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Complex Non - Skeletal Problems in Preadolescent Children: Preventive & Interceptive Treatment
Complex Non - Skeletal Problems in Preadolescent Children: Preventive & Interceptive Treatment
Complex Non - Skeletal Problems in Preadolescent Children: Preventive & Interceptive Treatment
CHAPTER 12
COMPLEX NON – SKELETAL
PROBLEMS IN PREADOLESCENT
CHILDREN: PREVENTIVE &
INTERCEPTIVE TREATMENT
CONTENTS
Eruption Problems ............................................................................................................................................................ 2
Transposition ................................................................................................................................................................. 2
Intrusion ........................................................................................................................................................................ 3
Extrusion ........................................................................................................................................................................ 3
Expansion for Crowding in the Late Mixed Dentition: Molar Distalization ............................................................... 8
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ERUPTION PROBLEMS
TRANSPOSITION
Definitions; it is positional interchange of two adjacent teeth.
o Caused genetically
Prevalence OR Most Common Transposed Teeth;
o Early Mixed Dentition; b/w permanent mandibular lateral incisor & mandibular permanent canine.
o Later Mixed Dentition; permanent maxillary canine & Premolar (Most Common) Maxillary canine &
Maxillary lateral.
Treatment of Transposition b/w Permanent Mandibular Lateral Incisors & Mandibular Permanent Canine;
o Caused due to distal eruption of mandibular lateral incisors resulting resorption of primary mandibular
canine & primary 1st molar.
o Treatment require repositioning the lateral incisor mesially by;
Bonding the tooth or gaining surgical access to tooth and applying traction to tip the tooth back
to its natural position followed by bodily movement of erupted tooth. getting anchorage by
lingual arch.
o Early intervention advantage is that simple tipping movement will treat the problem.
o The treatment should begin before the active eruption of canine to prevent the resorption of root of
mandibular lateral incisor.
Treatment of permanent maxillary canine & Premolar OR Maxillary canine & Maxillary lateral transposition;
o It is mostly caused by canine, so treatment will be to bodily repositioning of canine; by translating the
canine from lingual or facial side of other tooth.
o However, the best approach is that;
If the tooth is partially transposed – then move that tooth to total transposition. While,
If the tooth is fully transposed – leave it there.
o In both of these condition, reshape the transposed tooth to improve its appearance.
o We are not moving that transposed to tooth to their original position because difficulty in correcting
transposition is more difficult than reshaping the tooth in that abnormal transposed position.
INTRUSION
If the patient under 12 years old and apex is open;
o Best option is re – eruption OR Extrusion
o During re – eruption time tooth is monitored for pulp vitality. If
any condition to pulp occurs, manage accordingly.
o Treatment begins with elastomeric chain followed by;
Heavy base arch wire complemented by a NiTi overlay
wire for rapid tooth movement.
Base wire should be stepped facially to allow the
bracketed tooth pass on lingual side of base wire.
If the apex is closed & intrusion is less than 6 mm.
o Treatment is re – eruption or orthodontic.
Sever intrusion more than 6 mm, & age above 12 years
o Treatment is surgery due to time involved in orthodontic treatment.
Intruded teeth are initially repositioned to improve access for endodontic treatment.
Within 2 weeks of injury tooth should move to its pre trauma position, if not; then gingivectomy should be
performed for easy repositioning with orthodontic treatment.
EXTRUSION
If extruded teeth are not repositioned at the time of injury, they pose a difficulty in their reduction.
orthodontic intrusion of extruded teeth is avoided because of;
o bony defects on intrusion
o loss of pulp vitality (especially lateral incisors)
o decreased bony support
o abnormal crown – root ratio
so the best treatment option for extruded teeth is reshaping the elongated tooth by crown reduction.
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If the traumatically injured anterior teeth cannot be restored is to retain the root of the compromised tooth until
vertical growth is completed followed by placement of implant to prevent ridge resorption & need for bone grafting.
If the tooth is compromised can still be moved orthodontically, it can be repositioned and root buried is
performed.
o Root Burial; it involves de – corination (removal of clinical crown) roots are left in place and the overlying
soft tissues are closed.
o That root can be removed or implant is placed through it. Figure 12 – 7
EXCESS SPACE
Results from;
o Small teeth in normal – sized arches
o Normal teeth in large arches
Treatment in this condition will be allow eruption of all remaining permanent teeth followed by orthodontic
treatment by fixed appliances.
Failure of gingival elastic fibers to cross midline when a large diastema is preset.
Presence of large & inferiorly attached labial Frenum.
o Frenectomy should be done AFTER treating midline diastema because it is difficult to determine the
contribution of Frenum in midline diastema.
That’s why frenectomy before diastema treatment is contraindicated.
Most common non skeletal cause of maxillary dental protrusion & spacing is finger – sucking habit.
Most common SKELETAL cause of this problem is Class 2 malocclusion.
If there is no any deep bite & space available, this problem can be treated by removable appliances as mentioned
in chapter 11.
If, bodily movement, correction of rotations is required – Fixed appliance therapy is indicated.
o In these cases, a closing loop arch wire is used with bands on posterior teeth & brackets on anterior teeth.
