demands in the upper arch have already been identi ed. Options are a space maintainer with anchorage support (headgear), headgear alone, Nance palatal arch with/without transpalatal arch or temporary anchorage devices (TADs). Anchorage demands in the lower arch are modest; there is no need or anchorage rein orcement. Plan retention. Upper and lower vacuum- ormed retainers (Essix retainers) should be adequate to be worn night-time only or 1 year ollowed by a second year o every second night wear. ■ Wha t is the f nal orthodontic trea tment plan? Assu ming that Am y’s oral hygiene im proves and is m aintained at a high stand ard follow ing instru ction, then the plan w ou ld be as follow s: 1. Anchorage rein orcement in the upper arch by one o several means (see above). 2. Extraction o our rst premolars. 3. Upper and lower xed appliances. 4. Upper and lower Essix retainers. Key point Where anchorage is at a premium, always rein orce anchorage be ore any extractions or relie o crowding. Fig. 5.3 Nance button palatal arch. 29 • SEVERECROWDING 5 effectiveness betw een the ap p liances in term s of anchorage su pp ort, bu t there w ere m ore problem s reported w ith head gear and N ance bu ttons than w ith TADs. ■ Are there any risks with TADs? Fig. 5.4 Lingual arch. sid e and u se it to keep the 6’s and second prem olars from m oving m esially. ■ I all the spa ce rom lower premolar extra ctions ha d been required or lower labial segment a lignment, how could anchorage have been rein orced there? A low er rem ovable ap p liance is not w ell tolerated d u e to encroachm ent on tongu e sp ace, interference w ith sp eech and d if cu lty w ith achieving good ap p liance retention d u e to the lingu al inclination of the m olars. A low er lingual arch sold ered to band s on the rst p erm anent m olars is a better op tion (Fig. 5.4). Alternatively, the second perm anent m olars cou ld be bond ed or band ed and ligated to the rst perm anent m olars. Another op tion is to p lace a TAD into the retrom olar area on each sid e and use it to keep the rst perm anent m olars and second p rem olars from m oving m esially w hile p rovid ing anchorage for canine retraction. Key point Options or rein orcing anchorage in upper arch: • Upper removable appliance space maintainer with headgear support. • Headgear to molar bands. • Nance button palatal arch (with/without transpalatal arch). • TAD. Options or rein orcing anchorage in lower arch: • Lingual arch. • Bond/band 7 ’s and ligate to 6 ’s. • TAD. ■ How e ective are TADs a t rein orcing anchorage? How do they compare to other methods o anchora ge rein orcement? Evid ence ind icates that TADs are an effective, non-com p liant m eans of reinforcing anchorage or of m oving u p p er rst perm anent m olars d istally. A recent rand om ized clinical trial com pared anchorage sup plem entation w ith head gear or N ance button p alatal arch or TADs, in cases that requ ired m axim u m anchorage su p p ort; there w as no d ifference in Risks inclu d e: • Screw breakage during insertion (5%). • Root contact during placement (should heal unevent ully). • Failure necessitating TAD replacement/removal (~14%). • In ection (unlikely i the area around the screw is brushed gently with a small headed toothbrush and f uoride toothpaste and chlorhexidine mouthrinse (0.2%) is used or rst 5 days a ter insertion). • Screw loosening (may be replaced in original or di erent position). ■ I Amy were issued an upper removable space mainta iner with headgear support, how would you know at her 2-week review whether the a pplia nces were being worn as instructed? Amy shou ld be speaking norm ally w ith the u pper rem ovable ap pliance in p lace; she shou ld also be able to rem ove and insert the app liance u naid ed by a m irror. The baseplate should have lost its shine; there shou ld be evid ence of m ild gingival erythem a along the palatal m argins of the app liance and at the posterior extension of the basep late (if the app liance had a bite p latform , there w ou ld be m arks from the occlu sion also). She should also be able to insert, assem ble and rem ove the head gear easily. If it is being w orn as instru cted , the head cap w ill have signs of w ear and the head gear tu bes in the rem ovable ap p liance shou ld be free of any food d ebris from insertion of the facebow. The occlusion follow ing appliance w ear w ith head gear support and extraction of four rst premolars is show n in Fig. 5.5. The lower centreline shift corrected without appliance treatment. At this stage, Amy indicated that she was suf ciently pleased w ith the improvement in her dental appearance that she did not wish to proceed to further xed appliance therapy. This was fortunate as she was not keen on assisted tooth brushing by her mother and had struggled, due to continuing problems w ith right w rist mobility, to maintain a high standard of oral hygiene during removable appliance treatment, despite the use of a pow ered toothbrush. An Essix retainer w as tted in the u p p er arch only; Am y w as instru cted to w ear this at night-tim e only for 12 m onths initially. Arrangem ents w ere m ad e to review her occlu sion at that stage. ■ Wha t is an Essix reta iner, and what are its potential adva ntages over a Ha wley retainer in the upper a rch? Aside rom the usual advice regarding reta iners, what specif c advice should the pa tient be given regarding this retainer? An Essix retainer is a clear vacu u m-form ed therm oplastic retainer. Som e of its potential ad vantages over a H aw ley retainer are: • Better aesthetics. • Less di culty with speaking. • Cheaper. • Easier to make. 5 • 30 SEVERECROWDING ■ What do you notice in Fig. 5.6? Poor oral hygiene with plaque deposits on most teeth. Generalized marginal gingival erythema. 76543211234567 visible (note 3 cusp tip). 76543211234567 Caries- ree dentition. Moderate lower arch crowding with 3 impacted but erupting. A Severe upper arch crowding; 5 excluded palatally with 6 and 4 in contact; 6 rotated mesiopalatally; median diastema ~2 mm; 3 buccal and mesially inclined. Class I incisor relationship; overjet 2 mm (measured clinically); overbite average and complete; centreline shi t (lower was ~4 mm to the right). Right molar relationship is Class II; le t molar relationship is Class I. Crossbite 6 (5 also in crossbite). B ■ What is the IOTN (DHC) grade (see p. 264)? Expla in why. 4d – d u e to contact point d isplacem ent betw een 5 and 4 , or betw een 3 and 4. Althou gh 3 is imp acted , it is partially erupted and so w ould score 4t and not 5i (if 4 m m or less betw een 4 and 2.5i). ■ What a re the possible ca uses o the crowding and tooth displacements in the upper a nd lower arches? C Fig. 5.5 (A) Post-treatment: right buccal occlusion. (B) Post-treatment: anterior occlusion. (C) Post-treatment: le t buccal occlusion. Vacu um -formed retainers appear m ore effective than H aw ley retainers at m aintaining correction of the u p p er and low er labial segm ents, w ith greater effectiveness in the u pper than the low er arch. The retainer m u st not be w orn w hile eating and m u st never be w orn w hile consu m ing beverages, esp ecially carbonated d rinks, as w ith these there is a high risk of enam el d em ineralization. CASE2 SUMMARY Roger has recently relocated to your area rom another country. He presents with a tooth erupting in his palate and an impacted 3 . What are the causes o these problems, and how may they be managed? Roger has a Class I skeletal pattern with average FMPA and lower acial height; there is no acial asymmetry. The palatal exclusion of 5 is m ost likely d u e to early loss of E in an inherently crow d ed arch. Sp ace closure has been comp lete w ith 6 and 4 in contact. Factors in u encing the rate of sp ace closu re have been given in Table 5.1. N ote the characteristic m esiopalatal rotation of 6 follow ing early loss of E . Roger ’s m other con rmed that E had been extracted at age 5 d u e to caries. 3 is the last tooth to eru p t in the u p per left quad rant and is buccally d isplaced d u e to the inherent crow d ing. The lack of sp ace for 3 m ay be linked to the low er centreline shift (see possible cau ses below ). N ote the d istal tilt of 2 . Early loss of low er p rim ary m olars app ears unlikely d u e to the reasonably aligned bu ccal segm ents. ■ Why has 6 rotated mesiopalatally? As the p alatal root is the largest, the tooth rotates arou nd this rather than arou nd either of the bu ccal roots. ■ What is unusual a bout the eruption pa ttern in the lower arch? Usually the canines eru p t before the p rem olars (the op p osite is tru e in the u pper arch) so it is u nusual that 3 is im pacted . See Chapter 1 for the average eru ption d ates of teeth. ■ What is the likely cause o the lower centreline shi t? Prem atu re loss of C d ue to inherent crow d ing is a likely cause. Early u nbalanced loss of C or D d u e to caries is another p ossibility as E w as lost early d u e to caries. N o low er prim ary teeth had been extracted . Other cau ses of a centreline shift are given in Chap ter 14, Box 14.1, p age 88. 31 • SEVERECROWDING 5 B A C D E Fig. 5.6 (A) Right buccal occlusion. (B) Anterior occlusion. (C) Le t buccal occlusion. (D) Upper occlusal view. (E) Lower occlusal view. Key point 6 rotates mesiopalatally with mesial dri t ollowing early loss o E. Investigations Fig. 5.7 Dental panoramic tomogram. ■ A dental pa noramic tomogram (DPT) was taken by Roger’s previous dental pra ctitioner a ew months ago. You request this by email. What do you notice in Fig. 5.7? The DPT show s: Normal alveolar bone height. All erupted permanent teeth sound. 5 overlapping 4 ; impacted 3 . Four third molars developing. ■ Do you require any urther ra diogra phs? It is not possible to see the roots of 5 and 4 clearly; tw o periap ical rad iograp hs w ith a tu be shift cou ld be taken to assess this m ore com pletely and to exclu d e any resorption. Should the intraoral view s not provid e su f cient inform ation, a CBCT cou ld be taken. Periap ical view s ind icated no root resorption of either p rem olar. 5 • 32 SEVERECROWDING Diagnosis ■ Wha t is your diagnosis? Class I malocclusion on a Class I skeletal base with average FMPA. Generalized mild marginal gingivitis. Moderate lower and severe upper arch crowding with the lower centreline shi ted to the le t. Right buccal segment relationship is Class II; le t buccal segment relationship is Class I. Fig. 5.8 Digital simulation o potential outcome ollowing extractions and 3 alignment. Buccal crossbite 6 and 5 . Treatment ■ What are your aims o treatment? Establish good oral hygiene. Relie o crowding. De-rotation and crossbite correction o 6 . Correction o lower centreline. Establish Class I right and le t molar relationships. Retain. ■ Wha t is your treatment plan? 1. 2. 3. 4. 5. Oral hygiene instruction. Correct the crossbite on 6 and derotate 6 . 54 Extract . 44 Upper and lower xed appliances. Upper and lower vacuum- ormed retainers. ■ How could the crossbite be corrected on 6 and 6 be derotated? The crossbite m ay be corrected by cem enting band s to 6 and 6 and ru nning cross-elastics from an attachm ent on the palatal of 6 band to the hook on the bu ccal of 6 band . In ord er to facilitate band p lacem ent and to ensu re that m ovem ent of 6 is not obstru cted by 5 , it w ou ld be sensible to have 5 extracted p rior to band p lacem ent. The cross-elastics should be w orn fu ll-tim e, inclu d ing at m eals. Crossbite correction is likely to take a short tim e, follow ing w hich the elastics shou ld be d iscontinued for a m onth to assess stability. Derotation of 6 w ill likely occu r w ith increasing d iam eter of the archw ires w hen the rem aind er of the xed appliances has been p laced . An alternative is to u se a qu ad helix ap p liance and ad ju st it to both d erotate 6 and to m ove it buccally. There is, how ever, likely to be som e recip rocal u nw anted bu ccal m ovem ent of 6 by this m eans. Roger w as a keen ru gby p layer, and althou gh he w anted to im p rove the app earance of his teeth, he w as not p rep ared to w ear xed appliances. ■ Is there another option you could consider to address his wishes? An extraction-only p lan cou ld ad d ress several issues. Removal of 5 4 and 4 w ill relieve crow d ing and allow 3 to align and 3 to erup t. The m esial angulation of 3 is favou rable to allow it to m ove d istally follow ing 4 extraction, and it shou ld align consid erably u nd er cheek pressu re. Althou gh this m ay be incom plete, it w ill im prove 3 position greatly. This p lan accep ts the low er centreline shift and the very m ild crow d ing of the low er left bu ccal segm ent. These shortcom ings m u st be exp lained to Roger and his p arents shou ld he w ish to p roceed . A d igitally sim u lated im age of the p otential ou tcom e of this p lan is show n in Fig. 5.8. CASE3 SUMMARY Conal, a 12-year-old boy, presents complaining about the crowding o his upper and lower ront teeth. He is keen or treatment. What has caused this problem and how may it be treated? Conal has a mild Class III skeletal pattern with slightly increased FMPA and lower acial height; there is no acial asymmetry. His lips are competent and no temporomandibular joint signs or symptoms were recorded. ■ What do you notice in Fig. 5.9? Mild marginal gingival erythema. 6 has an amalgam restoration. 6 6 are ssure sealed. Severe lower and upper arch crowding with all canines erupting buccally. Class III incisor relationship; reduced and complete overbite; centreline shi t (lower was 3 mm to the le t and upper was 1 mm to the right). 6 and 2 in crossbite. Buccal segment relationship is Class I bilaterally. ■ What should you check or with the crossbite on the 2’s? You shou ld check if there is a m and ibu lar d isp lacem ent present on closing. N o m and ibular d isplacem ent w as d etected . ■ What is the likely cause o the upper and lower a rch crowding? Inherent d entoalveolar d isproportion is the m ost likely cau se. 33 • SEVERECROWDING A 5 B C D E Fig. 5.9 (A) At presentation: right buccal occlusion. (B) Anterior occlusion. (C) Le t buccal occlusion. (D) Lower occlusal view. (E) Upper occlusal view. ■ What is the IOTN (DHC) gra de (see p. 264)? Explain why. 4d – d u e to contact p oint d isp lacem ent >4 m m (present on several teeth, bu t greatest w ith 3 and ad jacent teeth). Investigations ■ What investigations would you request and why? A d ental p anoram ic view w ou ld be ad visable to check the cond ition of all eru p ted teeth and to ascertain if third m olars are d evelop ing. This revealed all teeth includ ing third m olars to be d evelop ing norm ally and in the correct p ositions w ith no ap p arent resorp tion of the 2’s by 3’s. The restoration in 6 w as d eep . A su bsequent periap ical rad iograp h of 6 ind icated second ary caries. A lateral cep halom etric lm is also requ ired to assess m ore fu lly the Class III skeletal p attern and the angu lations of the u pp er and low er incisors to their resp ective d ental bases. This revealed the follow ing: SN A = 81°; SN B = 81°; SN -m axillary plane = 5°; MMPA = 29°; 1 to m axillary plane = 112°; 1 to m and ibu lar plane = 91°; interincisal angle = 130°; facial p rop ortion = 58%. ■ How would you assess the long term prognosis o 6 ? As the patient’s general d ental p ractitioner, you shou ld check the clinical notes regard ing the last tim e 6 w as restored . This shou ld have record ed w hether an ind irect p ulp cap w as u nd ertaken or w hether the pu lp w as exposed d u ring the restorative p roced u re. You should also ask Conal if he is having any sym p tom s associated w ith 6 , then check the bu ccal su lcu s for any sw elling or sinu s related to 6 , as 5 • 34 SEVERECROWDING w ell as the restoration for integrity of the m argins, and assess w hether 6 is tend er to p ercu ssion. The clinical notes record ed a p u lp exp osu re and a d irect pu lp cap , so althou gh the tooth has been sym p tom -free, the prognosis w ou ld be som ew hat gu ard ed . ■ What is your interpretation o the cephalometric f ndings? Relative to Caucasian norm s, SN A is average and SN B is slightly increased , ind icating m ild m and ibu lar prognathism. The skeletal p attern is m ild ly Class III (SN A − SN B = AN B = 0°). SN to m axillary p lane is slightly less than average; MMPA is slightly increased ; 1 to m axillary p lane is slightly increased , and 1 to m and ibu lar p lane is slightly red u ced . The interincisal angle is red u ced and facial p roportion is increased . The 1 angu lation is com p ensating for the m ild ly increased MMPA (120° − 91° = 29°). 3. 4. 5. Upper and lower xed appliances. Upper and lower vacuum ormed retainers. Monitor third molars. ■ How may anchorage be rein orced in the upper and lower arches? Means to reinforce anchorage in the up per and low er arches have been ou tlined on p age 29. A lingual arch and a N ance palatal arch w ith transpalatal bar from 7 to 6 w ere placed (Figs 5.10 and 5.11). ■ Are there any means by which anchorage demands may be reduced in the upper arch? Extraction of 4 in ad d ition to 6 w ou ld red u ce anchorage d em and s in the u p p er right bu ccal segm ent. ■ Does this option ha ve a ny other potential benef ts? Are there any risks? Diagnosis ■ Wha t is your diagnosis? Class III malocclusion on a mild Class III skeletal base with slightly increased FMPA. Generalized mild marginal gingivitis. It w ould m ake alignm ent of 3 m u ch easier, as the 4 extraction sp ace is ad jacent. 7 shou ld also end u p in a Class I relationship w ith 6 . As the incisor relationship is m ild ly Class III, closure of three extraction sp aces (6 4 4) in the u pper arch m ay ru n the risk of bringing the incisors to an ed ge-to-ed ge relationship or even into a slight reverse overjet. Restored 6 with guarded long-term prognosis. Severe upper and lower arch crowding with upper and lower centreline shi ts (lower 3 mm to the le t, upper 1 mm to the right). Crossbite o 2 and 2 with no associated mandibular displacement. Molar relationship is Class I bilaterally. Treatment ■ What are the aims o treatment? Improve oral hygiene. Relieve crowding. Align upper and lower arches. Correct centrelines. Maintain Class I buccal segment relationship. A ■ I 6 is removed in view o its guarded prognosis, wha t implica tions will that have or trea tment and the f nal outcome? Anchorage d em and s are alread y high in the upp er arch and extraction of 6 rather than 4 w ill increase that fu rther on the u pper right sid e as both p rem olars w ill requ ire retraction before 3 can be aligned . So althou gh 6 is a larger tooth m esiod istally than 4 , the sp ace created is further from the site w here space is required and its rem oval w ill m ake treatm ent m ore com p lex. If 6 is extracted , the cu sp tip of 5 should occlu d e w ith the bu ccal groove of 6 at the end of treatm ent. ■ Wha t is your treatment plan? 1. 2. Rein orce 6 Extract 4 upper and lower arch anchorage. 4 . 4 B Fig. 5.10 (A) Lingual arch. (B) A ter the removal o 4 4 (note small amount o space remaining). 35 • SEVERECROWDING Key point Extraction o a f rst permanent molar in an upper arch with severe labial segment crowding will complicate anchorage requirements. The occlusion follow ing canine retraction and alignment is show n in Fig. 5.11. The nal occlu sion is show n in Fig. 5.12. Primary resources and recommended reading Fig. 5.11 Nance palatal arch with transpalatal arch ( ollowing removal o 6 4 and retraction o 5 4 3 3; note minimal residual space). British Orthod ontic Society 2009 Patient Inform ation Lea et: Orthod ontic Mini-Screw s. Lond on: British Orthod ontic Society. Jam bi S, Walsh T, Sand ler J et al 2014 Reinforcem ent of anchorage d uring xed brace treatm ent w ith im plants or other su rgical m ethod s. Cochrane Database of Syst Rev Issu e 8. Art N o: CD005098. DOI: 10.1002/ 14651858.CD005098.p u b3. Row land H , H itchens L, William s A et al 2007 The effectiveness of H aw ley and vacuum -form ed retainers: a single-center rand om ized controlled trial. Am J Orthod Dentofacial Orthop 132:730–737. Sand ler J, Mu rray A, Thiru venkatachari B et al 2014 Effectiveness of 3 m ethod s of anchorage reinforcem ent for m axim um anchorage in ad olescents: a 3-arm m u lticenter rand om ized clinical trial. Am J Orthod Dentofacial Orthop 146:10–20. A Thornhill MH , Dayer M, Lockhart PB et al 2016 A change in the N ICE gu id elines on antibiotic p rop hylaxis. Br Dent J 221:112–114. Yaacob M, Worthington H V, Deacon SA et al 2014 Pow ered versus m anu al toothbru shing for oral health. Cochrane Database of Syst Rev Issu e 6. Art N o: CD002281. DOI:10.1002/ 14651858. CD002281.p u b3. For revision, see Mind Map 5, page 225. B C Fig. 5.12 (A) Post-treatment: anterior occlusion. (B) Right buccal occlusion (note position o 5 ). (C) Le t buccal occlusion. 5 6 Palatal canines CASE1 SUMMARY Diane, a 15-year-old girl, presents with both upper primary ca nines retained (Fig. 6.1). What is the cause and what treatment possibilities are there? History Diane is concerned about the size of the baby u pper ‘eye’ teeth that are present and by the spaces on either sid e of her u pper tw o front teeth. She is not bothered by the sm all sp ace betw een the u pp er front teeth. C is also slightly loose, and she is w orried in case it is lost, p rod u cing a big sp ace. History o complaint Diane has been aw are that the baby ‘eye’ teeth shou ld have been lost a few years ago. H er p reviou s general d ental practitioner, w ho retired last year, ad vised her that these teeth w ou ld eventu ally fall ou t by them selves and that w hen the new ‘eye’ teeth cam e throu gh, she w ou ld then need a brace to close the sp aces betw een her top teeth. There is no history of trau m a to C C areas, and all other prim ary teeth w ere lost natu rally. All p erm anent teeth have eru p ted on sched u le. She has noticed that C has been loose interm ittently for the p ast 18 m onths. It d oes not app ear to have got looser in recent m onths. Diane is very keen to im p rove the appearance of her u p p er teeth. Fig. 6.1 Anterior occlusion at presentation. Medical history Diane is t and w ell. Dental history Diane is a regu lar attend er at her general d ental p ractitioner bu t has never had any d ental treatm ent. Examination Extraoral Diane has a Class I skeletal pattern w ith average FMPA and low er facial height and no facial asym m etry. H er lip s are com p etent w ith the low er lip at the level of the incisal third of the u p p er incisors. There is a slight lateral m and ibu lar d isplacement to the 4 left on closure on . 4 Intraoral ■ The intra oral views are shown in Figs 6.1 a nd 6.2. Describe what you see. Oral hygiene is air with mild marginal gingival erythema related to 2 2 and the upper le t buccal segment teeth. No obvious buccal swellings in the C areas, but there seem to be mucosal swellings palatal to C2 2C, perhaps indicating the position o unerupted 3’s. Slight enamel demineralization buccally on 6 6. 7 6 5 4 C2 1 1 2 C4 5 6 7 erupted. 7654321 1234567 Mild lower labial segment crowding; 1| 1 very slightly mesiolingually rotated; lower buccal segments spaced. Upper arch uncrowded; spacing in the upper labial segment. Class I incisor relationship with a centreline shi t (clinically the lower centreline was 1.5 mm to the le t). Buccal segment relationship is Class I bilaterally; lingual crossbite o 4 with 4 ; buccal crossbite o 6 with 6. ■ What a re the potential causes o C’s being retained? Absence o 3’s this is highly unlikely (0.3% o Caucasians). Ectopic position o 3’s this is the most likely cause (1 2% in Caucasians with 8% o these being bilateral). ■ What a ctors are implicated in pa la tal ca nine ectopia? The aetiology of p alatal canine ectop ia is obscu re bu t m ost probably mu ltifactorial. Possible cau sative factors are: 1. Genetic palatally displaced 3 appears to result rom a polygenic mode o inheritance, with associated anomalies including incisor-premolar hypodontia, peg-shaped 2 (see below), in raoccluded primary molars, impacted 6, other ectopic teeth and transposition (see Chapters 1, 7 and 8). Class II division 2 malocclusion is also associated with an increased incidence o palatal 3. Lending urther support to a genetic aetiology is that palatal 3 has a predilection or those o European origin as well as those with a amilial tendency, with emales 37 • PALATALCANINES 3. 4. 5. 6. 6 3 has the longest path o eruption o any permanent tooth. Arch length discrepancy palatal displacement o 3’s has been mostly associated with an uncrowded or spaced arch. Note the spacing present in Diane’s upper arch. Trauma to the maxillary anterior area at an early stage o development this has been suggested, but there is no history o trauma in this case. Peg-shaped, short-rooted 2’s or absent 2’s guidance or 3 is reduced where these eatures are evident, doubling the incidence o palatal impaction o 3. A Key point Palatal displacement o 3: • A ects Europeans, emales and both sides o the arch more commonly. • Is more common in an uncrowded arch. • Is associated with small, absent or abnormal ormation o 2’s, hypodontia, impacted 6 in raoccluded primary molars, other ectopic teeth and Class II division 2 malocclusion. N ote in Diane’s case, the m esiod istal w id th of 2’s w ere the sam e as those of 2’s, ind icating that 2’s are sm aller than average and that a tooth-size d iscrepancy (TSD) or Bolton d iscrep ancy exists betw een the u p p er and low er labial segm ent teeth. B ■ Wha t is the prevalence o TSD, and which teeth are most commonly a ected? Betw een 5% and 14% of the p op u lation have a signi cant overall TSD, w hereas 20–30% have a signi cant anterior TSD (see below ). Althou gh a TSD is m ost com m only d ue to a size anom aly of the u p per lateral incisor, prem olars or other teeth m ay also be responsible. C ■ How would you assess or a TSD? Quick-check method • • D Fig. 6.2 (A) Lower occlusal view. (B) Upper occlusal view. (C) Right buccal occlusion. (D) Le t buccal occlusion. 2. a ected more than males and occurrence being more common on both sides o the maxillary arch than one would envisage. Crypt displacement where the position o 3 is grossly displaced, this may be an aetiological actor. For anterior TSD: compare the width o the upper and lower lateral incisors; i the upper lateral incisor is not wider than the lower, a TSD exists. For posterior TSD: compare the width o the upper and lower second premolars; these should be about equal size. Computational method A tooth-size analysis, often referred to as a Bolton analysis after its d evelop er, m ay also be performed . The m esiod istal w id th of each perm anent tooth, exclu d ing second and third m olars, is m easu red and then the su m m ed w id ths of the m axillary to m and ibu lar teeth are com p ared w ith a stand ard table. This allow s calcu lation of Bolton anterior (canine to canine) and overall ( rst m olar to rst m olar) ratios as follow s: (Sum mandibular anteriors)/(sum maxillary anteriors) × 100 = anterior ratio (%) 6 • 38 PALATALCANINES (Sum mandibular 6 6)/(sum maxillary 6 6) × 100 = overall ratio (%) Bolton obtained an anterior ratio o 77.2 ± 1.65% and an overall ratio o 91.3 ± 1.91%. Discrep ancies greater than 2SDs (2 stand ard d eviations) beyond these m ean valu es have been regard ed as clinically relevant to treatm ent p lanning. Tooth-size analysis m ay also be und ertaken using d igital m od els; the m easurem ents are as accurate and reliable as those obtained from p laster m od els. ■ Wha t are the implications o a TSD? The teeth m ust be proportional in size to ensure good occlusion. Rarely is a TSD of less than 1.5 m m of signi cance w ith regard to treatm ent p lanning, but w here larger d iscrep ancies exist, ad justm ent of the m esiod istal tooth w id th through either ad d ition to the enam el (e.g. com posite bu ild -u ps or porcelain veneers) or enam el rem oval (e.g. interd ental enam el strip p ing/ rep roxim ation) m ay be requ ired to close or open sp aces in the opp osing arch. Key point TSD: • May be assessed comprehensively by a Bolton analysis: mean anterior ratio is 77.2 ± 1.65%; mean overall ratio is 91.3 ± 1.91%. • Is rarely signif cant i 2SDs beyond Bolton mean values. Investigations ■ What investigations would you underta ke rega rding the reta ined C’s? Explain why. It w ou ld be essential to d eterm ine if 3’s are p resent and to localize their p osition. Initial assessm ent shou ld be clinical, and w here su spicion of 3 d isp lacem ent exists, rad iographic exam ination should follow. Clinical Palp ation of the buccal sulci and palatal m ucosae in the u pper canine regions, as w ell as observation of the 2 inclination, u su ally p rovid es a reasonable gu id e to the p robable position of an u neru p ted 3. Labial d isp lacem ent of 2 crow n ind icates 3 to be lying high and bu ccal over 2 root, or low and palatal. Radiographic Tw o lm s taken w ith either a vertical or a horizontal tu be shift are requ ired to assess accurately the location of u neru p ted 3’s. Alternatively, cone beam com p u ted tomograp hy (CBCT) m ay be u sed , bu t its use is generally con ned to cases w here there is specu lation of root resorption of ad jacent teeth or w here u ncertainty rem ains regard ing 3 position, having screened initial conventional rad iograp hs. A d ental p anoram ic tom ogram (DPT) gives a general good assessm ent of 3 position, althou gh its p otential for alignm ent is presented m ore favourably as 3 ap p ears at a m ore obtu se angle to the occlu sal p lane and less close to the m id line. The root length of C, the vertical and m esiod istal position of 3 relative to the incisor roots and the axial angu lation and apex location shou ld be assessed . An up per anterior occlu sal rad iograph or a periapical lm of each 3 is useful for d etecting incisor resorption and d eterm ining the prognosis of the C’s. Either of these view s, used in com bination w ith the p anoram ic view and ap p lication of p arallax (a palatal 3 m oves w ith the tu be shift), can be u sed to locate the 3’s. Localization of a palatally im p acted canine, how ever, has been show n to be best u nd ertaken u sing the com bination of an occlu sal and a p eriap ical rad iograp h allow ing horizontal p arallax. A lateral cep halom etric rad iograph is not ind icated in Diane’s case, bu t w here it is justi ed on clinical grou nd s, it provid es valu able inform ation about the position of 3’s, w hen u sed in com bination w ith the p anoram ic view. Three-d im ensional evalu ation of the canine p osition and any su sp ected resorption to the roots of other teeth is p rovid ed by CBCT, w hich cou ld in tim e, rep lace the rad iographic view s given above for canine localization (Fig. 6.3). The recent d evelop m ent of a low d ose protocol (~50% less) for CBCT of the anterior m axilla w ith an im p acted canine in paed iatric d entistry m ay facilitate this. Using CBCT, the incid ence of incisor root resorption from an im pacted m axillary canine has been estim ated to be as high as 68%, m ore than ve tim es higher than that rep orted from conventional rad iograp hs. A m ore robu st research base for orthod ontic ap plication of this techniqu e, how ever, is requ ired before it can be ad vocated m ore w id ely. Key point Using CBCT: • Incidence o incisor root resorption associated with an ectopic maxillary canine may be f ve times higher than with conventional radiographs. ■ Does CBCT have a ny other uses in orthodontics a side rom assisting with the localization o unerupted teeth a nd a ny associated pathology? CBCT also assists app raisal of alveolar bone height, w id th and volu m e, w hich m ay be bene cial for cases requ iring com bined su rgical–orthod ontic m anagem ent, cleft lip and palate for alveolar bone grafting, and orthod ontic– restorative care for im plant planning. In certain other cases, it may also be u sefu l for assessment of the airw ay or the temp orom and ibular joint. ■ How does the ra diation dose rom CBCT compare with that o a DPT? Althou gh the effective rad iation d ose is less (generally 50–500 µSv) than that of a conventional CT, one exp osu re equates to abou t 2–8 conventional panoramic rad iograp hs (3–24 µSv). 39 • PALATALCANINES A 6 A B B Fig. 6.4 (A) Dental panoramic tomogram. (B) Upper anterior occlusal radiograph. C Fig. 6.3 (A) Another case: dental panoramic tomogram showing 3 overlying 2. (B) Upper anterior occlusal radiograph indicating 3 to be slightly palatal with possible resorption o 2. (C) CBCT image showing 3 to be palatal to 2 and indicating the site and extent o resorption o 2. ■ Are there any other disadva ntages to CBCT in orthodontics? Cu rrently, CBCT u nits are costly and consid erable tim e m ust be allocated to view, and rep ort on, all the d ata obtained , in line w ith m ed icolegal requ irements. ■ Dia ne’s DPT and upper anterior occlusal radiograph are shown in Fig. 6.4. What are the eatures o note? • • • Four developing third molars. Presence o 3 3, which are palatal. Resorption o the roots o C C. ■ How may pa la tal ectopia o 3 be intercepted? Early d etection of an abnorm al erup tion path of 3 is essential in ord er to p rovid e, if ap p rop riate, an op p ortunity for intercep tive m easu res to be u nd ertaken. If 2 is peg-shaped , sm all or absent, then extra vigilance is requ ired from age 8 in view of the association of palatal 3’s w ith these anom alies. From 9 years of age, p alpation for u neru pted 3’s should be carried ou t rou tinely. Im p ortantly, the p osition of 3 m ust be localized before consid ering any intercep tive extractions. Rad iograp hic investigation is requ ired w hen a d ifference is d etected on clinical p alp ation of the u p p er bu ccal su lcu s betw een op posite sid es of the arch. Where 3 is d isp laced palatally in an u ncrow d ed arch, in a child aged 10–13 years old , rem oval of C m ay lead to 3 reverting to a normal path of eru ption. The am ou nt of im p rovem ent d ep end s on the d egree of overlap of 3 over 2 root, w ith a better p rognosis w hen 3 overlies the d istal rather than the m esial half of 2 root. Although im provem ent in 3 position m ay occu r even w here 3 is m arked ly d isp laced , sp ecialist ad vice mu st be obtained before rem oval of C. Consid eration m u st be given to balancing the extraction of C w ith rem oval of the op p osite C to p revent a centreline shift. N ormally, follow ing extraction of C, clinical and rad iograp hic re-evalu ation should be u nd ertaken at 6-m onthly intervals. If no im p rovem ent in 3 position is observed on a DPT w ithin 12 m onths, alternative treatm ent is requ ired . ■ How strong is the evidence to support extraction o C’s as an interceptive mea sure or palatally displaced canines? Clinical exp erience ind icates that there is evid ence to supp ort this intervention. H ow ever, a Cochrane review conclud ed that cu rrently there is no rm research base from controlled clinical trials on w hich to base this p ractice. 6 • 40 PALATALCANINES unerupted and displaced palatally); lower centreline shi t to the le t. Key point Removal o C’s between 10 and 13 years o age may encourage improvement in the position o a palatally ectopic canine, although there is no f rm research base or this. Class I molar relationship bilaterally; lingual crossbite o 4 with 4; buccal crossbite o 6 with 6. ■ What is the IOTN DHC grade (see p. 264)? Explain why. 5i – d u e to im p ed ed eruption (ow ing to palatal ectopia) of 3’s. When 3 d isp lacem ent is associated w ith crow d ing, elimination of crow d ing and sp ace m aintenance, if requ ired , m ay stim u late 3 p osition to im p rove. Treatment ■ What mana gement options are there or Diane’s unerupted Key point 3’s? What a re the indica tions or each option? In planning treatment or a palatally ectopic canine, assess the ollowing on radiograph: • The root length o C and root status o incisors. • The vertical and mesiodistal position relative to the incisor roots. • The axial angulation. • The apex location. These are sum m arized in Table 6.1. Key point Surgical exposure and orthodontic alignment o a palatal 3 requires a well-disposed patient with good oral hygiene and dentition. ■ Which option would you avour? Diagnosis ■ Wha t is your diagnosis? Class I malocclusion on a Class I skeletal base with average FMPA. 4 Lateral mandibular displacement on closure on . 4 Marginal gingivitis related to 2’s and upper le t buccal segment teeth; enamel demineralisation buccally on 6’s. As Diane is a highly m otivated patient w ith a high stand ard of general d ental care and the roots of C’s are resorbing, w ith the 3’s in reasonably favou rable p ositions for orthod ontic alignm ent, surgical exposu re of 3’s and orthod ontic alignm ent w ou ld be op tim al. ■ What a re the ideal aims o trea tment? Mild lower labial segment crowding but spaced buccal segments; uncrowded upper arch with C’s retained (3’s Alignment o 3’s. Build up 2’s to increase mesiodistal width. Correction o crossbites on 4 6 . Correction o lower centreline shi t. Table 6.1 Management options, with indications, or palatally displaced unerupted 3’s* Option Indications Comments Earlyremoval o C’s See comments in the text in relation to interceptive treatment Not a viable option in this case as Diane is 15 years old Retain 3 and observe Patient not keen or treatment Need to monitor radiographicallythe unerupted 3 or cystic degeneration and/or root resorption o incisors Pathologyor resorption o adjacent teeth not evident Good aesthetics/prognosis o C’s or 2 and 4 in good contact 3 severelydisplaced with no associated pathologyevident Surgical exposure o 3’s and orthodonticalignment Highlymotivated patient with excellent general dental health Remove 3 Patient not keen or alignment o 3 and radiographic evidence o associated cystic degeneration Spaced arch or possible to create space; vertical, anteroposterior and transverse position o 3 crown and root avourable Prognosis is good: the nearer 3 is to the occlusal plane, 3 overlaps at most the distal hal o 1 root, when 3 long axis is ≥30° to the midsagittal plane, when root o 3 is not dilacerated or ankylosed or 3 apexis not more distal than 5. Bond gold chain, bracket or magnet to 3 at surgery; alignment o 3 maycommence with removable appliance but fxed appliance required to align 3 apex Prosthetic replacement o Crequired when lost Hopeless prognosis or alignment o 3, 2 and 4 in good contact, or good root length on Cwith good aesthetics, or patient willing to undergo fxed appliance therapyto substitute 4 or 3. Earlyresorption o adjacent teeth Transplant 3 Adequate space in arch or 3 Intact removal o 3 possible Adequate buccal/palatal bone *Mayneed to address anyassociatedTSD. Prognosis best i root o 3 is 50–75% ormed, minimal handling o 3 root at surgery, and rigid splinting is avoided 41 • PALATALCANINES For treatm ent p lanning, Diane shou ld be seen by an orthod ontist, oral su rgeon and restorative colleagu e to d iscu ss m anagem ent of 3’s and 2’s. Orthod ontic alignm ent of 3’s, follow ing their su rgical exp osu re, w as agreed . Bu ild -u p of 2’s m esially w as to p reced e this. Mid -treatm ent, after 3’s w ere across the occlu sion, bu ild -u p of 2’s d istally w as p lanned . Diane, how ever, d ecid ed not to have 2 m esial build -u p s, and the likely effect of this on the nal resu lt w as explained to her. The need for low er centreline correction shou ld be 4 reassessed follow ing crossbite correction on . 4 ■ How would you proceed with treatment? Create space for 3’s alignment. This w ill be obtained by m oving 2 2 slightly m esially. As they are d istally angu lated , m esial tip ping only is requ ired . These m ovem ents, as w ell as palatal m ovem ent of 4 and bu ccal m ovem ent of 6, cou ld be accom p lished easily by u p p er rem ovable ap p liance therapy. Alternatively, a xed ap pliance m ay be u sed for these m ovem ents. ■ Detail the design o a suita ble removable applia nce. Activation Palatal nger springs (0.5 mm stainless steel wire to move 2’s mesially). Buccally approaching spring (0.7 mm stainless steel wire) with ‘u’loop to 4 . Screw section to move 6 buccally. Retention Adams clasps 6 6 (0.7 mm stainless steel wire). Southend clasp 1 1 (0.7 mm stainless steel wire). Anchorage From baseplate. Baseplate Full palatal acrylic coverage. Posterior bite plat orms ~2 mm in thickness to acilitate crossbite correction on 4 6. The acrylic needs to be relieved palatal and occlusal to 4 . ■ What instructions would you give the patient regarding turning o the screw? It should be turned one qu arter tu rn once per w eek (this is ~0.25 m m ). ■ When the crossbites on 4 6 ha ve been corrected, what would you do? Red u ce the posterior capping to half its height at one visit and then rem ove it com p letely at the follow ing visit to allow the p osterior occlusion to settle. It w ould then be ad visable to place an upp er xed appliance u nless this w as placed at the outset for the initial m ovem ents outlined above. A transpalatal arch, attached to band s on 6’s, shou ld be cem ented for anchorage. Brackets should be bond ed to all other up per teeth except 7C C7 and alignm ent continu ed u ntil a 6 rectangu lar stainless steel stabilizing archw ire (0.019 × 0.025-in stainless steel in an 0.022 × 0.028-in slot) can be p laced . Then arrange for surgical exp osu re of 3’s. If tem porary anchorage d evices (TADs), rather than a palatal arch, are u sed for anchorage, these could be p laced at the sam e time as su rgical exp osu re of 3’s. ■ Wha t methods o surgical exposure are there? Three m ethod s exist: 1. Open surgical exposure ollowed by spontaneous eruption. 3 needs to be o correct angulation or this to succeed. 2. Open surgical exposure o 3 with packing. 3. Closed surgical exposure o 3 with attachment bonded during surgery. With op en exp osure, the p alatal m u cosa overlying 3 is excised and a su rgical p ack is sutu red in p lace for 7–10 d ays. Follow ing rem oval of the pack, 3 can be allow ed to erup t for usually u p to 3 m onths before bond ing an attachm ent to comm ence traction. 3 is then aligned orthod ontically above the m u cosa. With closed exp osure, after u ncovering 3, an eyelet attachm ent w ith a gold chain is bond ed to either the bu ccal or palatal asp ect of 3, d ep end ing on ease of access. 3 is then m oved orthod ontically beneath the m u cosa into alignm ent. ■ Wha t is the evidence rega rding open versus closed exposure o palata lly displaced 3’s? A recent m u lticentre rand om ized clinical trial fou nd no d ifference in p eriod ontal health of p alatally d isp laced canines treated w ith an open or closed surgical techniqu e. Su rgical exposu re prod u ced a sm all aesthetic im pact, bu t this d id not d iffer betw een op en or closed techniqu es. Key point Surgical exposure o 3, whether by open or closed technique, has no signif cant e ect on: • Periodontal health. • Dental aesthetics. ■ How may the 3’s be aligned? Elastic traction m ay be ap p lied from the attachm ent bond ed to 3’s to the archw ire (Fig. 6.5) or to a TAD. Light forces (20–60 g) shou ld be used . When m ovem ent of 3’s is evid ent, C’s should be extracted . Once 3’s are close to the line of the arch, a bracket shou ld be bond ed to the m id -bu ccal aspect of each tooth. It is essential that the roots of 3’s are ad equ ately torqu ed to nalize their p ositioning. ■ Wha t actors may you consider or reta ining 3’s in their corrected positions? Asid e from fu ll correction of torqu e, early correction of rotations shou ld be u nd ertaken, follow ed by circum ferential breotom y to 3’s and then the p rovision of a bond ed retainer. 6 • 42 PALATALCANINES beyond the m esial aspect of 2 root, and the root ap ex d oes not go beyond 5 root. 3 crow n lies in the m id to apical third of 2, and the angulation of 3 to the m id sagittal p lane is >30°. ■ What other investigations would you require or treatment pla nning? A lateral cephalogram is required to provid e fu rther inform ation on the skeletal p attern and to assess m ore fu lly the incisor angu lations. Fig. 6.5 Mid-treatment view. ■ What is your interpretation o the ollowing cephalometric f ndings? CASE2 SUMMARY Paula, an 11-year-old girl, presented with 3 unerupted. How will you manage the problem? ■ The intraoral views at presentation are shown in Fig. 6.6 a nd the radiogra phs in Fig. 6.7. Describe what you see. Generalized slight gingival erythema. Caries- ree dentition. 654321 12456 visible. 654321 123456 Moderate lower arch crowding/moderate upper arch crowding with 3 erupting buccally; 2 2 mesiolabially rotated. Class II division 2 malocclusion; deep and compete overbite; upper centreline shi t slightly to the le t. Buccal segment relationship appears to be almost Class I bilaterally; (both, however, were hal Class II clinically). The dental panoramic tomogram and maxillary anterior occlusal radiograph show: Normal alveolar bone height. All teeth including third molars to be present. Caries- ree dentition. 3 palatal; roots o 1 1 appear narrow. SN A = 78°; SN B = 75°; AN B = 3°; SN -Max plane = 7°; MMPA = 22°; 1 to m axillary plane = 99°; 1 to m and ibu lar plane = 88°; interincisal angle = 151°. Relative to Cau casian m ean values, SN A and SN B are red uced bu t w ithin the norm al range. AN B ind icates a Class 1 skeletal pattern, but ap plication of the Eastm an correction, as the SN to Maxillary plane angle, is w ithin the range of 8° ± 3°, ind icating a m ild Class II skeletal pattern (3° + 1.5° = 4.5°; 1.5° arises from half the d ifference of SN A from the average SN A value of 81°). Com p ared w ith Caucasian norm s, the MMPA angle is red u ced ; u p p er and low er incisor inclinations are d ecreased ind icating retroclination. The 1 incisor angle is m ore retroclined than it shou ld be for the MMPA; the 1 incisor angle should be 98° (120° − 22°). The interincisal angle is increased ind icating a d eep overbite. ■ What is your dia gnosis? An 11-year-old girl w ith a Class II d ivision 2 m alocclu sion on a m ild Class II skeletal base w ith d ecreased MMPA. Generalized m ild m arginal gingivitis. Mod erate u pper and low er arch crow d ing w ith 3 u neru p ted and p alatally d isplaced . The up p er centreline is slightly to the left. Bu ccal segm ent relationship is m ild ly Class II bilaterally. ■ What is the IOTN (DHC) grade (see p. 264)? Expla in why. 5i – d u e to the im p acted 3. Treatment ■ What a re your aims o treatment? ■ Wha t risk actor is evident or 3 being pa la tal? Improve oral hygiene. Paula has a Class II d ivision 2 m alocclu sion. Relieve upper and lower arch crowding. ■ Wha t a spects o Class II division 2 malocclusion ha ve been Reduce the overbite. proposed as predisposing to this risk? Class II d ivision 2 m alocclu sion has a strong genetic linkage and is associated w ith m u ltip le d ental anom alies inclu d ing palatal 3. The anterior transverse w id th of the u pp er arch, especially in the canine/ rst p rem olar area, is w id er in Class II d ivision 2 m alocclu sion than in other m alocclu sions and afford s 3 greater scop e to w and er in the anterior m axilla. In ad d ition, d u e to their retroclination, the gu id ance to 3 provid ed by the root of 2 is lacking. ■ Is the position o 3 a vourable or orthodontic alignment? The position of 3 is reasonably favou rable for alignm ent (see Table 6.1). The crow n of 3 only extend s m arginally Align the arches, including 3. Correct the upper centreline. Correct the molar and incisor relationships to Class I. Retain and monitor third molars. Pau la and her m other w ere keen on avoid ing extraction of any p erm anent teeth, if possible. ■ How would you relieve lower and upper arch crowding? In Class II d ivision 2 m alocclusion, a non-extraction approach is favou red (see Chapter 12). Fitting an u p per removable ap pliance w ith a at anterior bite plane w ou ld free the anterior occlu sion and allow the low er incisors to 43 • PALATALCANINES A B C D E Fig. 6.6 (A) Anterior occlusion at presentation. (B) Right buccal occlusion. (C) Le t buccal occlusion. (D) Upper occlusal view. (E) Lower occlusal view. A B Fig. 6.7 (A) Dental panoramic tomogram at presentation. (B) Upper anterior occlusal radiograph. 6 6 • 44 PALATALCANINES p rocline unrestrained by the u p p er incisors. This w ill p rovid e som e space for relief of low er arch crow d ing, bu t the alignm ent of the teeth w ill require a xed appliance. As a non-extraction approach is being ad opted in the low er arch, a sim ilar strategy shou ld be consid ered for the u pper arch. ■ How could you create space or 3 a lignment? This w ou ld involve d istalizing the u p p er rst p erm anent m olars initially follow ed by retraction of the p rem olars to op en sp ace for 3. This cou ld be accom p lished by head gear, TADs or head gear in com bination w ith a rem ovable (Ten H ove ap p liance; Fig. 6.8A) or xed ap p liance (Fig. 6.8B). ■ When should 3 be surgically exposed? The typical treatm ent sequ ence w ou ld be to rstly create space for 3 and then to organize for su rgical exposu re of 3, follow ed by a 2–3-m onth p eriod to allow 3 eru p tion p rior to the app lication of traction to align 3. H ow ever, in this case, as no extractions are p lanned for the u p per arch, it w ou ld be bene cial to have 3 su rgically exposed at the start of treatm ent so 3 can then eru p t w hile other asp ects of the treatm ent are p rogressing. Op en or closed exp osure shou ld be d iscussed w ith the surgeon. ■ What procedure would you pre er? Cu rrent evid ence ind icates that it is a m atter of personal preference w hether to u se an op en or closed su rgical techniqu e. In this case, after d iscu ssion betw een the orthod ontist and oral su rgeon, open exp osure w as favoured . ■ How may 3 be brought across the occlusion? When su f cient sp ace has been created for 3 and a m inim u m of an 0.018-in stainless steel archw ire has been in place (assu m ing an 0.022 × 0.028-in slot), orthod ontic traction m ay be ap p lied to 3 either by an au xillary w ire attached over the base archw ire or by elastic chain (Fig. 6.9A). The form er involves ‘p iggy-backing’ an 0.012-in or 0.014-in nickel–titanium archw ire on an 0.018-in stainless steel w ire, or one of greater d im ensions. It w ill also be necessary to d isengage the occlu sion to allow 3 to be free of occlu sal interference d u ring m ovem ent across the low er arch. This can be achieved by one of the follow ing short-term m easu res: p rovision of a low er rem ovable app liance w ith buccal cap ping of 2–3 m m to ‘clip over ’ the low er xed ap p liance; bond ing of glass ionom er cem ent to the occlu sal su rfaces of the rst p erm anent m olars or bond ing of stainless steel ‘bite turbos’ to the palatal aspect of the u p p er central incisors (Fig. 6.9B). The last option given is the m ost favourable in this case as it d oes not com prom ise overbite red u ction. A A B Fig. 6.8 (A) Upper occlusal view showing space created by distalization o 6’s by Ten Hove appliance and headgear. (Note: 3 erupting ollowing open surgical exposure). (B) Le t buccal view showing space or 3 then being created by retraction o 4 with elastomeric chain as urther space is opened with nickel titanium coil spring. (Note anchorage was supported by maintenance o headgear wear at night-time). B Fig. 6.9 Upper occlusal views: (A) showing elastomeric traction to 3 with bite turbos bonded palatal to 1 1; (B) with 3 moved across the occlusion. 45 • PALATALCANINES ■ What are the adva ntages o nickel–titanium a rchwires in 3 alignment? N ickel–titaniu m archw ires offer greater exibility and greater resistance to d eform ation than stainless steel archw ires. Fu rtherm ore, even if the archw ire is d e ected several m illimetres, as in this case to engage the attachm ent on 3, a light force is app lied w ithou t d eforming the w ire. ■ What type o retainer would you consider? A low er bond ed retainer from 3 to 3 and an u p p er bond ed retainer from 2 to 2 should be placed in view of the planned p roclination of the low er labial segm ent and the initial rotations on 2 and 2. This shou ld be supp orted by provision of an u pp er H aw ley retainer w ith a at anterior bite plane to be w orn at night only and a low er vacu um form ed retainer also to be w orn at night only; both of these retainers should t over the xed retainers. The occlu sion follow ing alignm ent of 3 is show n in Fig. 6.10. Primary resources and recommended reading Flem ing PS, Sharm a PK, DiBiase AT 2010 H ow to … m echanically eru p t a p alatal canine. J Orthod 37:262–271. H id algo Rivas JA, H orner K, Thiru venkatachari B et al 2015 Develop m ent of a low -d ose p rotocol for cone beam CT exam inations of the anterior m axilla in child ren. Br J Rad iol 1054:20150559. A H u sain J, Bu rd en D, McSherry P 2010 Managem ent of the p alatally ectop ic m axillary canine. Faculty of Dental Su rgery of the Royal College of Su rgeons of England . Available at: http :/ / w w w.rcseng.ac.u k/ fd s/ p u blications-clinicalgu id elines/ clinical_gu id elines/ ind ex.htm l. Isaacson KG, Thom AR, Atack N E et al 2015 Orthod ontic Rad iograp hs: Gu id elines, 4th ed . British Orthod ontic Society, Lond on. Kokich VG, Sp ear FM 1997 Guid elines for m anaging the orthod ontic-restorative p atient. Sem in Orthod 3:3–20. N oar J, Pabari S 2013 Cone beam com pu ter tom ograp hy – current u nd erstand ing and evid ence for its orthod ontic app lications? J Orthod 40:5–13. B Othm an SA, H arrad ine N W 2006 Tooth-size d iscrep ancy and Bolton’s ratios: a literatu re review. J Orthod 33:45–51. Parkin N , Benson P 2011 Cu rrent id eas on the m anagem ent of p alatally d isplaced canines. Fac Dent J 2:24–29. Parkin N , Furness S, Shah A et al 2012 Extraction of p rim ary (baby) teeth for u neru p ted p alatally d isp laced p erm anent canine teeth in child ren. Cochrane Database Syst Rev Issue 12. Art. N o.: CD004621, DOI:10.1002/ 14651858.CD004621.pu b3. Parkin N A, Milner RS, Deery C et al 2013 Period ontal health of p alatally d isp laced canines treated by op en or closed su rgical techniqu e: a m u lticenter, rand om ized controlled trial. Am J Orthod Dentofacial Orthop 144:175–184. C Fig. 6.10 Post treatment. (A) Right buccal occlusion. (B) Anterior occlusion. (C) Le t buccal occlusion. 6 Parkin N A, Freem an JV, Deery C et al 2015 Esthetic ju d gem ents of p alatally d isp laced canines 3 m onths postd ebond after surgical exp osu re w ith either a closed or an op en technique. Am J Orthod Dentofacial Orthop 147:173–181. For revision, see Mind Map 6, page 226. 7 More canine problems 654321 1 7654321 12 visible with 3 erupting mesial o 2 . Uncrowded upper and lower arches: space mesial to 3 ; 2 bodily displaced lingually and tilted distally; 3 rotated distobuccally; space between 11; Class I incisor relationship. Molar relationship is slightly Class III; 3 in crossbite with 2 . ■ What do you notice in Fig. 7.2? Mild marginal gingival erythema related to most teeth, more marked interproximally. 654C21 12 visible with 4 erupted orward o 3 and 654321 123 displaced palatally. Moderate lower and upper arch crowding; mesiopalatal rotation o 3 ; distopalatal rotation o 2 ; mesiolabial rotation o 1 . Class I incisor relationship. CASES1 AND2 SUMMARY Two similar ca nine-related problems are shown. What is the cause o each, and how may they be managed? ■ Wha t do you notice in Fig. 7.1? Fair oral hygiene with marginal gingival erythema related to several teeth. A B Fig. 7.1 (A) Case 1 at presentation: right buccal occlusion. (B) Case 1 at presentation: lower sectional occlusal view. Molar relationship is Class I (4 was in buccal crossbite with 4 ). ■ What is the term used to describe the anomaly in position o the ca nine teeth? How common is this? The term u sed is transposition (positional interchange of tw o ad jacent teeth or tooth d evelopm ent/ erup tion in a position normally occu pied by a non-ad jacent tooth). In the general population, prevalence remains u nd er 1% bu t varies accord ing to the sam ple investigated . A B Fig. 7.2 (A) Case 2 at presentation: right buccal occlusion. (B) Case 2 at presentation: upper sectional occlusal view. 47 • MORECANINEPROBLEMS ■ Which arch and which teeth are a ected mostly? Is there a gender di erence in incidence? Table 7.1 Factors to consider in treatment planning or transposition Factor(s) Reason(s) Transp osition is m ore com m on in the u pp er arch, w here it m ost com m only affects the canine and rst p rem olar, follow ed by the canine and lateral incisor. In the low er arch, it seem s to affect exclu sively the canine and lateral incisor. The left sid e seem s to be favoured in the u pper arch and the right sid e in the low er arch. A fem ale p red ilection has been highlighted in som e stud ies, w hereas others have ind icated either no d ifference in gend er p revalence or a m ale pred ilection. Underlying malocclusion, acial aesthetics, degree o crowding These will in uence need or extraction(s) Stage o dental development and position o root apices When root development is complete, interception (by extraction o primaryteeth) is unlikelyto lead to spontaneous improvement in tooth position ■ What is the aetiology o this anomaly? Dental morphology I transposition is to be maintained, reshaping is necessaryto disguise or incorrect tooth position Althou gh several theories have been p rop osed – interchange of d evelop ing tooth bu d s, altered eru p tion paths, presence of retained p rim ary teeth, trau ma – the aetiology is now su ggested to be m u ltifactorial w ith involvement of comp lex relationship s betw een genetic and environm ental factors. There is evid ence of associated gend er pred ilection, hypod ontia, p eg-shap ed m axillary lateral incisors and retained prim ary teeth. Occlusal considerations Judicious grinding o the palatal cusp o a maxillary frst premolar will be required where it is aligned in the canine position Key point Transposition: • In maxilla: more commonly a ects 3 and 4 than 3 and 2. • In mandible: a ects 3 and 2 almost exclusively. • Prevalence: less than 1%. • Aetiology: genetic and environmental. With complete transposition and root apices closed, acceptance o transposition maybe best due to the root resorption and periodontal risks (e.g. gingival recession, alveolar dehiscence) involved in correction Key point Management options or transposition: • Intercept. • Accept/tooth reshaping. • Extract most displaced tooth. • Align orthodontically: consider relative position o root apices. ■ How would you ma nage Ca se 1 and Case 2? ■ Could you classi y this anomaly? The transposition may be partial or comp lete, the ap ices of the affected teeth being transposed in the latter. ■ What actors would you consider in treatment? These are given in Table 7.1. ■ What are the trea tment options? These are as follow s: Interceptive treatment: i detected early (on average, between 6 and 8 years o age), extraction o primary teeth may be undertaken in an attempt to guide the transposed teeth to their normal positions while ensuring that space is maintained by either an upper removable appliance/palatal bar or lingual arch. This approach is only possible where the teeth a ected are tilted so their roots are near the desired positions (sometimes called pseudotransposition). Acceptance: especially i transposition and root ormation are complete, ollowed by reshaping o incisal/occlusal sur aces and/or composite additions to camouf age or tooth position. Extraction o the most displaced tooth: this strategy has been recommended where the arch is crowded or or caries; appliance therapy may be required therea ter. Orthodontic alignment: whether the a ected teeth are aligned in their transposed positions or whether these are corrected, depends on the relative position o the root apices. Requ est a p eriap ical rad iograp h of the transp osed teeth to d eterm ine p osition of the root ap ices. • Case 1: this indicated that the apex o 2 was slightly ahead o the long axis o 3 ; root ormation was nearing completion. No root resorption was observed. • Case 2: this indicated that hal the root length o C was remaining; root apices o 4 were marginally ahead o 3 root; no root resorption was visible. Treatm ent options are to align the transposed teeth in their transp osed position or to correct the transp ositions. • Case 1: in view o the relation o the 2 apex to the 3 root, it was decided to proceed with orthodontic alignment, correcting the transposition. • Case 2: a periodontal specialist’s opinion deemed that as 4 was quite markedly palatal (almost in line with the palatal cusp o 5 ), there was adequate alveolar bone to align 3 in its correct position without risk o gingival recession/alveolar dehiscence. To encourage 3 to move mesially, C was removed initially and an upper removable space maintainer was tted. It was decided to commence treatment on a non-extraction basis and to review need or extractions based on urther cephalometric evaluation o pro le and incisor inclinations when the arches were aligned. ■ What appliance type will be required? Explain why. Fixed ap p liance therap y is ind icated in both cases in view of the need for bod ily m ovem ent. These are: Case 1: the 7 7 • 48 MORECANINEPROBLEMS A A B Fig. 7.4 (A) Pre-treatment ollowing surgical exposure o 3. (B) Following xed appliance alignment accepting the transposed positions o 3 and 2. B Fig. 7.3 (A) Case 1 ollowing xed appliance alignment. (B) Case 2 ollowing xed appliance alignment. CASE3 SUMMARY positions of 3 and 2 to be corrected ; rotational correction of 3 ; sp ace closure. Case 2: p ositions of 43 to be corrected ; rotational correction of 321 ; correction of incisor relationship; space closu re. In Case 1, the u pp er arch also required xed ap pliance therap y to close the m ed ian d iastem a. In Case 2, the low er arch requ ired xed ap pliance alignm ent. ■ How would you check that the positions o the corrected transposed teeth are optimal? Palpate the labial/ bu ccal su lci for root p osition of the corrected teeth (Case 1: 3 and 2 ; ad d itional labial crow n torqu e m ay be requ ired in a rectangu lar steel or TMA archw ire to m axim ize root p ositions; Case 2: 4 and 3 ; ad d itional bu ccal root torque m ay be required to 4 and palatal root torqu e to 3 in rectangu lar steel or TMA w ires for m axim u m correction). Take a periapical radiograph to check root alignment and any root resorption o the corrected teeth. Check unctional occlusion, lateral and protrusive movements, to ensure no occlusal inter erences. The occlusion ollowing xed appliance alignment or Case 1 and Case 2 is shown in Fig. 7.3A and B, respectively. An example o a case where the transposition o 3 and 2 was accepted is shown in Fig. 7.4. Adrienne, an 11.5-year-old girl, presents with mobile 2’s and C’s with 3’s unerupted and not palpable buccally (Fig. 7.5). You order a dental panoramic tomogram and upper anterior occlusal radiograph. ■ What do you notice in Fig. 7.5? Mild marginal gingival erythema. 654C21 12C456 654321 123456 . Attrition o C’s. Uncrowded upper and lower arches. Class I (tending toward Class III) incisor relationship. Molar relationship Class I bilaterally. ■ Why are radiographs requested? To localize the position of the unerup ted 3’s and to d eterm ine the cau se of m obility of 2’s. ■ What do you notice on the radiographs (Fig. 7.6)? Normal alveolar bone height. All permanent teeth present except or third molars; all erupted permanent teeth appear to be caries- ree with possible exception o 6. 49 • MORECANINEPROBLEMS 7 ■ Wha t is the most likely ca use o root resorption o the incisors? It is probably cau sed by a com bination of inherent pressure d u e to m igration of the d isp laced , eru p ting canines and their p hysical contact w ith the incisor roots. ■ Wha t is the incidence o root resorption o 2’s by ectopic 3’s? What sites a re most commonly a ected? Is there a gender predilection? Depend ing on the m od ality of d iagnosis and pop ulation samp led , an incid ence of betw een 12% and 68% has been reported , w ith the apical and m id d le third s of the incisor roots m ost com m only affected . It is m ore com m on in fem ales. A ■ How accura te is the in ormation rega rding resorption o 2’s rom the ra diogra phs? B Fig. 7.5 (A) Case 3 at presentation: right buccal occlusion. (B) Case 3 at presentation: le t buccal occlusion. Due to su p erimp osition of the m alp ositioned canine, esp ecially w hen it is bu ccal or palatal to the incisor root, the true extent of the inju ry may be obscu red . If, how ever, the angu lation of 3 to the m id line is greater than 25°, the risk of incisor resorp tion increases by 50%. Even w ithout overlap ping teeth, intraoral rad iographs m ake it d if cu lt to d etect resorp tion on the p alatal sid e. Key point Incisor resorption by an ectopic maxillary canine: • Has an incidence o 12 68%. • Is more common in emales. • Risk increases by 50%, i angulation o 3 to the midline is greater than 25°. A ■ How may more detailed in ormation regarding 2’s resorption be obtained? Cone beam com p u ted tom ograp hy (CBCT; see p. 38) has proved u seful. Key point Detection o incisor root resorption may be: • Di cult on conventional radiographs. • Facilitated by CBCT. ■ Wha t other investigations would you do in relation to 2’s? B Fig. 7.6 (A) Case 3 at presentation: dental panoramic tomogram. (B) Case 3 at presentation: upper anterior occlusal radiograph. Sensibility tests and period ontal assessm ent (pocket d epths/ bleed ing on probing/ attachm ent loss) should be u nd ertaken. It w ould also be w ise to enqu ire regard ing bru xing habits. Both 2’s w ere vital on electric p ulp testing; asid e from m ild bleed ing on p robing consistent w ith slight m arginal gingivitis, no period ontal p ocketing of >2 m m or loss of attachm ent w as noted ; no bruxing habits w ere rep orted . Root resorption o C21 2C with less than hal the root length o 2 remaining; slight pipette root morphology o 1 and apical curvatures developing on 5 45. ■ Wha t are the treatment options in rela tion to 2’s? 3’s palatally positioned (3 much more so than 3 by parallax; see p. 7 and p. 38). A ccept and monitor: this is not ad visable as the resorption of 2’s is likely to w orsen d u e to p resence of 3’s im pinging on 7 • 50 MORECANINEPROBLEMS their roots. Sw ift intervention is requ ired as the p rogression of incisor resorp tion can be rap id . Extraction o C2 2C: both 3’s may erupt spontaneously, or 3 may erupt and 3 may require surgical exposure. In view o the lack o upper arch crowding, it would be di cult to then close the upper labial segment spacing by xed appliance therapy without creating a reverse overjet; opening space or the lateral incisors, to be replaced with resin-retained bridges or by implants at a later stage, would likely be a better option. Extraction o C’s and surgical exposure o 3’s: orthodontic alignment by xed appliance therapy would then be required; lower arch xed appliance therapy may also be required to detail the occlusion. There is a risk of fu rther root resorp tion to 2’s by aligning 3’s; how ever, if this occu rs and p rognosis of 2’s is d eem ed hopeless, retaining 2’s for as long as p ossible w ill p reserve alveolar bone for possible im p lant p lacem ent later. Otherw ise 2’s may be rep laced on resin-retained brid ges. After d iscu ssion w ith Ad rienne and her m other, they d ecid ed to p roceed w ith the last op tion. They w ere both w arned in relation to the p ossible resorp tion risk to several other teeth d u e to their root m orp hology. Fig. 7.7 Case 3: upper anterior occlusal radiograph mid-treatment. Key point Swi t intervention is required or incisor resorption by an ectopic 3. ■ How would you minimize a nd monitor resorption o the upper incisors during orthodontic treatment? This is d ealt w ith on p age 120. ■ What is the short- to medium-term prognosis o 2 with the markedly resorbed root? From the lim ited evid ence available in the literatu re, this shou ld be reasonable. In a Sw ed ish stu d y, even in cases of severe resorption, the incisor roots show ed good healing w hen assessed at a m ean tim e of 3.5 years (range 2–10 years) after treatm ent w ith xed ap p liances. Su ch healing w as observed in m ost cases after m anagem ent of the ectop ic canine, either by surgical exp osu re and orthod ontic alignm ent or by su rgical rem oval. The resorbed incisors w ere incorporated in the orthod ontic ap pliance system , and end od ontic treatm ent w as not ind icated to arrest further root resorption. Key point Severely resorbed maxillary incisors: • May heal a ter management o the associated ectopic canine. • May be incorporated in an orthodontic appliance. • Do not require endodontic treatment to arrest urther root resorption. Fig. 7.8 Case 3: occlusal view ollowing surgical exposure o 3’s and during xed appliance alignment. exposu re and xed ap pliance alignm ent of 3’s (Fig. 7.8). There w as m inor fu rther resorp tion of the other u p p er incisors. Primary resources and recommended reading Alqerban A, Jacobs R, Lam brechts P et al 2009 Root resorp tion of the m axillary lateral incisor cau sed by im p acted canine: a literatu re review. Clin Oral Investig 13:247–255. Bjerklin J, Bond em ark L 2008 Ectop ic m axillary canines and root resorption of ad jacent incisors. Does com p u ted tom ograp hy (CT) in u ence d ecision-m aking by orthod ontists? Sw ed Dent J 32:179–185. Ciarlantini R, Melsen B 2007 Maxillary tooth transp osition: correct or accep t? Am J Orthod Dentofacial Orthop 132:385–394. Ely N J, Sherriff M, Cobourne MT 2006 Dental transp osition as a d isord er of genetic origin. Eu r J Orthod 28:145–151. Falahat B, Ericson S, Mak D’Am ico R et al 2008 Incisor root resorp tion d u e to ectop ic m axillary canines: a long-term rad iograp hic follow -u p. Angle Orthod 78:778–785. Peck S, Peck L 1995 Classi cation of m axillary tooth transp ositions. Am J Orthod Dentofacial Orthop 107:505–517. Rad iograp hic follow -u p d u ring treatm ent (Fig. 7.7) show ed m inim al change in 2 root resorption after surgical For revision, see Mind Map 7, page 227. 8 In raoccluded primary molars inform ed . To red uce exposure, m ore frequ ent cleaning of the su rgery w ith a p rotein w ash and changing of the air lters is recom m end ed . Latex-free prod u cts shou ld be kept separately in a screened area aw ay from latex prod u cts. Em ergency d ru gs and resu scitation equ ip m ent shou ld also be latex-free. Sp eci cs regard ing orthod ontic m anagem ent are su m m arized in Ap pend ix 4. Fortu nately, Aileen w as d eem ed not to requ ire any speci c p recau tions. Dental history She is a regu lar attend er at the fam ily’s general d ental practitioner. N o d ental treatm ent has been requ ired to d ate. Family history Aileen’s m other has several p erm anent teeth m issing, and these have been replaced by brid gew ork. SUMMARY Examination Aileen is 11 years old. She is re erred by her general dental practitioner or in raoccluded lower primary molars (Fig. 8.1). What is the cause, and how would you treat it? Extraoral examination History Aileen has a m ild Class II skeletal pattern w ith average FMPA and no facial asym m etry. The lip s are incom p etent w ith the low er lip lying at the incisal ed ges of the u pper incisors. There are no tem p orom and ibular joint signs or sym ptom s. Complaint Intraoral examination Aileen is unconcerned by the p osition of her back teeth. Soft tissu es of the tongu e, oor of m outh, palate/ oropharynx and the oral m u cosa are healthy. The intraoral view s are show n in Figs 8.1 and 8.2. History o complaint Aileen and her m other w ere u naw are of any problem w ith her m olars u ntil this w as brou ght to their attention recently by their general d ental p ractitioner. There is no d iscom fort associated w ith these teeth and they are not loose. Medical history Ap art from a possible latex allergy, Aileen is t and w ell. ■ What implications does this have or her mana gement? Aileen shou ld be referred to a clinical im m u nologist, allergist or d erm atologist for testing. If a latex allergy is conrmed , the clinical team and rad iograp hers shou ld be ■ What do you see? Plaque deposits on many teeth with associated marginal gingival erythema. Dentition appears caries- ree; ssure sealants are present occlusally in the rst permanent molars. 6E4321 1234E6 6E4321 1234E6 erupted. Uncrowded lower labial segment; E E in raoccluded; uncrowded upper arch. Mild Class II division 1 incisor relationship (overjet is 4.5 mm measured clinically); overbite slightly increased and complete. Lower centreline to the right. First molar relationship: right hal unit Class II with 6E in crossbite; le t Class I. ■ What is the prevalence o in ra occlusion o primary molars? Betw een 1% and 9% of child ren seem to be affected , bu t p revalence estimates vary. ■ What is the a etiology o in raocclusion o prima ry molars? Is it linked to any other anomalies? Fig. 8.1 Lower occlusal view at presentation. Cu rrent ep id em iological evid ence su ggests a genetic link and an association w ith p alatally d isplaced canines (see Chap ter 6), ectopic erup tion of rst perm anent m olars (see Chap ter 1) and absent p rem olars. 8 • 52 INFRAOCCLUDEDPRIMARYMOLARS Investigations ■ What investigations would you undertake? Explain why. Clinical A B Assess: 1. Mobility o –E’s i these are mobile, this tends to indicate that they are close to ex oliation and that the permanent successors are present. 2. Extent o in raocclusion o –E’s i these teeth are in danger o submerging below gingival level, their removal is indicated. 3. I –E’s are ankylosed typically a ‘tin-can’sound is audible when the occlusal sur ace is percussed with the stainless steel handle end o a dental mirror and the sound compared with that obtained rom percussion o adjacent ully erupted teeth. 4. Overeruption o opposing teeth this could lead to inter erences in unctional occlusion and present di culties i prosthetic replacement o –E’s spaces is required in the absence o 5’s. Key point – With in raoccluded E’s, assess: – • Mobility o E’s. • Extent o in raocclusion. – • I E’s are ankylosed. • Overeruption o opposing teeth. • I 5’s are present. C Radiographic 1. D Fig. 8.2 (A) Upper occlusal view. (B) Right buccal occlusion. (C) Anterior occlusion. (D) Le t buccal occlusion. ■ Why does in raocclusion o prima ry molars occur? Separate phases of resorption and repair occu r in the exfoliation of p rim ary teeth. Althou gh resorp tion p red ominates in m ost cases, som etim es rep air p revails tem p orarily lead ing to ankylosis of a p rim ary m olar. As alveolar grow th and eruption of the ad jacent teeth continu e, the tooth infraocclu d es. Key point In raocclusion o a primary molar is due to ankylosis o the tooth while alveolar growth and eruption o the adjacent teeth continues. A dental panoramic tomogram to determine i unerupted teeth are present, in normal developmental position and o normal orm and size. 2. A lateral cephalometric radiograph may be required later i xed appliance therapy is planned and the patient is keen to proceed. It would allow more accurate determination o the skeletal pattern in the anteroposterior and vertical dimensions and or the incisor inclinations to be assessed. – Both E’s w ere fou nd to be non-m obile and w ere not infraocclu d ed below gingival level, bu t clinically both w ere ankylosed . ■ The dental panoramic tomogram is shown in Fig. 8.3. What are the f ndings o note? • • • • Dental development corresponds with chronological age. Extensive resorption o the roots o E’s; short roots on –E’s. Absent 5’s and all third molars. Absence o periodontal ligament space related to E E. ■ What is the prevalence o hypodontia in the permanent dentition? Which teeth and gender does hypodontia a ect most commonly? A recent system atic review found the prevalence of hypod ontia in the perm anent d entition to be around 6% w ith a 53 • INFRAOCCLUDEDPRIMARYMOLARS Fig. 8.4 Fixed appliances. Fig. 8.3 Dental panoramic tomogram. Treatment ■ Wha t treatment options are there or the lower arch? signi cant d ifference betw een continents; it is highest in Africa (~13%) and low est in Latin Am erica (~4%), w ith a prevalence in Eu rop e of 7%. In Cau casians, third m olars are m ost com m only affected (20–30%) follow ed by 5 (3%), then 2 (2%) and 5 (less than 2%). Fem ales are affected m ore than m ales, and tooth size in the rem aind er of the d entition tend s to be red uced . Key point Hypodontia: • Prevalence: ~6% in permanent dentition and di ers signif cantly by continent. • Frequency: 8’s, then 5, 2, 5. • Females more than males. Follow ing p erusal of the p anoram ic tom ogram and preliminary d iscussion of treatm ent options w ith Aileen and her m other, a lateral cep halom etric rad iograp h w as taken. Analysis revealed the follow ing: SN A = 82°; SN B = 76.5°; AN B = 5.5°; 1 to m axillary p lane = 112°; 1 to m and ibular plane = 92°; MMPA = 26°; facial prop ortion = 55%. ■ What do these values tell you (see p. 270)? They con rm the clinical im p ression of a m ild Class II skeletal p attern w ith average FMPA. Incisor inclinations to their u nd erlying d ental bases are also w ithin the norm al range. Diagnosis ■ What is your diagnosis? Mild Class II division 1 malocclusion on a mild Class II skeletal base with average FMPA. Generalized marginal gingivitis, uncrowded lower arch with –’s. in raoccluded E Uncrowded upper arch. First molar relationship right hal unit Class II with 6E in crossbite; le t Class I. Hypodontia o 5’s and third molars. ■ What is the IOTN (DHC) gra de (see p. 264)? Explain why. 4h – d ue to absent 5’s . Expla in why. In view of the lack of crow d ing: 1. Accept the position and status o E E, realizing their poor long-term prognosis due to the short root length, but build up E E with occlusal onlays in composite to bring them into occlusion. This procedure has been shown to improve longevity o in raoccluded molars. Maintaining E E rather than extracting them also preserves alveolar bone. When eventually they are lost, resin-bonded or conventional bridgework or implants may be used to replace the missing units. Aileen and her mother would need to be aware o the implications o this treatment proposal over the li etime o the dentition, including the need or replacement o any prosthesis as required. 2. Extract E E in view o their poor long-term prognosis and as in raocclusion is likely to progress with the absence o 5’s. Then, close the extraction spaces with a lower xed appliance. This has the advantage o removing the need or a prosthesis, but a retainer would need to be worn post-treatment or several years at night to minimize the likelihood o space opening. Alternatively bonded retainers could be placed on the buccal aspects o 6 4 4 6 to maintain space closure. ■ Wha t implications do these options have or the upper arch? I –E’s are retained, the slight overjet increase could be accepted as the teeth are aligned, provided the patient is in agreement. I –E’s are to be extracted and a lower xed appliance planned, it would be sensible to resort to an upper premolar extraction on either side in the upper arch (probably 5’s in view o the small overjet and absence o crowding, although it will be necessary to await their eruption) and proceed to xed, appliance therapy to achieve Class I molar and incisor relationships. Following several visits to the hygienist, Aileen’s oral hygiene improved, and having considered all options, she decided to proceed with xed appliance therapy (Fig. 8.4). ■ What type o f xed a ppliance is shown in Fig. 8.4? Wha t means a re there to close premolar extraction spaces with this a ppliance type? What method is most e ective? This is a p re-ad ju sted ed gew ise ap pliance. Space closing slid ing mechanics w ith this app liance m ay be u nd ertaken 8 8 • 54 INFRAOCCLUDEDPRIMARYMOLARS A Fig. 8.5 Another case with Ni-Ti coils used or the closure o premolar extraction spaces. in each qu ad rant by one of the follow ing m ethod s, each of w hich is attached from the rst m olar band hook to the hook on the canine bracket or to a sold ered hook on the archw ire (so-called p osted archw ire): • Polyurethane powerchain narrow spaced polyurethane powerchain is stretched to about double its resting length. • Active ligatures a grey elastic module is stretched by a ligature to double its resting length (otherwise known as a Berman ligature). • Nickel-titanium (NiTi) springs attached as or the active ligatures (Fig. 8.5). A force of 100–200 g has been recomm end ed . Class II elastics m ay also be u sed to assist w ith closure of upper and low er p rem olar extraction sp aces. A rand om ized clinical trial com p ared the three op tions listed above. The m ost rap id rate of sp ace closure w as achieved w ith N iTi sp rings and w as consid ered the treatm ent of choice. Elastic chain, how ever, w as as effective and is cheaper. The ad d ition of Class II elastics d id not seem to affect the rate of sp ace closu re. – The occlu sion follow ing rem oval of E E, then 5 5 and E’s and xed app liance therap y is show n in Fig. 8.6. ■ I 5’s had been present radiographically, what would have been your treatment plan? – Ankylosis of E’s is likely to be tem porary w hen perm anent – successors exist, and E’s should exfoliate w ithin a norm al – time fram e. The p osition of E’s should be m onitored until then, and if the infraocclu sion p rogresses, extraction is rec– omm end ed , particu larly if the crow n of E m oves to lie below gingival level (reinclu sion) and / or apical closu re is alm ost com plete on 5. Key point Management options or in raoccluded E¯: ¯ to ex oliate. • 5 present, no reinclusion: allow E • 5 present, and reinclusion: extract or surgically ¯. remove E • 5 absent: retain and place onlay: • extract and space close. • extract and prosthetic replacement. B C Fig. 8.6 (A) Post-treatment: right buccal occlusion. (B) Post-treatment: anterior occlusion. (C) Post-treatment: le t buccal occlusion. Primary resources and recommended reading Bjerklin K, Al-N ajjar M, Karested t H et al 2008 Agenesis of m and ibu lar second p rem olars w ith retained p rim ary m olars: a longitud inal rad iograp hic stu d y of 99 su bjects from 12 years of age to ad ulthood . Eu r J Orthod 30:254–261. Dixon V, Read MJF, O’Brien KD et al 2002 A rand om ized clinical trial to com p are three m ethod s of orthod ontic sp ace closu re. J Orthod 29:31–36. H u d son AP, H arris AM, Morkel JA et al 2007 Infraocclu sion of p rim ary m olars: a review of the literatu re. SADJ 62:114, 116,118–122. Khalaf K, Miskelly J, Voge E et al 2014 Prevalence of hyp od ontia and associated factors: a system atic review and m eta-analysis. J Orthod 41:299–316. Ku rol J, Koch G 1985 The effect of extraction of infraocclu d ed d ecid uou s m olars: a longitu d inal stu d y. Am J Orthod 87:46–55. Patel A, Burd en DJ, Sand ler J 2009 Med ical d isord ers and orthod ontics. J Orthod 36:1–21. For revision, see Mind Map 8, page 228. 9 Increased overjet ■ How common is bullying among school children? What in uence do prominent teeth have, and does bullying have any long-term consequences? Using a valid ated m easu re, the prevalence of bullying among 8–18-year-old s in 11 European cou ntries w as found to be 20.6%. In a recent UK stu d y, nearly 13% of child ren aged 10–14 w ho w ere assessed for orthod ontic treatment had been bullied d u e to their m alocclu sion, and bu llying w as signi cantly associated w ith an increased overjet. The negative im pact on self-esteem and oral health–related qu ality of life w as also rep orted by those w ho had been bu llied . Long-term effects of bu llying into ad u lthood have also been review ed and have ind icated im p acts on physical and m ental w ell-being. ■ Wha t is the risk o trauma with an increa sed overjet? For an overjet of 3–4 m m , the risk is d oubled and increases for an overjet of 5–7 m m . SUMMARY Emma, aged 11, is teased at school about her prominent upper ront teeth (Fig. 9.1). What are the possible causes, and how may it be treated? History Complaint Em m a’s u pp er front teeth stick out. H er mother is very concerned abou t her d au ghter ’s ap p earance and is anxiou s for her to be treated . History o complaint The u p per front teeth have alw ays been p rom inent, even w hen the p rim ary incisors w ere p resent. Em m a is teased abou t her teeth at school, and the teasing is u p setting her. She recently fell in the school yard and hit her tw o up per front teeth on the grou nd . Fortu nately there w as only m inimal incisal enam el d amage to 1 1. ■ Wha t is the signif cance o the history o teasing and incisor trauma? It w ou ld be im portant to ascertain the intensity of the teasing and w hether Em m a is bu llied at school abou t her teeth. If so, it w ould be p ru d ent not to d elay treatm ent especially as 1 1 have also suffered trau m a. There is a risk of teeth w ith a history of trau m a becom ing non-vital in the fu ture. This shou ld be assessed before, and m onitored d u ring, any orthod ontic treatm ent. Traum atized teeth also have a greater risk of root resorption d u ring orthod ontic treatm ent. Althou gh su ggested as a risk factor for orthod onticallyind uced tooth reabsorp tion, p reviou s trau m a seem s an u nlikely cau se (see p . 120). Em m a and her m other should be ad vised accord ingly as part of inform ed consent prior to treatm ent. Medical history Em m a has had asthm a since she w as 4 years old . This is m anaged w ith a salbu tam ol inhaler (Ventolin). ■ Is teasing the same as bullying? Teasing is som etim es confu sed w ith bu llying, bu t they are not the sam e. Teasing has been d escribed as am bigu ou s social exchange that m ay be friend ly, neu tral or negative, w hereas bu llying is d em arcated by rep eated aggressive behaviou r or intentional harm over tim e and is characterized by an im balance of p ow er. Key point An increased overjet increases the risk o incisor trauma and may predispose a child to teasing. Examination Extraoral Em m a’s fu ll facial and p ro le view s are show n in Fig. 9.2. ■ How would you assess Emma’s skeletal pattern? Fig. 9.1 Right buccal occlusion at presentation. The skeletal pattern is the relationship of the m and ibular to the m axillary d ental base in all three p lanes of sp ace – anteroposterior, vertical and lateral. Assessm ent shou ld be mad e w ith Em ma seated u p right in the natu ral head position (the p osition in w hich the head is supp orted naturally w hen looking straight ahead at a d istant object); the lip s shou ld 9 • 56 INCREASEDOVERJET 2. Frank ort-mandibular planes angle (FMPA). With a nger along the lower border o the mandible and a ruler placed along the Frank ort plane (lower border o the orbit to the superior aspect o the external auditory meatus), project both o these lines backwards in the imagination to estimate the FMPA. The FMPA is then classi ed as average (both lines intersect at the back o the skull, occiput), reduced (both lines meet beyond occiput) or increased (both lines meet anterior to occiput). A 3. B Fig. 9.2 (A) Full ace view. (B) Pro le. be at rest and the teeth in m axim u m interd igitation. Assessm ent shou ld be as follow s: 1. Anteroposterior. Viewing the so t tissue acial pro le in most cases allows the ollowing classi cation to be made: Class I: the mandible lies 2 3 mm behind the maxilla. ront o chin) acial thirds; this may be increased (Class II; convex pro le), average (12° + 4°; Class I) or reduced (Class III; concave). Emma has a Class II skeletal pattern. Vertical. Lower acial height. The distance rom the mid-eyebrow level to the base o the nose (upper acial height) should equal that rom the base o the nose to the in erior aspect o the chin (lower acial height). The lower acial height is reduced when the latter measurement is reduced, and the converse is true when this distance is increased. Emma has a slightly reduced lower acial height and FMPA. Transverse. Stand directly behind the patient and look down across the ace, checking the coincidence o the midlines o the nose, upper and lower lips and midpoint o the chin. Alternatively assess the ace rom the ront. It is important to note that slight acial asymmetry is common. The location (upper, middle or lower acial third) and extent o any asymmetry should be recorded. Emma’s chin point is marginally to the right. As this is very mild and has not been noticed by her or her mother be ore now, and as a slight degree o acial asymmetry is regarded as normal, there is no cause or concern. No mandibular deviation on closure or temporomandibular signs/symptoms were detected. The lips are habitually competent with the lower lip tending to lie under the upper incisors at rest (Fig. 9.2B). Intraoral ■ The intra oral views are shown in Figs 9.1 a nd 9.3. Wha t do these show? Class II: the mandible lies more than 2 3 mm behind the maxilla. There are plaque deposits on several teeth and overall mild marginal gingival erythema. Class III: the mandible lies less than 2 3 mm behind the maxilla. All teeth appear to be o good quality. Due to variation in lip thickness, this method is not always reliable and palpation o the alveolar bases over the apices o the upper and lower incisors in the midline has been claimed to give a better estimate o skeletal pattern. Two other assessments may also be made: 1. The relationship o the lips to zero meridian (a true vertical rom so t tissue nasion): the upper lip should be on, or slightly ahead, and the chin just behind. 2. The angle o acial convexity o the middle (mideyebrow to base o nose) to lower (base o nose to Emma is in the permanent dentition with 654321123456 present. (Note 7 7 are erupting.) 654321123456 The upper and lower arches are uncrowded. There is a Class II division 1 incisor relationship with increased overjet (measured 7 mm clinically); the overbite is increased and complete. The buccal segment relationship is a hal -unit Class II bilaterally. There is a lingual crossbite (scissors bite) a ecting 4. ■ What a re the causes o an increa sed overjet? These are given in Table 9.1. 57 • INCREASEDOVERJET 9 Investigations ■ What radiographs are indica ted? A d ental p anoram ic tom ogram is requ ired to check the presence, p osition, d evelop m ental stage and any abnorm alities of crow n and root of uneru p ted teeth. Untreated caries should also be noted and bitew ing rad iographs requ ested , if necessary. In view of the history of trau m a to the u pper incisor area, a p eriap ical view or an u pp er anterior occlu sal rad iograp h shou ld be taken and exam ined for p ossible ap ical p athology. A lateral cephalom etric rad iograph is ind icated as there is an anteroposterior and a vertical skeletal d iscrep ancy. In ad d ition, anterop osterior m ovem ent of the incisors is p lanned . The nd ings of the cep halom etric analysis are: SN A = 82°; SN B = 76°; SN to m axillary p lane = 9°; MMPA = 22°; 1 nomenclatu re to m axillary p lane = 114°; 1 to m and ibu lar p lane = 92°; facial p roportion = 52%. A ■ Wha t do these indicate (see p. 270)? ANB value o 6° (SNA minus SNB) indicates a Class II skeletal pattern. Reduced MMPA and acial proportion. Cause Aetiology Relative to m ean Cau casian valu es, the upp er incisors are proclined (bu t w ithin the norm al range) and the low er incisors are slightly retroclined . Although w ithin the norm al range the 1 to m and ibu lar p lane m ust be consid ered w ith the MMPA as there is an inverse relationship betw een the tw o valu es. 1 to m and ibu lar p lane (93°) and MMPA (27°) should total 120° or, alternatively, 1 to m and ibu lar p lane angle shou ld be 120° – MMPA. H ence in this case, the 1 to m and ibu lar p lane angle shou ld be 120° – 22° = 98°. At 92°, it is retroclined . Skeletal pattern Maybe Class I, IIor III ■ Wha t other important in ormation rega rding growth B Fig. 9.3 (A) Anterior occlusion. (B) Le t buccal occlusion. Table 9.1 Causes o an increased overjet I Class II, mandibular defciencyis almost entirely the primarycause but maybe excessive horizontal maxillarygrowth or a combination o the two actors So t tissues* Lower lip lying under the upper incisors to create an anterior oral seal will procline the upper incisors and retrocline the lower incisors (likelyi there is a Class II skeletal pattern, reduced lower acial height and lip incompetence) Hyperactive lower lip will retrocline the lower incisors Primaryatypical swallowing pattern (endogenous tongue thrust) will tend to procline upper (but also lower) incisors Digit sucking habit I present or more than 6 hours out o 24, it will procline upper incisors, retrocline lower incisors, create an anterior open bite and a tendencyto buccal segment crossbite Overjet increase is o ten asymmetrical due to digit positioning Crowding Labial displacement o upper incisors and/or lingual displacement o lower incisors Anycombinationo the above *E ects determined principallybythe skeletal pattern, and therea ter bythe manner in which an anterior oral seal is produced. potential may be obtained rom the lateral cephalometric f lm? How is this assessed? It may also be u sed to d eterm ine skeletal m atu rity. This is assessed by the cervical vertebral m atu ration (CVM) ind ex w hich has ve stages, each w ith m orphological changes in the second , third and fourth cervical vertebrae. The peak in m and ibu lar grow th occu rs betw een CVM stage II and CVM stage III; CVM stage V occurs 2 years after the p eak. ■ How valid and reliable is the CVM index? CVM has been show n to have high valid ity and reprod ucibility. ■ Would you consider a ny other investigations? It w ou ld be w ise to d o sensibility tests of 1 1. These proved p ositive for all tests, w ith no m arked d ifference in record ings betw een teeth. Diagnosis ■ Wha t is the diagnosis? Emma has a Class II division 1 malocclusion on a mild Class II skeletal base with reduced FMPA. 9 • 58 INCREASEDOVERJET There is generalized marginal gingivitis. 