Moderate Nonskeletal Problems in Preadolescent

Children: Preventive and Interceptive Treatment in

Family Practice
AAO recommends for children to go the orthodontist before the age of 7

Orthodontic Triage: Distinguishing Moderate From Complex Treatment Problems

Logical scheme for orthodontic triage for children (5steps) – adequate database and thorough problem list – cephalometric
radiograph is not required but appropriate dental radiographs, dental casts and photographs, space analysis are essential

Step 1: Syndromed and Developmental Abnormalities

- Separate out patients with facial syndromes or similarly complex problems
- Complex medical treatments, such as radiation bisphosphonates and growth hormones can affect dentofacial
development and responses to treatment

Step 2: Facial Profile Analysis

ANTEROPOSTERIOR AND VERTICAL PROBLEMS

- Class II and class III problems and vertical deformities of long-face and short-face require cephalometric evaluation to
plan appropriate treatment and its timing
- Class II treatment can be deferred until near adolescence
- Class III treatment for maxillary deficiency should be addressed earlier; for protrusive mandible requires either class III
elastics to skeletal anchors during adolescence or orthognathic surgery after growth has essentially stopped
- Treatment of long and short face problems usually can be deferred until adolescence – long-face or open bite can
improve during preadolescent growth, short-face problems can be managed well with comprehensive treatment during
adolescence unless there is maxillary palatal gingival damage due to deep bite

EXCESSIVE DENTAL PROTRUSION OR RETRUSION

 - excessive protrusion of incisors (bimaxillary protrusion, not excessive overjet) usually is an indication for premolar
extraction and retraction of the protruding incisors -> late in the mixed dentition or early in the permanent dentition

Step 3: Dental Development

- problems involving dental development often need treatment as soon as they are discovered

ASYMMETRIC DENTAL DEVELOPMENT

- asymmetric eruption (one side ahead of other by 6 months or more) -> selective extraction of primary or permanent
teeth

MISSING PERMANENT TEETH

- usually these teeth are maxillary lateral incisors and mandibular second premolars
- for missing posterior teeth is it possible to: 1) maintain the primary tooth 2) extract the overlying primary teeth and
allow the adjacent permanent teeth to drift 3) extract the primary teeth followed by immediate orthodontic treatment
4) decoronate the ankylosed primary tooth and replace with a later implant 5) replace the missing teeth prosthetically
or perhaps by transplantation or implant later
- for missing anterior teeth = maintain the primary teeth is often less of option because of the esthetics and spontaneous
eruption of adjacent permanent teeth into the space of the missing tooth -> early evaluation and planning are essential

SUPERNUMERARY TEETH

- 90% of all supernumerary teeth are found in the anterior part of the maxilla
- Presence of multiple supernumerary teeth indicated a complex problem, syndrome or congenital abnormality such as
cleidocranial dysplasia
- Single supernumeraries that are not malformed often erupt spontaneously, causing crowding
 OTHER ERUPTION PROBLEMS

- Ectopic eruption – eruption in the wrong place or along wrong eruption path; often leads to early loss of primary tooth
- Transposition of tooth

Step 4: Space Problems

- One possibility is for the incisor teeth to remain upright and well positioned over the basal bone of the maxilla or
mandible and then rotate or tip labially or lingually -> potential crowding is expressed as actual crowding
- The other is for the crowded teeth to align themselves completely or partially at the expense of the lips, displacing the
lips forward and separating them at rest
- For localized space loss of 3mm or less -> lost space can be regained
- For total arch space shortage of 5mm or less or crowding with adequate space, repositioning incisors labially or space
management, respectively during the transition is appropriate
- Space discrepancies of approximately 6mm or more, with or without incisor protrusion, constitute complex treatment
problems
- Severe crowding of 10mm or more also requires careful and complex planning

