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CHAPTER 12 COMPLEX NON – SKELETAL

PROBLEMS IN PREADOLESCENT CHILDREN: PREVENTIVE &

INTERCEPTIVE TREATMENT

CONTENTS

Eruption Problems ............................................................................................................................................................ 2

Transposition ................................................................................................................................................................. 2

Primary Failure of Eruption ........................................................................................................................................... 2

Impact of Radiation Therapy & Bisphosphonates ......................................................................................................... 3

Traumatic Displacement of Teeth (Management) ............................................................................................................ 3

Intrusion ........................................................................................................................................................................ 3

Extrusion ........................................................................................................................................................................ 3

Space Related Problems.................................................................................................................................................... 4

Excess Space .................................................................................................................................................................. 4

Generalized Spacing of Permanent Teeth without Protrusion .................................................................................. 4

Maxillary Dental Protrusion & Spacing ...................................................................................................................... 5

Missing Permanent Teeth .......................................................................................................................................... 5

Localized Moderate – Severe Crowding ........................................................................................................................... 7

Generalized Moderate & Severe Crowding ...................................................................................................................... 7

Expansion v/s Extraction in Mixed Dentition Treatment .............................................................................................. 7

Expansion for Treatment of Crowding in the Early Mixed Dentition ........................................................................ 8

Expansion for Crowding in the Late Mixed Dentition: Molar Distalization ............................................................... 8

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Early (Serial) Extraction ............................................................................................................................................ 10

The Borderline Crowding Case: What to Do? ................................................................................................................. 11

THE END .......................................................................................................................................................................... 11

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.

PRIMARY FAILURE OF ERUPTION

Primary failure of eruption is characterized by failure of some or all posterior permanent teeth to erupt even

though their eruption path has been cleared.

The cause is a failure of the eruption mechanism, apparently due to an abnormal periodontal ligament (PDL), and

because of the PDL abnormality, the unerupted permanent teeth do not respond to orthodontic force and cannot

be moved into the dental arch even though they are not ankylosed.

o If tooth movement is attempted, that tooth will ankylose after 1 – 1.5 mm.

Mostly affect permanent 1st molar.

Treatment Possibilities;

o Prosthetic replacement

o Acceptance of premolar occlusion in affected quadrant

o Segmental osteotomy or Distraction osteogenesis after growth completion.

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IMPACT OF RADIATION THERAPY & BISPHOSPHONATES

Effects of Radiotherapy or Chemotherapy on Teeth;

Missing teeth

Short roots

Eruption failure

o These teeth can be moved orthodontically without fear of tooth loss.

Orthodontic treatment should be attempted while bisphosphonates are being used.

TRAUMATIC DISPLACEMENT OF TEETH (MANAGEMENT)

If there is no any irreparable damage from dento alveolar trauma;

o Initial Treatment; reposition the tooth with finger pressure to normal position and out of occlusion. After

repositioning, stabilize the tooth with light wire or nylon filament for 7 – 10 days.

if the alveolar bone is also damaged along with tooth; teeth should be stabilized with a heavy wire

for approx. 6 weeks.

If after this initial treatment, tooth is not in normal position, creating esthetic problems, or occlusal interference,

then in them orthodontic treatment is indicated.

o These traumatic teeth should be moved cautiously because even

tipping force can lead to loss of vitality of tooth & root resorption.

o Before beginning orthodontic treatment, rule out horizontal or

vertical fracture of tooth.

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.

4 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

SPACE RELATED PROBLEMS

Irregular & malaligned teeth in the early mixed dentition arise from two major cause;

o Lack of adequate space for alignment resulting deflection of erupting tooth from its normal position.

o Interference with eruption which prevent permanent tooth from erupting on a normal schedule and in the

proper position.

Drifted & tipped teeth

Over retained primary teeth

Ankylosed primary teeth

Supernumery teeth

Transposed teeth

Ectopically erupting teeth

EXCESS SPACE

GENERALIZED SPACING OF PERMANENT TEETH WITHOUT PROTRUSION

EXCESS SPACE WITHOUT INCISOR PROTRUSION IN MIXED DENTITION

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.

MID – LINE DIASTEMA

It is a localized excess space problem.

Diastema more than 2 mm can be close by Mesial crown & root movement

if the situation demands bodily mesio – distal movement & NO retraction of central incisor teeth; then they are

treated by;

o attaching anterior segmental arch wire from central to central incisor, OR more anterior teeth.

o Initial alignment should be with a flexible wire followed by stiffer wire.

o 22 slot bracket, 18 mils round or 16 x 22 mil rectangular stainless steel wire are good choices.

o The force for moving incisors mesially will be provided with elastomeric power chains. Figure 12 – 8

o After space closure teeth are retained with fixed lingual retainer. Figure 12 – 9 A fixed retainer to maintain diastema closure. A bonded 17.5 mil multi strand wire with loops bent into the ends is

bonded to the lingual surfaces of anterior teeth to serve as a permanent retainer. This flexible wire allows physiologic

mobility of the teeth and reduces bond failure but can be used only when the overbite is not excessive.

o If the lateral incisors & canines have not erupted when diastema is closed, then removable retainer will

be given.

Retention Loss after Tx of Midline Diastema

o CAUSES

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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.