1 1 have su ered recent trauma. There is no crowding o the upper and lower arches. The buccal segment relationship is a hal -unit Class II bilaterally with a lingual crossbite o 4. ■ Wha t is the IOTN (DHC) grade (see p. 264)? Explain why. 4a – d u e to overjet >6 m m bu t ≤9 m m. Treatment ■ Wha t actors other than increased overjet predispose to upper incisor trauma? The risk is doubled where the overjet exceeds 9 mm. Lip incompetence due to the absence o lip protection. Gender o the patient trauma than girls. boys experience more upper incisor ■ What are the aims o treatment? gests that earlier treatm ent red u ces the incid ence of incisor trau m a bu t does not offer any other ad vantages com p ared w ith treatm ent in early ad olescence. Em m a has recently su ffered u p per incisor traum a, and starting treatm ent earlier m ay have averted this; how ever, she is still w ithin the scope of the ages d eem ed ‘early treatment’. Although this review rep orted no p sychosocial bene ts of early or later treatm ent, recent longitu d inal d ata from a UK stu d y on bu llied child ren fou nd that intercep tive treatm ent for an increased overjet red u ced the p revalence of bu llying and im p roved oral health–related qu ality of life. ■ What types o unctional appliances are there? Which is the most popular? Fu nctional app liances m ay be classi ed as tooth-borne (e.g. Tw in-Block appliance, m ed iu m op ening activator, H erbst) or soft tissu e borne (e.g. Frankel). The H erbst is a xed fu nctional ap pliance; all others are rem ovable, although the Tw in-Block appliance m ay also be cem ented in p lace. In the UK, the Tw in-Block app liance is m ost p op u lar, bu t the H erbst ap p liance is favou red in N orth Am erica. To reduce the overbite and overjet to establish a Class I incisor relationship. ■ Describe the records you would take to allow abrication o To correct the buccal segment relationship to Class I. The record s required are w ell-extend ed u pper and low er alginate im p ressions as w ell as a w ax registration taken w ith the m and ible postu red forw ard , usu ally to an ed ge-toed ge incisor relationship , the bite op en abou t 8 m m in the p rem olar areas w ith no appreciable shift in the u pper and low er d ental m id lines. This ‘w orking bite’ may be record ed by softening several layers of w ax in w arm w ater, form ing this to a horseshoe shape ind exed rm ly over the u pper teeth and nally gu id ing the m and ible to the correct anterop osterior, vertical and lateral position by checking the relationship of the centrelines and the incisal op ening. Alternatively, layers of w ax m ay be ad apted to a proprietary bite registration fork, w hich has grad u ated m arkings to facilitate assessm ent of the p ostu red m and ibu lar position. The w ax registration shou ld then be chilled , exam ined for ad equ ate d ental registration and re-checked for accuracy in the m outh before forw ard ing w ith the im pressions to the laboratory. Where the overjet is large, the m and ible m ay be ad vanced to 70–80% of m axim um protrusion to facilitate p atient com fort. To correct the crossbite on 4 . 4 ■ Wha t treatment would you advise? Explain why. Em m a’s m alocclu sion shou ld be am enable to correction by grow th m od i cation w ith fu nctional ap pliance therap y. Favou rable features are that Em m a is likely to be grow ing and is ap p roaching the p u bertal grow th sp u rt. The skeletal pattern is m ild ly Class II d u e to m and ibu lar retrusion rather than m axillary protru sion. The arches are u ncrow d ed and aligned ; the low er incisors are slightly retroclined ; the bu ccal segm ent relationship is a half-u nit Class II, so a m od est shift of the arch relationship is requ ired for it to be corrected to Class I. Fu nctional ap pliances are u su ally contraind icated w here the low er incisors are p roclined , as they ind u ce fu rther proclination throu gh generation of Class II interm axillary traction. Follow ing fu nctional ap p liance therap y, xed appliances m ay be requ ired to d etail the occlu sion. It w ou ld be ad visable then to retain the resu lt by night-only w ear of a functional ap pliance u ntil grow th is com p lete. Key point A unctional appliance: • Aims to ‘modi y’ growth. • Is only e ective in growing children, pre erably just prepubertal. ■ Should Emma have been treated earlier? What evidence is available regarding this? A recent Cochrane review com p ared the effects of orthod ontic treatm ent for child ren w ith prom inent upp er front teeth w hen treatm ent is started betw een 7 and 11 years com p ared w ith treatm ent started in early ad olescence. Evid ence su g- a Twin-Block a ppliance? ■ On issuing the Twin-Block appliance, what instructions would you give Emma ? The instructions w ould be as follow s: • The appliance should be worn ull-time, including at mealtimes, rom insertion. The only times it is removed are a ter meals or cleaning and or contact sports, during which times it should be stored in the hard plastic tub provided. • Speaking and eating will be di cult or the rst ew days but will improve i you persevere. • Avoid eating hard or sticky oods or consuming zzy drinks while wearing the appliance as these are likely to damage the appliance and/or your teeth. The appliance and the teeth should be cleaned thoroughly a ter every meal. • Mild jaw discom ort and muscle tenderness are common or the rst ew days but reduce a ter that. It may be 59 • INCREASEDOVERJET • necessary to take a mild analgesic, as required, during this ‘settling-in’period. Should a sore spot develop or there be any breakage o the appliance, you should contact us immediately by telephone to arrange an appointment to have any adjustments carried out. ■ How does a Twin-Block work a nd wha t e ects does it 9 Dentoalveolar (~70–80%) Retroclination o upper incisors/proclination o lower incisors. Promotion o mesial and upward eruption o lower posterior teeth (see below). Distal movement o the upper molars. Upper arch expansion. produce? The Tw in-Block ap p liance consists of u p p er and low er ap pliances incorporating bu ccal blocks w ith interfacing inclined p lanes (at abou t 70°), w hich p ostu re the m and ible forw ard on closu re (Fig. 9.4). This ap p liance w orks by u sing the forces generated by the orofacial m u scu lature, tooth erup tion and d entofacial grow th. The u p p er m id line expansion screw is u su ally ad ju sted once p er w eek by the p atient until the arch w id ths are coord inated w ith the m and ible postu red forw ard in a Class I incisor relationship . In this case, no exp ansion w as requ ired in view of the scissors bite 4 on . The effects are u su ally as follow s: 4 Skeletal (~20–30%) Forward growth o the mandible. Increase in lower anterior acial height. Key point A • • • unctional appliance or Class II correction: Postures the mandible downward and orward. Generates intermaxillary traction. Uses, removes or modif es orces o the oro acial musculature, tooth eruption and dento acial growth. ■ How do the e ects produced by a Twin-Block a ppliance di er rom those o other unctional applia nces? The recent Cochrane review also assessed the effect of orthod ontic treatm ent for p rom inent u p per front teeth w hen u nd ertaken by d ifferent orthod ontic app liances. Fu nctional app liance treatm ent, irresp ective of type, in early ad olescence app ears to prod u ce som e m inor bene cial skeletal changes. When the Tw in-Block w as com pared w ith other ap pliances, there w as no d ifference in overjet, bu t the Tw in-Block p rod u ced a statistically signi cant greater red u ction in AN B, althou gh this w as sm all. There w ere no ad vantageou s effects of other fu nctional app liances com pared w ith the Tw in-Block. ■ Following overjet correction by Twin-Block therapy, wha t occlusa l anomaly is usually mani est posteriorly in the dental arches? A posterior op en bite is u su ally p resent bilaterally d u e to the buccal blocks. ■ How may this be corrected? A B Fig. 9.4 Twin-block appliance. (A) Upper occlusal view. (B) Lower occlusal view. The design is modi ed rom the original developed by Clark. There are three possible m eans available to allow for correction of the posterior open bite by eru ption of the bu ccal segm ent teeth: • The patient may be instructed to proceed to part-time wear o the appliance. • The Adams’clasps on the lower molars may be removed initially and then acrylic trimmed progressively over a period o a ew months, rom the undersur ace o the lower block and the lower sur ace o the upper block, until a posterior occlusion is established. • Wear o the Twin-Block appliance may be ceased and the patient tted with an upper Hawley retainer (Adams clasps 0.7 mm on 6 6, labial bow 0.7 mm 3 to 3) with a ‘steep and deep’anterior inclined biteplane, which aims to maintain overjet correction by posturing the mandible orward while encouraging eruption o the lower buccal segment teeth. Full-time wear o the appliance is required, except or contact sports and teeth cleaning, until a well-interdigitating posterior occlusion is established. Then night-only wear o the appliance, until growth has ceased or until a second phase o treatment commences, is permissible. 9 • 60 INCREASEDOVERJET ■ I there is no progress at 6 months, what action would you take? Lack of overjet correction cou ld be d u e to p oor p atient response to the ap pliance, im p rop er d esign or p oor comp liance. Treatm ent shou ld be d iscontinu ed and a reevalu ation m ad e. The p atient’s stand ing height shou ld be record ed and com pared w ith the pre-treatm ent m easurem ent. This w ill give an ind ication of grow th over the intervening p eriod . Provid ed Em m a rem ains keen for orthod ontic treatm ent, new record s, includ ing a p rogress cep halom etric rad iograp h, shou ld be taken and analysed to allow for a new treatm ent p lan to be d evised . ■ What other treatment options are there? I a design problem with the appliance is identi ed as the cause o lack o treatment progress, then remaking the appliance to incorporate appropriate design modi cations could be undertaken and treatment recommenced. I poor compliance is to blame or no progress, then the reason(s) should be ascertained rom discussion with the child. I lack o motivation or interest in treatment is the cause, it would be prudent to avoid any urther appliance therapy until such time as the child has a change o heart regarding orthodontic treatment. interincisal angle is created. A use ul rule o thumb with tipping movement is that each millimetre o upper incisor retraction approximates to a 2.5° change in angulation. With an original overjet o 7 mm and a target overjet o 3 mm (representing a 4 mm reduction), this would equate to a 10° change producing a nal incisor angulation o 104°. This value is just within the normal range (109° ± 6°), and the incisors would be quite upright. An upper incisor angulation o 95° to the maxillary plane is regarded as the limit or acceptable retraction by tipping movements. ■ What a ctors govern stability o the corrected overjet? For the best p rospects of stability the interincisal angle shou ld be w ithin norm al lim its (135° ± 10°) and the overjet comp letely red uced w ith the incisors in soft tissue balance, i.e. no tongu e thru st and the low er lip covering at least one-third of the labial su rface of the u pp er incisors. A period of retention w ill nonetheless be requ ired , and this shou ld extend u ntil grow th is com p lete follow ing fu nctional appliance therapy. Most p atients, how ever, usu ally p roceed d irectly to a second p hase of xed ap p liance therap y to d etail the occlu sion follow ed by retention. Key point Orthodontic camou age by retraction o the upper incisors into rst premolar extraction spaces, accepting the Class II skeletal pattern. Importantly, this treatment should not be detrimental to acial aesthetics. Although some amount o tipping movement o the upper incisors is permissible, xed appliances would be required to ensure an optimal A ter unctional appliance therapy with or without subsequent f xed appliance therapy: • Ensure the upper incisors are in so t tissue balance and controlled by the lower lip. • Retain until growth is complete. B A C Fig. 9.5 (A) A ter unctional appliance therapy: pro le. (B) A ter unctional appliance therapy: le t buccal occlusion. (C) A ter unctional appliance therapy: anterior occlusion. 61 • INCREASEDOVERJET The p ro le and occlu sion follow ing fu nctional ap p liance therapy are show n in Fig. 9.5. Petti S 2015 Over tw o hund red m illion inju ries to anterior teeth attribu table to large overjet: a m eta-analysis. Dent Trau m atol 31:1–8. Primary resources and recommended reading Seehra J, Flem ing PS, N ew ton T et al 2011 Bu llying in orthod ontic p atients and its relationship to m alocclu sion, self-esteem and oral health-related qu ality of life. J Orthod 38:247–256. Baccetti T, Franchi L, McN am ara JA Jr 2005 The cervical vertebral m aturation (CVM) m ethod for the assessm ent of optim al treatm ent tim ing in d entofacial orthopaed ics. Sem in Orthod 11:119–129. Shah AA, Sand ler J 2009 H ow to … take a w ax bite for a Tw in Block ap p liance. J Orthod 36:10–12. Clark W 2010 Design and m anagem ent of Tw in Blocks: re ections after 30 years of clinical u se. J Orthod 37:209–216. Thiru venkatachari B, H arrison JE, Worthington H V et al 2013 Orthod ontic treatm ent for p rom inent u p p er front teeth (Class II m alocclusion) in child ren. Cochrane Database of Syst Rev Issu e 11. Art N o: CD003452. DOI: 10.1002/ 14651858.CD003452.p ub3. DiBiase AT, Sand ler PJ 2001 Malocclu sion, orthod ontics and bullying. Dent Up d ate 28:464–466. Wolke D, Lereya ST 2015 Long-term effects of bu llying. Arch Dis Child 100:879–885. Flem ing PS, Scott P, DiBiase AT 2007 H ow to … m anage the transition from fu nctional to xed app liances. J Orthod 34:252–259. For revision, see Mind Map 9, page 229. 9 10 Incisor crossbite Examination Extraoral The skeletal pattern is Class I w ith an average FMPA. There is no facial asym m etry. The lip s are com petent. There are no abnorm al tem p orom and ibular joint signs or sym p tom s. Intraoral ■ What eatures are visible on the intraoral views (Figs. 10.1 and 10.2)? SUMMARY Matthew is 8 years old. He presents with an upper incisor in crossbite (Fig. 10.1). What is the cause, and how would you manage it? Oral hygiene is fair. Marginal gingival erythem a is evid ent related to the incisor teeth. There is m arked attrition of C C, w ith cariou s involvem ent of C m esially and D D d istally. With the excep tion of the low er right quad rant w here D has been lost, 6EDC21 are p resent in each qu ad rant. Gingival recession ap p ears to be evid ent on the labial aspect of 1 . 1 is d isp laced labially; the low er arch ap p ears u ncrow d ed . 2 2 are rotated m esiolabially; 1 is d isp laced History Complaint Matthew ’s m other is concerned that her son’s u p p er front teeth are not straight and is anxious for treatm ent to be u nd ertaken soon. History o complaint 1 eru p ted insid e the low er teeth. There is no history of a fall or other trau m a to the prim ary p red ecessor or to 1 . A w as lost over a year ago, a little later than A. A Medical history Matthew is in good health. Dental history D w as extracted uneventfully u nd er local anaesthesia 8 m onths ago. B C Fig. 10.1 Anterior occlusion at presentation. Fig. 10.2 (A) Upper occlusal view. (B) Right buccal occlusion. (C) Le t buccal occlusion. 63 • INCISORCROSSBITE slightly palatally, and there is a sm all m ed ian d iastem a. Otherw ise the u p p er arch app ears uncrow d ed . The incisor relationship is Class I and 1 is in crossbite; 2 is p artially erup ted w ith the d istoincisal aspect in crossbite w ith C . ■ What is the prevalence o anterior crossbite reported in the literature? Dep end ing on the racial grou p , age at assessm ent and if an ed ge-to-ed ge incisor relationship w as inclu d ed or not, the reported p revalence varies from 2.2–11.9%. 10 Key point Where an incisor crossbite is present, check: • Periodontal status o lower incisors. • I an edge-to-edge incisor occlusion is achievable. • I mandibular displacement is present. • Amount o overbite. • Incisor inclination. • Amount o space required or correction. ■ What specif c ea tures would you check? Explain why. 1. 2. 3. 4. 5. 6. The periodontal status o 1 degree o mobility and pocket probing depth associated with 1 should be assessed to determine its prognosis as it is being displaced labially by def ecting occlusal contact (see below) and gingival recession is present. 1 exhibited grade 2 mobility, but probing pocket depth was less than 2 mm, indicating good periodontal prognosis in the event the crossbite relationship is corrected. 1 Is it possible to achieve an edge-to-edge relationship on ? 1 I so, this indicates that only a small amount o labial movement o 1 is required to correct the crossbite 1 relationship. An edge-to-edge relationship o was 1 easily achievable. Is there a mandibular displacement on closure? I the mandible is shi ted anteriorly or laterally on closure 1 2 rom initial tooth contact, on or into maximum 1 C interdigitation, early treatment to eliminate the displacement is indicated on dental health grounds. The rationale or this approach is that in susceptible individuals, mandibular displacement on closure due to premature tooth contact(s) may lead eventually to temporomandibular joint dys unction syndrome. A 3 mm anterior mandibular displacement on closure was 1 detected rom initial contact on ; there was no lateral 1 mandibular displacement associated with the crossbite 2 a ecting . C The amount o overbite on 1 as the amount o overbite post-treatment is a major actor governing stability o incisor crossbite correction and as overbite reduces when the incisor edge is moved upwards and orward during incisor proclination, a deep overbite pre-treatment is a avourable eature. In this case, the overbite was 3.5 mm on 1 and there is a good prospect o adequate overbite ollowing crossbite correction. The inclination o 1 an upper incisor that is upright or retroclined (1) is better or proclination than an incisor that is already labially inclined. Further proclination o the latter may not be possible or could result in un avourable occlusal loading. The amount o space required to procline 1 space already exists in the upper incisor area, and there is no need or any extractions. Investigations ■ What special investigations would you request? Why? As a d ental p anoram ic tom ogram taken 6 m onths prior to this visit by a previou s general d ental p ractitioner (see below ) w as available for inspection, a rep eat lm of this nature w as not ind icated on clinical grou nd s. From this rad iograp h it w as possible to check the presence/ absence of p erm anent teeth and w hether there w as a su pernu m erary tooth p resent in the up p er m id line. Shou ld there have been any susp icion of the latter, a m axillary anterior occlu sal view w ould be ind icated to note the relation of the su pernu merary tooth to the roots of the u p per incisors. N o su pernu merary tooth w as evid ent in the u pp er m id line. A p eriap ical rad iograph of the low er central incisors is not requ ired as the clinical exam ination d oes not lend signi cant cau se for concern to the p rognosis of these teeth. Bitew ing rad iographs should be taken to d iagnose accu rately the extent of carious involvem ent of the prim ary m olars. ■ The dental panoramic tomogram taken 6 months prior to this visit is shown in Fig. 10.3. What does it show? Normal alveolar bone height, except or apparent angular bone de ects related to the mesial aspects o 6 6. (Both teeth, however, were not mobile, and pocket depths were 2 m m betw een the retrud ed contact position (RCP) and the intercu spal position (ICP). ■ Wha t would you deem to be the prognosis or the la bial recession related to 1 ? For accu rate assessm ent of the extent of the labial recession, the soft tissu es shou ld be healthy, and at p resent gingival in am m ation is evid ent. There ap p ears, how ever, to be some attached gingiva labially, and the recession d oes not extend to the sulcu s re ection. It is also not associated w ith a frenal p u ll. At this stage, p rovid ed oral hygiene im proves and the crossbite is corrected , the gingival recession shou ld not w orsen, although the w id th of attached gingiva w ill not increase. ■ Why is 1 in crossbite? This is m ost likely d u e to a slightly p alatal ectop ic p osition of 1 tooth bud . Treatment ■ What treatment would you provide and why? 1. 2. 3. 4. Oral hygiene instruction this is required to improve gingival health and to remove the plaque insult to the gingival recession related to 1. Caries management a diet diary should be completed over 3 consecutive days (one o which should be a weekend day) and then appropriate dietary advice should be given based on the ndings (see Chapter 22). Although several primary molars are carious, none have associated symptoms. Restorative management o carious primary teeth is dealt with in Chapters 22 and 24. Upper removable appliance therapy to procline 1 due to the mandibular displacement that is producing periodontal trauma to 1, correction o the crossbite on 1 is required urgently. Monitor the lower centerline consider removal o D i a centreline shi t develops. ■ Describe the a pplia nce design you would use to align 1 . The ap p liance w ou ld have the follow ing d esign: Activation: Z spring (0.5 mm stainless steel wire) to procline 1. Fig. 10.5 Post-treatment. Retention: Adams clasps 6D D6 (clasps on 6 6 in 0.7 mm stainless steel wire; clasps on D D in 0.6 mm wire). Anchorage: rom baseplate. Baseplate: acrylic baseplate with ull palatal coverage incorporating posterior capping (~2 mm in height). The appliance is show n in Fig. 10.4. ■ What will determine stability o crossbite correction on 1 ? Provid ed there is 2–3 m m of overbite on 1 follow ing p roclination, the p rospect of stability is good . Su bsequ ent m and ibu lar grow th m u st also be favou rable. The occlu sion follow ing crossbite correction on 1 is show n in Fig. 10.5. Key point Early treatment o an incisor crossbite is advisable i there is associated mandibular displacement and/or periodontal trauma. ■ What other treatment possibilities are there? What evidence is there in relation to their e ectiveness? Other treatm ent op tions includ e xed appliances incorporating the incisors and rst p erm anent m olars (‘2 × 4’; although 2 is only partly erup ted p resently and w ill need to have the bond ed attachm ent rep ositioned as treatm ent progresses), u se of an inclined comp osite slop e bond ed to the opp osing low er incisor (at about a 45° incline and 3–4 m m in height), a com bination of these techniques, elastics attached to bond ed brackets/ bu ttons or m od i ed fu nctional app liances. A system atic review p u blished in 2011 65 • INCISORCROSSBITE ind icated that the evid ence level w as low w ith regard to anterior crossbite correction, bu t evid ence favou red the u se of xed ap pliances. A recent rand om ized controlled trial cond u cted in Sw ed en fou nd m inim al d ifferences betw een xed and rem ovable appliances for anterior crossbite correction; treatm ent d u ration w as slightly shorter (1.4 months) w ith a xed ap p liance (brackets bond ed to the m axillary incisors, p rim ary canines, prim ary rst m olar or rst prem olar, if erup ted ) than w ith a rem ovable app liance, bu t the latter treatm ent cost m ore. At 2-year follow -u p , stability w as sim ilar in both grou p s. Primary resources and recommended reading Borrie F, Bearn D 2011 Early correction of anterior crossbites: a system atic review. J Orthod 38:175–184. Gravely JF 1984 A stu d y of the m and ibu lar closu re p ath in Angle Class III relationship . Br J Orthod 11:85–91. Joss-Vassalli I, Grebenstein C, Top ou zelis N et al 2010 Orthod ontic therap y and gingival recession: a system atic review. Orthod Craniofac Res 13:127–141. McCom b JL 1994 Orthod ontic treatm ent and isolated gingival recession: a review. Br J Orthod 21:151–159. Wied el A, Bond em ark L 2014 Fixed versu s rem ovable orthod ontic ap p liances to correct anterior crossbite in the m ixed d entition – a rand om ized controlled trial. Eu r J Orthod 37:123–127. For revision, see Mind Map 10, page 230. 10 11 Reverse overjet Medical history Alistair is t and w ell. Family history Alistair ’s father reports that his ow n teeth m eet in a m anner sim ilar to his son’s, and he also has a slightly prom inent chin bu t is u nconcerned by it. H e had orthod ontic treatm ent w ith extraction of tw o low er teeth and xed ap p liances w hen he w as a teenager to correct the bite of his front teeth. H is bite changed a lot after he stop p ed w earing the retainers. Examination Extraoral CASE1 SUMMARY Alistair, 8.5 years old, presents with a reverse overjet on all o the upper incisors (Fig. 11.1). What is the cause, and how may it be treated? History Complaint Alistair is not bothered abou t the w ay his teeth bite together and is not concerned abou t any aspect of his facial appearance. H is father, how ever, feels that Alistair ’s chin is som ew hat p rom inent and gives the boy an aggressive-looking app earance. Som etim es Alistair is teased abou t his chin at school. History o complaint Alistair ’s perm anent up per front teeth erupted behind his low er teeth. H is m other ’s recollection is that the bite of his ‘m ilk’ teeth w as sim ilar. Alistair is not bothered by the occasional teasing he gets about his chin. Alistair ’s p arents are keen for treatm ent, if p ossible, at this stage to correct his bite and red uce the prom inence of his chin, w hich w ou ld rem ove the sou rce of teasing at school. Fig. 11.1 Right buccal occlusion at presentation. Alistair has a m ild Class III skeletal pattern w ith average FMPA (Fig. 11.2) and no facial asym m etry. ■ What other eatures would you check or? • Presence/absence o a mandibular displacement on closure. • Temporomandibular joint signs/symptoms. Alistair cou ld ju st achieve an ed ge-to-ed ge incisor relationship. A 3 m m anterior m and ibu lar d isplacem ent on 1 1 w as d etected from RCP to ICP. N o tem porom and ibu lar joint signs w ere noted , and Alistair reported no tem p orom and ibu lar joint sym ptom s. There w as no m asticatory m uscle tend erness. Intraoral ■ What a re your observations rom the intra oral views (Figs 11.1 and 11.3)? The soft tissues appear healthy w ith the exception of m ild m arginal gingival erythem a related to the incisor teeth. Oral hygiene is fair. The d entition ap pears caries free. 6EDC21 are present in each quad rant. Fig. 11.2 Pro le. 67 • REVERSEOVERJET 11 to the mean (109°) bu t are w ithin the norm al range. Taking account of the MMPA, the 1 angle shou ld be 120° − 25° = 95° but is 2° proclined at 97°. The MMPA and facial proportions are slightly red u ced from average values bu t are w ithin the norm al range. Diagnosis ■ What is your orthodontic diagnosis? Fig. 11.3 Le t buccal occlusion. Table 11.1 Causes o reverse overjet Alistair has a Class III m alocclu sion on a Class III skeletal p attern w ith slightly red u ced facial p roportions. There is an anterior m and ibu lar d isp lacem ent on closu re on 1 1. Marginal gingivitis related to the u p per and low er incisors. Upper and low er arches exhibit m ild incisor crow d ing; the u pper incisors are in crossbite. Up p er and low er centrelines are slightly d isp laced . The bu ccal segm ent relationship is Class III bilaterally. Cause Aetiology Skeletal UsuallyClass IIIdue to anyo the ollowing: long mandible; orward placement o glenoid ossa positioning the mandible more anteriorly; short and/or retrognathicmaxilla; short anterior cranial base ■ What is the IOTN (DHC) grade (see p. 264)? Explain why. Anterior mandibular displacement on closure Apremature contact maydisplace the mandible orward on closure into maximuminterdigitation 4c – d u e to >2 m m m and ibular d isp lacem ent betw een the RCP and ICP. Retained primaryupper incisors These mayde ect the eruption path o their successors palatallyinto crossbite ■ Wha t dental health reasons a re there or Pattern/excessive mandibular growth Forward pattern o mandibular growth will exacerbate a Class IIIskeletal pattern Excessive mandibular growth maybe due to excess growth hormone resulting roma pituitaryadenoma Restraint o maxillary growth Found in repaired cle t lip and palate and attributed to the e ect o post surgical scar tissue orthodontic treatment? Mand ibu lar d isplacem ent on closu re m ay increase the likelihood of tem porom and ibu lar joint d ysfunction in su sceptible ind ivid u als. In ad d ition, d isplacing occlusal contacts m ay lead to low er incisor m obility and contribu te to gingival recession. ■ What a ctors would you assess in orthodontic treatment planning? Upper and low er incisors are very m ild ly crow d ed and in crossbite. The overbite is average to slightly increased and com plete. Up p er and low er centrelines are d isp laced . The bu ccal segm ent relationship is Class III bilaterally. These are given in Table 11.2. ■ What are the possible causes o the reverse overjet? ■ Wha t orthodontic treatment would you undertake These are listed in Table 11.1. ■ What radiographic investigations would you request and why? A d ental p anoram ic tom ogram w ou ld be requ ired to accou nt for the p resence and p osition of all the rem aining p erm anent teeth. A lateral cep halom etric rad iograph is ind icated to assess m ore accu rately the m agnitu d e of the Class III skeletal pattern and the incisor inclinations, w hich w ill facilitate treatm ent p lanning. It w ill also form a baseline from w hich treatm ent progress/ grow th changes can be evaluated by comp arison w ith fu tu re cep halom etric lm s. The panoram ic rad iograph show ed all perm anent teeth to be d evelop ing. ■ What is your interpretation o the ollowing cephalometric f ndings? SN A = 80°; SN B = 82°; 1 to m axillary plane = 106°; 1 to m and ibu lar p lane = 97°; maxillary m and ibu lar planes angle = 25°; facial p rop ortion = 53%. The skeletal pattern is Class III (SN A − SN B = AN B = −2°) d u e to m ild m axillary retrognathism and m and ibu lar p rognathism . The u p per incisors are slightly retroclined relative Treatment and why? In view of the alread y app arent Class III skeletal pattern, the ability of the patient to ju st achieve an ed ge-to-ed ge incisor relationship , the inherent tend ency for d ow nw ard and forw ard m and ibular grow th and the fam ily history, a sensible option w ould be to accept the m alocclusion for the present and reassess in the light of fu rther m and ibular grow th. Alistair has not yet entered the p u bertal grow th spurt, w hich is likely to exacerbate the Class III m alocclu sion and chin prom inence as m and ibu lar grow th p roceed s. On average, m and ibu lar grow th continu es until 19 years of age in boys, bu t it m ay progress for longer. Key point Class III malocclusion in the mixed dentition is likely to worsen with mandibular growth, especially in boys. As the p arents are keen for treatm ent if possible, to try to red u ce any fu rther teasing at school, another op tion to consid er w ou ld be grow th m od i cation by fu nctional ap p liance therapy (Fränkel III or FR III, w here FR stand s for 11 • 68 REVERSEOVERJET Table 11.2 Factors to assess in treatment planning Factor Degree o anteroposterior and vertical skeletal discrepancy Potential direction and extent o uture acial growth Most important actor Re ected directlyin acial and dental appearance; patient’s perception o these will in uence complexity o treatment undertaken Assess relevant amilyhistory, age and gender o the patient and vertical acial proportions Reverse overjet is likelyto worsen with a orward growth rotation and horizontal pattern o mandibular growth, usuallyobserved when the anterior acial height is reduced or average The converse is likelywhere there is an increased vertical acial height Incisor inclinations I dentoalveolar compensation is alreadymarked, urther orthodonticcompensation is unlikelyto be stable or to produce an aesthetic result Amount o overbite The deeper the overbite, the better the likelihood o stable correction o the reverse overjet Abilityto achieve edge to edge incisor contact I this is not possible, correction o the incisor relationship bysimple means is unlikely Degree o upper and lower arch crowding Delayupper arch extractions until the reverse overjet is corrected, as this mayprovide space or relie o mild/moderate crowding I extractions are undertaken in the upper arch only, the reverse overjet mayworsen bythe upper labial segment moving palatally I mid upper arch extractions are necessary, extraction o 4 4 is usuallyadvisable to allow or correction o the incisor relationship continu ing grow th and of the need for reassessm ent in the light of ensuing grow th. This form of treatm ent shou ld only be u nd ertaken by a specialist and only w hen Alistair ’s oral hygiene has im proved . ■ How would you take a wax registration or this appliance? The m and ible is rotated d ow nw ard and backw ard u ntil the incisors are brought to an end -to-end relationship or better, w ith the bite open about 2 m m . Alistair m ay be instructed to place the tip of his tongu e at the back of the hard p alate and to m aintain it there w hile closing slow ly into a horseshoe of softened w ax p laced over the u p p er teeth u ntil the d esired p osition is reached . This w ax registration should then be chilled in cold w ater and its accu racy re-checked in the m ou th before forw ard ing to the laboratory w ith im pressions of the d ental arches to allow for appliance constru ction. ■ How much should Alista ir wear this appliance? H e shou ld bu ild up w ear over the rst w eek so that it is w orn for at least 14 hou rs ou t of 24. Encou ragem ent shou ld be given to increase w ear to fu ll-tim e w ith the exception of m ealtim es and d u ring sports, althou gh this may prove d ifcult for som e child ren. As its nam e im p lies, the Fu nction Regu lator w as d esigned w ith the intention of altering fu nction of the circu m oral and m asticatory m u scu lature. For this reason, the p atient shou ld be instru cted to ‘exercise’ these m uscles by gently op ening and closing into the ap pliance. Alistair shou ld be given a tim e sheet to allow him to record the nu m ber of hou rs of w ear per d ay. This shou ld be inspected at each visit and u sed to encou rage p rogress. ■ What e ects will this appliance have? The resp onse is a d ow nw ard and backw ard rotation of the m and ible accom panied by an increase in facial height. Evid ence su ggests that m and ibu lar grow th m ay be constrained by the FR3 bu t it d oes not prom ote forw ard m axillary grow th. The low er incisors are up righted , and the upp er incisors m ay be proclined slightly. The upp er molars shou ld erupt m ore than the low er ones. Key point The FR3 appliance or correction o Class III malocclusion: • May constrain mandibular growth. • Does not promote orward maxillary growth. • Produces mostly dentoalveolar changes. Fig. 11.4 Fränkel Ill appliance. Fu nction Regu lator; Fig. 11.4) to correct the incisor relationship becau se: • Skeletal pattern is mildly Class III. • An anterior mandibular displacement exists on closure, i.e. Alistair can achieve edge-to-edge incisor contact. • MMPA is slightly reduced. • Upper incisors are not proclined. • Lower incisors are very mildly proclined. • Overbite is average to slightly increased. It is essential, how ever, that Alistair and his parents are aw are of the need for p rolonged retention d uring ■ What other treatment options are there? An alternative ap proach to try to m od ify grow th w here m and ibu lar excess exists is by chincu p therap y. This requ ires specialist m anagem ent. The line of force app lication shou ld be oriented below the cond yle to prod u ce d ow nw ard and backw ard rotation of the chin. As a resu lt, low er anterior facial height is increased bu t chin p rom inence is red u ced simu ltaneou sly. In essence, the ap pliance w orks in exactly the sam e w ay as fu nctional ap p liances for m and ibu lar p rognathism . As a signi cant am ount of force from the chincu p is transferred to the base of the low er alveolar p rocess, the low er incisors are also u prighted . 69 • REVERSEOVERJET Prognosis ■ Wha t actors will in uence sta bility o the corrected incisor rela tionship? The amount of overbite is im portant in the short term , bu t the pattern of facial grow th, in particu lar the magnitu d e and d irection of m and ibu lar grow th, w ill in u ence longer-term stability. The pro le and occlu sion follow ing crossbite correction are show n in Fig. 11.5. CASE2 SUMMARY A Daniel, a 9.1-year-old boy, presents with all o the upper incisors in crossbite. Daniel is unconcerned by this. He is in good health. His mother is keen or treatment to correct Daniel’s bite. History History o complaint B Fig. 11.5 (A) Post-treatment: pro le view. (B) Post-treatment: occlusion. All of the perm anent upper front teeth eru pted insid e the low er teeth; the ‘baby’ teeth had the sam e bite. Medical history Daniel is in good health. Dental history H e has not had any p reviou s d ental treatm ent. If the p atient is not keen to try grow th m od i cation or the parents express concern abou t the need for p rolonged retention of the corrected incisor relationship , the m alocclu sion should be accep ted for the present. Arrangem ents shou ld be m ad e to review occlu sal d evelop m ent and to m onitor facial grow th. In Alistair ’s case it w ou ld be w ise to review his occlu sion in 18 m onths (at age 10) to check particularly on the position of the u nerupted perm anent m axillary canines and to m easure the reverse overjet. Once the p erm anent d entition is established , provid ed the reverse overjet has not w orsened m arked ly and the chin prom inence has not increased greatly, consid eration cou ld be given to rem oval of 4 4 only, in conju nction w ith up p er and low er xed app liance therapy to correct the incisor relationship . If the u pp er arch is crow d ed , 5 5 m ay be rem oved also, bu t it is w ise to d elay the d ecision regard ing the need for any u pper arch extractions until the reverse overjet has been corrected . It is im p ortant to assess the pattern of m and ibu lar grow th from an u p d ated cep halom etric rad iograp h p rior to this treatm ent ap p roach, and if there is any concern abou t it, treatm ent shou ld be d elayed u ntil grow th is alm ost com plete. If the reverse overjet increases consid erably w ith fu rther grow th, a com bined orthod ontic and su rgical app roach m ay be requ ired for correction, d epend ing on the p atient’s concerns. This treatment w ou ld not be u nd ertaken u ntil m and ibu lar grow th is com p lete in the late teens. Examination Extraoral Daniel has a Class III skeletal pattern with average FMPA and no facial asymmetry. The Class III pattern appears to be mostly maxillary rather than mandibular in origin, with mid face attening rather than a prominent chin. Lips are competent. There is no mandibular displacement on closure and no abnormal temporomandibular joint signs or symptoms. ■ Wha t do you notice in Fig. 11.6? Oral hygiene is poor with plaque deposits on most teeth and associated generalized mild marginal gingival erythema. The dentition appears caries- ree. EDC21 are visible in each quadrant. (6’s were erupted but not shown). Upper and lower incisors are very mildly crowded and in crossbite as is the mesial aspect o C. The overjet is reversed (measured 2 mm); the overbite is average to slightly reduced and appears complete on 2 . The buccal segment relationship is slightly Class III. ■ Wha t radiogra phic investigations would you request and why? A d ental p anoram ic tom ogram shou ld be requ ested to ascertain the p resence and p osition of all the uneru pted perm anent teeth. 11 11 • 70 REVERSEOVERJET Fig. 11.6 Pre-treatment: right buccal occlusion. This show ed all p erm anent teeth to be p resent. A lateral cep halom etric lm w ou ld also be requ ired to inform the d iagnosis more fu lly w ith regard to the skeletal com p onents of the Class III skeletal p attern and the extent of any com p ensation exhibited by the incisor inclinations; both these factors w ill help treatm ent planning. Fig. 11.7 Delaire-type acemask. ■ As Daniel is o mixed-race origin, how valua ble would cephalometric data be? The cep halom etric nd ings shou ld only be com p ared w ith approp riate racial norm s. Daniel’s m other w as Cau casian, bu t his father w as African. As there are no norm s available for this racial m ix to w hich com p arison can be m ad e, com parison to Cau casian norm s is not app rop riate. As clinical assessm ent takes p reced ence and is m ore valuable than any cephalom etric analysis, treatm ent p lanning shou ld be based on the clinical nd ings. A cephalom etric rad iograph w as taken to act as baseline from w hich to m onitor m and ibu lar grow th. ■ What is your interpretation o the ollowing cephalometric f ndings? SNA = 78°; SN B = 79°; 1 to m axillary p lane = 105°; 1 to m and ibu lar p lane = 89°; m axillary m and ibu lar planes angle = 26°; facial p rop ortion = 54%. Interp retation can only be in the broad est sense d u e to Daniel’s m ixed racial backgrou nd . With that in m ind , the follow ing should be interpreted w ith great cau tion. Based on the valu es given and consid ering Cau casian norm s, the skeletal pattern is Class III (SN A − SN B = AN B = −1°) d u e to the slightly m ore m axillary retrognathism than m and ibular p rognathism . Relative to the m ean value (109°), the u pper incisors are slightly retroclined but are w ithin the norm al range. Taking into accou nt the MMPA, the 1 angle should be 120° − 26° = 94° bu t is 5° retroclined at 89°. The MMPA and facial p rop ortions are only slightly red u ced from average valu es bu t are w ithin the norm al range. Diagnosis ■ Wha t is your diagnosis? Daniel has a Class III m alocclu sion on a Class III skeletal base w ith average FMPA and no m and ibu lar d isplacem ent. Mild m arginal gingivitis. Up per and low er arches are m ild ly crow d ed , and the bu ccal segm ent relationship is slightly Class III. Treatment ■ What treatment would you consider? Explain why? Protraction (reverse-pu ll) head gear, otherw ise know n as facem ask, treatm ent w ould be suitable. This treatm ent is m ost ap p rop riate w ith m ild to m od erate Class III skeletal problem s d ue to m axillary retrusion, in the early m ixed d entition (and preferably no later than 10 years) as it attem p ts to stim u late grow th at the m axillary su tu res to bring the m axilla forw ard . Daniel satis es all these criteria. ■ What is the design o the protra ction headgea r appliance? Several d esigns are com m ercially available and are ad ju stable at the chair-sid e. All incorporate forehead and chin pad s. The Delaire-typ e has tw o vertical rod s located to the lateral asp ects of the head w hich connect to the pad s and allow s ad ju stm ent vertically for op tim al t. (Fig. 11.7) If the plastic p ad s prod u ce skin irritation, pad d ing m ay need to be ad d ed or ventilation holes d rilled in the chin p ad . The ad ju stable m id line crossbow is connected via elastics to vestibu lar hooks (located in the region of D D) on a m axillary splint w hich is either cem ented or bond ed , u su ally to 6ED DE6; the app liance m ay or may not incorp orate an expansion screw (Fig. 11.8). Althou gh it w as form erly ad vised that rapid m axillary expansion be carried ou t simu ltaneou sly w ith facem ask treatm ent, this has now been show n not to be necessary. An alternative, rail-style d esign of facem ask is m ore stream lined , easier to ad ju st and ap pears to be m ore com fortable for sleep ing (Fig. 11.9). 71 • 11 REVERSEOVERJET Fig. 11.8 RME appliance. A Fig. 11.9 Rail-style acemask. B Fig. 11.10 Seven months later on removal o RME (A) pro le and (B) right buccal occlusion. Key point Facemask (reverse pull headgear) treatment may be considered or: • Mild to moderate Class III malocclusion due to maxillary retrusion. • ≤10 years. ■ How does this work? Forces of abou t 400 g p er sid e are app lied by elastics for 14 hou rs p er d ay from the vestibu lar hooks on the bond ed m axillary splint/ exp and er to the crossbow of the facem ask. These p u ll at 30° in a d ow nw ard and forw ard d irection to ad vance the m axilla. ■ What e ects does it have? Cephalom etric nd ings ind icate that, com p ared w ith an u ntreated control grou p, facem ask treatm ent p rod u ces a sm all am ou nt of m axillary p rotraction (m ean SN A change 1.4°), slight backw ard m ovem ent of the m and ible (m ean SN B change 0.7°) w ith an overall m ean skeletal change (AN B) of abou t 2°. The occlusal plane rotates u p w ard and forw ard w ith a d ow nw ard and backw ard rotation of the m axilla. Dentally, the overjet is increased and the low er incisors are retroclined by about 5°. The facial and occlu sal ou tcom es show n 7 m onths later and at 1-year follow -u p are show n in Figs 11.10 and 11.11, respectively. ■ Does treatment pose any risk to the ja w joints? Are there any psychologica l benef ts? In the one rand om ized controlled trial that record ed tem poromand ibu lar joint signs and sym ptom s w ith facem ask treatm ent com pared w ith an u ntreated control grou p, no ad verse effects w ere reported at 15-m onth and 3-year follow -up . The sam e trial found no im provem ent in the child ’s self-esteem at either point in tim e. At 15-m onth review, a signi cant red u ction w as record ed in the im pact of malocclu sion scores relative to controls, w hich allud es to less u nease abou t d ental app earance, bu t this effect w as not present at 3-year review. 11 • 72 REVERSEOVERJET ■ Are there a ny alternatives to a cemask treatment that may produce the same, or greater, outcome? Greater m axillary protraction has been reported by the follow ing means: Application o the acemask to miniplates placed either posteriorly in the maxilla at the base o the zygomatic arch or anteriorly in the maxilla above the incisors. Application o Class III intermaxillary elastic traction rom miniplates located at the base o the zygomatic arch to screws positioned in the anterior mandible, usually mesial to the canines. This is known as bone anchored maxillary protraction (BAMP). ■ What a re the adva ntages and disadva ntages o BAMP? A The m ajor ad vantages are that fu ll-tim e elastic traction is possible w ith no need for an extraoral app liance. In ad d ition, although m ore effective than treatm ent by conventional facem ask therap y w ith m ore skeletal m ovem ent than from a facem ask attached to m inip lates in the anterior m axilla, both p lacem ent and rem oval of the m iniplates requires a su rgical p roced ure. Primary resources and recommended reading Battagel JM 1993 The aetiological factors in Class III m alocclu sion. Eu r J Orthod 15:347–370. Cevid anes L, Baccetti T, Franchi L et al 2010 Com p arison of tw o p rotocols for rap id m axillary p rotraction: bone anchors versu s face m ask w ith rap id m axillary exp ansion. Angle Orthod 80:799–806. B Fig. 11.11 At 1-year review: (A) pro le and (B) right buccal occlusion. ■ How success ul is a cemask treatment or Class III malocclusion in the short term? Facem ask treatm ent ap p ears to be 70% su ccessful at 15-m onth and 3-year follow -u p . ■ What is the long-term success rate o this trea tment? The longest follow -u p to d ate has been for 6 years for patients treated in the trial m entioned above. Alm ost 70% of those treated by p rotraction facem ask m aintained a p ositive overjet. Panel consensu s ind icated that 36% of those treated by protraction facem ask need ed orthognathic surgery versu s 66% of the control grou p . Patients in the control grou p w ere 3.5 tim es m ore likely to need surgery. Self-esteem , how ever, d id not d iffer signi cantly betw een the grou ps. Key point Facemask treatment or Class III malocclusion in the early mixed dentition: • Is 70% success ul at 3 year ollow-up. • Has no adverse e ect on the TMJs. • Reduces the need or orthognathic surgery. Jam ilian A, Cannavale R, Piancino MG et al 2016 Method ological qu ality and ou tcom e of system atic review s rep orting on orthopaed ic treatm ent for Class III m alocclusion: Overview of system atic review s. J Orthod 43:102–120. Levin AS, McN am ara JA Jr, Franchi L et al 2008 Short-term and long-term treatm ent ou tcom es w ith the FR-3 app liance of Frankel. Am J Orthod Dentofacial Orthop 134:513–524. Mand all N , Cou sley R, DiBiase A et al 2016 Early class III p rotraction facem ask treatm ent red u ces the need for orthognathic su rgery: A m u lti-centre, tw o-arm p arallel rand om ised , controlled trial. J Orthod 43:164–175. Mand all N A, Cou sley R, DiBiase A, et al 2012 Is early class III p rotraction facem ask treatm ent effective? A m u lticentre, rand om ised , controlled trial: 3-year follow -u p . J Orthod 39:176–185. Watkinson S, H arrison JE, Fu rness S et al 2013 Orthod ontic treatm ent for p rom inent low er front teeth (Class III m alocclu sion) in child ren. Cochrane Database of Syst Rev Issu e 9. Art N o: CD003451. DOI: 10.1002/ 14651858.CD003451.pu b2. Yang X, Li C, Bai D et al 2014 Treatm ent effectiveness of Fränkel fu nction regu lator on the Class III m alocclu sion: a system atic review and m eta-analysis. Am J Orthod Dentofacial Orthop 146:143–154. For Revision See Mind Map 11, page 231. 12 Increased overbite Family history H arry’s father has the sam e arrangem ent of the u pp er anterior teeth as his son. H e had four teeth rem oved and treatm ent w ith xed app liances as a teenager. H ow ever, the treatm ent resu lt relap sed and the u pper front teeth have largely returned to their original positions. H arry’s m other is keen that this d oes not hap p en to her son. Examination Extraoral ■ Ha rry’s prof le view is shown in Fig. 12.2. What do you notice about the anteroposterior skeleta l pattern and the lips? CASE1 SUMMARY Harry, aged 10 years and 6 months, presents with crowded upper teeth and a deep traumatic overbite (Fig. 12.1). What has caused these problems, and how may they be treated? History Complaint H arry d oes not like the ap p earance of his u p p er teeth and has recently com p lained abou t the gu m behind his u p p er front teeth being sore. H is m other is keen for treatm ent. History o complaint H arry has a Class II skeletal p attern w ith slightly red u ced FMPA. The lips are com petent. Intraoral ■ The appearance o the mouth is shown in Figs 12.1 a nd 12.3. What do you see? So t tissues appear healthy apart rom mild gingival erythema related to the upper incisors. The oral hygiene is air with no visible carious lesions. There are no restorations visible. Harry is in the mixed dentition with the ollowing teeth visible: 6E4321 124E6 (21 1 2 are erupted but are covered 6E43 3456 by the upper incisors). Mild upper labial segment crowding. Class II division 2 malocclusion with deep complete overbite. Buccal segment relationship is a hal -unit Class II bilaterally. H is p rim ary teeth w ere m ild ly irregu lar. H is perm anent u pper front teeth erup ted in a ‘crooked ’ p osition and have not changed since. Medical history H arry is t and w ell. Dental history H arry is a regu lar attend er at his general d ental p ractitioner and has not requ ired any d ental treatm ent so far. Fig. 12.1 Anterior occlusion at presentation. Fig. 12.2 Pro le at presentation. 12 • 74 INCREASEDOVERBITE 3. A B Fig. 12.3 (A) Right buccal occlusion. (B) Le t buccal occlusion. Table 12.1 Causes o increased and traumatic overbite in Class II division 2 malocclusion Cause Aetiology Skeletal: anteroposterior and vertical AClass IIskeletal pattern in combination with a reduced lower acial height Growth pattern An anterior mandibular growth rotation tends to increase overbite So t tissues E ects are via the skeletal pattern – reduced lower acial height leads to a high lower lip line that will retrocline the upper incisors, leading to overbite increase Ahyperactive high lower lip, in association with a reduced lower acial height, leads to bimaxillaryretroclination Dental actors Absence o a well defned cingulumstop on the upper incisors leads to continued eruption o the lower incisors, increasing overbite ■ What are the possible causes o the tra umatic overbite? In a Class II d ivision 2 m alocclu sion, several factors contribu te to an increased overbite. These are listed in Table 12.1. ■ What urther investigations would you underta ke? 1. 2. Assessment o the extent o so t tissue trauma palatal to the upper incisors and labial to the lower incisors rom the increased overbite. Periodontal pocket depth should be recorded in these areas and any gingival recession should be noted. Incisor mobility should also be assessed. Although there was evidence o tooth impingement on the gingivae palatal to 11 and labial to 1, periodontal probing depths did not exceed 2 mm and there was no gingival recession or incisor mobility. Assessment o tooth sur ace wear on the upper and lower incisors this may be on the labial aspect o the lower and/or the palatal aspect o the upper incisors as well as the incisal edges. Harry should be asked about any bruxing habit, and his mother should be asked i she is aware o him having any nocturnal bruxing habit. I wear o the incisors is observed, site and extent should be noted or uture monitoring; as this is better undertaken rom dental casts, impressions should be recorded o the dental arches to allow these to be constructed. There was no noticeable incisor wear, and no bruxing habit was reported. Assessment o the amount o upper and lower arch crowding. Space may be obtained to relieve mild/ moderate lower arch crowding and level an increased curve o Spee by some proclination o the lower labial segment and by a small amount o intercanine width expansion, which appear to be stable in this malocclusion. There ore, in Class II division 2 malocclusion, lower arch extractions should generally only be undertaken i crowding is severe. In this case, lower arch extractions should be considered with great reservation, as this will allow the lower labial segment to drop lingually and aggravate an already traumatic overbite. There was 2 mm o lower labial segment crowding, and space analysis indicated su cient space or the canines and premolars (21 mm present in each quadrant; 21 mm is required, on average, to accommodate 3, 4, 5). Key point In Class II division 2 malocclusion: • Beware o lower arch extractions only, as a deep overbite may become traumatic. • Some proclination o 2 11 2 and mild lower intercanine expansion are o ten possible and stable. 4. Radiographic investigations. The ollowing views are required: • Dental panoramic tomogram, to account or the presence/absence, position and orm o all unerupted teeth. This showed: normal alveolar bone height; a normal developing dentition with a ull complement o teeth. No tooth appeared to be in an ectopic position or to be o abnormal size or shape. • A lateral cephalometric radiograph to assess the anteroposterior and vertical skeletal relationships and the inclination o the incisor teeth to their underlying dental bases. ■ What is your interpretation o the ollowing cephalometric f ndings (see p. 270)? SN A = 81°; SN B = 74°; AN B = 7°; MMPA = 22°; 1 to m axillary p lane = 99°; 1 to m and ibu lar p lane = 88°; interincisal angle = 162°; facial p roportion = 51%. Relative to Cau casian norms, this ind icates SN A is average; SN B is red u ced ; AN B is increased , ind icating a Class II skeletal pattern; MMPA is red u ced , w hich in conju nction w ith the Class II skeletal p attern is contribu ting to the increased overbite; 1 to m axillary p lane is retroclined ; 1 to m and ibu lar p lane is retroclined and not com p ensating comp letely for the red u ced MMPA; the interincisal angle is increased ; facial proportion is red uced . 75 • INCREASEDOVERBITE Diagnosis ■ What is your diagnosis? Class II division 2 malocclusion in the late mixed dentition on a Class II skeletal base with reduced FMPA. Mild marginal gingivitis related to the upper incisors. Traumatic overbite onto gingivae palatal to 1 1 and labial o 1. Mild upper and lower arch crowding. Buccal segment relationship is hal -unit Class II bilaterally. ■ What is the IOTN (DHC) gra de (see p. 264)? Explain why. 4f – d u e to the trau m atic overbite. Treatment ■ What are your aims o treatment? Aims of treatm ent are to: Improve oral hygiene. Relieve upper and lower arch crowding. Reduce the overbite. Correct the incisor relationship to Class I. Correct the molar relationship to Class I. Retain the corrected occlusion. ■ How do you propose to achieve these aims? As H arry is grow ing and has Class II and d eep bite skeletal problem s, grow th m od i cation by a fu nctional app liance w ou ld be the treatm ent of choice. A p relim inary phase of u pper rem ovable appliance therapy w ill be required to align 1 1 by p roclination and to exp and the u p p er arch slightly, allow ing the m and ible to be p ostu red forw ard w ith the arch w id ths coord inated for the constru ction bite for the fu nctional ap p liance. Alternatively, a sectional xed ap p liance m ay be u sed in conju nction w ith the u p p er rem ovable ap pliance to align and procline 21 12 p rior to fu nctional ap pliance treatm ent. Follow ing this, nal d etailing of the occlu sion w ith fu ll u p p er and low er xed ap p liances is likely to be requ ired prior to proceed ing to retention. ■ Describe the design o applia nces you would use. The u p p er rem ovable ap p liance to p rocline 1 1 w ould have the follow ing d esign: • Activation: Z springs to 11 (0.5 mm stainless steel wire). Midline expansion screw. • Retention: Adams clasps 64 6 (0.7 mm stainless steel wire). 4 is insu ciently erupted at present to clasp. • Anchorage: rom baseplate. • Baseplate: ull palatal acrylic coverage with f at anterior biteplane, initially to hal the height o 11. A measurement o the overjet plus 3 mm should be orwarded to the laboratory at the time o appliance construction to ensure adequate posterior extension o the biteplane. As treatm ent p rogresses, ad d ition of cold -cu re acrylic to the at anterior bitep lane m ay be m ad e at the chairsid e, until suf cient overbite red u ction has been achieved . The 12 u pper incisor teeth should be overproclined slightly to allow for som e retroclination u nd er the in u ence of the fu nctional ap p liance. The patient shou ld be instructed to tu rn the m id line expansion screw one quarter tu rn p er w eek. Arch coord ination should be m onitored at each recall by getting the patient to posture the m and ible forw ard u ntil the m olars are in a Class I relationship and checking to ensu re that the bu ccal segm ent teeth are not in crossbite. As the u pp er arch in Class II Division 2 m alocclusion is usually square-shap ed and the low er arch is ‘u ’-shap ed , only a sm all am ou nt of upper arch exp ansion is generally requ ired to achieve coord ination of the arch w id ths w ith the m and ible postu red forw ard . An activator-type fu nctional ap pliance is particu larly u sefu l in this type of m alocclusion. A H erbst ap p liance is less recom m end ed as it m ay tend to d ep ress u p p er m olars and inhibit correction of the d eep bite problem . For this case, the construction bite for the activator ap pliance shou ld be taken w ith the m and ible postured forw ard ed ge-to-ed ge w ith the incisors 3–4 m m ap art and the centrelines correct. If the centrelines had been d iscrepant by several m illim etres initially, the bite should not comp ensate for this. The d esign of a m ed ium opening activator to be used here w ou ld be as follow s: • Adams clasps and occlusal rests to 6 6 (0.8 mm stainless steel wire). • Labial bow 3 to 3 (0.8 mm stainless steel wire); palatal bow 2 to 2 (0.8 mm stainless steel wire). • Acrylic palatal baseplate, deep acrylic capping o the lower incisors and canines with acrylic struts joining the upper to the lower part o the appliance. The acrylic should be heat-cured. An alternative to u sing an upp er rem ovable appliance (w ith or w ithou t a sectional xed ap p liance to 21 12) to p rocline and align the u p per incisors, follow ed by an activator-type app liance, is to u se a m od i ed Tw in-Block ap pliance to achieve the d esired tooth m ovem ents. The d esign of this ap p liance incorp orates Z sp rings to p rocline 1 1 and has no labial bow ; it m ay also be u sed w ith or w ithout a sectional xed appliance to the u pper incisors. ■ Wha t are the goals o the unctional appliance trea tment? To correct the skeletal Class II problem by di erential growth o the jaws, in particular addressing the mandibular retrusion. To increase the lower acial height and to correct the deep bite by preventing incisor eruption, controlling eruption o the upper posterior teeth while allowing eruption o the lower posterior teeth. This di erential control o incisor/molar eruption aims to rotate the occlusal plane in a manner that allows Class II correction. To convert the incisor and molar relationships to Class I. Key point Class II division 2 malocclusion in the mixed dentition may be amenable to unctional appliance correction, taking advantage o acial growth to aid in overbite reduction. 12 • 76 INCREASEDOVERBITE B A C Fig. 12.4 (A) Post-treatment. Pro le. (B) Post-treatment: le t buccal occlusion. (C) Post-treatment: anterior occlusion. ■ Why may a later phase o f xed appliance therapy be required? Rotational correction, esp ecially of 2 2, and d etailing of the buccal segm ent occlusion requ ire the u se of xed ap pliance therapy. ■ Wha t aspects o the corrected occlusion a re prone to relapse? How may you try to prevent/minimize relapse? Rotations o 2 2 pericision (severing o the ree gingival bres) should be undertaken a ew months prior to xed appliance removal as it reduces the relapse tendency. A bonded retainer, however, will be required to maintain upper labial segment alignment in the long term. Overbite the tendency or anterior mandibular growth rotation to continue into late teens and beyond will encourage the overbite to increase. To combat this, a f at anterior biteplane should be incorporated on an upper Hawley retainer (designed to t around the upper bonded retainer) to be worn at night until growth has reduced to adult levels. Key point The corrected aspects o Class II division 2 malocclusion most prone to relapse are: • Rotational correction o 2 2. • Overbite reduction. CASE2 SUMMARY Gillian is 14 years old and does not like the appearance o her teeth. She had 6 extracted 4 years ago due to ca ries. Both she and her mother would pre er to avoid any urther extractions with orthodontic treatment i at all possible. What are the causes, and how may it be managed? Examination Extraoral Gllian has a m ild Class II skeletal p attern w ith slightly red u ced FMPA and low er facial height. The low er lip lay at the m id d le to gingival third of the u pper incisors. There w as no facial asym m etry. There w ere no temp ororm and ibular joint signs or sym p tom s. ■ What do you notice in Fig. 12.5? Fair oral hygiene with generalised mild marginal gingival erythema. Apart rom upper le t quadrant where 6 has been extracted, 1234567 erupted in all quadrants. 6 , 6 6 and 5 restored; caries 4. The facial p ro le and the occlu sion after fu nctional app liance, follow ed by xed ap p liance therap y, are show n in Fig. 12.4. Severe lower arch crowding with 2 lingually displaced; 3 upright and 3 distally angulated; 2 mesiolingually rotated; moderate upper arch crowding with 3 3 buccally displaced; 3 upright and 3 distally angulated. 77 • INCREASEDOVERBITE A 12 B C D E Fig. 12.5 Case 2 at presentation. (A) Anterior occlusion. (B) Right buccal occlusion. (C) Le t buccal occlusion. (D) Upper occlusal view. (E) Lower occlusal view. Class II division 2 incisor relationship; deep complete overbite; 2 in crossbite with 3 (there was a 2.5 mm mandibular displacement between RCP and ICP). Right molar and canine relationships, Class I; le t canine relationship is Class III. A lateral cephalometric radiograph was taken to assist with diagnosis and treatment planning. ■ What is your interpretation o the ollowing cephalometric f ndings? SN A = 82°; SN B = 77°; MMPA = 23°; 1 to m axillary plane = 98°; 1 to m and ibu lar p lane = 88°; interincisal angle = 153°; facial p rop ortion = 52%. Relative to m ean Cau casian valu es, SN A is slightly increased and SN B m ild ly red u ced . The skeletal p attern (SN A-SN B) is m ild ly Class II (AN B 5°). The u p per and low er incisors are retroclined ; the low er incisor angle is not comp ensating for the red u ced MMPA; w ith an MMPA of 23°, the low er incisor angle shou ld be 97° (120° – 23°). The interincisal angle is increased , and facial p rop ortion is slightly red u ced . Diagnosis ■ Wha t is your diagnosis? Class II division 2 malocclusion on a mild Class II skeletal base with reduced FMPA and lower acial height. Generalized mild marginal gingivitis. Caries 4. Severe lower and moderate upper arch crowding with a deep complete overbite. Crossbite o 2 with anterior mandibular displacement on closing. Buccal segment relationship is Class I on the right and Class III on the le t. ■ What is the IOTN DHC gra de (see Appendix A1)? Explain why. 4c – d u e to the m and ibu lar d isp lacem ent. ■ Wha t is the aetiology o the deep overbite? Several factors have contribu ted : m ild Class II skeletal p attern, red u ced MMPA and facial proportions, high low er 12 • 78 INCREASEDOVERBITE lip line, retroclination of the u p p er and low er incisors p rod u cing a steep interincisal angle (Table 12.1). ■ Wha t implications does the lower incisor inclination have on treatment pla nning? In view of the m arked retroclination of the low er incisors, there is scop e for these to be proclined . This w ill p rovid e sp ace for relief of the low er labial segm ent crow d ing and alignm ent of the low er arch; any d ecision regard ing possible low er arch extractions shou ld be d elayed u ntil this has been achieved . ■ I a non-extraction, approach is adopted or the lower arch, what impact has this or the upper arch? Either no fu rther extractions are u nd ertaken or extraction of u pper rst p rem olars is consid ered ; in the latter case, the nal m olar occlu sion w ou ld be a fu ll u nit Class II bilaterally. If only 4 is rem oved , consid ering the p reviou s loss of 6, the m olar relationship w ill be Class II on the right and Class I on the left. Fu rther up per arch extractions w ou ld be u nw ise as the u pper incisors are alread y very retroclined . effect of also extru d ing the molars. Use of Class II or Class III interm axillary elastics w ill extru d e low er m olars or up p er molars, respectively, and assist w ith overbite red uction. Care m ust be taken, how ever, to p revent extrusion of the u p p er incisors w ith the elastics w hich w ill offset efforts to red u ce the overbite. Lower incisor proclination Moving the low er incisors labially w ill red uce a d eep overbite bu t need s to be und ertaken w ith cau tion as u ncontrolled movem ent is likely to lead to relapse. In Class II d ivision 2 m alocclu sion, w here the low er incisors may be retroclined by the u pp er incisors, som e low er incisor proclination may occu r naturally by freeing the anterior occlu sion. This m ay be achieved by m oving the up p er incisors forw ard , by d isengaging the anterior teeth w ith a at anterior bite plane on an up per rem ovable appliance, or by p lacing bite tu rbos (see Fig. 6.9A). Key point Overbite reduction by incisor intrusion is di cult to achieve. ■ What options are there to reduce the deep overbite? These are sum m arised in Box 12.1. Incisor intrusion This requ ires xed ap p liances. In reality, true incisor intru sion is d if cu lt to achieve and ‘relative’ intrusion occurs. The incisors are held vertically as vertical facial grow th occu rs w ith som e m olar extru sion, as this occu rs m ore read ily than incisor intru sion. Placing a reverse cu rve of Sp ee in a low er rectangu lar archw ire and / or an increased cu rve of Sp ee in an u p p er rectangu lar archw ire w ill achieve ‘relative’ incisor intru sion (Fig. 12.6A). Use of tem p orary anchorage d evices (TADs) or au gm enting m olar anchorage, by typ ical ad d ition of second m olars (Fig. 12.6B) to the anchor u nit, w ill increase the likelihood of incisor intru sion and lim it m olar extru sion. Attem pts to achieve tru e incisor intru sion by the u se of u tility arches, w hich p u sh the incisors against the m olars, avoid ing the bu ccal segm ent teeth, have achieved p artial su ccess as limited m olar extru sion also takes p lace. Molar eruption In a grow ing p atient, freeing the p osterior occlusion w ith a at anterior bite p lane on an u p p er rem ovable ap p liance w ill allow the m olar teeth to eru p t, thereby red u cing the overbite; this is accom plished by a sim u ltaneous increase in low er facial height. The interincisal angle should also be red u ced w ith rm incisor contact to m aintain the ou tcom e. Treatment ■ What a re the aims o treatment? These are to: Improve oral hygiene. Restore 4. Relieve upper and lower arch crowding. A Molar extrusion Use of cervical head gear w ith a d ow nw ard and backw ard pu ll w ill extru d e the u pp er m olars and increase low er facial height, an effect that is com p ensated for in a grow ing child . Sim ilarly, u se of m echanics listed above to attem p t intru sion of incisors has in m ost cases the Box 12.1 Options o overbite reduction Incisor intrusion. Molar eruption. Molar extrusion. Incisor proclination. B Fig. 12.6 (A) Mid-treatment: anterior occlusion. (B) Mid-treatment: lower occlusal view. 79 • INCREASEDOVERBITE Reduce the overbite. Correct the incisor relationship to Class I. Maintain right molar relationship Class I; close 6 space and establish Class I buccal segment relationship. Retain the corrected occlusion. ■ How will these be achieved? Gillian’s oral hygiene and caries statu s w ill be review ed follow ing tw o visits to the d ental hygienist and restoration of 4. If oral hygiene is satisfactory, arrangem ents can be m ad e for xed ap p liance therap y to be com m enced on a non-extraction basis. The u p p er xed ap pliance can be placed initially to ad vance and p rocline the u p p er incisors to allow placem ent of the low er xed ap pliance. headgear wear, otherwise known as a Ten Hove appliance (Fig. 12.8). • TADs. Another Class II d ivision 2 case w ith increased overbite (Figs 12.9–12.12) is show n and w as treated by u sing a Ten H ove ap p liance for d istal m ovem ent of the u p p er bu ccal segm ents (Fig. 12.10), follow ed by xed ap pliance therap y (Figs 12.11 and 12.12). See also Chap ter 6 (Case 2). ■ Wha t guidance does the best current evidence provide regarding management o Cla ss II division 2 malocclusion? A recent system atic review ind icated that the evid ence w ith regard to treatm ent and stability of this m alocclusion is ■ Why may a non-extraction approach be avoured in Cla ss II division 2 malocclusion? Althou gh evid ence is slim and of low qu ality, prop osed bene ts of a non-extraction ap p roach inclu d e less or no risk of the overbite increasing, overbite red u ction is favou red , there is unlikely to be any u nfavou rable retraction of the lips and , as there are no extraction sp aces to close, treatm ent d u ration is u nlikely to be p rotracted . Gillian’s nal occlu sion is show n in Fig. 12.7A and B. ■ What other non-extraction options are there or the upper arch in Class II division 2 malocclusion? Asid e from the op tions show n in Cases 1 and 2, other possibilities are d istalization of the u p p er bu ccal segm ents by either: • An upper removable appliance with 0.7 mm springs to banded 6’s supported by night-time (8 10 hours) Fig. 12.8 Ten Hove appliance. A A B B Fig. 12.7 (A) Post-treatment: anterior occlusion. (B) Post-treatment: le t buccal occlusion. Fig. 12.9 (A) Pre-treatment: right buccal occlusion. (B) Pretreatment: le t buccal occlusion 12 12 • 80 INCREASEDOVERBITE A A B B Fig. 12.10 Following retraction o 6’s: (A) right buccal occlusion; (B) le t buccal occlusion. Fig. 12.12 (A) Post-treatment: right buccal occlusion. (B) Post-treatment: le t buccal occlusion. • Retain long-term with a bonded retainer with or without an upper removable appliance with f at anterior biteplane. Key point A non-extraction approach is avoured in management o Class II division 2 malocclusion. A Primary resources and recommended reading Dyer FM, McKeow n H F, Sand ler PJ 2001 The m od i ed tw in block app liance in the treatm ent of Class II d ivision 2 m alocclu sions. J Orthod 28:271–280. Gianelly AA 1998 A strategy for non-extraction Class II treatm ent. Sem in Orthod 4:26–32. Kim TW, Little RM 1999 Postretention assessm ent of d eep overbite correction in Class II d ivision 2 m alocclu sion. Angle Orthod 69:175–186. B Fig. 12.11 Mid-treatment with xed appliances. (A) Right buccal occlusion; note active “Berman”ligatures in place or space closure. (B) Le t buccal occlusion with Class II elastic. lim ited and highly biased . The best gu id elines that w ere forthcom ing from this review w ere to: • Treat in a timely manner to maximize growth potential. • Treat pre erably non-extraction. • Reduce the overbite and correct the interincisal angle. Lap atki BG, Mager AS, Schu lte-Moenting J et al 2002 The im portance of the level of the lip line and resting lip p ressu re in Class II d ivision 2 m alocclu sion. J Dent Res 81:323–328. Millett DT, Cu nningham SJ, O’Brien KD et al 2012 Treatm ent and stability of Class II d ivision 2 m alocclu sion in child ren and ad olescents: a system atic review. Am J Orthod Dentofacial Orthop 142:159–169.e9. N g L, Major PW, H eo G et al 2005 Tru e incisor intru sion achieved d uring orthod ontic treatm ent: a system atic review and m eta-analysis. Am J Orthod Dentofacial Orthop 128:212–219. Selw yn-Barnett BJ 1996 Class II/ Division 2 m alocclu sion: a m ethod of p lanning and treatm ent. Br J Orthod 23:29–36. For revision, see Mind Map 12, page 232. 13 Anterior open bite Dental history Gerald is a regu lar attend er at his general d ental practitioner and has cooperated w ell w ith previous d ental treatm ent. Examination Extraoral ■ Gera ld’s acia l prof le is shown in Fig. 13.2. What do you notice? Gerald has a m ild Class II skeletal pattern w ith increased FMPA and increased low er anterior facial height. The lip s are com p etent. There w as no facial asym m etry. Mou th op ening w as w ithin norm al d im ensions, and there w as no tem porom and ibu lar joint tend erness or crepitu s. N o m asticatory m u scle tend erness w as noted . SUMMARY Gerald is 11 years old. He presents with no contact o his incisor teeth (Fig. 13.1). Identi y the cause(s) and discuss the treatment options. ■ Wha t other eatures should you assess? Explain why. 1. History Complaint Gerald com p lains that his front teeth d o not m eet. This em barrasses him w hen eating as he cannot bite into food . H is p arents are also concerned by this and by lisp ing d u ring sp eech, w hich they attribu te to the p osition of his front teeth. They are anxiou s for treatm ent. History o complaint Gerald ’s p arents rep ort that his p rim ary incisors d id not m eet either, bu t the sp ace betw een the u pp er and low er p erm anent incisors app ears to have increased in the past year. H is lisp has also becom e m ore noticeable. H e has no history of thu m b or d igit su cking. 2. The swallowing pattern. Where there is a space between the upper and lower anterior teeth, swallowing is likely to be achieved by orward positioning o the tongue between the anterior teeth to achieve an oral seal. This is particularly so where the vertical acial proportions are increased as the likelihood o lip incompetence is greater. Although such behaviour o the tongue is in most cases adaptive, in rare instances an endogenous (primary) tongue thrust exists. It has been suggested that this is associated with lisping and some proclination o the upper and lower incisors. Any attempt in these cases to close the open bite is doomed to ail as the tongue will return the incisors to their original positions. Speech. By asking Gerald to count rom 60 to 70 aloud or to say ‘Mississippi’, the degree o sibilance (lisping) can be detected. The tongue position during speech should also be observed. Medical history Gerald is t and w ell. Fig. 13.1 Anterior occlusion at presentation. Fig. 13.2 Pro le. 13 • 82 ANTERIOROPENBITE Gerald had a tongu e to low er lip sw allow ing p attern, and the lisp w as d eem ed to be m ild . ■ Wha t occlusal anomalies a re associated with speech problems? Are the latter likely to resolve i any underlying malocclusion is treated? Althou gh speech problem s are associated w ith incisor sp acing, Class II d ivision 1 m alocclu sion, Class III m alocclu sion and anterior op en bite, they d o not occu r in all ind ivid u als w ith these occlu sal anom alies. Fu rtherm ore, correction of these occlu sal p roblem s is no gu arantee that the associated sp eech p roblem w ill resolve satisfactorily. Where sibilance is ju d ged to be marked , referral to a sp eech therap ist w ould be p ru d ent, althou gh treatm ent m ay d o little to im p rove m atters. Intraoral ■ What a re the possible ca uses o an anterior open bite? These are given in Table 13.1. Key point A persistent digit-sucking habit o ten produces an asymmetrical anterior open bite. Table 13.1 Causes o anterior open bite Cause Aetiology Skeletal Increase in lower anterior acial height such that the compensatory abilityo the incisors to erupt into contact is exceeded. This maybe worsened bya downward and backward pattern o acial growth So t tissues Rarelyendogenous tongue thrust (Fig. 13.4) Habits Non nutritive sucking habit (NNSH) – pacifer (dummy; Fig. 13.5), blankets, digit (Fig. 13.6) or thumb Persistent digit sucking habit, which o ten leads to an asymmetrical anterior open bite (Fig. 13.7) Localized ailure o alveolar development Occurs in cle t lip and palate, although in other cases there maybe no known cause ■ Wha t other eatures do you see (Figs 13.1 and 13.3)? Mild marginal gingival erythema related especially to the incisors and 4 . No caries is visible. Mild spacing o the upper and lower labial segments; mesiolabial rotations o 11. Class I incisor relationship. Anterior open bite (measured clinically = 6 mm rom the 1 mesioincisal aspects o . 1 Class III molar relationship bilaterally. A A B B Fig. 13.3 (A) Right buccal occlusion. (B) Le t buccal occlusion. Fig. 13.4 Five-year-old boy with no history o a non-nutritive sucking habit: (A) anterior open bite in the primary dentition. (B) Suspected to be due to an endogeneous tongue thrust. 83 • ANTERIOROPENBITE 13 ■ How common are non-nutritive sucking habits (NNSHs) in children? The reported incid ence varies d epend ing on the age and region assessed , bu t N N SH s are very com m on in early child hood . An incid ence of abou t 80% has been reported in the 5 m onths after birth in a Sw ed ish stud y and of arou nd 70% in 2–5-year-old N orth American child ren. The incid ence, how ever, red u ces w ith age. Alm ost 50% of 4-yearold s still su ck a d igit or paci er, red u cing to 12% past the age of 7 and to alm ost 2% by 12 years. ■ Do NNSHs always produce a malocclusion? Fig. 13.5 Anterior open bite in a 3-year-old due to dummy sucking (note the buccal crossbite o C and le t buccal segment). Where there is a history of a N N SH , there is a greater likelihood of d eveloping a m alocclu sion than w ithou t. The longer the habit continues, the greater its im pact on the d evelop ing m alocclu sion, bu t it is im p ortant to realize that the effect is ad d itive to any und erlying p rimary skeletal cau se and d oes not lead p red ictably to a m alocclu sion. ■ Wha t are the e ects o protra cted pacif er use or a persistent digit-sucking ha bit on the occlusion other than creating a n anterior open bite? Application of pressure from an object su ch as a paci er or d igit d isru pts norm al erup tion. Developm ent of a posterior crossbite is associated w ith protracted paci er u se. Persistent d igit su cking m ay resu lt in retroclination of the low er incisors, p roclination of the u pp er incisors, increased overjet and a u nilateral bu ccal segm ent crossbite w ith associated m and ibu lar d isp lacem ent (see Chapter 14). Fig. 13.6 Anterior open bite due to sucking o two digits (second and third ngers); note abnormal shape o 2 . Key point Non-nutritive sucking habits: • Are common in early childhood. • Reduce with age. • Do no predictably lead to malocclusion. Investigations ■ Wha t special investigations would you require? Explain why. A Adental panoramic tomogram is required to indicate what other teeth have yet to erupt and to check their developmental position and orm. Alateral cephalometric radiograph is required to assess more ully the extent o the anteroposterior and vertical skeletal discrepancies, as well as the relationship o the incisors to the underlying dental bases. The d ental p anoram ic tom ogram show ed : Normal alveolar base height. A normal dentition. The developmental age matches Gerald’s chronological age. B Fig. 13.7 (A) Anterior open bite due to thumb sucking. (B) Following cessation o the habit and xed appliance therapy. Note that acid pumice microabrasion was used to improve the appearance o 11 (see Chapter 36). Third molars are present. The cephalom etric analysis revealed : SN A = 82°; SN B = 76°; AN B = 6°; MMPA = 34°; 1 to m axillary p lane = 111°; 1 to m and ibu lar plane = 86°; interincisal angle = 126°; facial p rop ortion = 60%. 13 • 84 ANTERIOROPENBITE ■ What is your interpretation o these f ndings? Relative to m ean valu es for Cau casians, SN A is slightly increased and SN B is slightly red u ced , but both are w ithin the norm al range; AN B is increased , ind icating that the skeletal p attern is m ild ly Class II; 1 to m axillary p lane show s that it is proclined relative to the m ean but w ithin the norm al range; 1 to m and ibu lar p lane show s that it is retroclined relative to the m ean, bu t it is at the correct angle to comp ensate for the increased MMPA (120° − 34° = 86°); relative to m ean valu es, the interincisal angle is red u ced but w ithin the norm al range and the facial proportion is increased . Diagnosis ■ Wha t is your diagnosis? Class I malocclusion on a mild Class II skeletal base with increased FMPA. Marginal gingivitis related to the incisors and 4 . Mild mesiolabial rotations o 1 1 with spacing o the upper and lower labial segments. Anterior open bite. Buccal segment relationship is Class III bilaterally. ■ Wha t is the IOTN (DHC) grade (see p. 264)? Explain why. 4e – d u e to the anterior op en bite. Treatment crib associated w ith high-p u ll chincu p are able to correct anterior op en bite. Key point Unless an anterior open bite is due to a habit, treatment is complex. ■ What mea ns have been tried in a n a ttempt to stop a digit-sucking ha bit? These range from sim ple strategies, su ch as covering the d igit w ith a p laster or p ainting the d igit w ith an u np leasanttasting su bstance, to attem pts to m od ify behaviou r w ith cognitive behavioural therapy, rew ard -based strategies and the use of positive reinforcem ent. The u se of intraoral app liances has also been tried either to stop the d igit being pu t in the habit p osition or to lessen the satisfaction felt in u nd ertaking the habit. ■ I the anterior open bite had been due to digit sucking, what treatment would you recommend? A recent Cochrane systematic review conclud ed that p rovision of a xed habit breaker (palatal crib or arch; Fig. 13.8A and B), p sychological intervention (p ositive or negative reinforcem ent) or both seem to be effective in assisting child ren w ith stop p ing a N N SH ; this, how ever, w as based on low -qu ality, highly biased evid ence. If the habit ceases, the ■ What treatment would you consider? As the anterior op en bite is not d u e to d igit su cking, treatm ent is likely to be com p lex. Gerald has anterop osterior and vertical skeletal p roblem s, the latter being m ore m arked , w ith a d ow nw ard and backw ard p attern of facial grow th that has p rod u ced the anterior op en bite. An attempt, therefore, to achieve incisor contact m ay be by grow th m od i cation aim ing for effective control of m axillary vertical skeletal and d ental grow th. This w ou ld requ ire sp ecialist care. A fu nctional ap p liance w ith p osterior bite blocks, e.g. a Tw in-Block app liance, w ould be op tim al. As the incisor relationship is Class I and the m olar relationship s are Class III, no forw ard p osturing of the m and ible for the registration bite is ad visable. The bite, how ever, m u st be op ened beyond the norm al resting vertical d im ension so that m olar eru p tion is prevented . As the app liance hold s the m and ible in this position, a vertical intru sive force is exerted on the p osterior teeth m ed iated by the stretch of the m u scles and other soft tissu es. Gerald should be instructed to w ear the app liance fu ll-tim e, inclu d ing for m eals. The anterior teeth are allow ed to eru p t w hile eruption of the p osterior teeth is inhibited , thereby red u cing the anterior op en bite. This is su p p lem ented by a tend ency for m and ibu lar grow th to be p rojected anteriorly w hile vertical control of m axillary skeletal and d ental grow th is effected . In this case, high-p u ll head gear should not be ad d ed to the ap p liance. As the m olar relationship s are Class III, any m olar d istal m ovem ent is not ind icated . Cu rrently, there is w eak evid ence that both the Fu nction Regu lator IV (FR IV) w ith lip -seal training and the p alatal A B Fig. 13.8 (A) Palatal crib. (B) Modi ed palatal arch. 85 • ANTERIOROPENBITE anterior open bite w ill u su ally red uce sp ontaneou sly, althou gh this is likely to take several years. Key point Currently, low-quality evidence indicates that e ective strategies to assist a child in stopping a digit-sucking habit include: • Fixed habit breaker. • Positive or negative rein orcement. • Both. ■ How would you manage a parent who is concerned a bout an anterior open bite produced by either a dummy or digit sucking habit in the prima ry dentition (Figs 3.4 and 3.5)? It w ould be pru d ent to ad vise the parent of the child that this is a very com mon issue at this stage of d evelopm ent and that, as the incid ence of N N SH s d ecreases throu ghou t the m ixed d entition, a ‘w ait and see’ ap p roach w ou ld be bene cial. Gentle p ersu asion to d iscontinu e the habit may also be consid ered , bu t as m ost child ren are likely to ou tgrow the habit, it w ou ld be im portant not to m agnify the issu e for the child . If either habit stop s, the anterior op en bite w ill red u ce. Many changes w ill occu r w ith grow th of the face and the eru ption of the p erm anent teeth, so the m alocclu sion can be reassessed in light of these changes at age 8 (w hen the incisors and rst p erm anent m olars eru p t); shou ld there be a d isp lacem ent of the low er jaw d u e to narrow ing of the u pp er arch by the habit, it can be assessed and corrected at that tim e. Any concerns regard ing sw allow ing pattern and sp eech are also likely to change as the p erm anent teeth eru p t and cou ld be assessed by a sp eech therapist, also at that tim e, if d esired . ■ What is the likely prognosis o treatment in Gerald’s case? As the anterior open bite is qu ite m arked and the vertical skeletal p attern is m od erately increased , the prognosis is A B 13 guard ed . Gerald and his parents should be m ad e aw are of this before treatm ent com m ences. Provid ed there is excellent coop eration w ith ap p liance w ear and vertical facial grow th is favou rable, functional ap pliance treatm ent has a reasonable chance of success at this stage. H ow ever, a second phase of treatm ent w ith xed app liances is likely to be requ ired to d etail the occlu sion. As these app liances d o not control eru p tion so favou rably, posterior bite blocks or sim ilar com ponents w ill also be required d uring that phase of treatm ent to m aintain the correction achieved in the earlier p hase. Thereafter, bite blocks w ill also need to be incorporated in any retainer. Long-term retention w ill be requ ired to avert the possible unfavourable effects of su bsequent vertical facial grow th. The lisp m ay imp rove w ith closu re of the anterior open bite, but Gerald and his p arents should not have high expectations regard ing this. ■ Are there any other treatment options? If Gerald d oes not cooperate w ith functional appliance w ear, treatment for the anterior open bite by a speci c typ e of xed appliance m echanics w ith m u ltiloop archw ires (Kim m echanics) m ay be consid ered , m ost likely in conjunction w ith the rem oval of the second or third m olars. This ap proach to ap p liance treatm ent requ ires specialist training. The objective is to correct the cant of ind ivid ual occlusal p lanes, u p righting the teeth in relation to the bisecting occlu sal plane. As this hap p ens, there is a red u ction in posterior facial and d entoalveolar heights, w hich red uces the anterior open bite; anterior vertical elastics then bring the incisors into contact. Im p ressive and stable correction of m arked anterior op en bite, in ad olescents and ad u lts, has been reported u sing this techniqu e. Sim ilar results can be achieved w ith ‘rocking horse’ archw ires u sed in com bination w ith anterior vertical elastics. Molar intru sion m ay also be achieved u sing tem p orary anchorage d evices (TADs; Fig. 13.9) in the form of either screw s or plates. To m axim ize m olar intrusion and p revent u nw anted bu ccal tipping of the m olars, use of bu ccal and C Fig. 13.9 TADs used to close anterior open bite: lateral cephalometric radiograph (A) pre-treatment; (B) ollowing molar intrusion with TADs (arrowed) and palatal arch; (C) nearing the completion o xed appliance treatment with extraction o our premolars. 13 • 86 ANTERIOROPENBITE palatal im p lants has been ad vised ; the skeletal anchorage, how ever, for m olar intru sion need s to be maintained d u ring the early retention phase in an attem p t to red u ce relap se. Shou ld the anterior op en bite w orsen consid erably, a com bined orthod ontic su rgical ap p roach m ay be sou ght w hen grow th is com p lete. Key point Management options or anterior open bite may be: • Accept. • Habit breaker. • Growth modif cation. • Orthodontic camou age, with or without TADs. • Surgery. Primary resources and recommended reading Baek MS, Choi Y-J, Yu H -S et al 2010 Long-term stability of anterior open-bite treatm ent by intrusion of posterior m axillary teeth. Am J Orthod Dentofacial Orthop 138:396–398. Borrie FBP, Bearn DR, Innes N PT et al 2015 Interventions for the cessation of non-nu tritive su cking habits in child ren. Cochrane Database of Syst Rev Issu e 3. Art N o: CD008694. DOI: 10.1002/ 14651858.CD008694.p u b2. British Orthod ontic Society 2012 Du m m y and thu m b su cking habits. Patient inform ation lea et. Available at: w w w.bos.org.u k. Johnson N C, Sand y JR 1999 Tooth p osition and sp eech – is there a relationship ? Angle Orthod 69:306–310. Kim YH 1987 Anterior openbite and its treatm ent w ith m u lti-loop ed gew ise archw ire. Angle Orthod 57:290–321. Lentini-Oliveira D, Carvalho FR, Qingsong Y et al 2007 Orthod ontic and orthop aed ic treatm ent for anterior op en bite in child ren. Cochrane Database of Syst Rev Issu e 9. Art N o: CD005515. DOI: 10.1002/ 14651858.CD005515.p u b3. Lop ez-Gavito G, Wallen TR, Little RM, et al 1985 Anterior op en-bite m alocclu sion: a longitu d inal 10-year p ostretention evalu ation of orthod ontically treated p atients. Am J Orthod 87:175–186. Mizrahi E 1978 A review of anterior op en bite. Br J Orthod 5:21–27. N gan P, Field s H W 1997 Op en bite: a review of etiology and m anagem ent. Ped iatr Dent 19:91–98. For revision, see Mind Map 13, page 233. 14 Posterior crossbite Examination Extraoral Kirsten has a m ild Class III skeletal pattern w ith slightly increased FMPA; the chin p oint is d isp laced slightly to the right. The lips are incom p etent but habitu ally held together. There is a tongu e to low er lip sw allow ing pattern. There is no m asticatory m u scle tend erness, temp orom and ibular joint tend erness or crep itu s, and m outh opening is not restricted . ■ What other eature would you check or, bearing in mind the history? Explain why. SUMMARY Kirsten is 7 years old. She presents with a crossbite o the right buccal segments (Fig. 14.1). What will be your assessment and management options or this problem? History Complaint Kirsten’s m other is concerned abou t the w ay her d aughter ’s teeth bite together. She has noticed that Kirsten’s jaw m oves to one sid e as she closes her m ou th. This m akes her face ap pear crooked , a fu rther cause of anxiety for her m other. History o complaint Kirsten u sed to su ck her thu m b u ntil 5 months ago w hen 1 1 started to eru p t. H er m other has becom e m ore aw are of her d au ghter ’s ‘d eviated bite’ in the p ast year and w ond ered if the thu m b-su cking habit cou ld have contribu ted to the problem . It is im p ortant to check if there is m and ibular d isplacem ent on closu re as this w ou ld ind icate that the facial asym m etry is more an app arent than a true skeletal asym m etry. For the former, orthod ontic correction of an associated crossbite should be straightforw ard , bu t for the latter, fu rther investigations w ou ld be required to d etermine if the asym m etry is p rogressive and more com p lex treatm ent w ou ld be requ ired to ad d ress the facial and occlu sal problem s. Early correction of a crossbite w ith a m and ibu lar d isplacem ent is ind icated to allow the occlu sion to d evelop in an u nd isplaced p osition. It is likely also to red u ce the possibility of d evelop m ent of tem porom and ibu lar joint d ysfu nction synd rom e, w hich m ay occur in su scep tible ind ivid u als in w hom this occlu sal d iscrep ancy exists. An anterolateral m and ibu lar d isp lacem ent on closu re C w as d etected on w ith an associated 3 m m shift betw een C retrud ed contact position (RCP) and intercusp al position (ICP). Key point Early correction o a posterior crossbite with associated mandibular displacement is advisable. Medical history Kirsten is t and w ell. Intraoral Family history ■ Wha t eatures are evident on the intraoral views (Figs 14.1 There is no fam ily history of facial asym m etry. and 14.2)? Mild marginal gingival erythema related to the erupting permanent incisors, but otherwise the so t tissues appear healthy. There is no caries visible. Upper arch seems V-shaped anteriorly; lower arch is more U-shaped anteriorly. 6EDCB1 are present in both upper quadrants and in the lower right quadrant; 12CDE6 are present in the lower le t quadrant. Spacing o the upper and lower incisors with distopalatal rotation o 1. Class III incisor relationship. Anterior open bite. Fig. 14.1 Anterior occlusion at presentation. Lower centreline shi t to the right. 