Retracting & space – closing force is applied via closing loops or elastomeric power chains.
o In this condition, rectangular arch wire should be used to control the tipping of teeth, because
uncontrolled tipping will cause uprighting of anterior teeth resulting rabbited teeth.
o Bodily incisor retraction will place large amount of opposing force on posterior teeth, that’s why
reinforced anchorage is obtained in this
condition via headgear.
Headgear should be chosen after consideration of
vertical facial & dental characteristics.
When maxillary lateral incisors are missing, one of the following Sequeale occurs;
o Erupting permanent canine resorb the primary lateral incisor & substitute for missing lateral incisor
followed by retention of primary canine.
But most primary canines are lost by adolescence even if they have no any successor permanent canine below them.
o Retention of primary lateral incisor & normal eruption of permanent canine.
Treatment Option of Missing Permanent Lateral Incisors; Have the permanent canine erupt in the space of missing
permanent lateral incisor.
o if the prosthetic Tx. is planned; allow the canine to erupt in lateral incisor space for development of
alveolar bone in that area followed by distalization of canine so that space can be opened for implant
placement.
o If prosthetic treatment is not planned; allow the canine to erupt in lateral incisor space & prepare it in the
shape of lateral incisors followed by extraction of retained primary canine, so that premolar & other
posterior teeth can be drifted mesially.
This type of space closure is best option in those patient who has protruded incisors & molars in class II relationship.
Because in that situation we can use reciprocal space closure mechanism b/w anterior & posterior teeth for
closing the spaces.
2nd mentioned space closure technique is avoided in patients with;
o Class 1 molar relationship
o Class 3 molar relationship
Will create anterior cross bite on retraction of incisors.
Unilateral orthodontic space closure is avoided in anterior areas;
o Either place implant for aesthetic purpose OR
o Remove contralateral permanent lateral incisors before eruption of permanent canines to maximize
drifting pattern for space closure.
This same procedure also applies for mandibular missing permanent lateral incisors.
AUTO TRANSPLANTATION
Sometimes there are patients with congenitally missing tooth or teeth in one area but crowding in another. – in
that situation auto transplantation can be achieved.
o Auto transplantation; it is transplantation of teeth from one position to another in same mouth.
Teeth should be transplanted that has approx. 2/3rd – 3/4th root formed.
Most Common Teeth to be Transplanted;
o Premolars are moved into location of maxillary central incisors
o 3rd molars are moved into location of 1st molar.
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After this surgical tooth transplantation, approx. 3 months for healing is required followed by light orthodontic
force to achieve final tooth position & restorative treatment to recontouring of the transplanted tooth.
Success rate of this treatment is high & predictable.
If both primary canines are lost and central incisors are tipped lingually; this will decrease arch circumference &
increase the crowding.
o Place lingual arch to expand the arch & align the teeth.
Lower incisor teeth can be tipped 1 – 2 mm facially, which can result in up to 4 mm of additional arch length.
o Moderate arch length increase can be accomplished using a multiple bonded and banded appliances and
a mechanism of expansion.
Bands on molars & bonded brackets on incisors.
Force is generated by compressed coil spring on labial arch wire. (figure 12 – 22 B) (Proffit, 2012)
After treatment, lingual arch is given for retention.
Maxillary dental & skeletal expansion can also be achieved (to gain space for relief of crowding) by using jackscrew
expander.
o Expansion with this device must be done carefully & slowly.
o Vertical facial height should be normal or have short face but not long face.
Because molar distalization can also open the bite.
o That’s why overbite is should be greater than normal because after treatment it will get corrected.
HEADGEAR
OTHER APPLIANCES USED FOR DISTALIZING THE MOLARS & INCREASE THE ARCH CIRCUMFERENCE.
02) Pendulum appliance can be used that also gains anchorage from the palate but uses helical springs to supply the
force.
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03) Fixed appliance using palatal & dental anchorage and NiTi coil springs to slide the molars along heavy lingual wires.
Figure 12 – 25 D – F.
If the patient is above 12 years of age, the primary method of molar distalization will be temporary anchorage devices.
o Undertaken near the time of eruption of the canines, after confirming that they are buccally palpable and
mesially angulated, if there is sufficient crowding to warrant premolar extractions and if all other teeth
are present and sound.
However, enucleation should also be done carefully, because premature enucleation will
leave bone defect at the site of 1st premolar which will persists.
After the loss of 1st premolar, extraction space is closed by mesial drift of 2nd premolar & permanent 1st molar and
by distal drift of canines.
During alignment of incisors, there is some lingual tipping of lower incisors & also increase in overbite after serial
extraction.
o This can be prevented by alternative approach to serial extraction which begins with extraction of primary 1st molar instead of primary canine
so that there is less lingual tipping of incisors & less tendency to develop deep bite.
Major goal of serial extraction is to prevent future crowding. However, some crowding persists which is corrected
by fixed appliance in later comprehensive treatment.
THE END
Author: DR. SARANG SURESH HOTCHANDANI
Email: hotchandaniss@hotmail.com