Step 5: Other Occlusal Discrepancies

- Whether crossbite and overbite or open bite should be classified as moderate or severe is determined for most children
from their facial form
- Posterior crossbite in preadolescent – moderate if no severe crowding is present. It should be treated early if child shifts
laterally from the initial dental contact position; if skeletal posterior crossbite is treated in adolescence, it will require
heavier forces and more complex appliances
- Anterior crossbite – usually reflects class III jaw discrepancy but can arise from lingual tipping of the upper incisors or
crowding as they erupt
- Excessive overjet, with the upper incisors flared and spaced, often reflects a class II skeletal problem but also can
develop in patients with good jaw proportions
- Anterior open bite in young child with good facial proportions usually needs no treatment – spontaneous correction with
additional incisor eruption
- Complex open bite (one with skeletal involvement or posterior dental manifestations) or any open bite in an older
patient whose teeth have erupted is severe
- Traumatically displaced erupted incisors -> risk of ankylosis after healing, especially after traumatic intrusion. Injuries in
older patients and involve less 4mm of intrusion -> observation

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Management of Occlusal Relationship Problems

Posterior Crossbite
- Usually results from narrowing of the maxillary arch and often present in
children with prolonged sucking habits
- Due to narrow maxilla or due to lingual tipping of the maxillary teeth
- If child shifts on closure or if the constriction is severe enough to significantly
reduce the space within the arch -> early correction is indicated, if not it can be
deferred a little
- Determine whether any associated mandibular asymmetry is the result of shift
of the lower jaw due to dental interferences or is due to a true maxillary or
mandibular asymmetry
- Posterior crossbite is related to skeletal maxillary retrusion or mandibular
protrusion
- Determine whether crossbite is skeletal or dental
- Heavy force and rapid expansion are not indicated in the primary or early
mixed dentition -> significant risk of distortion of the nose if this is done in
younger children
- Three basic approaches to the treatment of moderate posterior crossbite
1) Equilibrium to eliminate mandibular shift – solely to occlusal interference
caused by the primary canines or primary molars; can be diagnosed by carefully
positioning the mandible in centric occlusion, requires only limited equilibration
of the primary teeth to eliminate the interference and the resulting lateral shift
into crossbite
2) Expansion of a constricted maxillary arch – even a small constriction creates
dental interreferences that force the mandible to shift to a new position for
maximum intercuspation; if the permanent first molars are expected to erupt in
less than 6 months, it is better to wait for their eruption so that correction can
include these teeth if necessary; the preferred appliance for preadolescent is
adjustable lingual arch that requires little patient cooperation –
W-arch and the quad-helix are reliable and easy to use
quad-helix – more flexible version, best indication – combination
of posterior crossbite and finger-sucking habit
expansion should continue at the rate of 2mm per month (1mm
per side) until the crossbite is slightly overcorrected
3) Unilateral repositioning of teeth – move selected teeth on the
constricted side, can be done by using different length arms on W-
arch or quad-helix
- Crossbite elastics – 6 ounces, 3/16-inch
 -

Anterior Crossbite
ETIOLOGY

- Differentiate skeletal problems of deficient maxillary or excessive mandibular growth from crossbites due only to
displacement of teeth. If the problem is truly skeletal, simply changing the incisor position is inadequate treatment,
especially in more severe cases
- Most common etiologic factor – lack of space for the permanent incisor

TREATMENT OF NONSKELETAL ANTERIOR CROSSBITE

- Early mixed dentition correction for two reasons: 1) lingually positioned maxillary incisors limit lateral jaw movement,
these teeth or their mandibular counterparts sometimes sustain significant incisal abrasion 2) gingival recession is a risk
for anterior teeth in crossbite, especially for the lower incisors, when oral hygiene is less than ideal and gingival
inflammation occurs
- Adequate space for tooth movement
a) Removable Appliance Therapy
- removable appliance, using fingersprings for facial movement of the maxillary
incisors, if after 2 months the teeth in the opposing arch are moving in the same
direction – bite can be opened by adding orthodontic banding cement to the
occlusal surfaces of the lower posterior molars
- requires nearly full-time wear to be effective and efficient, if the fingersprings are
activated 1,5-2mm, they will produce approx. 1mm of tooth movement in month;
1-2 months of retention with passive appliance is usually sufficient
- or less frequently – active labial bow for lingual movement of mandibular incisors
b) Fixed Appliance Therapy
- 2x4 fixed appliance – 2 molar bands, 4 bonded incisor brackets -> finishing with rectangular wire is required even in
early mixed dentition
 Anterior Open Bite
ORAL HABITS AND OPEN BITES