14 • 88 POSTERIORCROSSBITE Table 14.1 Causes o buccal segment crossbite Cause Aetiology Skeletal Mismatch in the widths o the dental arches and/or an anteroposterior skeletal discrepancy– buccal and anterior crossbites are most commonly ound in Class IIImalocclusion. Rarely, mandibular growth restriction ollowing condylar trauma or hemimandibular hypertrophy maybe implicated, both producing asymmetry So t tissues/habit With a digit sucking habit, the tongue position is lowered with the teeth apart, and cheekcontraction is unopposed during sucking, narrowing the upper arch slightly A ■ What actors may be implicated in the aetiology o the crossbite? These are sum m arized in Table 14.1. ■ What is the most likely ca use o the posterior crossbite in this case? The thu m b-sucking habit (see also Chap ter 13). B Fig. 14.2 (A) Right buccal occlusion. (B) Le t buccal occlusion. Key point A digit-sucking habit may lead to posterior crossbite with associated mandibular displacement. Box 14.1 Causes o a lower centreline shi t • Unbalanced loss o C, Dand possiblyE; the age at extraction, the degree o crowding and the tooth extracted (the more anterior, the greater the e ect) in uence the extent o centreline shi t. ■ What is a possible explanation or the ma ndibular • Unilateral retained primary incisor, canine or molar. As the corners of the m ou th exp erience the greatest cheek p ressu re d uring thu m b su cking, it seem s plau sible for greater narrow ing to occu r across the canines rather than the m olars, resulting in a V-shaped u p per arch (see Fig. 14.1); hence p rem atu re occlu sal contact on one of the p rimary canines is the likely trigger for a lateral m and ibular d isp lacem ent on closu re. A narrow, V-shaped up per arch is m ore likely to resu lt w hen the thu m b is sucked intensely than w hen it ju st rests in the m ou th. Kirsten’s m other rep orted that Kirsten u sed to su ck her thum b for at least 12 hou rs per d ay for the past several years bu t gave u p the habit in recent m onths. • Hypodontia o an incisor or premolar. • Supplemental incisor or premolar. • Lateral mandibular displacement on closure producing unilateral buccal segment crossbite (o ten secondary to digit- or thumb-sucking habit). • Early unilateral condylar racture leading to defcient growth on the a ected side. • Hemi acial microsomia. • Hemimandibular hypertrophy(known ormerly as condylar hyperplasia). Cause is entirely unknown. Most likely in emales between the ages o 15 and 20, but may occur in either sex as late as the early thirties. Hal -unit Class II right molar relationship with buccal crossbite o the right buccal segments (note palatal inclination o the teeth). Class III le t molar relationship. ■ How would you assess the centrelines? The up per and low er centrelines shou ld be coincid ent w ith each other and w ith the m id line of the face. Both of these aspects shou ld be assessed , the latter by rst looking at the patient anteriorly and then d ow n on the face from above. With stu d y m od els alone, it is not p ossible to d eterm ine the relation of the d ental m id lines to the facial m id line. In this case the low er centreline is d isp laced to the right by about half the w id th of a low er incisor. displacement being on a primary ca nine rather than on the molars? Investigations ■ What special investigations would you undertake and why? A d ental p anoram ic tom ogram (Fig. 14.3A) is requ ired to su rvey the d evelop ing d entition for any abnorm alities of tooth nu m ber, size and p osition. Im p ressions of the d ental arches and a w ax registration in maximu m intercu spation shou ld be taken to allow stu d y m od els to be constructed . These w ill allow a thorou gh occlu sal assessm ent to be p erform ed and w ill act as a baseline record of the m alocclu sion. ■ What does the denta l panoramic tomogra m show? ■ What are the possible causes o a lower centreline shi t? Normal alveolar bone height. These are listed in Box 14.1. In this case it is d u e to the lateral aspect of the m and ibu lar d isp lacem ent on closu re. All permanent teeth developing apart rom third molars. No apparent caries or other pathology. 89 • POSTERIORCROSSBITE 14 Treatment ■ Wha t treatment plan would you propose? Oral hygiene instruction to improve gingival health. Correction o the right buccal segment and anterior crossbites. Regular review o the developing occlusion. ■ How may the crossbites be corrected? Describe the design A o any a ppliance you would use. B Fig. 14.3 (A) Dental panoramic tomogram. (B) Repeat o right hal dental panoramic tomogram. ■ What is the most likely reason or the blurred image on the right hal o the dental pa noramic tomogram? Movem ent of the p atient d u ring im age cap tu re, m ost p robably d ue to sw allow ing, is the likely cau se. ■ Why wa s a right hal , rather than a ull, dental panora mic tomogram retaken (Fig. 14.3B)? In line w ith cu rrent rad iology gu id elines, the rad iation d osage to the p atient shou ld be as low as reasonably achievable for the d iagnostic p u rp oses requ ired . Retaking the right-half im age only satis es d iagnostic need s here. Diagnosis ■ What is your diagnosis? Class III malocclusion on a mild Class III skeletal base with slightly increased FMPA; anterolateral mandibular C displacement on closure on . C Mild marginal gingivitis related to the erupting incisors. Spacing o the upper and lower incisors with 1 distopalatally rotated. Anterior open bite; lower centreline shi t to the right. Buccal segment relationship hal -unit Class II on the right and Class III on the le t. Buccal crossbite o the right buccal segments associated with the mandibular displacement. ■ What is the IOTN (DHC) gra de (see p. 264)? Explain why. 4c – d u e to m and ibu lar d isp lacem ent >2 m m betw een the RCP and the ICP. Possible ap proaches to treatm ent are as follow s: 1. As the digit-sucking habit has been abandoned and the mandibular displacement arises rom premature contact C on , judicious grinding o their cusp tips may remove C the occlusal inter erence and correct the buccal segment crossbite, although the success rate with this treatment has varied considerably, rom 27 64%. Placing composite onlays to allay mandibular shi t where occlusal inter erences exist has also been tried but with outcomes in erior to active appliance therapy. The permanent incisors are erupted insu ciently, at present, to consider their proclination and which means will be best. 2. As the upper buccal segment teeth are not tilted buccally, upper arch expansion by a midline screw in an upper removable appliance may be considered. The appliance may be clasped on 6D D6 (Adams clasps: 6 6 0.7 mm stainless steel wire; D D 0.6 mm stainless steel wire). Buccal capping will acilitate tooth movement by disengaging the posterior occlusion. Kirsten should be encouraged to turn the screw one quarter turn twice weekly (0.25 mm o activation with each turn) until the crossbite is corrected. A small amount o overexpansion is advisable as some relapse is to be expected. Then the capping should be reduced to hal its height at one visit and removed completely at the ollowing visit to allow the buccal segment teeth to erupt into occlusion. Provided there is a well-interdigitating buccal segment occlusion, the appliance should then be worn as a retainer at night or several months; 6 months o retention will likely su ce. The nal occlusion ollowing crossbite correction by an upper removable appliance is shown in Fig. 14.4. Correction o the incisor relationship and improvement in 1 alignment occurred spontaneously. 3. Alternatively, upper arch expansion may be undertaken using a quadhelix (see Fig. 4.11A). This consists o bands cemented to the rst permanent molars with soldered arms, which in this case should extend orward to the palatal aspects o the C’s. Alternatively, a pre ormed quadhelix may be employed that ts into sheaths soldered to the palatal aspects o the molar bands, allowing easy removal or adjustment. Activation is usually hal a tooth width on each side. To acilitate crossbite correction, it may be necessary to disengage the buccal occlusion temporarily by placing glass ionomer cement on the occlusal sur aces o the molars. Once the crossbite has been corrected, the cement may 14 • 90 POSTERIORCROSSBITE A A B B Fig. 14.4 Post-treatment (A) Right buccal occlusion. (B) Anterior occlusion. Fig. 14.5 (A) Pre-treatment: anterior occlusion (note C retained and mobile; 3 unerupted). (B) Post-treatment: anterior occlusion. be removed and the quadhelix should be rendered passive prior to cementation or 3 6 months as a retainer. Another case treated by a quad helix is show n in Figs 14.5A and B. over another w ith regard to the other ou tcom es assessed (intercanine exp ansion, stability of crossbite correction, signs and sym p tom s of tem p orom and ibu lar joint d ysfu nction, signs and sym ptom s of resp iratory d isease and quality of life). ■ What will determine i the corrected buccal segment Key point Management options or a unilateral posterior crossbite with associated mandibular displacement in the mixed dentition: • Grind C’s. • URA with midline screw. • Quadhelix. crossbite is likely to be stable? Good buccal segm ent interd igitation and absence of any d isp lacing occlu sal contacts. Key point Correction o a unilateral buccal segment crossbite in the mixed dentition may be more success ul with a quadhelix than with a removable expansion plate. ■ Based on current evidence, what treatment moda lity is most e ective or correction o a bucca l segment crossbite in the mixed dentition? A recent system atic review su ggests that crossbite correction and exp ansion of the interm olar w id th for child ren in the early m ixed d entition (aged 8–10) m ay be m ore su ccessfu l w ith a qu ad helix than w ith an u p p er rem ovable exp ansion ap p liance, althou gh the qu ality of evid ence w as low to m od erate. Com p ared w ith rem ovable exp ansion p lates, a quad helix app liance m ay achieve 1.15 m m m ore m olar expansion and m ay be 20% m ore likely to correct crossbites. There w as insu f cient evid ence to favou r one intervention Primary resources and recommended reading Agostino P, Ugolini A, Signori A et al 2014 Orthod ontic treatm ent for p osterior crossbites. Cochrane Database of Syst Rev Issu e 8. Art N o: CD000979. DOI: 10.1002/ 14651858.CD000979.p u b2. Prim ozic J, Ovsenik M, Richm ond S et al 2009 Early crossbite correction: a three-d im ensional evalu ation. Eu r J Orthod 31:352–356. For revision, see Mind Map 14, page 234. 15 she snores and is prone to d ay-tim e d row siness, w hich her teachers have noticed . Otherw ise she is w ell. H er m other w ond ers if the narrow appearance of Jean’s u pper teeth is related to her m ou th breathing and snoring. She is keen to know if Jean’s m outh breathing and snoring cou ld be im p roved by any brace treatm ent. ■ Wha t is the relevance o Jean’s mode o breathing to Bilateral crossbite CASE1 SUMMARY Jean has just turned 12. She presents with bilateral buccal crossbites (Fig. 15.1). What are the possible causes, and how could it be managed? History Complaint Jean d oes not like the ‘narrow ’ ap p earance of her u p p er teeth, esp ecially w hen she sm iles. History o complaint H er mother says that Jean’s ‘baby’ teeth had the sam e ap pearance, and she also has a sim ilar ap p earance of her u p per teeth to her d au ghter. Jean’s teeth eru p ted in the p osition they are in at p resent. There is no history of traum a to her u pp er jaw, and birth w as norm al. Medical history Jean is asthm atic and u ses a salbu tam ol (Ventolin) inhaler. She is prone to u pper respiratory tract infections and is u nable to breathe throu gh her nose. H er m other reports that snoring and to her complaint? Comp u lsive mouth breathing, d u e to inability to breathe through the nose, m ay contribu te to an altered head p osture and low tongu e position; this m ay lead to unop posed action of bu ccinator mu scu latu re and bilateral narrow ing of the u pper arch creating bilateral bu ccal crossbites. Inability to breathe throu gh the nose is also linked w ith snoring, w hich is associated w ith sleep apnoea, a m ajor cau se of d ay-tim e d row siness. Prolonged in am m ation of the nasal m ucosa associated w ith allergies (in Jean’s case there is a history of asthma) or chronic infection (she is prone to u pp er resp iratory tract infections) could prod uce some d egree of nasal obstru ction and lead to m ou th breathing. The norm ally large p haryngeal tonsils or ad enoid s in child ren m ay also contribu te. Key point • Mouth breathing may contribute to altered head posture, low tongue position and bilateral buccal crossbite, but it is not the sole or even the major cause o such crossbites. Dental history Jean is an irregu lar attend er at her general d ental p ractitioner. She has ssure sealants to several m olar teeth and one lling. There is no history of d igit-su cking. ■ How may a digit-sucking habit cause a bucca l segment crossbite? This is given in Table 14.1 (p . 88). Social history Jean has tw o you nger sisters. N either of them have had orthod ontic treatm ent, and neither of them have teeth like hers. Examination Extraoral Jean has a Class I skeletal p attern w ith slightly increased FMPA and no facial asym m etry. Lip s are incom p etent. There are no signs or sym ptom s associated w ith the tem porom and ibu lar joints. Intraoral ■ The appearance o the teeth on presentation is shown in Figs 15.1 and 15.2. Describe wha t you see. Fig. 15.1 Case 1: anterior occlusion at presentation. Fair oral hygiene with generalized marginal gingival erythema. 15 • 92 BILATERALCROSSBITE Table 15.1 Possible causes o bilateral buccal crossbite Bilateral buccal crossbite Possible causes Skeletal Mismatch in relative widths o arches or anteroposterior discrepancy (commonlyassociated with Class IIImalocclusion) So t tissues Possible role o adenoids/tonsils (see text) Lowtongue position possiblydue to altered head posture associated with mouth breathing Scar tissue o cle t repair restraining growth in upper arch width A Radiographic A d ental p anoram ic tom ogram w ou ld be u sefu l to d eterm ine the presence, p osition and form of u neru pted third m olars. A lateral cephalom etric rad iograp h w ill also be requ ired to ascertain the inclination of the u p p er and low er incisors to their respective d ental bases. The d ental panoram ic tom ogram ind icated fou r third m olars of good form and p osition to be p resent. The cephalom etric nd ings w ere as follow s: SN A = 81°; SN B = 79°; MMPA = 28°; 1 to m axillary plane = 113°; 1 to m and ibu lar plane = 93°; interincisal angle = 138°; facial prop ortion = 56%. B Fig. 15.2 (A) Case 1: right buccal occlusion. (B) Case 1: le t buccal occlusion. 654321 123456 visible (please note 7 7 are also erupted). 7654321 1234567 All teeth visible appear caries- ree; amalgam restoration in 6 . Moderate lower arch crowding; 11 appear slightly small (contact point displacements were 3 mm between 1 and 2; also between 2 and 3); mild upper arch crowding. Class I incisor relationship; average and complete overbite; upper and lower centreline shi ts (upper appears to the le t, lower to the right); 2 2 in crossbite. Molar relationship is Class I on right and Class III on le t with 6543 456 bilateral buccal crossbite a ecting . 6543 56 ■ What are the possible causes o bilateral buccal crossbite? Factors im plicated in the aetiology of a bilateral bu ccal crossbite are given in Table 15.1. Investigations ■ What investigations would you underta ke in relation to the ■ What is your interpretation o these f ndings? Relative to m ean valu es for Cau casians, SN A is norm al; SN B is slightly increased ; AN B (SN A − SN B) = 2°, ind icating a Class I skeletal p attern; MMPA is slightly increased ; 1 to m axillary p lane is increased , so the up per incisors are slightly proclined ; 1 to m and ibu lar p lane is norm al; interincisal angle is slightly increased ; facial proportion is slightly increased . All valu es are w ithin the norm al range for Cau casians. Diagnosis ■ What is your dia gnosis? Class I malocclusion on a Class I skeletal pattern with slightly increased FMPA and no acial asymmetry. Generalized marginal gingivitis. Moderate lower labial segment crowding: mild upper labial segment crowding with 2’s in crossbite; upper and lower centreline shi ts. Molar relationship is Class I on the right and Class III on le t 6543 456 with bilateral buccal crossbite a ecting . 6543 56 ■ What is the IOTN (DHC) grade (see p. 264)? Expla in why. 3d – d ue to contact point d isp lacem ent betw een 1 and 2; also betw een 2 and 3. bilateral buccal crossbite? Explain why. Clinical It w ou ld be imp ortant to ascertain if there is an associated m and ibu lar d isp lacem ent, althou gh this is rare w ith bilateral crossbites. It is m ore u su al to have a m and ibu lar d isplacem ent associated w ith a u nilateral bu ccal crossbite. N o m and ibu lar d isp lacem ent w as noted . Treatment ■ What a re the aims o treatment? To improve oral hygiene. To correct the bilateral buccal crossbite. To relieve upper and lower arch crowding. 93 • BILATERALCROSSBITE 15 Table 15.2 Management options or bilateral buccal crossbite Management option Indications Comments Accept and monitor Patient not keen or correction. Not an option here as Jean is keen or correction Part o underlying skeletal IIIproblemwhich is likelyto worsen with mandibular growth, especiallyin males Removable appliance with midline screwor heavymidline spring Primary/earlymixed dentition Rate o expansion must be quite slowand orce employed low: otherwise retention o appliance compromised byhigher expansion orces Compliance with wear and activation maybe problematic Not cost e ective as o ten lengthytime required to produce desired expansion Quadhelix Pre erred approach in earlymixed dentition Made o 1 mmstainless steel wire attached to bands cemented to molar tooth on each side 3–5 mmmaxillaryexpansion required (mainlydental but some skeletal expansion) Delivers ewhundred grams o orce Teeth pre erablytipped palatallybut molar inclination maybe adjusted with fxed appliances later Produces e cient slowexpansion Mayderotate molars Maybe adjusted to give more expansion posteriorlyor anteriorly Maybe custom made or pre ormed types available Activation hal a tooth width each side Rapid maxillaryexpansion (RME) Child/adolescent Produces ~ equal amounts o dental/skeletal expansion Minimal/no palatal tipping o the buccal segment teeth, i.e. skeletal crossbite Maybe undertaken using a banded or bonded appliance (the latter limits the amount o downward backward rotation o the mandible) >5 mmtransverse maxillaryexpansion required Surgicallyassisted rapid maxillary expansion (SARPE) Mild anterior maxillarycrowding The older the age at expansion, the less likelythe increase in vertical acial height will be recovered bysubsequent growth Skeletallymature patient with severe skeletal crossbite in whomsegmental expansion in Le Fort Iosteotomymight compromise blood supplyto segments Not an attractive option i urther maxillaryrepositioning in the anteroposterior or vertical plane is required later >5 mmtransverse maxillaryexpansion required To align upper and lower arches with centreline correction. To correct the le t buccal segment relationship to Class I. ■ What treatment would you provide? Oral hygiene instru ction by a hygienist. Provid ed the m arginal gingivitis is corrected then proceed to correction of the bilateral bu ccal crossbite (the need for extractions for relief of crow d ing and centreline correction shou ld be review ed follow ing crossbite correction). ■ What options are there or management o the bilateral buccal crossbite? Which would you choose? The op tions are given in Table 15.2. In view of the severity of the crossbite and the d esire to sim u ltaneou sly, if p ossible, im prove nasal breathing, rap id m axillary exp ansion (RME) w ou ld be the p referred choice of treatm ent. ■ What actors should be checked be ore using this trea tment? What are the chances o opening the midpalatal suture in this pa tient? It is p articularly ad visable to check that there is ad equate bu ccal su pp orting bone and w id th of attached gingiva on all of the u p p er bu ccal segm ent teeth. Before the age of 15, the chances of successfu l opening of the m id -palatal suture are alm ost 100% bu t red u ce after that d u e to greater interd igitation of the su tu res. Key point • Mid-palatal suture opening by RME is almost 100% guaranteed be ore age 15. ■ Describe the design o the a ppliance you would use. What instructions would you give Jean regarding this appliance? The mechanism of m id -palatal su tu re sep aration is expansion by a screw bu ilt into a xed ap pliance that is attached rigid ly to as m any teeth as p ossible. The appliance m ay only com prise m etal or acrylic fram ew ork against the teeth, w hich d oes not contact the palatal m u cosa or m ay be m ad e w ith acrylic p alate-covering shelves. The latter type m ay, in theory, p rod u ce m ore bod ily positioning of the alveolar p rocesses bu t m ay im pinge on the palatal tissu es. For that reason, app liances that are toothborne are preferred . The appliance used in Jean’s case w as as follow s (Fig. 15.3): • Activation: mid-palatal expansion screw (Hyrax). • Retention: bands on 4’s and 6’s. • Anchorage: 4’s and 6’s and the joining metal struts between the bands on these teeth. • Baseplate: no palatal acrylic or buccal capping. 15 • 94 BILATERALCROSSBITE m icrofractures of the interd igitating bone spicules. Because closu re begins p osteriorly in the m id -p alatal su tu re and the other m axillary stru ctu res also exert a bu ttressing effect in this region, the sutu re opens w id er and faster anteriorly, often p rod u cing a med ian d iastem a. Som e overcorrection is ad visable (m axillary p alatal cu sps in line w ith m and ibular bu ccal cu sps) as there is a strong relap se tend ency d u e to palatal soft tissu e elasticity. Key point Fig. 15.3 Case 1: rapid maxillary expansion appliance with Hyrax screw. Rapid mid-palatal suture expansion: • Exerts a orce o 10 20 lb (approximately 4.5 9 kg) over 2 3 weeks. • Produces ~0.5 mm movement per day. • Creates a median diastema. • Has a strong relapse tendency, requiring overcorrection. ■ How will you retain the crossbite correction? Fig. 15.4 Case 1: anterior occlusion ollowing RME and prior to proceeding to upper/lower xed appliance therapy. ■ Wha t should Jean be advised o rega rding the e ects o expansion? As the su tu re expand s m ore anteriorly than posteriorly, an u pper m ed ian d iastem a w ill u su ally d evelop w ithin d ays of appliance activation (Fig. 15.3). Follow ing correction of the bilateral crossbite and several m onths retention, d u ring w hich tim e the app liance is left in p lace, the pu ll of the gingival bres and som e skeletal relapse w ill close the d iastem a (Fig. 15.4). With transverse m axillary expansion, som e m olar extru sion is likely and cu sp al interferences are created that cau se the m and ible to rotate d ow nw ard and backw ard . This w ill red u ce the overbite. ■ Describe how the a ppliance works. It separates the m id -palatal su tu re as if on a hinge at the nasal base. Rap id exp ansion is achieved u sing forces of 10–20 lb (ap proxim ately 4.5–9 kg) over 2–3 w eeks w ith the patient tu rning the screw tw ice d aily (~0.5 m m m ovem ent per d ay). This contrasts w ith slow expansion (force of 2–4 lb (0.9–1.8 kg) over abou t 2.5 months w ith the screw being tu rned once every other d ay, 1 m m per w eek). Minim al suture d isrup tion takes place w ith slow expansion. With a screw d evice for rap id exp ansion, force is transm itted rst to the teeth and then to the su tu re, prod u cing The exp ansion ap p liance shou ld be rend ered p assive and remain in place for 3 m onths as a retainer. On its rem oval, a rem ovable retainer w ith p alatal acrylic coverage shou ld be tted unless fu rther treatm ent is being carried ou t im m ed iately, in w hich case a heavy expand ed m axillary archw ire m ay be p laced for retention. A m od i ed transpalatal arch w ith arms extend ing to the mesial of the 4’s or a 1 m m stainless steel archw ire throu gh the head gear tu bes are alternatives w hile light w ires align the rem aining teeth. On comp letion of treatm ent, an u p per H aw ley retainer (see p. 123) or a tted p alatal arch m ay be p laced . The occlu sion at rem oval of the RME ap p liance and im med iately p rior to proceed ing to further xed appliance therap y is show n in Fig. 15.4. CASE2 SUMMARY Aidan is 19 years old. He presents concerned about the appearance o his top teeth and his bite (Fig. 15.5). How may it be treated? ■ What are the main ea tures o note in Fig. 15.5? Narrow maxillary arch. Bilateral posterior buccal crossbite, extending to include 3 . Upper labial segment crowding with incisor rotations; very mild lower labial segment crowding. Class III incisor relationship with 2 2 in crossbite (distal aspects o 11 also in crossbite). Upper and lower centreline discrepancy (appears that lower centreline is shi ted to the right). Minimal overbite. Lateral open bites. 95 • BILATERALCROSSBITE 15 A Fig. 15.5 Case 2: anterior occlusion at presentation. History Complaint Aid an has been concerned for som e tim e regard ing his d ental ap pearance. H e now has a new job w ith a retail rm and feels embarrassed w hen he sm iles. A p revious orthod ontist told him that he w ou ld need to w ait u ntil he w as in his late teens before anything cou ld be d one regard ing the bite of his front teeth. ■ What makes a smile attractive? On sm iling, the full height of the u p per incisors shou ld be seen (usu ally at rest, there is 1 m m incisor show in m ales and 3 m m incisor show in fem ales). Although som e gingival d isp lay is accep table, the interp roximal gingivae only shou ld be visible for op tim al aesthetics. The contou r of the u pper incisor ed ges should m atch that of the low er lip (smile arc), w ith no u p p er incisor/ low er lip contact. In the transverse d im ension, the sm ile shou ld inclu d e at m inim um the u p per rst p rem olars. The d istance betw een the insid e of the cheek and the m axillary p osterior teeth (bu ccal corrid or), p articu larly the p rem olars, shou ld be narrow. Key point An attractive smile comprises: • Full length o the upper incisors. • Related interproximal gingivae. • Upper incisor edges contour matches that o the lower lip. • Extends laterally to include no less than upper f rst premolars. • Narrow buccal corridors. B Fig. 15.6 (A) Case 2: expansion appliance in situ a ter surgery. (B) Case 2: completion o alignment by xed appliances. Treatment ■ Why is RME not easible? In ad u lts the m id -p alatal and lateral m axillary su tu res are w ell-interd igitated , w hich afford increased resistance to the orthop aed ic-typ e p alatal exp ansion (RME) that m ay be used in ad olescents. ■ How is SARPE undertaken? Originally, surgically assisted rapid p alatal exp ansion (SARPE) w as u nd ertaken u sing bone cu ts only in the lateral m axillary bu ttress to d ecrease resistance su ch that in ad u lts the m id -palatal suture cou ld be m icrofractu red by forced opening. Althou gh this is com m only successfu l in p atients u nd er 30 years old , in old er patients there is a risk of u nw anted fractures in other areas. Currently, the p roced u re is often u nd ertaken u sing cu ts as for a Le Fort I osteotom y bu t w ithou t m axillary d ow n-fractu re. The m axilla is thu s able to w id en in a p rocess akin to d istraction osteogenesis (see p. 97) as resistance is provid ed by the soft tissues only. The RME appliance is cem ented p rior to su rgery, and activation of the screw u su ally com m ences w ithin 2 d ays at the same rate as for non-su rgically assisted RME. Fixed appliances are required to com plete alignm ent (Fig. 15.6). The im p roved occlu sion on com p letion of treatm ent is show n in Fig. 15.7. ■ How stable is SARPE? Medical and dental history Aid an is in good health. H e is u nable to breathe throu gh his nose. SARPE app ears to be m ore stable than su rgical w id ening of the m axilla. The latter has a high relap se tend ency d u e to elastic rebou nd of the stretched p alatal m u cosa. Even after SARPE, w ear of a palate-covering retainer for at least the rst p ost-su rgical year is recom m end ed to control relap se. 15 • 96 BILATERALCROSSBITE A A B B Fig. 15.7 (A) Case 2 post-treatment: anterior occlusion. (B) Case 2 post-treatment: le t buccal occlusion. Key point SARPE: • Is indicated or bilateral posterior crossbite correction in adults. • Allows widening o the maxilla against only so t tissue resistance. • Appears to be more stable than surgical widening o the maxilla. C CASE3 SUMMARY Simon is 13 years old. He presents complaining about the prominence o his top teeth and the crooked lower back teeth (Fig. 15.8). What are the causes, and what options are there or management? ■ What are the main eatures o note in Fig. 15.8? Enamel racture in incisal third o 1 with composite restoration ( 1 had su ered trauma 2 years previously but was symptom- ree). Caries 5 distally. Mild upper arch crowding; moderate lower arch crowding. Class II division 1 malocclusion; increased overjet; slightly increased overbite. Canine relationship hal -unit is Class II bilaterally. D Fig. 15.8 (A) Case 3 at presentation: right buccal occlusion. (B) Case 3 at presentation: anterior occlusion. (C) Case 3 at presentation: le t buccal occlusion. (D) Case 3 at presentation: lower occlusal view. Bilateral lingual crossbite (also re erred to as scissors bite or Brodie bite) a ecting 54 5. ■ Given the position o 5 45, what would you enquire about? It w ou ld be u sefu l to know if there had been early loss of – both low er E’s w hich w ou ld encourage m esial d rift of 6s and lingu al d isp lacem ent of 5s. Sim on had E DE rem oved w hen he w as 7 years old . 97 • BILATERALCROSSBITE Key point Lingual crossbites are associated with Class II malocclusions. Extraoral Sim on has a Class II skeletal pattern w ith slightly red u ced FMPA; there is no facial asym m etry. N o m and ibular d isplacem ent or tem poromand ibu lar joint signs or sym p tom s w ere d etected . ■ What are the causes o bilateral lingual crossbite? clip (Speed ) or retaining springs (Sm art-Clip ). These replace the stainless steel ligatures or elastom eric m od ules that are u sed (the latter m ainly) to retain the archw ire in the bracket slot w ith conventional non-self-ligating system s. Claim ed ad vantages inclu d e faster ligation, low er friction, faster treatm ent, less pain and few er app ointm ents. Com p ared w ith conventional pre-ad ju sted ed gew ise brackets, cu rrent p rospective evid ence for self-ligating brackets ind icates no clinically signi cant d ifference in treatm ent d u ration betw een the tw o system s; sim ilar effects on arch form for Table 15.4 Management options or bilateral lingual crossbite These are given in Table 15.3. In Sim on’s case, a com bination of local and skeletal causes are im plicated in the bilateral lingu al crossbite. Option Possible indications Extraction Single tooth on either side a ected and completelyexcluded lingually ■ What treatment options are there or correction o bilateral Reciprocal movement o a ected upper and lower teeth Depends on inclination o teeth, number o teeth a ected and presence/absence o underlying Class IIskeletal discrepancy Growth modifcation An appliance that in uences so t tissue orce balance maybe use ul, eg, Frankel II Orthodontic camou age Extraction/non extraction therapydepending on local/skeletal components lingua l crossbite? It is im portant to ascertain the nu m ber of teeth affected and to check the inclination of the affected teeth. These w ill help to ind icate the severity of any u nd erlying skeletal com ponent and w hether recip rocal m ovem ent of the affected teeth w ith the op posing teeth only w ill su f ce for correction. Managem ent op tions are given in Table 15.4. In view of the u nd erlying Class II skeletal problem , Simon w as treated rst by grow th m od i cation w ith a Frankel II appliance follow ed by non-extraction u pper and low er xed ap p liance therap y (Fig. 15.9). Fixed appliances required An appliance that acilitates lower interpremolar expansion maybe help ul, eg, Damon appliance Midline distraction osteogenesis Severe mandibular crowding with well aligned upper arch, v shaped mandible and narrowmandibular arch with bilateral scissors bite a ecting several teeth Orthognathic surgery Adult skeletal Class IIwith mandibular defciency Key point Correction o a bilateral lingual crossbite: • Single tooth a ected on each side: consider extraction o displaced teeth. • Several teeth a ected on each side: consider combination o buccal movement o a ected lower teeth/palatal movement o a ected upper teeth. ■ Simon was treated with the f xed appliances shown in Fig. 15.9. What type o a ppliance is this? What are its claimed adva ntages compared with conventional f xed appliance systems? This is a self-ligating xed ap p liance (Dam on). The archw ire is not pressed rm ly against the bracket base but is held in place by either a rigid (as w ith the Dam on system ) or spring A Table 15.3 Causes o bilateral lingual crossbite Local Bilateral earlyloss o E’s mayallow5s to be displaced completelylingually Skeletal Mismatch in relative width o arches or a Class II skeletal discrepancy B Combination o local and skeletal Rarer causes Pierre Robin anomaly(mandibular retrognathia, cle t palate, glossoptosis) Fig. 15.9 (A) Case 3: mid-treatment with Frankel II. (B) Mid-treatment with xed appliances. 15 15 • 98 BILATERALCROSSBITE each system ; m od est tim e-saving for tying and untying selfligating brackets, bu t tim e saving varies w ith bracket d esign. More w ell-d esigned p rosp ective clinical trials u sing id entical w ire sequ ences and m echanics are requ ired to p rovid e m ore robu st d ata regard ing self-ligating brackets. ■ How does distra ction osteogenesis work, and what a re the complication risks o mandibular midline distraction? Based on the m anip u lation of a healing bone, d istraction osteogenesis stretches an osteotom ized site before calci cation has taken place to generate form ation of ad d itional bone and investing soft tissu e. As there is insu f cient soft tissue in the m and ibu lar sym physeal area to cover a bone graft necessary for w id ening the m and ibu lar sym physis by orthognathic surgery, d istraction afford s the op p ortu nity for form ation of new bone (osteogenesis) and soft tissu e (histogenesis) to create new p eriosteu m over the d istracted area. Althou gh in concept m and ibu lar m id line d istraction is basically the sam e as SARPE, in contrast to the m axilla no lateral surgical d isjunction is perform ed as the m and ible is not connected rigid ly to the skull. Distraction of the m and ible, therefore, w ill not be parallel bu t w ill alw ays rotate arou nd the cond yles. Vertical cu ts are m ad e throu gh the m and ibu lar facial and lingual cortical p lates, usu ally extend ing all the w ay through the sym physis. Follow ing a 5–7-d ay latency period , d istraction begins by tu rning the screw tw ice per d ay (0.5 m m ) u ntil the d esired m ovem ent is achieved . The d istractor m ay be tooth-borne or screw ed to the bone; in the latter case, it is rem oved about 4 m onths post-operatively. Com plications of m and ibu lar m id line d istraction, arising w ithin 2 w eeks post-operatively, are relatively rare and m ainly of a m ild or transient natu re. Only 3% of patients experience m ore seriou s d amage d u e to fractured incisor roots or gingival recession. Mand ibu lar m id line d istraction, thu s, appears a relatively safe m ethod for expansion of the m and ible. Sim on’s nal occlu sion is show n in Fig. 15.10. A w ellinterd igitating buccal occlusion w ill facilitate stability of bilateral lingual crossbite correction. Primary resources and recommended reading A Battagel JM 1996 Obstru ctive sleep apnoea: fact not ction. Br J Orthod 23:315–324. Flem ing PS, Johal A 2010 Self-ligating brackets in orthod ontics: A system atic review. Angle Orthod 80:575–584. Freem an DC, McN am ara JA Jr, Baccetti T et al 2009 Long-term treatm ent effects of the FR-2 ap p liance of Frankel. Am J Orthod Dentofacial Orthop 135:570.e1–e6. H erold JS 1989 Maxillary exp ansion: a retrosp ective stud y of three m ethod s of exp ansion and their long-term sequ elae. Br J Orthod 16:195–200. B Lagravere MO, Major PW, Flores-Mir C 2005 Long-term d ental arch changes after rap id m axillary exp ansion treatm ent: a system atic review. Angle Orthod 75:155–161. Kou d staal MJ, Poort LJ, van d er Wal KG et al 2005 Su rgically assisted rap id m axillary exp ansion (SARME): a review of the literatu re. Int J Oral Maxillofac Su rg 34:709–714. Magnu sson A, Bjerklin K, N ilsson P et al 2009 Su rgically assisted rapid m axillary exp ansion: long-term stability. Eu r J Orthod 31:142–149. Parekh SM, Field s H W, Beck M et al 2006 Attractiveness of variations in the sm ile arc and bu ccal corrid or sp ace as ju d ged by orthod ontists and laym en. Angle Orthod 76:557–563. C Fig. 15.10 (A) Case 3 post-treatment: right buccal occlusion. (B) Case 3 post-treatment: anterior occlusion. (C) Case 3 posttreatment: le t buccal occlusion. Vig KWL 1998 N asal obstru ction and facial grow th: the strength of evid ence for clinical assu m p tions. Am J Orthod Dentofacial Orthop 113:603–611. von Brem en J, Schafer D, Kater W et al 2008 Com p lications of m and ibu lar m id line d istraction. Angle Orthod 78:20–24. For revision, see Mind Map 15, page 235. 16 Late lower incisor crowding SUMMARY Graham is almost 20 years old. He presents with crowding o his lower incisors (Fig. 16.1). What is the cause, and how would you treat it? History Complaint Graham is concerned abou t the crow d ing of his low er front teeth and w ond ers if it w ill get w orse. History o complaint H is low er front teeth w ere straight until 18 m onths ago, w hen he noticed crow d ing d evelop ing. H e now nd s it m ore d if cu lt to keep his low er front teeth clean. Calcu lu s build -up also seem s to occu r m ore easily on the insid e of the low er teeth, w hich he nd s annoying. H e is also aw are of the tw o w isd om teeth eru p ting at the back of his low er jaw for the p ast 18 m onths. These d o not cau se him any p roblem s, but he w ond ers if they are m aking his low er front teeth crooked . Medical history Graham is t and w ell. Dental history Tw o years ago Graham had a course of xed appliance therapy to close a large space betw een 1 1, follow ed by com p osite bu ild -u p of 2 2. Examination Extraoral examination Graham has a Class I skeletal pattern w ith average FMPA and no facial asym m etry. Lips are com petent. There are no signs or sym p toms associated w ith the tem porom and ibu lar joints. Intraoral examination The ap pearance of the teeth on p resentation is show n in Figs 16.1 and 16.2. ■ What do you notice? So t tissues appear healthy with the possible exception o mild gingival erythema related to 34 associated with slight plaque deposits; otherwise oral hygiene appears good; slight gingival recession on 4. All lower permanent teeth present; 21 123456 visible in upper arch (note 7 was erupted). Lower labial segment crowding with 8 8 erupting; worst incisor contact point displacement was 2.5 mm. Upper le t quadrant appears aligned. Class I incisor relationship, although it appears to be tending towards Class III. Le t buccal segment relationship is Class III. ■ Is development o lower incisor crowding common in the late teens? In m od ern p opu lations, there is a strong tend ency for crow d ing of the low er incisor teeth to d evelop in the late teens. This occurs even if the teeth w ere w ell aligned or spaced initially, lead ing usu ally to m ild crow d ing, w hereas Fig. 16.1 Lower occlusal view at presentation. Fig. 16.2 Le t buccal occlusion. 16 • 100 LATELOWERINCISORCROWDING initial m ild crow d ing tend s to becom e w orse. Low er labial segm ent crow d ing also occu rs in patients in w hom extractions for relief of crow d ing and xed appliance therapy have been u nd ertaken (u nless a bond ed lingu al retainer has been placed ). ■ Wha t are the possible causes o late lower incisor crowding? The aetiology is m u ltifactorial and the m ajor theories p roposed are as follow s: Late mandibular growth. Forward mandibular growth, especially i a growth rotation is also present, and where maxillary growth has stopped, aided by lip pressure, tends to reposition the lower incisors lingually, reducing arch length and causing anterior crowding. Currently it is thought that as the lower incisors, and perhaps the whole lower dentition, move posteriorly relative to the mandibular body late in mandibular growth, lower incisor crowding almost always develops. The greater the magnitude o late mandibular growth when other growth has essentially stopped, the greater the likelihood o developing late lower incisor crowding. On average, in a male patient, as is the case here, mandibular growth is complete by 19 years o age, but it may continue or longer. Gingival and/or occlusal orces. Pressure rom the transseptal bres and/or the anteriorly directed component o occlusal orces lead to mesial migration o the dentition. Lack o approximal attrition in modern diet. This was thought to explain absence o lower labial segment crowding in Australian aborigines but has not been borne out by research ndings. Reduction in intercanine width. The mandibular intercanine width reduces gradually during the teenage years, and this decrease progresses at a reduced rate into adult li e. The result is an increase in lower labial segment crowding, most marked during the late teens. The presence o third molars. Their role is controversial. Two theories abound: • They may exert mesial pressure on the lower dentition during eruption, tending to produce lower labial segment crowding. • They may prevent the lower teeth rom moving distally in response to orces generated by mandibular growth or so t tissues. However, late lower incisor crowding develops even when third molars are absent so their presence is not the critical actor in the aetiology o the problem. The amount o late mandibular growth is paramount. Investigations ■ What investigations would you undertake? Explain why. Radiographic A d ental p anoram ic tom ogram w ou ld be u sefu l to assess the position and inclination of the p artially eru pted low er third m olars. As a rad iograp h w as taken prior to com m encing orthod ontic treatm ent, this shou ld be consu lted rst, and the need for a fu rther rad iograp h shou ld be assessed based on the clinical assessm ent and the rad iograp hic nd ings. Study models Upper and low er im pressions and a w ax registration in centric occlu sion shou ld be taken for stu d y m od els to record accu rately the current m alocclu sion and to aid fu rther treatm ent p lanning. ■ What do you notice on the denta l panoramic tomogram taken pre-orthodontic treatment (Fig. 16.3)? Normal alveolar bone height. All teeth present and o good quality. 8 is slightly mesioangularly impacted. 8 is upright. Bone overlies the distal hal o the crown o both lower third molars. Diagnosis ■ What is your dia gnosis? Class I malocclusion on a Class I skeletal base with average FMPA. Lower incisor crowding. Impacted third molars. Le t buccal segment relationship is Class III. ■ What is the IOTN DHC grade (see p. 264)? Explain why. 3d – based on the 2.5 m m w orst contact p oint d isplacem ent betw een the low er incisor teeth. ■ What a re the management options or la te lower incisor crowding? Accept and monitor. As this is a normal maturational change in the lower arch, it would be sensible in a late teenager, and Key point Possible actors in the aetiology o late lower incisor crowding include: • Late mandibular growth. • Gingival and/or occlusal orces. • Reduction in intercanine width. • Third molars? Fig. 16.3 Dental panoramic tomogram. 101 • LATELOWERINCISORCROWDING where the crowding is mild, to keep it under observation. Where more marked crowding is present, intervention may be considered. Interproximal stripping. This is only acceptable in an adult with mild lower incisor crowding. By removing 0.25 mm at most rom the mesial and distal aspects o each incisor, up to 2 mm o space can be obtained or relie o crowding. Incisor alignment may then be achieved by either a sectional xed appliance or a removable appliance. For ultimate aesthetics, a lingual xed appliance may be used. A removable appliance clasped on the rst permanent molars, with an acrylated labial bow or Invisalign®(a clear vacuum- ormed thermoplastic aligner) made to t a duplicate study model with the incisors aligned with their mesial and distal sur aces reduced, are alternative approaches. With Invisalign®, however, several appliances will be required to achieve incremental change (~0.25 0.3 mm per aligner worn or about 20 hours per day and changed about every 2 weeks) until the nal alignment has been realized. A bonded retainer will be required to maintain the result long term. 16 low er labial segm ent alignm ent w hile p reserving the integrity of the bu ccal segm ents. ■ Would you advise removal o the lower third molars? Low er third m olars shou ld not be rem oved in an attem pt to p revent further increase in low er labial segm ent crow d ing, as their relation to this aspect of m alocclusion is u nproven. Current gu id elines ad vise rem oval of low er third m olars only if they are associated w ith recurrent ep isod es of pericoronitis or other p athology. In this case, as neither of these ap ply at p resent, the low er third m olars should be retained and their p osition review ed if sym ptom s d evelop. Key point Management options or late lower incisor crowding: • Accept and monitor. • Interproximal stripping with appliance therapy. • Lower incisor extraction with appliance therapy. ■ Aside rom enhanced a esthetics, are there other adva ntages o lingual appliances? Tooth position is easier to d iscern, as the labial crow n is clearly visible. There is also no risk of labial enam el d em ineralization. There are, how ever, som e shortcom ings of lingual orthod ontics and clear aligner therap y; these are given in Chapter 18, p age 112. Extraction of a lower incisor. Where the low er labial crow d ing is m arked , rem oval of a low er incisor m ay be ind icated to give su f cient space for alignm ent of the rem aining u nits. It is ad visable to carry out a d iagnostic w ax-u p on a d up licate set of stu d y m od els to ascertain w hat the nal resu lt is likely to be and to ensu re the p atient is hap p y w ith this before p roceed ing w ith the extraction. Unless the incisor to be extracted is com p letely exclud ed from the arch and the remaining incisors are w ell aligned , xed ap p liance therapy is inevitably ind icated to d etail the p osition of the rem aining labial segm ent teeth. Bond ed lingu al retention w ill then be requ ired . ■ Are there any possible undesirable e ects rom extraction o one permanent lower incisor? The p atient shou ld be w arned of the p ossibility of tw o und esirable sequ elae: the u p p er labial segm ent m oving palatally, w ith resu ltant m isalignm ent, in resp onse to the low er labial segm ent being aligned slightly lingu ally and / or a slight increase in overjet. Extraction of lower premolars. Where the bu ccal segm ent occlu sion is w ell interd igitated and crow d ing is con ned to the low er labial segm ent, it is p referable to avoid low er m id -arch extractions becau se these w ill d isru p t the bu ccal occlu sion. Instead rem oval of a low er incisor w ill exped ite ■ How would you manage the lower incisor crowding? As the low er labial segm ent crow d ing is m ild , Graham should be ad vised to accept it for the p resent. It shou ld be kept und er review, and if the crow d ing increases, consid eration could be given to treatm ent. The eru p tion of the low er third m olars shou ld be m onitored . Primary resources and recommended reading Dacre JT 1985 The long-term effects of one low er incisor extraction. Eu r J Orthod 7:136–144. Ghaem inia H , Perry J, N ienhu ijs MEL et al 2016 Su rgical rem oval versu s retention for the m anagem ent of asym p tom atic d iseasefree im p acted w isd om teeth. Cochrane Database of Syst Rev Issu e 8. Art N o: CD003879. DOI:10.1002/ 14651858.CD003879. p u b4. H arrad ine N W, Pearson MH , Toth B 1998 The effect of extraction of third m olars on late low er incisor crow d ing: a rand om ized controlled trial. Br J Orthod 25:117–122. Little RM, Ried el RA, Artu n J 1988 An evalu ation of changes in m and ibu lar anterior alignm ent from 10 to 20 years p ostretention. Am J Orthod Dentofacial Orthop 93:423–428. N H S Centre for Review s and Dissem ination, York 1999 Prop hylactic rem oval of im p acted third m olars: is it ju sti ed ? Br J Orthod 26:149–151. Richard son ME 2002 Late low er arch crow d ing: the aetiology review ed . Dent Up d ate 29:234–238. For revision, see Mind Map 16, page 236. 17 Prominent chin andTMJDS History o complaint Jocelyn has been m ore aw are of her p rom inent chin and her bite since she w as in her last year at school. After consu ltation w ith an orthod ontist at age 12, she had tw o u pper teeth rem oved to p rovid e sp ace for the u p p er eye teeth (she had both low er rst perm anent m olars extracted at age 8 becau se of d ecay.) She d id not w ear any braces on her teeth. She w as ad vised to w ait u ntil she w as in her late teens to have the bite of her front teeth reassessed . In the past 6 m onths she has becom e qu ite self-consciou s abou t her facial ap pearance, althou gh she feels that her chin d oes not app ear to have becom e m ore prom inent in the past 4 years. ■ What questions would you ask a bout the temporomandibula r joint pa in? When and how the pain started. Type and duration o pain. SUMMARY Jocelyn, aged 23, is re erred by her general dental practitioner because o her prominent chin (Fig. 17.1) and pain in her le t temporomandibular joint (TMJ). What are the causes and how would you manage these problems? History Complaint Jocelyn’s m ain concern is that she d oes not like the p rom inent ap p earance of her chin and her u p p er teeth biting insid e her low er teeth. She has pain in her left jaw joint and has som e d if cu lty chew ing. She is also aw are that she has a lisp , w hich she d islikes. Frequency. Is it localized? Site o radiation. Associated symptoms, e.g. muscle pain, click, jaw locking, trismus. Aggravating actors, e.g. stress. Any habits, e.g. nail-biting, bruxism, pen-chewing. Relieving actors, e.g. heat, analgesics (type and amount). The p ain started su d d enly w hen Jocelyn w as p rep aring for exam inations in her rst year at u niversity. She has had interm ittent d iscomfort in her left jaw joint since then, but it has been of a m ild natu re. The d iscom fort is an ache that is p rincipally in the left jaw joint area but rad iates to the jaw m uscles on that sid e. It d oes not keep her aw ake at night, bu t she feels it is w orse in the m orning. Typ ically it lasts for a few hours and then d isap p ears. It tend s to retu rn w hen Jocelyn is stressed by w ork. She is aw are of grind ing her teeth w hen stressed . She d oes not engage in chew ing pencils or p ens or nail-biting. She feels that in the past year the p ain has recu rred m ore frequ ently and has becom e w orse. Chew ing hard food or op ening her m ou th too w id e m akes the p ain w orse; one or tw o p aracetam ol tablets usually relieves the ache. Jocelyn is also aw are that she has a jaw click. Medical history Jocelyn is t and w ell. Dental history Jocelyn is a regu lar attend er at her general d ental p ractitioner and bru shes tw ice d aily. Family history Jocelyn’s sister also has a prom inent chin, bu t not as m arked as hers, and her sister ’s bite w as corrected w ith xed braces. Examination Extraoral examination ■ What do you observe rom Jocelyn’s prof le view (Fig. 17.1)? Fig. 17.1 Pro le at presentation. Class III skeletal pattern w ith average FMPA. Com p etent lips. 103 • PROMINENTCHINANDTMJDS 17 ■ Based on the history, what other aspects would you assess extraora lly? Temporomandibular joints. Opening and lateral mandibular movements should be assessed by rst observing the patient rom the ront and second by palpation o the condylar heads while listening or the presence o crepitus or a joint click. As symptoms are present, the masticatory muscles should also be palpated. A le t TMJ click and le t masseteric tenderness were detected. Mandibular path o closure. The path o closure rom rest position to maximum interdigitation should be assessed, noting any anterior or lateral mandibular displacement produced by a premature contact. A In this case there is an anterior m and ibu lar d isp lacem ent 7 on closu re on contact of (centric relation to occlusion 8 shift of ~3 m m ). Intraoral examination The intraoral view s are show n in Fig. 17.2. ■ Wha t do you see? Gingival tissues appear healthy; gingival recession related 63 356 to . 7 B Oral hygiene appears overall good, apart rom slight plaque 765321 12356 deposit on 3 are visible. 8754321 123457 No obvious caries. Very mild lower incisor crowding with spacing between the 4’s and 5’s. Very mild upper arch crowding with slight mesiolabial rotations o 2 2. Class III incisor relationship with reverse overjet (measured 4 mm clinically), reduced overbite and coincident dental centrelines. Class I canine relationship bilaterally. 7 Buccal crossbite a ecting . 8 C Fig. 17.2 (A) Right buccal occlusion. (B) Anterior occlusion. (C) Le t buccal occlusion. ■ What is the most likely cause o the considerable spacing in the lower premola r area s with 5’s dri ted into contact with 7 ’s? Early rem oval of 6E E6 in an u ncrow d ed arch is the m ost likely exp lanation for the sp acing. An uncrow d ed low er arch is com m on in Class III m alocclu sion. ■ What occlusal eatures ma y predispose to temporomandibula r joint dys unction syndrome? Crossbites, Class III m alocclu sion and anterior open bite have been show n to have a signi cant association w ith tem porom and ibu lar joint d ysfu nction synd rom e (TMJDS) in some stu d ies w hile others have fou nd no link betw een signs and sym p tom s of TMJDS and m and ibu lar d isp lacem ent. The aetiology of TMJDS is m ultifactorial w ith the im plicated involvem ent of psychological, trau m atic and occlu sal elem ents. The m ost salient factor is p robably stress, w hich m ay transm it its effect by a p arafu nctional habit, stem m ing from a d isplacing occlusal contact in su scep tible 7 ind ivid u als. In this case a d isp lacem ent exists on on 8 closu re. There are also anterior and p osterior crossbites p resent. ■ Why was Jocelyn advised to wa it until her late teens or reassessment? In a Class III m alocclu sion, the am ou nt of reverse overjet tend s to increase w ith forw ard m and ibu lar grow th d u ring teenage years. Waiting u ntil m and ibu lar grow th is essentially com pleted , w hich is generally abou t 17 years of age in girls and 19 years of age in boys, has three ad vantages. First, it allow s treatment planning to be und ertaken w ith 17 • 104 PROMINENTCHINANDTMJDS reasonably stable facial and occlu sal characteristics. Second , if treatm ent is und ertaken, it safegu ard s against relap se d u e to further grow th. Third , the m agnitu d e of occlu sal change d u e to m and ibu lar grow th in u ences w hether treatm ent can be u nd ertaken by orthod ontic m eans alone or w hether a com bined orthod ontic-su rgical ap p roach is necessary. Orthod ontic treatm ent involves ind ucing d entoalveolar com p ensation for the und erlying skeletal p attern, bu t if u nsuccessfu l d u e to continu ed ad verse m and ibu lar grow th, the com pensation w ou ld need to be u nd one as p art of presurgical orthod ontics. This m ay involve op ening up low er prem olar extraction sp aces. H ence the d ecision to treat a Class III m alocclu sion in early teenage years by orthod ontic cam ou age that inclu d es low er arch extractions m u st be m ad e w ith great cau tion. In this case the severity of the anteroposterior skeletal pattern, the likely pattern of mand ibu lar grow th, the am ou nt of d entoalveolar com p ensation, the am ou nt of overbite and the relative absence of crow d ing (follow ing the rem oval of u pper rst prem olars and low er rst perm anent m olars) w ou ld all have been consid erations in d elaying any fu rther orthod ontic intervention. Whether the patient cou ld achieve an ed ge-to-ed ge incisor relationship w ou ld also need to have been assessed . Table 17.1 Investigations required in combined orthodontic-surgical planning* Investigation required Reason Thorough clinical assessment o acial ormin ull ace and profle To locate anycranial, maxillary, nasal, mandibular or chin de ormities To assess the height and width proportions o the ace, interalar distance, nasolabial angle, upper incisor exposure, relation o upper dental midline to other acial midlines, the ormand tone o the so t tissues Assessment o TMJ To record signs and/or symptoms o TMJ dys unction. Treat these conservativelyi possible prior to treatment; i marked occlusal problems contributing to dys unction, aimto correct these with treatment Dental panoramictomogram(DPT) To assess the general dental status and prognosis o the dentition as well as the position o unerupted third molars (bitewing or periapical radiographs maybe required depending on clinical and/or DPTfndings) Lateral cephalometric radiograph To ascertain the aetiologyo the malocclusion and to acilitate surgical planning Facial and dental photographs To record the acial and dental characteristics o the malocclusion To allowsurgical planning bymatching the digital profle acial image with the lateral cephalometrictracing Key point Waiting until at least the late teens be ore considering an orthodontic-surgical approach is desirable, as: • Facial and occlusal characteristics stabilize. • It sa eguards against relapse due to urther growth. • Camou age or surgery is determined by the extent o mandibular growth. Investigations ■ What investigations are required a nd why? The patient’s prim ary concern is about her facial ap pearance, and she has a m alocclu sion w hich is likely to be u ntreatable by orthod ontic m eans alone. A com bined orthod ontic-surgical app roach is requ ired . The investigations requ ired , in su ch cases, together w ith reasons for their selection, are listed in Table 17.1. If possible, threed imensional (3D) facial im ages, at rest and sm iling, shou ld also be record ed at this stage to act as a baseline from w hich to m onitor robu stly the 3D facial changes p rod u ced by surgery and d u ring su bsequ ent follow -u p . Sim ilarly, if feasible, cone beam comp uted tom ograp hy (CBCT) m ay be u nd ertaken. • The TMJ assessment has already been undertaken or Jocelyn (p. 103). • The dental panoramic tomogram showed no condylar pathology. Studymodels and duplicates mounted on an articulator To allowthorough orthodontic/occlusal assessment and model surgery *Three dimensional (3D) acial images, where possible, and when combined with cone beam computed tomography, allow3Dsurgical planning, although urther development is required to optimize this. The cephalom etric values are as follow s: SN A = 79°; SN B = 85°; AN B = −6°; 1 to m axillary p lane = 113°; 1 to m and ibu lar p lane = 82°; interincisal angle = 139°; MMPA = 26.5°; SN to m axillary plane = 11°; facial p roportion = 56%. ■ What is your interpretation o these f ndings (see p. 270)? Moderately severe Class III skeletal pattern due to a combination o maxillary retrognathia and mandibular prognathism. As SNA is 2° less than the mean o 81°, application o the Eastman correction adds 1° to the ANB to give a revised ANB value o −5°. Slightly proclined upper incisors (although inclination is within the normal range) and markedly retroclined lower incisors indicating dentoalveolar compensation or the Class III skeletal pattern. The lower incisor angle should be 120° − 26.5° = 93.5° but is 82°. Interincisal angle is increased but within the normal range or Caucasians. MMPA, SN to maxillary plane and acial proportion are all slightly out o the mean values but lie within the normal range or Caucasians. 105 • PROMINENTCHINANDTMJDS 17 TMJDS with le t TMJ click. and she w as given app ropriate oral hygiene instru ction aim ed to p revent any d eterioration in the areas affected by gingival recession. A pre-treatment gingival graft to the low er incisors w as not d eem ed necessary; m aintenance of good oral hygiene p ractices d u ring orthod ontic ap p liance therap y w as em phasized . Period ontal review w as arranged 6 m onths into orthod ontic treatm ent. Gingival recession on 63 356 and 7 . ■ How will this case be managed? Previous loss o 6’s and 4’s. Short term A hard fu ll coverage u p p er acrylic sp lint shou ld be mad e, and Jocelyn shou ld be instructed to w ear this fu lltime u ntil the TMJ sym p tom s subsid e. She shou ld also be ad vised to take a soft d iet and to avoid straining her jaw joints by, for exam ple, yaw ning w id ely. Mild analgesics should also be taken as requ ired . Diagnosis ■ What is your diagnosis? Class III malocclusion on a Class III skeletal base with average FMPA. Very mild upper and lower labial segment crowding. All o the upper arch in crossbite with the exception o 65 56. 7 Buccal crossbite on with associated mandibular 8 displacement. ■ What is the IOTN DHC gra de (see p. 264)? Explain why. 5 m – d u e to reverse overjet greater than 3.5 m m w ith reported m asticatory and speech d if culties. Treatment ■ What are the aims o treatment? • • • • • • Relie o the TMJDS. Control o the gingival recession. Correction o the underlying skeletal Class III problem. Establish Class I incisor and molar relationships. Correct the buccal segment crossbites. Restore the lower buccal segment spaces. Longer term A com bined orthod ontic-su rgical-restorative ap proach is requ ired to correct the facial and occlu sal problems. The TMJDS sym ptom s m ay ease w ith orthod ontic treatm ent. This is d u e to tooth m ovem ent rend ering the teeth tend er on biting, so parafu nctional activity stops becau se tooth clenching/ grind ing d oes not prod u ce the same su bconsciou s p leasu re as previously. The imp rovem ent in sym p tom s m ay be transient, even if d isplacing 7 occlu sal contacts (present here on ) are elim inated . 8 The patient shou ld be w arned about the u np red ictable im pact of orthognathic su rgery on TMJDS to avoid u nreasonable expectations of treatm ent. Key point Orthodontic treatment and/or orthognathic surgery cannot be guaranteed to eliminate TMJDS. ■ What trea tment is required? Explain why. A com bined orthod ontic-su rgical-restorative ap p roach is need ed d u e to: The patient’s concern relating to acial and dental appearance. ■ Explain how you would proceed with surgical planning or this case. 1. The severity o the underlying Class III skeletal pattern. Despite the degree o dentoalveolar compensation, a reverse overjet o 4 mm exists. An ANB angle o greater than −4° and lower incisor angulation to the mandibular plane o less than 83° have been ound indicative o an orthodontic-surgical approach. Pre-surgical lower arch decompensation will open up more space between the premolars and then require restorative management to optimize the nal occlusion. 2. In addition, lower incisor decompensation may run the risk o creating gingival recession, particularly as Jocelyn already has several teeth a ected by minor gingival recession. A specialist periodontal opinion should be sought be ore embarking on pre-surgical orthodontics. It w as d ecid ed that the sp acing in the low er bu ccal segm ents w ou ld be m anaged by resin-retained brid gew ork follow ing u prighting of the prem olars. The p eriod ontist ad vised Jocelyn to ad ju st her toothbru shing techniqu e, 3. A team approach is required involving the orthodontist and the oral and maxillo acial surgeon. The input o a restorative specialist is also required in relation to management o the lower premolar spacing. The involvement o a clinical psychologist with an interest in orthognathic surgical cases would also be help ul. Jocelyn must understand that to obtain the best acial and occlusal result possible, xed appliance therapy is essential to the overall plan. Surgical planning may be undertaken by various means. To provide in ormation about the inter-relationships o the dento acial complex components, namely the cranium and cranial base, nasomaxillary complex and maxillary dentition, mandible and related dentition, specialized cephalometric analyses exist. These allow comparison o individual cephalometric data with ‘normal’data that should be matched or age, gender and racial background. Computer programs then allow surgical, skeletal and dental movements to be planned and displayed visually on screen be ore printing. By linking the patient’s digital pro le image with the cephalometric tracing, specialized planning so tware can 17 • 106 PROMINENTCHINANDTMJDS A B C Fig. 17.3 Another case: (A) Pre-treatment: pro le. (B) Super-imposition o lateral cephalometric radiograph tracing on a digital pro le view and morphing using Dolphin®so tware to simulate the post-treatment pro le. (C) Post-treatment: pro le. 4. automatically morph the image in response to planned surgical and orthodontic movement undertaken virtually on the computer. The likelihood o di erent treatment options can thus be explored. In addition, the patient can view the nal computerized prediction to appreciate more clearly the possible likely outcome on pro le aesthetics, although it should be understood that this is not guaranteed (Figs 17.3A–C). Using re erence lines to measure distances, planned surgical movements should then be trans erred to a duplicate set o study models, mounted on a semi-adjustable articulator in this case as maxillary surgery is planned. The ability to plan orthognathic surgery in 3D (superimposing 3D acial images and CBCT scans) is being developed and o ers exciting possibilities. The nal plan should be explained to Jocelyn, ensuring that she is aware that her pro le will be worsened by pre-surgical orthodontics and that she realizes what her nal acial appearance is likely to be. Provision o an in ormation leaf et and DVD on orthognathic surgery will also assist in recognizing the ull consequences o what treatment involves and are an important part o obtaining in ormed consent. Key point Planning orthodontic-surgical treatment: • Requires a team approach. • May be assisted by matching the digital acial prof le image with the lateral cephalometric tracing and using computer prediction so tware. ■ Describe the phase o pre-surgica l orthodontics. This p hase of xed ap p liance treatm ent aim s to allow the jaw s to be m oved to their d esired location w ithou t interference from tooth positions. The u p per and low er arches are aligned and coord inated as w ell as establishing the vertical and anteroposterior p osition of the incisors. This involves d ecom p ensating for any existing d entoalveolar com p ensation. For Jocelyn, this w ill involve p rim arily labial m ovem ent of the low er incisors, w hich w ill elim inate the m ild crow d ing and slight up righting of the upp er incisors. The fu ll extent of the skeletal d iscrep ancy is thu s revealed , m axim izing the extent of possible su rgical correction. Class II interm axillary traction m ay be required to aid d ecom p ensation. N o extractions are ind icated in this case to achieve the d esired tooth m ovem ents. The gingival statu s, labial to the low er incisors, shou ld be m onitored d u ring d ecom p ensation to ensu re that gingival recession d oes not ensu e. When the requisite tooth m ovem ents have been achieved , rigid rectangular stainless steel archw ires shou ld be u sed to passively stabilize tooth position. Final p re-su rgical record s – stu d y m od els, photograp hs and a cep halom etric lm – w ill then be taken to assess the changes that have occu rred and to d ecid e if the original surgical plan w ill be follow ed or requ ire som e am end m ent. H ooks shou ld be attached to the archw ires ju st p rior to su rgery u nless brackets w ith an integrated hook on each tooth have been u sed . The hooks facilitate interm axillary xation and / or elastic traction p ost-op eratively. ■ What surgical procedures are likely to be required? Le Fort I advancement. Mandibular setback. 107 • PROMINENTCHINANDTMJDS Key point Pre-surgical orthodontics: • May involve extractions. • Usually involves decompensation or any dentoalveolar compensation. • Aligns and coordinates arches or arch segments. • Establishes the vertical and anteroposterior position o the incisors. • Place rigid rectangular archwires with ball-hooks (unless brackets with integrated hooks are used) immediately pre-surgically. ■ What orm o splint and f xation is likely to be required? A An interocclu sal acrylic w afer, fabricated to t articu lator m ou nted casts positioned to the d esired occlu sal resu lt, is recom m end ed rou tinely to ensu re accu racy of the p ostsu rgical resu lt. Follow ing Le Fort I ad vancem ent and m and ibu lar setback osteotom ies, m ini-p lates and m ini-plates/ screw s are likely to be requ ired resp ectively for xation. Intermaxillary elastics then d irect the teeth into the requ ired position and assist w ith jaw fu nction. ■ Describe the post-surgical orthodontic pha se. With som e m ild jaw exercises, m ou th op ening is usu ally satisfactory w ithin a few w eeks. Lighter, round stainless steel archw ires shou ld then be p laced to allow for occlu sal settling, often aid ed by the u se of p osterior box elastics w ith a slight anterior force vector, w hich help s m aintain the sagittal correction. When good interd igitation has been achieved , elastic w ear shou ld be d iscontinu ed . Rarely w ill this p hase of treatm ent take longer than 6 months to com plete. A period of retention is then requ ired , no d ifferent from that for other ad u lts w ho have com p leted rou tine orthod ontic treatm ent. Su rgical follow -u p shou ld be for a m inim um of 2 years. B Fig. 17.4 (A) Post-treatment: pro le. (B) Post-treatment: occlusion. Key point Stability is enhanced when surgical movement is modest and does not induce so t tissue tension. ■ What actors in uence post-surgical stability? Stability w ill be in u enced by: • Orthodontic and surgical plans being correct, realistic, well-integrated and undertaken competently. • Modest surgical movement no greater than 6 mm in any direction in the maxilla or 8 mm in the mandible. This does not place the so t tissues under tension, and the condyles are not distracted at surgery. • Absence o tongue thrust, previous surgical scarring. • Patient compliance with all aspects o treatment, particularly post-surgical wear o elastic traction. • Adequate xation. • The post-surgical pro le and occlusion are shown in Fig. 17.4. Primary resources and recommended reading British Orthod ontic Society 2012 Tem p orom and ibu lar Disord ers (TMDS) and the Orthod ontic Patient. Ad vice sheet. British Orthod ontic Society, Lond on. Cevid anes LH C, Tu cker S, Styner M et al 2010 Three-d im ensional surgical sim u lation. Am J Orthod Dentofacial Orthop 138:36–371. H ajeer MY, Millett DT, Ayou b AF et al 2004 Ap p lications of 3D im aging in orthod ontics: Part II. J Orthod 31:154–162. H u nt N P, Ru d ge SJ 1984 Facial p ro le and orthognathic su rgery. Br J Orthod 11:126–136. Lu ther F 2007 TMD and occlu sion p art I. Dam ned if w e d o? Occlu sion: the interface of d entistry and orthod ontics; TMD and 17 17 • 108 PROMINENTCHINANDTMJDS occlusion p art II. Dam ned if w e d on’t? Functional occlu sal p roblem s: TMD epid em iology in a w id er context. Br Dent J 202:E2, Br Dent J 202:E3. Prof t WR, White R, Sarver D 2003 Contem p orary Treatm ent of Dentofacial Deform ity. Mosby, St Lou is. Ryan F, Shu te J, Ced ro M et al 2011 A new style of orthognathic clinic. J Orthod 38:124–133. For revision, see Mind Map 17, page 237. 18 Dri ting incisors Dental history Iain has been a regu lar attend er at another d ental practice for m any years before m oving to you r area. H e is highly m otivated and d oes not w ish any tooth to be lost. 1 w as trau m atized in his early tw enties and has becom e p rogressively d arker, bu t he is u nconcerned by this. Iain had orthod ontic treatm ent w ith xed ap p liances as a teenager becau se his u pp er and low er teeth w ere crooked . N o teeth w ere extracted , and he w ore rem ovable retainers for 1 year (6 months fu ll-tim e and 6 m onths part-tim e) follow ing treatment. After he stopped w earing the retainers, his bite changed and his orthod ontist said it w as d u e w as d u e to his low er jaw grow ing m ore. Medical history Iain has d iabetes w hich is w ell controlled by insulin. H e is otherw ise t and w ell. SUMMARY Social history Iain, a 51-year-old man, presents with spacing and mobility o his upper incisors (Fig. 18.1). What is the cause, and what can be done? Iain sm okes 10 cigarettes a d ay and has d one so for 30 years. History Complaint Iain com plains of the sp acing of his u pper front teeth and looseness of all his front teeth, p articu larly of 2 and 2. H e is self-consciou s of the spacing and is w orried in case his front teeth fall ou t. History o complaint H e has noticed increasing m obility of his u p p er front teeth over the p ast few m onths. The sp acing betw een the teeth ap peared at the sam e tim e and is becom ing p rogressively w orse. There is no pain associated w ith the m obility of the teeth, bu t eating has becom e u ncom fortable. H e is also aw are of m obility of his low er front teeth and of several u p per and low er back teeth. Recently he has exp erienced an u np leasant taste in his m ou th, w hich app ears to be d erived from the u p p er front teeth. Examination Extraoral There are no p alpable subm and ibu lar or cervical lym ph nod es. Intraoral ■ Wha t do you notice in Figs 18.1 a nd 18.2? Oral hygiene appears air with generalized interproximal staining. Interdental gingivae related to the lower central and lateral incisors appears slightly oedematous. Generalized gingival recession. Heavily restored dentition with 1 discoloured. 7654321 present in all quadrants; 8 also in lower right quadrant. Mild lower incisor crowding. Uncrowded upper arch with incisor spacing. Class III incisor relationship with minimal overbite and overjet except or 2 1; upper and lower centrelines are not coincident. Class I molar relationship bilaterally. ■ Ba sed on wha t you know so a r, what are the possible actors implicated with respect to mobility and dri ting o 21 12? Chronic periodontal disease is a de nite possibility when the overall periodontal condition is observed. Periapical periodontitis is another possibility, but this would also tend to lead to extrusion o these teeth, which is not markedly evident. Root resorption. This would have to be extensive to produce such spacing and mobility. Root ractures. This is not a possibility in view o the history. Fig. 18.1 Occlusion at presentation. Other pathology such as radicular cyst or bony lesions are rarer possibilities. 18 • 110 DRIFTINGINCISORS A B C D Fig. 18.2 (A) Lower occlusal view. (B) Upper occlusal view. (C) Right buccal occlusion. (D) Le t buccal occlusion. ■ Wha t would you check or specif ca lly in relation to the history? Degree o any tooth mobility. Presence, extent and location o plaque and/or supragingival/ subgingival calculus deposits. Presence/site o bleeding on probing. Presence/site o periodontal purulent exudate. Presence/site o a sinus and/or associated exudate. Presence/site o any deep carious lesion. Occlusal actors that may contribute to tooth mobility, e.g. displacing occlusal contacts and/or a bruxing habit. Other habits, e.g. pen-chewing, nail-biting. Calculus is present subgingivally on all teeth with generalized 4 6-mm pocketing and delayed bleeding on probing. There is a purulent discharge rom the periodontal pocket on the mesial aspect o 2 . No sinuses are present. There are no carious teeth. Upper and lower molars, premolars and canines exhibit grade I mobility buccolingually but not vertically. Upper and lower incisors have grade I mobility buccolingually but not vertically except or 2, which exhibits grade II mobility buccolingually and vertically. Fig. 18.3 Full-mouth periapical radiographs. Iain has right and le t group unction in lateral excursions. There are no occlusal inter erences in protrusion. There is no bruxism, pen-chewing or nail-biting habit. Investigations ■ What other investigations would you ca rry out? Why? Full-m ou th periap ical rad iograp hs are requ ired to assess accu rately the period ontal status, particu larly the alveolar bone height as w ell as the presence of any p eriapical pathology. ■ Full-mouth periapica l radiographs are shown in Fig. 18.3. What do you see? Generalized horizontal bone loss o at least 50% with angular 2 1 bone de ects a ecting . 63 26 111 • DRIFTINGINCISORS 70 80% alveolar bone loss a ecting the lower incisor teeth. Heavily restored dentition, but no caries visible. Diagnosis ■ What is your diagnosis? Chronic moderate periodontitis with localized areas o advanced disease. Class III malocclusion with mild lower incisor crowding and spacing/dri ting o the upper incisors. Upper and lower centreline shi ts. Buccal segment relationship is Class I bilaterally. ■ With loss o periodontal attachment, how ma y labial dri ting o the incisors occur? Alveolar bone loss compromises the ability o the teeth to deal with so t tissue and occlusal orces, thereby leading to tooth movement. A traumatic occlusion may result rom extrusion as a consequence o periodontal disease. Dri ting may occur where periodontal support is also reduced. Labial shi t o periodontally involved upper incisors may result also rom a displacing occlusal contact on closure producing a orward mandibular slide. Undue orces may be placed on the incisors, where posterior tooth support is lacking due to tooth loss, and these can lead to upper incisor proclination. Key point Migration o periodontally involved incisors may be exacerbated by: • A orward mandibular displacement on closure. • Def cient posterior occlusal support. Referral for joint periodontal/orthodontic consultation. Iain’s cond ition requ ires sp ecialist care in view of the ad vanced natu re of the p eriod ontal d isease. ■ Wha t periodonta l treatment do you envisage will be required? Oral hygiene instruction, particularly in the use o interproximal cleaning aids. Full-mouth scaling and root planing. Reassessment. Consider localized surgery to those areas where response to primary phase therapy is inadequate, i.e. bleeding/purulent exudate on probing persists. ■ How would you describe the prognosis o Iain’s dentition? Prognosis d epend s on the response to initial therap y and p atient factors such as m otivation tow ard s m aintenance of a very high stand ard of oral hygiene and cessation of the sm oking habit. Based on the am ou nt of alveolar bone loss, the prognosis of the u pp er incisors is likely to be better than that of the low er incisors. ■ Wha t are the treatment options or the upper labial segment spacing? 1. Orthodontic alignment o the upper labial segment teeth with space closure. Six months a ter completion o periodontal therapy, the periodontist should re-evaluate the periodontal status. Provided it has not deteriorated and Iain is not averse to the prospect o wearing an orthodontic appliance, orthodontic treatment could be considered. 2. Extraction o 2 or o 2112 and replacement on a partial upper denture or adhesive bridgework. Extraction o 112 may be required also with similar prosthetic replacement to the extracted upper units. Iain op ted for xed ap p liance therap y to align the u p p er teeth (Fig. 18.4). ■ Wha t options are there with regard to improving appliance aesthetics in an adult pa tient? ■ What is the signif cance o the medical history a nd social history to the diagnosis? Diabetes affects the host resp onse to p eriod ontal p athogens by altering polym orph chemotaxis. Althou gh Iain’s d iabetes is w ell controlled , p eriod ontal d isease is chronic and generalized d u e to inad equ ate oral hygiene m easu res aggravated by the host resp onse. Sm oking contribu tes signi cantly to p eriod ontal d isease throu gh a variety of m eans. Gingival blood ow is red uced ; salivary ow is slow ed also, lead ing to p oorer rem oval of p eriod ontop athic bacteria and encou raging calcu lu s bu ild -up . Options are aesthetic brackets (p olycarbonate or ceram ic), clear aligner therap y (Invisalign ®) and lingu al orthod ontics. Each, how ever, is not w ithout its shortcom ings (Table 18.1). Treatment ■ What treatment would you advise? Cessation of smoking. The patient should be encouraged to stop sm oking to p revent any fu rther insu lt to his p eriod ontal health im posed by this habit. 18 Fig. 18.4 Upper xed appliance. 18 • 112 DRIFTINGINCISORS Table 18.1 Shortcomings o aesthetic orthodontic appliances Treatment option Shortcomings Aestheticbrackets Polycarbonate brackets Stain, de orm, poor torque control (improved with metal insert) Ceramic brackets Cannot bond to composite unless a silane coupling agent is used, which increases bond strength and risko enamel damage at debond (overcome bydi erent base designs to allowmechanical bond) Enamel damage at debond (problemovercome with di erent base design but must ollowmanu acturer’s instructions specifc or di erent bracket designs) Bracket breakage Fig. 18.5 Final occlusion (bonded palatal retainer in place). Wear o opposing enamel Increased riction compared with metal (overcome byinsertion o metal slot) Clear aligner therapy Control o root movement and possible intermaxillarycorrection limited unless bonded attachments added appropriately Extraction site space closure di cult Lingual appliances Regu lar p eriod ontal recall shou ld be u nd ertaken throu ghou t orthod ontic treatm ent. Due to the loss of p eriod ontal attachm ent and alveolar bone, p erm anent bond ed retention w ill be required . The nal occlu sion is show n in Fig. 18.5. Tongue discomort Speech adjustment Di cult to place (indirect bonding required) and adjust (operator/patient time and cost implications) ■ Wha t specia l considerations are there with orthodontic treatment in a periodontally compromised dentition? Band s shou ld be avoid ed d u e to the risk of further com p rom ising p eriod ontal su p p ort by p lacem ent of the band m argin su bgingivally, creating a nid u s for p laqu e accu m ulation. Bond ed attachm ents, therefore, shou ld be p laced on all teeth inclu d ing m olars. It is also p referable to u se stainless steel ligatu res rather than elastom eric m od u les to retain orthod ontic archw ires, as m od u les attract higher levels of plaqu e m icro-organism s. If several p osterior teeth have been lost, anchorage for the tooth m ovem ents required m ay not be su f cient and reinforcem ent w ith a bond ed transpalatal arch or a tem porary anchorage d evice m ay be necessary. With red u ced alveolar bone su p p ort, light forces shou ld be applied to the teeth. When gingival recession is evid ent p re-treatm ent, the patient shou ld be w arned as to the p ossibility of this being aggravated by orthod ontic tooth m ovem ent. Key point For orthodontic treatment in a periodontally involved dentition: • Avoid bands. • Use light orces. • Ensure regular periodontal recall during treatment. • Retain permanently. Primary resources and recommended reading Gu stke CJ 1999 Treatm ent of period ontitis in the d iabetic p atient. A critical review. J Clin Period ontol 26:133–137. Joffe L 2003 Invisalign ®: early experiences. J Orthod 30:348–352. Joss-Vassalli I, Grebenstein C, Top ou zelis N et al 2010 Orthod ontic therap y and gingival recession: a system atic review. Orthod Craniofac Res 13:287–297. Johnson GK, H ill M, 2004 Cigarette sm oking and the p eriod ontal p atient. J Period ontol 75:196–209. N attrass C, Sand y JR 1995 Ad u lt orthod ontics – a review. Br J Orthod 22:331–337. For revision, see Mind Map 18, page 238. 19 Appliance related problems A CASE1 SUMMARY Owen, an 8-year-old boy, presents or a routine check o his upper removable appliance. You notice a reddened palate (Fig. 19.1A). What is your diagnosis and how would you manage this? History Complaint Ow en’s only com plaint is that his up per rem ovable ap pliance is loose. H e is not aw are of any p roblem w ith his p alate. History o complaint Ow en has been w earing the upp er rem ovable appliance for the p ast 8 w eeks to correct a crossbite on 1. The current ap pliance has been getting progressively looser over the p ast m onth. Medical history Ow en is asthm atic and has used a salbutam ol (Ventolin) inhaler for the p ast 4 years. H is asthm a is w ell controlled . Examination Extraoral Ow en has a Class I skeletal pattern w ith average FMPA and no facial asym m etry. H is lips are com p etent, w ith the low er lip ju st covering the incisal third of the u pper anterior teeth. There are no tem p orom and ibu lar joint signs or sym p tom s. B Fig. 19.1 (A) Appearance o the palate at presentation. (B) Upper removable appliance. ■ Describe the appearance o the palate. The lesion affecting the p alate can be d escribed as follow s: Site palatal mucosa and attached gingivae. Size area a ected relates primarily to that covered by the baseplate o the upper removable appliance (Fig. 19.1B). Shape the outline is de ned by, and posteriorly extends slightly beyond, the shape o the baseplate. Colour uni ormly reddened appearance o the palate and attached gingiva primarily underlying the baseplate. Background mucosa and gingivae not covered by the baseplate appear o normal colour except an area in the palatal midline beyond the baseplate. ■ Wha t are your observa tions rega rding the upper removable appliance? The appliance has Adams clasps on 6 6 and D D with a Z spring to 1. The distal arrowhead on D clasp and the mesial arrowhead on 6 clasp do not engage the undercuts optimally. Intraoral The baseplate has posterior capping over 6ED DE6. The soft tissu es ap p ear norm al excep t for generalized m ild m arginal gingivitis and the p alatal m u cosa, w hich is show n in Fig. 19.1A. Oral hygiene is fair. Appliance hygiene does not appear as it should ood debris and plaque deposits are visible, through the baseplate, on the tting sur ace o the appliance. 19 • 114 APPLIANCE-RELATEDPROBLEMS ■ Wha t is the most likely diagnosis based on the in orma tion you have so a r? Palatal (d entu re) stom atitis, as the p atient is sym p tom free. ■ Wha t other condition would produce a similar appea rance? Acrylic allergy. This, how ever, is u nlikely as a ‘bu rning’ sensation of the m ucosa und erlying the baseplate w ou ld have been rep orted early after insertion of the ap p liance and there w ou ld be erythem a of all of the soft tissu es ad jacent to the acrylic. ■ What is the aetiology o ‘denture’ stomatitis? Candida is the princip al cause. Althou gh a norm al oral com m ensal, p roliferation of Candida is facilitated by local environm ental or system ic factors, thereby allow ing it to becom e pathogenic (Table 19.1). Key point Candida is the principal cause o palatal stomatitis related to an upper removable appliance. ■ Wha t actors in this case ma y have predisposed Owen to ‘denture’ stomatitis? The u se of a steroid inhaler, p oor app liance hygiene and fu ll-tim e w ear of the ap p liance are likely to be the m ain contribu tory factors. A d irect relationship has been show n betw een the p resence of an up p er rem ovable ap p liance, Candida and low salivary p H levels. In ad d ition, u p per removable ap p liance therap y has a p ositive, thou gh transient, in u ence on the p revalence of Candida and d ensity of oral cand id al carriage, su ggesting that the carrier state m ay be initiated by the appliance. Investigations ■ How would you conf rm the diagnosis? The ideal investigation is a smear rom the palatal mucosa underlying the baseplate or microbiological testing. Saliva sampling or Candida counts. Culturing or accurate identi cation and sensitivity testing may also be undertaken. ■ What stains identi y Ca ndida? Gram stain: Candida is strongly Gram positive. Periodic acid Schi (PAS): the magenta stain locates carbohydrate in ungal cell walls. Treatment ■ How would you treat this condition? Ow en shou ld be ad vised to: 1. Leave the appliance out at night. Due to the in ection, it would be wise to wear the appliance throughout the day but remove it at night until the palatal mucosa returns to health. 2. Improve appliance hygiene brush the tting sur ace and soak it in a 1% hypochlorite solution. 3. Improve oral hygiene teeth, gingivae and palatal mucosa should be brushed thoroughly a ter every meal. 4. Reduce sugar intake alter diet to low carbohydrate consumption. 5. Anti ungal agents (nystatin or amphotericin suspension or miconazole oral gel) should be applied to the tting sur ace o the appliance our times daily. A 0.2% chlorhexidine mouthwash may also be bene cial due to its anti ungal e ect. As the asthm a is w ell controlled , there is no need to refer Ow en to his general m ed ical p ractitioner. Key point Management o palatal stomatitis: • Leave appliance out at night. • Improve appliance and oral hygiene. • Reduce carbohydrate consumption. • Anti ungal agents. Table 19.1 Causes o denture stomatitis Factor Aetiology ■ What is the prognosis or this condition? Local In ection with Candida (~90%due to Candida albicans) Provid ed all the above strategies are follow ed , the cond ition shou ld resolve com p letely w ithin a few w eeks. Poor denture/appliance hygiene Night time wear o denture/appliance Poor salivaryclearance o oral commensals CASES2 AND3 High sugar intake providing substrate or Candida proli eration SUMMARY Ironandvitamindefciencies Two common f xed appliance problems are shown. What is the cause o each, and what treatment would you provide? Possible trauma Systemic Steroids Drugs that cause xerostomia Endocrine abnormalities, e.g. diabetes Antibiotictherapy } predispose to Candida in ection ■ What problem do you notice in Fig. 19.2A? A bracket has becom e d ebond ed from 5 . 115 • APPLIANCE-RELATEDPROBLEMS Table 19.2 Causes o bracket bond ailure Factor Aetiology Operator Insu cient etch time Poor etch pattern* Poor moisture control during bonding Non adherence tomanu acturer’s instructions with the bonding adhesive chosen Movement o the bracket a ter initial placement, which inter eres with bond ormation within the adhesive Application o high orce to the bracket to accomplish archwire engagement Patient Eating hard/sticky oods Possiblyuse o phenolic containing mouthrinses that so ten composite Occlusal trauma/bruxing habit Pen chewing/nail biting A *Etch pattern is poorer on premolars than on canine or incisor teeth. This contributes to the greater bond ailure rate on premolars (note ailure in Fig. 19.2Ais on 5). B A C Fig. 19.2 (A) Lower occlusal view. (B) Following removal o ligature wire and 5 bracket. (C) Following replacement o ligature wire and rebonding o a 5 bracket. B Fig. 19.3 (A) Upper occlusal view. (B) Following shortening and adjustment o upper archwire. ■ Why ha s this occurred? Bond failu re m ay occu r for variou s reasons (Table 19.2). Treatment ■ What trea tment would you provide? Explain why. The p atient shou ld be ad vised rst to contact their orthod ontist for rep air of the ap p liance (Figs 19.2B,C). If this is not p ossible and the loose bracket is at risk of being sw allow ed or inhaled , it shou ld be rem oved . In this case, how ever, this risk is less likely as the bracket rem ains attached to a ligatu re w ire and elastom etric m od u le. Should the loose bracket be a source of d iscom fort to the p atient, as a general d ental p ractitioner, you cou ld rem ove the loose bracket and the loose ligatu re. The p atient should be ap pointed w ith their orthod ontist at the earliest op portu nity. ■ Wha t problem do you notice in Fig. 19.3A? The cheek m u cosa is ulcerated d u e to trau m a from the overextend ed rou nd archw ire. 19 19 • 116 APPLIANCE-RELATEDPROBLEMS ■ How has this problem arisen? The am ount of projection of the archw ire beyond the m olar band m ay have been overlooked at the tim e of archw ire placem ent, or the archw ire m ay have m oved to its current position follow ing insertion, as the teeth aligned or d u e to loss/ bond failu re of another ap p liance com p onent. ■ How would you manage this problem? As a general d ental p ractitioner (GDP), you shou ld , rst, ad vise the patient to contact their orthod ontist to d eal w ith this p roblem . If this is not p ossible then you shou ld provid e emergency care. ■ As a GDP, what emergency ca re would you provide? A The d istal end of the archw ire shou ld be cut u sh w ith the terminal aspect of the m olar tube or the archw ire end tu rned u nd erneath the m olar tube or angled inw ard aw ay from the cheek. As a rou nd nickel titaniu m w ire is in p lace, w ith the terminal end heat-treated (note blackened ap p earance), this is easily cu t to the d esired length or p ositioned to avoid cheek trau m a (Fig. 19.3B). The patient should be ad vised to m aintain a high stand ard of oral hygiene and to rinse w ith lu kew arm salty w ater after m eals u ntil the u lceration heals. Provision of a su p ply of soft w ax to ap p ly over the m olar tu be and the ad justed w ire end m ay also be help fu l in the intervening p eriod . The patient shou ld also sched u le an app ointm ent in the near fu tu re w ith their orthod ontist. Key point Emergency treatment or: • Loose bracket: remove i risk o ingestion/inhalation. • Overextended archwire: cut wire and/or turn wire end inward away rom the cheek. CASES4 AND5 SUMMARY Two problems with retainers are shown. How might each o these have occurred, and what treatment would you provide? ■ What problem do you notice in Fig. 19.4A? There is a m id line fractu re of a low er vacu u m -form ed (Essix) retainer. ■ How might this problem have occurred? How may it have been prevented? This is a clean-cu t fractu re rather than a small crack and , as su ch, is u nu su al w ith a vacu u m -form ed retainer. Crazing of the retainer or sm all cracks are m ore typ ical. Extraorally, accid entally d ropp ing the retainer w hile cleaning or rinsing it, follow ed by an im pact from a sharp or heavy object, is possible; rep eated exu re of the retainer w ou ld also lead to reakage. Intraorally, eating hard food s w ith the retainer in situ or ‘biting’ the retainer into p lace w ith the op p osing Fig. 19.4 (A) Lower retainer. (B) Lower occlusal view showing retainer halves abutted; arrow indicates racture line. teeth are also p ossibilities. A w eakness in the retainer d uring m anu factu re is another op tion. Accid ental d am age is d if cu lt to p revent, but on issu ing the retainer the p atient shou ld have been instru cted to take care w hen rinsing or cleaning the retainer to avoid it being d rop p ed and d am aged ; w ear of the retainer for eating is also not requ ired . Flexing the retainer is to be avoid ed ; w hen not in u se, it should be stored in the hard , p lastic retainer box provid ed . The low er alginate im p ression should have been checked for any tray contact of the low er incisors or ‘d ragging’ that cou ld com p rom ise the m anufactu ring process. In this case the retainer had been accid ently stood on after being d ropp ed d u ring rinsing. It had only been issu ed 2 w eeks prior to the incid ent, w hen the low er xed appliance w as rem oved . Treatment ■ As a GDP, what treatment would you provide? Expla in why. The p atient shou ld rstly be inform ed to m ake contact w ith his or her orthod ontist to explain the situation and arrange to be seen as soon as possible for a replacem ent retainer. If this is not possible, you shou ld check each part of the retainer to see if the pieces t together and , if so, rinse and d isinfect them before assessing the t in the m ou th. As the pieces abutted w ell (Fig. 19.4B), they could be w orn as a tem p orary m easu re to p revent any relap se u ntil a rep lacem ent retainer is issued . Until a rep lacem ent retainer is tted , 117 • APPLIANCE-RELATEDPROBLEMS d ay-tim e w ear, ap art from eating and d rinking, w ou ld be p referable to night-tim e w ear, as there is a risk of one or both parts of the retainer becom ing d islod ged and p erhap s being sw allow ed . If, how ever, the orthod ontist is agreeable, an alginate im pression could be taken for a rep lacem ent retainer, w hich you m ay t w ith his or her gu id ance. A follow -u p ap p ointm ent w ith the orthod ontist shou ld be sched u led for the near fu tu re. ■ Could such a problem have been preempted a t debond? A At d ebond , it is ad visable to issu e the patient w ith tw o vacuu m -form ed retainers to allow for inad vertent breakage or loss. The sp are retainer can be w orn u ntil another ap pointm ent is possible w ith the orthod ontist, at w hich tim e a new sp are vacu u m -form ed retainer can be m ad e from the m od els constru cted w hen the xed ap p liance w as rem oved . ■ What problem (arrowed) do you notice in Fig. 19.5A? The com p osite overlying the w ire on 2 has been lost exp osing the w ire. (N ote the retainer w ire had previously fractured in the m id line; the w ire end s had been sm oothed and covered w ith com p osite.) B Fig. 19.5 (A) Lower occlusal view. (B) Anterior view. ■ How has this occurred? Eating sticky or hard food s or chew ing gu m is the m ost likely cau se. ■ How will you manage the problem? Enqu ire from the p atient w hen the exp osed w ire on 2 w as rst noticed , w hether there are p resently or have been any problems w ith this, how long the retainer has been in p lace and if the orthod ontist still sees the p atient for review. The patient rst noticed this 2 w eeks ago after chew ing a toffee; it rubs the tongu e and has p rod u ced a sm all u lcer. The retainer fractu red in the m id line 2 years ago, at w hich time it had been in p lace for 1 year; the w ire end s w ere sm oothed and covered w ith comp osite. Since then there have been no problem s. The p atient is d u e for a review w ith the orthod ontist next year. As such, the p atient should contact the orthod ontist to have the retainer assessed w ith regard to repair or replacem ent as soon as possible. ■ In the meantime, what would you do to improve patient com ort? As 2 is still aligned w ith the ad jacent teeth and com posite remains attached to the enam el and und ersurface of the w ire, a sm all com p osite ad d ition cou ld be m ad e to the w ire on 2 . The w ire su rface should be cleaned gently w ith pu mice, the com p osite rou ghened slightly on 2 w ith a green stone, then resin and com p osite ap p lied and light-cu red . An ap pointm ent shou ld be arranged w ith the orthod ontist in the near future. alignm ent w ith clear aligner therapy and replacem ent of the bond ed retainer w ould be optim al. Key point Emergency treatment or: • Broken vacuum- ormed retainer: arrange replacement. • Bonded retainer: composite repair/smooth wire end or arrange replacement. Primary resources and recommended reading Arend orf T, Ad d y M 1985 Cand id al carriage and p laqu e d istribu tion before, d u ring and after rem ovable orthod ontic ap p liance therap y. J Clin Period ontol 12:360–368. H obson RS, Ru gg-Gu nn AJ, Booth TA 2002 Acid -etch p atterns on the bu ccal su rface of hu m an p erm anent teeth. Arch Oral Biol 47:407–412. Mand all N A, Millett DT, Mattick CR et al 2002 Orthod ontic ad hesives: a system atic review. J Orthod 29:205–210. Patel A, Sand ler J 2010 First aid for orthod ontic retainers. Dent Up d ate 37:627–730. ■ What urther trea tment do you think will be required? Wilson J 1998 The aetiology, d iagnosis and m anagem ent of d entu re stom atitis. Br Dent J 185:380–384. In light of the m inor shifts in alignm ent that are now visible on several teeth (Fig. 19.5A and B), rem oval of the retainer, For revision, see Mind Map 19, page 239. 19 20 A B B A Tooth movement and related problems Fig. 20.1 Diagram illustrating zones o pressure (A) and tension (B) in the periodontal ligament induced by a tipping orce. CASE1 SUMMARY Darren, a 13-year-old boy, has been undergoing upper removable appliance therapy or 6 months to retract and align 3 , ollowing extraction o 4 . Tooth movement has been very slow with no movement recorded at the last two visits. Key point Tipping movement, typically, requires orces o 30 50 g or 0.3 0.5 N. ■ What are the possible reasons or a slow rate o orthodontic tooth movement? These can be d ivid ed broad ly into p atient, ap p liance and op erator factors. Patient actors Non-compliance with instructions regarding wear o the appliance. Incorrect positioning o the spring on appliance insertion or distortion o the spring. Contact o the tooth with the buccal cortical plate or with a retained root part o 4 . Occlusal inter erence rom the opposing arch. Appliance actors Acrylic and / or w ire m ay be interfering w ith tooth m ovem ent. Operator actors Design aw s, u nd eractivation, overactivation or activation of the sp ring su ch that 3 is d irectly buccally into contact w ith the cortical plate rather than through the cancellous corrid or of bone. ■ What orce ra nge is optima l or retraction o 3 by tipping movement? The op tim al force range is 30–50 g or 0.3–0.5 N . ■ What cellula r response is there ollowing activation o the spring to retract 3 by tipping movement? The consequ ence of activating the spring is to set u p zones of pressu re and tension w ithin the period ontal ligam ent. H alf of the p eriod ontal ligam ent is stressed w ith m axim u m pressu re created at the alveolar crest in the d irection of m ovem ent and at the d iagonally op posite ap ical area (Fig. 20.1). Pressure zones The cellu lar response d epend s on w hether a light or heavy force is ap plied . With a light sustained force, tooth m ovem ent occu rs w ithin a few second s as p eriod ontal ligam ent uid is squeezed ou t and the vascu lar sup ply is com pressed , setting off a com p lex biochem ical response. Within 2 d ays, osteoclast invasion occu rs and frontal resorp tion follow s. When a heavy sustained force is app lied , the period ontal ligam ent is com p ressed to su ch a d egree that the blood su p p ly is cu t off com p letely, prod ucing an area of sterile necrosis (hyalinization). Sm all areas of hyalinization are inevitable, even w ith light forces, bu t the area of hyalinization is extend ed w ith forces of greater m agnitu d e. Osteoclast d ifferentiation is im p ossible w ithin the necrotic period ontal ligam ent space, bu t after several d ays osteoclasts app ear ad jacent to and w ithin the ad jacent cancellou s sp aces. From there they invad e the bone ad jacent to the hyalinized area and tooth m ovem ent eventually occurs by und erm ining resorp tion. Tension zones Follow ing initial ap plication of a light force, the blood vessels vasod ilate and the p eriod ontal ligam ent bres are stretched w hile broblast and preosteoblast p roliferation occu rs. The stretched bres become em bed d ed in osteoid , w hich later m ineralizes. The norm al period ontal ligam ent w id th is eventu ally regained by sim u ltaneous collagen bre rem od elling. With heavy forces, rup tu re of blood vessels and severing of the p eriod ontal ligam ent bres are likely, bu t both are restored w ith the rem od elling p rocesses. 119 • TOOTHMOVEMENTANDRELATEDPROBLEMS Key point Application o a sustained orce to a tooth creates areas o pressure and tension within the periodontal ligament which ultimately lead to bone resorption and deposition, respectively. ■ What is the mechanism or tooth movement? Althou gh the histological response to an app lied orthod ontic force has been investigated extensively, the m echanism by w hich a m echanical stim u lu s is transferred to a cellu lar response is com p lex and is at present u nresolved . It is likely that vascular changes in the p eriod ontal ligam ent in areas of p ressu re and tension, electrical signals in response to alveolar bone exing follow ing force ap p lication, as w ell as prostagland ins and cytokine release interact in this p rocess. ■ How would you manage the problem in this case? Managem ent is sp eci c to each cau se. The action taken m ay be one or more of the follow ing: The need or ull-time wear o the appliance must be emphasized to the patient/parent. They must be made aware that treatment will stop unless ull cooperation is orthcoming. Show the patient how to insert the appliance with the spring positioned correctly and explain the action o the spring. Ensure that the appliance is not being removed by the spring. Check the activation o the spring and adjust it appropriately. Remove any acrylic or wire obstruction to tooth movement. This may require a remake o the appliance to an improved design. Add to a f at anterior biteplane or buccal capping to disengage the occlusion, i this is hampering tooth movement. Ask the patient and check his or her case notes or any recorded problem with 4 extraction. I indicated, take a periapical radiograph o 4 area to check or a retained root ragment. I this is detected, seek an oral surgical opinion regarding its removal or whether it could be le t in situ and its position monitored radiographically. Check 3 is not ankylosed. This is unlikely in this case as some movement o 3 has occurred since 4 was extracted. Darren admitted to intermittent wear o the appliance and, in particular, to leaving it out at meals. He was advised accordingly. Key point Full-time wear o an upper removable appliance is required or an optimal rate o tooth movement. Fig. 20.2 Periapical radiograph. ■ Wha t treatment would you advise? Com p lete retraction of 3 is u nlikely d u e to the p resence of this root fragm ent. H ow ever, its rem oval w ou ld requ ire a surgical proced ure, w hich w ould rem ove a consid erable amou nt of alveolar bone and m ay d am age the roots of the ad jacent teeth. The root fragm ent m ay resorb in tim e and becom e con u ent w ith the alveolar bone. In view of the surgical risks, it w ou ld be w ise to leave the root fragm ent in situ, monitor its status rad iographically and accep t the lim itation this p oses to com p lete retraction and alignm ent of 3 . The p atient should be ad vised accord ingly. CASE2 SUMMARY Alan is reviewed 3 months a ter completion o a 2-year course o upper and lower f xed appliance therapy. He is wearing upper and lower removable retainers at night only. On removal o the retainers, you detect grade 2 mobility o the upper incisors and grade 1 mobility o all other teeth anterior to and including the f rst permanent molars in both arches. His oral hygiene is good, and there is no bleeding on probing. You order a dental panoramic tomogram. ■ Why is the ra diogra ph ordered? It w ill allow a general screen of alveolar bone height and root length of all teeth. ■ Wha t do you notice on the f lm (Fig. 20.3A)? Generalized ap ical blunting (root resorp tion) of all teeth, anterior to and inclu d ing the rst perm anent m olars w ith the p ossible excep tion of the second p rem olars. The u p per incisors ap p ear to have the m ost root resorp tion. ■ Which teeth experience most orthodontically induced root resorption? ■ What do you notice on the peria pical radiograph o another ca se (Fig. 20.2)? There is a sm all retained ap ical root fragm ent of 4 . The u pper incisors, follow ed by the low er incisors and rst p erm anent m olars, have consistently m ore root resorption than other teeth irrespective of suggested genetic or treatm ent-related risk factors. 20 20 • 120 TOOTHMOVEMENTANDRELATEDPROBLEMS evid ence sup p orts the u se of light forces, esp ecially for incisor intru sion. Alan su stained coronal fractu res to 1 1, involving enam el and d entine, 3 m onths before starting orthod ontic treatm ent. Key point Root resorption: • Increases in incidence and severity with comprehensive orthodontic treatment. • Is promoted by the use o heavy orces. A ■ Could root resorption ha ve been prevented? Root resorption is regard ed as an u navoid able sequ ela of orthod ontic tooth m ovem ent. Althou gh, on average 1 m m of root length w ill typ ically be lost over a 24-m onth cou rse of orthod ontic treatm ent, w id e ind ivid u al variation exists. Determ ining risk factors to id entify those su sceptible to orthod ontically ind uced root resorp tion, and the m eans by w hich its severity and prevalence m ay be red uced , requires fu rther w ell-d esigned clinical research stu d ies. Du ring treatm ent excessive force ap p lication shou ld be avoid ed . Where early root resorp tion is d etected on progress rad iograp hs, taken 6–12 m onths into treatm ent (Fig. 20.3B), fu rther root resorp tion m ay be red u ced by a 2–3-m onth p ause (w ith a p assive archw ire). Where severe root resorption is d etected (>4 m m or one-third of the original root length), the treatm ent goals should be reconsid ered w ith the p atient and other options explored . B C Fig. 20.3 (A) Dental panoramic tomogram. (B) Periapical radiographs o upper incisors taken 6 months into treatment. Note no apical root resorption apparent on 12, but slight apical resorption o 21 roots. (C) Periapical radiographs indicating marked root resorption o 2112. ■ What risk a ctors have been suggested in rela tion to orthodontica lly induced root resorption? Suggested patient-related risk factors inclu d e patient age and sex, root shap e, history of p reviou s trau ma, teeth w ith short roots and previous root resorp tion, cortical bone p roximity to the root, genetic factors and system ic factors. Su ggested treatm ent-related risk factors inclu d e length of treatm ent, force m agnitu d e and m ethod of ap p lication, d irection of m ovem ent, ap p liance typ e, treatm ent m echanics and extent of ap ical m ovem ent. ■ What does current evidence suggest with regard to orthodontica lly induced root resorption? System atic review s ind icate that previous traum a and u nusu al root m orphology are u nlikely causes; root lled teeth d o not app ear to be m ore vulnerable than contralateral vital teeth. An increased incid ence and severity occu rs w ith comp rehensive orthod ontic treatm ent w ith total root resorp tion red u ced by a 2–3-m onth pau se in treatm ent. Bracket prescrip tion, self-ligation and archw ire sequ ence d o not affect this. H eavy forces prod u ce m ost root resorp tion, and ■ What must the orthodontist ensure be ore treatment commences? The risk of apical root resorp tion as a consequ ence of orthod ontic treatm ent m u st be exp lained to the p atient/ p arents and d iscu ssed w ith them. In ad d ition, an informed consent form signed by p atient/ p arents and the orthod ontist m u st d escribe, in p articular, the risk of apical root resorption. Treatm ent shou ld not be offered unless the anticip ated bene ts far ou tw eigh the risk of m inor ap ical resorp tion seen in most p atients. Ap prop riate rad iographs shou ld be available, and the need for progress rad iograp hs, as requ ired , shou ld be explained . Key point • Root resorption is a common consequence o orthodontic treatment. • Explain the risk to the patient be ore treatment starts and obtain consent. • Monitor radiographically as required. ■ What would you do in this case? Ask the patient i he is aware o marked mobility o any teeth and/or any other symptoms. Clinically, the mobility o all teeth should be recorded. Alan was aware o upper incisor mobility. 121 • TOOTHMOVEMENTANDRELATEDPROBLEMS 20 Enquire about bruxism or other habits, such as nail-biting. None were reported. Sensibility testing o the incisors and canines should be undertaken. All teeth were responsive to sensibility testing and no marked di erences in recordings were detected between each tooth and its opposite number in each arch. ■ What treatment would you provide? Alan shou ld continu e w ith night tim e w ear of his retainers. The retention p lan m ay need to be re-evalu ated d ep end ing on the resorp tion statu s of the incisors (see below ). Periap ical rad iograp hs shou ld be taken of the u pp er incisors as these exhibit grad e 2 m obility (Fig. 20.3C). Follow -u p rad iograp hic examinations and sensibility tests are recom m end ed at 6 m onths to ascertain if the ap ical root resorp tion is progressive. This, how ever, shou ld be u nlikely as ‘active’ orthod ontic treatm ent has been conclu d ed . In the u nlikely event that fu rther resorp tion is observed at follow -u p, rad iograp hic exam ination is recom m end ed u ntil the resorp tion is stabilized . In the long term (10–25 years) after orthod ontic treatm ent, teeth w ith root length of ≥10 m m and a healthy period ontiu m have been show n to rem ain stable. CASE3 A B Fig. 20.4 (A) Right buccal occlusion at presentation. (B) Anterior occlusion at presentation SUMMARY Lisa, an 18-year-old girl, had previous extraction o lower f rst premolars and f xed appliance therapy to success ully correct her Class III malocclusion. Both upper second premolars were congenitally absent. On removal o the f xed appliances 1 year ago, a palatal bonded retainer was placed rom 3 to 3; she was also issued an upper Hawley retainer, designed to f t over the bonded retainer, and a lower vacuum- ormed retainer. Both removable retainers were to be worn at night only. ■ What do you notice in Figure 20.4 A and B? So t tissues appear healthy; 6 seems to be restored with an amalgam restoration. Lower arch is reasonably aligned with a small space between 5 and 3 . Right upper buccal segment and labial segment aligned with the possible exception o 6 . Spacing between 1 1 and 1 and 2 with slight mesiolabial rotation o 1 and 2. Average overjet; overbite average to slightly reduced but complete; mild centreline discrepancy (lower appears shi ted to the le t by about 2 mm). Molar relationship is Class I with crossbite a ecting the mesiobuccal cusp o 6 . ■ What does this indica te? There has been relap se in the p osition of Lisa’s teeth follow ing treatm ent. ■ Why has this occurred? The follow ing factors are likely to d estabilize the nal orthod ontic resu lt. Forces rom the supporting tissues Reorganization of p rincipal p eriod ontal ligam ent bres and su p p orting alveolar bone occu rs w ithin 4–6 months after cessation of active tooth m ovem ent. At least 7–8 m onths, how ever, are requ ired for the su p racrestal bres to reorganize becau se of the slow tu rnover of the free gingival bres. Rotational correction and sp ace closure are, therefore, liable to relap se. Pre-treatm ent view s of Lisa’s m alocclusion are show n in Figs 20.5A and B. N ote the rotated teeth and spacing of the arch. Forces rom the oro acial so t tissues Follow ing ap pliance therapy, the teeth shou ld be in a p osition of soft tissu e balance. The original m and ibu lar arch form shou ld rem ain u nchanged as m arked alteration in the inclination of the low er incisors w ill prom ote relapse. Lim ited p roclination of the low er labial segm ent, how ever, m ay be stable in Class II d ivision 2 m alocclu sion, or if the low er incisors w ere retroclined by a thu m b-sucking habit or by a low er lip trap . If a thu m b- or d igit-su cking habit is not ceased before treatm ent com m ences, its p ersistence w ill prom ote overjet relapse. One-third to half of the labial su rface of the u p p er incisors should be covered by the low er lip to give the best chance of stable overjet correction. Where the lips are grossly incom p etent post-treatm ent, the u pp er incisor position w ill 20 • 122 TOOTHMOVEMENTANDRELATEDPROBLEMS Key point A B Fig. 20.5 (A) Right buccal occlusion (pre-treatment); note rotations o 621 1 and spacing. (B) Anterior occlusion (pre-treatment); note incisor spacing and rotations. be inherently u nstable, and the mechanism by w hich an anterior oral seal is achieved w ill aggravate this further. Occlusal actors A poor buccal segm ent interd igitation w ith d isp lacing occlu sal contacts and an u nfavou rable interincisal angu lation w ill encou rage instability. Post-treatment acial growth Facial grow th continues into ad u lt life and , althou gh of lesser m agnitu d e than that observed d uring child hood , it varies am ong ind ivid u als. On average, fem ales tend to d em onstrate a backw ard m and ibular rotation, and this w ill not aid overjet stability. Late facial grow th also im pacts on the d evelopm ent of late low er incisor crow d ing. Retention plan An inap p rop riate d esign of retainer, retention regim en and / or inad equ ate com pliance by the patient w ith the prescribed retainer w ear w ill facilitate relap se. Firm ru les, how ever, d o not exist for retention follow ing active tooth m ovem ent; instead the retention plan should be d ecid ed ind ivid u ally for each case. H ow long this shou ld be for is unknow n at present and probably unlikely to be ascertained d u e to the m u ltip licity of com p lex factors involved in m alocclu sions and their treatm ent, as w ell as the inherent d if culties in u nd ertaking clinical trials on the m any likely retention strategies. It is acknow led ged that the only m eans of guaranteeing that the p ost-treatm ent resu lt rem ains u nchanged long-term is to ad vise long-term retention. This should be exp lained to the patient by the orthod ontist before treatm ent starts as a p art of inform ed consent; im portantly, the p atient’s resp onsibility in the retention process m u st also be em phasized . Relapse may be due to: • Forces rom: • Supporting tissues. • Oro acial so t tissues. • Occlusion. • Facial growth. • Inappropriate retainer design or retention regime, and/ or patient compliance. Pre-treatment: • Discuss relapse and retention as part o in ormed consent. • Highlight patient’s responsibility to adhere to long-term retainer wear. Lisa ind icated that she had w orn the rem ovable retainers for a few m onths at night but then had d iscontinu ed w ear. The u p p er bond ed retainer had com e aw ay from 13 2 w eeks ago, and the w ire had fractu red betw een 1 1. She w as now concerned abou t the sp aces that had d evelop ed and that her front teeth w ere ‘tw isting’ back to the w ay they u sed to be. ■ What designs a re there o f xed and removable retainers? Several d esigns of xed retainers exist, althou gh in the low er arch this is m ost com m only either a sm ooth, rou nd w ire w ith sand blasted end s bond ed to the canines only or a mu ltistrand / spiral w ire bond ed to each of the incisors and canines ind ivid u ally (Fig. 20.6). In the upp er arch, a m ultistrand w ire is com m only bond ed to the incisors only or to the canines and incisors. For either arch, a 020 in m u ltistrand w ire is recom m end ed . Bond ing is u sually w ith lightcu red com posite. Rem ovable retainers m ay either be vacu um -form ed (Fig. 20.7) or have a w ire labial bow (u su ally H aw ley or Begg typ e: Fig. 20.7; Fig. 20.8A); the latter m ay be acrylated to im prove app earance (Fig. 20.8B). ■ What does current evidence indicate with regard to post-orthodontic retention? A recent upd ate of a Cochrane review found that m ost stud ies on types of retainers and d u ration of retainer w ear w ere of low qu ality. Based on a sm all nu m ber of p articip ants in one w ell-cond ucted short term (6 m onths) stud y, mod erate qu ality evid ence ind icates that there is no d ifference in stability betw een fu ll-tim e or p art-tim e w ear of therm oplastic retainers. There is, how ever, insu f cient high qu ality evid ence w ith regard to retention p rotocols and p roced ures follow ing orthod ontic treatm ent to m ake rm recom m end ations. ■ How ca n relapse be prevented long-term? N ight-tim e w ear of a rem ovable therm oplastic retainer shou ld continu e long-term , althou gh w ear on alternate nights red uced to biw eekly m ay be suf cient w ith the onu s on the p atient to m onitor occlu sal change. Du e to the u npred ictability, bu t high likelihood , of late low er incisor crow d ing d eveloping post-treatm ent (see Chapter 16), instead of ad vising long-term w ear of a rem ovable retainer, a bond ed lingu al retainer m ay be tted to the 123 • TOOTHMOVEMENTANDRELATEDPROBLEMS 20 A A B Fig. 20.8 (A) Upper Begg retainer. (B) Upper Hawley retainer with an acrylated labial bow. ■ What specif c indications are there or a f xed (bonded) retainer over a remova ble retainer? B Fig. 20.6 (A) Lower bonded retainer (multistrand wire). (B) Upper bonded retainer (multistrand wire) with Hawley retainer. A xed bond ed retainer is ind icated in the follow ing circu mstances: w hen the lip s are incom p etent after correction of an increased overjet; follow ing sp ace closu re in spaced d entitions (Figs 20.5A,B; also inclu d es m ed ian d iastem a, Chap ter 1); w here the anterop osterior p osition of the low er labial segment has been rad ically altered ; after alignm ent of severely rotated teeth (Fig. 20.5) or of an im p acted u p p er incisor (Chap ter 2) or p eriod ontally involved d entitions (Chap ter 18); cleft lip and p alate (Chapter 21) and w hen m inim al overbite exists follow ing incisor crossbite correction (Chap ter 10). In ad d ition, w here a com prom ised occlusion w as the treatm ent goal, albeit w ith im proved app earance, xed retention shou ld be used . Key point A bonded retainer is indicated ollowing correction o : • Severely rotated teeth and spaced dentitions. ■ Ha s the general dental practitioner (GDP) got a role with Fig. 20.7 Lower vacuum- ormed retainer and upper Hawley retainer. low er incisors and canines; increasingly this is left in place perm anently to m aintain low er incisor alignm ent. Key point In the short-term, night-time wear o a thermoplastic removable retainer seems su cient to maintain tooth alignment a ter f xed appliance therapy (except in cases with high relapse potential when a bonded retainer is required). regard to orthodontic retention? The GDP has a general inform ative and im portant su pportive role w ith regard to p ost-orthod ontic retention and retainer w ear by their patients. This is su m m arized in Table 20.1 ■ Wha t oral hygiene mea sures should the patient be instructed to ollow a ter placement o a bonded retainer? In ord er to m aintain optimal oral hygiene in relation to the bond ed retainer, the patient shou ld be tau ght how to effectively use interd ental cleaning aid s such as Su per oss and interd ental bru shes. Instru ctions in relation to a rem ovable (Essix) retainer are given in Chapter 5. 20 • 124 TOOTHMOVEMENTANDRELATEDPROBLEMS Table 20.1 Role o the general dental practitioner (GDP) in relation to post-orthodontic retention and retainer wear When Role Speci c aspect o retention Re erral/pre treatment In orm Retention vital component o treatment Post treatment at review Rein orce Need or retainer wear and howto maintain optimal oral and retainer hygiene Removable retainer Confrm Retainer wear as advised Ensure good ft Adjust as required Repair/replace? *Depends i still under reviewwith orthodontist Check Wire/composite, integrityo bond and related oral hygiene Bonded retainer Repair *Seekadvice, as required, romorthodontist regarding repair o broken/debonded retainer *It is important when the patient is no longer under reviewbythe orthodontist, but still wearing retainers, that the orthodontist communicates with the GDPwith regard to the retainer type and retention protocol. 3. A compromise plan would be to use a sectional clear aligner to the upper labial segment teeth only. Then, prolonged retention would be required to maintain the result, as outlined in option 2 above, with the vacuum- ormed retainer con ned solely to the labial segment. As Lisa is now a u niversity stud ent, she w as not keen for fu rther xed ap p liance therap y and op ted for sectional aligner therapy follow ed by prolonged retention. Primary resources and recommended reading Brezniak N , Wasserstein A 2002 Orthod ontically ind u ced in am m atory root resorp tion. Part I. The basic science aspects. Part II: The clinical asp ects. Angle Orthod 72:180–184. H arts eld JK Jr, Everett ET, Al-Qaw asm i RA 2004 Genetic factors in external ap ical root resorp tion and orthod ontic treatm ent. Crit Rev Oral Biol Med 15:115–122. H ennem an S, Von d en H off JW, Maltha JC 2008 Mechanobiology of tooth m ovem ent. Eu r J Orthod 30:299–306. Key point Following placement o a bonded retainer, instruction must be provided in relation to interdental cleaning. ■ What management options are there or Lisa’s problem? The follow ing options exist: 1. Accept and monitor study models should record the current tooth position and occlusion to allow or comparison with the pre- and post-treatment study casts and to act as a baseline rom which to assess any urther occlusal change. I there is urther relapse, then consider options 2 or 3 below. 2. Re-treatment ull case assessment is required with study models and photographs; radiographs are not indicated. For comprehensive recorrection, xed appliance therapy is an option, but clear aligner therapy with Invisalign is also likely to produce a satis actory outcome due to the mild nature o the relapse; the slight centreline shi t could be accepted with the latter treatment option. Long-term bonded retention will be required, therea ter, to the upper labial segment; it would also be advisable to provide a vacuum- ormed retainer to t over the bonded retainer. Although this dual retention ( xed and removable retainer) strategy was adopted ormerly, it must be emphasized to Lisa that should the bonded retainer partially debond, then the vacuumormed retainer must be worn to maintain tooth alignment prior to repair or replacement o the bonded retainer. Johnston CD, Littlew ood SJ 2015 Retention in orthod ontics. Br Dent J 218:119–122. Jonsson A, Malm gren O, Levand er E 2007 Long-term follow -u p of tooth m obility in m axillary incisors w ith orthod ontically ind u ced ap ical root resorp tion. Eu r J Orthod 29:482–487. Kotescha S, Gale S, Kham asha–Led ezm a L et al 2015 A m u lticenter au d it of GDPs know led ge of orthod ontic retention. Br Dent J 218:645–653. Littlew ood SJ, Millett DT, Dou bled ay B et al 2016 Retention p roced u res for stabilising tooth p osition after treatm ent w ith orthod ontic braces. Cochrane Database of Syst Rev Issu e 1. Art N o: CD002283. DOI: 10.1002/ 14651858.CD002283.p u b4. Little RM 2009 Clinical im p lications of the University of Washington p ost-retention stu d ies. J Clin Orthod 43:645–651. Melrose C, Millett DT 1998 Tow ard a p ersp ective on orthod ontic retention? Am J Orthod Dentofacial Orthop 113:507–514. Pand is N , Vlahopou los K, Mad ianos P et al 2007 Long-term p eriod ontal statu s of p atients w ith m and ibu lar lingual xed retention. Eu r J Orthod 29:471–476. Ren Y, Maltha JC, Ku ijp ers-Jagtm an AM 2003 Op tim u m force m agnitu d e for orthod ontic tooth m ovem ent: a system atic literatu re review. Angle Orthod 73:86–92. Roberts-H arry D, Sand y J 2004 Orthod ontics. Part II: orthod ontic tooth m ovem ent. Br Dent J 196:391–394. Walker SL, Long DT, Flores-Mir C 2013 Rad iograp hic com p arison of the extent of orthod ontically ind u ced external apical root resorp tion in vital and root- lled teeth: a system atic review. Eu r J Orthod 35:796–802. Weltm an BJ 2011 External root resorp tion and orthod ontic treatm ent—assessm ent of the evid ence. In: H u ang GJ, Richm ond S, Vig KWL (ed s), Evid ence-based orthod ontics. Wiley-Blackw ell, Chichester, p p. 63–88. For revision, see Mind Map 20, page 240. 21 Cle t lip and palate ■ How common is a a mily history with cle t lip and palate? Is this the same or cle t palate (CP) only? In arou nd 40% of cases w ith CLP, there is a fam ily history. For CP alone, how ever, a fam ily history is less (arou nd 20%). ■ Wha t is the preva lence o cle t lip and palate? It affects abou t 1 in 700 live births am ong Cau casians, but the prevalence varies betw een racial grou ps as w ell as geographically and is increasing. Cleft lip only is fou nd in abou t 9% of all clefts, w hereas a cleft of the lip and alveolus com p rises about 3% of all clefts. Com p lete u nilateral CLP is the m ost com m on type of cleft and rep resents 50% of all clefts. ■ Is there a sex a nd side va riation or CLP? Females are affected less frequ ently than m ales, and the right sid e is involved less com m only than the left. ■ How does this ma l ormation occur? SUMMARY Karen, a 9-year-old girl, is unhappy about the appearance o her teeth (Fig. 21.1). What is the cause, and how will it be treated? History Complaint Karen d oes not like the crooked ness and spacing of her u p per front teeth. H er m other is also aw are that the bite of Karen’s sid e teeth is not correct and feels that she m oves her jaw to the sid e w hen she closes her teeth together. History o complaint Karen’s baby front teeth w ere also crooked and spaced . H er m other has noticed the p roblem w ith her bite for several m onths. Failu re of fu sion of the m ed ian and lateral nasal p rocesses and the m axillary process at abou t 4–6 w eeks of intrau terine life lead s to a cleft of the p rim ary p alate (the u p p er lip and the alveolu s in the anterior region as far p osteriorly as the incisive foramen). Cleft of the second ary p alate (hard palate from incisive foram en back and soft p alate) is d u e to failu re of the palatal shelves to elevate and fuse at abou t 8 w eeks in utero. Genetic and environm ental factors, e.g. steroid therapy, folic acid d e ciency or anticonvu lsant d rugs, interact in the aetiology. Key point CLP: • Prevalence o 1 in 750 live Caucasian births. • Aetiology due to genetic and environmental actors. • Positive amily history in ~40% o cases. • More common in males and on the le t side. Medical history Karen w as born w ith a cleft lip and p alate (CLP), w hich has been repaired . Family history Karen’s parents have no fam ily history of cleft lip and p alate. H er old er brother and sister are also unaffected . ■ Wha t genetic risk is there o CLP? How does this compare to CP alone? As in this case of CLP, w here neither parent has a cleft and one child is affected , there is a sm all (4%; 1 in 25) risk that the follow ing child w ill be affected ; if the m other or father is affected , there is a 2% (1 in 50) likelihood of the rst child having CLP. Due to the lesser genetic involvem ent in clefts of the second ary palate, for u naffected parents of a child w ith isolated CP, the risk of a su bsequ ent cleft-affected child is 1 in 80. Key point There is a greater genetic risk with CLP than there is with CP. Fig. 21.1 Anterior occlusion at presentation. Karen has been attend ing a cleft clinic at the regional d ental teaching hosp ital since birth. 21 • 126 CLEFTLIPANDPALATE ■ Why is this? What treatment will have been provided to date, a nd what role have you to play as her general dental practitioner? Due to the interd isciplinary care required , treatment is facilitated for the patient and family by coord inating m anagement in a specialized centre w ith a team com prising an orthod ontist, speech therapist, health visitor and clinical psychologist as w ell as plastic, EN T and maxillofacial su rgeons. Treatm ent u ntil now is likely to have been as follow s: Neonatal period to 18 months Parental counselling by a member o the Cle t Lip and Palate Association (CLAPA) and/or clinical psychologist, as well as reassurance o the uture treatment by an orthodontist and member o the surgical team. Advice and support to the parents by a specialized health visitor, particularly in relation to eeding. In this case eeding problems are likely to have been modest, as the cle t only involves the primary palate. Planning o lip repair: this usually occurs at 3 months, although neonatal repair is being assessed. In this case closure o the alveolar de ect may be undertaken at the same time. Where a palatal cle t exists, on average, this is repaired between 6 and 9 months. Primary dentition First ormal speech and hearing assessment at around 18 months and then speech therapy as required. Regular speech and hearing assessments should be undertaken; consider closure o any palatal stulae to assist speech development. Consider pharyngoplasty to reduce velopharyngeal incompetence at 4 5 years, thereby attempting to improve any nasal intonation to speech. Consider lip revision at 4 5 years only i clearly indicated. As a general d ental p ractitioner you r role is to: Liaise with the CP team. Provide dietary advice and oral hygiene instruction to the parents, at regular intervals, rom eruption o the primary incisors. Consider the use o f uoride tablets i the level o f uoride in the local domestic water supply is below 1 ppm. On the cle t side, 2 is either absent, o abnormal size and/or shape, hypoplastic or present as two conical teeth on either side o the cle t. A supernumerary or supplemental tooth may exist on either side o the cle t. 1 is o ten rotated and tilted toward the cle t and may be hypoplastic. Eruption is delayed. Tooth size elsewhere in the mouth is small. Class III incisor relationship is common with crossbite o one or both buccal segments and a lateral open bite on the cle t side. Key point Incisor and buccal segment crossbites are common in repaired CLP. Examination Extraoral ■ What do you notice rom Fig. 21.2? Karen has a Class I skeletal p attern w ith average FMPA and no obviou s facial asym m etry. The lips are com petent w ith a scar on the right sid e of the u p p er lip . N o clicks, locks or crep itu s of the tem porom and ibu lar joints w ere d etected . ■ How is lip closure a chieved? A Millard rep air w ith or w ithou t its m od i cations is the m ost pop ular, aim ing, after d issection, to p lace the lip m uscles and alar base in their correct anatom ical location. Whether subperiosteal or su p raperiosteal d issection and skin-lengthening cuts are u sed , to obtain tissue m ovem ent, remains controversial. The extent of alar cartilage d issection or the u se of a vom er ap also rem ains u nresolved . Intraoral ■ The appea rance o the teeth is shown in Figs 21.1 and 21.3. Attend to any dental treatment required. What are your observa tions? Your particular aim in dental care is to promote and maintain excellent dental health or Karen, thereby avoiding the need or restorative treatment or en orced loss o primary teeth through dental caries. Oral hygiene is air. Plaque deposits are visible on several teeth. There is marginal gingival erythema related to most teeth. Key point Management o CLP requires a team approach. ■ Wha t skeletal/dental/occlusal problems a re commonly ound with CLP? Skeletally, there is a tendency or the maxilla and mandible to be retrognathic, the upper acial height to be reduced and the lower acial height to be increased. A Class III skeletal pattern is common. EDCB1 12CDE visible (6 6 were erupted but not shown). 6EDC21 12CDE6 E restored; possible caries in E DE; 1 slightly hypoplastic. Mild lower labial segment crowding. Spaced upper labial segment with 1 distolabially rotated. The cle t repair involves the right upper lip and alveolus bony depression is evident in the 2 area. a Class III incisor relationship with average overbite; B in crossbite; lower centreline shi t to the right. Right molar relationship hal -unit Class II with buccal segment crossbite involving CDE ; (6 was also involved but not shown); le t molar relationship is Class I. 127 • CLEFTLIPANDPALATE A A B B Fig. 21.2 (A) Pro le. (B) Full ace. C Fig. 21.3 (A) Lower occlusal view. (B) Right buccal occlusion. (C) Le t buccal occlusion. ■ In view o the unila teral crossbite o the right buccal segment, what should you check or? How would you do this? It w ou ld be im portant to check if there is a m and ibular d isp lacem ent on the p ath of closu re associated w ith the crossbite. As Karen’s m other has alread y noticed a shift of the low er jaw on closu re, a d isplacem ent is likely. To d etect this, Karen shou ld be instru cted to m aintain the tip of her tongue in contact w ith the back of her palate as she closes her teeth together. Carefu l observation should be m ad e of rst tooth contact on the path of closu re and the extent and d irection of any m and ibu lar d isp lacem ent into m axim u m intercuspation shou ld be record ed . There is a m and ibular d isplacem ent to the right on C closu re resu lting from p rem atu re contact of . C Investigations ■ What investigations are required? Explain why. A d ental p anoram ic tom ogram shou ld be taken to accou nt for the presence and p osition of any u neru p ted teeth and to ascertain w hether there are any perm anent teeth absent. An upp er anterior occlu sal rad iograph is requ ired to d eterm ine the extent of the alveolar cleft and the p osition of the perm anent m axillary canine on the cleft sid e. ■ Ka ren’s dental pa noramic tomogram and upper a nterior occlusal radiograph are shown in Fig. 21.4. What do you notice? The d ental panoram ic tom ogram show s: • Normal alveolar bone height except or the alveolar cle t in the 2 area, which extends to involve 3 . • All permanent teeth are present, except or 2 and third molars; ED DE are slightly in raoccluded. • 1 is hypoplastic; E E appear to have secondary caries underneath the restorations with possible urcation radiolucencies. • There is carious involvement o D D distally. • The upper anterior occlusal radiograph con rms the extent o the alveolar cle t, and when assessed in combination with the dental panoramic tomogram, 3 appears to be lying in the line o the arch. 21 21 • 128 CLEFTLIPANDPALATE A Fig. 21.5 Right buccal occlusion ollowing crossbite correction with quadhelix. ■ What would you do at this stage? Rein orce oral hygiene practice in preparation or orthcoming orthodontic treatment. Restore the lower primary molars. Fissure seal the rst permanent molars. B Fig. 21.4 (A) Dental panoramic tomogram. (B) Upper anterior occlusal radiograph. Liaise with the orthodontist on the cle t team regarding the planned orthodontic treatment. ■ What orm do you envisage the orthodontic trea tment to take? Diagnosis ■ Wha t is your diagnosis? Repaired right unilateral cle t lip and alveolus. Class III malocclusion on a Class I skeletal base with average FMPA. C Mandibular displacement to the right on closure on . C Generalized mild marginal gingivitis. Caries ED DE. Upp er arch exp ansion, by a qu ad helix appliance, to correct the right bu ccal segm ent crossbite is likely to be und ertaken p rior to alveolar bone grafting. ■ When is secondary alveolar bone gra ting usua lly undertaken and wha t adva ntages does it con er? Optim ally, it is u su ally u nd ertaken at arou nd 9–10 years. It p rovid es bone through w hich 3 can eru p t, restores arch integrity, im p roves alar base sup p ort, aid s closure of an oronasal stu la and allow s orthod ontic space closu re. ■ The occlusion prior to bone gra ting is shown in Fig. 21.5. What may you consider at this stage? Spaced upper labial segment with 1 distolabially rotated; absent 2 . Due to the ad vanced state of root resorption of C (see also Fig. 21.4), it w ould be u sefu l to rem ove this at least 3 w eeks before grafting to allow tim e for socket healing, thereby im proving the likelihood of graft success as an access rou te for oral infection is rem oved . Lower centreline to the right. ■ What treatment will be required ollowing alveolar Mild lower labial segment crowding. Right molar relationship hal -unit Class II with buccal crossbite o the right buccal segments; le t molar relationship is Class I. ■ Wha t is the IOTN DHC grade (see p. 264)? Explain why. 5p – d u e to CLP. Treatment ■ What are the aims o treatment at this stage? Caries control. Elimination o the mandibular displacement with correction o the right buccal segment crossbite. Elimination o the alveolar cle t de ect. bone gra ting? Once 3 eru pts, consid er space closu re w ith 2 replacem ent by 3 as the right u pper bu ccal segm ent is brou ght forw ard . This is a feasible plan and is the p referred op tion, as it obviates the need for any p rosthetic rep lacem ent of 2 . Consid er relief of crow d ing in the non-cleft qu ad rant and in the low er arch. Delay any low er arch extractions if orthognathic su rgery is p lanned at a later d ate. Fixed app liance therap y w ill be necessary for the active tooth m ovem ents requ ired . Bond ed retention w ill then be requ ired to m aintain up per labial segm ent alignm ent, and restorative treatm ent w ill be requ ired to make 3 sim ulate an u pper lateral incisor. 129 • CLEFTLIPANDPALATE ■ What restorative considerations a re there when 3 replaces 2 ? Restorative consid erations d ep end on the colou r, size and shap e of 3 in 2 p osition and an assessm ent of fu nctional occlu sion (see Chapter 3). Close assessm ent shou ld be m ad e of 2, so that insofar as p ossible, 3 is a close match to 2. Bleaching of 3 m ay be requ ired to tone in w ith the incisors. Some reshap ing of the 3 crow n is also likely – in p articu lar, red u cing the prominence of the cu sp tip and p ossible com posite ad d ition to the m esial su rface so that it m ore closely resem bles a 2 . As 4 w ill then be in the p osition of a canine, occlu sal ad ju stm ent of the p alatal cu sp m ay be necessary to rem ove any interference in lateral m and ibu lar excu rsions. Alternatively, if 4 has been intru d ed orthod ontically to achieve coincid ence of the gingival m argins of 4 and 1 , com p osite ad d ition m ay be need ed to achieve ‘canine’ gu id ance. In the late teenage years, consid eration m ay be given to fu rther lip revision or orthognathic su rgery w ith rhinoplasty later, if a m arked anterop osterior and / or vertical skeletal d iscrep ancy exists. In Karen’s case, p rovid ed facial grow th is reasonably favou rable, orthognathic su rgery m ay not be requ ired . Key point Secondary alveolar bone gra ting: • Provides bone or 3 eruption. • Restores arch integrity. • Improves alar base support. • Aids oronasal f stula closure. • Allows orthodontic space closure. Primary resources and recommended reading Bergland O, Sem b G, Abyholm FE 1986 Elim ination of the resid ual alveolar cleft by second ary bone grafting and subsequ ent orthod ontic treatm ent. Cleft Palate J 23:175–205. Gu o J, Li C, Zhang Q et al 2011 Second ary bone grafting for alveolar cleft in child ren w ith cleft lip or cleft lip and palate. Cochrane Database of Syst Rev Issu e 6. Art N o: CD008050. DOI: 10.1002/ 14651858.CD008050.p ub2. Mossey P, Little J, Mu nger RG et al 2009 Cleft Lip and Palate. Lancet 374:1773–1785. Rivkin CJ, Keith O, Craw ford PJM et al 2000 Dental care for the p atient w ith a cleft lip and palate. Part 1: From birth to the m ixed d entition stage; Part 2: The m ixed d entition stage throu gh to ad olescence and you ng ad u lthood . Br Dent J 118:78–83, 131–134. Thom AR 1990 Mod ern m anagem ent of the cleft lip and p alate p atient. Dent Up d ate 17:402–408. For revision, see Mind Map 21, page 241. 21 22 Nursing and early childhood caries ■ What is the cause o this pattern o decay? ‘N ursing caries’, or ‘nursing bottle m ou th’ or ‘bottle m outh caries’. ■ What can cause this? Consum ption of a sw eetened d rink or fruit- avoured d rink from a bottle or d inky feed er, esp ecially if the feed er is constantly in the m ou th or the child falls asleep w ith it in the m ou th. Care shou ld also be taken w ith lactu lose-free alternatives to d airy m ilk su ch as soya or rice m ilk. Persistent on-d em and breastfeed ing at night after 12 m onths of age (child is allow ed to sleep on the breast) m ay cause caries. There are many biological and social variables that confou nd this com p lex relationship . As can be seen, the term ‘nu rsing caries’ is p robably the m ost accu rate as it encom p asses both breastfeed ing and bottle feed ing. ■ Why are the teeth a ected in this pattern? SUMMARY Kelly-Ann is only 3 years old. She has been brought to the dentist by her mother because her upper ront teeth are ‘wearing away’ (Fig. 22.1). What has caused this, and how may it be treated? Teeth become carious in the ord er in w hich they eru pt (Fig. 22.2), w ith the exception of the low er p rim ary incisors, w hich are p rotected by tw o m ajor m echanism s: the p osition of the su bmand ibu lar d u cts that op en ad jacent to these teeth and the position of the tongu e in su ckling, w hich covers the low er incisors. ■ What additional actors make the upper prima ry incisors History The teeth apparently never cam e throu gh properly and w ere never w hite like the rest of her teeth. There has been no p ain from the teeth, and Kelly-Ann is eating and d rinking norm ally. Medical history Kelly-Ann is a healthy child . She has had all her vaccinations and has had no illnesses. She has never taken any m ed ication. Examination more predisposed to ca ries? High bow-shaped upper lip in in ants which does not cover the upper incisors and results in an increased evaporation o any saliva on these teeth. Gravity, which keeps submandibular saliva pooled around the lower incisors and less likely to reach the upper incisors. Any liquid with sugar that is allowed to bathe the teeth on a requent basis will cause caries. This is especially so at night when the protective unction o saliva reduces as less saliva is produced. Even breast milk, ormula milk or cows’milk with their lowered natural sugars can still be cariogenic on this basis. Extraorally there is no sw elling and no facial asym m etry. Intraorally she is in the fu ll prim ary d entition w ith the second p rim ary m olars having ju st eru p ted . There is caries affecting the u p per incisors and cavitation in all rst p rim ary m olars. Fig. 22.1 Early cavitation in nursing caries a ecting upper right lateral and central primary incisor and upper le t central incisor. Fig. 22.2 Classical distribution o a ected teeth in nursing caries in upper arch. This is a more advanced case than Kelly-Ann’s, with sign cant caries involving all maxillary primary incisors and upper central incisors non-vital and in ected. Occlusal caries is also seen in upper rst primary molars. 131 • NURSINGANDEARLYCHILDHOODCARIES A Fig. 22.3 Hypomineralization and hypoplasia are seen on the buccal sur aces o DBA ABD. In some situations maxillary incisors may erupt with hypoplastic or hypomineralized de ects, thus making the teeth less resistant to the development o dental caries (Fig. 22.3). B Key point Nursing caries: • A ects teeth in order o eruption. • Lower incisors are protected by saliva. • Can be caused by any sugar-containing liquid even i the sugar is naturally occurring rather than added to the liquid. Fig. 22.4 (A&B) Upper and lower dentition o a child with EB ABE extensive early childhood caries ( ) with a di ering ED DE pattern to that o nursing caries. Please note the gross caries in the lower second primary molars with an associated sinus E and exposure o root E. Treatment Prevention ■ Wha t should be your advice about night-time eeding? Only w ater should be given d uring the night after 12 m onths of age. The term early child hood caries (ECC) is a further term u sed to d escribe caries presenting in one or m ore p rim ary teeth of child ren u nd er the age of 5. Som e child ren p resent w ith extensive caries that d oes not follow the ‘nu rsing caries’ pattern and often p resent later, betw een 3 and 5 years old (Fig. 22.4). ■ How could you identi y pre-school children in need o denta l ca re? Encou rage p arents to bring their child ren for a d ental check-u p as soon as the rst p rim ary tooth eru p ts. Develop good w orking relationships w ith local health visitors, baby clinics, m other and baby grou p s, nu rseries and their local general m ed ical practice to encou rage w id er health and nu rsery staff to p rovid e ap p rop riate oral health ad vice. This ad vice shou ld follow the gu id ance of the Dep artm ent of H ealth (DoH ) Prevention Toolkit. Pu blic health p rogram m es in som e cou ntries encou rage and train general health p rofessionals, su ch as health visitors, to ‘lift the lip’ to id entify early caries affecting the u p p er m axillary incisors. ■ Kelly-Ann is at high risk or caries. List all the main actors you ca n think o or placing someone in the high risk group or denta l ca ries. See Table 22.1. ■ Wha t preventive a dvice would you provide or Kelly-Ann’s mother? Preventive ad vice shou ld follow the DoH Prevention Toolkit gu id ance. This provid es ad vice for child ren of d ifferent ages (in Kelly-Ann’s case, 0–3 years old ) follow ing placem ent in the high risk for caries category. Home based advice Although m any parents are fully aw are of the cau ses of d ental caries in their child or child ren, changing family behaviou r to u nd ertake healthier rou tines is more com plex. Consequently, carefu l consid eration is need ed in how preventive ad vice is given and w ho d elivers it. All m em bers of the d ental team shou ld have a basic u nd erstand ing of how they can support parents and child ren to und ertake these changes, and those d elivering these preventive m essages shou ld have a m ore d etailed know led ge of behaviou r change strategies. Toothbrushing and f uoride toothpaste Kelly Ann’s p arents shou ld u nd ertake toothbru shing for her last thing at night 22 22 • 132 NURSINGANDEARLYCHILDHOODCARIES Table 22.1 ‘High-risk’ actors or caries Risk actor Aetiology Clinical evidence Newlesions scores (w ith or w ithou t a d isclosing agent) allow s the d ental professional to m onitor p arental com p liance w ith the toothbru shing ad vice. Premature extractions ■ What advice should be given i Kelly-Ann does not like Anterior caries or restorations Multiple restorations Fixed appliance orthodontics Partial dentures Dietaryhabits Frequent sugar intake Social history Social deprivation High caries in siblings Lowknowledge o dental disease Irregular attendance Readyavailabilityo snacks Lowdental aspirations Use o uoride Drinking water not uoridated No uoride supplements No uoride toothpaste Plaque control In requent, ine ective cleaning Poor manual control Lacko parental involvement in brushing Saliva Low owrate Lowbu ering capacity High Streptococcus mutans and Lactobacillus counts Medical history Medicallycompromised Physical disability Intellectual disability Xerostomia Long termcariogenic medicine and at least on one other occasion every d ay. On each occasion, a sm ear of 1350–1500 p p m toothp aste shou ld be u sed . ■ Why is parental involvement important? Child ren need help from their p arents if effective oral hygiene is to be achieved . This help shou ld extend u p to at least 7 years old . Bru shing need s to start as soon as the rst tooth eru pts. Stand ing or kneeling behind the child in front of a sink or m irror is often the best w ay to bru sh a you ng child ’s teeth. Other su ccessfu l w ays inclu d e the child lying on his or her p arents’ legs. Su pervision of bru shing is im portant so that an ap p rop riate am ou nt of p aste is p laced on the bru sh to p revent/ red u ce ingestion of p aste. Carefu l qu estioning of p arents and hand s-on d em onstration of how to u nd ertake toothbru shing is im p ortant. Qu alitative research has reported a num ber of barriers that parents d escribe w hen trying to u nd ertake their child ’s toothbru shing. A nu m ber of these barriers relate to p arenting skills, such as m anaging tod d lers w ho w ant to bru sh them selves, or establishing and maintaining routines. Consequ ently ad vice and gu id ance need s to ad d ress these w id er p arenting issu es. The use of sim p le serial p laqu e and gingivitis strong, mint- avoured toothpaste? Some child ren struggle w ith the strong m int avours u sed in ad ult toothp aste. As a d ental care p rofessional, you shou ld be able to ad vise on alternative child -friend ly toothp astes. These shou ld have a mild , non-m inty avour that still have the required levels of u orid e. Other child ren m ay struggle w ith the foam ing action of the toothp aste, and again you shou ld be able to p rovid e ad vice on the availability of toothpastes w ithou t these agents (for exam p le, sod iu m lauryl su lp hate-free toothp astes). ■ Is there a role or uoride supplements? Fluorid e sup plem ents althou gh still recom m end ed are no longer consid ered a m ainline intervention. The reason for this relates to the p oor com p liance w ith these su p p lem ents in the families w ith child ren at high risk. All uorid e prod ucts, inclu d ing toothp aste, shou ld be treated as a m ed icine and kep t ou t of reach of you ng child ren to prevent excessive ingestion. The DoH Prevention Toolkit provid es fu rther read ing and ad vice on preventing u orosis, especially for child ren at low caries risk living in areas w ith u orid ated w ater su p p lies. Diet advice The only w ay to effectively u nd ertake d ietary ad vice is to ask p arents to com plete a 4-d ay d iet d iary. From this a w ritten analysis can be p rod uced . It is im portant to try to obtain 1 d ay’s history from a w eekend , as they are invariably d ifferent from w eekd ays. In m od ern society it is comm on for m ost p arents to w ork and the child to be looked after by a carer or nu rsery. It is critical to establish w ho is the carer on w eekd ays and w eekend s. Ad vice need s to be clear at all tim es, bu t if it has to be relayed from a p arent in the su rgery to a carer, then it need s to be clear, su ccinct and w ritten. Frequ ent consu m ption of sugar-containing d rinks and food s is the key aetiological featu re in m any pre-school child ren w ith caries. Red u cing the frequency of sugarcontaining snacks is an imp ortant m essage. If the child is a ‘poor eater ’, there is need to bu ild u p the am ount of food at m ealtim es and , therefore, red u ce the need for frequent snacking. Child ren d o not need zzy d rinks or fru it-based d rinks. These d rinks often m ake u p for calories m issed at m ealtim es. Only m ilk and w ater should be taken betw een m eals. A sm all am ou nt of fru it-based d rink can m ore safely be taken w ith a m eal. As p reviou sly m entioned , it is critical to stop the night-tim e bottle w ith anything other than w ater. In you r d ietary ad vice you m u st be practical, personal and positive. Avoid m aking the p arent feel excessively gu ilty, but concentrate on p ractical strategies. It is p robably unreasonable to give ou t m ore than fou r pieces of w ritten ad vice. These should concentrate on d ay-tim e d rinks, night-time d rinks, betw een-m eal snacks, and m aking sure the child has no food or d rink for 1 hou r before going to bed and cleans their teeth just before bed . Furtherm ore, d ietary ad vice shou ld not be lim ited to su gary snacks bu t also brie y evaluate the d iet as a w hole and assess if it is in line w ith the eat w ell plate. 133 • NURSINGANDEARLYCHILDHOODCARIES Medication For child ren on regu lar m ed ication, this shou ld , w here p ossible, be su gar free. Often this w ill requ ire liaison w ith their general m ed ical p ractitioner. A carefu l m ed ical history–taking is essential, as som e p arents m ay not perceive regu lar nu tritional su p p lements or laxatives as m ed ication. Pro essional interventions For Kelly-Ann, cu rrent ad vice is that u orid e varnish shou ld be ap plied to her teeth three to fou r tim es a year. Site-sp eci c ap p lication of u orid e varnish can be very valu able in the m anagem ent of early, sm oothsu rface and ap p roxim al cariou s lesions. The m ost com m only u sed varnish – 5% sod iu m u orid e – has 22 600 p pm . Before ap p lying the varnish the child ’s asthm a statu s and any history of allergy to colop hony shou ld be checked . In cases w here child ren have been hosp italized for their asthm a or have a history of an allergic reaction to sticky plasters (w hich can contain colop hony), the u se of colophony containing u orid e varnishes are contraind icated . Alternative, non-colophony-containing varnishes are available. When ap plying the varnish, ensure the correct d ose and instru ctions are given. The recall interval betw een d ental clinic visits w ill red u ce to 3 m onths. This w ill enable the m ore frequ ent ap plication of u orid e varnish, m ore intense preventive su p port and the exam ination of Kelly-Ann’s d entition for caries progression or new lesions. Why can Kelly-Ann not have f uoride mouthwash? These are contraind icated in child ren less than 6 years of age because m ore than half the m ou thw ash w ill be sw allow ed , increasing the risk of u rosis. This is also the reason w hy parents are ad vised to u se only a sm ear-sized (for 0–3-yearold s) or pea-sized (for 4–6-year-old s) am ou nt of toothpaste and w hy the child is encou raged to sp it ou t the excess resid ue of the toothpaste as soon as he or she is able to d o so. Treatment Restorative care (Please see Chapter 24, w hich p rovid es greater d etail of treatm ent op tions and treatm ent p lanning.) Kelly-Ann has caries involving her u pper incisors (Fig. 22.1) and cavitated occlu sal caries in her rst prim ary m olars. Treatment can be p rovid ed in a nu m ber of w ays and relates to parental expectations and w illingness to com ply w ith the hom e-based p reventive ad vice, p arents’ expectations and w ishes, child ’s coop eration and any history of toothache or other sym p toms. Child coop eration can change rap id ly as the child grow s, and consequ ently, over a few m onths, d ifferent treatm ent op tions m ay be ap prop riate w ith im proving behaviou r and cooperation. In Kelly-Ann’s case, w ith no history of p ain, tim e w as available at rst to tem porize and seal in the caries w ith glass ionom er cem ent (GIC) u ntil coop eration im p roved . ■ How would you restore the upper incisors? There are a nu m ber of d ifferent op tions and m aterials available. These inclu d e the p revention-only ap p roach w ith no caries rem oval or d isking, tem p orarization w ith GIC or comp lete caries rem oval w ith d e nitive restoration u sing 22 either a d irect com p osite or a com p osite crow n u sing a p lastic strip crow n. Follow ing the tem p orary GIC restorations, Kelly-Ann’s coop eration im proved signi cantly to p erm it the placem ent of d irect com posite restorations und er local anaesthetic several m onths later. ■ How would you restore the early cavita tion in the f rst primary mola rs? Similar to the incisors, d ifferent options are available: Prevention only namely to modi y the cavity to permit plaque removal using a toothbrush and regular application o f uoride varnish. Regular plaque scores will allow you to monitor how well parents are complying with your toothbrushing instructions. Seal with partial or no caries removal namely to seal the caries with composite and/or ssure seal ollowing limited caries removal with a slow handpiece. Complete caries removal using local anaesthetic, rubber dam and handpieces to remove caries ollowed by composite restorations. Initially a p reventive ap p roach w as taken w ith the cariou s rst p rim ary m olars. As Kelly-Ann’s coop eration im proved , a com plete caries removal ap p roach w as und ertaken, as both her and her m um w anted w hite coloured llings rather than stainless steel crow ns. ■ What method o caries removal, without a handpiece, may be applica ble here? With the ad vent of the H all techniqu e (see Chapter 24) chem ical caries rem oval has had lim ited u se. An exam ple of chem o-m echanical caries rem oval is the u se of Carisolv. It consists of a p ink gel that contains m ainly the am ino acid s leucine, lysine, glu tam ic acid and hypochlorite. In ad d ition, there is cellulose and a colou ring agent, erythrocin. The amino acid s and hypochlorite w ork to sep arate carious d entine from sou nd d entine, and the cariou s d entine is removed w ith the aid of special hand instrum ents that have d ifferent cu tting ed ges and hand actions to excavators. They are used in a w hisking, rotating or u p-and -d ow n m ovem ent. Because the sou nd d entine is not stim u lated by the temperatu re or vibration of a hand piece, or the tem perature changes of a three-in-one sp ray, it is a p ainless p roced u re. The cavity shou ld be d ried by saline-d am pened cotton w ool, then d ry cotton w ool, prior to restoring w ith an ad hesive m aterial. Bond strengths to ad hesive m aterials are the same as conventionally p repared cavities. The d isad vantages of the techniqu e inclu d e the taste of Carisolv if it should leak ou t of the cavity, the tim e taken to rem ove caries and the noises and sensation of the hand instru m ents. ■ How is pain relie best achieved in the child with nursing ca ries in Fig. 22.2? This is a case w here general anaesthesia for tooth rem oval is ju sti ed . This is covered in Chapter 26. Depend ing on the type of the general aneasthetic (extraction only or com p rehensive care), d ental care w ou ld consist of either extracting all cariou s teeth (DBA ABD) or extracting irreversibly in am ed and non-vital p rimary teeth and restoring other teeth affected by caries together w ith ssu re sealants of other p rim ary m olars. 22 • 134 NURSINGANDEARLYCHILDHOODCARIES Primary resources and recommended reading Am erican Acad em y of Ped iatric Dentistry 2014 Guid eline on caries-risk assessm ent and m anagem ent for infants, child ren, and ad olescents. Ped iatr Dent 36 (6):127–134. Am erican Acad em y of Ped iatric Dentistry 2014 Policy on early child hood caries (ECC): unique challenges and treatm ent op tions. Ped iatr Dent 36 (6):53–55. Deery C 2013 Caries d etection and d iagnosis, sealants and m anagem ent of the p ossibly cariou s ssu re. Br Dent J 214 (11):551–557. H ealthcare Im provem ent Scotland 2014 SIGN 138: Dental Interventions to Prevent Caries in Child ren. Ed inbu rgh, SIGN . Available at: http:/ / w w w.sign.ac.u k/ p d f/ SIGN 138.p d f. Public H ealth England 2014 Delivering Better Oral H ealth: An Evid ence-Based Toolkit for Prevention, 3rd ed . Lond on, Public H ealth England . Available at: http s:/ / w w w.gov.u k/ governm ent/ u p load s/ system / u p load s/ attachm ent _d ata/ le/ 367563/ DBOH v32014OCTMainDocu m ent _3.pd f. Scotish Dental Clinical Effectiveness Program m e (SDCEP) 2010 Prevention and Managem ent of Dental Caries in Child ren: Dental Clinical Gu id ance. Du nd ee, SDCEP. Available at: http :/ / w w w.sd cep .org.u k/ w p-content/ u p load s/ 2013/ 03/ SDCEP_PM_Dental_Caries_Fu ll_Gu id ance1 .p d f. Marshm an Z, Ahern S, McEachan R et al Parents exp eriences of tooth bru shing w ith child ren: a qu alitative stu d y. Accepted for p u blication in Jou rnal of Dentistry Clinical and Translational Research, 2016. For revision, see Mind Map 22, page 242. 23 High caries risk adolescents Dental history At the age of 5 years he had a num ber of his p rim ary teeth extracted u nd er general anaesthetic. H e has su bsequ ently requ ired restorative care and an extraction of his u p p er right rst p erm anent m olar u nd er local anaesthetic several years ago. You have not seen Peter for at least 3 years (Fig. 23.1). ■ Which aspects o his presenta tion and history help to determine his ca ries risk status so a r? • • • • SUMMARY Peter is 13 years old. He is concerned about the appearance o his teeth, especially the spaces between his ront teeth, and would like this improved (Fig. 23.1). He is not very keen on the prospect o complex restorative or orthodontic treatment. On assessment he is diagnosed as high caries risk. How would you plan preventive treatment or this patient? History Complaint Peter attend s your su rgery for the rst tim e in a nu m ber of years. H e ad vises you he w ou ld like the sp aces betw een his front teeth corrected (Fig. 23.1). History o complaint Peter is a sp orad ic attend ee. H e rep orts no p ain from any of his teeth. H e is now keen on having the app earance of his front teeth im p roved and is eager to learn how this can be achieved . Medical history Social history irregular attendance and low dental aspirations to date (high caries risk). Fluoridated water living in an area with no f uoride in the drinking water (high caries risk). Medical history t and well (low caries risk). Dental history primary tooth extractions under general anaesthesia and subsequent permanent tooth extraction and restorations with local anaesthetic (high caries risk). Examination Extraoral N othing relevant is revealed . Intraoral Peter ’s oral hygiene is poor. Basic Period ontal Exam ination (BPE) scores of one in each sextant are record ed . N orm al saliva levels are noted . Caries is evid ent in the low er left second p erm anent m olar. H e is in the perm anent d entition w ith missing both low er central incisors and a retained low er left prim ary central incisor. H is u pper right rst p erm anent m olar w as extracted p reviou sly and the u p p er and low er left rst p erm anent m olars and low er right rst and second m olars restored . N o ssu re sealants are present. There is evid ence of m ild buccal crow d ing in the low er arch w ith low er left second perm anent prem olar lingually p laced . The u pper left second p erm anent p rem olar is u nerupted and palatally d isplaced (Figs 23.2 and 23.3). ■ Which urther a spects o his clinical presentation help determine his ca ries risk status? Clinical evidence New caries in the lower le t second permanent molar, previous restorations and a missing permanent tooth which Peter is t and w ell. H e is not taking any m ed ication. Fig. 23.1 Anterior view o teeth at presentation. Fig. 23.2 Upper occlusal view at presentation, with upper right six previously extracted. 23 • 136 HIGHCARIESRISKADOLESCENTS was extracted are all noted (high caries risk). This caries risk category will have the largest weighting in scoring overall caries risk. Plaque control separate time to brushing his teeth, or example a ter coming in rom school or a ter dinner is well remembered by many high caries risk patients. Dietary history Oral hygiene poor, BPE scores all one. His oral hygiene is especially poor in the upper anterior region (high caries risk). Saliva Normal saliva levels noted (low caries risk). For a fu ll list of caries risk factors, see Chap ter 22, Table 22.1. This w ill help bu ild u p a p ictu re of caries risk and form u late a p revention p lan that is tailored to the p atient’s requ irem ents. ■ At present what ca ries risk status would you assign Peter to? H igh caries risk. Frequency a nd timing o a ll ood a nd drinks including milk a nd wa ter? Carbonated drinks are consumed at least our times a week with diluted juice consumed on a daily basis. Frequency a nd timing o ood. Peter is a grazer and likes to eat well into the evening. Peter is advised to complete a 4-day diet diary (at least 1 day should be completed over the weekend; high caries risk). Peter ’s history, clinical assessm ent and fu rther qu estioning com bine to give a nal caries risk assessment, w hich ind icate a high caries risk statu s (Table 23.1). ■ What urther in ormation would you ask Peter to complete Key point his ca ries risk assessment? Fluoride history Wha t strength/type o f uoride toothpa ste does he use? I Peter is not aware o the f uoride strength o the toothpaste he uses, he should be shown how to determine this on a toothpaste tube. He should be using toothpaste strength at least 1350 1500 ppm F (children 6 and older). He is presently using a brand which is the correct strength/type or a low caries risk child o his age. How ma ny times a da y does he brush his teeth? He presently brushes twice daily, but not e ectively. Twice daily or 2 minutes should be recommended and the technique demonstrated. Does he presently rinse with wa ter a ter brushing? He rinses his teeth with water a ter brushing. The ‘spit but don’t rinse’with water guidance should be recommended. Is he presently using a ny f uoride mouthwa sh? I so, when does he do this? At present only toothpaste is used. Fluoride mouthwash should be recommended 0.05% NaF at a Caries risk assessment: • The largest weighted caries risk assessment category is clinical evidence. • The completion o a caries risk assessment helps ormulate an enhanced prevention plan specif c to this patient. Preventive care and treatment Peter is presently high caries risk. Prior to restorative w ork being u nd ertaken, the preventive treatm ent p lan shou ld ensure that his caries risk status is red uced and he remains caries free in the fu tu re. Radiographs ■ A ter the initial bitewing radiographs are taken (Fig. 23.4), when should Peter have radiographs ta ken a ga in? In 6 m onths’ tim e if he rem ains at high caries risk. Fig. 23.4 Bitewing radiographs. These show dentinal caries in the le t lower second permanent molar and enamel lesions on upper le t rst permanent premolar and the lower right rst permanent molar. Fig. 23.3 Lower occlusal view at presentation. Table 23.1 Peter’s caries risk assessment Clinical evidence Dietary habits Social history Fluoride use Plaque control Saliva Medical history Caries risk LH LH LH LH LH LH LH LH 137 • HIGHCARIESRISKADOLESCENTS ■ What other orms o preventive ca re would he benef t rom? Toothbrushing instruction Oral hygiene instru ction w ith a toothbru shing d em onstration at each recall visit for enhanced prevention. Child ren of Peter ’s age should be show n how to bru sh their teeth u sing d isclosing tablets or solu tions. Disclosing tablets should be used before going to bed w hen tim e can be d evoted to im p roving bru shing techniqu es. Although patients or p arents m ay ask abou t the bene ts of a m anu al or pow ered toothbru sh, clinically it is m ore im p ortant w hat he d oes w ith the toothbru sh in resp ect to the thorou ghness of the bru shing and its frequ ency. Does he use a nyt hing t o clea n in bet w een his t eet h? H e w as show n previou sly how to d o this, bu t ‘his m u m forgot to bu y m ore oss’. Exp lain the im p ortance of interd ental cleaning and ask Peter to d em onstrate ossing in his ow n m ou th. Give m otivational feed back. This is esp ecially im portant, as enam el lesions are visible on the bitew ing rad iograp hs. Table 23.2 helps highlight the com plete p ackage of preventive care that Peter shou ld receive prior to any restorative w ork is und ertaken. Where m ore extensive caries is seen in an ad olescent, stabilization of the d entition is often an app ropriate rst step. This can be u nd ertaken w ith simp le hand excavation and glass ionom er cem ent tem p oraries. This w ill slow d ow n the progress of caries w hile the resp onse of the child and family to the preventive ad vice can be evaluated . As gingival health im proves, d e nitive caries rem oval and com posite or other restorative options can be u nd ertaken. Fu rther bene ts of this ap proach are d iscu ssed in Chapter 24. Only on comp letion of this initial p hase of prevention and sim ple restorative treatm ent shou ld com p osite build u ps or other ad hesive brid gew ork be consid ered (Figs 23.7 and 23.8). In Peter ’s case the retained low er left prim ary Strength o f uoride toothpaste In ad d ition to the ad vice on ad ult toothp aste strength on initial p resentation, d u e to Peter ’s age and high caries risk statu s, he w ou ld gain ad d itional bene t from a prescription of a higher-strength 2800 p pm F toothp aste. Fluoride varnish application The evid ence su ggests an ad d itional bene t of three to fou r ap p lications annu ally of uorid e varnish for child ren at high caries risk. Even if Peter ’s caries risk statu s w ere to subsequ ently red u ce to low caries risk, tw ice-yearly ap p lication of a u orid e varnish, termed stand ard p revention care (2.2% sod ium u orid e 22 600 pp m F), w ou ld still be recom m end ed . Fluoride supplements Flu orid e m outhw ash at 0.05% sod iu m u orid e, alcohol free, is recom m end ed for d aily use at a sep arate tim e to toothbru shing. Dem onstrate to the patient on a m ou thw ash bottle w here the u orid e concentration inform ation is w ritten. This then allow s the p atient to make an inform ed choice regard ing the m any brand s of m ou thw ash available for u se on a d aily basis. The m outhw ash should be sw ished arou nd the m ou th for 60 second s before spitting out the resid ue. Fig. 23.5 Fissure sealants in upper premolars. The upper le t second permanent premolar is unerupted and visible as a budge on the palate. Diet analysis As stated in Chap ter 22, a 4-d ay d iet d iary can highlight frequ ency and tim ing of food s that enable p ractical and p atient-centred ad vice to be given. Ad vice shou ld be given in line w ith the eat-w ell p late. Child ren of second ary school age can be given inform ation that enables them to make inform ed choices regard ing their eating and d rinking practices. In m any situ ations, sim p le changes can red u ce their caries risk signi cantly. Fissure sealants Peter required prem olars (Figs 23.5 and 23.6). ssu re sealants on all his Fig. 23.6 Fissure sealants in lower premolars. Table 23.2 Peter’s prevention plan Radiographs (Frequency) 6 months Toothbrushing Instruction With disclosing tablets and interdental advice and demonstration 23 Strength F− toothpaste (F− ppm) F− varnish ( requency) F− supplements (dose) Diet analysis 2800 ppmF 3–4 monthly application Dailyuse uoride mouth wash 0.05%Na F 4 day ood diary (in line with the eat well plate) Fissure sealants Sugar- ree medicines Yes Yes N/A Yes Yes 23 • 138 HIGHCARIESRISKADOLESCENTS ■ What else might you suggest when Peter is older that could help urther reduce his caries risk status or the uture? Fig. 23.7 Final restorative treatment o the upper incisors. Fig. 23.8 Final restorative care o the anteriors. central incisor w as assessed and d u e to lim ited root length, he w as ad vised of its p oor long-term p rognosis. The p rim ary incisor w as extracted and a one-u nit Maryland brid ge p rovid ed w ith fu rther related oral hygiene instru ction. This includ ed the u se of su p er oss to clean beneath the p ontic. At a later stage, shou ld Peter d ecid e he w ou ld like m ore com p lex treatm ent su ch as xed orthod ontics or im plants, this can still be provid ed . Key point Preventive care: • The evidence to date suggests an additional benef t rom application o uoride varnish 3 4 yearly in high caries risk children. Apply twice yearly in low caries risk children. • Fluoride mouthwash at 0.05% sodium uoride is recommended or daily use at a separate time to toothbrushing. • For high caries risk children (age 10 and over) and adolescents, higher strength prescription uoride toothpaste (2800 ppm F) is recommended. Higher st rengt h uoride t oot hpa st e (5000 ppm F). The effect of uorid e toothpaste is concentration d ep end ent. The m axim al over-the-cou nter prod u ct is 1500 p pm uorid e. Prescrip tion-only toothp astes containing 2800 and 5000 p pm u orid e allow s the d ental p rofessional to target high caries risk ad olescents. The resu lts of a nu m ber of rand om ized clinical trials su ggest that in the range 1000– 2500 p pm u orid e, every ad d itional 500 p pm u orid e, over and above 1000 pp m u orid e, w ould provid e a cu m u lative 6% red uction in caries increm ent. This d ose resp onse is highest in high caries risk child ren and those aged over 11 years. H ow ever, this w ou ld only be p rescribed after assessing su itability and com p liance w ith instru ctions for the u se of higher strength u orid e toothp aste. It shou ld be em p hasized that such high-strength u orid e toothpastes should be kept ou t of reach of you nger child ren. Ind ivid uals for w hom this toothp aste is p rescribed should be encouraged to expectorate after bru shing. The 5000 pp m u orid e toothp aste is u sed for ad olescents over 16 years of age and ad u lts. Toot h mousse or t oot h mousse plus (CP P -ACP or CP P ACFP ). Tooth m ou sse is a w ater-based cream containing Recald ent (casein p hosp hop ep tid e-am orp hou s calciu m p hosphate or CPP-ACP). Tooth m ou sse plus, a stronger tooth m ou sse, is recom m end ed at night only for p atients w ho either have m arked salivary d ysfu nction or increase risk of m ineral loss from d ental caries or erosion of teeth. Child ren should be at least 6 years of age before u sing tooth m ousse plu s. The p rop osed anticariogenic m echanism of CPP-ACP involves the enhancem ent of rem ineralization throu gh the localization of bioavailable calcium and phosp hate ions at the tooth surface. Casein p hosp hop eptid es (CPPs) stabilize high concentrations of calciu m and p hosp hate ions as em bryonic ACP nanoclusters together w ith u orid e ions at the tooth su rface by bind ing to p ellicle and p laque and act as a d elivery vehicle to the tooth su rface. The ions are freely bioavailable to d iffu se d ow n concentration grad ients into enamel su bsurface lesions, thereby effectively p rom oting rem ineralization. Tooth m ou sse m ay not be ap propriate for all p atients ow ing to its cost. This is ap proxim ately 5–10 tim es as expensive as a stand ard tu be of uorid e toothpaste. Suga r-free chew ing gum. Many chew ing gum s are now available as sugar-free w ith 50% sw eetened w ith su gar su bstitutes. Oral bacteria d o not u se these su gar substitutes to prod u ce the acid s that d em ineralize enam el and d entine. Fu rtherm ore, the act of chew ing stim u lates saliva ow, w hich increases bu ffering cap acity and enhances clearance of food d ebris and m icro-organism s from the oral cavity. Chew ing gu m containing xylitol, a p olyol 5 carbon sw eetener, red uces p laqu e salivary Streptococcus mutans levels and tooth d ecay, as w ell as enhancing rem ineralization. Primary resources and recommended reading Cochrane N J, Saranathan S, Cai F et al 2008 Enam el su bsu rface lesion rem ineralisation w ith casein phosphopep tid e stabilised solu tions of calciu m , p hosp hate and uorid e. Caries Res 42:88–97. 139 • HIGHCARIESRISKADOLESCENTS Facu lty of General Dental Practice (FGDP) 2013 Selection Criteria for Dental Rad iograp hy, third ed . Lond on, FGDP. H ealthcare Im provem ent Scotland , 2014. SIGN 138: Dental Interventions to Prevent Caries in Child ren. Ed inburgh, SIGN , sections 2–8. Available at: http :/ / w w w.sign.ac.uk/ p d f/ SIGN 138.p d f. Kiet AL, Milgrom P, Rothen M 2008 The potential of d entalp rotective chew ing gu m in oral health interventions. J Am Dent Assoc 139:553–563. Public H ealth England 2014 Delivering Better Oral H ealth: An Evid ence-Based Toolkit for Prevention, third ed . Lond on, Pu blic H ealth England , sections 2–5. Walsh T, Worthington H V, Glenny A-M et al 2010 Flu orid e toothpastes of d ifferent concentrations for p reventing d ental caries in child ren and ad olescents. Cochrane Database of System atic Review s 2010, Issu e 1. Art. N o.: CD007868. DOI: 10.1002/ 14651858.CD007868.pu b2. For revision, see Mind Map 23, page 243. 