- With normal vertical facial proportions – most likely caused by habit such as thumb- or finger-sucking
- Disproportionately large lower anterior face height with severe anterior open bite indicates skeletal problem (excessive
vertical growth and rotation of the jaws)
- Many of the transitional and habit problems resolve with either time or cessation of the sucking habit
a) Effects of Sucking Habits
- Extent to which such habit affect eruption depends on its frequency (hours per day) and duration (months or years)
- Frequent and prolonged sucking – maxillary incisors are tipped facially, mandibular incisors are tipped lingually and
eruption of some incisors is impeded, overjet increases and overbite decreases, posterior crossbite with V-shaped arch
form
- Increased prevalence of posterior crossbite with pacifiers, especially with pacifier use for more than 18 months
- As long as the habit stops before the eruption of the permanent incisors, most of the changes resolve spontaneously
with the exception of posterior crossbite
- Pacifier should be taken away at max. age of 2
b) Nondental Intervention
- Adult approach -> talking
- Reminder therapy – secure an adhesive bandage with waterproof tape on the finger that is sucked
- Reward system
c) Appliance Therapy
- Cemented reminder appliance that impedes sucking – maxillary lingual arch
with anterior crib device; good to leave the crib for 6 months after the habit has
apparently been eliminated
 -

Deep Bite
- Reduced lower face height, lack of eruption of posterior teeth or overeruption of the anterior teeth
- All of them need more complex treatment, rarely treated in the mixed dentition phase

Management of Eruption Problems

Over retained Primary Teeth

- Permanent should replace its primary predecessor when approx. ¾ of the root of permanent tooth has formed
- Primary tooth that is retained beyond this point should be removed because it often leads to gingival inflammation and
hyperplasia that cause pain and bleeding and sets the stage for deflected eruption paths of the permanent teeth that
can result in irregularity, crowding and crossbite
- If the tooth does not exfoliate by itself, extraction is indicated
- Most over retained primary mandibular molars have either mesial or distal root still intact and hindering exfoliation

Ectopic Eruption
- Permanent tooth erupts on a deviant eruption path
- Often causes damage to the roots of other teeth

LATERAL INCISORS

- When both mandibular primary canines are lost as the lateral incisors erupt – either substantial “incisor liability” or
there is true arch length shortage

MAXILLARY FIRST MOLARS

- Permanent first molar – if the blockage of eruption persists for 6 months or if resorption continues to increase,
treatment is indicated
 - Move ectopically erupting tooth away from the primary molar it is resorbing – 22-mil brass
wire looped and tightened around the contact between primary second molar and the
permanent molar is suggested; tightened at each adjustment visit, approx.. every 2 weeks
- Steel spring clip separator – difficult to place if the point of contact between the permanent
and primary molars is much below the cementoenamel junction of the primary molar; they can
be activated on a biweekly basis
- Elastomeric separators – wedged mesial to the first molar, but not recommended; potential to
dislodge in apical direction and cause periodontal irritation
- Band and looped spring – if the movement is not sufficient it can be reactivated in 2 weeks

MAXILLARY CANINES

- If at age of 10 there is no observable or palpable facial canine bulge -> ectopic eruption of maxillary canines should be
considered
- Impaction of the canine and/or resorption of permanent lateral and/or central incisor roots
- Extraction of the primary canine with maxillary expansion appears to encourage improved permanent canine eruption

SUPERNUMERARY TEETH

- Can disrupt normal eruption of other teeth and cause crowding or spacing
- Treatment is aimed at extracting
- Most common location is the anterior maxilla
- When multiple supernumerary teeth are discovered or suspected – difficulty of diagnosis and treatment is amplified

DELAYED INCISOR ERUPTION

- More than a year past the normal eruption time and adjacent teeth have erupted – no excuse for delaying treatment

ANKYLOSED PRIMARY TEETH

- Constitute a potential alignment problem for the permanent teeth

 - Maintaining it until an interference with eruption or drift of other teeth begins to occur -> extract and place a lingual
arch or other appropriate fixed appliance if needed
- Ankylosed primary tooth has no permanent successor -> should be extracted before large vertical occlusal discrepancy
develops or can be decoronated

Space Analysis: Quantification of Space Problems

- Reducing protrusion – reduced amount of available space
- Moving facially retroclined teeth – more space available
- Deep overbite and accentuated curve of Spee – leveling the arch will make teeth more protrusive