23 24 Pain control and treatment planning or carious primaryteeth SUMMARY Paul is 5 years old. He is in pain rom one o his upper right back teeth. He has never had any treatment be ore. How would you manage Paul’s problem? ■ What questions do you need to ask rega rding the pain? Site ask Paul to point to the tooth. Severity does the pain stop him rom playing, eating or sleeping? This question you o ten have to ask both Paul and his parents. Onset what makes the pain worse? Is it in response to hot, cold or sweet stimuli, or does it occur spontaneously? Does it wake him up rom sleep? Character is it a sharp pain or is it dull and throbbing? Duration how long does it last when the pain is present? How long has Paul su ered rom pain? What makes the pain worse or better (e.g. painkillers) A sim ple m nem onic can help you to rem em ber the d ifferent questions, SOCRATES (Site, Onset, Character, Rad iation, Association, Tim e cou rse, Exacerbating and relieving factors, Severity). You ng child ren m ay how ever nd som e of these qu estions d if cu lt to answ er, su ch as rad iation and association. Moreover, care need s to be taken to u se the m ost approp riate langu age. For exam ple, even thou gh child ren m ay not u nd erstand sensitivity, they or their p arents are likely to rep ort if they avoid cold d rinks or ice cream . The d ifferent characteristics of reversible and irreversible p u lp itis are show n in Table 24.1. The initial m anagem ent of a child attend ing in p ain is often constrained by the lack of sleep on behalf of the child or tim e available to the d entist to treat this extra ‘em ergency p atient’. An accu rate d iagnosis is essential before any treatm ent can be provid ed . Place a glass ionomer cement (GIC) or other temporary restoration (Kalzinol or Intermediate Restorative Material.). I the pain settles, a more de nitive restoration will be required when time permits and as part o a comprehensive treatment plan (see later). Irreversible pulpitis i possible, gently excavate the so test layer o coronal caries, then, place a poly-antibiotic and steroid paste (e.g. Ledermix or Odontopaste) beneath the GIC. These pastes are e ective at reducing the symptoms rom the tooth. Again, more de nitive treatment (extraction or pulpectomy) will be required or this tooth when time permits and as part o a comprehensive treatment plan. Acute apical periodontitis i a tooth is abscessed, there is o ten signi cant coronal destruction. The pulp chamber o such teeth can o ten be accessed, and a dressing o Ledermix or Odontopaste on some cotton wool placed within the chamber and sealed with a GIC will o ten lead to temporary resolution o symptoms and swelling. Again, more de nitive treatment (extraction or pulpectomy) will be required or this tooth when time permits and as part o a comprehensive treatment plan. Where tim e and p atient cooperation p erm it, d ressing open cavities has a nu m ber of ad vantages (see Key Point box and Fig. 24.1): Simple introduction to dental procedures. Oral mutans streptococci count is reduced when excavation o gross caries is accomplished. I the cavity is then completely sealed by a GIC, there is evidence that the viability o the remaining organisms decreases and caries progression is greatly reduced. This buys the dentist time to institute preventive and behaviour management programmes be ore reassessing teeth with temporary restorations. GICs act as a f uoride reservoir. Makes toothbrushing and eating more com ortable. Table 24.1 Pain characteristics Reversible Irreversible Transient or short duration (minutes) Long duration Response to hot, cold, sweet Response to pressure (chewing) Sharp Spontaneous Does not stop playor sleep Throbbing Stops playor sleep ■ Wha t dressings ca n help mana ge pulpitis initia lly? Reversible pulpitis i possible, gently excavate the so test layer o coronal caries: Fig. 24.1 Temporary GIC restoration placed, the bene ts o which are described in the text. 141 • PAINCONTROLANDTREATMENTPLANNINGFORCARIOUSPRIMARYTEETH Key point Advantages o dressing (stabilization) open cavities are: • Introduction to dental procedures and usually does not involve local analgesia or complete caries removal. • Reduction o Streptococcus mutans count. The temporary restoration deprives the bacteria in the active lesion o sugar and oxygen. • GIC acts as a uoride reservoir. • Eating and toothbrushing are more com ortable. A An acute and / or spread ing infection or sw elling m ay requ ire the p rescrip tion of antibiotics. This is d iscu ssed in Chap ter 25. Antibiotics shou ld only be p rescribed for pain in the absence of sw elling for im m u nosu ppressed p atients. Ad vice abou t analgesics for pain w ill be necessary to su p p ort the em ergency treatm ent (Table 24.2). Table 24.2 Dosages or common paediatric analgesics ( or children 12 and older, re er to adult doses) Drug Dosage Paracetamol 20 mg/kg initiallythen 10–15 mg/kg every4–6 hours Maximumo our doses in a 24 hour period B Fig. 24.2 (A&B) Paul’s upper and lower arches. Ensure adequate hydration Ibupro en (non steroidal anti in ammatorydrug (NSAID)) 10 mg/kg every8 hours Can be used in conjunction with paracetamol Best given with ood and drink History Questioning su ggested an irreversible p ulpitis in the u pper right qu ad rant. Examination Pau l has no extraoral sw elling or asym m etry. Intraorally he has all his prim ary teeth. There is occlu sal caries of E and m esial caries of A A. The E is grossly cariou s (Fig. 24.2A). There is no associated soft tissu e sw elling. A ■ What investiga tion is essential to allow you to ormula te a treatment plan? Bitew ing rad iograp hs are necessary to d iagnose ap p roxim ate caries in p rim ary m olars w ith their w id e contact areas and to con rm the d ep th of d entine caries. Rad iograp hs w ill increase the d iagnosed yield of caries by 50%. Frequ ency of su bsequ ent bitew ing rad iograp hs w ill d ep end on the classi cation of caries risk: high risk p atients shou ld have rad iograp hs taken every 6–12 m onths; m ed iu m risk 12–18 m onths; low risk 18–24 months. In Pau l’s case, the low er arch (Fig. 24.2B) and bitew ing rad iograp hs (Figs 24.3A and B) show extensive caries of E involving the p u lp. There is E also caries extend ing into the m id -d entine for . E DE Treatment Initial tem porization of Pau l’s E w as w ith w ith Od ontop aste and GIC. B Fig. 24.3 (A&B) Paul’s bitewing radiographs. ■ Wha t is your def nitive trea tment plan or E ? The E w as u nrestorable w ith the d istal m argin of the caries extend ing su bgingivally. Therefore the only option for the E w as extraction. The tem porary d ressing alleviated fu rther p ain from this tooth and allow ed for behaviou r 24 24 • 142 PAINCONTROLANDTREATMENTPLANNINGFORCARIOUSPRIMARYTEETH m anagem ent and acclim atization to the d ental su rgery to be u nd ertaken. Extracting p rim ary teeth on a child ’s rst visit to a d entist should be avoid ed w here possible. If an extraction is u nd ertaken on the rst visit, it is likely to lead to signi cant d ental anxiety and relu ctance to attend further d ental visits. Table 24.3 Paul’s proposed treatment plan ■ Will local a naesthetic be needed or extracting E ? Where the d ecision has been m ad e to extract E , local anaesthetic is essential. It is tim e consum ing to give local anaesthetic in a p ain free and child -friend ly w ay and ensu re the entire tooth is anaesthetized p rior to the extraction. Often child ren and p arents are su rp rised how qu ickly the tooth is extracted in com parison to the tim e taken for the local anaesthetic stage. ■ Wha t are the consequences o extracting E ? Extracting the E is likely to lead to localized sp ace loss, w ith the 6 d rifting m esially into this sp ace. This esp ecially is the case w hen the extraction is u nd ertaken p rior to the eru p tion of the rst p erm anent m olar. The d rifting w ill exacerbate any tend ency for crow d ing and can frequently lead to the palatal exclu sion of the m axillary p erm anent second prem olar in ad olescence. Althou gh sp ace m aintainers have been ad vocated to p revent sp ace loss follow ing p rem atu re extraction of primary m olars, there is a lack of robu st evid ence to support their longevity and cost effectiveness in you ng child ren w ith extensive d ental caries. Teeth af ected by caries Extent o caries Restorative plan E Into pulp Extraction AA Outer 1/3rd dentine Disk E EE Mid 1/3rd dentine Hall crown D Outer 1/3rd dentine Partial caries removal, ollowed bycomposite restoration and fssure sealant Table 24.4 How preventive and restorative treatment was provided or Paul on a visit by visit basis Visit Preventive plan Restorative plan 1 Pain control E temporary 2 Bitewing radiographs Toothbrushing instruction Fluoride advice Hand out diet diary Plaque score Apply uoride varnish 3 Collect in diet diaryand give advice 4 Toothbrushing instruction ■ How do we underta ke treatment pla nning and devise a plan which is appropriate or ea ch and every pa tient? There are several im p ortant stages to treatm ent p lanning: A. The rst priority is to relieve pain. Where pain relie can be provided, even over a short time rame, this permits time to develop a holistic treatment plan described in steps B E. B. Identi y all pathology. Bitewings (Figs 24.3A and B) and other radiographs are essential to support the detection o caries. A list should be drawn up o each tooth a ected by caries together with the depth o caries Plaque score Restore D would be available? Treatment planning DD DD DiskAA ■ I the E was restorable, what other treatment options The only other option for a tooth d iagnosed w ith irreversible p u lp itis or w here it is necrotic and non-vital is a p u lp ectomy. A p u lp ectom y is sim ilar to a root canal treatm ent in perm anent teeth. It is m ad e m ore com p lex by the ared and irregu lar shap e of the root canals, as w ell as the need for the roots to resorb, thu s allow ing natu ral exfoliation of the primary tooth. Althou gh hand les are u sed for gentle shap ing, the m ost im p ortant stage of the proced u re is d isinfection of the root canal w ith carefu l u se of hyp ochlorite. Like in the perm anent d entition, a ru bber d am is essential to prevent salivary ingress into the root canal and the escap e of the hypochlorite into the oral cavity. Once the w orking length is established and the root canals d isinfected , canals are lled w ith either zinc oxid e cem ent or a calciu m hyd roxid e-iod oform p aste w hich w ill resorb w ith the root as part of the p hysiological root resorp tion. Fissure seal Place separators E 5 Rein orce diet advice Hall crown E Place separators EE 6 Toothbrushing instruction Plaque score Hall crowns EE 7 Post extraction pain control C. D. E. Extract E penetration. Table 24.3 shows such a list or Paul based on his clinical examination and bitewings. Develop a robust and rigorous preventive plan as described in Chapters 22 and 23 and shown in Table 24.4. Evaluate Paul’s cooperation to treatment ollowing the delivery o behaviour management strategies described in Chapter 26. Although several visits may be required to develop the child’s cooperation, it is not acceptable to leave an in ected tooth untreated or longer than 3 months. There are multiple options available or treating primary teeth, and f exibility in approach is needed as treatment options may change in response to parental expectations and willingness to comply with the home-based preventive advice, the child’s cooperation and the development o urther toothache or other symptoms. In addition, the choice o how the treatment is undertaken, e.g. local anaesthetic, sedation or general anaesthetic, described in Chapter 26, may dictate what treatment is available and appropriate. For example, all carious teeth may be extracted even when some are restorable where an ‘extraction-only general anaesthetic’is the only method available or an uncooperative child in pain. 143 • PAINCONTROLANDTREATMENTPLANNINGFORCARIOUSPRIMARYTEETH Key point The ollowing considerations will in uence the treatment provided: • Parental expectations and willingness to comply with home-based preventive advice. • Child’s cooperation. • Development o urther pain and symptoms. • Dental care pro essional’s expertise and training in di erent treatment procedures. Di erent restorative philosophies These d ifferent ap proaches can be used at a p atient level or at a tooth level w ith several em p loyed w ithin one p atient. Table 24.4 show s Paul’s treatm ent plan and includ es several d ifferent approaches to m anage his cariou s teeth. • Prevention only. This approach requires a high level o engagement and cooperation rom the parents as treatment is predicated on their compliance with the preventive advice provided. Preventive advice as discussed in Chapters 22 and 23 is provided with regular clinic visits or f uoride varnish application. To support daily plaque removal, carious cavities can be adjusted to acilitate toothbrush access to remove plaque. For Paul, early dentinal caries was identi ed on the mesial aspects o A A. The mesial aspects o these teeth were ‘disked’to allow or better toothbrush access. This decision was made based on the short time these teeth had to be retained be ore they ex oliated, the dark appearance o the caries suggesting it was arrested, the low likelihood o caries progression or pain and parent satis action with this approach. • Sealing in caries with no or partial caries removal. This approach is based on the biological principle that by sealing the cavity, the carious process cannot progress without nutrients and will there ore either slow down or arrest completely. There ore ensuring a good seal is essential. This can be achieved using a number o di erent materials and with or without partial caries removal. Best examples o these techniques in the primary dentition are the Hall technique, sealing in dentinal caries and indirect pulp therapy. For Paul, his cooperation was limited and there was little likelihood o him cooperating or our separate visits o complete caries removal under local anaesthetic. There ore Hall crowns were provided on the three other a ected E second primary molars ( ) and a composite restoration EE on D. The D used simple hand and slow handpiece excavation to remove only the in ected dentine. • Complete caries removal. This approach involves complete caries removal and necessitates the need or local anaesthetic, rubber dam and ast and slow handpieces. Consequently it requires signi cant levels o cooperation rom the child. All in ected carious dentine is removed. Only once this is completed is the tooth restored. Where caries extends into the pulp, a pulpotomy is undertaken. Paul coped with one visit o local anaesthetic where the 24 E was extracted. This was provided towards the end o his course o treatment. Earlier, simpler visits (Table 24.4) had developed his cooperation and con dence, thus permitting this more di cult procedure to be undertaken without the need to use sedation or general anaesthesia (see Chapter 26). Key point Advantages and disadvantages o di erent restorative approaches: • Preventive Advantages: limited child cooperation needed, some cooperation is needed to modi y carious cavities to improve toothbrushing access. Disadvantages: high levels o parental cooperation, as they will need to undertake a rigorous preventive plan, more requent clinic visits, accurate diagnosis o the extent o caries to ensure these teeth are at low risk o pain or in ection. • Sealing in caries with partial or no caries removal Advantages: moderate child cooperation, no local anaesthetic and minimal or no drilling. Disadvantages: more requent clinic visits to monitor seal, more radiographs to monitor any caries progression, accurate diagnosis o the extent o caries with a low risk o irreversible pulpitis, short term occlusal disturbance ollowing Hall crown placement. • Complete caries removal Advantages: high levels o child cooperation, can directly assess pulpal health at time o pulpotomy, permits treatment o more extensive caries, can modi y crown to ensure f t o stainless steel crown, permits tooth coloured restorations or caries involving the outer and mid third o dentine. Disadvantages: risk o iatrogenic damage to adjacent teeth, requires high levels o clinical expertise and e ciency, local anaesthetic and rubber dam needed. Hall crowns and indirect pulp therapy ■ Wha t are Hall crowns? Stainless steel crow ns are a very effective m ethod for restoring cariou s p rim ary m olars. H istorically, it w as only felt that these crow ns cou ld be placed u sing a com plete caries removal approach to ensure a good t w as achieved thereby optim izing the coronal seal. Furtherm ore, this approach m inim ized any occlu sal d istu rbance. Using this conventional approach (inclu d ing occlusal red uction and m esial and d istal slices) excellent long-term outcom es w ere achieved . In the last ten years, an alternative (H all crow n) ap proach to their application has em erged . This involves no caries removal or local anaesthetic. The correct size of crow n is chosen and lled w ith GIC. The crow n is then p u shed onto 24 • 144 PAINCONTROLANDTREATMENTPLANNINGFORCARIOUSPRIMARYTEETH the tooth using the child to bite it d ow n into p lace. The coronal seal generated by the crow n and cem ent lead s to the arrest of the u nd erlying caries. Fu rther inform ation on the H all techniqu e is provid ed in a sp eci c m anu al w ith the w eblink p rovid ed in the Prim ary Resou rces and Recom m end ed Read ing section. ■ When ca n I use Hall crowns? There are several im p ortant caveats to H all crow ns, and like all restorative techniqu es, they have ad vantages and d isad vantages to their u se. Most im p ortantly, a carefu l pain history and bitew ing rad iograp hs are im p ortant stages in id entifying p u lpal health. Where caries is w ithin the inner third of d entine or there is history of pain or signs and symp tom s of p u lpitis or p u lp al necrosis, it is u nw ise to u nd ertake a H all crow n. For Pau l, the caries w as lim ited to the outer half of the d entine and there w ere no sym p toms E from . E E Ow ing to the tight contacts seen in the p rim ary d entition, pu shing the crow n throu gh these contacts can take signi cant force. Where tight contacts are seen, an alternative approach is to place orthod ontic sep arators for u p to 2 w eeks to p rovid e sp ace for p lacem ent of the crow n. ■ Wha t will happen to the child’s occlusion ollowing the placement o a Hall crown? As there is no occlu sal red uction as p art of the H all techniqu e, the crow n w ill be p rou d and cau se occlu sal interference. Research has show n that after a few w eeks, there is occlu sal ad ju stm ent w ith the crow n no longer sitting p rou d . A post-op erative bitew ing is ad visory once all H all crow ns have been p laced to ensu re the crow ns are fu lly seated and have sealed the cariou s cavity. This esp ecially is tru e for proxim al caries. ■ How does indirect pulp therapy (IPT) di er rom a Hall crown? IPT is a proced ure requ iring local anaesthetic and ru bber d am. Infected caries is rem oved from the m argins of the cavity. At the cavity base, carefu l caries rem oval is u nd ertaken to rem ove as m u ch soft infected d entine as possible bu t to ensure there is no pu lp al exp osu re. Calciu m hyd roxid e is then p laced over the d eep caries before a d e nitive restoration is placed . It is essential that the restoration provid e an excellent coronal seal. IPT and H all crow ns are sim ilar in that they both requ ire an excellent d iagnosis of p u lp al health. In both techniqu es infected caries is left, and both rely on an op tim al coronal seal to p revent caries p rogression. The d efau lt restoration m aterial for both techniqu es is a stainless steel crow n. In the perm anent d entition, step w ise caries rem oval (of w hich IPT is a form of) has show n very p ositive resu lts in red u cing the need for root canal treatm ent. Pulpotomies ■ Wha t is a pulpotomy? Pu lpotom y is a proced u re for d eep caries involving or in close ap p roxim ation to the p u lp . Carefu l p re-op erative d iagnosis is essential to ensu re the absence of signs and sym p tom s su ggesting irreversible p u lp itis (see Table 24.1) or p ulp al necrosis. This includ es the absence of a sinu s, sw elling, peri-furcation rad iolucency, internal resorption, tend erness to p ercu ssion or a clinical history of irreversible pu lpitis. The in am ed coronal pulp is rem oved u nd er local anaesthesia (LA) and ru bber d am w ith the healthy non-in am m ed pu lp stum ps d ressed for 15 second s w ith 15.5% ferric su lphate. Follow ing this ap plication, bleed ing from the pu lp stu m p s shou ld stop . The technique allow s one fu rther ap plication of ferric su lphate if the bleed ing has not stop ped entirely after the rst ap plication. The cham ber is then lled w ith zinc oxid e eu genol cem ent or Mineral Trioxid e Aggregate. The d efau lt restoration for a pu lpotom ised p rim ary m olar is a stainless steel crow n to facilitate an excellent coronal seal. If the pu lp stu m p s d o not stop after tw o applications of ferric su lp hate, treatm ent shou ld p roceed to either a vital p ulpectom y (a variation of the p u lpectom y techniqu e d escribed earlier in the chap ter) or the tooth shou ld be extracted . This continu ed bleed ing d em onstrates in am m ation extend ing into the p u lp stu m p s and early tooth loss is likely if a p ulp otom y is u nd ertaken (as a resu lt of internal resorp tion). Pu lpotom ies are an area of active research as show n by the recent Cochrane review on the su bject. This id enti ed 47 rand om ized controlled trials on the su bject. Current areas of active research inclu d ed how haem ostasis is achieved and alternatives to ferric su lphate and old er agents such as form ocresol. Althou gh form ocresol has show n long-term su ccess and is still u sed in som e parts of the w orld , there have been international concerns over its toxicity both locally and system ically. These concerns have grow n in the past 15 years w ith form ald ehyd e, one of the im portant com ponents of form ocresol being associated w ith nasop haryngeal cancer. Form ocresol is no longer ad vocated as a front-line m ed icam ent for p u lp otom ies and is no longer tau ght in UK u nd ergrad u ate cu rricu la. Primary resources and recommended reading Am erican Aced em y of Ped iatric Dentistry 2014 Policy on p ed iatric p ain m anagem ent. Reference Manu al 36 (6):78–79. Pain control for child ren 2013 In: Cam eron A, Wid m er R (ed s), H and book of Ped iatric Dentistry, 4th ed n. Mosby, Ed inbu rgh, p p . 25–46. Deery C 2013 Caries d etection and d iagnosis, sealants and m anagem ent of the p ossibly carious ssu re. Br Dent J 214 (11):551–557. Du ggal MS, Day PF 2005 Op erative treatm ent of d ental caries in the p rim ary d entition. In: Welbu ry RR, Du ggal MS, H osey MT (ed s), Paed iatric Dentistry, third ed . Oxford University Press, Oxford , p p . 149–174. Evans D, Innes N 2010 The H all Technique: A Minim al Intervention, Child Centred Ap proach to Managing the Cariou s Prim ary Molar. University of Du nd ee. Available at: http s:/ / d entistry.d u nd ee.ac.u k/ sites/ d entistry.d u nd ee.ac.u k/ les/ 3M_93C%20H allTechGu id e2191110.p d f. Facu lty of General Dental Practice (FGDP) 2013 Selection Criteria for Dental Rad iograp hy, third ed . Lond on, FGDP. Franzon R, Gu im araes LF, Magalhaes CE et al 2014 Ou tcom es of one-step incom plete and com plete excavation in prim ary teeth: 145 • PAINCONTROLANDTREATMENTPLANNINGFORCARIOUSPRIMARYTEETH a 24-m onth rand om ized controlled trial. Caries Res 48 (5):376–383. Ricketts D, Lam ont T, Innes N P, et al 2013 Op erative caries m anagem ent in ad u lts and child ren. Cochrane Database of Syst Rev Issue 3. Art N o: CD003808. DOI: 10.1002/ 14651858. CD003808.pub3. Scotish Dental Clinical Effectiveness Program m e (SDCEP) 2010 Prevention and Managem ent of Dental Caries in Child ren: Dental Clinical Gu id ance. Du nd ee, SDCEP. Available at: http :/ / w w w.sd cep .org.u k/ w p -content/ u p load s/ 2013/ 03/ SDCEP_PM_Dental_Caries_Fu ll_Gu id ance1 .p d f. Sm ail-Fau geron V, Courson F, Du rieu x P et al 2014 Pu lp treatm ent for extensive d ecay in p rim ary teeth. Cochrane Database of Syst Rev Issu e 8. Art N o: CD003220. DOI: 10.1002/ 14651858. CD003220.p u b2. For revision, see Mind Map 24, page 244. 24 25 Facial swelling and dental abscess SUMMARY Danny is 12 years old. He attended with a large acial swelling a ter an episode o trauma 3 weeks previously. He eels unwell, and his right eye is closing (Fig. 25.1). The presentation o acute in ection, as demonstrated by Da nny, is very di erent rom chronic in ection. ■ List our symptoms and signs specif c to each type o in ection Acu te: • Sick, upset child. • Raised temperature. • Red, swollen ace. • Reduced intake o ood and drink Chronic: • Buccal sinus may be present. • Mobile tooth. • Halitosis. • Discoloured tooth. Other signs and sym ptom s can be seen in both acu te and chronic infection, includ ing pain and lym p had enop athy. Acu te infections tend to present w ith facial cellulitis rather than a facial abscess w ith p us. Danny w as febrile, althou gh he w as not in any signi cant pain, because the infection had perforated the cortical plate. The m ainstay of treatm ent is rem oval of the cause – either p ulpal extirpation or extraction of the tooth. History Danny traum atized his u pper right lateral incisor 3 w eeks ago, su staining a d eep enam el d entine fractu re. The d entine w as d ressed w ith calciu m hyd roxid e and a glass ionom er cem ent w as p laced over the exp osed d entine and enam el. H e had a review appointm ent w ith his d entist the follow ing w eek. On Saturd ay m orning his m other noticed that his cheek w as sw ollen and the tissu es arou nd his right eye w ere ‘p u ffy and red ’. H e attend ed the accid ent and em ergency d epartm ent of the local hosp ital, w here he w as prescribed Am oxicillin 250 m g tablets to be taken three tim es d aily for 5 d ays. Unfortu nately, by Sund ay evening Danny had becom e listless and his sw elling had increased . H e felt hot. Examination Extraorally there w as facial asym m etry w ith a sw elling of the right m axillary canine fossa. The overlying skin w as red and hot. The right eye ssure w as partially closed . Danny’s temp erature w as 39°C. Maxillary canine fossa infections can sp read via em issary veins, w hich have no valves, to the intracranial venou s system causing either a cavernou s sinus throm bosis or a brain abscess. The pathw ays of the IIIrd and VIth cranial nerves lie in the w alls of the cavernou s sinu s. Throm bosis in the cavernou s sinu s can present w ith a squ int d u e to involvem ent of the IIIrd and VIth cranial nerves, w hich are involved in control of the extraocu lar m u scles. ■ What is the major problem with mandibula r in ections? Spread alongside the ascial planes that surround the airway with subsequent narrowing o the airway and stridor. Spread via the ascial planes to the mediastinum to cause a mediastinitis. ■ What is the basic mana gement o a ny in ection? Removal o the cause extraction or root canal therapy. Local drainage and debridement and drainage. Fig. 25.1 Severe in ection o canine ossa. via root canal or incision Oral antibiotics i systemic involvement (see Table 25.1) Amoxicillin or Penicillin V are usually the drugs o rst choice. Amoxicillin has the advantage that it is given with ood and only needs to be taken three times per day. Metronidazole, which is active against anaerobes, can be added to either Amoxicillin or Penicillin i the in ection is severe. O ten the extraction o the abscessed tooth alone will bring about resolution without antibiotic therapy. It is important that antibiotics alone should not be considered as a rst line o treatment unless there is systemic involvement. In a child a temperature o 39°C or higher can be considered signi cant (normal 37°C). Immunosuppressed patients and those with 147 • FACIALSWELLINGANDDENTALABSCESS 25 Table 25.1 Common antibiotics used in paediatric dentistry Drug Route Dose Frequency Notes PO 25–50 mg/kg/day tds Syrup or chewable tablets or young children IV 100–400 mg/kg/day tds Amoxicillin plus clavulanic acid PO 20–40 mg/kg/day tds Ampicillin IV 50–100 mg/kg/day qds IV 50 mg/kg stat IV 15–350 mg/kg/day Antibiotics Amoxicillin Benzyl penicillin 20000–500000 U/kg/day PenicillinV PO For beta lactam resistant organisms only qds First IVdrug o choice or odontogenic in ections > 5 years 1–2 g/day qds Give 1 hour be ore meals qds Cephalexin PO 25–50 mg/kg/day Cephazolin IV 25–50 mg/kg/day Erythromycin PO 25–40 mg/kg/day qds Ethylsuccinate is readilyabsorbed Metronidazole IV 22.5 mg/kg/day tds Not in pregnancy Gentamicin PO 10–15 mg/kg/day tds Clindamycin PO,IV 15–40 mg/kg/day qds Risko pseudomembranous colitis Analgesics see Chapter 24, Table 24.2 PO, per oral; IV, intravenous; IM,intramuscular; PR, per rectum; tds; three times daily; qds, our times daily; stat, at once (Frontline antibiotics used or acial swellings and dental abcesses are Amoxycillin, Penicillin Vand Metronidazol) cardiac disease should receive antibiotics immediately i any in ection is suspected. ■ What are the criteria or hospital a dmission with oro acial in ection? Dehydration. Ask whether the child has had a decreased requency o micturition (urine output) in previous 12 hours. Signi cant in ection or temperature greater than 39°C. Floor o mouth swelling. ■ What will the hospital mana gement o a severe in ection d azole shou ld be ad d ed as anaerobic organism s p lay a signi cant role. Maintenance uid s w ill be given until the child is d rinking norm ally again. Warm saline m ou thw ashes. Ad equ ate pain control com m only w ith paracetam ol or ibu p rofen (Table 24.2). If the eye is shu t d u e to a sw elling in the canine fossa, it may be necessary to give chloram p henicol eye d rop s 0.5% or chloram p henicol ointm ent 1.0% to prevent conju nctivitis. involve? Extraction of involved teeth. It is im p ossible to d rain a signi cant infection solely throu gh the root canals of a tooth. Drainage of any p u s. In ad d ition to extractions, there m ay be a need to incise and d rain p u s, often leaving a d rain in situ for a few d ays to enhance d rainage. With severe m and ibular sw ellings or w here the oor of the m ou th is raised , it may be necessary to have an extraoral d rain throu gh a skin incision or a ‘throu gh and throu gh’ d rain, w hich p asses comp letely throu gh the area of infection. Extraoral incisions are to be avoid ed if at all p ossible d u e to p ost-op erative scarring. Sw abs of p u s for laboratory cu lture to establish accu rate sensitivities of the organism s concerned to com mon antibiotics. Intravenou s antibiotics. Benzyl p enicillin is the d ru g of rst choice, or Am oxicillin. Cep halosp orins are effective if there is a p enicillin allergy, bu t there is som e cross-reactivity in those patients allergic to penicillin and so cephalosporins shou ld be u sed w ith care, esp ecially w hen there w as a severe reaction to p enicillin. In severe infections, m etroni- Key point Hospital admission in oro acial in ection is necessary with: • Dehydration. • Temperature >39°C. • Floor o mouth swelling. • Trismus or signif cant swelling around the eye leading to complete closure. • Breathing and swallowing di culties. Treatment Danny w as treated by the follow ing regim en: 1. Extirpation o 2 . The tooth was immature and good drainage o pus was achieved through the root canal. 2. Open drainage o the tooth or 2 days. 25 • 148 FACIALSWELLINGANDDENTALABSCESS 3. Amoxicillin 250 mg three times daily, metronidazole 200 mg twice daily or 5 days each. 4. Hot saline mouthwashes. After 2 d ays Danny w as review ed . The sw elling w as red u ced around his right cheek, and his right eye w as norm al. The 2 w as cleaned and led and non-setting calcium hyd roxid e placed into the canal. The access cavity w as sealed w ith cotton w ool and glass ionom er cem ent. The non-setting calciu m hyd roxid e w as rep laced once after a m onth. Once the root canal w as free from any signs or symp tom s of infection, the tooth w as obu rated w ith a Mineral Trioxid e Aggregate p lu g and w arm gu tta p ercha. Primary resources and recommended reading Cam eron A, Wid m er R (ed s), 2013 Paed iatric oral m ed icine and p athology. In: H and book of Ped iatric Dentistry, 4th ed n. Mosby, Ed inbu rgh, p p . 209–268. Am erican Acad em y of Ped iatric Dentists 2015 Guid eline on u se of antibiotic therap y for p ed iatric d ental p atients. Ref Man 36 (6):284–286. For revision, see Mind Map 25, page 245. 26 The uncooperative child and adolescent be m ore d if cu lt to treat. They often give up becau se they ‘never succeed ’ and are often called ‘failures’ by their p arents or peers. Communicative management. This is the m ost fu nd am ental form of behaviour m anagem ent. It is the basis for establishing a relationship w ith a child that w ill allow you to su ccessfu lly com p lete d ental p roced u res and help the child d evelop a p ositive attitu d e tow ard d ental health. ■ What main orms o communica tive mana gement are there? Non-verbal communication. Tell-show-do. Positive rein orcement. Distraction. Voice control. Parental presence/absence. CASE1 SUMMARY Liam is 5 years old. He is shaking and tear ul as he is brought into the surgery. His mother says he has been in pain rom his teeth or a long time. How would you manage Liam and his dental treatment? ■ What do you understand by the term behaviour management? Behaviou r m anagem ent inclu d es a nu m ber of skills: emp athy, com m u nication, coaching and listening. These skills need to be com bined w ith an u nd erstand ing of child d evelop m ent and p sychology. The goals are to establish com m u nication, alleviate fear and anxiety, d eliver qu ality d ental care, build a tru sting relationship betw een d entist and child and prom ote the child ’s p ositive attitu d e tow ard s oral/ d ental health. All d ecisions m u st be based on a bene t versu s risk evaluation. Parents/ legal gu ard ians share in the d ecisionm aking p rocess regard ing treatment of their child ren. They are also resp onsible for d ental attend ance, Liam ’s oral health regim e (inclu d ing p u rchase of toothp aste and u nd ertaking toothbru shing) and control w hat Liam eats and d rinks. It is therefore essential to establish a good relationship w ith p arents to ensu re they are su p p ortive and com p ly w ith the p reventive ad vice p rovid ed . ■ What history is important in Liam’s case? Liam’s dental history. It is cru cial to id entify any p reviou s ep isod es at the d entist, d octor or hosp ital, u su ally involving need les, that m ay have frightened him . If there are no previou s p recip itating factors he m ay have been frightened by stories or com m ents from his p eers or fam ily. Family dental history. Parental fear, and a negative attitud e tow ard d ental and oral health, can signi cantly affect the coop eration of a child . Liam’s development. Delayed d evelop m ent and p oor cognition can affect the ability of a child to u nd erstand w hat you are trying to d o to help. Child ren w ith a negative im age of them selves w ho have never su cceed ed at anything w ill Non-verbal communication is the reinforcem ent and gu id ance of behaviou r throu gh ap prop riate contact, p osture and facial exp ression. Objectives: To enhance the e ectiveness o other communicative management techniques. To gain or maintain the patient’s attention and compliance. Ind ications: May be used with any patient. Contraind ications: None. Tell-show-do is a techniqu e of behaviou r shap ing u sed by m any p aed iatric p rofessionals. The technique involves verbal explanations of proced u res in phrases approp riate to the d evelop mental level of the patient (tell); d em onstrations for the p atient of the visu al, aud itory, olfactory and tactile asp ects of the p roced ure in a carefully d e ned , non-threatening setting (show ); and then, w ithou t d eviating from the exp lanation and d em onstration, com pletion of the p roced u re (d o). The tell-show -d o techniqu e is u sed w ith com m u nication skills (verbal and non-verbal) and positive reinforcem ent. The langu age chosen m ust be appropriate to the child ’s level of u nd erstand ing and exp erience. Objectives: To teach the patient important aspects o the dental visit and amiliarize the patient with the dental setting. To shape the patient’s response to procedures through desensitization and well-described expectations. Ind ications: May be used with any patient. Contraind ications: None. Positive rein orcement In the p rocess of establishing d esirable patient behaviou r, it is essential to give appropriate feed back. Positive reinforcem ent is an effective technique to rew ard d esired behaviou rs and thus strengthen the 26 • 150 THEUNCOOPERATIVECHILDANDADOLESCENT recu rrence of those behaviou rs. Social reinforcers includ e positive voice m od u lation, facial exp ression, verbal praise and ap p ropriate physical d em onstrations of affection by all m em bers of the d ental team. N on-social reinforcers inclu d e tokens and toys. The d elivery of p ositive reinforcem ent shou ld follow these p rinciples. When the d esired behaviou r is show n it should be immediately rew ard ed . Each tim e the behaviou r is show n, consistency is need ed in rew ard ing this behaviou r. It should be clear w hat behaviou r is d esired . The p ositive reinforcer is only u sed contingent on that behaviou r being d isp layed . Objective: To rein orce desired behaviour. Ind ications: May be use ul or any patient. Contraind ications: None. Distraction is the techniqu e of d iverting the p atient’s attention from w hat m ay be perceived as an unpleasant proced u re. Objectives: To decrease the perception o unpleasantness. Objectives: To gain the patient’s attention and compliance. To avert negative or avoidance behaviours. To establish appropriate adult-child roles. To enhance the communication environment. Ind ications: May be used with any patient. Contraind ications: None. All these com m unication techniqu es m ay be need ed to enhance the evolution of a comp liant and relaxed patient. It is an ongoing subjective process rather than a singular technique and is often the extension of the personality of the d entist. Key point Positive rein orcement should be: • Immediate. • Clear. • Consistent. • Contingent. To avert negative or avoidance behaviour. Ind ications: May be used with any patient. Examination To gain the patient’s attention and compliance. After sp end ing som e tim e talking to Liam and show ing him that you are genuine in w anting to help , he allow s you to look at his teeth. Both low er rst p rim ary m olars are cariou s. All the other teeth are sou nd . Liam has been frightened by stories from his friend s. H is fam ily are very su p portive and are regu lar attend ers. Liam resp ond s w ell to com m u nicative m anagem ent, but although he w ants to have his treatm ent carried ou t, he ju st cannot overrid e his fear of the u nknow n. To avert negative or avoidance behaviour. ■ What a dditional help might you consider giving Lia m? To establish appropriate adult-child roles. Inhalational sed ation has been an effective and safe m ethod of red u cing anxiety and enhancing effective comm u nication for the past 30 years. Its onset of action is rap id , the d ep th of sed ation is easily titrated and reversible and recovery is rap id and com p lete. Ad d itionally, nitrou s oxid e m ed iates a variable d egree of analgesia, am nesia and gag re ex red uction. The need to d iagnose and treat, as w ell as the safety of the patient and practitioner, shou ld be consid ered before the use of nitrou s oxid e. The d ecision to u se nitrou s oxid e m u st take into consid eration the follow ing p oints: Contraind ications: None. Voice control is a controlled alteration of voice volu me, tone or pace to in uence and d irect the patient’s behaviou r. Objectives: Ind ications: May be used with any patient. Contraind ications: None. Parental presence/absence This techniqu e involves u sing the presence or absence of the parent to gain cooperation for treatm ent. A w id e d iversity exists in p ractitioner p hilosop hy and p arental attitu d e regard ing p arents’ p resence or absence d u ring p aed iatric d ental treatm ent. Practitioners are u nited in the fact that com m u nication betw een d entist and child is p aram ou nt and that this com m u nication d em and s focu s on the p art of both p arties. Child ren’s responses to their parents’ presence or absence can range from very bene cial to very d etrim ental. It is the resp onsibility of p ractitioners to d eterm ine the com m unication m ethod s that best op tim ize the treatm ent setting; recognizing their ow n skills, the abilities of the p articu lar child and the d esires of the sp eci c parent involved . Alternative behaviour management modalities. (Although nitrous oxide sedation is e ective or mild to moderately anxious patients, it is not e ective or children who cannot or will not breath through their nose some young children have not developed the level o maturity and understanding to be able to ollow this requirement.) Dental needs o the patient. The e ect on the quality o dental care. The patient’s emotional development. 151 • THEUNCOOPERATIVECHILDANDADOLESCENT The patient’s physical considerations. Written in ormed consent must be obtained rom a legal guardian and documented in the patient’s record prior to use o nitrous oxide. The p atient’s record shou ld inclu d e: In ormed consent. Indication or use. N itrou s oxid e d osage: • Percent nitrous oxide/oxygen and/or f ow rate. • Duration o the procedure. • Post-treatment oxygenation procedure. Objectives: To reduce or eliminate anxiety. To reduce untoward movement and reaction to dental treatment. To enhance communication and patient cooperation. To raise the pain reaction threshold. To increase tolerance or longer or more di cult treatment. To aid in treatment o the mentally/physically disabled or medically compromised patient. 26 CASE2 SUMMARY Maria is a 12-year-old girl with early ca ries in her mandibular f rst permanent molars. She has an increased overjet, and the orthodontic plan includes our premolar extractions, provided her ca ries risk is reduced and the dental disease is treated. ■ How would you motivate Ma ria to reduce her ca ries risk and assess and treat her dental anxiety? History Complaint Maria says she d oes not like to sm ile and is getting teased at school. History o complaint A mild to moderately ear ul, anxious or obstreperous patient. Maria w ent to her local d entist recently and received preventive ad vice bu t d id not m ange to accept local analgesia. Fu rther qu estioning revealed that she rem em bered being ‘forced ’ to have a p rim ary tooth extracted at age 6 years and has been fearfu l of d ental treatm ent since then. Certain mentally, physically or medically compromised patients. Medical history To reduce gagging. Ind ications: A patient whose gag ref ex inter eres with dental care. A patient in whom pro ound local anaesthesia cannot be obtained. Contraind ications: May be contraindicated in some chronic obstructive pulmonary diseases. Where the child has a blocked nose, common cold or tonsillitis, their appointment should be postponed until they have recovered. May be contraindicated in certain patients with severe emotional disturbances or drug-related dependencies. Patients in the rst trimester o pregnancy. May be contraindicated in patients with sickle cell disease. Patients treated with bleomycin sulphate. Neuromuscular disease, e.g. myasthenia gravis, multiple sclerosis. Liam had inhalational sed ation, w hich enabled com p letion of his treatm ent and helped him overcom e his fear of local anaesthesia. Key point The patient’s record in inhalational sedation should include: • In ormed consent. • Indications or use. • Nitrous oxide dosage. There is no relevant m ed ical history. Family history Maria’s m other says she is also afraid of going to the d entist. Examination Extraoral examination Maria has a slightly p rom inent increased overjet, bu t a Class I skeletal base and norm al face height w ith no asym m etry. Intraoral examination Maria has good oral hygiene. She has stained ssu res on the m and ibu lar m olars. Bitew ing rad iograp hs su ggest that the caries is into the enam el only. ■ Wha t recommenda tions are used regarding diet, toothbrushing and uoride or adolescents? Id eally, w e w ou ld all hop e that by ad olescence a child is d isease free and therefore w ill need little op erative treatm ent. H ow ever, there are ad olescents w ho have caries or other d ental problems, su ch as non-caries tooth tissu e loss; perhap s d ue to acid erosion, or period ontal d isease; or w ho have aesthetic need s that require orthod ontic treatm ent, w hich p erhap s inclu d e p rem olar extractions as p art of the treatm ent plan. Ad olescents w ho need orthod ontic extractions, in p articu lar, may not have had very m uch d ental treatm ent in the past, esp ecially if they are low caries risk. On the other hand the ad olescent w ho has high caries risk (ap p roxim ately 14% of the ad olescent p op ulation, 26 • 152 THEUNCOOPERATIVECHILDANDADOLESCENT Child Dental H ealth Su rvey 2013) often has a heavy bu rd en of d isease requiring m any visits to com p lete their restorative treatm ent. To overcom e the bu rd en of d isease, p reventive action is need ed . This is a tw o-pronged ap p roach that involves good , clear, evid ence-based p reventive ad vice from the d entist and the active agreem ent to im p lem ent the ad vised behaviour changes from the ad olescent. The Dep artm ent of H ealth (DoH ) Oral H ealth Preventive Toolkit contains evid encebased prevention ad vice inclu d ing tw ice d aily toothbru shing w ith 1450 p p m u orid e toothp aste, the need for regu lar d ental check-u ps and red u cing su gar frequency. In Maria’s case, 2800 p p m u orid e toothp aste shou ld be recomm end ed . This is su itable for child ren over 10 years of age w ho m ay be at risk for tooth d ecay, inclu d ing p atients w ith active tooth d ecay or a history of tooth d ecay, exp osed root surfaces, high-su gar d iets, orthod ontic ap pliances or d ry m ou th. Ad vice given should be evid ence based and given in a know led geable context of ad olescent m ind -set and behaviour change p sychological theory, su ch as u sing m otivational interview ing and cognitive behaviou r therap y. These theories are generally based on ad olescents und erstand ing their ow n d ental need s and the challenges that they face in imp lem enting recom m end ations and then taking action, and ‘rew ard ing’ them selves for d oing so. This ap p roach to p revention w ill also help in Maria’s anxiety m anagem ent becau se she w ill feel that she has a role and a say in her ow n d ental m anagem ent. In this w ay, the d entist and Maria w ill alread y be w orking together; ‘on the sam e sid e’ against the d ental d isease. Key point • Prevention o urther dental caries is essential, provided the caries that is already present is managed. • Adherence to preventive advice is key to progression to orthodontic treatment a terwards. • The DoH toolkit gives clear, evidence-based preventive recommendations. shou ld also includ e habits su ch as sm oking, experim ental d ru g and alcohol frequ ency; e.g. ‘alco-p ops’ and also ‘recreational’ d ru gs that cau se thirst lead ing to increased acid ic/ su gary d rink consu m p tion. Key point • Adolescents are sel -conscious and can have a ragile sel -esteem. • They want to be able to determine and make their own choices in li e. • They have concerns about their looks. • They want to f t in with their peers. • Question or habits such as smoking, experimental drugs and alcohol. • Be alert to bullying and sa eguarding issues. ■ Ca n a nxiety be measured, and what questions should be asked? There are variou s anxiety scales that help alert a d entist to d ental anxieties. Thou gh these are not sensitive enou gh to tease ou t the d ifferences betw een these tw o possible aetiologies, they m ay be of valu e. The com m on ones are the Mod ied Child Dental Anxiety Scale (MCDAS) and the Child Fear Su rvey Sched u le (CFSS). A sim p ler m easure, w hich can also be valu able in younger child ren, is the Facial Im age Scale (FIS); this is sometim es com bined w ith the MCDAS to assist you nger child ren’s com prehension. An exam ple is show n in Fig. 26.1. H ow ever, these also need to be au gm ented by carefu l and thou ghtful qu estioning, especially relating to p ast d ental history and p ossible p erceived traum atic events. Those w ho report that they have a need le phobia should be asked if they m anaged to accept their vaccinations at school; e.g. the tetanu s/ polio booster is usu ally given at arou nd 13 years of age in the UK. Treatment ■ What are the anxiety management options? ■ Wha t is the aetiology o dental a nxiety? There are tw o reasons behind ad olescent anxiety. The rst is d ental anxiety that is learnt over the p reced ing years and cau sed by real or p erceived trau m a of p reviou s d ental or m ed ical treatm ent. The second is d ental anxiety that is part of a d eep er p sychological d istu rbance that is beginning to emerge. ■ Why should a n a dolescent be ma naged di erently orm a younger child? There are som e fu rther d etails that a d entist cannot overlook w hen m anaging an anxiou s ad olescent. These relate to the m ind -set and to the em erging character of the ad olescent them selves. Ad olescents have a rather fragile self-esteem yet w ant to be able to d eterm ine and m ake their ow n choices in life. They have concerns abou t their looks, especially d ental aesthetics, and w ant to t in w ith their p eers. A d etailed history, perhap s based on som e subtle qu estioning, N on-pharm acological behaviou r m anagem ent is just as effective w ith ad olescents as it is w ith you nger child ren, so positive reinforcem ent, tell-show -d o and enabling a hand signal to ‘stop ’ to enhance Maria’s sense of control shou ld all be u sed . Giving information abou t w hat w ill hap pen, w hat it w ill feel like and how to cop e beforehand and d u ring the p roced u re are all im p ortant. Psychological interventions su ch as cognitive behaviou ral therap y can also p lay a key role. The id ea behind this technique is to help Maria reconsid er her belief that a fu tu re d ental extraction w ill be as trau m atic as that rem em bered from her child hood . Maria has alread y u nd ergone a d ental extraction at an earlier age, and in her m emory this w as traum atic. It is not uncom m on for a child to perceive a p ast experience as ‘traum atic’, even if in reality it w as not. The fact is that in Maria’s ow n m ind the event w as d am aging to her, so this has to be taken into accou nt. In Maria’s case, she w ill need to u nd ergo extractions as part of her orthod ontic treatm ent p lan. It is 153 • THEUNCOOPERATIVECHILDANDADOLESCENT Modified Child Dental Anxiety Scale – MCDAS For the next eight questions I would like you to show me how relaxed or worried you get about the dentist and what happens at the dentist. To show me how relaxed or worried you feel, please use the simple scale below. The scale is just like a ruler going from 1, which would show that you are relaxed, to 5, which would show that you are very worried. 1 would mean: relaxed/not worried 2 would mean: very slightly worried 3 would mean: fairly worried 4 would mean: worried a lot 5 would mean: very worried. How do you feel about … … going to the dentist generally? 1 2 3 4 5 … having your teeth looked at? 1 2 3 4 5 … having your teeth scraped and polished? 1 2 3 4 5 … having an injection in the gum? 1 2 3 4 5 … having a filling? 1 2 3 4 5 … having a tooth taken out? 1 2 3 4 5 … being put to sleep to have treatment? 1 2 3 4 5 … having a mixture of ‘gas and air’ which will help you feel comfortable for treatment but cannot put you to sleep? 1 2 3 4 5 Fig. 26.1 MCDAS with FIS images. (FromWong(1998), with permission.) likely that d iscu ssing Maria’s fears w ith her and p u tting them into a d ifferent context, in line w ith a cognitive behaviou ral therap y ap proach, and u sing excellent behaviou ral m anagem ent skills, giving her a locu s of control, and ensu ring ad equ ate analgesia w ill enable her to proceed to accep t her p lanned orthod ontic extractions. Resou rces and fu rther gu id ance on the u se of cognitive behaviou ral therap y are listed in the fu rther read ing section. to assess treatm ent progression and to evalu ate w hither the p lan is likely to su cceed . ■ Wha t treatment plan would you propose? The treatm ent plan: VISIT 1 1. ■ What is the commonest conscious sedative in children and adolescents? For m od erately anxiou s child ren, nitrou s oxid e inhalation sed ation is the m ost com m only u sed sed ative and is effective in ad olescents w ho requ ire p rem olar extractions. Maria m ay need this in ad d ition to the behaviou ral techniqu es alread y d escribed . The key is to carry ou t a thorou gh assessm ent based on a frank d iscu ssion w ith her and her p arent(s) before the treatm ent p lan is d evelop ed , to inclu d e inhalation sed ation from the start if it is need ed , rather than have a ‘failed ’ behavioural m anagem ent visit before consid ering consciou s sed ation as an option. It is also w ise to bu ild in a reassessment of the agreed plan after the rst or second visit 2. Preventive advice (this is discussed in greater detail in Chapter 23) ollowing the DoH toolkit, so including: a. Prescription o twice daily brushing with 2800 ppm f uoride toothpaste. b. Handing out a 4-day diet diary. Ask Maria to sign a contract to: a. Reduce dietary sugar intake requency based on tailored advice derived rom her diet diary. b. Implement twice daily toothbrushing with a 2800 ppm f uoride toothpaste. c. Attend pre-agreed and booked dental appointments. d. Conduct a discussion between dentist, parent(s) and patient that leads to written parental consent and 26 26 • 154 THEUNCOOPERATIVECHILDANDADOLESCENT e. . g. h. adolescent assent o sedative choice and operative treatment. Document the consent and assent process and document written in ormed consent. Disclose dental plaque and modi y toothbrushing technique and choice o toothpaste regarding f uoride dose; consider 2800 ppm f uoride toothpaste. Introduce her to the inhalation sedation nasal mask and technique. Fissure seal a maxillary rst permanent molar and introduce topical analgesia. VISIT 2 (preventive advice will continue and expand on 2a, 2b, 2 ) 3. Use a. b. c. inhalation sedation or the rst time: Fissure seal the remaining rst permanent molars. Introduce topical analgesia. Reassess Maria’s caries risk by checking compliance with dietary changes and toothbrushing, and con rm premolar extraction plan with the orthodontist. Reassess the use o nitrous oxide inhalation sedation. Does Maria still need it? VISIT 3 AND 4 (preventive advice will continue and expand on 2a, 2b, 2 ) 4. Begin orthodontic premolar extractions perhaps in two quadrants per visit. O ten an extraction in maxillary and mandibular quadrant is undertaken rather than extracting both mandibular premolars on the same visit. For mandibular extractions, in ltrations using Articaine local anaesthetic rather than in erior dental blocks with Lidocaine is an e ective but less invasive method. ■ Wha t ollow-up does Maria need now? Maria has su ccessfu lly u nd ergone the p rem olar extractions and has red u ced her su gar frequ ency and is toothbrushing w ith 2800 p pm u orid e tooth p aste. Therefore she is proceed ing to have orthod ontic xed ap p liance treatm ent. As such, her caries risk is still high and she w ill need regular, four-m onthly follow -u p s d u ring her orthod ontic treatm ent. She w ill also need fu rther bitew ings to assess for new d ental caries once yearly (once her orthod ontic ap p liance is removed , u ntil no fu rther caries is seen and she is d eem ed to be at low caries risk). Maria feels hap py and p roud to have u nd ergone the extractions. She now enjoys visiting the d entist for checku ps and is excited abou t her new sm ile. CASE3 SUMMARY Un ortunately, there are some children and adolescents or whom inhalational sedation is unable to overcome their anxiety, and alternative sedation agents or general anaesthesia is the only option that will allow relie o pain and completion o dental treatment. ■ What other sedation techniques are availa ble? Other sed ation techniqu es su ch as oral or intravenou s m id azolam are effective. Dental sed ationists w ho offer this type of treatm ent have to show that they have u nd ergone fu rther training in the technique, as w ell as continu ed com petency and experience in line w ith contem porary national gu id elines and recom m end ations. For young child ren oral sed ation is a viable option u sing m id azolam . A num ber of recent stud ies have show n that its use in a d ose of 0.3–0.5 m g/ kg, d epend ing on age, has been therap eu tically effective in p rod u cing sed ation that has allow ed su bsequ ent d ental treatm ent. For ad olescents w ho require m ore invasive p roced ures or w ho are m ore severely p hobic, m id azolam intravenou s sed ation is an op tion becau se it has the ad d ed bene t of causing am nesia. Am nesia also occu rs w ith oral m id azolam . The p atient cannot rem em ber u nd ergoing the proced u re. They m ay rem em ber the start of the d ental visit and the beginning of the sed ation, bu t nothing u ntil after the sed ative effect has begu n to w ear off. ■ What a re the indications or general anaesthesia? Patients who are unable to cooperate due to a lack o psychological or emotional maturity and/or mental, physical or medical disability. Patients or whom local anaesthesia is ine ective because o acute in ection, anatomical variations or allergy. The extremely uncooperative, ear ul, anxious or uncommunicative child or adolescent. Extensive dental caries involving dental treatment in multiple quadrants. Patients requiring signi cant surgical procedures ( or example, the extraction o all rst permanent molars or a severely in raoccluded primary molar). Patients or whom the use o general anaesthesia (GA) may protect the developing psyche and/or reduce medical risks. Patients requiring immediate, comprehensive oral/ dental care. ■ What a re the contra indications or general anaesthesia? A healthy, cooperative patient with minimal dental need. Predisposing medical conditions that would make GA inadvisable. General anaesthesia is a controlled state o unconsciousness accompanied by a loss o protective ref exes, including the ability to maintain an airway independently and respond purpose ully to physical stimulation or verbal command. It should only be provided in premises with resuscitation capability and intensive care back-up (e.g. an acute hospital setting). All equipment must ollow current guidelines (please see re erence section). Parental or legal guard ian inform ed consent m ust be obtained and d ocu m ented prior to the u se of general anaesthesia. The p atient’s record should inclu d e: • In ormed consent. • Indications or the use o GA. 155 • THEUNCOOPERATIVECHILDANDADOLESCENT In ormed consent Regard less of the behaviour m anagem ent techniques u tilized by the ind ivid u al p ractitioner, all m anagem ent d ecisions m u st be based on a su bjective evalu ation w eighing bene t and risk to the child . Consid erations regard ing need of treatm ent, consequ ences of d eferred treatm ent and p otential p hysical/ em otional trau m a m u st be entered into the d ecision-m aking equ ation. Delivery of d ental treatm ent is often a com p lex d ecision. Decisions regard ing the u se of behaviou r m anagem ent techniqu es other than com m u nicative m anagem ent cannot be m ad e solely by the d entist. Decisions m u st involve a legal gu ard ian and , if app rop riate, the child . The d entist serves as the exp ert abou t d ental care, i.e. the need for treatm ent and the techniqu es by w hich treatm ent can be d elivered . The legal gu ard ian shares w ith the p ractitioner the d ecision w hether to treat or not to treat and m u st be consu lted regard ing treatm ent strategies and p otential risks. Therefore the successful comp letion of d iagnostic and therapeutic services is view ed as a p artnership of d entist, legal gu ard ian and child . Althou gh the behaviou r m anagem ent techniqu es inclu d ed in this chap ter are u sed frequ ently, p arents m ay not be entirely fam iliar w ith them . It is im p ortant that the d entist inform the legal gu ard ian abou t the natu re of the technique to be u sed , its risks, bene ts and any alternative techniques. All qu estions m u st be answ ered . This is the essence of inform ed consent. ■ Who can consent or a child? Mother all mothers automatically have parental responsibility. Fathers i married at the time o the child’s conception, birth or sometime a ter this, this responsibility is not lost i the mother and ather divorce. Unmarried athers only have parental responsibility i either given parental responsibility by a court order or in agreement with the mother that is registered with the High Court or the child was born a ter 1/12/03 ( or England and Wales) and is named on the birth certi cate. Step parents court order. only have parental responsibility i given by a Grandparents, relatives, riends other people may be given responsibility by a court order or by being appointed guardian upon the death o the parents. Social services social care may have, or share, parental responsibility i a child is under a care order or is a ward o court. (Reproduced with kind permission o Brad ord District Care NHS Trust.) ■ Ca n an adolescent consent or themselves? Ad olescents w ant to be in charge of their d estiny and feel that they are com p etent to m ake their ow n d ecisions. Legally, w ritten consent for treatm ent, su ch as sed ation, d oes still requ ire w ritten p arental agreem ent, bu t the d iscu ssions that lead u p to this shou ld inclu d e the ad olescent’s w ishes and incorp orate their assent. 26 Therefore agreeing to a contract w ith an ad olescent p atient, w here they sign-u p to agree to d ietary behaviou r changes and regu lar toothbru shing w ith the correct d osage of u orid e toothp aste, not only p rovid es them w ith a sense of self d eterm ination and esteem but also tailors and claries the preventive practices that und erp in the d ental treatm ent p lan. It is alw ays p ru d ent to involve both the ad olescent and the ad u lt w ith parental responsibility. Child ren u nd er 16 years of age can consent for treatm ent if they u nd erstand w hat is proposed . ‘It is u p to the d entist to d ecid e w hether the child has the m atu rity and intelligence to fu lly und erstand the natu re of the treatm ent, the op tions, the risks involved and the bene ts. A child w ho has su ch u nd erstand ing is consid ered Gillick com petent. Key point • It is good practice to gain consent rom the adult with parental responsibility and assent rom the child up to 16 years o age. • Where a child is considered Gillick competent, they can consent or their own dental treatment. • Di erent ages and rules apply in di erent parts o the UK. Primary resources and recommended reading Am erican Acad em y of Ped iatric Dentistry 2015 Gu id eline on behavior guid ance for the p ed iatric d ental patient. Reference Manu al 37 (6):180–193. Am erican Acad em y of Ped iatric Dentistry 2015 Gu id eline on use of local anesthesia for p ed iatric d ental p atients. Reference Manu al 37 (6):199–205. Am erican Acad em y of Ped iatric Dentistry 2015 Gu id eline on use of nitrou s oxid e for p ed iatric d ental p atients. Reference Manual 37 (6):206–210. Cam pbell C, Sold ani F, Bu su ttil-N au d i A et al 2011 N onPharm acological Behaviou r Managem ent Gu id eline. Available at: http :/ / bsp d .co.u k/ Portals/ 0/ Pu blic/ Files/ Gu id elines/ N on-p harm acological%20behaviou r%20m anagem ent%20.p d f. Davies C, H arrison M, Roberts G 2008 Gu id eline for the Use of General Anaesthesia (GA) in Paed iatric Dentistry. Lond on: Royal College of Su rgeons of England . Available at: http :/ / w w w.rcseng.ac.u k/ fd s/ p u blications-clinical-gu id elines/ clinical_gu id elines/ d ocu m ents/ Gu id eline%20for%20the% 20u se%20of%20GA%20in%20Paed iatric%20Dentistry% 20May%202008%20Final.p d f. H osey MT 2002 Managing anxiou s child ren: the u se of conscious sed ation in p aed iatric d entistry. UK N ational Clinical Gu id eline. Int J Paed iatr Dent 12:359–372. Intercollegiate Ad visory Com m ittee for Sed ation in Dentistry 2015 Stand ard s for Consciou s Sed ation in the Provision of Dental Care. Lond on: Royal College of Surgeons of England . Available at: http s:/ / w w w.rcseng.ac.u k/ fd s/ Docu m ents/ d ental-sed ation-rep ort-2015-w eb-v2.p d f. Marshm an Z, Baker S, Cresw ell C et al 2016 Cognitive behaviou r therap y for d ental anxiety. Resou rces are available for the d ental 26 • 156 THEUNCOOPERATIVECHILDANDADOLESCENT team , child ren and their p arents. Available at: http:/ / d ental.llttf .com . Med ical Protection Society 2014 Consent – child ren and you ng p eop le. Available at: http :/ / w w w.m ed icalprotection.org. N u nn J, Foster M, Master S et al 2008 Consent and the Use of Physical Intervention in the Dental Care of Child ren. Lond on: Royal College of Su rgeons of England . Available at: https:/ / w w w.rcseng.ac.uk/ fd s/ p ublications-clinical-gu id elines/ clinical_gu id elines/ d ocu m ents/ p aed _d ent_intervention.p d f. Public H ealth England 2014 Delivering Better Oral H ealth: An Evid ence-Based Toolkit for Prevention, third ed . Pu blic H ealth England , Lond on. Available at: http s:/ / w w w.gov.u k/ governm ent/ u p load s/ system / u p load s/ attachm ent_d ata/ le/ 367563/ DBOH v32014OCTMainDocu m ent_3.p d f. Wong H M, H um p hris GM, Lee GTR 1998 Prelim inary valid ation and reliability of the m od i ed child d ental anxiety scale. Psychol Rep 83:1179–1186. For revision, see Mind Map 26, pages 246 247. 27 Children with disabilities and learning di culties SUMMARY Sa njeev is an 8-year-old boy with Asperger’s syndrome. You receive a letter rom a community dentist who has undertaken a routine school inspection. The letter reports that Sanjeev has caries in his f rst and second primary molars. On entering the clinic, Sa njeev’s mother gives the receptionist a communication passport (http:// www.autism.org.uk/living-with-autism/out-and -about/my-hospital-passport.aspx). She asks the dentist to read the passport be ore seeing her son (Fig. 27.1). d iagnosis w as nally m ad e. Sanjeev’s m other has only recently retu rned to p art-tim e w ork, now that he seem s m ore settled in school. ■ What challenges ha s Sanjeev’s a mily aced? The fam ily m ay have faced genuine d if cu lties relating to access to m ed ical and d ental care. A key focu s for Sanjeev’s parents w as to get a thorou gh assessm ent of his m ed ical cond ition. They also had to w ork w ith his school and w ith social services to have his ed u cational and social need s assessed . As a resu lt of these assessm ents, Sanjeev now has better access to health care, social and ed ucational sup port, and his p arents have been in touch w ith other parents w ho have child ren w ith Asperger ’s synd rom e. Sanjeev has tw o healthy brothers w ho also need su p p ort and attention in their ow n right. Sanjeev’s m other gave u p her p art-tim e job to look after him . Although she is p leased that she has achieved stability, su pport and m ed ical care for her child , she is w orried abou t his teeth. She has previously p rioritized the m any ed u cational and school assessm ents, w hich led to Sanjeev’s irregu lar d ental attend ance. ■ How will you ma nage him? History Complaint Sanjeev’s m other reports that she d oes not think he is in p ain. H e has been eating and sleep ing normally. Sanjeev says, bu t only w hen he is p rom p ted , that he has occasional p ain w hen he eats sw eets. History o complaint There is no relevant history. Medical history Sanjeev is t and w ell. H e w as d iagnosed w ith Asp erger ’s synd rom e last year. H e d oes not take any m ed ication. Asp erger ’s synd rom e is a typ e of high-fu nctioning au tism . Social history Sanjeev is in a m ainstream school and receives ad d itional su p p ort d u ring his lessons from a teaching assistant. H is m other rep orts that she had to ght very hard for this su pport and w ent through nu m erou s ed ucation assessments – esp ecially before the Asp erger ’s synd rom e Fig. 27.1 Sanjeev’s communication passport where he describes how best to manage his dental visit. Passport originated by National Autism Society. See http://www.autism.org.uk/about/ health/hospital-passport.aspx. Reproduced with permission. 27 • 158 CHILDRENWITHDISABILITIESANDLEARNINGDIFFICULTIES Key point Key eatures o Autism, Asperger’s syndrome and Attention Def cit Hyperactivity Disorder (ADHD): • Please see http://www.autism.org.uk or urther in ormation. Autism is a spectrum o disorders with children showing varying levels o severity in three key categories: • Communication children show delayed language development and limited comprehension o non-verbal communication. Severely a ected children may have rudimentary or no speech. • Social interaction children o ten live in their own world and have limited interest and interaction with other children and adults. • Social imagination children may struggle to interpret other people’s eelings and actions. Asperger’s syndrome, as already described, is at the high- unctioning end o the autistic spectrum. It is characterized by normal spoken language development, and the child can have average or above average intelligence. He or she o ten does not have learning delay but can have specif c learning di culties. There are three key eatures o the diagnosis: • Love o routines. • Intense interests. • Sensory impairment which can be either under or over unctioning, or example taste, sound, sensation, hearing or sight. ADHD is a diagnosis made be ore the age o 7 with children demonstrating a triad o symptoms, which can be treated with medication or therapeutic interventions. • Inattention. • Impulsivity. • Hyperactivity. Although many children are diagnosed with highunctioning autism and ADHD, they are two separate conditions. ■ Wha t ca n dentists do to a ssist the a mily and help them overcome ba rriers o access to dental care? Managing child ren w ith d isabilities and learning d if cu lties can som etim es seem to be a challenge, bu t it is alw ays rew ard ing. For m any of these fam ilies, being able to access d ental care in a p rim ary setting is a w elcom e resp ite from the other specialist services that they attend . Many d entists w ho begin to treat a child w ith a d isability often continu e to d eliver care for the w hole fam ily and provid e a continu ed source of su pport. For m any child ren w ith Asp erger ’s synd rom e, rou tine is very im p ortant and being seen by the sam e d entist in the sam e su rgery help s w ith fam iliarization and their cooperation. From a d ental p oint of view, it is not u ncom m on to have a ‘w arrior-m u m ’ w ho has becom e cond itioned to ght for her child ’s care and so can ap p ear overly d em and ing or imp atient. H ow ever, being aw are of these other challenges that the fam ily is facing can help d evelop a strong af nity and level of tru st. Parents w ill be grateful for ap pointm ents and treatm ents that m inim ize the am ou nt of tim e out of school and aw ay from w ork. Examination ■ How will you examine Sanjeev? Sanjeev has provid ed consid erable help and guid ance on how best he can cope w ith the d ental exam ination. Follow ing his ad vice w ill only help w ith the appointm ent. Many child ren w ith d isabilities and learning d if culties can read ily accep t a d ental examination. H ow ever, some can have more challenging behaviour and even a d ental examination can be d if cult to perform. Some of these d if culties can be overcome by a sequence of short introd uctory visits, each one set up in exactly the same w ay as the previou s but just build ing on the examination; this can w ork w ell w ith a child w ith autistic spectrum d isord er. Other d istractions arou nd the surgery should be minimized , e.g. noise or interruption. Keep ing instru ction sim p le and d irect help ed Sanjeev sit in the d ental chair and allow ed for a qu ick d ental exam ination. Extraoral There w ere no relevant nd ings. Intraoral Caries w as id enti ed in the occlusal surfaces of all fou r second p rim ary molars. There w ere d istal cavities on both m and ibu lar rst p rim ary m olars. Radiographic investigation ■ What is the best radiographic investigation? With carefu l and sim p le explanation, Sanjeev tolerated bitew ing rad iographs. If this was not possible, a ‘teeth-only dental panoramic tomogram (DPT)’ or a standard DPT (depending on what settings are available) is an alternative. A trial run to familiarize Sanjeev with the equipment and what is expected is a very helpful halfway step. This w ill increase the likelihood of Sanjeev staying still for the DPT. Although the radiation exposure is higher for a DPT, w here a radiograph of the carious primary teeth w ill in uence the treatment provided , this DPT radiograph is still justi ed if bitewings are not possible. The bitew ings show ed that the: • First permanent molars have no caries. • Occlusal caries in the second primary molars was into the inner hal o the dentine. • Caries in the mandibular rst primary molars appears close to the pulp with the roots almost completely resorbed by the permanent successors. ■ What is Sa njeev’s dental dia gnosis? Sanjeev appears to have reversible pulpitis rom his carious and restorable second primary molars. The mandibular rst primary molars may also be causing him some annoyance, especially as they become more mobile. In common with other children his age, he may be xated by his ex oliating teeth. 159 • CHILDRENWITHDISABILITIESANDLEARNINGDIFFICULTIES Key point • Parents o a child with a learning disability will have many competing demands on their time. • Routine is key and there ore it is important that the child sees the same sta , in the same surgery to develop amiliarity. • Keep instructions simple and direct. • Children may not always sit in the dental chair and there ore take whatever opportunity arises to examine their teeth (e.g. sitting on their parents’ lap, in the waiting room, on the surgery oor). • Clear communication with a parent is essential to identi y how much support and/or restraint they are happy to provide to permit a dental examination. Any restraint must be proportionate with the history and the need or a dental examination. ■ What are the trea tment options or Sanjeev? The m anagem ent of the d ental d isease is the sam e as d escribed in Chap ter 24. bu t it is the m ethod of d elivery than can be d ifferent. Prevention is the key. The DoH Prevention Toolkit is a valu able sou rce of gu id ance. Every visit presents an op p ortu nity to p revent caries: w hether this is ad vice to red u ce sugar frequ ency, to u se 1450 p p m u orid e toothp aste or to ap ply top ical u orid e. There are a nu m ber of w ays p arents can be su p p orted to ensu re they are u nd ertaking toothbru shing for their child . This includ es m od i ed toothbru shes (three-sid ed toothbru sh), nger-gu ard s or u sing a tw o toothbru sh techniqu e. The second toothbru sh can be u sed to keep the teeth ap art, thus p erm itting the other to bru sh the occlu sal su rfaces of the teeth. ■ Ca n Sa njeev be managed in a primary ca re setting? The answ er to this qu estion d ep end s on the d e nitive treatm ent p lan and the p atient’s level of coop eration. Referral to a specialist (com m u nity) or hosp ital-based paed iatric d entistry u nit m ay be requ ired , esp ecially if general anaesthesia is need ed . ■ What are the dental management options? Sanjeev m ight m anage to have the carious second prim ary m olars restored w ith com p lete caries rem oval, bu t he w ill need to accep t local analgesia ow ing to the d ep th of caries in all fou r of these teeth and their sym p tomatic history. Conventional caries rem oval is likely to take at least a fu rther ve visits. Therefore, in the rst instance, stabilizing the caries using glass ionom er cem ent (GIC) tem p orary restorations is the best op tion. It also p rovid es Sanjeev w ith fu rther acclim ation to the d ental su rgery and gives an ind ication of how he w ill cop e w ith m ore invasive treatm ent. In these earlier visits, ad d ressing the causes of caries is essential as d escribed in Chap ters 22 and 23. Many au tistic child ren can stru ggle w ith som e of the sensations of d entistry su ch as the tastes, sm ells, noises and textu res. ■ Would Hall crowns be an a ppropriate treatment option? The extent of the caries and the history of p ain w ou ld red u ce the chances that the H all ap p roach w ou ld be effective. 27 Guid ance for the u se of H all crow ns (see Chapter 24) w ou ld ad vocate their u se at an earlier stage of the caries process, before sym ptom s d evelop. H ow ever, in som e situ ations, and after carefu l d iscu ssion w ith the parents, treatment m ay be u nd ertaken if there is a clear und erstand ing of the poor p rognosis and the need for one or m ore teeth to be extracted if fu rther signs and sym p tom s show irreversible p u lp itis or ap ical p eriod ontitis (e.g. non-vital). For som e child ren w ith d isabilities, especially w here there are signs of bruxism and tooth w ear, great thou ght shou ld be taken before ap plying H all crow ns. The p ropp ing op en of the occlusion m ay exacerbate their grind ing and increase the risk of a p erforated crow n. ■ When will these prima ry teeth exo oliate? This is an im portant consid eration w hen treatm ent p lanning. For Sanjeev, the m and ibu lar prim ary rst m olars are likely to exfoliate very shortly and therefore, u nless sym ptomatic, can be left to exfoliate. For the second prim ary m olars, these teeth exfoliate arou nd the age of 12. Therefore any restorative plan w ill requ ire m aterials w ith good evid ence of longevity over this 4-year tim e p eriod . Such m aterials inclu d e com posite, am algam or stainless steel crow ns. The longer the restoration need s to survive the m ore likely a stainless steel crow n w ill be the restorative op tion as these have the greatest longevity. ■ Does beha viour management work with children with Asperger’s syndrome? N on-p harm acological behaviou r m anagem ent can w ork w ell in child ren w ith Asp erger ’s synd rom e. H ow ever, this m ay need to be au gm ented w ith voice control to gain Sanjeev’s attention if he becomes d istracted , so p ositive reinforcement, tell-show -d o and enabling a hand signal to ‘stop’ should all be u sed . Giving sim ple inform ation abou t w hat w ill happ en, w hat it w ill feel like and how to cope beforehand and d u ring the proced u re are all im p ortant. The langu age u sed should be ap propriate for his level of u nd erstand ing and experience. A constant sim ple and rep etitious d ialogu e need s to be maintained , otherw ise Sanjeev w ill get d istracted . Key point • Behaviour management techniques should be used. • A constant dialogue should be maintained to keep the child engaged and ocused on the dentist. • Voice control may sometimes be required to ocus the child’s attention. ■ Does nitrous oxide inhalation sedation work or children with Asperger’s syndrome? N itrou s oxid e inhalation sed ation is the m ost com m only u sed sed ative in child ren. The key is to carry out a thorou gh assessm ent based on a frank d iscu ssion w ith Sanjeev and his m other. The su ccess of the technique is d epend ent on Sanjeev’s ability and w illingness to breathe in and ou t through his nose. Many child ren w ith Asp erger ’s synd rom e 27 • 160 CHILDRENWITHDISABILITIESANDLEARNINGDIFFICULTIES enjoy the active engagem ent of this activity. It is also w ise to assess progress after the rst or second visit and to evalu ate w hether Sanjeev w ill m anage to accep t local analgesia. ■ Does Sa njeev need a general anaesthetic? This d ecision is a balance as there are a nu m ber of d isad vantages of this ap p roach. The w hole general anaesthetic event can be trau m atic for the child , and research has show n that child ren are m ore d entally anxious afterw ard s. H ow ever, for som e parents the ability to treat the d ental caries ef ciently (e.g. all d ental care is p rovid ed in one go) and their child ’s lim ited ability to rep ort any p ain and su ffering can m ake a general anaesthetic an attractive option. Other consid erations w hich in uence the d ecision includ e the likelihood of the child coop erating d u ring treatm ent, the pain history and the w aiting tim e for this treatm ent. Sanjeev d oes not need u rgent treatm ent, and he is not in severe p ain. Therefore a general anaesthetic is not cu rrently ju sti ed esp ecially as in Sanjeev’s case there is tim e to stablise his caries and see how he and his sym ptom s resp ond to this initial treatm ent. ■ Wha t treatment plan would you propose? Using the principles d iscussed in Chap ter 24, a treatm ent plan should be d raw n u p together w ith a visit-by-visit p lan. As for all child ren, it is essential to ensu re a rigorou s p reventive plan. Sanjeev may alw ays need extra su p p ort w hen attend ing the d entist and therefore keep ing him caries free is a key p riority. By follow ing Sanjeev’s instru ctions, he cop ed w ith the temporary restorations and both his m um and he engaged in the p reventive regim e (d iscu ssed in Chap ters 22 and 23). Sanjeev’s cooperation w as good bu t limited . H ow ever, he respond ed w ell to nitrou s oxid e sed ation. Conventional caries rem oval w as u nd ertaken u nd er local anaesthetic and nitrou s oxid e sed ation. This w as very effective, and Sanjeev comp leted treatm ent. While the m and ibu lar second p rim ary m olars w ere anaesthetized , the alm ost exfoliated m and ibular p rim ary m olars w ere extracted . Common disabilities ■ Wha t are the common disabilities? There are m any other physical d isabilities and learning d ifculties. These can be grou p ed into sensory, p hysical, m ental and m ed ical d isabilities. The com m onest of these are show n in Table 27.1. Som etim es these can be intertw ined . The im p act of m ed ical cond itions on d ental care is d iscu ssed in Chap ter 28. ■ How would this plan be altered i Sa njeev’s disability had been more severe? Sanjeev coped w ell w ith a d ental p lan that w as based on prevention, stabilization and then d e nitive care. As su ch, it d id not challenge him too m u ch and it also incorp orated very good behaviou ral management. H ow ever, for som e child ren, their p hysical and learning d isability is m ore severe and their d ental need s m ore u rgent. A typical exam ple is a child w ith epilep sy and cerebral p alsy w ho is u nable to control his or her m ovem ents. This child m ay have had a seizu re and fallen, thu s trau m atizing a tooth. In su ch a case, the child m ay be u nable to cop e w ith treatm ent for a non-vital central incisor and a general anaesthetic m ight be requ ired to m anage the trau m atized tooth. While asleep, any other d ental care w ould also be carried ou t, su ch as ssu re sealants, extractions or restorations. ■ Are there more complica tions to genera l anaesthesia or children with a disa bility? Many child ren w ith a d isability or learning d if cu lty are otherw ise p hysically healthy and can u nd ergo d aycase general anaesthesia w ithou t fu rther concern. N evertheless, the w hole general anaesthesia event can be anxiety provoking, and so p rep aring the child and fam ily can help red uce the psychological anxiety that su rrou nd s the event. Psychological su p p ort inform ation m ay help ; one su ch online and freely available p ackage that has increased fam ily satisfaction can be fou nd at w w w.scottga.org. Som e m ay not have the cop ing skills to coop erate w ith the anaesthetic ind uction and m ay need pre-m ed ication beforehand . The com m onest pre-m ed ication is m id azolam 0.5 m g/ kg given app roxim ately 30 m inutes before the general anaesthetic ind uction. ■ What medical comorbidities can children with a disability commonly present with? Apart from his Asperger ’s synd rom e, Sanjeev is otherw ise healthy. H ow ever, som etim es d isabilities are linked w ith a m ed ical com orbid ity. An exam p le of this is a child w ith Dow n synd rom e, w ho m ight not only have a card iac d efect bu t also be p rone to acu te lym phoblastic leu kaem ia, especially if the Philad elp hia chrom osom e is carried together w ith trisom y 21. The m anagem ent of these child ren w ith com p lex cond itions need s liaison w ith paed iatricians and is best referred to a hospital p aed iatric d entistry team . Key point • Learning disabilities can be linked to epilepsy, cardiac de ects and other medical problems. • There needs to be liaison with the child’s paediatrician. • Re erral to a community or hospital based paediatric dentistry specialist team may be needed, especially i general anaesthesia treatment is required and their medical comorbidity will complicate the general anaesthesia. ■ How does a dentist communicate with children with a disa bility? Com m u nication w ith child ren w ith com p lex need s inclu d es a mixtu re of m ethod s and technologies that can sup plem ent the spoken and w ritten w ord and gestu re. For som e, gestu res, facial exp ressions, bod y p ostu res, eye gaze and m ime is need ed . For others, sign langu age, e.g. British sign langu age, or other hand signals and pictures and sym bols or other m ed ia su ch as a sou nd board m ay be u sed . The bestknow n technique is MAKATON , d evelop ed in the 1970s to help p eop le w ith learning d isabilities to com m unicate. It u ses som e British sign langu age signs com bined w ith sp eech, facial expression, eye contact and bod y langu age along w ith gestu res and sym bols. N ow ad ays, MAKATON 161 • CHILDRENWITHDISABILITIESANDLEARNINGDIFFICULTIES Table 27.1 Types o disability Type Example(s) Dental implications Solutions Physical Cerebral palsy Varying degrees o paralysis/muscular dys unction Epilepsy Behavioural problems Visual and/or hearing impairments Compromised speech and learning skills Bruxism Reduced vertical dimension Anterior open bite Drooling Inabilityto per ormadequate oral hygiene Phenytoin induced gingival hyperplasia Wheel chair access Oral hygiene support Modifed brushes Teaching carers howto brush 2800 ppm uoride toothpaste or children aged 10 and over Regular check ups and scaling Corsodyl gel applied via a toothbrush daily, separate rom uoride toothbrushing Reduce sugar requency Wherever possible consider re erral to interdisciplinaryteam or assessment o drooling to avoid surgeryto relocate submandibular salivarygland outlet, as this will signifcantlyincrease caries riskespeciallylower anterior teeth Augmentive and alternative communication skills Learning Down syndrome Class IIIocclusion Macroglossia Hypodontia Microdontia Delayed exoliation o primaryteeth Predisposition to periodontal disease Oral hygiene support Modifed brushes Teaching carers howto brush 2800 ppm uoride toothpaste or children aged 10 and over Regular check ups and scaling Corsodyl gel applied via a toothbrush daily, separate rom uoride toothbrushing Reduce sugar requency Medical problems: Cardiac de ect Leukaemia Recurrent chest in ection Sensory disabilities Severe developmental delay Di cult to examine or to provide dental care Consider gentle holding to prevent harm– known as‘clinical holding’ Mouth props (thimble) Towels Pillows Sa etybelts Pharmacological restraint Pre medication General anaesthesia Hearing Di cultygiving a history Di culty ollowing instructions while in the dental chair, especiallyi the dentist is behind Hearing aids and cochlear implants maydistort sounds and enhance the volume o dental drills and scalers so much that it is pain ul and distressing Uses other means o communication Sign language Lip reading Other communcation aids or media such asVOCA Lip reading Do not over emphasize mouth and lips when speaking – it causes di culties with lip reading Find out the best means o communication Take time to askthemto showit to you and agree howyou will use it to collaborate together to communicate Give child a hand mirror so that theycan see you Warn to switch o hearing aid or turn down volume be ore drilling or scaling Agree on hand signals or gestures to allowcontinued communication while hearing aids are o Cochlear implants Avoid monopolar electrosurgery Vision Needs toothbrushing instruction that is not based on visual cues such as disclosing Bright lights can hurt No visualization o surroundings or gestures o dentists or sta Access challenges Stairs Guide dog Directional signage has been au gm ented by new technologies and m ed ia (for exam p le http :/ / w id git-health.com / easy-read -sheets/ p d fs/ H ealthy%20teeth.p d f). Speech and language therap ists u se all of these techniqu es and tailor them to each child ’s need s so that every child can achieve som e level of com m u nication. As can be seen from Sanjeev’s case, the com m u nication p assp ort can w ork very w ell. The fu ll passp ort contains other help fu l sections su ch as ‘things I can’t cop e w ith and m ake m e d istressed ’ and ‘how to avoid d is- Use sunglasses and avoid shining light into eyes Give verbal cues Use and allowtouch shake hands/touch hands and shoulder Use Braille in li ts and in signage Thinkabout where the guide dog can be during treatment tressing m e’. Other lea ets and storybooks can help child ren p rep are for their d ental visit and w hat to exp ect. Key Point • Children with disabilities communicate by gestures, symbols, signing and multimedia. • Many have their own ‘communication passport’. 27 27 • 162 CHILDRENWITHDISABILITIESANDLEARNINGDIFFICULTIES Primary resources and recommended reading Facu lty of Dental Su rgery 2012 Clinical Guid elines and Integrated Care Pathw ays for the Oral H ealth Care of Peop le w ith Learning Disabilities. Lond on: Facu lty of Dental Su rgery, The Royal College of Su rgeons of England . Makaton®. Available at: w w w.m akaton.org. Mencap . Available at: https:/ / w w w.m encap.org.u k/ cqcrep orts. The N ational Au tistic Society. Available at: http :/ / w w w .au tism .org.uk. N u nn J, Foster M, Master S et al 2008 Consent and the Use of Physical Intervention in the Dental Care of Child ren. Lond on: Royal College of Su rgeons of England . Available at: http s:/ / w w w.rcseng.ac.u k/ fd s/ p ublications-clinical-gu id elines/ clinical_gu id elines/ d ocu m ents/ p aed _d ent_intervention.p d f. Peninsu la Cerebra Research Unit 2013 Dentistry for child ren and you ng p eop le w ith learning d isabilities and challenging behaviou r. Available at: http:/ / w w w.p encru .org/ evid ence/ d entistry/ . Pu blic H ealth England 2014 Delivering Better Oral H ealth: An Evid ence-Based Toolkit for Prevention, 3rd ed n. Lond on: Pu blic H ealth England . Available at: http s:/ / w w w.gov.u k/ governm ent/ u p load s/ system / u p load s/ attachm ent_d ata/ le/ 367563/ DBOH v32014OCTMainDocu m ent_3.p d f. Research Au tism . Available at: http :/ / researchautism .net RN IB Know led ge and Research H u b. Available at: http :/ / w w w .rnib.org.u k/ know led ge-and -research-hu b. Scott’s H ospital Dental Visit. Available at: w w w.scottga.org. For revision, see Mind Map 27, page 248. 28 Common medical problems in children CASE1 SUMMARY Hannah is 9 years old. She was diagnosed with acute lymphoblastic leukaemia (ALL) 3 months ago. She has toothache, and her medical team has asked you to see her. History H annah has been su ffering from toothache for the last 3 d ays. She rep orts that the pain is com ing from the u pper left qu ad rant and feels her gu m is sw ollen (Fig. 28.1). Medical history Over the 6-m onth p eriod p rior to her ALL d iagnosis, H annah started to feel tired and lethargic. A blood test at her general m ed ical p ractitioner id enti ed an excessive num ber of im m atu re and p oorly d ifferentiated lym p hocytes. A bone m arrow asp iration con rm ed the d iagnosis of ALL. She w as ad m itted to hospital and started on a stand ard chem otherap y regim e. For girls, treatm ent involves several stages of chemotherapy over a 2 year p eriod w ith the aim of eliminating the leu kaem ic cells and p reventing their recu rrence. Dental history She had a p reviou s lling in the E w ith no local anaesthetic abou t a year ago. N o bitew ing rad iograp hs w ere taken. Examination Extraorally there is no sw elling and no facial asym m etry. There is left-sid ed su bm and ibu lar lym phad opathy. Intraorally she is in the m ixed d entition. Intraorally there is a u ctu ant sw elling associated w ith DE. ■ Why a re you concerned with this dental history? At the tim e of the lling, no bitew ing rad iograp hs w ere taken to id entify the d epth of the caries, the p roxim ity of the caries to the pu lp and the p ulpal resp onse to the caries. Moreover, the lack of local anaesthetic w hen u nd ertaking conventional caries rem oval often resu lts in incom p lete removal, as the child nd s the d rilling uncom fortable. The temporary cem ent in the m ed iu m term w ill d eteriorate, lead ing to m icroleakage and caries p rogression. ■ What a re the e ects o chemotherapy on cells with a ra pid turnover? Chemotherapy targets different stages of cell mitosis and is toxic to all differentiating cells. Therefore hair, skin, mucosal cells lining the gastro-intestinal tract, red blood cells, w hite blood cells and platelets will be affected in addition to the cancer cells. This results in loss of hair, dry and fragile skin, mucositis, anaemia, leukopenia and thrombocytopenia. Fig. 28.2 illustrates how chemotherapy works. Rapidly replicating cells (e.g. hair, mucosa, skin, red blood cells, white blood cells and platelets) are able to repair and recover quicker following chemotherapy than the cancerous cells. Each tumour w ill have a different chemotherapy regimen and timeline. This schematic is for a solid tumour with the bone marrow recovery taking about 3 weeks before the next dose of chemotherapy. Providing care for children on chemotherapy requires liaison with their oncologist. Acute dental care is often provided once the bone marrow counts have recovered and shortly before their next dose of chemotherapy. ■ What urther in ormation do you need? Dental in ormation A full oral assessm ent is need ed . At d ifferent stages of the chem otherap y cycle, patients w ill have very low w hite cell cou nts (in particu lar, low neu trophil counts), w hich w ill lim it their ability to ght infections. A lack of facial sw elling or lym phad enopathy d oes not necessarily m ean there is no infection related to a necrotic tooth, especially if a patient is pyrexic. Therefore White cell count Cancerous cell count Normal levels Cell number bone marrow recovery 0 5 Chemo 21 Chemo 28 42 47 Chemo 63 68 Chemo Day Fig. 28.1 E with a temporary restoration, D distal caries with buccal swelling. Fig. 28.2 A schematic and simple diagram to explain the e ect o chemotherapy on bone marrow and cancer cell numbers. 28 • 164 COMMONMEDICALPROBLEMSINCHILDREN taking H annah’s tem p eratu re is essential. H er tem peratu re is 38.5°C. The oral assessment should include bitewings and a d ental panoramic tomogram, when the patient can tolerate these radiographs (Fig. 28.3). Follow ing the clinical and radiographic examination, a complete problem list and treatment plan (see Chapter 24, Table 24.3) should be drawn up. Any primary teeth with a poor prognosis, including those with deep caries, should be extracted rather than restored. For necrotic and infected permanent teeth, either they should be extracted or rst stage end odontics should be und ertaken w here there is con d ence that the infection can be eliminated. Medical in ormation Close collaboration is required w ith the m ed ical team coord inating H annah’s chemotherapy. There are only a few short w ind ow s in w hich invasive d ental treatm ent can be p rovid ed as a resu lt of the anaem ia, leukopenia and throm bocytopenia associated w ith her treatm ent. Therefore it is essential to nd ou t the cu rrent fu ll blood cou nt (red cell cou nt, w hite cell cou nt, neu trophil cou nt and p latelet cou nt) and w hether the cou nt w ill im p rove or get w orse in the im m ed iate fu tu re. Moreover, at d ifferent points of ALL chem otherap y regim ens, child ren w ill u nd ergo a lu m bar p u nctu re and bone m arrow asp iration. These are invariably carried ou t u nd er general anaesthetic and m ay therefore p rovid e an op p ortu nity to und ertake any acu te extractions. Treatment ■ What acute treatment does Hannah need? The presence of a tem peratu re, together w ith the bu ccal sw elling associated w ith the E and / or D, need s to be d iscu ssed w ith the m ed ical team im m ed iately. Treatm ent w ill inclu d e the u se of approp riate antibiotics (for exam ple, amoxicillin and m etronid azole or sim ilar antibiotics given intravenously or orally d ep end ing on the severity of the infection) and painkillers (these are frequ ently paracetam ol and opioid s, as non-steroid al anti-in am m atories such as ibuprofen are avoid ed ow ing to the low p latelet cou nt and the risk of bleed ing). H annah w as ad m itted to the oncology w ard and started on intravenou s antibiotics. At the m ost ap prop riate tim e, in relation to the chem otherap y regime and fu ll blood cou nt, the DE w ill need to be extracted . Althou gh sw elling is m ost likely to arise from the E, for H annah the safest option w ou ld be to extract both DE to elim inate all potential sou rces of infection. In id entifying the m ost ap p rop riate tim e for this treatm ent, consid eration shou ld be given to how long it w ill take the socket to heal p ost-extraction becau se her cou nts w ill start to d rop again w ith the next cou rse of chem otherap y. ■ What other denta l care does Hannah require? A H annah requires an intense preventative regim e against any fu rther oral d isease. For som e child ren u nd ergoing chem otherap y, their d iet w ill change signi cantly d u ring treatm ent. This is fu rther exacerbated by the sid e effects of chem otherapy, such as m ucositis and the need to m aintain ad equ ate calori c oral intake. On occasions w here child ren are failing to eat su f cient calories, they m ay be fed via a nasogastric tu be, gastrostom y or intravenou sly. ■ What are the oral implica tions o childhood ca ncer treatment? Treatm ent for leukaem ia and solid child hood cancers can includ e chem otherapy, rad iotherap y and su rgery. Boxes 28.1 and 28.2 list the short- and long-term oral com plications of chem otherapy and rad iotherapy. Box 28.1 Short and long-termoral side e ects o chemotherapy B Short-term oral side ef ects – chemotherapy At risk o peri- and intra-oral in ections – bacterial, viral and ungal, especiallyas chemotherapyand associated medication will lead to changes in oral ora Ulcers and mucositis Bleeding and gingivitis Xerostomia and dysgeusia Dysphasia Trismus Phantompain in jaw – o ten associated with vincristine or romleukemic infltration into the jaw or dental pulp C Fig. 28.3 Hannah’s bitewings (A, B) and dental panoramic tomogram (C). Long-term oral side ef ects – chemotherapy Anomalieso dental development – e.g. aplasia, hypoplasia or hypomineralizedcrowns, diminutive or rudimentaryrootsandor crown, delayed eruption andex oliation 165 • COMMONMEDICALPROBLEMSINCHILDREN Box 28.2 Short and long-term oral side e ects o radiotherapy involving the oral cavity Short-term oral side ef ects – radiotherapy Trismus Osteomyelitis Sialadenitis In ections Erythema Pulp pain or hypersensitivity Drymouth, impaired salivary unction Long-term oral side ef ects – radiotherapy Increase risk o caries Drymouth, xerostomia Change in taste Anomalies o dental development At risk o osteoradionecrosis Fig. 28.4 6E caries. CASE2 SUMMARY Hugo is 8 years old and presents or a routine check-up. He has Haemophilia A. Clinical and radiographic examination reveal mid-dentine caries in E and 6 (Fig. 28.4). A dental panoramic tomogram identif es both mandibular second permanent premolars to be missing (5 5). History H u go com p lains of no p ain or p roblem s from his teeth. Medical history H u go has severe H aemop hili A and is u nd er the care of the p aed iatric haem atologist. H e requ ires alternate d ay injections of factor VIII, w hich are ad m inistered at hom e by his m other. 28 ■ What is Haemophilia A? H aem op hilia is an X-linked recessive d e ciency of factor VIII. The d efective gene is p assed d ow n throu gh his m other, w ho is a carrier for this cond ition, w hich only affects boys. Factor VIII is an essential part of the clotting cascad e and enables the platelet p lu g to be stabilized w ith brin. Primary haem ostasis is not affected . The cond ition is classied by the p ercentage of factor VIII activity, w ith severe classi ed as less than 1%, m od erate 1–5% and m ild less than 5%. ■ Wha t dental treatment does Hugo require? A full clinical and rad iograp hic exam ination id enti ed m id d entine caries in 6 E. The absence of the 5 5 w ill in u ence the treatm ent op tions available. Treatm ent p lanning for p oor prognosis rst perm anent m olars is d iscussed in m ore d etail in Chap ter 34. Follow ing an orthod ontic consu ltation, it is felt that restoration of both teeth is the most ap p rop riate option. Conventional caries rem oval is the treatm ent choice for both 6 E. H u go is cooperative and happy to have the treatm ent p rovid ed u nd er local anaesthetic. The qu antity of treatm ent and the num ber of visits this w ill take m ay in uence w hether treatm ent is provid ed u nd er local or general anaesthetic. For E the m ost ap p rop riate restoration w ou ld be a stainless steel crow n, ow ing to its enhanced longevity in comparison to other restoration m aterials. Long-term ou tcomes for the H all techniqu e are only available for 5 years. Realistically the E m ay su rvive for 15–30 years, and therefore, w hen the child is cooperative, conventional caries w ould be the m ost ap propriate op tion. For the 6 a single su rface restoration w ith either an am algam or com p osite w ith ssure sealants of the rem aining occlu sal surfaces w ould be the m ost app ropriate option. If a com p osite is chosen, treatm ent und er ru bber d am is essential to optim ize m oistu re control and hence longevity. As im p ortant as the restorative p lan is the p reventative p lan to m inim ize fu rther d ental caries. H ugo w ill requ ire enhanced p revention as d iscu ssed in Chap ters 22 and 23. ■ Wha t are the ora l implica tions o Haemophilia A on Hugo’s restorative treatment? Carefu l liaison w ith the haem atology team is requ ired to d iscu ss the treatm ent need ed and a p lan to system ically m inim ize any bleed ing. For H ugo, the follow ing m ed ical plan is d raw n up : Firstly, transexam ic acid m outhw ash is prescribed at least one d ose prior to his treatm ent and then continu ed three tim es a d ay for 3–7 d ays d ep end ing on the d ental treatm ent requ ired . H ugo need s to gargle the m ou thw ash and then sw allow it to optim ize its effectiveness. Transexam ic acid is an anti brinolytic and help s p revent clot breakd ow n. Second ly, he is ad vised to take his factor VIII on the m orning of his d ental treatm ent and to take a further d ose the next m orning if there are any signs of post-op erative bleed ing from the gingivae or su bm ucosal haem atom a. If not, he should continu e w ith his regular alternate d ay p attern for taking factor VIII. ■ Wha t local mea sures ca n you take to minimize bleeding? There are a num ber of su rgical principles to m inim ize bleed ing. These inclu d e taking great care w hen m anipu lating the soft tissues, for exam ple, w hen p lacing ru bber d am clam ps 28 • 166 COMMONMEDICALPROBLEMSINCHILDREN and m atrix band and w hen u sing high-volu me suction. Where teeth have been extracted , the u se of su tu res, Su rgicel and pressu re is com m only u sed . On rarer occasions bone w ax, Coe-Pak d ressings and bip olar d iatherm y m ay be need ed d ep end ing on the oral su rgery being u nd ertaken. Care shou ld be taken to carefu lly exp lain the p ostoperative instru ctions to p revent d istu rbance or loss of the blood clot, for exam p le, avoid ing p oking the clot, eating hard food s, d rinking hot d rinks or exercise. N on-steroid al anti-in am m atory p ainkillers shou ld be avoid ed in all patients w ith a bleed ing d iathesis. ■ Inf ltra tions versus in erior alveolar block injection Althou gh the factor VIII prophylaxis w ill cover inferior alveolar block injection, w hen in ltration injections w ill achieve sim ilar p ain control, they shou ld be u sed instead . Therefore, for both the E and 6 in ltration injections, u sing Articaine w ou ld be the m ost ap p ropriate op tion. The ad renaline contained w ithin both Articaine and Lignocaine w ill again help achieve haem ostasis. CASE3 SUMMARY Harriet is 3 years old. Her mum is concerned with the appearance o the E . She reports that the tooth erupted with brown staining and that it appears to be getting worse (Fig. 28.5). History H arriet sometim es com p lains of p ain from the E w hen eating ice cream . Medical history H arriet has had a su rgical correction for a tetralogy of Fallot at the age of 4 months. The heart cond ition w as d iagnosed in pregnancy at the 20-w eek scan. H er rst m onths of life w ere sp ent in and ou t of hosp ital p rior to her card iac su rgery. Cu rrently there are no p lans for fu rther su rgery, althou gh she is still seen on a regu lar basis by the card iologists. ■ What are the oral implications o Harriet’s ca rdiac history? H arriet’s congenital heart d efect p u ts her at an increased risk of infective end ocard itis. Infective end ocard itis is a bacterial infection in w hich there is potential for bacterial Fig. 28.5 E hypomineralized with post-eruptive breakdown. vegetation to become established , ow ing to im p aired blood ow in the heart. These colonies w ill then cau se p yrexia, new or changing heart m u rm urs and em bolic events. Infective end ocard itis carries w ith it signi cant m orbid ity and m ortality, and consequ ently its p revention is a high p riority for at risk child ren and ad u lts. Bacteraem ias from the oral cavity are com m on follow ing d ental extractions or other treatm ents involving gingival m anipu lation. H ow ever, bacteraem ia is also seen w hen child ren bru sh their teeth or chew, esp ecially if there is m arked gingivitis and poor oral hygiene. Consequ ently, good oral hygiene is a key preventative behaviou r in m inim izing the risk of infective end ocard itis. ■ Is antibiotic prophylaxis required or denta l procedures? In the UK, N ational Institu te of Clinical Excellence (N ICE) guid elines ad vocate that no antibiotic cover is requ ired for d ental proced u res. This is d ifferent in other countries, su ch as Au stralia and the USA, w here antibiotics are still ad vocated for d ental p roced ures that cau se bacteria. The logic behind the N ICE gu id ances w as that since no antibiotic cover w as ad vised for the frequ ent oral bacteraem ia associated w ith everyd ay behaviours (such as chew ing and brushing) it therefore d id not m ake sense for antibiotics to be u sed to cover infrequ ent d ental proced u res. H ow ever, a recent article has id enti ed an increase in infective end ocard itis since this gu id ance w as p u blished w ith the consequ ent fall in prescribing of antibiotic prop hylaxis in the UK. In light of these nd ings, N ICE has review ed their gu id elines bu t has conclud ed that this evid ence is not suf cient to change their ad vice. ■ What treatment is appropriate or Harriet? Preventive plan It is essential that a robust p reventive p lan be d raw n u p for H arriet. Ow ing to her card iac cond ition, H arriet shou ld be p laced on an enhanced p reventative plan, as the consequ ences of d ental caries are potentially signi cant. Furtherm ore, very careful attention should be paid to her oral hygiene. H er parents shou ld be encou raged to actively u nd ertake her tooth bru shing and ensu re that both the teeth and gingivae are bru shed to m inim ize gingivitis and hence bacteraem ias of oral origin. Restorative care A carefu l clinical exam ination and bitew ings are essential. The exam ination id enti es that the E is hypom ineralized w ith p ost-eruptive breakd ow n and is sensitive to cold air. There are no signs or sym ptom s that the E is non-vital and infected . The rest of the d entition is caries free. Bitew ing rad iographs show no rad iograp hic signs of a non-vital E . In d iscu ssion w ith H arriet’s p arents, they feel she w ou ld stru ggle to coop erate for a conventional stainless steel crow n (e.g. com p lete caries and hyp om ineralized enamel rem oval) but m ay cope w ith a stainless steel crow n placed u sing the H all crow n techniqu e (e.g. no caries or hypom ineralized enam el rem oved ). Therefore a d if cult choice exists becau se a conventional stainless steel crow n w ou ld requ ire a general anaesthetic and w ou ld involve risks of m orbid ity and m ortality. A carefu l d iscu ssion w ith H arriet’s parents is requ ired to d iscu ss the d ifferent treatment options. Certainly if a H all crow n w as chosen, very carefu l follow -up , both clinically and rad iographically, is 167 • COMMONMEDICALPROBLEMSINCHILDREN Table 28.1 Common medical problems and their impact on the provision o dental care Type Example(s) Dental implications Solutions Medical Cardiac – cyanotic Increased risko bleeding Complicated and potentiallyhigh riskgeneral anaesthetic Avoid stress at the dental visit Some cyanoticpatients are on war arin and there ore at increased risko bleeding Close liaison with cardiologist; treat in a specialist cardiac centre Bleeding AV– mal ormation – vascular anomalyseen on perioral skin or intra mucosa Inherited bleeding disorder Close liaison with surgeon/radiologist to identi ythe extent o the lesion and involvement o the maxilla or mandible – risko pro use bleeding Close liaison with haematologist – identi yseverityo disorder and medical management; local surgical management as described is essential Diabetes Discussed in Chapter 41 Transplants Depends on the type o transplant theyhave had, however, all will be on immunosuppressants toprevent organ rejection At increased risko bacterial, viral or ungal in ections; some anti rejection drugs associated with gingival enlargement (e.g. cyclosporine); liaise with paediatrician i oral in ections (bacterial, ungal, or viral) are identifed, as these need to be aggressivelymanaged; care ul vigilance as long termimmunosuppression is associated with development o cancers including oral cancers Asthma Identi yseverityo asthma, howit is managed, what triggers it, what medication theyare takingandlast hospital admission Salbutamol and inhaled steroids each have direct e ects on the oral cavity(e.g. reduced salivary ow, increase risko oral candidiasis) Ensure salbutamol is available in emergencydrug box Care with some topical uorides, as theycan veryrarelycause breathlessness Epilepsy Identi ythe type/s o seizures and their duration, when was the last seizure, howwas it managed and did it require rescue medication or hospitalisation tostopthe seizure Some epilepticmedication can increase the risko gingival overgrowth (phenytoin); risko trauma to the dentition during seizure; parents are normallyveryaware and perceptive o an impending seizure; ensure anti epileptic medication has been taken prior to attendance Cystic fbrosis Multi systemdisorder predominantlyafectinglungs and digestive system; need toidenti ycurrent respiratorystatus, have theybeen admitted or intravenous antibiotics toclear chest in ections or have theybeen colonized bypseudomonas Studies showthat children with cystic fbrosis have a lower risko developing dental caries; however, i caries develops, treatment is complicated byhigh risk or general anaesthetic; may have nutrition supplemented bygastrostomy eeding; long termtreatment options mayinclude lung transplant Metabolic Multiple diferent disorders afectingdiferent biochemical pathways; treatment o ten involves strict diets that avoid aminoacids, which cannot be broken down, or medication to circumvent these pathways Acare ul historyis needed to identi ytheir diet restrictions and eeding; or some children they are exclusivelyor predominantlygastrostomy ed; in ections (including systemic in ections o oral origin) can lead to decompensation and hospital admission; admission or general anaestheticrequires care ul liaison to identi yhowbest to manage pre operative starving required to m onitor any signs of infection as a result of the tooth becom ing non-vital. Avoid ance of non-vital and infected teeth is essential to m inim ize the increased risk of infective end ocard itis. H arriet’s p arents, follow ing this d iscu ssion, op ted for the H all crow n and very carefu l follow u p . They felt that if she d id have a general anaesthetic, they w ou ld elect to have E extracted . Where a general anaesthetic is requ ired for d ental care, child ren w ith com p lex congenital heart d efects (rep aired or u nrep aired ) or w ith rhythm ic d isord ers (for examp le Wolf Parkinson White synd rom e) should be referred to specialized card iac hospitals. Exam p les of other com m on m ed ical p roblem s and how they im pact d ental care is provid ed in Table 28.1. Key point With all medical conditions: • Enhanced prevention is essential to prevent or minimize caries • Care ul liaison with the medical team leading the patient’s care Primary resources and recommended reading RCS Guid eline for Oral Managem ent of Oncology Patients Requ iring Rad iotherap y, Chem otherap y and / or Bone Marrow Transp lantation 2012 Available at: http s:/ / w w w.rcseng.ac.u k/ fd s/ p u blications-clinical-gu id elines/ clinical_gu id elines/ d ocu m ents/ clinical-gu id elines-for-the-oral-m anagem ent-of -oncology-p atients-requ iring-rad iotherap y-chem otherap y-and -or-bone-m arrow -transp lantation. Dayer MJ, Jones S, Prend ergast B et al 2015 Incid ence of infective end ocard itis in England , 2000–13: a secu lar trend , interru p ted tim e-series analysis. Lancet 385 (9974):1219–1228. N ICE Guid eline (CG 64) 2008 Prop hylaxis against Infective End ocard itis: Antim icrobial Prop hylaxis against Infective End ocard itis in Ad u lts and Child ren Und ergoing Interventional Proced u res. Available at: https:/ / w w w.nice.org.u k/ gu id ance/ cg64. AAPD gu id elines 2015 Gu id eline on d ental m anagem ent of p ed iatric p atients receiving chem otherap y, hem atop oietic cell transp lantation, and / or rad iation therap y. Ped iatr Dent 37 (6): 298–306. For revision, see Mind Map 28, page 249. 28 29 The displaced primaryincisor SUMMARY James, who is 3 years old, tripped over while playing outside. He hit his ront teeth on the ground. How do you manage the immediate problem, and what do you advise his parents about potential damage to the permanent teeth? History Complaint Jam es has been brou ght to you r su rgery straight from hom e by his mother. She says his u p p er front tooth has been pu shed back (Fig. 29.1). History o complaint Jam es trip p ed and fell forw ard hitting his teeth on the grou nd . One tooth is ‘p u shed backw ard s’. Medical history Jam es is a healthy boy w ho has had no signi cant child hood illnesses and w ho is u p to d ate w ith all his vaccinations. Dental history Jam es has been a regu lar attend er at his d entist since the age of 2 years. H e has had his teeth p olished and has no caries. ■ What specif c questions would you ask a nd why? Was there any loss o consciousness? I so how long? I there was, then this signi es intracranial trauma and the child should be re erred to an accident and emergency department. The duration o loss o consciousness can provide an indication to the severity o the head injury. When did the accident occur? Delay in seeking help might arouse suspicions o a non-accidental injury. Where did the accident occur? An accident outside raises the additional problem o potential wound contamination. Any child brought up in the UK should be immunized against tetanus. I a child has not been immunized, seek the advice o a local general practitioner or accident and emergency department. What was the sur ace on which the accident occurred? Newly constructed playgrounds have to con orm to British Standards and should be either o an energy-absorbing polymer or bark chippings. Older playgrounds and normal pathways will have non-yielding sur aces and are likely to produce greater damage and potentially greater risk o more underlying injuries. Dirt or gravel can contaminate extra- and intra-oral wounds, and these oreign bodies will need to be care ully removed to prevent in ection and reduce scarring. How did the accident occur? This gives an indication o the orce that produced the injury. The clinician needs to be highly suspicious o the high-impact injury that looks simple. Always suspect a deeper underlying injury until proven otherwise. Fragments, where are they? Where a tooth or teeth have been ractured, these ragments need to be identi ed. Although in many cases they will have been spat out, there is a risk o these being swallowed, inhaled or incorporated into oral so t tissues (e.g. lacerated lips or tongue). Suspicion o inhalation o ragments is increased i there was any history o loss o consciousness, where the accident was not witnessed by an adult or i there was coughing or choking ollowing the injury. I in any doubt, re erral to an accident and emergency department to investigate this urther is needed and may necessitate a chest x-ray. What other parts o the body were injured? Frequently other parts o the body will also be injured such as abrasions to hands, elbows or knees. I visible they should be brief y examined to establish the extent o these injuries. Again, concerns o more signi cant injury, or example bony ractures, should be assessed at an accident and emergency department. Examination Extraoral James is d istressed , bu t there is no obviou s extraoral sw elling or facial asym m etry. Intraoral ■ The a ppea rance o the upper anterior teeth is shown in Fig. 29.1. What ca n you see? Fig. 29.1 Palatal luxation o A. Palatal d isp lacem ent of A and associated gingival traum a. 169 • THEDISPLACEDPRIMARYINCISOR ■ What specif c signs will you look or in your exa mina tion? The mobility o the teeth. Are they a danger to the airway? The occlusion. Do the injured teeth prevent normal occlusion? Mobility o a segment o teeth, e.g. the injured teeth move together rather than individually. This indicates a dentoalveolar racture. ■ What question should dentists keep at the back o their minds when examining children? Are the injuries consistent with the history, and i you eel they are, is this normal behaviour? Child physical abuse presents with oro acial signs o bruising, abrasions and lacerations, burns, bites and ractures in approximately 65% o cases. Dentists should have a copy o their local area Child Protection Committee guidelines. This will tell them who they should contact or advice. ■ What ea tures in the history and examination would lead to suspicions o child physical abuse? There are 10 item s to consid er. Five are qu estions to ask you rself, and ve are observations abou t the behaviou r of the child and the p arent(s): Could the injury have been caused accidentally and i so, how? Does the explanation or the injury t the age and the clinical ndings? I the explanation o the cause is consistent with the injury, is this itsel within the normally acceptable limits o behaviour? I there has been delay in seeking advice, are there good reasons or this? Does the story o the accident vary? an intruded tooth may occur, and close review is necessary. I re-eruption has not occurred within 4 6 months, an intruded primary incisor should be removed to minimize eruptive problems in the permanent dentition. An adult periapical lm used as an anterior occlusal is the easiest way to obtain a periapical view o the upper anterior region in a young child. James’s radiograph did not reveal any root ractures or dentoalveolar ractures. Vitality testing o primary teeth is not indicated, as young children are o ten unreliable in reporting any sensation elt. Direction o displacement provides important in ormation on the likelihood o any damage to the underlying permanent successor. Displacement o the crown labial indicates the root has moved palatally towards the permanent successor and vice versa. Radiographic assessment with periapical and/or occlusal lms is essential: a palatal intrusion o the root toward the successor moves away rom the x-ray source and yields an elongated image. A labial intrusion o the root away rom the successor moves near the x-ray source, yielding a oreshortened image and a gap between the apex o the primary incisor and crown o its successor. Extraoral lateral radiographs have been shown to have a limited value in showing labial positioning, especially in cases o intruded lateral incisors or multiple intrusions. Diagnosis ■ Wha t is your diagnosis? James has a palatal luxation injury to his upper le t primary central incisor. Treatment ■ Wha t are the three key components o the history and The child’s reactions to other people. examination in prima ry tooth trauma tha t will dictate i active treatment is required? The child’s reactions to any medical or dental examinations. Pain. Either spontaneous or on eating suggests pathosis. The general demeanour o the child. Mobility. Is the tooth a danger to the airway? Any comments made by the child and/or parent that give concern about the child’s upbringing or li estyle. For example, lack o parental supervision or a history o repeated trauma. Occlusal inter erence. A luxation injury that has prevented normal intercuspal occlusion will prevent normal eating. The nature o the relationship between parent and child. Investigations ■ What investiga tions would you per orm or James? Expla in why or each. Radiographs are required to visualize the traumatized area and assess whether there are any root ractures to either the traumatized or adjacent teeth. In addition, is a dentoalveolar racture evident? Are permanent successor teeth present? In an intrusive injury a child may have been re erred as an ‘avulsed’incisor. It is imperative always to check in these circumstances that the tooth is not intruded. Re-eruption o 29 ■ Wha t treatments are usua lly required or displaced prima ry incisors? Concussion and subluxation: observation. Lateral luxation: i no occlusal inter erence, the tooth is allowed to reposition spontaneously; i occlusal inter erence, extract. Intrusion: i the apex is displaced toward the labial bone plate, then leave or spontaneous repositioning. I no movement within 4 6 months, extract. In addition, i the root has per orated the buccal plate o bone, as identi ed by palpating the area, extract. I the apex is displaced into the developing tooth germ, extract. Extrusion: extract or reposition i only a minor extrusion. Avulsion: replantation is not indicated. 29 • 170 THEDISPLACEDPRIMARYINCISOR Key point Traumatized primary teeth may need to be extracted i : • Pain interrupts eating or sleeping. • Excessive mobility causes a danger to the airway. • There is occlusal inter erence. • Tooth becomes non-vital and child is uncooperative or a pulpectomy. I the tooth is le t in situ, urther damage to the developing permanent successor can result. ■ Wha t ra diogra phs would you take or these displa cement injuries? A periap ical and / or occlu sal view is ind icated for all p eriod ontal injuries includ ing concu ssion, su blu xation, lateral lu xation, intru sion, extru sion and avu lsion. Even in avulsion cases a rad iograp h is ind icated to ensu re the tooth has not been intru d ed , u nless the p arent attend s w ith the avulsed tooth. ■ What are you going to tell James’s mother about the risk to the permanent teeth? The rep orted incid ence of d am age to the d evelop ing p erm anent teeth as a resu lt of trau m a to p rim ary incisors ranges from 17–64%. An easily rem em bered gu re to tell all parents at the tim e of the initial p resentation w ou ld be 50%. It is better to be p essim istic and then be pleasantly su rprised on eruption of the perm anent teeth rather than the op posite. The you nger the child at the tim e of inju ry the greater the risk of d am age to the p erm anent tooth. Other factors increasing the risk of d am age inclu d e the typ e of inju ry (w ith avu lsion and intru sion m ost likely to cau se d am age), the severity of d isplacem ent (greater d isplacem ent lead s to an increased likelihood ) and p u lp necrosis. ■ Wha t a re the possible e ects on the permanent successor teeth? White or yellow-brown discoloration o enamel (hypomineralization). Enamel hypoplasia. Crown dilaceration. Crown-root dilaceration. Root dilaceration. Odontome ormation. Partial/complete arrest o root ormation. Sequestration o permanent tooth germ. Disturbance in eruption. ■ Can you tell all o these sequelae on a periapical ra diograph? N o. Only stru ctu ral abnorm alities and abnorm al root grow th w ill be visible. White and brow n areas of hypom ineralization w ill only be evid ent on eruption of the p erm anent teeth. ■ I you retain a luxated primary tooth how o ten would you review it? One w eek after the inju ry, 1 m onth, then 3-m onthly. Fig. 29.2 Endodontically treated primary incisor. ■ How would you review it? Historically: symptoms. Clinically: colour, sinus, tenderness, swelling, mobility. Radiographically: 6-monthly or 1 year and then when clinically indicated. Key point A ter primary tooth trauma: • Damage to permanent teeth may occur in 50% o cases. • Intrusive and avulsion injuries cause most permanent tooth damage. ■ Does a discoloured primary incisor alwa ys need trea tment? When there is progressive or persistent (greater than 3 m onths) greying of the inju red tooth, it is highly likely to be non-vital. When there is initial grey d iscoloration that im proves then vitality is likely to be m aintained . In the absence of infection a d iscolou red p rim ary incisor can be review ed . In the presence of infection, extraction or root canal therapy w ith zinc oxid e cement or a calciu m hyd roxid e-iod oform paste is ind icated (Fig. 29.2). Primary resources and recommended reading And reasen JO, Lau rid sen E, Bakland L et al 2014 Dental Trau m a Gu id e. Available at: http :/ / w w w.d entaltrau m agu id e.org. Day P, Bu ssel R, Clou gh S 2011 Managem ent of d ental trau m a in the p rim ary d entition. e-Den. http :/ / w w w.e-lfh.org.u k/ p rogram m es/ d entistry/ . Malm gren B, And reasen JO, Flores MT et al 2012 International Association of Dental Trau m atology gu id elines for the m anagem ent of trau m atic d ental inju ries: 3. Inju ries in the p rim ary d entition. Dent Trau m atol 28 (3):174–182. UK Com m ittee of Postgrad u ate Dental Deans and Directors 2013 Child p rotection for the d ental team . Available at: http :/ / w w w.cp d t.org.u k. For revision, see Mind Map 29, page 250. 30 The ractured immature permanent incisor crown Dental history Shay is a regular attend er at his d entist and has had local anaesthetic for a restoration. ■ What specif c questions would you a sk and why? Was there any loss o consciousness? When unconscious, patients lose their protective ref exes. Moreover, the duration o loss o consciousness together with the length o posttraumatic amnesia are key indicators or the severity o the head injury. Was the ractured piece o tooth located? A history o loss o consciousness together with a missing tooth ragment is an indication or a chest radiograph to check that the tooth ragment has not been inhaled. When, where and how did the injury occur? A clear and detailed description o the injury is essential. What other injuries were sustained at the time o the injury? The time rom the injury to presentation may a ect the treatment options. SUMMARY Shay is 8 years old. While saving a penalty or his school team, he collided with the goalpost and sustained enamel-dentine-pulp and enameldentine ractures to his upper central incisors. How would you manage the injuries? Outline a ollow-up treatment plan. History Complaint Did Shay cope well with his previous experience o local anaesthetic? The answer to this will dictate what behaviour management techniques (see Chapter 26) may be required to acilitate treatment. Examination Extraoral ■ Why is the presence o lip swelling together with a mucosal lacera tion important? This cou ld ind icate that the m issing tooth fragm ent is retained in the lip. The u p p er right and left p erm anent central incisors are fractured (Fig. 30.1). ■ How would you demonstrate there was a ragment o tooth History o complaint Take soft tissu e rad iograp hy u sing tw o view s at right angles to each other. A sim p le anterop osterior view using a p eriapical lm p laced behind the lip and in front of the teeth, follow ed by a lateral soft tissu e view u sing a lateral occlu sal lm (Fig. 30.2). Unless exp erienced and trained in nd ing these fragments, it is sensible to refer to a su rgical colleague to retrieve them . The inju ry w as su stained d u ring a gam e of soccer. There w ere no other inju ries. Medical history Shay is a healthy boy w ith no history of illness. H e has had all his vaccinations, inclu d ing a pre-school booster for tetanu s. in the lip? Key point Missing tooth ragments could: • Be within the so t tissues i there is a laceration. • Have been inhaled i there was loss o consciousness. • Have been spat out at the site o the accident. • Have been swallowed. Intraoral ■ Wha t injuries are visible in Fig. 30.1? Fig. 30.1 Trauma to the central incisors. Pulp exposure can be seen a ecting 1 . There is an enam el-d entine fractu re of 1 and an enam eld entine-p u lp fractu re of 1 of greater than 1 m m in d iam eter. 30 • 172 THEFRACTUREDIMMATUREPERMANENTINCISORCROWN also approp riate to brie y check the posterior teeth as they can on rare occasions be inju red as w ell. Investigations • • Radiographs (previously mentioned) or: — Foreign body in so t tissues i applicable. — Root maturity and apical status o teeth. — Presence or absence o root or alveolar ractures. Vitality testing o all upper and lower incisors. Treatment ■ What is the prime consideration or both the upper centra l incisors? Fig. 30.2 Fragments o tooth in lower lip (di erent case). It is essential that p eriod ontal inju ries are also d iagnosed . Unless special tests su ch as m obility or tend erness to percu ssion are u nd ertaken, d iagnoses su ch as concu ssion or sublu xation w ill be m issed . Crow n fractu res com bined w ith a period ontal injury have p oorer p u lp su rvival ou tcomes than those w ith no associated period ontal inju ry. ■ Are the roots o 1 and 1 likely to have open or closed apices? Open. Apices are not u su ally closed on u p per p erm anent central incisors before the age of 11 years. ■ How would you conf rm apical status? Periapical rad iograph. ■ Wha t other injuries must you exclude on the periapical ra diograph? Root fractu res. ■ What other eatures o the anterior teeth are important at examination? Mobility. In a buccopalatal direction. Excessive mobility suggests either a periodontal ligament injury or a root racture. Colour. This will indicate whether any direct pulpal damage causing haemorrhage into the dentinal tubules has occurred. Percussion. Tenderness suggests periapical damage and oedema. A dull note may suggest a clinically undiagnosed vertical crown racture or root racture. Vitality. Following trauma there may be a period o apparent loss o vitality on testing with hot and cold stimuli or the electric pulp tester even in teeth without obvious crown ractures. Nevertheless, the readings serve as a baseline against which subsequent tests can be compared. Teeth, which respond to vitality testing at the time o injury, have an excellent chance o maintaining pulp vitality. For teeth that do not respond at this time point, the pulp may be still be vital and respond at subsequent clinic visits. ■ Wha t teeth should be examined a ter trauma a ecting only the upper centrals? All u pper and low er incisors should be includ ed in an exam ination after any trau m a to the anterior region. It is To m aintain a vital p ulp w ithin the root, w hich w ill allow ongoing p hysiological d entine d eposition. This w ill resu lt in fu ll root grow th w ith norm al d entinal w all thickness, w hich w ill red u ce the chance of late stage crow n root fractu re. ■ What is the appropria te immedia te treatment or 1 (tha t ha s an enamel-dentine racture)? Reattachment o the ragment. or A bonded restoration/‘bandage’, which will produce a hermetic seal. Glass ionomer cement is not an adequate material or a ‘bandage’and will be lost shortly a ter placement resulting in bacterial ingress and thermal damage to the pulp rom hot and cold stimuli. A layer o setting calcium hydroxide cement should be placed over dentine where a pulpal shadow is visible prior to placement o an adhesive (composite) bandage. ■ What are the treatment options or 1 (that ha s a pulpal exposure)? • • Direct pulp capping. Pulpotomy Cvek, coronal or radicular (depth determined by level o inf ammation). Direct pu lp capp ing, the placem ent of w ou nd d ressings on an exp osed p u lp, is consid ered less unp red ictable by m any au thors. Partial p ulp otom y (Cvek) is the rem oval of only the ou ter layer of d am aged and hyp eraem ic tissu e in the exposed p ulps. This w ill leave healthy p ulp , w hich w ill perm it continu ed fu ll root grow th. Partial pu lpotom y is a highly su ccessfu l techniqu e. Where d am age to the pu lp has been more extensive (e.g. size of exp osu re or increased d u ration betw een inju ry and treatm ent), fu rther in am ed pu lp al tissue w ill have to be rem oved . Where this extend s to the root canal ori ce, this is called a cervical pulp otom y or a rad icu lar p u lp otom y w hen extend ing d ow n the root canal. The im portant asp ect of this treatm ent is to ensu re that all in am ed p u lp is rem oved leaving healthy (u ninamm ed ) tissue behind . ■ What a re the indica tions or permanent tooth pulpotomy? No history o spontaneous pain. Acute minor pain that subsides with analgesics. 173 • THEFRACTUREDIMMATUREPERMANENTINCISORCROWN No discom ort to percussion, no sulcus swelling, no mobility. Radiographic examination shows normal periodontal ligament. Tissue appears vital. Bleeding rom the pulp excision site stops within 2 5 minutes. ■ How would you carry out a pulpotomy? Local analgesia and ru bber d am . Flu sh exp osed pu lp tissue initially w ith isotonic saline. Then excise a 2 m m su per cial layer of exposed p ulp and su rrou nd ing d entine w ith a high sp eed d iam ond bu r u sing a light tou ch u nd er w ater sp ray cooling (partial p u lpotom y). Irrigate the su rface of rem aining p ulp w ith isotonic saline. If bleed ing ceases w ith p ressu re ap p lied to the p u lp stu m p u sing a d am p (isotonic saline soaked ) cotton w ool ball for 2–5 m inu tes, apply a pu lpal m ed icam ent w ith biologically available calciu m hyd roxid e and seal coronal cavity w ith a bond ed restoration. H ow ever, if the bleed ing d oes not cease, fu rther p ulp tissue shou ld be rem oved . Ap p ly a cotton w ool ball for a fu rther 2–5 m inu tes and reassess. If bleed ing has stop ped , then cover w ith a m ed icam ent as p reviou sly stated . H ow ever, if after removing the p u lp to a coronal level (a coronal p u lp otom y) there is still bleed ing, continu e d eeper into the root canal w ith care (rad icu lar p u lp otom y). If bleed ing p ersists d eep into the root canal, then the rem aining pu lp tissue shou ld be rem oved and root canal treatm ent instigated (p ulp ectom y). If on accessing the p ulp cham ber there is no bleed ing or there is an emp ty infected canal, then a pu lp ectom y is ind icated . The tim e from inju ry to p resentation, contam ination and the size of p u lp exp osu re w ill all in u ence the d ep th of in am m ation and necessitate greater am ou nts of in am ed p u lp tissu e to be rem oved . ■ How should the crown o 1 be restored? If the crow n fragm ent has been retrieved , then this can be stored in norm al saline w hile the p u lpotom y is com pleted . The fragm ent can then be reattached . If the crow n fragm ent is not available or the fractu re extend s signi cantly su bgingivally, a bond ed com p osite restoration shou ld be p rovid ed . The carefu l u se of retraction cord or electrosu rgery w ill ensu re good bond ing of the com posite to the fractu re m argins. Figs 30.3 and 30.4 show the crow n fragm ents before and after reattachm ent in Shay’s case. 1 had a p artial p u lp otom y as d escribed . ■ How should the upper centrals be reviewed a nd how o ten? De nitive crow n m orp hology shou ld be restored as soon as possible after em ergency treatm ent to re-establish norm al sagittal relations w ith the low er incisors. One-, tw o-, and then six-m onthly clinical and rad iographic exam inations shou ld be carried ou t to check for continu ed vitality and norm al root grow th. If there is evid ence of non-vitality, then the im m atu re tooth m u st be extirpated and non-setting calciu m hyd roxid e u sed to d isinfect the root canal. Root end closu re can then be achieved u sing Mineral Trioxid e Aggregate p rior to obtu ration w ith w arm gu tta percha. Fig. 30.3 Fragments ound at scene o incident. Fig. 30.4 Fragments reattached. Key point Partial or complete pulpotomy: • Has a high success rate. • Size o exposure and length o time between injury and treatment will in uence the extent o the pulpal in ammation that will need to be removed during the pulpotomy procedure. • Allows ull root growth with a vital radicular pulp. This will reduce the risk o long-term crown root ractures which is a common occurrence i an immature tooth was to become non-vital. Primary resources and recommended reading And reasen JO, Lau rid sen E, Bakland L et al 2014 Dental Trau m a Gu id e. Available at: http :/ / w w w.d entaltrau m agu id e.org. Diangelis AJ, And reasen JO, Ebelesed er KA et al 2012 International Association of Dental Trau m atology gu id elines for the m anagem ent of trau m atic d ental inju ries: 1. Fractures and lu xations of p erm anent teeth. Dent Trau m atol 28 (1): 2–12. Lau rid sen E, H erm ann N V, Gerd s TA et al 2012 Com bination inju ries 1. The risk of p ulp necrosis in p erm anent teeth w ith concu ssion injuries and concom itant crow n fractures. Dent Trau m atol 28 (5):364–370. 30 30 • 174 THEFRACTUREDIMMATUREPERMANENTINCISORCROWN Laurid sen E, H erm ann N V, Gerd s TA et al 2012 Com bination inju ries 2. The risk of p ulp necrosis in perm anent teeth w ith su blu xation inju ries and concom itant crow n fractu res. Dent Traum atol 28:371–378. Diangelis AJ, And reasen JO, Ebelesed er KA et al 2012 International Association of Dental Trau m atology gu id elines for the m anagem ent of trau m atic d ental inju ries: 1. Fractu res and lu xations of perm anent teeth. Dent Trau m atol 28 (1):2–12. For revision, see Mind Map 30, page 251. 31 The root ractured permanent incisor SUMMARY Andrea is 12 years old. She was trampolining at school when she ell and sustained middle third root ractures o 1 and 1. How do you manage this type o injury, and what do you advise her about the long-term prognosis or these teeth? History Complaint And rea is brou ght to you r surgery by a schoolteacher. She is com plaining that her up per perm anent central incisors are loose and feel ‘fu nny’ w hen she bites together. History o complaint And rea fell forw ard w hile on the tram poline at school and hit her teeth. H er m other arrives at the su rgery soon after And rea and her teacher. It app ears And rea w as not being su p ervised on the tram p oline and the foam p rotection w as not in the correct p osition on the m etal fram e of the tram p oline. H er m other is not happ y w ith the exp lanation by the teacher. ■ What does this alert you to? The p ossibility of legal action against the school. It is especially im p ortant to m ake d raw ings of any external inju ries on the face and keep accu rate record s of intraoral inju ries and su bsequ ent treatm ent. A p hotographic record w ill be an ad vantage. A stru ctu red history form (Append ix 6) can help clinicians ensu re that they u nd ertake a com p rehensive history and exam ination by p rom p ting them to record d ifferent p ieces of inform ation. Medical history And rea is und er regular care w ith her d entist and has had local anaesthetic w ithou t p roblem . ■ What specif c questions would you ask and why? Was there any loss o consciousness? I there was, then Andrea should be re erred to an accident and emergency department. Is there any p ain or d iscom fort w hile opening and closing the jaw ? Absence of sym ptom s should rule out any cond ylar injury/ fractu re. When the force that p rod u ces an inju ry is signi cant, it shou ld raise su spicion of a d eeper u nd erlying bony inju ry. Examination Extraoral There is som e sw elling of the up per lip and som e bru ising and sw elling u nd er the right eye. ■ Wha t questions and exa mination would you complete rega rding the swelling and bruising under the right eye? Is there any double vision? Palpate the in raorbital margin or ‘stepping’and then check or altered sensation over the distribution o the in raorbital (V2) nerve. Check that there is a ull range o eye movements especially upward gaze. Fracture o the in raorbital margin and in raorbital f oor could lead to entrapment o the in erior oblique extraocular muscle preventing upward and outward movement o the globe o the eye. Is there any altered sensation on the cheek? Oedema surrounding the in raorbital nerve or entrapment o the nerve in a racture can result in paraesthesia. I there is any doubt about a racture, then posteroanterior and occipitomental views will detect displacement o the in raorbital margin and tomograms will detect orbital f oor ‘blow-out’ ractures. Intraoral There is d ow nw ard and palatal d isplacem ent of the crow ns of 1 and 1, w hich are m obile. Centric occlu sion is not p ossible because of the slightly palatal position of 1 and 1. ■ What would be the dia gnosis based on the clinical f ndings alone? It is im portant to d ifferentiate betw een lateral lu xations and an extru sion. On exam ination both d iagnoses can have a similar ap pearance in the p osition the tooth or teeth are d isp laced to. The im p ortant d ifference is that the tooth w ill be m obile for an extrusion and im m obile for a lateral lu xation. With a lateral luxation there is fractu re w ithin the bony socket w ith the tooth locked into position. ■ Wha t tests would you do prior to repositioning the teeth? Radiographs. Intraoral periapicals (Fig. 31.1) or an anterior occlusal view are needed to diagnose root ractures compared with luxation injuries. The upper lateral incisors should also be checked or injury. Consideration should also be given to taking radiographs o the lower incisors, which may also have received either direct or indirect trauma. Where there is no signi cant displacement o the coronal portion o a tooth with a root racture, then an anterior occlusal radiograph will o ten detect root ractures that may not be so evident on periapical views. These radiographs will serve as baseline views be ore repositioning. Vitality tests o all upper and lower incisors. 31 • 176 THEROOTFRACTUREDPERMANENTINCISOR Cu rrent gu id ance ad vises a exible/ fu nctional splint for all d isplacem ent inju ries includ ing root and alveolar fractu res. The only d ifference betw een inju ries is the d u ration of sp linting p rop osed . Key point Splinting in dentoalveolar trauma: • Flexible 2 weeks or avulsions. • Flexible 4 weeks or luxations, dentoalveolar ractures and apical and middle third root ractures. • Flexible 4 months or coronal third root ractures. ■ Describe step by step your procedure or reduction and splinting Andrea’s 1 and 1. 1. Give topical and local anaesthesia labially and palatally. Good and widespread anaesthesia is important to enable pain- ree manual reposition. 2. While the local anaesthetic is taking e ect, bend your splint so that it will sit passively on the upper labial segment o all our incisor teeth. When splinting teeth, i the splint is not passive, active orthodontic movement will be seen in the splinted teeth. 3. Gently reposition 1 and 1 and hold these in approximate position. The repositioned tooth/teeth are unstable and will need to be held in their new position. Although it is enticing to use ngers to hold the repositioned teeth, this makes the rest o the splinting procedure more complex, as both hands are needed. Some red wax palatally, which extends over the incisal edges o 1 and 1, or cotton wool rolls between the upper and lower incisors are appropriate methods to hold the repositioned teeth in the correct position. Etch the labial sur aces o 2 and 2; wash, dry and place bonding resin and a spot o composite in the centre o the labial sur ace. Place the splint into position on 2 and 2. Use a bonding brush to mould the composite already on the teeth over the wire. Add extra composite i required. Cure the composite. 4. Remove the wax or cotton wool rolls, and with a nonworking hand, bring 1 and 1 into an accurate position against the wire splint. Hold them in this position while etching, washing, bonding and adding composite with the working hand. Cure the composite. 5. Smooth any rough areas with sandpaper discs. Fig. 31.1 Middle third root ractures. ■ Wha t is the diagnosis based on the clinical and ra diogra phic f ndings? For both 1 and 1 a d iagnosis of a m id third root fractu re w ith an extru sion of the coronal fragm ent. Treatment ■ Wha t design o splint would you use or 1 and 1? You have conf rmed on ra diography tha t they have middle third root ractures (Fig. 31.1). The sp lint shou ld be exible/ fu nctional and d esigned to have one sou nd (u ninju red ) abu tm ent tooth on either sid e of the root-fractu red teeth. ■ How long should the splint be in place in root ra ctures? For 4 w eeks in apical and m id d le third fractures u ntil the m ajority of p eriod ontal ligam ent bres have healed . This time can be extend ed to 4 m onths in coronal third fractu res. The old regim en of rigid splinting for root fractu res has been show n to have no bene t. Rigid splinting w as m eant to give the fractu re its best chance of a hard tissu e union. Research has show n that hard tissu e u nion is m ost likely to occu r if there w as little d isplacem ent at the tim e of the original injury rather than being a fu nction of the typ e of sp lint emp loyed . In other w ord s, the larger the d isp lacem ent at the fracture line at the tim e of the injury, the sm aller the chance of a hard tissu e u nion betw een the fractu re end s after red u ction and splinting. ■ Do a ny orms o dentoa lveolar injury need to be rigidly splinted? N o. H istorically, rigid sp linting w as used for d entoalveolar fractures. A rigid sp lint involved tw o sou nd abu tm ent teeth on either sid e of the inju ry and a stiffer arch w ire. It w as prop osed that this style of sp linting w ou ld ensu re no m ovem ent betw een bony fragm ents, thereby allow ing healing. ■ What materials could be used or splinting? An ideal splint should be simple and quick to place and remove, easy to bend to ensure it is passive, biologically compatible and relatively cheap. The splint must allow for functional movement of the teeth while holding the teeth in their new position and allow ing thorough cleaning around the gingival margins. The most common materials used are pieces of orthod ontic w ire, for example 0.014-in or 0.016-in stainless steel or twist ex (w hich is three pieces of 0.010-in wire twisted around each other). Each of these wires requires moderate skills in wire bending to achieve a passive splint. New materials such as titanium are now available for splinting, and these have the bene t of being much easier and therefore quicker to passively ad apt to teeth (Chapter 32, Fig. 32.1B). 177 • THEROOTFRACTUREDPERMANENTINCISOR ■ On removal o the splint how o ten would you review Andrea? After 1 m onth, 3 m onths, 6 m onths and then yearly. ■ What tests would you complete at each o these reviews? For all trau m atized teeth, a stand ard regimen shou ld be follow ed . If this is carried ou t in every case, then om issions are less likely to be m ad e. • Clinical: Colour (palatal sur ace best). Buccal sulcus sensitivity to digital pressure. Sinus or swelling presence. Tenderness to percussion. Percussion sound. Mobility. Sensibility testing. • Radiography: long cone periapicals. ■ Is sensibility testing accurate? N o form of sensibility testing on its ow n is accu rate. Electric pu lp testing (EPT) is p robably the m ost accu rate, bu t its real valu e lies in successive num erical read ings w ith the sam e type of EPT. N u m erical valu es can then be comp ared . At each visit, resp onses (both positive and negative) shou ld be com p ared against u ninju red teeth and also if each tooth is consistent in its response and the d u ration before any p ositive sensation is acknow led ged . Cu rrent sensibility testing relies on sensation of stim u li, w hereas true pu lp al vitality is m ore appropriately tested by the presence of blood ow. In the fu tu re, the w id espread u se of Dop pler in d etecting blood ow in a trau m atized tooth w ill inform all d ecisions regard ing p u lp al necrosis and the necessity for extirp ation. Key point What types o healing occur in root ractures? • Hard tissue. • Connective tissue (see Fig. 31.2). This type o healing is o ten combined with osseous healing. As the two ragments grow apart over time, bone will f ll in the gap that was originally only f lled with connective tissue. • Granulation tissue. Technically this is not a type o healing but is seen when the coronal ragment is in ected. Once the in ection is treated, healing will take place by connective tissue. 31 Place non-setting calcium hydroxide 1 mm short o racture line with aim o inducing barrier ormation. Change non-setting calcium hydroxide 3-monthly until barrier orms, or alternatively use MTA to generate a 4 5-mm barrier. Obturate with gutta percha to barrier. Annual radiographic review. ■ What ha ppens to the a pical ragment? In nearly all cases this w ill u nd ergo pu lp canal obliteration and w ill not need treatm ent. If there is infection of the apical fragm ent, it m ay requ ire su rgical removal. Root canal therapy across a root fracture is frau ght w ith d if cu lty becau se of p roblem s keeping the d istal canal d ry. ■ Is the prognosis good in coronal or gingival third root ractures? N o. Decisions need to be m ad e early regard ing options. Long-term stability and long-term retention of the w hole tooth in these inju ries are uncom m on. Research show s a survival rate of one-third at 10 years post-traum a, w ith m any of these teeth being lost as a resu lt of fu rther trau m a or excessive m obility. These consequ ences relate to the u nfavourable crow n root ratio. ■ Wha t are the treatment options in coronal or gingival third root ractures? Retain crown temporarily with an endodontic post across the racture line. Remove coronal ragment. Root treat apical ragment and orthodontically extrude prior to post, core and crown placement. Remove coronal ragment. Cover, ‘bury’, the apical ragment with a mucoperiosteal f ap. The width and height o the alveolus are thus retained or uture implant placement. Prosthetic replacement required. Remove all portions o tooth. Prosthetic replacement required. Future implant placement. ■ Ca n root ra ctured teeth maintain vitality? Yes. The m ajority d o so (literatu re rep orts betw een 72% and 90% m aintain their vitality). Figs 31.2 and 31.3 show And rea’s teeth 3 years after the original injury. The teeth m aintained vitality and u nd erw ent p rogressive p u lp canal obliteration. In ad d ition, the d istal fragm ents are resorbing. Im portantly, there has been no infection. ■ Ca n root ractured teeth be moved orthodontically? ■ Wha t is the likely radiographic appearance at the racture line i the coronal tooth portion becomes non-vital? There w ill be increasing w id ening and translu cency su rround ing and betw een the fractu red end s of the root. ■ I the coronal portion o an apical or middle third root ra ctured tooth beca me non-vita l, how would you root treat the tooth? Extirpation to the racture line only. Establish working length to racture line. Yes, bu t w ith cau tion. If there is not a hard tissu e u nion betw een the fractu re end s, then the apical p ortion w ill remain static and only the coronal portion w ill m ove. Regu lar rad iograp hic review w ill be necessary d u ring any orthod ontic treatm ent. Orthod ontic m ovem ent m ay cau se fu rther root resorption, w hich w hen com bined w ith an alread y com prom ised crow n root ratio can lead to longterm m obility of the coronal fragm ent at the end of orthod ontic treatment. Consequently, great care is need ed w ith the orthod ontic treatm ent to m inimize the risk of further root resorp tion. 31 • 178 THEROOTFRACTUREDPERMANENTINCISOR Primary resources and recommended reading And reasen JO, Ahrensbu rg SS, Tsilingarid is G 2012 Root fractu res: the in u ence of typ e of healing and location of fractu re on tooth su rvival rates – an analysis of 492 cases. Dent Trau m atol 28 (5):404–409. And reasen JO, And reasen FM, Mejare I et al 2004 H ealing of 400 intra-alveolar root fractu res. 1. Effect of pre-inju ry and inju ry factors su ch as sex, age, stage of root d evelopm ent, fractu re typ e, location of fractu re and severity of d islocation. Dent Trau m atol 20 (4):192–202. And reasen JO, Lau rid sen E, Bakland L et al 2014 Dental Trau m a Gu id e. Available at: http :/ / w w w.d entaltrau m agu id e.org. Diangelis AJ, And reasen JO, Ebelesed er KA et al 2012 International Association of Dental Trau m atology gu id elines for the m anagem ent of trau m atic d ental inju ries: 1. Fractu res and lu xations of perm anent teeth. Dent Trau m atol 28 (1):2–12. For revision, see Mind Map 31, page 252. Fig. 31.2 Radiographic appearance a ter 3 years. Fig. 31.3 Clinical appearance a ter 3 years. 32 4. 5. 6. 7. 8. The avulsed incisor 9. CASE1 SUMMARY Kathryn is 9 years old. She was playing with her riends at a brownie camp with a skipping rope, when the rope caught behind one o her upper central incisors and avulsed it. Her teacher has got the tooth. How would you manage this problem? ■ Kathryn’s teacher phones your surgery or advice. She ha s 10. laceration to the upper lip as well as an avulsion o 1 and subluxation o 1 (Fig. 32.1A) Give labial and palatal local anaesthesia. Irrigate socket with normal saline to remove the blood clot. Recontour labial plate with f at plastic instrument, i required. Gently reposition the avulsed tooth. Bend a titanium trauma splint (or alternative splinting material as discussed in Chapter 31) to include one uninjured tooth on either side o the avulsed tooth CC ( ) and ollow guidance described in this chapter or splint placement. Fig. 32.1B shows the splint in situ. Prescribe chlorhexidine mouthwash. Antibiotics (such as Amoxicillin or Penicillin V or 5 7 days) can be prescribed at the clinician’s discretion. Chlorhexidine 0.2% should be used twice daily to enhance oral hygiene. Arrange a review appointment or 14 days. ■ What a ctors a re important when deciding whether root ca nal treatment is necessary in Ka thryn’s case? Root development. How long the tooth was out o the mouth (extra-alveolar time). A tooth that has com pleted root d evelopm ent w ill not u nd ergo revascu larization. The only tooth that has a chance the tooth in a handkerchie . The accident occurred 10 minutes ago. Wha t is your a dvice? Check that Kathryn has no other injuries, i.e. head injuries that require re erral to an accident and emergency department. Check or any known medical history. Hold tooth by crown and wash gently under cold water to remove any debris or 10 seconds. Replant in socket ideally. Hold tooth in socket by biting on a handkerchie . Come to surgery. I replantation is not possible, place the tooth in either milk or normal saline ( rst aid box) and bring it to surgery with Kathryn as quickly as possible. A ■ The tooth is brought to the surgery in milk. How would you proceed? 1. 2. 3. Check medical history or any reason not to replant. For children who are immunosuppressed (e.g. midchemotherapy, organ transplant or primary immune de ciency) or at risk o in ective endocarditis, a discussion with their medical consultant would be prudent be ore replantation. Gently shake the pot containing the tooth and milk to remove any oreign bodies. Check state o root development. Undertake a brie history and examination to ensure there are no other injuries (see structure history orm shown in Appendix 6). Examine the patient and check or other injuries. Examination shows a small intraoral B Fig. 32.1 (A) 1 avulsed and 1 subluxed. (B) 1 replanted and splinted with a titanium trauma splint. 32 • 180 THEAVULSEDINCISOR of revascu larization is the im m atu re tooth w ith an open apex that is replanted w ithin 30–45 m inu tes. All other teeth should be extirpated p rior to sp lint rem oval at 7–10 d ays. Different gu id elines argu e for d ifferent lengths of total and d ry tim e w here revascu larisation is u nlikely (for exam p le, British Society of Paed iatric Dentistry (BSPD) – less than 30 m inu tes d ry tim e and / or 90 m inu tes total tim e; International Association of Dental Trau m atology (IADT) – less than 60 m inu tes d ry tim e). The reason for giving the tooth tim e to revascularize is only reserved for teeth w here if the pu lp is extirpated it w ou ld leave a non-vital im m atu re tooth w ith increased risk of late stage crow n root fractu re. H ow ever, if revascu larization d oes not occu r, there is a strong chance of infection-related resorp tion, w hich can lead to rap id d estru ction of the tooth. Therefore in situ ations w here an im m atu re tooth is given a chance to revascu larize, very carefu l follow -u p is required to ensure any com plications are id enti ed and treatm ent instigated as soon as possible. Kathryn w as seen for sp lint rem oval at 14 d ays after the injury. The rad iograph show ed an im m atu re root form . The tooth w as rep lanted w ithin 30 m inu tes, w ith 10 m inu tes stored d ry and the rem aind er of the tim e kep t in m ilk. The d ecision w as therefore taken to see if the tooth w ou ld revascu larize. ■ Wha t actors are important in predicting root resorption? Extra-alveolar dry time (EADT). Extra-alveolar time (EAT). Storage medium prior to replantation. Contamination. Root maturity. Research has show n that teeth w ith a d ry tim e of greater than 5 m inu tes have a signi cantly increased risk of resorption. The tw o p referred storage m ed ia, m ilk and norm al saline, are iso-osmolar, and that is w hy they are the recom m end ed storage m ed ia. Even in these ap prop riate m ed ia, period ontal ligam ent vitality is not m aintained for long. Key point Critical in ormation to ask about in avulsion cases: • EADT. • EAT. • Storage medium and duration in it. • Contamination o the root sur ace. ■ What types o resorption are there? Repair-related resorption (previously called sur ace resorption): most commonly seen as blunting o tooth apices a ter application o excessive orthodontic orces or on the roots o upper lateral incisors as a result o canine tooth impaction. The vitality o the tooth is not related to this type o healing, e.g. the tooth may be vital or non-vital. Following trauma this can be present on any part o the root sur ace but is only visible on conventional 2D radiographs as saucer shaped cavities along the mesial and distal sur aces o the root. Following the avulsion injury and extraoral storage there is damage to the periodontal ligament and cementum. Following replantation these areas o damage are removed including areas o adjacent root sur ace giving these saucer shaped cavities. Adjacent cementum and periodontal healing then grows over these cavities, and the periodontal and cemental architecture is restored. In ection-related resorption (previously called external in ammatory resorption): this type o resorption is only seen where there is damage to the periodontal and cemental architecture ( or example ollowing trauma) combined with a non-vital and in ected root canal. The immunological response (destructive phase) removes the necrotic and in ected material on the root sur ace, thus opening up the dentinal tubules. This opens up a pathway through which the bacteria toxins are transmitted, thus exacerbating the immunological response and stimulating urther the root resorption. Radiographically, the sur aces o the roots have punched-out craters with radiolucency seen in the adjacent bone. Only when the necrotic pulp is extirpated and the root canal disin ected will this resorption stop. The root sur ace is then able to repair (healing phase) with the type o healing dictated by the amount o damage. Either the cementum and periodontal ligament will re-establish themselves (repairrelated resorption) or the adjacent bone will use to the root (ankylosis-related resorption). Ankylosis-related resorption (previously called replacement resorption): this is characterized by the absence o the periodontal ligament with bone used to the cementum and dentine. The tooth becomes part o the bone and is constantly remodelled, resulting in progressive resorption o the root until the entire root is resorbed and the crown ractures o . In growing children, ankylosis-related resorption causes the local cessation o growth with the appearance o the a ected tooth or teeth staying still (in raoccluding) while the adjacent teeth continue to erupt. Key point Types o root resorption ollowing trauma: • Repair-related. • In ection-related. • Ankylosis-related. ■ What is the treatment or in ection-related resorption ollowing trauma? The only m ed icam ent that is proven to arrest infectionrelated resorp tion is non-setting calcium hyd roxid e. Its antibacterial prop erties relate to its alkalinity (p H 11–12). It should be placed w ithin the root canal at least tw ice w ith a m onth gap betw een ap p lications. Applications continu e u ntil rad iographs show the lack of rad iolucency in the bone ad jacent to the affected tooth. Once this is d etected , the root can be obtu rated w ith gu tta p ercha. 181 • THEAVULSEDINCISOR 32 A A B Fig. 32.3 (A) Clinical appearance o 1 12 months ollowing avulsion injury. (B) Radiographic appearance o 1 12 months ollowing avulsion injury, showing urther root development. B Fig. 32.2 (A) A post-replantation radiograph taken at 14-day review, 1 showing an immature root orm. (B) 1 radiograph taken at 6-month review showing continued root development. Follow ing splint rem oval, Kathryn’s 1 w as carefully review ed at 6 w eeks, 3 m onths, 6 m onths and 12 m onths. At each visit, special tests (d escribed in Chap ter 31) and rad iographs w ere taken. This w as to ascertain the type of period ontal healing and to look for signs of p u lp al necrosis and or infection-related resorp tion. As can be seen in Fig. 32.2, continu ed root form ation w as seen d em onstrating pu lp revascu larization. At 12 m onths (Figs 32.3A and B) there w as clear clinical and rad iographic signs of period ontal healing (re-establishm ent of a norm al period ontal ligam ent w ith a few sm all areas of rep air-related resorp tion) and continu ed root grow th and ap ical closu re (signs of revascu larization). Kathryn w as therefore d ischarged back to her general d ental practitioner w ith the prognosis that the 1 w ill be retained as a fu nctional tooth for the rest of her life. CASE2 SUMMARY Justin is 11 years old. He ell o his scooter, avulsing his 1 . His riends at the park ran home to get his parents, who arrived within 15 minutes. They took Justin and his tooth to an accident and emergency department. At hospital his tooth was placed in milk. Three hours later his tooth was replanted and splinted. The EAT was 4 hours, and the EADT 1 hour. ■ Justin’s parents book a n emergency a ppointment so see you the ollowing day, what will you do? Fig. 32.4 show s a su tu re splint. This typ e of splint is inapprop riate, as the patient w ill nd it very d if cu lt to m aintain good oral hygiene. Moreover, this typ e of sp lint is unable to hold the tooth in the rep lanted p osition w ith the 1 slightly extru d ed on presentation. The sp lint w as rep laced for a more conventional sp lint (d iscu ssed in Chapter 31); how ever, Ju stin w ou ld not tolerate fu rther rep ositioning of the tooth to im p rove its p osition. Ad vice d escribed earlier in this chap ter is reiterated , and Ju stin w as booked for a review appointm ent 8 d ays after his accid ent. 32 • 182 THEAVULSEDINCISOR Fig. 32.4 Showing 1 replanted with an inappropriate suture splint. Reproducedwith permission romthe RCSEDen project, Royal College o Surgeons o England. ■ Wha t is the cha nce o pulp survival? Rad iograp hs show 1 has com p lete root d evelop m ent. Therefore there is no chance of p u lpal revascu larization. In ord er to prevent infection-related resorp tion, root canal treatm ent is com m enced at this visit. It is good practice to extirp ate the necrotic pu lp and d isinfect the root canal before rem oving the splint. Justin w as booked for a fu rther review and d isinfection of the root canal 1 m onth later. ■ Wha t intracana l medicament should be pla ced in the extirpated tooth? There has been som e anim al-based research that has show n that w hen non-setting calciu m hyd roxid e is placed too early after rep lantation (w ithin the rst 7 d ays) in a tooth w ith a d am aged p eriod ontal ligam ent, this can aggravate favou rable p eriod ontal healing and lead to ankylosis-related resorp tion. With this in m ind som e au thorities ad vocate that a steriod / polyantibiotic p aste shou ld be the rst d ressing placed in root canals of avu lsed teeth as soon after the inju ry as p ossible. They argued that the steroid / antibiotic paste w ill d am pen the im m u ne resp onse p rom oting favou rable healing. Cu rrently there is no d e nitive research su pporting one app roach over another. Therefore gu id elines ad vocate either ap proach. For Ju stin’s tooth, a non-setting calcium hyd roxid e d ressing w as p laced at his d ay-8 review appointm ent. ■ Wha t are the cha nces o periodontal healing? There is very little chance of period ontal healing w ith the tooth almost gu aranteed to heal by ankylosis-related resorp tion. Therefore early referral to an interd iscip linary team is essential. At this interd iscip linary clinic they w ill d iscu ss the d ifferent treatm ent op tions w ith Ju stin and his parents. BSPD and IADT gu id elines d iffer slightly w ith their cu t off p oints of w hen ankylosis-related resorp tion is highly likely. Beyond EADT of 30 m inu tes and EAT of 90 m inutes, BSPD gu id elines rep ort that there is less than a 10% chance of p eriod ontal healing. For IADT, beyond EADT of 60 m inutes there is less than a 1% chance of p eriod ontal healing. Justin is beyond both of these cu t off p oints, and therefore ankylosis-related resorption is almost guaranteed . H ow ever, m aintaining a tooth w hich w ill u ltim ately fail is very im p ortant over the short to m ed iu m term . The tooth w ill help m aintain good aesthetics for the p atient as w ell as the height and w id th of the alveolus. Careful follow -u p is essential to d iagnose infraocclu sion as soon as it becom es ap parent. ■ What long-term treatment options are available? There are a nu m ber of d ifferent op tions w hich w ere assessed for Ju stin. These inclu d ed d ecorontation, orthod ontic space closure and cam ou age of the lateral incisor, d entu re, resin retained brid ge and p rem olar transplant. In a grow ing patient (e.g. a child or ad olescent) an osseointregrated im plant is contraind icated as they have not com p leted their facial grow th. The d ifferent op tions w ere d iscu ssed w ith Ju stin and his parents at the interd iscip linary clinic. Justin had crow d ing in his u pper and low er arches and w as keen on und ergoing orthod ontics to im prove his app earance. As p art of the treatm ent p lan a p rem olar w as to be extracted in each qu ad rant. The best prognosis for prem olar transp lant is w hen the root form ation is betw een three-qu arter and comp lete root length d evelopm ent bu t w ith an open ap ex. Ju stin tted the criteria for a p rem olar transp lant and both he and his parents w ere keen to pu rsu e this option (see Figs 32.5 A-D). Ju stin had a tooth extracted in each qu ad rant includ ing the 5 w hich w as u sed for the p remolar transp lants. This w as bu ilt up initially d u ring the healing p hase of the transplant before the orthod ontic treatm ent w as u nd ertaken. On the comp letion of his orthod ontic treatm ent, a nal com posite bu ild u p w as p rovid ed . The transplant d em onstrated both pu lp al and period ontal healing. The prognosis for the transplant is that it w ill be retained as a fu nctional u nit for the rest of Ju stin’s life. 183 • THEAVULSEDINCISOR A B C D Fig. 32.5 (A) 1 week a ter the premolar transplant procedure with initial composite build up. (B) Radiograph o the premolar transplant taken 1 week a ter the premolar transplant procedure. Reproduced with permission romthe RCSEDen project, Royal College o Surgeons o England. (C) Radiograph o premolar transplant taken 6 months a ter the premolar transplant, showing periodontal and pulpal healing (continue root growth). Reproduced with permission romthe RCSEDen project, Royal College o Surgeons o England. (D) Premolar transplant (1 ) a ter orthodontic treatment and nal composite build up. Reproducedwith permission romthe RCSEDen project, Royal College o Surgeons o England. Primary resources and recommended reading And ersson L, And reasen JO Day P et al 2012 International Association of Dental Trau m atology gu id elines for the m anagem ent of traum atic d ental inju ries: 2. Avu lsion of p erm anent teeth. Dent Trau m atol 28 (2):88–96. And reasen JO, Laurid sen E, Bakland L et al 2014 Dental trau m a gu id e. Available at: http :/ / w w w.d entaltraum agu id e.org/ Exam ination.aspx. Day P, Gregg T 2012 Treatm ent of avu lsed p erm anent teeth in child ren. British Society of Paed iatric Dentistry. Available at: http :/ / bspd .co.u k/ Resou rces/ BSPD-Gu id elines. Day PF, Kind elan SA, Sp encer J et al 2008 Dental trau m a: p art 2. Managing poor prognosis anterior teeth - treatm ent options for the su bsequ ent sp ace in a grow ing p atient. J of Orthod 35:143–155. Trope M 2011 Avu lsion of p erm anent teeth: theory to p ractice. Dent Traum atol 27 (4):281–294. For revision, see Mind Map 32, page 253. 32 33 Disorders o eruption and exoliation CASE1 SUMMARY Beth was only 20 days old when it was noticed she had two teeth at the ront o her lower jaw (Fig. 33.1). ■ Wha t is the correct terminology or these early erupting teeth? If the teeth are present at birth, ‘natal’ is the correct term . If they are not present at birth but eru pt w ithin the rst month of life, ‘neonatal’ is correct. The prevalence rates for both natal and neonatal teeth are reported as 1 in 2000–3000 live births. The m ost com m only presenting tooth is the low er central incisor. More rarely, m axillary incisors or rst m olars have been rep orted . The early eru ption is thou ght to be caused by the ectopic position of the tooth germ d u ring fetal life. N atal and neonatal teeth m ay follow a sp orad ic p attern, or they m ay be fam ilial. H ow ever, they can be associated w ith speci c synd rom es: Pachyonychia congenita. Ellis van Creveld. Hallermann Strei . ■ What a re the main problems associated with natal and neona tal teeth? Mobility. Ulceration o ventral sur ace o tongue. Nipple soreness (breast eeding mothers). The teeth are m obile becau se the d evelop m ent of the tooth is consistent w ith age. Only abou t ve-sixths of the crow n, and u sually no root, is form ed . Ad d itionally, the crow n is occasionally d ilacerated and the enam el hypoplastic or hypom ineralized . Excessive mobility is a d anger to the airw ay from aspiration, and the tooth should be rem oved . Care shou ld be taken to ensure that the entire tooth inclu d ing the p ulpal tissue is removed , otherw ise d entine and a root w ill form , w hich w ill requ ire eventual rem oval. If teeth can be left, then continued root d evelopm ent w ill occu r. N ipp le soreness m ay occasionally necessitate tooth rem oval. Ulceration on the ventral su rface of the tongu e m ay respond to carm ellose sod iu m oral p aste. Sm oothing of the incisal ed ges w ith sand p ap er d iscs m ay also help . If the d ecision is m ad e to rem ove the tooth, d o rem em ber the local anaesthetic d oses, as these you ng babies are likely to w eigh betw een 2–4 kg. N ew borns are given vitam in K in the rst w eek of life. Check that they have received this as either an injection or an oral d ose in hosp ital or from their m id w ife. Key point Natal and neonatal teeth may need to be removed i : • Mobility causes concern about inhalation. • Ulceration under the ventral sur ace o the tongue persists. • Nipple soreness is signif cant. ■ What actors ca n cause generalized premature eruption but still be considered as ‘normal’? Familial a amily history is a common nding. Children with high birth weights. Maternal smoking during pregnancy. Lower socioeconomic status. Reduced maternal physical activity. Race generally Negroids tend to erupt their permanent teeth earlier than Mongoloids, who are in turn in advance o Caucasians and nally Asian children. Racial group can a ect eruption times and eruption patterns o the primary dentition. Sex emales tend to erupt permanent teeth several months ahead o males. The opposite of prem atu re erup tion is d elayed eru ption. ■ When is generalized delay in eruption o primary teeth expected? Preterm in ants. Fig. 33.1 Natal teeth. Very low birth weight in ants. 185 • DISORDERSOFERUPTIONANDEXFOLIATION ■ What conditions may lead to a generalized delayed eruption o teeth in both primary a nd permanent dentitions? Chromosomal abnormalities syndrome. Down syndrome and Turner Gross nutritional de ciency. A Hypothyroidism/hypopituitarism. Hereditary gingival bromatosis (HGF). Acquired gingival overgrowth (drug-induced cyclosporin, sodium channel blockers). phenytonin, Acquired reduction in bone turnover (drug-induced bisphosphonates). ■ What specif c condition is a ssociated with grossly delayed or ailed eruption o teeth in the permanent dentition? Cleid ocranial d ysp lasia – this is an au tosom al d om inantly inherited cond ition w here, in ad d ition to m u ltip le su pernu m erary teeth cau sing d elayed exfoliation of p rim ary teeth and d elayed eru p tion of permanent teeth, there is ap lasia of the d istal end or total absence of the clavicles. ■ What local a ctors ca n account or delayed eruption o B Fig. 33.2 (A) Cyclic neutropenia. (B) Cyclic neutropenia. permanent teeth? Box 33.1 Di erential diagnosis o causes o premature ex oliation o primary and permanent teeth Supernumerary teeth or odontomes. • Neutropenias and qualitative neutrophil de ects: Ectopic crypt positions o permanent teeth. Cystic change in the ollicle o permanent teeth. Crowding. Thickened mucosa due to early primary tooth removal. Exfoliation of teeth (like eru ption) can be either premature or d elayed . • Cyclic neutropenia. • Congenital neutropenia (Kostmann disease). • Prepubertal periodontitis. • Juvenile periodontitis. • Leucocyte adhesion de ect. • Papillon–Le èvre syndrome. • Chediak–Higashi disease. • Langerhans cell histiocytosis – leading to bony destruction. CASE2 SUMMARY George was 3 years o age when his mother f rst noticed that his lower primary incisors were loose. History George w as born after a norm al p regnancy and d elivery bu t had p roblem s after birth w ith recu rrent cou ghs and cold s, u p per and low er resp iratory tract infections, and oral u lceration. H e w as extensively investigated and w as con rm ed as having a cyclic neu trop enia. • Hypophosphatasia with aplasia or hypoplasia o cementum. • Sel -injuryin either a psychotic disorder or the congenital insensitivity to pain syndrome. • Ehlers–Danlos syndrome (type VIII) – disorder o collagen ormation causing progressive periodontal destruction. • Scurvy – loss o tooth due to ailure o proline hydroxylation and collagen synthesis. Prem ature loss of prim ary teeth is an im portant d iagnostic event, as m ost cond itions cau sing it are potentially serious and w arrant im m ed iate investigation (Box 33.1). Generally teeth m ay be lost early becau se of: Metabolic disturbances. Severe periodontal disease. Loss o alveolar bone support. Dental history George and his m other had regu lar toothbru sh instruction, and his oral hygiene w as excellent. H e also u sed 0.2% chlorhexid ine gel at night instead of u orid ated toothp aste. Desp ite these efforts his low er p rim ary incisors exfoliated betw een age 4 and 5 years, and by his sixth birthd ay he had erup ted his low er perm anent central incisors and rst p erm anent m olars (Figs 33.2A and B). Sel -injury or non-accidental injury. George w ill continu e to have regu lar d ental care and supervision of bru shing. Even in the p resence of im m acu late p laqu e control w e can exp ect that his neu trop hil d efect w ill p red isp ose him to p eriod ontal d isease and p rem atu re loss of som e if not all his p erm anent teeth. The opposite of prem ature exfoliation is d elayed exfoliation. 33 33 • 186 DISORDERSOFERUPTIONANDEXFOLIATION ■ Wha t ca uses delayed ex oliation o prima ry teeth? Double primary teeth. Hypodontia a ecting permanent successors. Ectopically placed permanent successors. Trauma or periradicular in ection o primary teeth causing interruption o physiological resorption. In raocclusion or ankylosis. In 40% of cases, d ou ble p rim ary teeth are associated w ith an abnormality in the p erm anent d entition nu m ber. Parents shou ld be ad vised of this and a d ental p anoram ic tom ogram shou ld be taken arou nd the age of 6. Fu rther information on d ou ble teeth is p rovid ed in Chap ter 37. Infraocclu sion is the p referred term for either ‘su bm erged teeth’ or ‘ankylosis’ w hen d escribing teeth that have failed to achieve or m aintain their occlu sal relationship to ad jacent or op p osing teeth. Most com m only, p rimary teeth have reached a norm al occlu sal level before becom ing infraocclud ed . The tooth m ost com m only affected is the mand ibu lar rst p rim ary m olar. Males and females are affected equ ally. Infraocclu d ed prim ary teeth are associated w ith a higher incid ence of absent p erm anent su ccessors. Fu rther d etails of their m anagem ent is d iscu ssed in Chapter 8. Key point In raocclusion: • Mandibular f rst primary molar is most commonly a ected, with mandibular primary molars more commonly a ected than maxillary primary molars. • More common in primary teeth than in permanent teeth. • Equal sex ratio. • Higher incidence o absent permanent successors. • Prevalence o 2 8%. ■ How is in raocclusion graded? • Grade I occlusal level above contact point o adjacent tooth. • Grade II occlusal level at contact point o adjacent tooth. • Grade III occlusal level below contact point o adjacent tooth. Grad e III infraocclu sions, if progressive, m ay be com p letely subm erged by the surround ing hard and soft tissu es. Rad iographs of infraocclu d ed teeth show blu rring or absence of the period ontal sp ace. Primary resources and recommended reading Ald red M, Cam eron A, Georgiou , A 2013 Paed iatric oral m ed icine, oral p athology and rad iology. In: Cam eron A, Wid m er R (ed s), H and book of Ped iatric Dentistry, 4th ed . Mosby Wolfe, St Lou is. Craw ford PJM, Ald red MJ 2012 Anom alies of tooth form ation and eru p tion. In: Welbu ry RR, Duggal MS, H osey MT (ed s), Paed iatric Dentistry, 4th ed . Oxford : Oxford University Press. Managem ent of u nerup ted m axillary incisors 2010. Lond on: Royal College of Su rgeons of England , Facu lty of Dental Su rgery. Available at: http s:/ / w w w.rcseng.ac.u k/ fd s/ p u blications-clinical-gu id elines/ clinical_gu id elines/ d ocu m ents/ ManMaxIncisors2010.p d f. N tani G, Day PF, Baird J et al 2015 Maternal and early life factors of tooth em ergence patterns and nu m ber of teeth at 1 and 2 years of age. J Dev Orig H ealth Dis 6:299–307. For revision, see Mind Map 33, page 254. 34 Poor qualityfrst permanent molars SUMMARY Lisa is 9 years old. Her mother has brought her to your surgery because her recently erupted permanent teeth at the back o her mouth are brown and there are creamy patches on her adult incisors. What has caused these discolorations? How may they be treated? the labial su rfaces of the new ly eru pted u pper and low er p erm anent central incisors (Figs 34.1 and 34.2). Up p er and low er arches w ere u ncrow d ed . Space assessed from the d istal of 2’s to m esial of 6’s in each qu ad rant w as 21.5 m m in the low er arch and 22 m m in each u pp er arch qu ad rant. On average, 21 m m and 22 m m are requ ired for these d istances in the low er and u pper arches, to p rovid e suf cient space for the p rem olars and canines to align w ithin the arch. The incisor relationship w as Class I on 1 1; the m olar relationship w as Class I bilaterally. Key point • Hypoplasia is the name given when there is a reduced thickness o enamel but the enamel is well mineralized (e.g. there is reduced quantity but normal quality o enamel). • Hypomineralization is the name given when there is reduced mineral content o enamel but a normal amount o enamel has been laid down (e.g. there is reduced quality o enamel but normal quantity). • Post-eruptive breakdown is where the tooth erupts with hypomineralized enamel. Shortly a ter eruption this area o enamel ractures o exposing underlying dentine. • Atypical restorations is where the classical appearance o the restoration or dental caries ( ollowing Black’s cavity design) is not seen. History Lisa has com p lained that for the p ast few m onths these teeth have been p ainfu l on eating hot and cold food s. The pain is of 1–2 m inu tes’ d u ration. Toothbru shing also has cau sed sensitivity at the back of the m ou th. There has been no pain on biting and eating food s. Very recently Lisa felt that one of the back teeth has started to cru m ble. H er m other has also noticed this w hen she has help ed w ith bru shing. Lisa has not requ ired any analgesics for the d iscom fort cau sed by her teeth. Medical history Lisa is a healthy child w ho has never been in hosp ital. Dental history Lisa and her fam ily are regu lar d ental attend ers. The fam ily m em bers all have a low caries risk. Lisa has had no restorations in her p rim ary d entition. She u sed a child ren’s toothp aste (1050 p p m) u ntil recently and is now u sing the sam e ad u lt toothp aste as her p arents (1450 p p m ). Fig. 34.1 Hypomineralized and hypoplastic upper rst permanent molars. Examination Intraoral examination revealed that all fou r rst perm anent m olars (FPMs) w ere hyp om ineralized w ith areas of brow n enam el. In ad d ition, there w ere areas of post-eru ptive breakd ow n (hypoplasia) w here the enam el had chipped aw ay, exp osing the u nd erlying d entine. The m axillary m olars w ere the w orst affected by p ost-eru p tive breakd ow n. 6 had a large atyp ical am algam restoration. In ad d ition, some cream y hyp om ineralized areas w ere visible on Fig. 34.2 Hypomineralized upper and lower permanent incisors. 34 • 188 POORQUALITYFIRSTPERMANENTMOLARS ■ Do you think that the enamel hypomineralization and hypopla sia noted on the f rst perma nent molars and the permanent incisors ollows a chronological pattern? I so, a t what time wa s the a ected enamel ormed? ■ What other di erential diagnoses might you consider? • Yes, it is p ossible that there is a chronological pattern. The cu sp tip s of the rst p erm anent molars begin mineralizing from the eighth m onth of p regnancy, and the cu sp tips of the incisors and cu spid s (canines) from abou t 3 m onths of age (the u pp er lateral incisor slightly later at 10–12 m onths). Mineralization d ates for the p erm anent d entition are given in Table 34.1. ■ Wha t specif c questions would you like to ask Lisa’s mother? Pre-natal. Mother’s health during pregnancy. Were there any concerns such as high blood pressure, proteinuria or preeclampsia? Peri-natal. Di cult birth. Was the delivery prolonged? Was there a need or assisted delivery by orceps, ventouse or caesarean? All o these can be associated with etal distress. • Post-natal. Did Lisa spend any time in the special care baby unit (SCBU)? Illnesses in the f rst 2 years o li e, e.g. meningitis, measles, respiratory in ections, chickenpox. These disturbances may mani est as enamel de ects distributed in the enamel that was orming around birth and in the rst 2 years o li e. • Fu rther qu estioning revealed that Lisa w as born after a norm al p regnancy and d elivery bu t had a signi cant nu mber of respiratory infections d u ring the rst year of life. This con rm s you r d iagnosis of chronological hyp op lasia. The correct nam e for this cond ition is m olar incisor hypom ineralization (MIH ). Post-eru ptive breakd ow n and atyp ical restorations are consistent w ith this d iagnosis. Table 34.1 Mineralization times or the permanent dentition Tooth Mineralization begins (months) Upper Central incisor 3–4 Lateral incisor 10–12 Canine 4–5 First premolar 18–21 Second premolar 24–27 First molar At birth Second molar 30–36 Third molar 84–108 Lower Central incisor 3–4 Lateral incisor 3–4 Canine 4–5 First premolar 21–24 Second premolar 27–30 First molar At birth Second molar 30–36 Third molar 96–120 Caries. Newly erupted teeth are particularly prone to dental caries until their enamel maturation is complete. However, it seems very unlikely, even in the presence o particularly deep ssures, that Lisa, who has no caries in her primary teeth, should develop such caries in her permanent teeth. In addition, the overall colour o the permanent molars is not consistent with caries in a tooth o normal morphology. The exposed dentine is slightly so tened and does have caries, but the overall pattern o destruction o the tooth suggests that caries is secondary to some other predisposing actor, such as hypomineralization/hypoplasia. Another actor to consider that is against a diagnosis o caries is the creamy hypomineralized areas on the incisors. They are neither the shape nor the distribution o white spot or precarious lesions that one would expect with poor oral hygiene. Amelogenesis imper ecta. Although the presenting eatures could be a hypomature orm o amelogenesis imper ecta, there are several actors that suggest this is not the case: there is no amily history; the primary dentition is not a ected; the pattern o the de ects is chronological. All o these combined make an inherited abnormality unlikely. Fluorosis. The severe enamel de ects on the molar teeth could only occur i there was a history o very high endemic f uoride levels, probably in excess o 6 ppm. Such levels do not occur in the UK. Mild f uorosis is seen where children have swallowed toothpaste or have been given supplementation in addition to swallowing toothpaste. However, in such cases there are usually ne, opaque, white lines ollowing the perikymata and small irregular enamel opacities or f ecks that merge into the background enamel colour. Fluorosis does not produce well-demarcated opacities like those seen on the incisors. Key point In • • • • patients with MIH, your questioning should include: Pre-natal period. Natal period. Post-natal period. Systemic illnesses in f rst 2 years o li e. ■ Is pain rom such molar teeth common? Yes. There is evid ence that these teeth have 5–10 tim es greater treatm ent need than norm al teeth and are m ore d ifcult to anaesthetize. A p alatal as w ell as a bu ccal in ltration is essential. There is also evid ence that child ren w ith hypom ineralized rst permanent m olars (H FPMs) have m ore behaviou r management p roblem s than other child ren, necessitating ad juncts to treatm ent su ch as sed ation. In recent years, the prevalence of H FPMs varies across d ifferent pop u lations in the w orld . The average prevalence is 16% w ith a range betw een 3% and 44%. The histology of extracted H FPMs show s that the yellow / brow n areas are m ore p orou s and occu p y the entire enam el layer. The w hite/ cream y areas occu py the inner parts of enam el. The affected areas have a higher carbon and low er 189 • POORQUALITYFIRSTPERMANENTMOLARS calcium and p hosp hate content (e.g. less m ineral and m ore protein). Investigations ■ What investigations are indicated and why? Intraoral radiographs are ind icated in ord er to assess the p roximity of the coronal d efects to the d ental p u lp . These can be d if cu lt to interp ret, as MIH -affected teeth have a d ifferent rad iographic app earance to d ental caries. A panoramic tomogram is necessary to ascertain the p resence and stage of d evelopm ent of the rem aining p erm anent d entition in view of the p oor long-term p rognosis of the rst p erm anent m olars. A panoram ic tom ogram revealed all p erm anent teeth, includ ing third m olars, to be present. The fu rcation of 7’s w as calcifying. Second ary caries w as evid ent in all rst 6 6 perm anent m olars but w as m ost p ronou nced in . 6 Treatment ■ What are the main clinical problems in this case? Loss o tooth substance: breakdown o enamel tooth wear secondary caries. Sensitivity. Appearance. Key point Children with MIH: • Have a higher treatment need. • Have signif cantly higher behaviour management problems. Achieving good local anaesthetic o the entire tooth is essential, as requently these teeth can be very sensitive (histology o a ected MIH teeth shows signif cant pulpal in ammation). Treatment under rubber dam is requently needed to prevent sensitivity rom a ected adjacent teeth. Composite These can be d e nitive restorations w hen there are sm all areas of hypom ineralization. It is im p ortant w hen restoring these teeth that all the hypomineralized area is removed . This is achieved w ith gently ru nning a slow hand p iece w ith a large rose bur over the d iscolou red enam el. The soft enam el w ill give w ay, leaving hard , less affected enam el behind . Stainless steel crowns These are the m ost d u rable restoration and can m aintain a tooth u ntil a perm anent crow n can be placed in the teenage years, or until a planned extraction. Adhesively retained copings These m ay be su itable for teeth that are not signi cantly affected by hypomineralization. When the d efect has been removed and replaced by GIC, a cop ing can be placed on top of the restoration and cover the rem aind er of the occlu sal and cu sp al su rface. Extraction For m od erate to severely affected H FPM this is the preferred treatm ent option because: • HFPMs are o poor long-term prognosis. Although ull coverage coronal restorations could be undertaken to retain them, this is an ambitious plan in a 9-year-old child. The restorations undoubtedly would require replacement at some uture date due to possible microleakage at the margins and caries. This would incur additional inconvenience, expense and li e-long treatment or the patient. • It is the optimal developmental stage to remove 6’s as the urcation o 7’s is calci ying and predictable bodily movement o 7 orward is most likely. Timing o 6 removal is more critical than that o 6 as the mesial dri t tendency is greater in the upper arch. • Third molars are also developing and should erupt eventually i the 7’s migrate orward to occupy the position o the 6’s (Fig. 34.3). ■ What are the treatment options or the HFPMs in this case? Sensitivity. Composite. A Stainless steel crowns. Adhesively retained copings. Extraction. Sensitivity This can be m anaged in a nu m ber of d ifferent w ays. Ad vising p atients to u se antisensitivity toothpaste and / or toothmousse (see Chap ter 23) can be affective. For child ren over the age of 10, u se of a high- u orid e toothp aste (e.g. 2800 pp m ) can also w ork. For localized areas that are sensitive to toothbrushing or cold d rinks and food , tem porary glass ionomer cem ents (GICs) are often u sed to red u ce the sensitivity sym p tom s. This is often u sed to maintain sym p tom atic m olars u ntil the id eal age for their extraction. 34 B Fig. 34.3 (A) Dental panoramic tomogram be ore removal o all rst permanent molars. (B) Dental panoramic tomogram ollowing removal o all rst permanent molars. 34 • 190 POORQUALITYFIRSTPERMANENTMOLARS • As the molar relationship is Class I bilaterally, removal o 6’s necessitates the removal o 6’s to encourage maintenance o the buccal segment relationship. This is known as compensating (removal o the equivalent opposing tooth) extractions and preventing overeruption o the 6’s. Key point • Ensure all permanent teeth, especially 5’s and 8’s, are present radiographically be ore considering FPM extraction. In some situations the FPM may be extracted even i the 8’s are absent. • An orthodontic assessment o the patient is essential to establish their malocclusion. A consultation with an orthodontist is prudent in Class II and III cases. • Timing o the extraction o 6 is more critical than that o 6. Ideal timing or a 6 is between the ages o 8.5 9.5 (when there is calcif cation o the bi urcation o the 7). The timing or the extraction o a 6 is be ore the 7 erupts. • Consider compensating extractions o upper FPM where there is moderate to severe MIH in lower FPM. ■ What are the treatment options or the incisors in this ca se? Bleaching. Microabrasion. Localized composite restoration. Full composite veneer. Bleaching is controversial in these cases. Firstly, there are legal issu es arou nd bleaching child ren’s teeth (see Chap ter 36). Second ly, the bleaching can cau se sensitivity, and therefore p atients m ay stru ggle to com p ly w ith instru ctions for u se w hen their teeth are alread y sensitive. Finally, the im p act of the bleach is m ore likely to lighten the ad jacent tooth arou nd the d efect, thereby red u cing the contrast betw een the tw o. Im portantly this is the least invasive treatm ent w ith no rem oval of enam el. Controlled enam el m icroabrasion m ay p rod u ce a m ore acceptable result w ithou t rem oving the w hite areas. This is becau se the su rface enamel layer after m icroabrasion is relatively p rism less and w ell com pacted . The optical properties are changed and a w hite area m ay becom e less p erceptible. The techniqu e shou ld not be u sed if there is a red u ced thickness of enam el. Localized com p osites can give very accep table resu lts bu t are d estru ctive of enam el and m ay w eaken the tooth stru ctu re if large areas are rem oved . Fu ll com posite veneers w ith a thin layer of a relatively op aqu e com p osite m ay p rod u ce an accep table resu lt w ithou t any, or very little, enam el red u ction. This w ill, how ever, m ake the tooth bu lkier. Primary resources and recommended reading D3 Grou p 2016 Develop m ent Dental Defects w ebsite. Available at: http :/ / w w w.thed 3grou p .org. Jalevik B 2010 Prevalence and d iagnosis of m olar-incisorhyp om ineralisation (MIH ): a system atic review. Eu r Arch Paed iatr Dent 11:59–64. Jalevik B, Klingberg GA 2002 Dental treatm ent, d ental fear and behaviou r m anagem ent p roblem s in child ren w ith severe enam el hyp om ineralisation of their p erm anent rst m olars. Int J Paed iatr Dent 12:24–32. Lygid akis N A, Wong F, Jalevik B et al 2010 Best clinical p ractice gu id ance for clinicians d ealing w ith child ren p resenting w ith m olar-incisor-hyp om ineralisation (MIH ): an EAPD p olicy d ocu m ent. Eur Arch Paed iatr Dent 11:75–81. Royal College of Su rgeons A Gu id eline for the Extraction of First Perm anent Molars in Child ren 2009. Available at: http :/ / w w w.rcseng.ac.u k/ fd s/ p u blications-clinical-gu id elines/ clinical_gu id elines/ d ocu m ents/ A%20Gu id eline%20for% 20the%20Enforced %20Extraction%20of%20First%20Perm anent %20Molars%20in%20Child ren%20rev%20March%202009.pd f. For revision, see Mind Map 34, page 255. 35 Tooth discoloration, hypomineralization and hypoplasia CASE1 SUMMARY Simon is 8 years old. He has been brought to your surgery by his mother because his teeth are very dark and he is being teased at school. How would you determine the origin o the discoloration? History Sim on says that the colou r of his perm anent teeth has rem ained the sam e since they erupted (Fig. 35.1). ■ What other questions do you need to ask about the teeth? Do they chip or wear? Are all the teeth a ected? Was the primary dentition a ected? Has anyone else in the amily got, or had, similar teeth? Positive answ ers to the last three qu estions m ay su ggest an inherited abnormality of the teeth su ch as am elogenesis or d entinogenesis im p erfecta. Medical history ■ What specif c questions do you need to a sk his mother with rega rd to potential causes o discoloration? The pregnancy. The health of Sim on’s m other d u ring her pregnancy and Sim on’s health d u ring the birth and d elivery are im portant w hen consid ering the cond ition of the rst perm anent m olars (FPMs). The FPMs w ere the only perm anent teeth that had started to m ineralize before birth (arou nd the eighth m onth of pregnancy). Cond itions that m ay suggest som e fetal d istress and d ysm ineralization m ay be raised m aternal blood p ressu re; early ad m ission to hosp ital; prematu re d elivery; p rolonged d elivery; assisted d elivery, e.g. forcep s or ventou se, em ergency caesarean section; or ad mission to the sp ecial care baby u nit (SCBU). Childhood illnesses. These m ay resu lt in a ‘chronological hyp op lasia’ affecting those p arts of the teeth that w ere m ineralizing at the time of the illness. Although ‘chronological hyp op lasia’ u su ally involves som e failu re of d evelopm ent of enam el m atrix giving obvious lines or rid ges on the teeth, there m ay be m ild er form s that can only be felt w ith a p robe and that p resent for care becau se they attract extrinsic stain. Tablets or medications taken during childhood. Tetracycline staining shou ld not occu r now in child ren w ho have been brought u p in d evelop ed cou ntries. It is still com m on in child ren from d evelop ing cou ntries w here tetracycline is still u sed becau se it is a very effective, cheap , broad spectru m antibiotic. The only child ren w ho m ay still be affected in d eveloped countries are those w ith cystic brosis w ho have d evelop ed mu ltip le d ru g resistances as a resu lt of recu rrent resp iratory infection. Sim on w as born w ith prim ary biliary atresia. This resulted in progressive liver failure, increasing levels of circu lating biliru bin and eventu ally a liver transp lant at the age of 2.5 years. All the perm anent teeth d eveloping prior to the transp lantation w ill have intrinsic d iscoloration as a result of the high circu lating biliru bin. The p rim ary d entition w ill be affected to a lesser extent as a resu lt of staining in second ary d entine. Althou gh not seen w ith Sim on, som e child ren can have gingival overgrow th as a resu lt of im m u nosu p p ressive treatm ent w ith cyclosp orine. The colour of the second perm anent m olars is likely to be entirely norm al as these teeth started m ineralizing arou nd the age of 3 w hen there w as a fu nctioning new liver and norm al levels of biliru bin. Dental history ■ Wha t other lines o questioning do we need to explore i we are considering all the possible causes o intrinsic discoloration? Was there a history o in ection and/or extraction or decay o any o the primary teeth? Localized infection on p rim ary teeth can cau se localized abnorm alities of enam el form ation and m ineralization of p erm anent teeth (Tu rner ’s tooth). Fig. 35.1 Intrinsic discoloration. 