Principles of Space Analysis

- Comparison between the amount of space available and space requires
- Space available – mesial of one first molar to the other
- Space required – measuring mesiodistal width of each erupted tooth

Estimating the Size of Unerupted Permanent Teeth

1. Measurement of the teeth on radiographs – periapical
radiographs; proportional relationship
2. Estimation from proportionality tables –
3. Tanaka and Johnston – for children from European
population

Treatment of Space Problems

Premature Tooth Loss with Adequate Space: Space Maintenance

- Early loss of primary tooth presents potential alignment problem
- If permanent successor will erupt within 6 months, space maintainer is unnecessary
- Monitored 3-6 months intervals

BAND-AND-LOOP SPACE MAINTAINERS

- Unilateral fixed appliance indicated for space maintenance in the posterior segments
- Teeth with SS crowns should be banded like natural teeth
- Survival rate of around 18 months, dement failure cited as the most frequent problem
- Evaluate space maintainers at routine recall visits

PARTIAL DENTURE SPACE MAINTAINERS

- Most useful for bilateral posterior space maintenance

- Also in conjunction with replacement of missing primary incisor or delayed permanent incisor
eruption

DISTAL SHOE SPACE MAINTAINERS

- Appliance of choice when primary second molar is lost before eruption of the permanent first molar
- Metal or plastic guide plane along which permanent molar erupts – attached to fixed or removable
retaining device
- Guide plane must extend into the alveolar process so that it is located approx. 1mm below the mesial
marginal ridge of the permanent first molar

LINGUAL ARCH SPACE MAINTAINERS

- Space maintenance when multiple primary posterior teeth are missing and the permanent incisors have erupted
 - Can be soldered to the molar bands or can be removable
- Should be positioned to rest on the cingula of the incisors, approx. 1-1.5mm off the soft tissue
- Survival time is estimated at less than 24 months
- In maxilla – Nance arch or TPA

Localized Space Loss (3mm or less): Space Regaining

- Up to 3mm of space can be reestablished in localized area

MAXILLARY SPACE REGAINING

- Easier to regain in the maxillary than in the mandibular arch

- Distal tipping and de-rotation often are satisfactory to regain 2-3mm
- Unilateral space regaining with bodily movement of the permanent first molar
– fixed appliance with coil spring on segmental archwire with support of
modified Nance arch

MANDIBULAR SPACE REGAINING

- Unilateral mandibular space regaining – fixed appliance, lingual arch and coil spring
- If space is lost bilaterally – lip bumper or adjustable lingual arch – posterior movement of molars can occur and forward
movement of the incisors, some expansion also can be done
- Lingual arch can be left as space maintainer but lip bumper should be replaced

Mild-to-Moderate Crowding of Incisors with adequate space

IRREGULAR INCISORS, MINIMAL SPACE DISCREPANCY

- Up to 2mm of incisor crowding may resolve spontaneously without treatment during transition from primary to the
mixed dentition

Space Deficiency Largely Due to Allowance for Molar Shift: Space Management
- Moderate crowding but little or no space discrepancy -> lingual arch in the late mixed dentition, before the second
primary molars exfoliate
- Incisor segment is straight, without anterior arch curvature -> extraction of primary canines usually leads to spacing of
the incisors or maintenance of essentially the same arch form

Generalized Moderate Crowding

 - Generalized arch length discrepancy of 2 to 4mm and no prematurely missing primary teeth can be expected to have
moderately crowded incisors

Other Tooth Displacements

SPACED AND FLARED MAXILLARY INCISORS

- In children with class I molar and good facial proportions – space analysis should show space available is excessive
rather than deficient; often in mixed dentition after prolonged thumb-sucking and frequently in connection with some
narrowing of the maxillary arch -> appears “tongue thrust” which is not the cause of the protrusion or open bite and
should not be the focus of therapy!
- Upper incisors are flares forward and no contact with lower incisors -> can be retracted quite satisfactorily with
removable appliance – Hawley-type appliance using multiple clasps and labial bow

MAXILLARY MIDLINE DIASTEMA

- Ugly duckling stage of development – flared and spaced incisors -> tend to close spontaneously when canines erupt and
incisor root and crown positions change
- When larger diastema (>2mm) is present -> midline supernumerary tooth or intrabony lesion must always be suspected
- Sometimes frenum attachment is blamed – early frenectomy should be avoided