35 • 192 TOOTHDISCOLORATION, HYPOMINERALIZATIONANDHYPOPLASIA Was there ever any trauma to the primary teeth? There is a 50% chance of enam el anom alies of perm anent su ccessor teeth after p rim ary trau m a (see Chap ter 29). These w ill be localized anom alies. Fluoride history. A fu ll history from birth, inclu d ing areas that the child has lived in, u orid e su p p lem entation and bru shing habits is requ ired . Flu orosis w ill p rod u ce a system ic or chronological d istribu tion affecting the teeth that w ere form ing w hen excess u orid e w as taken. The im p ortant categories and qu estions for a history into intrinsic tooth d iscoloration and hypoplasia are show n in Box 35.1. Examination The im portant features to note about any intrinsic d iscoloration or hypoplasia are: Is it generalized or localized? Does it a ect the primary and permanent dentitions? ■ What is the only method o treatment that will help Simon’s appea ra nce? Veneering. Com p osite veneers should be provid ed u ntil the age of 16 years w hen they can be replaced w ith porcelain veneers. Com posite veneers m ay not m ask the severe green stain u nless op aquing agents are u sed . Porcelain veneers m ay be the only realistic alternative; how ever, they are not ap propriate until the gingival m argin has m atu red and stabilized in late teens or early tw enties. The m ethod of placem ent of comp osite veneers is covered in Chap ter 36. An alternative, less d estru ctive ap p roach is the u se of vital nightgu ard bleaching (see Chap ter 36, together w ith d iscu ssions abou t the cu rrent legality of bleaching for child ren und er 18 years old ). This requ ires no irreversible d estru ction of enam el, and althou gh it m ay not fu lly correct the d iscolou ration, it m ay be su f cient for the patient. For severe d iscolou ration several months of night-tim e bleaching m ay be requ ired . At 3 years there is rep orted colou r relap se in a third of all cases. H ow ever, top up bleaching is feasible and an accep table ou tcom e for som e p atients and their parents. ■ In the major ca tegories or questioning shown in Box 35.1, which a re likely to ca use genera lized discolora tion and which are likely to ca use localized discoloration? Generalized: medical; amily; f uorosis. Localized: pregnancy; dental; trauma. Sim on has generalized intrinsic d iscoloration as a resu lt of biliary atresia cau sing increased levels of biliru bin. Box 35.1 Intrinsic tooth discoloration and hypoplasia Maternal and neonatal history Key point Lines o questioning in discoloration, hypomineralization and hypoplasia: • Maternal. • Trauma. • Medical. • Fluoride. • Dental. • Family. • History o pregnancy – maternal problems. • History o birth – caesarean, orceps, etal distress. Family history • Is anyone in the amily similarly a ected. Medical history • Dates o prolonged illnesses, e.g. childhood in ections, haematological disorders, nutritional diseases etc. ■ I a patient ca me to you with a single discoloured root-f lled incisor, what orm o treatment should you consider f rst? N on-vital bleaching: this techniqu e has certain ad vantages, especially in the you nger and ad olescent p atient: Non-destructive o tooth tissue (already root lled). • Medications taken (such as topical or systematic tetracyclins). No irritation to gingival health that can occur with veneers. Dental history No change in contour o tooth that may make oral hygiene more di cult. • Does the discoloration a ect all the teeth or just a ew. • Does the discoloration a ect both primary and permanent dentitions. • Has the colour got worse or did the teeth erupt with this appearance. • History o abscesses o the primarydentition. • Anypain or sensitivity rom teeth. • Are the teeth chipping or wearing away. Trauma history • Has the child any historyo an accident to primaryor permanent teeth. Fluoride history • Where has the child lived. • History o uoride supplements. • Age at commencement o brushing. • Amount and type o toothpaste. • Toothpaste eating habits. Patient has some control over the amount o colour change achieved, as they are responsible or the requency and duration o application, although as the dentist, you control how many tubes o bleach (10% carbamide peroxide) are used. The only contraind ications to non-vital bleaching w ou ld be teeth that are p oorly obtu rated as they w ould need retreatm ent. Patients w ith teeth that have com posites need to be w arned that these m ay need to be replaced once bleaching has nished . Althou gh there are other method s, su ch as sealing in sod iu m perborate, these have very mu ch been su p ersed ed by insid e outsid e technique and the d if culty in obtaining sod iu m perborate. 193 • TOOTHDISCOLORATION, HYPOMINERALIZATIONANDHYPOPLASIA Ideally the de nitive composite should be avoided or several days as the bleaching may inter ere with composite bonding. Technique Visit 1 1. 2. 3. Make a diagnosis or the discolouration. Take pre-operative periapical radiographs; these are essential to check i there is an adequate root lling and no symptoms or signs o apical pathology. Clean the teeth with pumice and make a note o the shade o the discoloured tooth. It is prudent to take clinical photographs o the anterior teeth with and without the shade guide visible. Take an upper alginate impression o the entire arch. Ask the technician to cast up the impression and to block out a well on both the buccal and palatal aspects o the a ected tooth. Then to construct a so t vacuum ormed tray made o thermoplastic material. The tray should be cut back and scalloped around the gingival margin. 35 Visit 4 13. Remove the glass ionomer cement and cotton wool ball and provide a de nitive composite. Slight overbleaching is d esirable, as there is likely to be some relap se. Although bleaching has been associated w ith later occu rrence of external cervical resorp tion, resorption has never been reported w ith 10% carbam id e peroxid e. Key point Restorative techniques in discoloration: • Bleaching. • Microabrasion. • Localized composite. • Composite veneers. Visit 2 4. 5. 6. 7. 8. 9. 10. 11. Check that the bleaching tray ts and trim back any rough edges that may irritate the gingival margin. Place rubber dam, isolating the a ected tooth. Ensure adequate eye protection or the patient, operator and dental nurse. Remove the palatal restoration to permit access to the root canal. Remove root lling to 1 2 mm below the dentogingival junction you may need to use adult burs in a miniature contra-angle head. Place 1 mm o glass ionomer cement over the gutta percha. Use an ultrasonic to remove debris blocking the dentinal tubules on the labial sur ace. Alternatively, very lightly use a slow hand piece with a round bur. Do not remove excessive dentine. Show the patient (or parent) how to ll up the access with 10% carbamide peroxide and then seat the bleaching tray. A small amount can also be placed in the well o the bleaching tray around the discoloured tooth. Provide written and verbal instructions. In summary advise the patient to remove the bleaching tray and replace the bleach 3 5 times a day. This should continue or several days up to 2 weeks until the patient is happy with the colour. It is sensible to provide the patient with a maximum o two tubes o bleach so that they are orced to return or a review appointment a ter a week. The bleaching tray should be worn at all times except or tooth brushing. Phoning the patient a couple o days a ter their visit is sensible to check how they are getting on. O ten at this point they will not have seen any change in colour. CASE2 SUMMARY Tony is 14 years old. He has come to your surgery because he is concerned by the colour o his teeth and his bad breath (Fig. 35.2). History H e has noticed his teeth changing colou r over the p ast year. H is friend s have also com mented on his bad breath over this period of tim e. The colour of the teeth in Fig. 35.2 is a resu lt of extrinsic staining from chrom ogenic bacteria d u e to inad equate oral hygiene. The staining is classically in the gingival and cervical areas of the teeth. ■ Are there any other causes o extrinsic staining? Food and drink. Tea, co ee and dishes such as curry can cause staining o the teeth. Most commonly this occurs in the gingival or cervical areas initially, but i oral hygiene is poor, then it can a ect a signi cant part o the whole tooth sur ace (Fig. 35.3). Arrested caries. This produces a brown stain as a result o chromogenic bacteria. Visit 3 12. Check that the patient is happy with the colour. Wash out the access cavity and place a cotton wool ball and a temporary restoration (glass ionomer cement). Fig. 35.2 Extrinsic chromogenic staining. 35 • 194 TOOTHDISCOLORATION, HYPOMINERALIZATIONANDHYPOPLASIA be ore school, and then last thing at night with a 2800 ppm f uoride toothpaste based on a high caries risk. Show him the ‘white spot’lesions. Explain that these will progress to decay i the brushing is not corrected. Daily f uoride mouthwash (0.05% sodium f uoride) used at a separate time to brushing to encourage enamel remineralization. ■ What actors in children a nd adolescents are important in halitosis (bad brea th)? Plaque index. Bleeding sites in gingiva. Fig. 35.3 Extrinsic ood staining. Food impaction. Medical condition. In biliary atresia and jaundice it is possible or bile pigments in the gingival crevicular f uid to cause extrinsic staining. This is yellow/green in colour. Drugs. Ferrous sulphate in liquid iron preparations can result in black staining. Ri abutin, an antituberculous drug, is excreted in the crevicular f uid. This results in an orange-red staining. Chlorhexidine mouthwash, when used requently, can cause a brown-black staining. All these extrinsic stains originate initially arou nd the gingival or cervical area of the tooth but can progress to involve a signi cant am ou nt of the tooth su rface. ■ How ca n you conf rm your diagnosis o extrinsic discolora tion? Extrinsic stains can prop hylaxis. be p olished off. Carry ou t a ■ What additiona l clinical signs are there in Fig. 35.2 to back up your diagnosis o chromogenic sta ining secondary to poor ora l hygiene? Marginal gingivitis. ‘White spot’demineralization lesions in the gingival third o the labial enamel are visible on the anterior teeth. Treatment ■ How would you treat Tony’s bad brea th? Encourage him. Remember teenagers do not take criticism well! Tell him that he is not alone and lots o ‘busy’young people orget twice daily brushing. Toothbrushing instruction utilizing disclosing tablets or disclosing solution. Brushing twice daily, a ter break ast and Nasal in ection. Tonsillar and adenoidal in ection. Furred tongue, especially posterior tongue. ■ As well as improving his gingiva l health with improved toothbrushing, what else could be done with the toothbrush? Bru shing the d orsu m of his tongu e! Alternative m ethod s can be used to clean the su rface of the tongu e, and variou s types of ‘tongu e scrap ers’ are available com m ercially. Very occasionally in a child or ad olescent the origin of halitosis can be ulceration of oesophageal or gastric origin. If there are sym ptom s of this, then a m ed ical referral should be m ad e. Primary resources and recommended reading Bharath KP, Su bba Red d y VV, Poornim a P et al 2014 Com p arison of relative ef cacy of tw o techniques of enam el stain rem oval on u orosed teeth. An in vivo stu d y. J Clin Ped iatr Dent 38:207–213. Bu rrow s S 2009 A review of the ef cacy of tooth bleaching. Dent Up d ate 36:537–538, 541–44, 547–548. Bu rrow s S 2009 A review of the safety of tooth bleaching. Dent Up d ate 36:604–606, 608–610, 612–614. Kilp atrick N M, Bu rbrid ge L 2012 Anom alies of tooth form ation and eru p tion. In: Welbu ry RR, Duggal MS, H osey MT (ed s), Paed iatric Dentistry, 4th ed n. Oxford : Oxford University Press. Poyser N J, Kelleher MG, Briggs PF 2004 Managing d iscoloured non-vital teeth: the insid e/ ou tsid e bleaching techniqu e. Dent Up d ate 31:204–210, 213–214. For revision, see Mind Map 35, page 256. 36 Mottled teeth ■ What childhood illnesses and in ections did she ha ve, and when? A chronological hyp om ineralization or hyp op lasia w ou ld suggest a system ic origin. There w ere no signi cant illnesses. ■ Wha t is Sophie’s uoride history? This m u st inclu d e w here she has lived , any history of su pp lem ents, type and am ount of toothp aste used and any history of eating toothp aste. It transp ired that Sop hie had never received any su p p lem ents or u sed toothpaste excessively. H ow ever, she lived on a farm w ith its ow n ‘w ell’ w ater sup p ly. This w as su bsequ ently analysed and w as fou nd to be over 1 ppm uorid e. The d iagnosis w as one of u orosis. Examination SUMMARY Sophie is 8 years old. Her main concern is that some o her permanent teeth have white patches, especially the upper central incisors. She is getting teased at school because the upper centrals also have brown patches. What are the causes o the white patches? How may they be treated? History Sophie noticed that the p erm anent teeth cam e through w ith the w hite and brow n patches (Fig. 36.1). They have not changed in ap p earance since eru p tion. ■ What important questions would you now a sk her mother? Were the p rim ary teeth norm al? If the answ er to this is yes, then it is u nlikely to be an inherited d efect and m ore likely to have a system ic origin. ■ Is anyone else in the a mily a ected? Unless siblings are subjected to exactly the sam e systemic d iseases and cond itions it is likely that an affected sibling w ill ind icate an inherited d efect. Sop hie’s p rimary teeth w ere norm al, and she has no siblings. N either her m other ’s nor her father ’s fam ily has anyone w ith sim ilar d ental ap pearance. ■ Wha t is the distribution o the mottling that you can see in Fig. 36.1? White and brow n m ottling of the incisal half of the labial surface of 1 1 and w hite m ottling of the incisal third of the labial su rface of 2 2. ■ Do you know why the labia l sur aces o the upper permanent central incisors are o ten more a ected by mottling? Research has show n that these teeth are p articu larly su scep tible to an excess ingestion of uorid e betw een 24 and 30 m onths of age. Mild uorosis gives a d iffu se m ottling that m ay m anifest as d iffu se lines or patches that m erge into the backgrou nd enam el. When the uorosis becom es m ore severe the lines and patches coalesce to p rod u ce a con u ent w hite su rface. In very severe cases there is also p itting of the enam el. Welld e ned or w ell-d em arcated p atches (su ch as m olar incisor hypom ineralization; see Chapter 34) that d o not follow a system ic or chronological d istribu tion, or are localized , are u nlikely to be d ue to u orosis. ■ Which part o the enamel does mild uorosis a ect? The ou ter 200–300 µm . ■ How ca n you use this knowledge to your adva ntage during your clinica l examination? Look for areas of the d entition that are su bject to erosion or attrition, e.g. the occlusal su rfaces of the rst perm anent m olars. If the m ottled enam el has been rem oved on these surfaces then that con rm s that the m ottling is in the outer aspect of the enam el and the d iagnosis is likely to be one of u orosis. Key point Fig. 36.1 Dis guring f uorotic mottling a ecting upper permanent central incisors. History taking in suspected uorosis: • Fluoridated water in places o residence. • Amount o paste and age brushing started. • Type o toothpaste used and uoride concentration. • Flouride supplements. • Toothpaste eating habits. 36 • 196 MOTTLEDTEETH ■ In some cases o uorosis there is, in addition to white mottling, some brown stain. What is the cause o the brown sta ining? This is u su ally d u e to extrinsic agents becom ing incorp orated into the m ore p orou s w hite m ottled areas of enam el. The brow n m ottling tend s to get w orse w ith tim e. Treatment ■ What treatment options or Sophie would you consider or uorotic mottling? Fig. 36.2 A ter acid pumice microabrasion. Microabrasion. Composite veneers. Vital Bleaching. Microabrasion can be carried ou t in a variety of w ays and is a controlled rem oval of the su rface layer of enam el in ord er to im p rove d iscolorations that are limited to the ou ter enam el layer. It is not su itable for d eep enam el or d entine d iscoloration. One of the m ost reliable m ethod s that has been u sed extensively since 1986 is the hyd rochloric acid (H Cl)-pu m ice m icroabrasion techniqu e. It is achieved by a combination of abrasion and erosion – the term ‘abrosion’ is som etim es u sed . In the clinical technique that w ill be d escribed , no m ore than 100 µm of enam el is rem oved . Once comp leted the p roced u re shou ld not be rep eated again in the fu ture. Too m u ch enamel rem oval is p otentially d am aging to the p ulp , and cosm etically the u nd erlying d entine colou r w ill becom e m ore evid ent. Ind ications: • Fluorosis. • Idiopathic speckling. • Post-orthodontic treatment demineralization. • Prior to veneer placement or well-demarcated stains. • White/brown sur ace staining, e.g. secondary to primary predecessor in ection or trauma (Turner’s teeth). Materials: • Bicarbonate o soda/water. • Copalite varnish/Vaseline. • Fluoridated toothpaste. • Non-acidulated f uoride (f uoride drops). • Pumice. • Rubber dam. • Rubber prophylaxis cup. • Sandpaper polishing discs. • 18% hydrochloric acid. Technique: 1. Per orm pre-operative vitality tests; take radiographs and photographs. 2. Clean the teeth with pumice and water, wash and dry. 3. Isolate the teeth to be treated with rubber dam, and paint Copalite varnish around the necks o the dam (alternatively place Vaseline around the necks o the teeth under the rubber dam). 4. Place a mixture o sodium bicarbonate and water on the dam behind the teeth, as protection in case o spillage. 5. Mix 18% hydrochloric acid with pumice into a slurry and apply a small amount to the labial sur ace on either a rubber prophylaxis cup rotating slowly or a wooden stick rubbed over the sur ace or 5 seconds, be ore washing or 5 seconds directly into an aspirator tip. Repeat until the stain is reduced, up to a maximum o 10 × 5 second applications per tooth. Any improvement that is going to occur will have done so by this time. 6. Apply the f uoride drops to the teeth or 3 minutes. 7. Remove the rubber dam. 8. Polish the teeth with the nest sandpaper discs. 9. Polish the teeth with f uoridated toothpaste or 1 minute. 10. Review in 1 month or vitality tests and clinical photographs (Fig. 36.2). 11. Review biannually, checking pulpal status. Critical analysis of the effectiveness of the techniqu e shou ld not be m ad e im m ed iately but d elayed for at least 1 m onth, as the appearance of the teeth w ill continu e to im prove over this tim e. Exp erience has show n that brow n m ottling is rem oved m ore easily than w hite, bu t even w here w hite m ottling is incom p letely rem oved it nevertheless becomes less percep tible. This phenom enon has been attributed to the relatively prismless layer of com p acted su rface enamel p rod u ced by the ‘abrosion’ techniqu e, w hich alters the op tical p rop erties of the tooth su rface. Long-term stu d ies of the techniqu e have found no association w ith p u lpal d am age, increased caries su sceptibility or signi cant p rolonged therm al sensitivity. Patient com pliance and satisfaction is good , and any d issatisfaction is usu ally d ue to inad equ ate pre-op erative explanation. The techniqu e is easy to p erform for the op erator and p atient and is not tim e consum ing. Removal of any m ottled area is perm anent and achieved w ith an insigni cant loss of surface enamel. Failu re to im p rove app earance by the H Cl-p u m ice m icroabrasion techniqu e has lim ited harm fu l effects bu t w ill be less d estru ctive than localized or fu ll-face com posite veneers. Key point Microabrasion: • Will improve sur ace de ects, e.g. uorosis. • Will not improve deeper de ects ( ull thickness o enamel lesions), e.g. amelogenesis imper ecta. 197 • MOTTLEDTEETH Fig. 36.2 show s the appearance of Sophie’s 1 1 1 m onth after H Cl-p u m ice m icroabrasion. ■ Is vital bleaching lega l or children? Changes in EU legislation in 2012 perm it d ental bleaching to be u nd ertaken for ad u lts. This gu id ance sp eci ed that the m axim u m concentration of 6% hyd rogen p eroxid e w as p erm itted for d ental bleaching; 10% carbam id e p eroxid e breaks d ow n to 3.4% hyd rogen p eroxid e. For child ren u p to the age of 18 it is illegal. It w as only in 2014, that the General Dental Council changed its gu id ance for d entists. Their statem ent id enti ed that d entists cou ld bleach child ren’s d iseased teeth w ithout fear of d iscip linary action. It is alw ays sensible to check w ith you r d ental d efence organization on the latest p osition. N o matter w hich treatment op tion you choose, you r d iscu ssions w ith the p arents need to be record ed in the patient’s clinical record s and w ritten consent taken. ■ Has blea ching o teeth any part to play in the treatment o sur ace enamel discoloration? Yes, external vital bleaching has been u sed as an initial treatm ent for u orotic m ottling and as a second ary treatm ent for resid ual brow n staining after m icroabrasion. It is, how ever, usually associated w ith the bleaching of the yellow d iscoloration of ageing – so-called ‘nightgu ard vital bleaching’. This technique involves the d aily p lacem ent of 10% carbam id e p eroxid e gel into a cu stom - tted tray of either the up per or the low er arch. As the nam e su ggests it is carried ou t by the p atient at hom e and is initially d one on a d aily basis. Materials: • Upper impression and working model. • So t mouthguard avoiding the gingivae. • 10% carbamide peroxide gel. Techniqu e: 1. Take an alginate impression o the arch to be treated and cast a working model in stone. 2. Relieve the labial sur aces o the teeth by about 0.5 mm and make a so t, pull-down, vacuum- ormed splint as a mouthguard. The splint should be no more than 2 mm in thickness and should not cover the gingivae. It is only a vehicle or the bleaching gel and not intended to protect the gingivae. 3. Instruct the patient on how to f oss the teeth thoroughly. Per orm a ull mouth prophylaxis and instruct them how to apply the gel into the mouthguard. 4. Note that the length o time the guard should be worn depends on the product used. 5. Review about 2 weeks later to check that the patient is not experiencing any sensitivity, and then at 6 weeks, by which time 80% o any colour change should have occurred. Sensitivity occurs in almost all patients, and reducing the duration o mouthguard wear is e ective at minimizing symptoms. However, around 14% may stop this technique owing to the sensitivity it causes. Carbam id e p eroxid e gel (10%) breaks d ow n in the m ou th into 3.4% hyd rogen p eroxid e and 7% urea. Both u rea and hyd rogen p eroxid e have low m olecu lar w eights, w hich 36 allow them to d iffu se rap id ly throu gh enam el and d entine and thus explains the transient pu lp al sensitivity occasionally exp erienced w ith hom e bleaching system s. Pulpal histology w ith regard to these m aterials has not been assessed , bu t no clinical signi cance has been attribu ted to the changes seen w ith 35% hyd rogen peroxid e over 75 years of usage, except w here teeth have been overheated or trau m atized . By extrapolation, 3.4% hyd rogen peroxid e in the hom e system s is therefore safe. Althou gh m ost carbamid e peroxid e m aterials contain trace am ounts of p hosphoric and citric acid s as stabilizers and p reservatives, no ind ication of etching or a signi cant change in the su rface m orp hology of enam el has been d em onstrated by scanning electron m icroscopy analysis. There w as early concern that bleaching solutions w ith a low p H w ou ld cau se d em ineralization of enam el w hen the pH fell below the ‘critical’ p H of 5.2–5.8. H ow ever, no evid ence of this process has been noted to d ate in any clinical trials or laboratory tests, and this m ay be d ue to the u rea (and subsequ ently the am m onia) and carbon d ioxid e released on d egrad ation of the carbam id e p eroxid e elevating the p H . There is an initial d ecrease in bond strength of enam el to com p osite resin im m ed iately after hom e bleaching, bu t this retu rns to norm al w ithin 7 d ays. This effect has been attribu ted to the resid ual oxygen in the bleached tooth surface, w hich inhibits p olym erization of the com posite resin. The hom e bleaching system s d o not affect the colou r of restorative m aterials. Any perceived effect is p robably d ue to super cial cleansing. Minor u lceration or irritation m ay occu r d u ring the initial treatm ent. It is im p ortant to check that the m ou thgu ard d oes not extend on to the gingivae and that the ed ges of the gu ard are sm ooth. If u lceration persists, a d ecreased exposu re time m ay be necessary. If there is still a problem then allergy is a possibility. The exact mechanism of bleaching is u nknow n. Theories of oxid ation, photo-oxid ation and ion exchange have been su ggested . Conversely, the cau se of red iscoloration is also u nknow n. This m ay be a com bination of chem ical red u ction of the oxid ation p rod ucts previou sly formed , m arginal leakage of restorations allow ing ingress of bacterial and chem ical byp rod ucts, and salivary or tissu e uid contam ination via p erm eable tooth stru ctu re. ■ Wha t are the indica tions or composite veneers? Com p osite veneers m ay be requ ired to m ask d ense w hite u orotic p laqu es that are refractory to m icroabrasion and bleaching. Most com p osite veneers p laced in child ren and ad olescents are the d irect type fashioned at the chairsid e rather than the ind irect or laboratory-m ad e typ e. Before p roceed ing w ith any veneering techniqu e, the d ecision m u st be m ad e w hether to red u ce the thickness of labial enam el before placing the veneer. Certain factors should be consid ered : • Increased labiopalatal bulk makes it harder to maintain good oral hygiene. This may be courting disaster in the adolescent with a dubious oral hygiene technique. • Composite resin has a better bond strength to enamel when the sur ace layer o 200 300 µm is removed. 36 • 198 MOTTLEDTEETH • I a tooth is very discoloured, some sort o reduction will be desirable, as a thicker layer o composite will be required to mask the intense stain. • I a tooth is already instanding or rotated, its appearance can be enhanced by a thicker labial veneer. N ew generation, highly p olishable, hybrid com posite resins can replace relatively large am ou nts of m issing tooth tissu e and be u sed in thin sections as a veneer. Com binations of shad es can be u sed to sim ulate natu ral colour grad ations and hu es. Within these system s, op aqu ers can be very u sefu l at blocking ou t the transm ission of the d iscolou red enam el d efect throu gh the com p osite. Ind ications for com posite veneers: • Discoloration. • Enamel de ects. • Diastemata. • Malpositioned teeth. • Large restorations. Contraind ications: • Insu cient available enamel or bonding. • Oral habits, e.g. woodwind musicians. ■ How do you undertake a composite veneer? The m aterials required are: • Rubber dam/contoured matrix strips. • Preparation and nishing burs. • New generation, highly polishable, hybrid composite resin. • So -Lex polishing discs and interproximal polishing strips. Technique: 1. Use a tapered diamond bur to reduce labial enamel by 0.3 0.5 mm. Identi y the nish line at the gingival margin and also mesially and distally just labial to the contact points. 2. Clean the tooth with a slurry o pumice in water. Wash and dry and select the shade. 3. Isolate the tooth either with rubber dam or a contoured matrix strip. Hold the latter in place by applying un lled resin to its gingival side against the gingiva and curing or 10 seconds. 4. Etch the enamel or 60 seconds, wash and dry. 5. Where dentine is exposed, apply dentine primer. 6. Apply a thin layer o bonding resin to the labial sur ace and roughly shape it into all areas with a plastic instrument, then use a brush lubricated with un lled resin to ‘paddle’and smooth it into the desired shape. Cure or 60 seconds gingivally, 60 seconds mesioincisally, 60 seconds distoincisally, and 60 seconds rom the palatal aspect i incisal coverage has been used. Di erent shades o composite can be combined to achieve good matches with adjacent teeth and a transition rom a relatively dark gingival area to a lighter more translucent incisal region. For some darkly stained dentine, a thin layer o composite opaquer is an alternative to removing urther enamel and dentine. This is placed as the rst layer beneath the incremental composite build-up o di erent composite shades. 7. Flick away the un lled resin holding the contour strip and remove the strip. 8. Finish the margins with diamond nishing burs and interproximal strips and the labial sur ace with graded sandpaper discs. Characterization should be added to improve light ref ection properties. The exact d esign of the com posite veneer w ill d ep end on each clinical case, bu t w ill u su ally be one of fou r types: intra-enam el or w ind ow preparation; incisal bevel; overlapped incisal ed ge; or feathered incisal ed ge. Tooth preparation w ill not u su ally expose d entine, bu t this w ill be u navoid able in som e cases of localized hypoplasia or caries. Sou nd d entine m ay need to be covered by glass ionom er cem ent p rior to placem ent of the com posite veneer. Primary resources and recommended reading Bu rrow s S 2009 A review of the ef cacy of tooth bleaching. Dent Up d ate 36:537–538, 541–544, 547–548. Bu rrow s S 2009 A review of the safety of tooth bleaching. Dent Up d ate 36:604–606, 608–610, 612–614. Kilp atrick N M, Bu rbrid ge LA 2012 Anom alies of tooth form ation and eru p tion. In: Welbu ry RR, Duggal MS, H osey MT (ed s), Paed iatric Dentistry, 4th ed n. Oxford University Press, Oxford , p p . 174–198. Poyser N J, Kelleher MG, Briggs PF 2004 Managing d iscoloured non-vital teeth: the insid e/ ou tsid e bleaching techniqu e. Dent Up d ate 31:204–210, 213–214. For revision, see Mind Map 36, page 257. 37 ■ There are a signif cant number o syndromes o the head and neck tha t mani est with missing teeth. Can you name some? Ectodermal dysplasia. Cle t lip and/or palate. Down syndrome. Multiplemissingand abnormallyshapedteeth CASE1 SUMMARY Ellen is almost 11 years old. She is very concerned by the gaps between her upper and lower ront teeth. She is hoping to become an actress. She is a new patient to your surgery and has been brought by her mother. What are the causes o the problem, and how may it be treated? History Ellen is a regu lar attend er w ith no caries. H er oral hygiene is excellent. There is no history of tooth extraction in either the prim ary or perm anent d entitions. Medical history Ellen has no m ed ical p roblem s. She is an active girl w ho is involved in orienteering w ith her fam ily as w ell as particip ating in the local am ateu r d ram atic society. Chondro-ectodermal dysplasia (Ellis van Creveld syndrome). Reiger syndrome. Incontinentia pigmenti. Oro- acial-digital syndrome (types I and II). Ectodermal dysplasia d escribes a group of inherited d isord ers involving ectod erm ally d erived stru ctures, i.e. hair, teeth, nails, skin and sw eat gland s. The m ost com m on form is the hyp ohid rotic X-linked form . The usu al p resentation is a male child w ith: Multiple congenital absence o teeth. Fine, sparse hair with sha t abnormalities. Dry skin. Frontal bossing. Maxillary hypoplasia. Thin lips showing little vermilion margin. Heterozygous emales can be identi ed dentally with microdontia and hypodontia. Down syndrome affects 1 in 700 births, is com m oner in offsp ring of old er m others and is a resu lt of chrom osom al translocation. Ap art from the morphological featu res characteristic of the synd rome, there is com m only d elayed eru ption and generalized m icrod ontia, as w ell as hypod ontia of some teeth. The d iagnosis and m anagem ent of all d ental anom alies is extrem ely im p ortant and shou ld not be d elayed . Genetic consu ltation is often d esirable to not only con rm the d iagnosis bu t also to help p arents u nd erstand the risk of fu tu re offsp ring and generations being affected . Conversely, geneticists m ay requ ire help from p aed iatric d entists to clarify a d iagnosis. ■ What question do you need to a sk Ellen’s mother? Is there a fam ily history of m issing teeth or gaps? As you are sp eaking to Ellen’s m other you notice that she has a m issing u p p er right lateral incisor and the canine tooth is p rom inent. She con rm s your qu estion that not only has she got a missing tooth bu t her brother and her nep hew (son of her brother) have either m issing or very sm all u p p er lateral incisors. Key point Hypodontia: • Prevalence is 3.5 6.5% in permanent dentition (excepting third molar). • May be associated with a number o syndromes. • Requires interdisciplinary care. ■ How prevalent are missing teeth in the population? 0.1 0.9% in the primary dentition. 3.5 6.5% in the permanent dentition (discounting third molars). More common in emales than males (1.4 4×). The most common teeth to be absent are the last teeth in each series (i.e. lateral incisor, second premolar, third molar). The presence o a conical (peg) tooth is requently associated with a missing tooth on the opposite side o the arch. There is requently a amily history. ■ What a ctors would you consider important in the management o dental anomalies? Reassurance o child and parent. Elimination o pain. Prevention o caries and periodontal disease. Genetic counselling. Restoration o aesthetics. 37 • 200 MULTIPLEMISSINGANDABNORMALLYSHAPEDTEETH Provision o adequate unction. Maintenance o vertical dimension o occlusion. Interdisciplinary ormulation o de nitive treatment plan. • • Examination Extraoral Ellen had a norm al facial ap p earance w ith a Class 1 skeletal pattern. Intraoral The follow ing teeth w ere present: 6E D C B1 1 BC D E 6 D D w ere m obile. The other 6E 321 234E6 prim ary teeth w ere rm . The p rim ary m olars w ere infraocclu d ed . • Fixed appliance to close the upper median diastema; retain with a palatal bonded retainer. Poor prognosis B B. As the spaces are o concern to Ellen, consider extraction o B B and replacement with an upper partial denture with prosthetic 2 2. Alternative approaches include the extraction o the B B and the provision o resin retained cantilever bridges. Another short- to medium-term option is to build up the primary lateral incisors with composite. In adulthood there will be the option o implants to replace the missing maxillary and mandibular teeth. Hence the importance o interdisciplinary planning to ensure short-term solutions do not compromise long-term plans. CASE2 ■ Wha t special investigations are required? SUMMARY A d ental p anoram ic tom ogram (Fig. 37.1) to check on the presence/ absence of other p erm anent teeth. Cameron was 3 years old when his mother brought him to the surgery because she was concerned that two o his teeth were joined together (Fig. 37.2). What is the cause, and how may it be treated? ■ Wha t is visible rom the radiograph? 87532 234578 Absence of: . 8754 1 57 ■ Wha t is the condition known as? It is term ed severe hyp od ontia. This is d e ned as having six or more p erm anent teeth m issing, not inclu d ing the m issing w isd om teeth. ■ Wha t would you do? Take im p ressions and a w ax registration for stu d y m od els. Arrange a joint consultation w ith paed iatric d ental/ orthod ontic/ restorative colleagu es. Frequ ently these interd iscip linary team s d iscu ss the cases before they see the patient. Taking facial and intraoral view s as w ell as relevant and justi able rad iograp hs w ill all help at this p lanning m eeting. ■ What treatment is likely to be required? • • • Attempt to retain the primary molars or as long as possible. Management o in raoccluded primary molars (see Chapter 8). Assess mesiodistal width 11. Probable addition o composite to distal aspect o these teeth to achieve mesiodistal width o 8.5 9 mm. Fig. 37.1 Severe hypodontia. ( romMillett andWelbury(2000) with permission). Medical and dental history Cam eron is an active child w ith no m ed ical p roblem s. H e has no caries. ■ What can you see in Fig. 37.2? The crow ns of the u p p er central and lateral p rim ary incisors are joined together. A nu m ber of d ifferent term s have been u sed to d escribe the p rocess of the form ation of d ou ble teeth either on the p rim ary or perm anent d entitions: fu sion, gem ination, d ichotom y, synod ontia, schizod ontia and connation. The m od e of d evelop m ent given in old er textbooks for the d ifferent nam es are unclear and unproven. The neu tral term ‘d ou ble teeth’ is not contentious and d escribes accu rately w hat the tooth looks like clinically. ■ How prevalent do you think double teeth are? 0.5 1.6% in primary dentition. 0.1 0.2% in permanent teeth. No clear mendelian trait established. Fig. 37.2 Double incisor teeth. 201 • MULTIPLEMISSINGANDABNORMALLYSHAPEDTEETH 37 The clinical m anifestation of the anom aly m ay vary consid erably from a m inor notch in the incisal ed ge of an abnorm ally w id e incisor crow n to the ap p earance of tw o sep arate crow ns. There m ay be hard tissu e continu ity betw een either the crow ns or the roots of the tw o elements or betw een both. Sim ilarly there m ay be one u ni ed p u lp cham ber and rad icular p u lp or sep arate ones. In the prim ary d entition, d ou ble teeth m ore com m only occu r in the labial segm ents of the arches and m ost frequ ently in the m and ible. Double permanent teeth can occu r anyw here in the arch and frequ ently involve the incisor teeth. ■ What are the most important clinical aspects o a double tooth in the prima ry dentition? Caries m ay occu r in the ‘join’ betw een the tw o coronal elem ents if it is not easily accessible to a toothbru sh. This risk can be red u ced by ssu re sealing the groove if there is food stagnation, staining or enam el d ecalci cation. The p resence of a nu m erical abnorm ality of the perm anent d entition. Cou nting a d ou ble tooth as one u nit in the primary d entition, w ith relation to the total nu mber of teeth present, m ay be help fu l in p red icting the typ e of nu m erical abnorm ality of the p erm anent d entition. H ypod ontia is usually follow ed by m issing p ermanent teeth. A norm al number of teeth in the p rim ary d entition is often associated w ith p erm anent su p ernu m eraries. The overall frequency of perm anent nu m erical abnorm alities follow ing prim ary d ou ble teeth is betw een 30% and 50% in Caucasians and is 75% in the Jap anese p op u lation. Rad iograp hy is therefore im p ortant at an ap p rop riate time, so the p arent can be ad vised of fu tu re treatm ent and prognosis and a treatm ent p lan formu lated . Extraction of d ou ble p rim ary teeth m ay be necessary if p hysiological root resorp tion is signi cantly retard ed . Su rgical rem oval of su pernu m erary teeth m ay be requ ired to facilitate eru p tion of norm al u nits. Often treatm ent p lanning is m ost ap prop riately u nd ertaken w ithin an interd iscip linary team . Key point Double primary teeth may: • Be associated with numerical abnormalities o the permanent dentition. • Be a caries risk. • Not undergo normal physiological resorption. Fig. 37.3 Talon cusp. ■ What other types o crown abnormalities do you know? Accessory cusps. Invaginations. Evaginations. Ad d itional p rim ary cu sp s are seen on the m esiobu ccal aspect of maxillary rst m olars and the m esiop alatal asp ect of maxillary second m olars. The com m onest ad d itional cusp in perm anent teeth is often on the lingual cingulu m , m ore com m only in the m axilla than the m and ible. The nam e ‘talon cu sp’ is often given to the ad d itional cu sp (Fig. 37.3). The cu sp is com posed of enam el, d entine and a horn of p ulp tissu e. Talons in maxillary anterior teeth su ch as that show n in Fig. 37.3 can cau se a nu m ber of p roblem s: Appearance. Occlusal inter erence. Caries in the deep grooves between the cusp and the tooth. The com m onest accessory cu sp in the perm anent d entition is the m esiopalatal sited tu bercle of Carabelli on the m axillary rst m olar (10–60%). ■ Wha t are the treatment options or a talon cusp on a maxillary tooth? Selective grinding o cusp to encourage obliteration o the pulp horn by secondary dentine. Aseptic removal o the cusp under rubber dam ollowed by a limited pulpotomy procedure (immature or mature root). Aseptic removal o cusp and one-stage endodontic treatment (mature root). ■ What are the important actors tha t will dictate whether you retain or extract double permanent teeth? Space in the arch. Aesthetics. Morphology o pulp chambers and roots. If the coronal parts of the d ou ble teeth are joined bu t the roots are sep arate, then it m ay be feasible to d ivid e the crow n and extract one p ortion of the crow n and its root, thereby retaining the other portion of the crow n w ith its root. The retained p ortion w ill requ ire root canal treatm ent and su bsequ ent coronal restoration. Failure of a pu lp otomy techniqu e in an im m atu re tooth w ill resu lt in the need for ind u ced ap ical closu re w ith Mineral Trioxid e Aggregate. Many clinicians favou r w aiting u ntil fu ll root form ation has occu rred p rior to rem oval of the cu sp. Invaginations or invagination of the enam el ep ithelium into the d ental papilla of the u nd erlying tooth germ has been d escribed as ‘d ens in d ente’, ‘gestant com posite od ontome’ and ‘d ilated com posite od ontom e’. The correct d escriptive term is ‘d ens invaginatus’ or ‘invaginated tooth’. The anom aly m ay vary clinically from a d eep cingulum pit in a tooth of norm al form (Fig. 37.4) to a tooth w ith grossly d istorted crow n and root. Invaginated teeth are relatively 37 • 202 MULTIPLEMISSINGANDABNORMALLYSHAPEDTEETH Evaginations consist of enam el, d entine and a pu lp al extension. Evagination shou ld be su sp ected if a prem olar w ithou t caries d evelop s a p eriap ical lesion shortly after eruption. Treatm ent is the same as ‘talon cu sp’. ■ What abnormalities o root orm do you know? Taurodontism. Accessory roots. Pyramidal roots. Tau rod ontism (bull-like teeth) ap plies to m u ltirooted teeth in w hich the bod y of the tooth is enlarged coronoapically at the exp ense of the roots. Rad iographs show apparent enlargem ent of the coronal p u lp cham ber, u su ally extend ing below the level of the alveolar crest before root d ivision. The norm al constriction at the level of the am elocem ental ju nction is frequ ently absent in affected teeth. The cond ition is uncom m on in p rim ary teeth but m ay occu r in perm anent m olars in 6% of the p op u lation. Fig. 37.4 Dens in dente o lateral incisor. ■ What conditions ma y taurodontism be associated with? Amelogenesis imper ecta. com m on, occurring in 1–5% of p erm anent teeth. Prim ary invaginations are rare. The m ain p roblem w ith invaginations is infection. The enam el lining of the invagination is either incom p lete or very thin and easily breached , resu lting in d entinal caries that qu ickly progresses to involve the pu lp cau sing a rapid ly spread ing infection presenting w ith acu te facial cellu litis or acu te d entoalveolar abscess. Rarely a large invaginated tooth m ay cause im paction and non-eru ption of an ad jacent tooth. There is an association betw een invaginated teeth and supernu m erary teeth. A fu ll rad iograp hic exam ination is ju sti ed if an invaginated tooth is id enti ed . Invaginations in crow ns of norm al m orphology should be sealed prop hylactically as soon as p ossible after eru ption. If these ‘high’ invaginations d o become pu lpally involved then root treatm ent is p ossible, becau se the invaginated portion is accessible and can be rem oved w ith a crow n bu r allow ing access to the norm al root canal. All other invaginations u su ally requ ire extraction ow ing to their com p lex root m orp hology. ‘Evaginated teeth’ or ‘d ens evaginatus’ or ‘tu bercu lated teeth’ occu rs com m only as a conical tu bercu lar p rojection arising from the occlu sal su rface of the central ssu re or the lingual p lane of the bu ccal cu sp . Prem olar teeth are the com m onest teeth affected , w ith p erm anent m olars and canines less com m only affected . The cond ition is m ainly seen in people of Mongolian race (1–4%), althou gh rarely it is seen in Cau casians. Trichodento-osseous syndrome. Ectodermal dysplasia with hypodontia. Ellis van Creveld syndrome. Achondroplasia. Kline elter syndrome. Accessory roots can occu r in alm ost any tooth. Rarely they m ay be d ue to early traum a to a form ing root. The m ajority are likely to be d u e to genetic factors that rem ain to be speci ed . Pyram id al roots d escribe the red uction in root nu m ber in m ultirooted teeth. Any molar tooth m ay be affected . Primary resources and recommended reading H olid ay R, Lu sh N , Chap ple J et al 2014 Aesthetics and fu nction p art 2: m anagem ent. Dent Upd ate 41:891–898. Lu sh N , H ollid ay R, Chap ple J et al 2014 H ypod ontia: aesthetics and fu nctions p art 1: aetiology and the p roblem s. Dent Up d ate 41:811–815. Millett D, Welbu ry R 2000 Orthod ontics and Paed iatric Dentistry: Colou r Gu id e. Chu rchill Livingstone, Ed inbu rgh. Tahm assebi JF, Day PF, Tou m ba KJ et al 2003 Paed iatric d entistry in the new m illenniu m : 6. Dental anom alies in child ren. Dent Up d ate 30:534–540. For revision, see Mind Map 37, page 258. 38 Amelogenesis imper ecta either hypop lasia, d ue to d e cient m atrix prod u ction, or hypom ineralization, from im perfect m ineralization of the m atrix proteins. In hyp op lasia the enam el m ay be thin, grooved or p itted , w hereas in hyp om ineralization it m ay ap pear m ottled bu t of norm al thickness. The com p lete range of cau ses of d evelopm ental abnorm alities of enam el are show n in Box 38.1. Enam el d efects of genetic origin m ay occu r either as a p henom enon p rim arily involving the enam el, w ith p ossible second ary effects in other d ental tissues (su ch as d elayed eru p tion, anterior op en bite, id op athetic resorption) and craniofacial stru ctures (eye or hearing anom alies), or as a com p onent of a m ore com p lex synd rom e in w hich d efective enam el is only one of a num ber of m ore generalized abnorm alities. Medical history SUMMARY Mark is 10 years old. He and his parents are concerned because his teeth seem rough. They also stain easily. What is the cause o these problems? What treatment is possible? ■ Wha t ca n you see in Fig. 38.1? All erup ted teeth have pitted hypoplastic enam el. History Mark has no m ed ical p roblem s. H e is d oing very w ell at school and is a keen basketball player. Examination Intraoral exam ination revealed that all the su rfaces of all the eru p ted p erm anent teeth are affected by a rou ghness or ‘p itting’ (Fig. 38.1). The second prim ary m olar teeth that are still p resent have a sim ilar roughness that, although not as evid ent on visu al exam ination, w as obviou s on tactile exam ination w ith a probe. There w as no tooth w ear. ■ Why is this pattern o enamel hypopla sia unlikely to be caused by systemic (chronological) in uences? Mark’s m other says that she noticed w hen the teeth rst erupted that they w ere rough. They picked up stain and w ere d if cult to clean. What key questions do you need to ask? Primary and permanent teeth all a ected. ■ Was there any systemic illness rom birth to early Positive amily history. childhood? N o. ■ Were the primary teeth similarly a ected? There w as a slight rou ghening of the prim ary teeth, althou gh not as bad ly affected as the p erm anent teeth. All the enamel sur ace o the teeth is a ected. Am elogenesis im p erfecta (AI) occu rs as a resu lt of gene m u tations that follow au tosom al-d om inant, au tosom alrecessive or X-linked patterns of inheritance. The prevalence varies arou nd the w orld w ith rates of 1 in 718 in northern Sw ed en and 1 in 14 000 in Michigan, USA. A global qu oted gu re is often 1 in 10 000. ■ Is anyone else in the amily similarly a ected? Mark’s father and his cou sin (father ’s brother ’s son) have similar rou ghness of their teeth. After obtaining this history it is m ost likely that Mark has an inherited enam el d efect involving enam el – am elogenesis im p erfecta. H ow ever, d efective enam el form ation m ay be cau sed by genetic or environm ental factors. The d efective enam el w ill exhibit Box 38.1 Di erential diagnosis o enamel de ects General actors • Genetic: • Primarily involving enamel – amelogenesis imper ecta. • Associated with generalized de ects. • Systemic (chronological): • Nutritional defciencies. • Metabolic or biochemical disorder. • Toxic substances. • In ectious illnesses: pre-natal; peri-natal; neonatal; in ancy; earlychildhood (see Chapter 34). • Excess Fluoride ingestion (see Chapter 36). • Idiopathic. Local actors • Trauma. Fig. 38.1 Hypoplastic amelogenesis imper ecta. • In ection. 38 • 204 AMELOGENESISIMPERFECTA Table 38.1 Treatment modalities or amelogenesis imper ecta Restoration Aesthetics Primarydentition: 0–5 years Adhesive restorations Minimal intervention Stainless steel crowns (SSCs) especiallyon E’s Composite veneers Mixed dentition: 6–16 years Adhesive restorations/SSCs on primarymolars Composite veneers SSCs/adhesive castings on permanent molars Fig. 38.2 Hypomineralized amelogenesis imper ecta. Permanent dentition: 16+ years Adhesive castings on premolars Porcelain veneers Full mouth rehabilitation ± crown lengthening Full crowns ■ Wha t are the main types o AI? • Hypoplastic. • Hypomineralized: hypocalci ed or hypomature. • Mixed pattern o both types. Althou gh historically, p hysiological categories of d ifferent typ es of AI w ere d escribed , there is grow ing realization the classi cations related to the genetic m utation are m ore approp riate. Consequ ently, rad iograp hic and clinical phenotyp es shou ld sim p ly d escribe their ap p earance (for exam p le, hypop lastic, hyp om ineralized ). A good d iagnostic gu id e is to exam ine rad iographs for u nerupted teeth to id entify the qu antity of enam el visible and the d ifferentiation betw een the enam el and d entine (e.g. the qu ality of m ineralization). Affected teeth, once eru pted into the m ou th, can qu ickly p ick u p p igmentation (for exam p le, change colou r from cream y to brow n), and the enam el su rface can break d ow n (giving the im p ression of being hypoplastic w hen it w as originally hyp om ineralized ). With a better u nd erstand ing of the genetic m u tations, the p athw ays through w hich these genes in u ence enam el form ation is slow ly being u nd erstood . Genetic enam el d efects can be associated w ith generalized d isord ers in a nu m ber of u ncom mon or rare genetically d eterm ined d iseases and clinical synd rom es. These d iseases and com plex synd rom es inclu d e ep id erm olysis bu llosa, tuberous sclerosis, pseudohypoparathyroidism, trichodentoosseous synd rom e, ocu lod ento-osseou s d ysp lasia, vitam in D-d ep end ent rickets, amelo-cerebrohyp ohid rotic synd rom e, amelo-onychohypohid rotic synd rom e and som e types of m u cop olysaccharid osis. Mark has a rou gh, hypop lastic typ e of AI. An exam ple of a hyp om inerliazed form of AI is show n in Fig. 38.2. Investigations ■ Wha t investigations are necessa ry? Dental panoramic tomogram This w ill con rm the p resence of all the perm anent d entition. In ad d ition, it w ill d iagnose any tau rod ontism w hich is associated w ith som e typ es of AI. Family examination If it is possible to examine Mark’s father ’s and his cou sin’s teeth, this w ill help to con rm you r d iagnosis. Re erral or genetic testing In the UK testing for d ifferent genetic types of AI is now available for N H S patients. Treatment The treatm ent of both am elogenesis and d entinogenesis im perfecta requires early d iagnosis in ord er to im prove the long-term p rognosis of teeth. Parents need to be ed u cated as to the im p lications of the cond ition, and prevention (d iet cou nselling, uorid e su pp lementation, oral hygiene instru ction (OH I)) is a cru cial elem ent in the su ccess of any restorative treatm ent. There are fou r m ain clinical problem s associated w ith inherited enam el and d entine d efects: • Poor aesthetics. • Chipping and attrition o the enamel. • Exposure and attrition o the dentine causing sensitivity. • Poor oral hygiene, gingivitis, calculus and caries. Long-term treatm ent need s – this m eans that treatm ent shou ld aim to m inim ize treatm ent in child hood to red u ce bu rn out and p otential d ental anxiety. Althou gh it is im p ossible to d raw up a d e nitive treatm ent p lan for all cases, it is p ossible to d e ne the p rinciples of treatm ent p lanning for this group of patients. It is im portant to realize that not all child ren w ith am elogenesis im p erfecta or d entinogenesis im perfecta are affected equally. Many w ill not have m arked tooth w ear or sym p tom s and w ill not requ ire ad vanced intervention. Table 38.1 d escribes the p rincip les of treatm ent in term s of the age of the child / ad olescent and w ith regard to the three aspects of care: prevention, restoration and aesthetics. Clinicians m u st be very aw are of the im p act that AI can have on the affected child and the w id er fam ily. The poor app earance of som e typ es of AI, especially those w ith brow n staining, can have a signi cant im pact on child ren, especially w hen starting at a new school and m aking new friend s. The im pact is not lim ited to child ren bu t also affects their fam ilies w ho need to take tim e off w ork to bring them to appointm ents and m ay experience possible guilt associated w ith genetic cond itions. For a few ad u lts w ith AI, the negative im pact of their teeth has led them to conclu d e that they d o not w ant child ren in case they are also affected . 205 • AMELOGENESISIMPERFECTA Key point Main treatment aims or dental anomalies: • To alleviate symptoms. • To maintain/restore occlusal height. • To improve aesthetics. • Try to maintain a positive dental attitude, prevent and minimize the likelihood o dental anxiety. be rep laced in ad olescence/ early ad ulthood by a porcelainbond ed full crow n (Table 38.1). A rand om ized controlled trial rep orting on the bene ts and longevity of tw o d ifferent types of conventional crow ns has recently been pu blished show ing good ef cacy for tw o types of crow n placed in ad olescence and early ad u lthood . Primary resources and recommended reading Am erican Acad em y of Ped iatric Dentistry 2013 Gu id eline on d ental m anagem ent of heritable d ental d evelopm ental anom alies. Reference Manu al 37 (6):266–271. Mark’s m ajor concern w as the staining and rou ghness of his front teeth. Fortu nately there w as no w ear of his posterior teeth and his p roblem, therefore, w as solely a cosmetic one. The pitting or hypop lasia on the upp er and low er incisors can be m asked by a thin, d irectly applied comp osite veneer. This shou ld be extend ed to inclu d e the canines and rst p rem olars w hen the arches are com p lete. On occasions, if the sm ile is a very ‘w id e’ one, it m ay be necessary to inclu d e second p rem olars. Com posite veneers can be rep laced by p orcelain veneers w hen the gingival contou r has m atu red in late ad olescence or early tw enties. If the am elogenesis had been of the hyp om ineralized variety w ith m ore d estru ction of enam el, it m ay have been necessary to consid er fu ll com p osite crow ns for aesthetics in the anterior teeth and either stainless steel crow ns or ad hesive castings on the p osterior teeth. These w ill need to McDonald S, Arku tu N , Malik K et al 2012 Managing the p aed iatric p atient w ith am elogenesis im p erfecta. Br Dent J 212 (9):425–428. Parekh S, Alm ehateb M, Cu nningham SJ 2014 H ow d o child ren w ith am elogenesis im p erfecta feel abou t their teeth? Int J Paed iatr Dent 24 (5):326–335. Pou sette Lu nd gren G, Morling Vestlu nd G, Tru lsson M et al 2015 A rand om ized controlled trial of crow n therap y in young ind ivid u als w ith am elogenesis im p erfecta. J Dent Res 94 (8):1041–1047. Seow WK 2014 Develop m ental d efects of enam el and d entine: challenges for basic science research and clinical m anagem ent. Au st Dent J 59 (Su p p l. 1):143–154. For revision, see Mind Map 38, page 259. 38 39 Dentinogenesis imper ecta ■ What investiga tions do you need to do to conf rm your suspicions? Dental panoramic tomogram If this is DI, the d ental panoramic rad iograph w ill p robably show the follow ing: • Bulbous crowns with pronounced cervical constriction. • Shortened roots. • Progressive pulp chamber and canal obliteration (Fig. 39.2 (di erent case)). • Spontaneous periapical abscess ormation. SUMMARY Siobhan is 9 years old. She and her parents are concerned because her permanent teeth are darker than normal and she is getting teased at school. What is the cause o the discoloration? How would you treat it? A History Siobhan’s m other says she noticed that w hen the perm anent teeth eru pted they looked d arker. Siobhan is very u nhapp y at school and refu ses to sm ile for any photograp hs. When she talks she has the habit of covering her mouth w ith a hand so it is imp ossible to see her teeth. What can you see in Fig. 39.1A? What key qu estions d o you need to ask? ■ Was there any systemic illness rom birth until early childhood? N o. Siobhan had no illness. ■ Were the primary teeth similarly a ected? The p rim ary teeth eru pted normally but very qu ickly chip ped aw ay, becom ing w orn to gu m level (see Fig. 39.1B). ■ Is anyone else in the a mily similarly a ected? B Fig. 39.1 (A) Dentinogenesis imper ecta. (B) Dentinogenesis imper ecta. Siobhan’s brother and her father have a problem w ith their teeth. Siobhan’s brother is 14, and he has need ed crow ns on his back teeth and veneers on his front teeth. Siobhan’s father need ed a lot of treatm ent w hen he w as you nger and has had som e teeth crow ned . Many of his p osterior teeth, how ever, w ere extracted . Even before you have exam ined the m ou th, the history suggests that Siobhan has an inherited d efect. Fig. 39.1A con rm s you r su sp icion that this is d entinogenesis imp erfecta (DI). ■ Why is this DI and not amelogenesis imper ecta (AI)? The teeth are translucent. The enam el is poorly ad herent to the u nd erlying d entine and easily chip s and w ears. The rem aining p rim ary canines and m olars in Figs 39.1A and B are w orn to gingival level and have a translu cent op alescent ap p earance. Fig. 39.2 Obliteration o root canals and pulp chambers in dentinogenesis imper ecta. 207 • DENTINOGENESISIMPERFECTA Box 39.1 Hereditary dentine de ects • Limited to the dentine • Dentinogenesis imper ecta type II (hereditaryopalescent dentine). • Dentine dysplasia type I (radicular dentine dysplasia). • Dentine dysplasia type II (coronal dentine dysplasia). • Fibrous dysplasia o dentine. Associated with generalized disorder • Osteogenesis imper ecta (dentinogenesis imper ecta type I). • Ehlers-Danlos syndrome. • Brachioskeletogenital syndrome. • Vitamin Dresistant rickets. • Vitamin Ddependent rickets. • Hypophosphatasia. Family examination • • Family examination o a ected members. Dentine de ects like those o enamel may be subdivided by cause into two main groups based on whether they are o genetic or environmental origin. • Dentine anomalies that are genetically determined may appear to be limited to the dentition or orm part o a more complex generalized disorder (Box 39.1). The m ost w ell d ocu m ented hered itary d entine d efects are DI type II (hered itary op alescent d entine), w hich only affects teeth, and DI typ e I, in w hich abnorm alities of teeth are associated w ith osteogenesis im p erfecta. DI type II Both d entitions are u su ally affected . The severity of the d efect varies consid erably betw een fam ilies and w ithin fam ilies. Prim ary teeth tend to be m ore severely affected than perm anent teeth, and the later form ing p erm anent teeth m ay be the least affected . Enam el tend s to chip aw ay from the u nd erlying am elod entinal ju nction (ADJ), exposing the abnorm ally soft d entine that u nd ergoes rap id w ear. This is m ost m arked in the p rim ary d entition w here, w ithin 2 years, the crow ns m ay be w orn to the gingival m argin and ap p ear as am ber-colou red rem nants (Fig. 39.1B), w hich m ay be frequ ently infected and abscessed . In the p erm anent d entition, follow ing eru p tion, the enam el m ay look reasonably norm al, bu t histological stu d ies have show n hyp om ineralized areas in ap p roxim ately one-third of cases. Rad iograp hic signs are d escribed previou sly. H istologically, the ADJ m ay ap p ear attened , and w hile the su bad jacent p erip heral d entine m ay ap p roach normality, the rem aind er is grossly d isord ered w ith an am orp hous m atrix containing areas of interglobular calci cation, abnorm ally shap ed and sized tu bu les and cellu lar inclu sions. ■ Is DI more preva lent than AI? Possibly, 1:10 000). • Shell teeth. This is rare and seen in the primary dentition. The pulp remains large and the thin enamel and dentine rapidly ragments to cause pulpal in ection. DI type III (brandy wine type). This was rst described in Maryland, USA, and has been traced back to East Anglia in England. It was apparently taken to the USA by one o the sailors who accompanied the Pilgrim Fathers to Maryland. Type III de ect has been linked to the same locus on chromosome 4q21 as DI type II. DI type I associated with osteogenesis imper ecta Osteogenesis im perfecta is a grou p of connective tissu e d isord ers involving inherited abnorm alities of typ e I collagen. Increased bone fragility is only one aspect of the cond ition w hich m ay includ e lax joints, blue sclerae, opalescent teeth, hearing loss and a variable d egree of bone d eform ity. The inheritance p attern is either au tosom al recessive or d om inant. The recessive form is often lethal arou nd birth. Opalescent teeth are only rarely seen in surviving recessive types. They are com m only a featu re of the d om inant variety w ith accom p anying bone fragility, bone d eform ity and blu e sclerae. Ow ing to the bone fragility, frequently child ren w ith osteogenesis im p erfecta are treated w ith bisphosp honates. In ad u lts bisp hosphonates, esp ecially those given intravenou sly, are associated w ith osteonecrosis. Although no cases of osteonecrosis have been reported in child ren, great care, thought and interd isciplinary w orking w ith m ed ical colleagu es is requ ired w hen m anaging these com p lex child ren (see Chapter 28). The prim ary teeth in DI type I resem ble exactly those in DI typ e II. H ow ever, in the perm anent d entition the d efect is extrem ely variable. In m any cases the u pp er anterior teeth m ay have a norm al colour and app earance, w hereas the low er incisors and canines are opalescent, d iscoloured bluish-brow n and w ear at the incisal ed ges. In m ost cases the enam el d oes not chip aw ay from the und erlying d entine as read ily as in typ e II. Rad iographic appearances are as alread y d escribed w ith the excep tion that u pper teeth m ay retain their pu lp spaces long after those in the low er jaw. H istological app earances are ind istingu ishable from type II. Environm entally d eterm ined d entine d efects d o exist bu t are less w ell d ocu m ented than correspond ing anom alies of enam el: trau m a, nu tritional d e ciencies (m inerals, proteins and vitam ins) and d ru gs (tetracycline, chem otherapeu tic agents – cyclophospham id e) w ill likely prod u ce increased interglobular d entine, p red entine and osteoid . Key point Dentinogenesis imper ecta: • Occurs in 1 in 8000 o the population. • May be associated with osteogenesis imper ecta. gu res of 1 in 8000 have been estim ated (AI ■ Has DI got as many inheritance patterns as AI? N o. Invariably it is au tosomal d om inant w ith m arked expressivity and good p enetrance. Tw o clinical variants of the cond ition have been d escribed : 39 Treatment The m ain clinical problems associated w ith AI and DI and the key points of treatm ent objectives are covered in Chapter 38. The princip les of treatm ent for DI are the sam e 39 • 208 DENTINOGENESISIMPERFECTA as those for AI w ith the excep tion that in the p ermanent d entition from age 16, crow n-lengthening p roced u res are m ore com m on in DI and the p rovision of overd entu res and fu ll d entu res is not u ncom m on. The role of imp lants in these patients has yet to be d e ned . Siobhan’s m ajor concern w as of the colour of her perm anent incisors. There w as som e w ear of rst p erm anent m olars. The rst p erm anent m olars w ere treated w ith ad hesive castings w ith m icrom echanical retention to lu ting cem ent (Fig. 39.1B). The u p per and low er incisors w ere veneered w ith com p osite resin. This can be extend ed to inclu d e the canines and p rem olars w hen the arches are com plete. The com p osite veneers can be rep laced by p orcelain veneers around the age of 18 years. You ng child ren w ith DI often pose the greatest p roblem s. The p rim ary teeth und ergo su ch excessive w ear that they becom e w orn d ow n to the gingival level and are unrestorable. Teeth affected by DI are also prone to sp ontaneous abscesses d u e to the p rogressive obliteration of the pu lp cham bers. In these cases p u lp therapy is often u nsu ccessful and extraction of the affected teeth is necessary. Early consu ltation w ith an orthod ontist is ad visable in inherited abnorm alities of enam el and d entine in ord er to keep the orthod ontic requ irem ents sim ple. Treatm ent for these p atients is possible and in m any cases proceed s w ithou t p roblem s. The u se of rem ovable ap p liances, w here ap propriate, and orthod ontic band s rather than brackets w ill m inimize the risk of d am age to the abnorm al enam el. The p roblem is tw ofold : there m ay be frequ ent bond failu re d u ring active treatm ent or the enam el m ay be fu rther d am aged d uring d ebond ing. Som e orthod ontists prefer to use band s even for anterior teeth, w hile others w ill use glass ionom er cem ent as the bond ing agent in p reference to m ore conventional resin-based agents. In other instances, cosm etic restorative techniqu es (veneers and crow ns) m ay be m ore ap p rop riate than orthod ontic treatm ent. Primary resources and recommended reading Am erican Acad em y of Ped iatric Dentistry 2014/ 2015 Gu id eline on d ental m anagem ent of heritable d ental d evelopm ental anom alies. Reference Manu al 36 (6):264–269. Barron MJ, McDonnell ST, Mackie I et al 2008 H ered itary d entine d isord ers: d entinogenesis im p erfecta and d entine d ysplasia. Orp hanet J Rare Dis 20 (3):31. Dhaliw al H , McKaig S 2010 Dentinogenesis im p erfecta—clinical p resentation and m anagem ent. Dent Up d ate 37 (6):364–366, 369–371. For revision, see Mind Map 39, page 260. 40 Dental erosion su ch as titratable acid ity, the in uence of p laqu e pH and the buffering capacity of saliva w ill all in u ence the erosive p otential of a su bstrate. Fou r things, how ever, are clear w ith erosive loss: • It is worse i consumption is high. • It is worse i consumption occurs at bedtime. • It is worse i brushing occurs directly a ter consumption. • It is worse i children undertake swishing or holding habits when drinking. History Tom ’s only com p laint w as occasional sensitivity on his back teeth as a result of the visible d entine. ■ Wha t is the best way to f nd out about Tom’s diet? A 4-d ay w ritten d ietary history is the only w ay to accurately elu cid ate constitu ents of the d iet that m ay be erosive. SUMMARY Tom is 9 years old. He is a new patient to your practice. On examination you are concerned by the appearance o the occlusal sur aces o his lower primary molars. What has caused this, and how may it be managed? ■ What do you see in Fig. 40.1? There is erosion of the cu sp s of Tom ’s p rim ary m olars giving cu pp ing or p erim olysis of the cu sp s w ith loss of enam el and visible u nd erlying d entine. ■ How would you def ne erosion? An irreversible loss of tooth su bstance brou ght about by a chem ical p rocess that d oes not involve bacterial action. ■ What oods and drinks have erosive potential? See Box 40.1. While a w id e range of food and d rinks is implicated in the p roblem , the bu lk of the d am age is d one by soft d rinks, especially carbonated d rinks, w hich are increasingly available from vend ing m achines in schools and recreational facilities. All carbonated d rinks and fru itbased d rinks have low ered pH valu es, bu t the d irect relationship betw een p H and erosion is u nclear. Other factors ■ Ca n the pattern o erosion caused by dietary constituents be rela ted to the manner in which the substrate is consumed? This is ind eed the case. ‘Frothing’ of a d rink betw een the u pper anterior teeth w ith its retention labially can lead to palatal, interproximal and labial erosion. Retention of a d rink sp eci cally on one sid e of the m ou th can lead to erosion on that sid e only. ■ You have covered Tom’s dietary history. Is your history now complete, or a re there other questions you need to ask with relation to erosion? It is very im portant to consid er gastric acid as a cau se of erosion, even in a you nger patient. The cond itions in child ren that are associated w ith chronic regu rgitation are show n in Box 40.2. The acid ity of the stom ach contents is below pH 1.0 and therefore any regu rgitation or vom iting is d am aging to the teeth. ■ Wha t question would you ask to give you an indication that regurgitation was occurring? ‘Do you ever have a bitter taste in your m ou th?’ There is a group of patients w ho have gastro-oesophageal re ux d isease (GORD). This m ay be either sym p tomatic, in w hich the ind ivid u al know s w hat provokes the re u x, or m ore insid iously, asym ptom atic GORD, w here the p atient is u naw are of the p roblem . The latter case is m ost likely to occur at night w hen the horizontal sleeping p osition m akes it m ore likely that acid w ill re u x throu gh the low er Box 40.1 Foods and drinks with erosive potential • Citrus ruits, e.g. lemons, oranges, grape ruits. • Tart apples. • Vinegar, pickles, ketchup and brown sauce. • Yoghurt. • All ruit juices, including resh juice and ruit-based squashes. • Carbonated drinks, including low-calorie varieties, ‘sports drinks’and sparkling mineral water. Fig. 40.1 Erosion o cusp tips o primary molars. • Vitamin Ctablets and iron preparations (some medication will cause a drymouth therebyexacerbating other causes). 40 • 210 DENTALEROSION Box 40.2 Conditions associated with chronic regurgitation in children ■ What advice would you give to Tom regarding his high • Gastrooesophageal re ux. It is critically imp ortant w hen d ealing w ith child ren and ad olescents not to be too d ogm atic in your ad vice, and it is u nrealistic to expect youngsters w ho have been brought u p w ith a high intake of carbonated beverages to stop altogether. They shou ld be ad vised to erad icate betw een-m eal zzy d rink consu m p tion bu t to have the zzy d rink w ith m eals and preferably to d rink it w ith a straw. The presence of food , and the extra saliva that is generated at m ealtim es, w ill help neu tralize the acid ity. In ad d ition, a straw w ill d ep osit the m ajority of the carbonated beverage beyond the teeth. Make su re that the betw een-m eal carbonated d rink is not su bstitu ted by som ething w ith a sim ilar erosive p otential, e.g. fresh fru it ju ice or a ju ice-based squash. Milk and w ater are the m ost ap p rop riate betw een-m eal d rinks. If either of these proves im possible, then an extrem ely w ell-d ilu ted ‘no ad d ed su gar ’ squ ash can be accepted . N o carbonated d rinks or fru it d rinks should be given last thing at night. Ad vocate the consu m p tion of a neu tral food im m ed iately after a m eal, e.g. cheese. • Oesophageal stricture. • Chronic respiratorydisease, e.g. asthma. • Disease o the liver/pancreas/biliary tree. • Over eeding. • Feeding problems/ ailure to thrive conditions. • Learning delay. • Anorexia. • Bulimia nervosa. • Cyclic vomiting syndrome. • Cerebral palsy. • Rumination. oesop hageal sp hincter. In this case the qu estion about a bitter taste in the m ou th shou ld have the suf x ‘w hen you w ake u p ’. ■ What is the common pa ttern o erosive loss when there is chronic gastric regurgitation? Initially there is erosion of the palatal su rfaces of the up per incisors, canines and prem olars. With time this extend s to the occlu sal and buccal surfaces of the low er m olars and prem olars. Whenever there is u nexp lained erosive loss, an eating d isord er should be su sp ected . There are three su ch d isord ers: anorexia nervosa; bulim ia nervosa; and ru m ination. The latter is a cond ition in w hich food is volu ntarily regu rgitated into the oral cavity and either expelled or sw allow ed again. ■ Is there a specif c pattern o erosive loss in recurrent vomiting? All tooth surfaces can be affected w ith the relative exception of the lingu al su rfaces of the low er teeth, w hich are p rotected by the tongu e and the saliva from the sublingu al papillae. intake o f zzy drinks? Management The m ost im p ortant asp ect of the m anagem ent of Tom ’s erosion w as early d iagnosis before there had been d am age to the p erm anent teeth, and su bsequently to establish the aetiology and elim inate the cau se. Key point Management o erosion: • Early diagnosis. • Establish aetiology. • Eliminate cause. • Monitor or urther tooth sur ace loss. ■ Wha t would you do i you suspect, a ter questioning Tom and his parents, that there may be asymptoma tic GORD? Referral to a p aed iatrician w ith an interest in gastrointestinal d isease w ou ld be ap p rop riate. The p aed iatrician w ill seek to elim inate organic d isease and then attem p t to qu antify the p roblem . The latter m ay involve 24-hou r p H m onitoring of the oesop hagu s, w ith p robes in the low er and u pper oesop hagu s. An ad d itional p robe cou ld be ad d ed to an intraoral ap pliance to measu re m ou th p H . Med ical and / or su rgical treatment m ay be requ ired to control GORD. Chronic regu rgitation can lead to scarring of the oesop hagu s and d ysp lastic change, and this is therefore an im p ortant cond ition to d iagnose and treat. In su ch cases m ed ication or su rgery are ind icated to p revent regu rgitation. ■ Tom only has occasional sensitivity. Wha t treatment, i a ny, Summary o Tom’s history There w as no evid ence of any gastrointestinal illness, bu t Tom d id consu m e a nu m ber of zzy d rinks, especially betw een m eals and w hen he w as at the local sp orts centre. In ad d ition to these, he rarely d rank w ater and m ilk. If there is p rogressive sensitivity then the areas of enam el loss and d entine exp osu re cou ld be p rotected by an ad hesive restoration. In m any cases, if erosion is d iagnosed early then p reventive cou nselling and the above ad vice m ay be su f cient. It is a good id ea to take photographs and m ake does he need? Probably none. The follow ing w ou ld be realistic initially: Daily neutral sodium f uoride mouthwash (0.05%) to maximize the resistance to remaining enamel and desensitize the dentine. High concentration sodium f uoride varnish (Duraphat) to be applied three to our times a year. High f uoride toothpaste (2800 ppm or children aged 10 years and older, 5000 pmm or children aged 16 years and older). 211 • DENTALEROSION stu d y casts of all p atients w ith signs of erosion or attrition or abrasion to m onitor the rate of p rogression. In m ore ad vanced cases than Tom ’s, as in Figs 40.2A and B, w here there are signi cant sensitivity or cosm etic p roblem s, m ore active intervention is requ ired . Table 40.1 show s the m erits of the d ifferent options available. 40 Key point Treatment objectives or erosion: • Resolve sensitivity. • Restore missing tooth sur ace. • Prevent urther tooth tissue loss. • Maintain a balanced occlusion. ■ Erosion is only one element o tooth sur ace loss or wear. What are the other elements? Attrition: the wear o the tooth as a result o tooth-to-tooth contact. A Abrasion: physical wear o tooth substance produced by something other than tooth-to-tooth contact. B Fig. 40.2 (A) Signi cant erosive tooth sur ace loss o labial sur aces o upper permanent incisors. (B) Signi cant erosive tooth sur ace loss o palatal sur aces o upper permanent incisors. Table 40.1 Treatment techniques or tooth sur ace loss Technique Advantages Disadvantages Cast metal (nickel/chrome or gold) Fabricated in thin section – requires only0.5 mmspace Maybe cosmeticallyunacceptable due to the‘shine through’o metallicgrey Veryaccurate ft possible Cannot be simplyrepaired or added to intraorally Verydurable Suitable or posterior restorations in para unction Does not abrade opposing dentition Composite: direct Composite: indirect Least expensive Technicallydi cult or palatal veneers Can be added to and repaired intraorally Limited control over occlusal and interproximal contour Aestheticallysuperior to cast metal Inadequate as a posterior restoration Can be added to and repaired intraorally Requires more space – minimumo 1.0 mm Aestheticallysuperior to cast metal Unproven durability Control over occlusal contour and vertical dimension Porcelain Best aesthetics Potentiallyabrasive to opposing dentition Good abrasion resistance In erior marginal ft Well tolerated bygingival tissues Verybrittle – has to be used in bulk section Hard to repair In child ren, abrasion is usu ally d ue to overzealou s toothbrushing, w hich tend s to d evelop w ith increasing age. The abnorm al bru shing techniqu e m u st be corrected before signi cant tooth tissu e is rem oved and pu lpal exp osu re occu rs. Attrition cau sed by norm al m astication is com m on, especially w ith the ageing p rim ary d entition. Alm ost all prim ary teeth show signs of attrition by the tim e they exfoliate. ■ Wha t categories o patient exhibit more attrition than norma l? Those w ith signi cant p arafu nctional activity, e.g. cerebral palsy and other p hysical and d evelop m ental d isord ers w ith intracranial abnorm alities. Controlling attritional w ear in these p atients can be very d if cu lt. Som e d rugs act to try to red u ce su ch p arafu nctional activity, bu t even if this is successful in the lim bs, there is often still resid u al oral parafu nction. This is p robably d u e to the neu ronal sensitivity of the m outh and the structu res w ithin it. For child ren w ith p rofou nd neu rological cond itions w ho stru ggle to comm u nicate, grind ing is very com m on. If p arents p resent w ith an increase in frequ ency or d urations of grind ing, a thorou gh oral exam ination is essential to elim inate any intraoral p athology and / or p ain w hich m ay have led to this activity. ■ Wha t restorative materials are the most durable or attritional wear a s a result o para unction? Amalgam and stainless steel crow ns. Carefu l consid eration w hen using these m aterials is necessary, as occlu sal d erangem ent m ay exacerbate parafu ctional habits. One research pap er id enti ed higher levels of stainless steel crow n failu re in child ren w ith d evelopm ental d isabilities, w hich they su ggested m ay related to bru xist habits. Primary resources and recommended reading Kilp atrick N M, Bu rbrid ge LA 2012 Anom alies of tooth form ation and eru ption. In: Welbu ry RR, Du ggal MS, H osey MT (ed s), Paed iatric Dentistry, 4th ed . Oxford University Press, Oxford . 40 • 212 DENTALEROSION N g MW, Tate AR, N eed lem an H L et al 2001 The in u ence of m ed ical history on restorative p roced u re failu re rates follow ing d ental rehabilitation. Ped iatr Dent 23:487–490. Su rgeons. Available at: / e a u e c t g a s s a s e a o r p y r m l e s c o c v u e f t o o e y s c b a m a i n e d m e r t e e r s c a n i e r s r c m s a n r i m e a y 2 e m y – 3 m 1 1 9 3 ~ ~ ~ : ~ o e n t : t o n i e e l t o i s i t p t i a n t m e e n r o d e c c d n y i y r l d l r a e a o x m n u i i i r s m p u m n a s e 43 • 220 MINDMAP1A 221 • MINDMAP1B local Indicative of crowding Aetiology significantly larger 6 more mesial angle of eruption of 6 small maxilla hereditary familial tendency non-cleft 2–6% cleft lip and palate 20–25% Prevalence 6 disimpacts reversible 6 erupts spontaneously rare after 8 years Classification until treated (see below) 6 remains impacted irrreversible E lost spontaneously Impacted Upper First Permanent Molar ? E mobile clinical ? caries 6 Investigations ? DPT extent of E resorption radiographs ? bitewing ? caries 6 Management irreversible impaction 6 more mesial eruption path 6 eruption blocked by distal E distal E resorbs Clinical features brass wire separator disc distal E without extraction E separating spring move 6 distally marked resorption when 6 cannot be disimpacted access required to restore 6 with extraction E consider move 6 distally leads to space loss accept and treat later 43 43 • 222 MINDMAP2 absence – very rare genetic gender male : female (2:1) tuberculate (~ 12%) most common with unerupted 1 conical (~ 75–78%) types supplemental supernumerary teeth odontome incidence 1.5–3.5% permanent dentition (exct 8’s) inverted Aetiology everted position midline (mesiodens) maxilla / mandible (9:1) hypodontia supernumerary teeth family history cleft lip and palate history trauma previous surgery to premaxilla swelling dental charting Investigations labial palpation clinical examination palatal space analysis adjacent incisors possible sensibility test cleidocranial dysplasia multiple Gardner syndrome cleft lip and palate DPT upper anterior occlusal or periapical view radiographic ? CBCT ectopic tooth germ dilaceration arrested development previous surgery scar tissue cleft lip / palate repair tumour pathology dentigerous cyst trauma to primary dentition Unerupted Upper Central Incisor joint orthodontic / oral surgical planning assess patient wishes / likely compliance with future treatment remove A – and any pathology ectopic tooth germ arrested development Management mild prosthesis; bridge; implant later replace 1 probable surgical removal 1– – 2 drift mesially; ? orthodontic alignment; crown 2 – – prosthesis; bridge; implant later probable surgical removal 1– replace 1– 2 drift mesially; crown 2 – – surgically expose and align orthodontically if 1 apex not destined to perforate cortical plate dilaceration prosthesis; bridge; implant later replace 1 surgical removal 1 – 2 drift mesially; crown 2 severe – – – tumour biopsy for further diagnosis dentigerous cyst marsupialize activation retention design using ARAB anchorage ? start with URA baseplate surgical / orthodontic orthodontic alignment fixed appliance bonded retainer open space for 1 always balance for unilateral loss/extraction of C surgically expose 1–, closed technique: bond attachment e r a l p e r n a l p e r e r n n a l o p n n o o t l o o r e a m r o n l e h p e e A t n y e og ol i t e p y t t n o n e n y r a e t m e a h e r e n p n o g e a p y t o n l n e e a p e a m y M o r r a a m a t p o e r m n t a a n e h e t l y t m n p r n p a o p m y l n m e e e o p l m o l r m a a s h a l t r n n o l p r m o m e o p y i t n e e h r r e a n t y a a o t t y t n m r t l n n y e e n a a a e n o l r p n e r p e m l p n e m p e n r t n t a a e n n a m p n m l e e r y a t n e o a r n r r e p n a T h a a o r o m a l o t t l l e n e a m t n o m o t t r l e p e l o o r a t e n p h a n e a t p o a m o n r a r t e a n e a r e t n p r e a o o m e a p r o o a l e h t r t n l r t e r o y p n o a m o r e l r l r e r a h l e t o a a p t l e a n n e o e m a l r n r e r e o t a l e t o r t r o e a n a t o r m n a m e e o a r r e t o n r e a n a l a p o a r p m h t t m n e e o e a n r r h l o p m m r a t h o a t o e r n r r e y e p p r a e t a r l n s a i s on t i n t a o g d i t o p e y v H n I r o l e a a r t a t n a i y e s m l t n t p a o e h l s e g o r y i m t h d e p t l h h o a l t a l p e e a m i v e e r e t c r t e t i e a d t y n b f d r l r o o r t a e t a t e t e a p e c v y m n n i e a w e e o r t e h o n h o t h y l p c t d d h o i r e t t n e p r d d a l d e o s e r t o e e a r e a e l c n a l d y i o i e u h t a p a m r a h l d t e c e n e m o e e n r r s i a d l l a n n n n r r o o a e e p h t t t t o ) a a l o o n 5 n t r l e t o – r l a ) a l t 3 l o ( 6 l a a t ) t t e > e 2 l n n t ( l a e e a e n t r h e ≤ y l r ( e p o a e r d t a d v l r i o a y t e p l m s m a o r n e h t a e n n n n e o o r r a m l a a h p e 223 • MINDMAP3 43 43 • 224 MINDMAP4 refer to dermatologist females > males nickel allergy medical history if confirmed use nickel-free appliance components crowding spacing angula ion o lower incisors canine inclina ion lower arc irs o er i e dep idline s i ild degree o crowding odera e assess space increased o er i re e uire en s se ere cen reline s i assess oo o e en appliance pe re uired i agine correc ed posi ion os arc Buccal 3–'s usuall crowded las per anen oo re ained C o erup an erior o o align lower arc Treatment planning en all reposi ion s o Class rela ions ip wi correc ed posi ion o s a e allowance or lower la ial seg en spacing and or oo si e discrepancies e g pegs s aped decide w e er space as o e crea ed a oun and o e en re uired plan upper la ial seg en and rela ed ec anics decide inal olar rela ions pe o Crowding and Buccal Upper Canines ip and rela ed ec anics anc orage re en ion e prognosis si e o crowding racs ion e en o crowding indi idual oo posi ions surgical e posure crea Treatment i re uired er rarel undern a in lower arc e spac e arc e pansion dis al o e en ena el s ripping co ina ion re o a le id e appliances eadgear pala al arc id e re ainer s re o a le e incidenc e decalci ica ain ris s ion s and pre roo resorp ion relapse s care ul pa ien selec ion en iondie ar ade ic applica ion o luo wee l around rac e sodiu luoride e 225 • MINDMAP5 pulpal pathology Turner’s hypoplasia causes caries severe crowding trauma space loss affected by: age at removal arch from which removed degree of crowding tooth lost: greater if posteriorly in arch 6 rotates mesiopalatally following loss of E occlusion possible effects space lost by mesial drift premolar / molar rotation premolar / canine impaction crossbite of premolar with / without mandibular displacement centreline shift inherent dentoalveolar disproportion Causes early loss of primary teeth supernumerary teeth megadont Severe Crowding radiographic DPT Investigations average space for 3,4,5 = 22 mm space analyses average space for 3,4,5 = 21 mm upper arch Management where anchorage demands are maximal lower arch made more complex by loss of 6 if severe labial segment crowding URA with headgear support headgear support to upper molar bands Nance button palatal arch with/without transpalatal arch TAD lingual inclination of molars lower removal appliance not acceptable encroachment on tongue space lingual arch bond/band 7's and ligate to 6's TAD 43 43 • 226 MINDMAP6 o ilit olour wear palpate palatall in lination lini al tooth with longest path of eruption r pt ispla e olar h po ontia he ent in isor pre ost o on ou les feaf ts s in i en peg e or a sent Aetiology infrao lu e pri ar olar usuall un row e ar h pol geni i pa te geneti asso iate other e topi teeth ano alies transposition lass i ision uropeans fe ales ales ilateral with greater fre uen than e pe te anterior a illar trau a au asians au of whi asians a sent Retained C – ilateral eh topi two fil s Investigations ra iographi assess italit alatal wi th of anines an for erti al or hori ontal tu t e shif paralla ost resorption of a a ent teeth un ertaint a out position on stan sar fil root length erti al position ofto roots of in isor s esio istal position of to roots of ins isor a ial in lination ape lo ation higher wit in isor root resorption esti ate than with on entio patholog ra iographs test ean anterior ratio ean o erall ratio olton anal s si re inter eption o e s ut no fir resear h e as s ear o erlaps istal half root a ti e treat ent if no onths onitor onths within patient not een for treat ent no patholog resorption retain an o ser e prognosis goo an in onta t goo s aestheti se erel ispla e no patholog highl oti ate patient ellent ental healt h Management e pose an align e spa e for or possi le to reate spa e position fa oura e l re o e transplant no signifi ant ifferen e l enta ental aestheti s open lose te hni health ue patient not een for align ent st for ation poor prognosis to align an goo t onta goo aestheti s prognosis earl resorption of a a ent h teet a e uate spa e inta t re o al possi le a e uate u al palatal one rarel a ress signifi ant if lini all e on signifi ant if olton ean alues s h 227 • MINDMAP7 maxilla: a ma a i l :a a la al a i l m alm i i a : a : i i : a x l ial a a i i l m l m al l i Transposition i x a i a i i l i i i ima a a i a mai ai a i i a ma i a i m l a a a m x a a i i a i i a la i ali la m i ix i a i i lia i l m i i m mm i i i mal a i m li i al i i a a la xi ili a i mi li i l i ili i Associated incisor root resorption i a i x a m m x a a i a a i i i i i a m i a al i a ma i ma i x i l i i a i l ll a al i a l i a i ai i al a i all x i i ll i i ma a a i a m i a a i ia a m 43 43 • 228 MINDMAP8 ti li o i tio i ylo i Aetiology it o ti m i t b t o t it m l f o ol titio o ti t Prevalence y o o ti Latex allergy? ti l il to i t m o t by f m l l t l mobility of E t of i f o l o to tio of o l io of E li i l io Investigations o i t t io o l if im f fo o fi m y if ob o i t i l i o mo yt ti l t f ol o Management ll o o i tio o oo o l b t lo l y oo bm oot fo m tio open or close space o o b lol o t i i l o o 229 • 43 MINDMAP9 e a c ea e c pete tea eate t a May predispose to p ppe c t a ta a e t eta a a e c a e a c ea e e e p e t a t p ace e t p ace e p a c e pe a t e t p e p app ct ea t a Management e eta e eta t a a t c e e e t act app a ce p t a ea e ate t ca e e a t act a a e e c ac a at ce et c p ete e ta e c ect p c a e te a e c ate e a t t a ete t e e pe e a a c p app p p a eta ce p ce t t eta ac a e t ace t e ce ea e e e e e e c e a pat e t a t t e e e ac cea e pt ac a e a eta a t act t e t e ct ca a a a e ate t a c a a ea a e e ect e ea e ta e a e a a ea e a e e a p a e a c app te e cat e e e a ea pat e t t e ap ca t t t e ate a cep a t te t Diagnosis t a a ap t t t e et a e t pe accept c a a a a p pe eact e e e t c a a a c at e et pete t e c a ta t t c c e ce e Aetiology e a c ea t 43 • 230 MINDMAP10 ret ine osition o ecto ic see re or toot sin b e incisor Aetiology s ern er r erse o er et or ore incisors Investigations erio ont c n c n ib c inic o nt o incisor inc in o nt o root st r io r ic s st t s o o er inciso ie e e e to e e in r tis ce en o erbite ntio cro in t s ern er r Prevalence erio ont tr May predispose to Incisor Crossbite no e tr scttoCenco r n ib r is ce ent no erio ont tr cce t n re ie ini o erbite n ib r is ce ent Management erio ont tr e o erbite incre se o r b e o erbiteroc i ine incisor e s rin consi er osterior c in cost o re ess t o er i e n e i nc Stability of correction s o nt o oe erbit bse ent n ib 231 • MINDMAP11 Investigations long mandible anterior position of glenoid fossa skeletal III short and / or retrognathic maxilla short anterior cranial base mandibular displacement retained BA | AB excess mandibular growth forward pattern restraint of maxillary growth 43 ? familial tendency profile A-P skeletal vertical growth direction / extent extent greater in males clinical ? mandibular displacement periodontal trauma gingival recession amount of overbite site and extent of crowding ANB Aetiology Reverse Overjet see ‘incisor crossbite’ positive family history ? direction / extent of future mandibular growth Frankel III / chincup mild/moderate Class III (maxillary retrusion) year s growth modification facemask (protraction headgear) su ess ul at year ollo no ad erse e e ts on one lates ase o y omati ar and anterior mandi BAMP s eletal mo ement t an a emas retrocline 21|12 ? procline 21|12 – camouflage usuallly extract 4’s only if prognosis favourable Class III intermaxillary traction avoid –6 extrusion accept and monitor Management fixed appliances severe skeletal III surgery fixed appliances align and decompensate arches pre-surgery patient not keen for surgery accept and align arches severe skeletal III 43 • 232 MINDMAP12 red ced anteri r a s s e andib ar r eractive i er i absence cin eta t r tati n Aetiology er i ine red ced and er i eve a c inica in iva tra incisor mobility cr din Assessment radi be s i ed a e icatera ce are er arc e tracti ns n Treatment planning e r c inati n a be stab e iances it it ti it di t s inc arc incisor es intrusion ic t n molar eruption cervica ead ear molar ec anics t intr de incis rs isted ab extrusion ve ass II III inter a i s ar e astic lower incisor proclination t r ra red ced red ced a ra assess incis r inc inati ns de Increased Overbite Methods of overbite reduction at anteri r bite ane s n e eta I ncti na a iance i d derate s e i ed a iances a ter e tracti ns i ed a iances n e tracti ns i d derate s er incis rs c rrect interincisa an e derate severe s i ed a iances verbite dee tra s r er s i d II r in eta II e eta II n n r atient e eta II a atient Management (non-extraction approach favoured for Class II division 2 malocclusion) in Stability at anteri r bite b nded retainer a ane n ata t in ass II div 233 • MINDMAP13 o n o oe not pre i it on in e re i t e t in re e A r n n ip n op e et r ro t p ttern ton t e t r i en o eno in er p i ier r i oo e it non ne triti e e n to o etri AOB ite e Aetiology in it ( in re e A n e et ini e i tit ton et r t ) io Assessment i re o eo r e e op ent r Anterior Open Bite (AOB) AOB i t i it n i eept re ie e ro in i n r e i e r it re e po iti e or ne ti e rein or e ent ot po terior e et r AOB e n tion o er pp i n e e it i i p r n e i e r it i A it p ppin 43 p int ero t e or i i ppin ip e in tr inin on tion Treatment p AOB i re ie e ro in pp i n e it it oi e tr ion AOB e ere ro t o p t i o o t eter er it A e io r p i ter i ep in re e o r in re e A 43 • 234 MINDMAP14 lass emimandibular pertr di it suc in Aetiology cr din in sciss rs bite earl l ss in cr ded arc buccal cr ssbite s c ec centrelines c ec it mandibular displacement inclinati n p steri r teet clinical Assessment cr din c nd lar anat m radi rap ic it unilateral bilateral Classification ut mandibular displacement mandibular displacement Treatment needed ma predisp se t e eletal steri r sprin r scre c nsider relie secti n n cr din e tract se erel it ut mandibular t in cr ssbite i ed applianc e displaced t teetdisplacement it cr ss elastics accept teet unilateral buccal cr ssbite rinds it mandibular displacement it midline scre uad eli ma be m re success ul bilateral buccal cr ssbite Treatment t an in mi ed dentiti n usuall accept see ind ap c nsider rapid ma illar e pansi n i ed appliances it mandibular displacement pand l er c ntract upper arc c mplete unilateral sur ern mandibular displacement lin ual cr ssbite c mplete bilateral usuall accept see ind ap c nsider sur er r ssbite d buccal interdi nitati Stability n displacin c ntact s a urable r t n abits 235 • 43 MINDMAP15 eletal o aetiology o t ti a li i al eat e o it la alo att a ti e ae t eti ile ile e late al e a a e o iate i li atio t i e tigatio a o i atie e t a i i o te io o i la la t ot ee o eito lyi g it a i e i li e o a age e e e al ot i e a ti ate io e to a eli o ie ie et lo y e o e a eletal o ite o e i e e titio eai g a t to gi e a io e otate ola e i it a o e e ti atio i e a a t a illa y o e aetiology lo al a Lingual e ie i gle t eat e o ta eletal o o t ti at e io o le o e t a o a ig e a a e lia ia o teoto y e i e ally ta it o t t l a e ia al teete te a ela ig t t y illa agai a illa e io ly o a i e te o e te io ly o t e a ay al i te o e o etai a te e t o o i e ea lia ye e it alatal a o e age o i a ea y e o a e it i t o ly e e o i e ate a ay loo o o o t ti e ge e i ta io o itio o ea o i e e t a tio o i la e toot i e o i e o i atio o ealatal te o e e al o e ee tet o lo ae teet a el e o i i atio tio o it eo o ti ae ot a lage allo a g o t e e ati o aly t e o le o o i te a o t io a i e i g o i e i g o alo to g e e o o te e et o ei ei g al o io t a tee e o e age a io o teoto y la o e i le ea ly lo toot e e gi al it e o t a t e e e g e alatala g a i it ay to t o g eletally li t o et tie e o e ti e e e titio al ola toot i t i e a e o e o e ite lo e o e ie li eit o e i o ea ly io a at t to li ely to o ea lia y o ly e o ilate ea t a at lea t eat e eletal la g o t e o to al lo e ge al e t i a it e al eg e t teet gi gi al ti e a o Buccal a io o i le ole o a e oi to il alte e ea o t e e to o t eat i g e lo to g e o itio a ti e e to le t e ai ll le gt o e i i o o e a elate i te o i al gi gi ae oo i l o ea i t a tio o t og at i i lie et i o teoge toot o a i ge y la lia el ligati g e t a tio o o teoge e i ay late y o li atio at a t teet o e e a e a i e a i toge e e i io y e i t a to o ai ly il a e lia a e e t a ie 43 • 236 MINDMAP16 orward andi growt as sto transse ta i res anterior co onent gingi o occ sa orces a ead to esia igration o osterior teet e ert esia re dista ti actoria ar growt w ere a i ed aided e i ress ar r c inica se Investigations and or occ saAetiology orces radiogra st d erit ic ode o crowding s s red ction in intercanine widt ress re d ring n er tio ent osterior teet ot ird ing os ar in res onse to ot er orces Late Lower Incisor Crowding acce Management t and onito r nti ates teen crowding a increas e deter ine ate o d t ir o ars i resent i d crowding c ear a rigne inter ro i a stri g a in iance t era i ed a iance a onded retainer i ed a iance a ia ing a e tract a ower incisor onded retainer 237 • MINDMAP17 ae TMJDS a ma e ula g o ae olog Prominent chin g o o a o o ma c olog cal auma c olog mul fac o c alo e occlu al la a e o e o lac g co ac e a afu c o e ma ageme l e a occlu al e u l a o ageme o c gua a ee o o o o o om e eam a camouflage u ge full e e of ma com a e a a ma c e fo ual age a ce a ecge al e e alome com u e l mo of a ma e a mage ou e o al alome o l a fe u l ca e u g cal la e ec a el e of gula ee a g o mo la ele e ga o Treatment la ual l u g cal la e a oac ula o mal ace al e e al ce alog am e of cle omage c ac g og am g ce c a c gua fo u ge u mou e o c o og a u l ca e mo el u ge lla cula o la e ee occlu al a l e afegua e fac al ela fac al e al f ma a o o og a el a og a c oo fac al mage e a a m l g of le eou come c o c olog cal a e me mo eme o e fo ma o leafle u mo el e ac o ecom e a ee u g cal o a eo ao c e c al g coo ec e a e cal c o o o e a all oo u le ac e m l ou occlu al e follo a le a l u g m mo e m mal e c e eel a c o u ge l g o mum ea eg a e u g cal mo e a l of ue e ela a c e oo 43 43 • 238 MINDMAP18 andi la periodontal disease periapi al pat olog st t o r Aetiology r ing nail iting a it pen e ing lar displa e ent o l sal o posterior teet Investigations ri ting dia ete edi al in l en e on periodonti attendan e istor dental treat ent s or e aries dental stat s lini al sin s gingi al s elling le toot o ilit e a ination periodontal stat s periodontal po eting andi lar displa e ent o l n sio e tent o posterior s tppor or periapi als radiograp i pat olog al eolar one le els n isors assess dental and periodontal prognosis assess patient s is es s o ing essation ad i e ontrol periodontal diseas e root anal t erap and periapi al s rger re Management e dis o o e tra st t teet o o rage a sal ad t o r repla opeless prognosi s e ridge it partial dent er i plants its st ent in periodontall re ao ilitationsal splint ens re periodontal ondition sta a oid ands se stainless steel ligat sre in ol ed dentition lig t or es reg lar periodontal re per anent retention ort odontis onsider applian e aest eti s in ads lt aest eti ra lear aligners ling al applian es ets all le pre treat 239 • MINDMAP19 Candida Red palate Bond failure Overextended archwire T T Broken vacuum-formed retainer T Broken bonded retainer T 43 43 • 240 MINDMAP20 or e operator app aet o o a pat e too e e a e ato app t a o a Slow / no tooth movement or e t pp o tr rotat o a a e e t re o a r e orre t ort a p ate a reta e root ter tte t e ear orre t po a ter ere e tr e reta a t e o e o t a ate aet o o r tho ont ll n e oot e o t on e t a ro e a a e e ept a t pe treat o pro t o re pre e ar treat e t ear ra or po t treat e e t re o a e a ea pr re tort o re re o er o t orp o o or e or o e p a po ra tor o e pa e o ter o at o o ter e e pa o rap o o r root t t ter p a treat e e a ate a t a t erap treat e ra o t erap p ate t a o t o t o t t o ate ort o o t a t o t e o rap e t rete t o ret a e t o t a r o ter t o tor r o t e o pete t a ter o er et re e t t o terat o a tero po ter or po rotate teet p a o t e o tor ere re orpt o o ear treat e t ra root o rapa a o e or e t treat e or e orpt o rea e e o e t ort o o t o t ar o rap orpt o o o t pro re ere re e t e tra a toot e a ra o a rat o appropr ate o a or o tor et pre r pt o re e e e e part o t ee a ea e rap aro p pa e ar e a e ere pa te per o o ta e t o ea e t o t re a e ate treat e appropr t a o e e rete e t e appropr ate tortt e at o a pra rete a o pre e e e ea or e e o e tor ea t re o t o r ea e root e e pport t e oro a a o t t e or e aet o o o o a a ro t e appropr ate rete t o re e re ap e pre treat e t pre e t o t re po a at o tor a a pre p el o e pr pre te re o e t o e re e eter o o o ra oot e ter ere re a o ta t re o orpt o epo t o ate or e e e t app a e e ate app a e ear a r re a e o tr o t o p e appropr orre appropr e t o or e ta o o er 241 • MINDMAP21 Aetiology CLP fa left palate (CP eneti eate i en i n ental il i t it fa il i t CLP t an CP ale left ide e ) p i a e palat e nda e palat nilate al ilate al eplet in eplet t Classification Ca 43 a ian Prevalence n lef Cleft Lip and Palate (CLP) et nat i a illa and andi le ed ed ppe fa ial ei t eletal in ea ed l e fa ial ei t Cla ante i ite p te i l al late al pen ite Clinical features a ent left ide all i aped tated tilted t a dental d left Management e all dela ed e pti n e all all t t i e pe n e a teet i in teet inte ne di iplina pa ental ealt natal plan a p i a dentiti p n ellin feedin ad e i i it p e enti e dental ad i e lip nt e palate nt peeea in t e ap e pee ea n e i e lip t eat ent e enti e dental ad e dental i e t in i al e la aft ea i edpe anent dentiti n e ne ala all all l e pe late teena e ea elie e anent t t t ea a e t pp e pti n pa e l e na al inte ite it epla e n idee i e ind palatal al fi t la ape p f ent eline din n n left nded etenti n nat i e ad ant and l e a n f n 43 • 242 MINDMAP22 sweetened or fruit-flavoured drinks sugar added to drinks sugar in some lactulose-free milk frequency prolonged bottle or feeding on-demand nocturnal breast feeding Aetiology Pattern of caries Managing cooperation (see Chapter26) Nursing and Early Childhood Caries clinical evidence dietary factors social history use of fluoride plaque control saliva medical history eruption sequence submandibular ducts bow upper lip gravity tongue position Risk assessment diet diary (4 day) toothbrushing instructions parent and child fluoride Treatment restoration extraction parental undertaking of brushing toothpaste – 1450 ppm topical-varnish prevention only seal +/– partial caries removal (see Chapter 24) complete caries removal positioning parenting skills managing unwilling or uncooperative child 243 • MINDMAP23 c ri s nt i r nc ious r ious r stor s tion h o stic n ctors og n sis i ntinog n sis i c inic oor or ti ing in nt h g in r u nc sug r Aetiology u t uori r gi i t r High caries risk ns soci is o nt i it in us in r ct ct tt n nt s nc s ro ri t tooth ro ri t ti ing o ir tion st str uors contro rosto i i ic ri s oor histor u igh r ctors uori s tr ction histor sc nts onstrn tio toothbrushing instruction isc osing t b ts tooth st str ngth ic high r str ngth tooth st su nts n ti uori ing rnish ic tion ch oo rin ing gu i t issur sug r r ic s s Treatment / preventive care nts icin ic Restorative care nt r s stor tion sth tic nt rior co or bri g or osit s 43 43 • 244 MINDMAP24 site onset character radiation association time course exacerbating severity Characteristics reversible pain to hot and cold pain transient / short duration pain ‘sharp’ in nature irreversible pain on chewing dull ache – continuous / long duration spontaneous pain non-vital abscess sinus swelling tender to percussion perifurcation radiolucency internal resorption History Pain Control and Treatment Planning for Carious Primary Teeth Treatment plan identify caries (clinically and radiographically) problem list depth of caries treatment options per tooth prevention visit-by-visit plan behaviour management temporary/definitive treatment child’s cooperation parent’s expectation influence by parent’s engagement with prevention further pain and symptoms dental team’s expertise and experience prevention only Definitive treatment indirect pulp therapy seal in caries Hall crowns fissure seal composites stainless steel crowns complete caries removal pulpotomy pulpectomy extraction pain control Acute treatment paracetamol ibuprofen temporization cement introduction to dental procedures reduces Streptococcus mutans count why fluoride reservoir increase comfort for eating, brushing reversible pulpitis Glass Ionomer Cement poly-antibiotic dressing how irreversible pulpitis + Glass Ionomer Cement 245 • MINDMAP25 reduced intake of food and drink pain sick child acute temperature raised red, swollen face lymphadenopathy sinus mobile tooth halitosis chronic discoloured tooth pain lymphadenopathy Type Hospital admission dehydration temp > 39ºC culture and sensitivity trismus complete closure of eye breathing and swallowing difficulties Facial Swelling and Dental Abscess Hospital treatment extract remove cause RCT incision RCT local drainage extract oral antibiotics if systemic involvement dentist Management extraction incision and drainage culture and sensitivity IV antibiotics fluid maintenance saline mouthwash pain control chloramphenicol eye drops 43 43 • 246 MINDMAP26A a a lo il nt ntal i al a ntal History la o nition l int o o n o t t l an io o i ni i ant al ana th ia ot an ont ain i ation a l a o al hil in i ation an ation Preventive plan (see Chapter 22) Consent Communicative i a an i al h n i o oo ini al ati ati nt h t ati ith i al on ition otional i i al lo in i al ini al h ati nt in i ation an non al non ont ain i ation ati nt in i ation an t ll ho o non ont ain i ation i iat l on i t nt l a nt nt o iti in o ontin ati nt in i ationan non ont ain i ation ati nt in i ation an i t a tion non ont ain i ation oi a i o al ntal n o oo a h i al on ition h n al ana th ia ina i a l an io ati nt h ha io ana ot in l hat holo i al o i al o tion a iation lo in holo i al o ntal ont ain i ation mother father (if ...) who has parental responsibility step-parents (if ...) relative, friends (if ...) social services (if ...) ith ntal a th ia annot l ona i a an n i nan t h alth ith ati i all n oo ati n o ni ati i al o o iat i n oo h i all ati nt lo al ana h oni ti otional i t lat n ont ain i ation i t t i t o i l ll i a ati nt t at ith l o la o na l to oo at ntal h a t in lo al ana th ia tiin anato i al all Pharmacological h t ntall o i a h in i ation n an io tain o in i ation inhalation ation l ati nt in i ation an ont ol non ont ain i ation ati nt in i ationan ntal n a non n ont ain i ation n nt at it i al h i ntal n ation ina 247 • MINDMAP26B iet Peer pressure tool it iary an tailore iet a vice patient contract Preventing disease cognitive behavioural therapy behaviour change theorie otivational intervie ing u ing concern previou Habits lo el e tee ocial e ia bullying recreational rug o ing alcohol perio ontal Dental diseases carie carie to otivate veneer Concerns about aesthetics bleaching non carie entoalveolar trau a ortho ontic treat ent pre olar e traction 43 i ea e ri a tooth e ent aci ero ion ur ace lo attrition Consent co petency he po itive rein orce ent tell ho o Behavioural chil a ent ocu o control e g management ignal increa ing el e tee top han techniques onitor having a ay in eveloping the treat ent plan blunter giving a han irror cognitive behavioural therapy pecial techni ue he an n iou ole cent intravenou e ation Conscious sedation inhalation e ation ng gui eline General anaesthetic (see Mind Map 26A) Assessing anxiety care ea ul ue pa t trau atic ental even t tioning perceive re e bere trau atic even pa t trau atic e ical event e g uring an iety ealing ith parental eparation an co ple a ily relation Changing hip relationship with parents Self-guarding groo ing neglect abu e phy ical orce arriag e e ual e otional s a s n i s o n n s i o f a n l a s o a l a a c n s i n a i o n o s n n a o n l o s o s o s c i s f o i n a n i o l s n o a s f n o i c l o n o i s s l i o n o i a l i o n c a n a i a c n i f i a f l i i l i s i f a i n a a a a a n f s a o o l c i f a f i s i l i l i i a n s i c i s i t c o y n i t n i s c e l o i l e f a i m o l o of u e a e s n q o r g e a e m o a a c i c n o n n I l n a a s f t a s a t f a m c p n a l f a c n l a e a o a a n a e t a o c o c r n d n c l s i a e a s a e l i o ou a d i c n a n s s i v of o o i t s d l s s s a s e a u e t h n c o s a l i c n a e i i o i r a l s c l c i a l c s l B i c a a c e n n n E a a s o R a o n o n f f a s n o n n a i s a c i o s l i i s o a l c i a o l l a l n l l a i s o c f i a l a s i s y t a i i l i s b e a y t i d i b or o i t k a s i d r e s e n s a c o a l n c i c c i v r i s l s a i c c n c c n i n i n a s o i i f c o o o o c l n a i i o n a n n s o s s i c s n n i n o i o a i c i o l l i i o a a c i l a f s i s s a i a a a i i l a a l i l s s e a c i o n l i s s n o i o n s s s n n a n i t r n o p p u s e i s m h t s i s o s a r a ou c i l l a i i c c c d e a l a f n o a s l e a p r y e c i d s o gh i s on H C d n a e M n i ol n T n a s o h e G c S i s l a f a s l l l n a o i i c s c s a i s s s s l o f n i a s o c c i s s c o i n i o s i s n i l o i a f s o i l s s i a i a a l o i l c n c n i o a i l a o n a o a o l i a s f n a a c a i a a l c i l s n s a s s a o l i o a n a l i a c i n l l s i a i s n s i s s s s c n n s o c i i i c n l i a s c a a l a a n a n i o o s n i n s c l a a l f f n f a s o n i i f n f o n a s o l o o n s s i o o l l c n o s a i o c i i n s l s n s l o o a s o o c a s n s a i c s i n c i s s c s i o o a o s a a i s i c i a i c a l n i i l a n o n i n i s i l l c i f a f s c s s s o f a a c a i n o o l n i s 43 • 248 MINDMAP27 249 • MINDMAP28 infecti e endocarditis leedin i aired i nitBroad implications Identify extent of disease increase likelihood of extraction a oid infection hich a rather than co lex restorati e careco ro ise eneral health direct conse histor clinical exa radio ra s h dia nosis ro le list see ha ter ence of treat ent edication Impact of medical treatment on oral health direct conse ence of disease ana e ent of ental aries in hildren ith o on edical ro le s i decrease ca acit to Liaise with medical colleagues act of edical treat ent on coo eration Cooperation of child ndertake lon and co licated treat ent lans Comprehensive and rigorous prevention toolkit a ha e to odif as of edical treat ent 43 43 • 250 MINDMAP29 ? accident, if so how does injury fit the age and clinical findings is explanation consistent with injury ? delay in seeking advice ? story of accident relationship between parent and child to other people reactions to medical or dental examinations demeanour of child infection pain required if mobility occlusal interference observation concussion and subluxation ? Child physical abuse comments by child / parent that give concern about upbringing / lifestyle of child intrusion Treatment loss of consciousness when? where? what surface? how? lip/tongue swallow fragments inhale spat out tetanus status congenital heart disease / rheumatic fever immunosuppression bleeding disorders allergies extrusion extract avulsion replantation not indicated 1 week 1 month then 3 months symptoms review if retain luxated tooth colour sinus tenderness radiograph 6 monthly no periapical pathosis review History Medical history discoloration Displaced Primary Incisor extraoral Examination intraoral periapical concussion and subluxation periapical lateral luxation periapical intrusion radiographs periapical extrusion periapical avulsion spontaneous reposition extract spontaneous reposition extract lateral luxation Investigations not indicated vitality testing Effect on permanent successor pathosis extract RCT with zinc oxide paste general demeanour to other people reactions to medical / dental treatment bruising abrasions lacerations ? child physical abuse burns bites fractures tooth mobility dentoalveolar segment occlusion may occur in 50% of cases intrusive trauma most damaging enamel hypomineralization enamel hypoplasia crown dilaceration crown / root dilaceration root dilaceration odontome formation disturbance in eruption sequestration of permanent tooth germ 251 • MINDMAP30 previous treatment previous local anaesthetic attitude to treatment swelling asymmetry occlusion extraoral Dental history lip laceration – check for teeth fragments soft tissue colour mobility teeth percussion sensibility occlusion bone Examination intraoral congenital heart disease / rheumatic fever immunosuppression bleeding disorders allergies tetanus status Medical history Fractured Immature Permanent Incisor Crown how when where fragments previous injury chest x-ray History Radiographs periapical check for root and alveolar fractures check periapical status loss of consciousness and missing fragment smooth/restore enamel fracture reattach fragment temporary adhesive bandage enamel / dentine fracture acid etch tip partial pulpotomy enamel / dentine / pulp fracture complete coronal pulpotomy calcium hydroxide pulpectomy monitor vitality Review Treatment clinically radiographically monitor root maturation monitor adjacent teeth 43 43 • 252 MINDMAP31 a ri i i lee e ere pre i l c ec i e e car i i ppre i Medical history i i r er aller ie History i r ci Dental history pre pre a i i i rea e l cal c a ae e rea e i e elli e e ra ral a ccl Examination e r c re Structured i r and examination r history pli i i r r e e re i ili i ili rac al Review rac a re ace re er a i e ee ee ra ci ral Radiographs Treatment re c i i ili a i c l r e i i e ie lile i le e r e c l i i r ili ee perc r e ccl i e i periapical a eri r irepli e a i 253 • MINDMAP32 at risk of infective endocarditis immunosuppression bleeding disorders allergies Dental history Medical history how when where extra-alveolar dry time History storage medium total extra-alveolar time previous injury contamination previous treatment previous local anaesthetic attitude to treatment extraoral Examination decoronation denture Early referral to resin retained bridge interdisciplinary team orthodontic space closure transplant colour intraoral mobility adjacent teeth percussion sensibility place in normal saline/milk tooth in medium establish apical status The Avulsed Incisor open apex replanted – may revascularize Endodontics change non-setting calcium hydroxide 3 monthly repair infection monitor resorption ankylosis obturate if no progressive resorption swelling asymmetry occlusion soft tissue extirpate prior to splint removal all others initial dressing antibiotic / steroid paste (days 0–10) or initial dressing with non-setting calcium hydroxide (days 7–10) Review monitor sensibility of adjacent teeth flexible splint 7–14 days may need antibiotics chlorhexidine 0.2% irrigate socket replant flexible splint 7–14 days may need antibiotics chlorhexidine 0.2% replant flexible splint 4 weeks may need antibiotics chlorhexidine 0.2% 30 min DT 90 min EAT IADT 60 min DT BSPD Radiographs already replanted Treatment milk or normal saline dry > 60 min periapical anterior occlusal 43 43 • 254 MINDMAP33 aetiology double primary teeth problems hypodontia affecting permanent successor Delayed exfoliation of primary teeth ectopic successor abnormal physiological resorption infraocclusion / ankylosis Natal / neonatal teeth treatment spontaneous familial syndromic mobility tongue ulceration nipple soreness mobility extract nipple soreness extract tongue ulceration carmellose paste smooth tooth extract Disorders of Eruption and Exfoliation Generalized premature eruption of permanent teeth neutropenia neutrophil defect histiocytosis Metabolic hypophosphatasia scurvy Ehlers–Danlos syndrome periodontal disease familial high birth weight race sex maternal smoking in pregnancy reduced maternal physical exercise lower socioeconomic status Premature loss of primary teeth psychosis self injury congenital insensitivity to pain non-accidental injury primary teeth pre-term very low birth weight primary and permanent teeth Generalized delay in eruption permanent teeth chromosomal nutritional hypothyroid hypopituitarism hereditary gingival fibromatosis (HGF) acquired gingival overgrowth generalized cleidocranial dysplasia supernumerary / odontome ectopic localized cystic follicular change crowding thickened mucosa 255 • MINDMAP34 first permanent molars mineralize around birth maternal illness pre-natal early admission to hospital prolonged delivery natal assisted delivery special care baby unit Hypomineralized / hypoplastic meningitis measles type post-natal respiratory illness childhood illness chronological duration and time family history primary teeth affected Amelogenesis imperfecta other permanent teeth affected Dentinogenesis imperfecta generalized drugs Fluorosis occlusal interproximal oral hygiene diet discrete creamy or brown hypomineralized areas affecting permanent molars and incisors post-eruptive breakdown atypical restorations Caries Poor Quality First Permanent Molars Restored preventive measures Molar incisor hypomineralization restoration Treatment buccal 6’s lingual 6’s check cervically caries dental status diet diary occlusion 6’s caries / hypoplasia number, position, status of unerupted teeth ? furcation calcifying developmental state 7’s DPT periapical / bitewing extraction clinical radiographic Investigations endemic F levels toothpaste ingestion recurrent caries periapical pathology antisensitivity toothpaste sensitivity toothmouse GIC temporary oral hygiene diet advice ? fluoride supplements composite stainless steel crown adhesively retained copings assess all 6’s ensure all permanent teeth especially 5’s and 8’s present timing more critical for lower first permanent molars compensate colour brown worse than creamy What is the long-term prognosis? size of area cusps affected 43 43 • 256 MINDMAP35 50% chance of damage to permanent successor hypomineralized hypoplastic age started brushing type of paste amount of paste swallowing of paste supplements generalized localized defect Trauma to primary teeth Infection of primary teeth localized defect hypomineralized hypoplastic Post-natal special care baby unit can affect 6’s Fluorosis Natal family history primary teeth affected permanent teeth affected generalized Tooth Discoloration, Hypomineralization and Hypoplasia prolonged delivery assisted delivery can affect 6’s Amelogenesis imperfecta family history primary teeth affected Dentinogenesis imperfecta permanent teeth affected generalized type duration and time (chronological) drugs can affect 6’s and other permanent teeth generalized maternal illness Pre-natal early admission to hospital can affect primary molars and 6’s Childhood illness requires a primary predecessor trauma to primary teeth infection to primary teeth amelogenesis dentinogenesis systemic illness fluorosis inherited Localized Generalized 257 • MINDMAP36 Diffuse defect how does it work? what do you do? indications? legality? advantages and disadvantages long-term outcomes Techniques Treatment of Mottled Teeth composite veneer external bleach leave defect microabrasion (how superficial within the enamel is the defect?) porcelain veneer in late adolescence composite veneer remove defect Demarcated defect microabrasion composite veneer porcelain external bleach 43 43 • 258 MINDMAP37 taurodontism accessory roots Root abnormalities pyramidal roots 0.1–0.9% primary prevalence 3.5–6.5% permanent (excluding 8’s) 1.4–4 times more common in females than males hair, teeth, nails, skin, sweat glands most common hypohidrotic X-linked usually male multiple congenital absence of teeth fine, spare hair with shaft abnormalities ectodermal dysplasia dry skin frontal bossing maxillary hypoplasia syndromes thin lips, little vermillion border cleft lip and / or palate 1:700 delayed eruption Down syndrome microdontia / hypodontia Ellis–van Creveld syndrome Reiger syndrome Orofacial digital syndrome (types I and II) reassure child and parent eliminate pain genetic counselling restoration of aesthetics management provide adequate function maintain vertical dimension formulate interdisciplinary treatment plan Other crown abnormalities accessory cusps invagination evagination Multiple missing teeth Multiple Missing and Abnormally Shaped Teeth prevalence high chance of abnormal number in permanent dentition 0.5–1.6% primary dentition 0.1–0.2% permanent teeth primary check normal resorption space in arch aesthetics Double teeth treatment permanent morphology of pulp chambers and roots ? surgical division mask with restorations extraction 259 • MINDMAP38 Inheritance 1 in 10000 epidermolysis bullosa tuberous sclerosis pseudohypoparathyroidism trichodento-osseous syndrome occulodento-osseous dysplasia vitamin D dependent rickets Amelo-cerebrohypohidrotic syndrome Amelo-onychohypohidrotic syndrome mucopolysaccharidosis autosomal dominant autosomal recessive X-linked Incidence Generalized disorder association hypoplastic Main clinical types hypomineralized mixed Amelogenesis Imperfecta alleviate symptoms maintain / restore occlusal height improve aesthetics maintain positive dental attitude Treatment principles prevention minimize likelihood of dental anxiety interdisciplinary care Treatment modalities adhesive restorations SSCs cast onlays full crowns composite veneers porcelain veneers 43 43 • 260 MINDMAP39 1 in 8000 Incidence Inheritance osteogenesis imperfecta Ehlers–Danlos syndrome brachio-skeletogenital syndrome vitamin D resistant rickets vitamin D dependent rickets hypophosphatasia autosomal dominant Generalized disorder association type I (associated with osteogenesis imperfecta) Main clinical types type II (not associated with osteogenesis imperfecta) Dentinogenesis Imperfecta Complicating factors alleviate symptoms maintain / restore occlusal height improve aesthetics maintain positive dental attitude prevention minimize likelihood of dental anxiety interdisciplinary care Treatment principles shortened roots progressive pulp chamber and canal obliteration wear spontaneous periapical abscesses bulbous crowns adhesive restorations SSCs cast onlays Treatment modalities full crowns composite veneers porcelain veneers 261 • MINDMAP40 diet diary study models Dental investigation photographs diagnostic index Desensitization bulimia / anorexia drugs for reflux surgery oesophageal monitoring antisensitivity toothpaste high fluoride paste low abrasive paste fluoride varnish fluoride supplements sugar-free gum bonding agents Medical treatment and investigation Dietary advice citrus fruits tart apples vinegar and pickles yoghurt foods and drinks fruit juices carbonated drinks vitamin C tablets swimming pools leisure medications and oral hygiene products gastro-oesophageal reflux oesophageal stricture chronic respiratory disease liver / pancreas / biliary disease overfeeding failure to thrive gastric acid learning delay cerebral palsy rumination anorexia / bulimia drug induced limit acids to meals reduce frequency finish meal with alkaline foods avoid acid foods at night avoid toothbrushing after acid foods check pH of medications / mouthwashes Dental Erosion extrinsic Aetiology intrinsic Restorative treatment cast metal onlays direct composite indirect porcelain 43 43 • 262 MINDMAP41 local Bleeding systemic eruption gingivitis acute / chronic gingivitis chronic periodontitis foreign body entrapment ANUG haemangioma reactive hyperplasia factitial hormonal diabetes mellitus anaemia leukaemia platelet disorder clotting defects anticoagulants scurvy HIV Assessment Gingival Bleeding and Enlargement congenital Enlargement 7–12 years old s o assess de ee s ores 2 1 s l ed as hereditary gingival fibromatosis mucopolysaccharidosis infantile systemic hyalinosis puberty / pregnancy gingivitis plasma cell gingivitis infections – HSV acute myeloid preleukaemic haematological aplastic anaemia vitamin C deficiency (scurvy) phenytoin, ciclosporin, calcium channel blockers, vigabatrim drugs mucocutaneous amyloidosis deposits leukaemia acquired chronic granulomatous disorders sarcoidosis, Crohn disease, orofacial granulomatosis e 1 –17 years ol d s o er odo al e a de ee s ores 1 2 263 • MINDMAP42 coeliac disease genetic nutritional host factors systemic disease immunity trauma cheese chocolate nuts tomatoes allergy environmental factors citrus fruits benzoates cinnamon aldehyde infection stress minor major Aphthae herpetiform Behçet breakdown of surface epithelium Gastrointestinal disease Crohn disease ulcerative collitis Aetiology Haematological disease Oral Ulceration haematinic replacement treat gastrointestinal disease exclusion diet treat infections topical anaesthesia Treatment topical antimicrobial oral rinse topical anti-inflammatory paste symptomatic topical coricosteroid medications/mouthwashes systemic corticosteroids Carcinoma Infections direct damage iron deficiency B12 folic acid herpes labialis VZV EBV cytomegalovirus herpes virus Coxsackie virus human papilloma virus Trauma lichen planus pemphigus Mucocutaneous disorders pemphigoid lupus erythematosus Radiotherapy reduced saliva reduced life span of oral epithelium FromHeasman P2008 Master DentistryVol. 2, Restorative Dentistry, PaediatricDentistryand Orthodontics, 2nd Edn. Edinburgh, Churchill Livingstone. Fig. 110, with permission. 43 A1 The indexo orthodontic treatment need: dental health component Grade Characteristics 1. None Extremelyminor malocclusions including displacements 3.5 mmbut ≤6 mmwith competent lips Reverse overjet >0 mmbut ≤1 mm Anterior or posterior crossbite with ≤1 mmdiscrepancybetween retruded contact position and intercuspal position Displacement o teeth >1 mmbut ≤2 mm Anterior or posterior open bite >1 mmbut ≤2 mm Increased overbite ≥3.5 mmwithout gingival contact Prenormal or postnormal occlusions with no other anomalies; includes up to hal a unit discrepancy 3. Moderate a. b. c. d. e. . Increased overjet >3.5 mmbut ≤6 mmwith incompetent lips Reverse overjet >1 mmbut ≤3.5 mm Anterior or posterior crossbites with >1 mmbut ≤2 mmdiscrepancybetween retruded contact position and intercuspal position Displacement o teeth >2 mmbut ≤4 mm Lateral or anterior open bite >2 mmbut ≤4 mm Increased and complete overbite without gingival or palatal trauma 4. Great a. Increased overjet >6 mmbut ≤9 mm b. Reverse overjet >3.5 mmwith no masticatoryor speech di culties c. Anterior or posterior crossbite with >2 mmdiscrepancybetween retruded contact position and intercuspal position d. Severe displacements o teeth >4 mm e. Extreme lateral or anterior open bites >4 mm . Increased and complete overbite with gingival or palatal trauma h. Less extensive hypodontia, requiring prerestorative orthodontics or orthodonticspace closure to obviate the need or a prosthesis l. Posterior lingual crossbite with no unctional occlusal contact in one or both buccal segments m. Reverse overjet >1 mmbut 9 mm h. Extensive hypodontia with restorative implications (more than one tooth missing in anyquadrant) requiring prerestorative orthodontics i. Impeded eruption o teeth (with the exception o third molars) owing to crowding, displacement, the presence o supernumeraryteeth, retained deciduous teeth and anypathological cause m. Reverse overjet >3.5 mmwith reported masticatoryand speech di culties p. De ects o cle t lip and palate s. Submerged deciduous teeth FromHeasman P2013 Master DentistryVol. 2, Restorative Dentistry, Paediatric Dentistryand Orthodontics, 3rd edn. Churchill Livingstone, Edinburgh, with permission. A2 Classifcation and defnitions Extraoral Skeletal pattern (Anteroposterior) Skeletal pattern (Vertical: FMPA) Skeletal pattern (Transverse) Skeletal pattern Nasolabial/lips/smile TMJ/mandibular position Incisor relationship (British Standards Institute classifcation) Class I Mandible 2–4 mmbehind maxilla Class II Mandible >4 mmbehind maxilla Class III Mandible 12 = increased; Curvature o occlusal plane in sagittal plane Complete Lower incisors occlude with upper incisors or palatal mucosa Traumatic Occlusion o lower incisors with palatal mucosa with ulceration lncomplete Lower incisors do not occlude with opposing upper incisors or palatal mucosa when buccal segment teeth are in occlusion Bimaxillary Crossbite Lower incisors lie anterior to upper incisors; i one or two incisors are involved, termanterior crossbite used Curve o Spee Open bite Occlusion Distance between upper and lower incisors in horizontal plane; normal = 2–4 mm Anterior No vertical overlap o incisors when buccal segment teeth are in occlusion Posterior When teeth are in occlusion, there is space between posterior teeth Proclination Upper and lower incisors are proclined relative to skeletal base Retroclination Upper and lower incisors are retroclined relative to skeletal base Dentoalveolar compensation Inclination o teeth compensates or underlying skeletal pattern, so occlusal relationship less marked Bolton (tooth size) discrepancy Mismatch between sumo m d widths o maxillaryand mandibular dentition Dilaceration Abnormal bend or curve in root or crown o ten ollowing trauma Supernumeraryteeth Teeth in excess o normal series Centric Position o maximuminterdigitation Ideal Anatomicallyper ect arrangement o the teeth; rare Normal Acceptable variation romideal occlusion Buccal Buccal cusps o lower premolars and/or molars occlude buccallyto buccal cusps o upper premolars and/or molars Lingual (scissors bite) Buccal cusps o lower premolars and/or molars occlude linguallyto palatal cusps o upper premolars or molars Crowding Insu cient space to accommodate teeth in per ect alignment in arch, or segment o arch Rotation Tooth twisted around long axis Impaction lmpeded tooth eruption, maybe as a result o displacement o tooth, crowding or supernumerary Leewayspace Di erence in diameter between C, D,Eand 3, 4, 5 Midline diastema Space between 1–1; more common in upper arch Spacing Teeth do not touch interproximally; localized or generalized Hypodontia One or more permanent teeth (excluding third molars) congenitallyabsent Anchorage Source o resistance to orces generated in reaction to active components o an appliance lntermaxillary Between arches lntramaxillary Within same arch Tilting Movement o root apexand crown o tooth in opposite directions around a ulcrum Bodily Equal movement o root apexand crown o tooth in same direction Uprighting Mesial or distal movement o root apexso root and crown o tooth are at ideal angulation Torque Movement o root apexbuccolingually, with no or minimal movement o crown in same direction Centroid Imaginarypoint in root, ~ 13 romapex, about which a tooth will tip when orce applied to crown Moment (o a orce) Tendencyo a orce to cause rotation Migration Physiological (minor) movement o tooth Relapse Return, ollowing correction, o eatures o original malocclusion Hyalinization Loss o cells roman area as per light microscopy Transseptal fbres Periodontal fbres interconnecting adjacent teeth Camou age Occlusal compensation byorthodontictooth movement or skeletal discrepancies 267 • CLASSIFICATIONANDDEFINITIONS Extractions Functional occlusion Appliances Balancing Extraction o same (or adjacent) tooth on opposite side o arch to maintain symmetry Compensating Extraction o same tooth in opposing arch Serial Extract C’s at 8.5–9.5 years, D’s ~1 year later, 4’s as 3’s erupting Working side Side to which mandible shi ts during normal masticatory unction Non working side Side away romwhich mandible moves during normal masticatory unction Non working side inter erences Occlusal contacts present on non working side during lateral excursion o mandible Disclusion Dynamic separation o opposing teeth during mandibular movements Canine guided Contact maintained on working side canine teeth during lateral excursion o mandible Group unction Contacts maintained between several teeth on working side during lateral excursion o mandible Removable Appliance removable rommouth consisting primarilyo wire and acryliccomponents; maybe active or passive; used almost exclusively in upper arch; most unctional appliances are removable Fixed Appliance fxed to teeth byattachments through which orce application is byarchwires or auxiliaries Archwire Wire engaged into orthodontic brackets to provide active orces or tooth movement or to stabilize teeth Anchorage Lingual arch Mandibular fxed anchorage rein orcing appliance, wire soldered onto 6 6 bands extends orward to contact lingual sur aces o incisors, to maintain arch length Nance palatal arch Maxillaryfxed anchorage rein orcing appliance, wire soldered onto the 6 6 bands connected to acrylic button contacting anterior vault o palatal. Quadhelix Maxillaryexpansion appliance, stainless steel wire, our helices, attached to 6 6 bands Transpalatal arch Maxillaryfxed anchorage appliance, wire connecting 6 6 bands, to maintain intermolar width Two by our Fixed appliance to 6 6 and 21 12 Couple Pair o equal and opposite parallel orces applied to a body Functional Appliance using, removing or modi ying orces generated byoro acial musculature, tooth eruption and dento acial growth Headgear Extraoral appliance using cervical or cranial anchorage (or both) to apply orces to teeth or jaws or tooth movement or growth modifcation Facemask Extraoral appliance using anchorage romchin and orehead to applyanterior orces to maxillarydentition and/or maxilla; requently used in class IIImalocclusion Cephalometric analysis Cephalometricanalysis Evaluation and interpretation o both lateral and p a radiographs o head (usuallyconfned to ormer) Ricketts’ELine Tangent to chin and nose used to assess lip ullness; see Appendix5, Fig. A5.3 Ortho gnathic surgery(OGS) Pre surgical orthodontics Orthodontictreatment in preparation or OGS Decompensation Removal o dentoalveolar compensation prior to OGS OGS Surgical repositioning o mandible and/or maxilla or correction o dento acial de ormity Osteotomy Bilateral sagittal split (BSSO) Surgical mandibular procedure, ramus split parallel to sagittal plane, used to advance, setbackor rotate mandible Le Fort 1 Surgical maxillaryprocedure, maxilla osteotomised above tooth apices, used to advance or vertically reposition maxilla Tooth sur ace loss Growth Autorotation Rotation o mandible around condylar axis a ter vertical maxillaryrepositioning Distraction osteogenesis Surgical technique or lengthening bones and their associated so t tissue envelope, involving corticotomy, ollowed bygradual separation (distraction) o bone segments (1 mm/day) and osseous infll Genioplasty Surgical chin procedure to reposition bonychin point a p, verticallyand/or transversely Abrasion Loss o tooth substance as a result o wear caused bydissimilar materials Attrition Loss o tooth substance as a result o tooth wear Erosion Loss o tooth substance as a result o chemical dissolution Growth rotation Rotation o core o mandible and maxilla in relation to cranial base; occurs with normal growth; maybe clockwise or anticlockwise Functional matrixtheory Theorysuggesting skeletal growth determined by unctional spaces and so t tissues associated with skeletal unit A2 A3 Orthodontic problems: re erral guide When to re er What to re er Primarydentition • Gross skeletal discrepancy • Markedlyslowdental development (see Chapters 1 and 33) • Cranio acial anomalies, especiallycle t lip and/or palate (unless care provided alreadybyspecialist team) (see Chapter 21) Mixed dentition • Increased overjet with associated severe teasing or marked lip incompetence (greater trauma risk1) (see Chapter 9) • Severe reverse overjet2 (see Chapter 11) • Anterior crossbite with marked mandibular displacement, with or without associated periodontal trauma (see Chapter 10) • Posterior crossbite with marked mandibular displacement (see Chapter 14) • Unerupted upper permanent incisor(s) (see Chapter 2) • Ectopic eruption o 6 (see Chapter 1) • Poor qualityfrst permanent molars (see Chapter 34) • Developmentallyabsent permanent teeth (see Chapter 8) • Palatal/ectopic canine (see Chapter 6) • Pathology, e.g. root resorption o 2’s by3’s (see Chapter 6) • Medicallycompromised (see Appendix4) Permanent dentition • Mani est malocclusion with or without skeletal problem (see Chapter 5) • Dri ting incisors (see Chapter 18) • Temporomandibular joint problem(see Chapter 17) • Complexcombined orthodontic restorative or orthodontic orthognathicproblems (see Chapter 17) 1 Earlygrowth modifcation indicated 2 Likelyto beneft romearlyorthopaedic intervention Adaptedbypermission romScott JK&AtackNE, 2015The developingocclusiono childrenandyoung people in general practice: when to watch and when to re er. Br Dent J. Macmillan Publishers Ltd. Adapted with permission o BOS. Primary resources and recommended reading British Orthod ontic Society 2010 Managing the Develop ing Occlu sion – A Gu id e for Dental Practitioners, Lond on. Cobou rne M 2014 N ational clinical gu id elines for the extraction of rst p erm anent m olars in child ren. Br Dent J 217:643–648. Scott JE, Atack N E 2015 The d evelop ing occlu sion of child ren and you ng p eop le in general p ractice: w hen to w atch and w hen to refer. Br Dent J 218:151–156. A4 Implications o some medical problems or orthodontics Problem Implications Asthma • Risko intraoral candidiasis with steroid based inhalers • Maintain excellent oral and appliance hygiene, especiallywith URA Allergy Latex Nickel • Re er or testing to confrm • Avoid latexgloves and latex containing orthodontic products • Treat earlymorning to avoid exposure to airborne latexproducts • Uncommon or intraoral allergy • Place plastic sleeving on headgear to avoid extraoral dermatitis; i intraoral atopyconfrmed, use nickel ree appliance components Bleeding diathesis • Liaise with medical specialist regarding extractions/surgery • Mayusuallyproceed with orthodontictreatment • Avoid mucosal/gingival irritation romappliances Biphosphonates • Discuss potential treatment with physician, especiallyi extraction is likely • Assess risko osteonecrosis and advise on slowtooth movement/reduced bone healing Cardiac de ect with IErisk • Current guidelines indicate ABCis not recommended routinely or procedures likelyto produce bacteraemia • Consult patient’s cardiologist i anyconcern Diabetes • Onlyconsider treatment i diabetes is well controlled • Greater risko periodontal disease • Time appointment to minimize inter erence with control regime and possible hypoglycaemic attack Drugs Steroids NSAIDs TSADs • Sloworthodontic tooth movement Epilepsy • • • • Treat onlyi epilepsyis well controlled Avoid headgear and removable appliances due to risks associated with seizure Phenytoin induced gingival hyperplasia Ensure patient has rested, eaten and taken antiepileptic medication be ore appointment to reduce risko seizure Juvenile rheumatoid arthritis • • • • Steroid injections intoTMJ mayreduce jawgrowth Prone to periodontal breakdown due to long termsteroids Controversywith regard to role o unctional appliances Avoid prolonged orthodontictreatment Leukaemia • • • • Delaytreatment to >2 years post BMT Mayhave short blunt roots and increased risko root resorption Reduced resistance to oral in ections Growth modifcation guarded prognosis, as growth maybe suppressed URA, upper removable appliance; IE, in ective endocarditits; ABC,antibiotic cover; NSAIDs, non steroid anti in ammatorydrugs; TSADs, tricyclic antidepressants; BMT,bone marrowtransplant. A4 • 270 IMPLICATIONSOFSOMEMEDICALPROBLEMSFORORTHODONTICS Primary sources and recommended reading Patel A, Burd en DJ, Sand ler J 2009 Med ical d isord ers and orthod ontics. J Orthod 36:1–21. A5 Cephalometric interpretation For Cau casians, com p are ind ivid u al valu es w ith Eastman norm s (Table A5.2). Skeletal relationships • Lateral cephalometric analysis • Tooth position • Aim and objective o cephalometric analysis Aim : To assess the anteroposterior and vertical relationships of the up p er and low er teeth w ith su p p orting alveolar bone to their respective m axillary and mand ibu lar bases and to the cranial base. Objective: To com p are the p atient to norm al p op u lation stand ard s ap p rop riate to his or her racial grou p , id entifying any d ifferences betw een the tw o. A-P. I SNA is 81° and S N/maxillary plane is within 8° ± 3°, correct ANB as ollows: or every degree SNA is >81°, subtract 0.5° rom the ANB value and vice versa. Vertical. MMPA and acial proportion should lend support to each other usually. To assess i overjet reduction is possible by tipping movement, do a prognosis tracing (Fig. A5.2), or or every 1 mm o overjet reduction, subtract 2.5° rom 1 angulation. I the nal angulation is not 2/3 3 = complete (apex open) 4 = complete (apex closed) For Avulsion Only 1. Extra Alv Period .................................................... 2. Method of Storage ................................................. Radiographs Views Report ............................................................................................................................................................. ........................................................................................................................................................................ ........................................................................................................................................................................ ........................................................................................................................................................................ Diagnosis Tooth Diagnosis Treatment Plan ......................................................................................................................................................................... ......................................................................................................................................................................... ......................................................................................................................................................................... ......................................................................................................................................................................... ......................................................................................................................................................................... ......................................................................................................................................................................... Signed Student ............................................................ Staff .................................................................... Formreproduced courtesyo MontyDuggal, Leeds Dental Institute. Index Page nu m bers follow ed by “f” ind icate gu res, “t” ind icate tables, and “b” ind icate boxes. A Abnorm ally shaped teeth, m ultip le, 199–202 Abscess, 146–148 Absent u p p er lateral incisors, 11–15, 11f–12f, 223f treatm ent op tions for, 13, 13b Accep tance of infraocclu d ed prim ary m olar, 53 of root resorption, 49–50 of transposition of canines, 47 Accessory cu sp, 201 Accessory roots, 202 Aciclovir, for prim ary herpetic gingivostom atitis, 216–217 Acrylated labial bow, low er incisor crow d ing, 101 Acrylic allergy, 114 Activator-type fu nctional ap pliance, for increased overbite, 75 Active ligatu res, 54 Acu te lym phoblastic leu kaem ia, d ental care and , 163 ADH D. see Attention d e cit hyp eractivity d isord er (ADH D) Ad hesively retained cop ings, 189 Ad olescent anxiou s, 247f consent for, 155 gingival bleed ing in, 214b high caries risk, 135–139, 135f–136f, 136t preventive care for, 137–138, 138b, 138f uncoop erative child and , 149–156, 152b Aesthetics for am elogenesis im p erfecta, 204t app liances, d rifting incisors, 111 AI. see Am elogenesis im p erfecta (AI) Alignm ent m inor shifts in, 117, 117f in transp osition, 47 of u pper canine, 118 Allergens, in recurrent ap hthae, 218b Allergy acrylic, 114 im p lications of, 269 Alveolar bone grafting, for cleft lip and palate, 128, 129b Alveolar d evelop m ent, localized failu re of, in anterior op en bite, 82t Am elogenesis im p erfecta (AI), 188, 203–205, 259f com p ared w ith d entinogenesis im perfecta (DI), 206, 206f Analgesics, for cariou s prim ary teeth, 141t Anchorage in bilateral crossbite, 93 w ith crow d ing, 27, 28b tem p orary, 28–29 w ith incisor d rifting, 112 in increased overbite, 75 w ith p alatal canines, 41 w ith u p p er and low er arches, 34, 34f–35f Angu lation, canines/ incisors, 13 Ankylosis-related resorp tion, 180 Anterior occlu sion, 25f, 36f Anterior op en bite (AOB), 81–86, 81f–82f, 233f cau ses of, 82, 82b, 82t, 83f d iagnosis of, 84 exam ination of, 81–83, 81f–82f treatm ent of, 84–86, 84b, 86b Antibiotics intravenous, 147, 147t oral, 146–147, 147t p rop hylaxis, 166 Antifu ngals, p alatal stom atitis, 114 Anxiety d ental, 152 m anagem ent, 152–153 Ap hthae recu rrent. see Recu rrent ap hthae typ es of, 217–218 Ap ical p eriod ontitis, acute, 140 Ap pliance-related p roblem s, 239f Ap pliances in anterior open bite, 84 ARAB (activation, retention, anchorage, basep late), 9, 9b in bilateral crossbite, 93–94, 93t, 94f w ith canine transp osition, 47–48 w ith crow d ing, 28–29, 28f d em ineralization in, 19–20, 20b xed for absent u p p er lateral incisors, 13 w ith crow d ing and buccal upp er canines, 17–18 hygiene, 114 for incisor crossbite, 64 w ith increased overbite, 73, 75 in lingu al crossbite, 97–98, 97f low er incisor crow d ing, 101 orthod ontic, 112t for p osterior crossbite, 89–90 qu ad helix, for buccal up per canines, 23, 24f related problem s, 113–117 rem ovable, w ith absent u p p er lateral incisors, 14, 14b, 14f rem ovable p roblem s, 113f upp er, 113 rem oval of, in u neru p ted u pp er perm anent central incisor, 9, 9f repair of, 115 risk of, 19 u p p er xed , 111f Arch affected by transp osition of canines, 47 crow d ing, treatm ent options for, 23 expansion, in bu ccal u p p er canines, 23 length d iscrep ancy, 37 u pp er, severe crow d ing and , 26 Archw ire ad justm ent of, 115f p rojection of, 116 Arrested caries, 193 Asp erger ’s synd rom e, 158b Asthm a, im p lications of, 269 Attention d e cit hyp eractivity d isord er (ADH D), 158b Attrition in late low er incisor crow d ing, ap p roxim al, lack in m od ern d iet, 100 w ear d u e to, 211 Au tism , 158b Avu lsed incisor, 169, 179–183, 179f, 253f long-term treatm ent op tions for, 182 B Bacteria, chrom ogenic, 193 Bad breath, 194 BAMP. see Bone anchored m axillary p rotraction (BAMP) Band s avoid ance w ith p eriod ontal d isease, 112 for d entinogenesis im p erfecta, 208 Basep late in bilateral crossbite, 93 in increased overbite, 75 w ith palatal canines, 41 Begg retainer, 122, 123f Behaviou r m anagem ent, 149–150 nonp harm acological, 152 Behçet synd rom e, 218 Bilateral crossbite, 91–98, 91f, 92t, 235f Bip hosp honates, im p lications of, 269 Bitew ing rad iograp hs of caries, in ad olescents, 136f for cariou s p rim ary teeth, 141, 141f Bleaching, for enam el d iscoloration, 197 Bleed ing d iathesis, im p lications of, 269 Bolton d iscrep ancy, 37, 38b Bond ed retention, for cleft lip and palate, 128 Bone anchored m axillary p rotraction (BAMP), 72 ad vantages and d isad vantages of, 72 Brackets bond failu re, 115f, 115t d rifting incisors, 112t Brand y w ine typ e (DI typ e III), 207 Breastfeed ing, and caries, 130 Breath, bad , 194 Brow n staining, u orosis, 196 Bu ccal crossbite, bilateral, 91, 91f, 92t Bu ccal eru p tion, of u p p er p erm anent canines, 16–20, 16f–17f, 17b, 19f Bu ccal occlusion, right, 46, 46f • 276 INDEX Bu ccal segm ent of absent upper lateral incisors, 13–14 crossbite, 87, 87f, 90, 90b Bu llying com p ared to teasing, 55 consequ ences of, 55 p rom inent teeth and , 55 C Candida, and p alatal stom atitis, 114, 114b Canine fossa infection, m axillary, 146, 146f Canines eru ption d ates, 2t p alatal, 36–45 p rim ary, u nilateral loss of, 6, 6b p roblem s, 227f rem oval of, 27–28 retraction and alignm ent of, 35, 35b, 35f transposition in, 46 u pp er, crow d ing and bu ccal, 16–20, 16f–17f, 17b, 19f Carbam id e p eroxid e gel, 197 Carbonated d rinks, cau sing erosion, 209, 209b Card iac d efect w ith IE risk, im p lications of, 269 Caries, 188 in ad olescents, 135–139, 135f–136f, 136t risk assessm ent of, 136b arrested , 193 in d iabetic p atient, 214 early child hood , 130–134, 131f d iet ad vice for, 132 high-risk factors for, 132t hom e based ad vice for, 131 m ed ication for, 133 p rofessional interventions for, 133 rem oval of, 133 m anagem ent of, for incisor crossbite, 64 Cariou s prim ary teeth, p ain control and treatm ent p lanning for, 140–145, 140f Carisolv, for early child hood caries, 133 Cast m etal, w ith tooth surface loss, 211t Cavernou s sinu s throm bosis, 146 Cavitation, in early child hood caries, 130f, 133 Cellulitis, facial, 146 Centerline, low er, m onitor of, for incisor crossbite, 64 Central incisors, trau m a to, 171f Centreline shift w ith bu ccal u p p er canines, 21, 22f in p osterior crossbite, 88, 88b w ith u neru p ted u p p er central incisors, 6 correction of, 10, 10b p revention of, 6 Cephalom etric analysis, lateral, 271–272 aim and objective of, 271 interpretation of, 271, 272t p ractice of, 271, 271f, 271t Cep halom etric nd ings, 34 Cep halom etric rad iograp h in bilateral crossbite, 92 for increased overjet, 57 for reverse overjet, 67, 70 Cephalom etric values, TMJ p ain and p rom inent chin and , 104, 104t Cep halom etry in anterior op en bite, 83 of bu ccal u pper canines, 22 in increased overbite, 74, 77 Cervical pu lp otom y, for fractu red p erm anent incisor crow n, 172 Cervical vertebral m atu ration (CVM) ind ex, 57 Cheek m u cosa, 115 Chem otherap y d ental care and , 163, 163f sid e effects of, 164b Chew ing gu m , su gar-free, for ad olescents, w ith caries, 138 Child p hysical abu se, 169 Child ren w ith d isabilities and learning d if cu lties, 157–162, 161t com m unication w ith, 160–161, 161b d ental m anagem ent for, 159 general anaesthetic for, 160 m ed ical com orbid ities in, 160, 160b nitrou s oxid e inhalation sed ation for, 159–160 nonp harm acological m anagem ent of, 159, 159b rad iograp hic investigation for, 158–160 treatm ent p lan for, 160 m ed ical p roblem s in, 163–167, 167b, 167t acu te lym phoblastic leu kaem ia as, 163, 163f–164f congenital heart d efect as, 166, 166f haem op hilia A as, 165, 165f vital bleaching for, 197 Chin, p rom inent, and TMJ p ain, 102–108, 102f Chronic m od erate p eriod ontitis, 111, 111b Chronic p eriod ontal d isease, 109 Chronological hyp op lasia, in child hood illnesses, 191 Class II d ivision 2 m alocclu sion, 42 Class III m alocclu sion d iagnosis of, 105 TMJ p ain and p rom inent chin and , 103–104 Classi cation and d e nitions, 265–267 Cleft lip and p alate (CLP), 125–129, 125f, 241f d iagnosis of, 128 exam ination of, 126–127 extraoral, 126, 127f intraoral, 125f, 126–127, 127f genetic risk of, 125, 125b investigations of, 127 p revalence of, 125, 125b sex and sid e variation and , 125 treatm ent of, 128–129 Cleid ocranial d ysp lasia, 185 CLP. see Cleft lip and p alate (CLP) Cold sore, 216, 217f Colou r, canines/ incisors, 13 Com a, d iabetic, 214 Com bined orthod ontic-su rgical ap p roach, TMJ p ain and p rom inent chin and , 104–105, 105b Com bined orthod ontic-su rgical p lanning, 104t Com m unication, w ith child ren w ith d isabilities, 160–161, 161b Com m u nication p assp ort, 157, 157f Com m u nicative m anagem ent, 149–150 Com posite, p oor qu ality rst perm anent m olars and , 189 Com posite d irect/ ind irect, w ith su rface loss, 211t Com p osite veneers, u orotic m ottling, 197–198 Com p u tational m ethod , of tooth-size d iscrep ancy, 37–38 Com p u ted tom ograp hy, of palatal canines, 38, 38b, 39f Cone beam com p u ted tom ograp hic (CBCT) view, for u neru p ted u pp er perm anent central incisor, 8 Consent, inform ed , 155, 155b Cop ings, ad hesively retained , 189 Coronal p ortion, of non-vital, root fractu red tooth, 177 Coxsackie viru s, 217 Crossbite, 32 bilateral, 91–98, 91f, 92t–93t buccal segm ent, 87, 87f, 90, 90b in cleft lip and p alate, 126b, 127 w ith p alatal canines, correction of, 41 p osterior, 87–90 Crow d ing buccal u p p er canines and , 224f in increased overjet aetiology, 57t lack of, 53 late low er incisor, 99–101 causes of, 100 d iagnosis of, 100–101 m anagem ent of, 100–101 low er and u p p er arch, 42–44, 44f–45f severe, 25–35, 26f Crow n, shape abnorm alities of, 201 Crow n fragm ents, p artial p u lp otom y for, 173, 173f Cryp t d isp lacem ent, 37 Cu sp, accessory, 201 Cyclic neu trop enia, 185f Cytom egaloviru s, 217 D Deep overbite, 77–78 Delaire-typ e facem ask, 70, 70f Delayed d evelop m ent, 149 Dens evaginatu s, 202 Dens invaginatu s, 201–202, 202f Dental anom alies, treatm ent for, 205b Dental anxiety, 152, 152b Dental caries, in child ren w ith com m on m ed ical p roblem s, m anagem ent of, 249f Dental erosion, 209–212, 261f Dental health com p onent, 264 Dental m anagem ent, for child ren w ith d isabilities, 159 Dental p anoram ic tom ogram (DPT), 31, 31f, 100f in am elogenesis im p erfecta, 204 of d entinogenesis im p erfecta, 206, 206f Dentine d efects, environm entally d eterm ined , 207 Dentinogenesis im p erfecta (DI), 206–208, 207b, 260f treatm ent of, 204 Dentoalveolar inju ry, sp linting of, 176, 176b ’Dentu re’ stom atitis, w ith xed app liances, 114 cau ses of, 114t p rognosis of, 114 treatm ent of, 114 Develop m ental abnorm alities of enam el, 203b in u pper prem olar rotations, 27 DI. see Dentinogenesis im p erfecta (DI) 277 • INDEX Diabetes gingival bleed ing and enlargem ent in, 213 im p lications of, 269 period ontal p athology and d rifting incisor, 111 Diastem a, m ed ian causes of, 2t ectopic eru ption and , 1–4, 1f labial segm ent p roblem s in, 3, 3f up p er rst p erm anent m olar of, 1–4, 1f Dietary ad vice, for d iabetic p atients, 215 Dietary allergens, in recu rrent aphthae, 218b Dietary causes (food and d rinks) of erosion, 209, 209b staining d ue to, 193–194, 194f Dietary constituents, cau sing erosion, 209 Dietary history, of ad olescents, w ith caries, 136 Digit-su cking habit, 121 anterior op en bite d u e to, 83, 83f, 85b in bu ccal segm ent, 91 in increased overjet aetiology, 57t w ith p osterior crossbite, 88b, 88t, 89 Direct p ulp capping, 172 Direction of d isplacem ent, in d isplaced prim ary incisor, 169 Disability, in child ren, 248f Discoloration/ staining, 187 extrinsic, 193–194 restorative techniqu es in, 193b Disp laced prim ary incisor, 168–170, 250f Disp lacem ent, in p osterior crossbite, 88 Distraction, 150 Distraction osteogenesis, in lingual crossbite, 97t, 98 Dou ble perm anent teeth, 201 Dou ble prim ary teeth, 201, 201b Dou ble teeth, 200–201 Dow n synd rom e, 199 DPT. see Dental p anoram ic tom ogram (DPT) Drainage of pu s, 147 Dressing, for open cavities, 140, 140f, 141b Drifting incisors, 109–112, 238f sp eci cally relation to history, 110 of low er second p rem olars into contact w ith second m olars, 103 Dru gs d entinogenesis im perfecta d ue to, 207 im p lications of, 269 staining d ue to, 194 Dry tim e, teeth w ith, 180 Du m m y su cking, anterior op en bite d u e to, 83f E EADT. see Extraalveolar d ry tim e (EADT) Eating d isord er, 210 EBV. see Epstein-Barr viru s (EBV) Ectod erm al d ysp lasia, 199 Ectop ic eru p tion clinical featu res of, 3–4 treatm ent of, 4, 4b, 4f up per canines, bu ccal, 16–20, 16f–17f, 17b, 19f up per rst perm anent m olar of, 1–4, 1f. see also Im p acted u pp er rst m olars Elastic traction, 41, 42f Electric p u lp testing (EPT), 177 for fractu red incisor crow n, 172 for root resorp tion, 49 Em ergency care, ap p liance related p roblem s, 116, 116b Enam el, u orosis-related , 195 Enam el d efects, d evelop m ental cau ses of, 203, 203b Enam el m icroabrasion, 190 Enam el-d entine fractu re, 172 End ocard itis, infective, risk of, 25 Environm ental cau ses, d entine d efects, 207 Ep ilep sy, im plications of, 269 Ep stein-Barr viru s (EBV), 217 EPT. see Electric p u lp testing (EPT) Erosion, d ental, 209–212 m anagem ent of, 210–211, 210b treatm ent for, 211b, 211t Eru p tion d ates of, 2b, 2t exfoliation and , d isord ers of, 254f p rem atu re, 184 Essix retainers, 28–30 low er vacu u m -form ed , 116, 116f Evaginated teeth, 202 Exfoliation, 185, 185b eru ption and , 184–186 External in am m atory resorp tion, 180 Extirpated tooth, intracanal m ed icam ent in, 182 Extraalveolar d ry tim e (EADT), 180 Extraction in bu ccal u p p er canines, 23 w ith canine transp osition (of m ost d isp laced tooth), 47 of carious prim ary teeth, 141–142 w ith crow d ing, 27 of rst p rem olars, 27 of u p p er canines, 27–28 w ith crow d ing and bu ccal u p p er canines, 17–18 of rst p rem olars, 18–19, 19b of infraocclud ed prim ary m olar, 53 in lingu al crossbite, 97t w ith p oor qu ality rst p erm anent m olars, 189–190, 190b w ith root resorp tion, 50 of u pper canines, 119 Extraction-only p lan, 32, 32f Extraoral exam ination in bilateral crossbite, 91 in increased overbite, 73, 73f, 76–77, 77f in late low er incisor crow d ing, 99 in lingu al crossbite, 97–98 in p osterior crossbite, 87, 87b TMJ p ain and p rom inent chin and , 102–103 Extrinsic staining, 193–194, 193f Eye sw elling, root fractu red p erm anent incisors and , 175 F Facem ask, 70, 72b d esign of, 70, 70f–71f effects of, 71, 71f–72f p sychological bene ts of, 71 su ccess of, 72 long-term , 72 Facial asym m etry, m ild , in buccal u p p er canines, 16 Facial convexity, 56 Facial grow th, p ost-treatm ent, 122 Facial height, low er, in increased overjet, 56 Facial p ro le, in anterior op en bite, 81, 81f Facial sw elling, d ental abscess and , 146–148, 245f Fissu re sealants, for ad olescents, w ith caries, 137–138, 137f, 137t Fixation, w ith TMJ p ain and p rom inent chin, 107 Fixed ap p liances for absent u p p er lateral incisors, 13 in anterior open bite, 85 in bilateral crossbite, 93 for cleft lip and p alate, 128 w ith crow d ing and buccal upp er canines, 17–18 w ith d eep overbite, 80f d rifting incisors, 109 for incisor crossbite, 64–65 w ith increased overbite, 73, 75–76 for infraocclu d ed p rim ary m olar, 53–54, 53f–54f in lingu al crossbite, 97–98, 97f p roblem s, 114 in tooth m ovem ent, 121, 121f–122f for transp osition of canines, 47–48, 48f Fixed bond ed retainer, 123, 123b–124b Fixed retainers, 122 Fizzy (carbonated d rinks), cau sing erosion, 210 Flu orid e for ad olescents, 151–152 history, 192b of ad olescents, w ith caries, 136 m ottling, 195 toothp aste, for child ren, 152 Flu orid e m ou thw ash of ad olescents, w ith caries, 136 for early child hood caries, 133 for erod ed teeth, 210 Flu orid e su p p lem ents for ad olescents, w ith caries, 137, 137t for early child hood caries, 132–133 Flu orid e toothp aste for ad olescents, w ith caries, 137–138, 137t for early child hood caries, 131–132 Flu orid e varnish ap p lication, for ad olescents, w ith caries, 137, 137t for erod ed teeth, 210 Flu orosis, 188, 192, 195, 195b FMPA. see Frankfort-m and ibular p lanes angle (FMPA) Forces, gingival/ occlu sal, 100 Form ocresol, for p u lp otom y, of carious p rim ary teeth, 144 Fractu re clean-cut, 116 incisor root, 109 root, d rifting incisors and , 109 Fractu red incisor crow n, 171–174 im m atu re perm anent, 251f Fractu red p erm anent incisor, root, 175–178 Frankel II ap p liance, for lingu al crossbite, 97, 97f Frankel III ap p liance for reversed overjet, 67–68, 68f Frankfort-m and ibu lar p lanes angle (FMPA), w ith increased overjet, 56 Fu nctional ap p liances in anterior op en bite, 84–85 w ith increased overbite, 75, 75b for increased overjet, 58, 58b–60b, 60f typ es for, 58 • 278 INDEX Fu nctional app liances (Continued) for reverse overjet, 67–68, 68f effects of, 68 w ear of, 68 G Gastric acid , causing erosion, 209 Gastro-oesop hageal re u x d isease (GORD), gastric regu rgitation and , 209–210 GDP. see General d ental p ractitioner (GDP) Gend er, affected by transp osition of canines, 47 General anaesthesia for child ren w ith d isabilities, 160 contraind ications for, 154 ind ications for, 154 General d ental p ractitioner (GDP), 116–117 Generalised slight gingival erythem a, 42, 43f Generalized m arginal gingival erythem a, 30, 31f Genetic enam el d efects, 203–204 Genetic factors, in palatal canine ectop ia, 36–37 GICs. see Glass ionom er cem ent (GICs) Gingiva bleed ing of, 213b enlargem ent, oral u lceration and , 216, 216f p ressure from , cau sing late low er incisor crow d ing, 100 Gingival bleed ing and enlargem ent, 213–215, 262f Gingival enlargem ent, system ic cau ses of, 214, 215b Gingival health, w ith toothbru shing, 194 Gingival recession, 62–63 Gingival third root fractu res, 177 Gingivitis, chronic, 213, 213f Gingivop lasty, labial, 10 Gingivostom atitis, p rim ary herpetic, 216, 216f Glass ionom er cem ent (GICs), 189 GORD. see Gastro-oesop hageal re u x d isease (GORD) Grafting, alveolar bone, for cleft lip and p alate, 128, 129b Greater m axillary protraction, for reverse overjet, 72 Grow th m od i cation, in lingu al crossbite, 97t H H aem op hilia A, 165, 165f H alitosis, 194 H all crow n technique, for child ren w ith m ed ical p roblem s, 166–167 H all crow ns for cariou s p rim ary teeth, 143–144 for child ren w ith d isabilities, 159 H and , foot and m outh d isease, 217 H aw ley retainer for severe crow d ing, 29–30 in tooth m ovem ent, 122, 123f H ead and neck synd rom es, associated w ith m issing teeth, 199 H ead gear w ith severe crow d ing, 28 w ear, for absent u pper lateral incisors, 14 H erbst ap pliance, increased overbite, 75 H ered itary d entine d efects, 207b H erp angina, 217 H erp es labialis, 217 H erp es sim p lex viru s (H SV), 216, 216b reactivation of, 217b H erp es viru s typ e 8, 217 H erp etic gingivostom atitis, p rim ary, 216, 216f H erp etiform ap hthae, 217 H igh caries risk ad olescents, 243f H osp ital ad m ission, for orofacial infection, 147, 147b H PV. see H u m an p apillom a viru s (H PV) H SV. see H erp es sim plex virus (H SV) H u m an p ap illom a viru s (H PV), 217 H yd rochloric acid (H Cl)-p u m ice m icroabrasion technique, 196, 196f H yp erglycaem ic com a, 213–214 H yp od ontia, 199b, 201 facial/ d ental/ occlu sal associated w ith, 13 genes associated w ith, 13 p revalence of, 52–53, 53b u p p er incisors, 11–15, 11f–12f H yp oglycaem ic com a, 214 H yp om ineralization early child hood caries and , 131f enam el, hyp op lasia and , 187b, 187f, 188 treatm ent for, 190 H yp om ineralized am elogenesis im p erfecta, 204f H yp op lasia early child hood caries and , 131f enam el cause of, 26 hyp om ineralization and , 187b, 187f, 188 system ic (chronological) in uences in, 203 H yp op lastic am elogenesis im p erfecta, 203, 203f I Ibu p rofen, for cariou s p rim ary teeth, 141t Im p acted u p p er rst m olars cau ses, 3, 4t frequ ency/ p revalence, 3 m anagem ent of, 4 p erm anent, 221f treatm ent of, 4, 4b, 4f Im p ressions of d ental arches, in p osterior crossbite, 88 u p p er and low er, 100 Incisor crossbite, 62–65, 62f, 230f d iagnosis of, 64 extraoral exam ination of, 62 featu res of, 63, 63b intraoral exam ination of, 62, 62f IOTN DH C grad e of, 64 labial recession in, p rognosis for, 64 p revalence of, 63 special investigations for, 63 treatm ent for, 64–65, 64b Incisors angu lations of, 21–22 central, u neru p ted u pp er, 5–10, 5f crow n, p erm anent, fractu red , 171–174 d ou ble (crow ns are joined ), p rim ary teeth, 200, 200f d rifting, 109–112 intrusion, in overbite red u ction, 78, 78b, 78f lateral, u p p er, absent, 11–15, 11f–12f m axillary, severely reabsorbed , 50b p erm anent central, affected by m ottling, 195 eru p tion d ates, 2t root fractured , 175–178 rotations, m ed ian d iastem a and , 2 up per, space creation in d evelop m ent, 2, 2b p rim ary, erup tion d ates, 2t resorp tion d etection of, 49b by ectop ic m axillary canine, 49b u p p er w ith increased overbite, 75 trau m a of, 58 Increased overbite, 232f Increased overjet, 229f Ind ex of orthod ontic treatm ent need , 264 Infection-related resorp tion, 180 Infective end ocard itis d ental care and , 166, 166f risk of, 25 Inferior alveolar block injection, 166 In ltration injection, 166 Inform ed consent, 155, 155b Infraocclu d ed p rim ary m olar, 51–54, 228f aetiology of, 51 cause of, 52, 52b d ental history, 51 d iagnosis of, 53 exam ination of, 51–52 extraoral, 51 intraoral, 51–52, 51f–52f fam ily history, 51 history of, 51 com plaint, 51 investigations for, 52–53 clinical, 52, 52b rad iographic, 52–53, 53f IOTN DH C grad e, 53 m ed ical history, 51 p revalence of, 51 treatm ent of, 53–54, 53f–54f, 54b Infraocclu sion, 186, 186b Infraorbital oor, fracture of, 175 Infraorbital m argin, fractu re of, 175 Inhalational sed ation, 150, 151b Insulin-d epend ent d iabetes, gingival bleed ing and enlargem ent in, 213–214 Intercanine w id th in d evelop ing d entition, 2b red u ced , cau sing late low er incisor crow d ing, 100 Intercep tive m easu re, for absent u p p er lateral incisors, 13–14, 14b Intercep tive treatm ent, for transp osition of canines, 47 Interm axillary xation, w ith TMJ p ain and p rom inent chin, 106 Interp roxim al strip p ing, late low er incisor crow d ing, 101 Intracanal m ed icam ent, in extirp ated tooth, 182 Intraoral exam ination in bilateral crossbite, 91–92, 92f in increased overbite, 73–74, 73f–74f, 74b in late low er incisor crow d ing, 99–100 in p osterior crossbite, 87–88, 87f–88f TMJ p ain and p rom inent chin and, 103–104, 103f Intraoral p eriap ical rad iographs, root fractu res in, 175, 176f 279 • INDEX Intravenou s antibiotics, 147, 147t Intrinsic d iscoloration, 191f Invaginations, 201–202 Invisalign, d rifting incisors and , 111 IOTN DH C grad e, 100, 105 Irreversible p u lp itis, 140, 140t J Joint period ontal, referral for, 111 Ju venile rheum atoid arthritis, im p lications of, 269 K Kim m echanics, in anterior open bite, 85 L Labial bow w ith absent u p p er p erm anent central incisor, 9 w ith increased overbite, 75 w ith low er incisor crow d ing (late presentation), 101 Labial gingivop lasty, 10 Labial segm ent crow d ing, 26, 29, 29b, 29f Labial segm ent problem s, in m ed ian d iastem a, 3, 3f Labial segm ent sp acing d rifting incisors and , 111 up p er, causes of, 12, 12b, 12t Labial su rface, of up per p erm anent incisors, affected by m ottling, 195 Lain’s d entition, p rognosis of, 111 Lateral cep halom etric analysis, 271–272 aim and objective of, 271 interp retation of, 271, 272t practice of, 271, 271f, 271t Latex allergy, 51 im p lications of, 269 Le Fort I ad vancem ent, TMJ pain and prom inent chin, 107 Learning d if culties, in child ren, 248f Left bu ccal occlu sion, 99f Lesions, in p alate, 113 Leu kaem ia, im p lications of, 269 Lingu al appliances, of late low er incisor crow d ing, 101 Lingu al crossbite, bilateral, 97b, 97t Lip sw elling, fractu red p erm anent incisor crow n and , 171 Low er arch crow d ing, 32, 42–44, 44f–45f eru p tion pattern in, 30 Low er bond ed retainer, 123f Low er centreline shift, 30, 31b Low er incisor crow d ing, late presentation, 99f, 236f extraction of, 101 in overbite red u ction, 78 Lu xated p rim ary tooth, 170 M Major ap hthae, 217 MAKATON , for child ren w ith d isabilities, 160–161 Mand ibu lar d isplacem ent on closure, 63 in p osterior crossbite, 88, 88b prom inent chin and TMJ p ain, 103 reverse overjet and , 67 Mand ibu lar grow th, 24, 24f in late, low er incisor crow d ing cau sation, 100 in posterior crossbite, 88t Mand ibu lar infections, 146 Mand ibu lar m id line d istraction, in lingu al crossbite, 98 Mand ibu lar p ath of closu re, p rom inent chin and TMJ p ain, 103 Mand ibu lar setback osteotom y, TMJ p ain and prom inent chin, 107 Maxillary canine fossa infections, 146, 146f Maxillary exp ansion, rap id , in bilateral crossbite, 93–94, 93b–94b, 93t, 94f Maxillary tooth, talon cu sp in, 201–202 MCDAS. see Mod i ed Child Dental Anxiety Scale (MCDAS) Med ian d iastem a, 220f causes of, 2t labial segm ent problem s in, 3, 3f u p p er rst p erm anent m olar of, 1–4, 1f Med ical com orbid ities, in child ren w ith d isabilities, 160, 160b Med ical cond ition, staining d u e to, 194 Med ical p roblem s, in child ren, 163–167, 167b, 167t acu te lym phoblastic leu kaem ia as, 163, 163f–164f congenital heart d efect as, 166, 166f haem op hilia A as, 165, 165f Microabrasion, u orotic m ottling for, 196b, 197 Mid azolam intravenou s sed ation, 154 for oral sed ation, 154 Mid d le third root fractures, 176f Mid line d istraction osteogenesis, in lingu al crossbite, 97t Mid -p alatal sutu re, in bilateral crossbite, 93 MIH . see Molar incisor hyp om ineralization (MIH ) Mild m arginal gingival erythem a, 32, 33f Millard rep air, 126 Mind m ap s, 219 Mineralization tim es, for p erm anent d entition, 188t Minor ap hthae, 217 Missing shap ed teeth, m u ltip le, 199–202 Missing teeth, 199 Mixed d entition, referral gu id e for, 268 Mobility, of natal teeth, 184 Mod i ed Child Dental Anxiety Scale (MCDAS), 152, 153f Mod i ed palatal arch, in anterior op en bite, 84–85, 84f Molar eru p tion, in overbite red u ction, 78 Molar extru sion, in overbite red u ction, 78 Molar incisor hyp om ineralization (MIH ), 188, 188b–189b Molar intru sion, in anterior op en bite, 85f Molars erosion in, 209, 209f p erm anent eru p tion d ates, 2t p oor quality rst, 187–190 u p p er rst, ectop ic eru ption of, 1–4, 1f p rim ary early loss, sp ace loss follow ing, 26, 26t, 27b rst, infraocclusion of, 186, 186b third in late low er incisor crow d ing, 100, 100b rem oval of, 101, 101b Mottled teeth, 195–198 treatm ent of, 257f Mottling, 195, 195f Mouth breathing, in bilateral crossbite, 91, 91b in increased overbite, ap p earance of, 73–74 Mu ltip le m issing and abnorm ally shap ed teeth, 258f Mu ltistrand w ire retainer, 122, 123f N N atal teeth, 184, 184b, 184f N eonates cleft lip and palate in, 126 teeth, 184, 184b N eu trop enia, cyclic, 185f N ickel, im p lications of, 269 N ickel allergy, 20–21, 20b, 21f N ickel titaniu m archw ires, ad vantages of, 45 N ickel-titaniu m (N iTi) sp rings, 54, 54f N ightgu ard vital bleaching, 197 N ight-tim e feed ing, early child hood caries and , 131 N itrou s oxid e, 151, 151b inhalation sed ation, 153 for child ren w ith d isabilities, 159–160 N N SH s. see N onnu tritive su cking habits (N N SH s) N onextraction ap proach, in d eep overbite, 78–79, 79f–80f, 80b N onnu tritive su cking habits (N N SH s), 83, 83b N onp harm acological behaviou r m anagem ent, 152 for child ren w ith d isabilities, 159, 159b N on-verbal com m u nication, 149 N on-vital bleaching, 192 N SAIDs, im plications of, 269 N u rsing caries, 130–134, 130f, 131b early child hood and , 242f O Occlu sal rad iograp h of cleft lip and p alate, 127, 128f of p alatal canines, 38 u neru p ted u p p er p erm anent central incisor, 7, 8f Occlu sion anterior, 94, 95f–96f bu ccal, 96, 96f nal, w ith d rifting incisors, 112f forces, cau sing late low er incisor crow d ing, 100 p osttreatm ent in bilateral crossbite, 95, 96f in increased overbite, 76, 76f in lingu al crossbite, 98, 98f in p osterior crossbite, 89, 90f at p resentation, w ith d rifting incisors, 109f–110f relap sed in, in increased overbite, 76, 76b TMJ p ain and p rom inent chin, 107, 107f Op alescent d entine, hered itary (DI type II), 207 • 280 INDEX Open bite, anterior, 81–86, 81f Oral hygiene in bilateral crossbite, 93 d iabetes d ue to, 214b w ith d rifting incisors, 109 instru ction, for incisor crossbite, 64 p oor, chrom ogenic staining d ue to, 194 severe crow d ing and , 25 Oral m anifestations, d iabetes, 215 Oral sed ation, 154 Oral u lceration, 216–218, 217b, 263f Orbital ow (blow ou t) fractu res, 175 Orofacial infection, 147, 147b Orofacial soft tissu es, forces from , 121–122 Orthod ontic alignm ent, 42 Orthod ontic cam ou age, 60 in lingu al crossbite, 97t Orthod ontic consu ltation, referral for, 111 Orthod ontic m ovem ent, of root fractu red teeth, 177 Orthod ontic p roblem s, referral gu id e for, 268 Orthod ontic treatm ent need , ind ex of, 264 for unerup ted teeth, risks of, 9 Orthod ontics, im plications of som e m ed ical p roblem s for, 269–270 Orthognathic su rgery in lingu al crossbite, 97t TMJ p ain and p rom inent chin, 105 Osteogenesis im p erfecta, DI typ e I associated w ith, 207 Overbite am ou nt of, 63 increased , 73–80 red u ction, 78b trau m atic, 73, 73f, 74t Overjet increased , 55–61, 55f aim s of treatm ent for, 58 cau ses of, 56, 57t d iagnosis of, 57–58 early, treatm ent for, 58 extraoral exam ination of, 55–56, 56f intraoral exam ination of, 56, 57f options for treatm ent of, 60 rad iographs for, 57 risk of traum a w ith, 55 reverse, 66–72, 66f, 70f cau ses of, 67t d iagnosis of, 67, 70 extraoral exam ination of, 66, 66f intraoral exam ination of, 66–67, 67f IOTN DH C grad e of, 67 prognosis of, 69 treatm ent for, 67–72, 67b–68b, 68f–69f, 68t, 71b P Pain control for cariou s p rim ary teeth, 140–145, 140f and treatm ent planning for cariou s prim ary teeth, 244f p oor quality rst perm anent m olars and , 188–189 relief, for nu rsing caries, 133 TMJ, and prom inent chin, 102–108, 102f Palatal canine ectop ia, 36–37, 37b, 37f Palatal canines, 226f exposu re, surgery of, 40t, 41, 41b Palatal crib, in anterior open bite, 84–85, 84f Palatal lu xation, of p rim ary incisor, 168f Palatal m u cosa, as d iagnosis of ap p liance, 114 Palatal stom atitis, m anagem ent of, 114b Palatally d isp laced canines, 39–40, 40b, 40t Palate, app earance of, 113 Panoram ic tom ogram acu te lym p hoblastic leu kaem ia and , 164, 164f in anterior open bite, 83 in bilateral crossbite, 92 for child ren w ith d isabilities, 158 for cleft lip and p alate, 127, 128f crow d ing and buccal u pper canines, 17, 17f in increased overbite, 74 of late low er incisor crow d ing, 100 m ed ian d iastem a, 3, 3f nickel allergy and , 20, 20f of palatal canines, 38, 39f of perm anent teeth, 200, 200f p oor qu ality rst p erm anent m olars and , 189, 189f in posterior crossbite, 88–89, 89f of severe crow d ing, 27 of tooth m ovem ent, 119, 120f of unerupted up per perm anent central incisor, 7, 8f Paracetam ol, for cariou s p rim ary teeth, 141t Parafu nctional activity, attritional w ear w ith, 211 Parental involvem ent, early child hood caries and , 132 Parental presence/ absence, in behaviou ral m anagem ent, 150 Partial pu lp otom y, for fractu red p erm anent incisor crow n, 172, 173b, 173f Periapical p eriod ontitis, d rifting incisors, 109 Periap ical rad iograp h for canine transp osition, 47 of fractured incisor crow n, 172 fu ll-m ou th, d rifting incisors and , 110–111, 110f intraoral, root fractu res in, 175, 176f of root fractu res, 172 of tooth m ovem ent, 119, 119f–120f Period ontal assessm ent, for root resorp tion, 49 Period ontal d isease, gingival and , 215f Period ontal healing, 181–182, 181f Period ontal ligam ent, d am aged , 182 Period ontal p robing d ep ths, in increased overbite, 74 Period ontal treatm ent, 111 Period ontally com p rom ised d entition, 112, 112b Period ontitis chronic m od erate, 111, 111b p eriap ical, d rifting incisors, 109 Perm anent d entition d elayed or failed eru ption of teeth in, 185 m ineralization tim es for, 188t referral gu id e for, 268 Perm anent incisor crow n, fractu red im m atu re, 171–174 erosive tooth su rface loss of, 211f Perm anent teeth d ou ble, 201 p rem ature exfoliation of, 185b treatm ent m od alities for, in am elogenesis im p erfecta, 204, 204t Perm anent tooth p u lp otom y, 172–173 Physical abu se, 169 Plaqu e control in ad olescents, 136 in caries, 132t Polyu rethane p ow erchain, 54 Poor qu ality rst p erm anent m olar, 255f Porcelain, for tooth su rface loss, 211t Position, tooth, cep halom etric analysis for, 271–272, 272f Positive reinforcem ent, 149–150, 150b Posterior crossbite, 87–90, 234f Posterior op en bite, 59 Post-su rgical orthod ontics, phase of, 107 Post-su rgical stability, in u ence of, 107, 107b Pre-ad ju sted ed gew ise ap p liance, 53–54, 53f–54f Pregnancy, rst perm anent m olars (FPMs) in, 191 Prem atu re eru p tion, 184 Prem axilla, anterior, vertical p arallax of, 7 Prem olars eru p tion d ates, 2t rst, extraction of, 18–19, 19b low er, extraction of, 101 rotations, cau ses of, 27 TMJ p ain and p rom inent chin, 105 transp lant, avu lsed incisor and , 183f Pressu re zones, in tooth m ovem ents, 118, 118f Pre-surgical orthod ontics, p hase of, 106, 107b Prim ary d entition in cleft lip and palate, 126, 126b d elayed or failed eruption of teeth in, 185 referral gu id e for, 268 Prim ary incisors d iscoloured , 170, 170f d isplaced , 168–170 p alatal lu xation of, 168f Prim ary teeth am elogenesis im p erfecta affecting, 203 carious, 140–145, 140f, 143b exam ination of, 141, 141f restorative treatm ent of, 142t, 143b treatm ent p lanning for, 142–143, 142t d elayed eru ption of, 184 d elayed exfoliation of, 186 d entinogenesis im perfecta affecting, 206 d ouble, 201, 201b luxated , 170 trau m a, 169, 170b treatm ent m od alities for, in am elogenesis im perfecta, 204, 204t Prom inent chin and TMJDS, 237f Protraction (reverse-p u ll) head gear, 70, 72b d esign of, 70, 70f–71f effects of, 71, 71f–72f long-term , 72 p sychological bene ts of, 71 su ccess of, 72 Pu lp capp ing, d irect, 172 Pu lp cham bers, obliteration of, in d entinogenesis im p erfecta, 206f, 208 Pu lp su rvival, 182 Pu lp tester, electric, for fractu red incisor crow n, 172 Pu lp therap y, ind irect, for cariou s p rim ary teeth, 143–144 Pu lp al exp osu re, of fractured p erm anent incisor crow n, 172 281 • INDEX Pulpectom y, for carious p rim ary teeth, 142 Pu lp itis, 140–141, 140t Pu lp otom ies for cariou s p rim ary teeth, 144 for fractu red p erm anent incisor crow n, 173 Pyram id al roots, 202 Q Qu ad helix app liance, for bu ccal u p p er canines, 23, 24f in bilateral crossbite, 93t for cleft lip and p alate, 128, 128f in p osterior crossbite, 89–90, 90f Qu ick-check m ethod , of tooth-size d iscrep ancy, 37 R Rad iographic investigations for child ren w ith d isabilities, 158–160, 159b in increased overbite, 74 Rad iography of absent u pper lateral incisors, 12 for ad olescents, w ith caries, 136–138, 136f in am elogenesis im p erfecta, 204 in anterior op en bite, 83 in bilateral crossbite, 92 of buccal upp er canines, 22 for cleft lip and p alate, 127 in d entinogenesis im p erfecta, 206 for d isp laced p rim ary incisor, 169–170 in d ou ble teeth, 201 for incisor crossbite, 63 for increased overjet, 57 for infraocclu d ed p rim ary m olar, 52–53 intraoral, p oor qu ality rst p erm anent m olars and , 189 of late low er incisor crow d ing, 100 for reverse overjet, 67, 69–70 root fractu res and , 175 root resorption, 48–49, 49f of severe crow d ing, 27 transp osition of canines, 47 unerupted teeth, 7, 7b Rad iology, in p osterior crossbite, 89 Rad iotherapy, sid e effects of, 165b Rapid m axillary exp ansion (RME), in bilateral crossbite, 93–95, 93b–94b, 93t, 94f, 96b, 96f not feasible, 95 su rgically assisted , 93t Recession, labial, 64 Recurrent aphthae aetiological factors in, 218, 218b d ietary allergens in, 218b therapy for, 218b Red u ction of d eep overbite, 78, 78b proced ure in, of root fractu red incisor, 176 Referral letter, to orthod ontist, 18f Regu rgitation, gastric, 210 Reinforcem ent, positive, 149–150 Rem ovable ap pliances w ith absent u p p er lateral incisors, 14, 14b, 14f in bilateral crossbite, 93t in increased overbite, 75 w ith p alatal canines, 41 in posterior crossbite, 89 w ith severe crow d ing, 29, 30f therap y, tooth m ovem ents and , 118 Rem ovable retainers, 122–123, 123b Rep air-related resorp tion, 180 Rep lacem ent resorp tion, 180 Rep lantation, avulsed incisor and , 180, 181f Resin-retained brid ge, for absent u p p er lateral incisors, 14, 14b, 15f Resorp tion (root), 49f avu lsed incisor and , 180, 180b cau ses of, 49 d rifting incisors, 109 incid ence of, 49 orthod ontically ind uced , 119, 120b p revention of, 120, 120b rad iographs of, 49 short- to m ed iu m -term p rognosis w ith, 50, 50f treatm ent op tions for, 49–50, 50b Restoration for am elogenesis im p erfecta, 204t of rst p erm anent m olar, 214–215 su rface tooth loss and , 211 Retainer, typ e of, 45, 45f Retaining, 41 Retention in bilateral crossbite, 94 in crow d ing, 28 in increased overbite, 75 orthod ontic, role of general d ental p ractitioner (GDP) in, 123, 124t in p alatal canines, 41 p lan, in tooth m ovem ent, 122, 122b Retraction, of u p per canines, 119 Reverse overjet, 231f Reversible pu lp itis, 140, 140t RME. see Rap id m axillary expansion (RME) Root lled incisor, non-vital bleaching for, 192 lling m aterial, orthod ontic tooth m ovem ent, 9 fractu red p erm anent incisor, 175–178, 252f in incisor trau m a, fractu re, 109 resorp tion, m onitoring of, 49–50 shap e abnorm alities of, 202 Root canal obliteration of, in d entinogenesis im perfecta, 206f treatm ent, avu lsed incisor and , 179–180 Rotational correction, in increased overbite, 76 Rotations, u p p er p rem olar, cau ses of, 27 S SARPE. see Su rgically assisted rap id m axillary exp ansion (SARPE) Screw tu rning, w ith palatal canines, 41 Sed ation, oral, 154 Sensibility testing, 177, 177b of incisor, 7 for root resorp tion, 49 Sensitivity w ith erosive loss, treatm ent of, 210–211 w ith p oor qu ality rst p erm anent m olars, 189 Severe class III skeletal p attern, as interpretation of nd ings, in TMJ p ain and prom inent chin, 104 Severe crow d ing, 225f Severe hyp od ontia, 200, 200f Shap e, canines/ incisors, 13 Shap ed teeth, abnorm ally, 199–202 Shell teeth, 207 Size canines/ incisors, 13 d iscrepancy, 37, 38b Skeletal p attern in anterior open bite, 82t, 84 in bilateral crossbite, 91, 92t of bu ccal u p p er canines, 22 in increased overbite, 73, 74t, 76–77 in increased overjet, 55–56, 57t in lingu al crossbite, 97 in posterior crossbite, 87, 88t Skeletal relationship s, cep halom etric analysis for, 271 Sm ile, attractive, 95, 95b Sm oking cessation of, 111 p eriod ontal d isease and , 111 SOCRATES, 140 Soft tissu es analysis, cep halom etric analysis for, 272, 272f increased overbite in, 73–74, 74t in increased overjet aetiology, 57t Sp ace closu re (therapeu tic), absent u pper lateral incisors, 13 creation absent u p per lateral incisors, 13 for crow d ing and bu ccal u p p er canines, 18, 18b–19b for u p p er p erm anent incisors, 2, 2b Sp eech w ith anterior op en bite, 81–82 w ith cleft lip and p alate, 126 Sp linting in root fractu res, 176 w ith TMJ p ain and p rom inent chin, 107 Stability of corrected overjet, 60 of crossbite correction, 64, 64f Stainless steel crow ns, p oor qu ality rst p erm anent m olars, 189 Steroid s, im p lications of, 269 Stom ach, acid ity of, and regurgitation, 209, 210b Stom atitis, p alatal (red p alate), w ith xed ap pliances, 114 Stress, TMJ p ain and , 103 Structured history form , 273, 273f–274f Stu d y m od els, of late low er incisor crow d ing, 100 Su blu xed incisor, 179f Su gar intake, red u ce, 114 Su gar-free chew ing gum , for ad olescents, w ith caries, 138 Su pernu m erary teeth aetiology of, 7, 7b treatm ent p lan for, 8 u neru p ted u p p er p erm anent central incisor d u e to, 6, 6b, 7f Su rface resorp tion, 180 tooth, loss or w ear erosion in, 211 in increased overbite, 74 Su rgically assisted rap id m axillary expansion (SARPE), in bilateral crossbite, 93t, 95, 95f–96f, 96b • 282 INDEX Su tu re splint, avu lsed incisor and , 181, 182f Sw allow ing p attern, in anterior op en bite, 81 Sw eetened d rink, early child hood caries and , 130 Synd rom es, associated w ith m issing teeth, 199 System ic d iseases, associated w ith ap hthae, 218 T TADs. see Tem porary anchorage d evices (TADs) Talon cusp, 201, 201f Tau rod ontism , 202 Teasing com p ared to bu llying, 55 history of, and incisor trau m a, 55 Teens late, low er incisor crow d ing in, 99–100 p rom inent chin and TMJ p ain, reassessed in, 103–104, 104b Teeth, affected by transposition of canines, 47 Tell-show -d o techniqu e, 149 Tem p orary anchorage d evices (TADs) in anterior op en bite, 85–86, 85f in overbite red u ction, 78 in severe crow d ing, 28–29 Tem p orom and ibu lar joint d ysfu nction synd rom e, 103 Tem p orom and ibu lar joint p ain and p rom inent chin, 102–108, 102f aim s of treatm ent of, 105 case m anage and , 105 surgical planning and , 105–106, 106b, 106f Ten H ove app liance, in d eep overbite, 79, 79f Tension zones, in tooth m ovem ents, 118, 118f, 119b Throm bosis, cavernous sinu s, 146 Thum b sucking, anterior op en bite d u e to, 83f Tip p ing m ovem ent, 118, 118b, 118f Titaniu m trau m a splint, avulsed incisor w ith, 179, 179f Tom ogram of incisor crossbite, 63, 63f for increased overjet, 57 of infraocclud ed prim ary m olar, 52, 53f for reverse overjet, 67, 69 Tongue scrap ers, 194 sw allow ing p attern in, w ith anterior open bite, 81 Tooth d iscoloration, hyp om ineralization, and hypop lasia, 191–194, 192b, 256f Tooth fragm ents, in fractu red perm anent incisor crow n and , 171, 171b, 172f Tooth m ou sse, for ad olescents, w ith caries, 138 Tooth m ovem ent, 118–124 m echanism for, 119 and related p roblem s, 240f slow rate of, 118 Toothbrushing, 194 for ad olescents, 151–152 w ith caries, 137, 137t early child hood caries and , 131–132 overzealous, 211 Tooth-size d iscrepancy (TSD), 37, 38b Transpalatal arch, 28–29 Transp osition, canines, 46, 47b aetiology of, 47 arch and teeth affected by, 47 classi cation of, 47 incid ence of, 47 positions of, correction of, 48 treatm ent for factors to consid er in, 47, 47t op tions in, 47, 47b Trau m a infection-related resorp tion and , 180–181 risk of, w ith increased overjet, 55, 55b up p er incisor, 58 Trau m atic overbite, 73, 73f, 74t TSADs, im p lications of, 269 TSD. see Tooth-size d iscrep ancy (TSD) Tuberculated teeth, 202 Turner ’s tooth/ hyp op lasia, 26 Tw in-Block ap pliance, 59, 59f in anterior op en bite, 84 effects of, and other fu nctional ap p liances, 59 fabrication of, 58 in increased overbite, 75 instructions for, 58–59 U Ulceration, oral, 216–218, 217b Uncooperative child , 246f and ad olescents, 149–156, 152b anxiety m anagem ent for, 152–154 behavior m anagem ent for, 149 com m unicative m anagem ent for, 149–150 d ental anxiety in, 152 inform ed consent for, 155 inhalation sed ation for, 150–151 treatm ent p lan for, 153–154 Uneru p ted teeth u p p er canines, 21–24, 22f u p p er central incisor, 5–10, 5f, 222f cau ses of, 6, 6b m anagem ent of, 10b Up p er arch crow d ing, 32, 42–44, 44f–45f Up p er perm anent central incisors, affected by m ottling, 195 Up p er rem ovable ap p liance therap y, 118, 119b to p rocline, for incisor crossbite, 64, 64f V Vacu u m form ed retainers, 30, 117, 122, 123f Varicella zoster viru s (VZV), 217 Veneers, com p osite, 192 d entinogenesis im perfecta and , 208 uorotic m ottling, 197–198 Vertical parallax, of anterior prem axilla, 7 Vital bleaching, for u orotic m ottling, 197 Vital p u lp ectom y, for cariou s p rim ary teeth, 144 Vitality of root fractured teeth, m aintain, 177, 178f tests, 175 for fractu red incisor crow n, 172 Voice control, 150 Vom iting, recu rrent, erosive loss, 210 VZV. see Varicella zoster viru s (VZV) W Water, ad olescent consu m p tion, 136 Wax registration for fu nctional ap p liances, reverse overjet, 68 of late low er incisor crow d ing, 100 in posterior crossbite, 88 White sp ot d em ineralization lesions, 194 Wire com posite, 117 sp u rs, w ith absent u p p er lateral incisors, 14, 14b, 14f

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Clinical problem solving in orthodontics and paediatric dentistry: clinical problem solving in orthodontics and paediatric dentistry - softcover, millett bdsc dds fdsrcps fdsrcs dorthrcseng morthrcseng, declan ; welbury mb bs bds phd fdsrcseng fdsrcps frcpch, richard.

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• About this title
• About this edition
• Focuses on clinical problem-solving in orthodontics and pediatric dentistry ― two closely-related topics that are usually separated into different texts.
• Offers practical help with treatment planning, guiding the reader through the process of decision-making.
• Provides two different approaches to coverage ― some topics include case scenarios with questions and answers; others include differential diagnosis with a focus on how to plan and manage treatment.
• Uses Evidence-Based boxes systematically to provide a rationale for treatment approaches.
• Includes colorful illustrations throughout to reinforce content.

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• Publisher Churchill Livingstone
• Publication date 2005
• ISBN 10  0443072655
• ISBN 13  9780443072659
• Binding Paperback
• Edition number 1
• Number of pages 208
• Rating 5 avg rating • ( 3 ratings by Goodreads )

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Clinical problem solving in orthodontics and paediatric dentistry.

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