MAXILLARY DENTAL PROTRUSION & SPACING

AKA SPACING IN PERMANENT TEETH WITH PROTRUSION

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.

THIS CLOSING LOOP (ARROW) ARCH WIRE WAS USED TO RETRACT

PROTRUSIVE MAXILLARY INCISORS AND CLOSE SPACE. EACH LOOP WAS

ACTIVATED APPROXIMATELY 1 MM PER MONTH, AND THE POSTERIOR

ANCHORAGE WAS REINFORCED WITH HEADGEAR.

It there is deep bite along with overjet (dental

protrusion);

o In this case, above mentioned method of

treatment will bring upper & lower teeth into vertical contact & maxillary teeth cannot be retracted

enough to close space b/w them.

So in this condition, bite plate is given to allow eruption of posterior teeth to reduce deep bite and

after that, retracting maxillary anterior teeth.

MISSING PERMANENT TEETH

The most common congenitally missing permanent teeth are;

o Mandibular 2nd premolar

o Maxillary lateral incisors

MISSING 2ND PREMOLAR

Permanent 2nd premolars rarely develop after the age of 8 years.

TREATMENT OPTIONS for Missing 2nd Premolars;

o Retain Primary 2nd Molar

o Extract Primary 2nd Molar & mesial drift of permanent 1st molar

o Gradually reduce the size of 2nd premolar on one side & hemi sectioning of the primary tooth (containing

no any 2nd premolar) and pulp therapy so that the 1st permanent molar is mesially drifted into primary

molar space. – described in chapter 15

6 RETAIN PRIMARY 2ND MOLAR

if the patient has acceptable occlusion. o These primary molars can survive till 40 – 60 years of age. o Mesio – distal width is reduced to improve interdigitation of posterior teeth.

However, there are chances of resorption of roots of retained primary 2nd molar after reduction when contacted by adjacent

permanent teeth. Retention of primary molar also preserve alveolar bone for future prosthetic treatment.

If the space, profile & jaw relationships are PROTRUSIVE; EXTRACT THE PRIMARY 2ND MOLAR & Allow 1st

Permanent Molar to Drift Mesially & Anterior Teeth to Drift Distally for spontaneous space closure. o If 2nd premolar is missing in one quadrant and not in other, and also decision is made to extract the primary 2nd molar & allow

drifting. In this case we have to extract contralateral primary 2nd molar so that mesial drifting can occur on both sides to achieve

ideal class 1 relationship.

o If we don’t do this, then, because of over eruption of 2nd molar;

Missing upper 2nd Premolar alone on one side will result in Class II relationship

Missing lower 2nd premolar alone on one side will result in Class III relationship.

MISSING MAXILLARY LATERAL INCISORS

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.

LOCALIZED MODERATE – SEVERE CROWDING

Moderate – severe crowding of more than 3 mm result from;

o Severe space loss

o Ectopic eruption

Resulting in impaction of succedaneous tooth

Management & Tx. options of Localized Crowding in Posterior Tooth;

o Extract the impacted tooth & close the space.

It is easier than gaining space & is sensible Tx. in case of localized crowding in posterior areas. o Gain the space & encourage eruption of impacted tooth.

If space is to be gained bilaterally, distal molar movement is the method of gaining space and it is described later in this chapter.

Management & Tx. options for Localized crowding in Anterior Teeth;

o Most common problem in anterior region of localized crowding is Shift of dental midline (mostly

mandibular)

MANAGEMENT OF MIDLINE SHIFT

o IF THE MIDLINE IS MOVED & SPACE IS INADEQUATE;

Gain space & treat midline shift before

eruption of permanent canine.

Lingual arch is placed to maintain molar

symmetry & control its mesial drift.

Followed by placing brackets on the

incisors & correcting the midline with

coil springs.

Space can be gained by disking or

extraction of primary canine or molar.

After correction lingual arch is used as

retainer.

1 THIN ARROW; COIL SPRING, THICK ARROW; ARCH WIRE

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.

GENERALIZED MODERATE & SEVERE CROWDING

EXPANSION V/S EXTRACTION IN MIXED DENTITION TREATMENT

Children with the largest arch length discrepancies often have well – aligned incisors in the early mixed dentition

because both primary canines are lost due to ectopic eruption of permanent lateral incisors.

Potential severe crowding (future crowding) is observable in primary dentition; having following symptoms; ye

features agar kisi bache me present honge to samjhlo use future me severe crowding hogi, to is topic me ham

parhenge ke future ke severe crowding ko kese prevent Karen expansion karke ya extraction kerke.

o Little developmental spaces among primary incisors

o Crowding in primary dentition

o Severe irregularity of erupting permanent incisors

o Early loss of primary canine due to ectopic eruption of permanent lateral incisors.

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EXPANSION FOR TREATMENT OF CROWDING IN THE EARLY MIXED DENTITION

Anterior crowding & inadequate space in early mixed dentition is treated by;

o Correcting crowding and expansion. For facial movement of incisors, facial gingival tissue should be sufficient. If not consult about periodontal graft before

or after tooth movement.

Expansion options

o Maxillary dental or skeletal expansion Dental expansion by moving teeth facially

Skeletal expansion by opening mid palatal suture

o Mandibular buccal segment expansion by facial movement of teeth.

o Facial movement of incisors & distalization of molar in either arch.

Aggressive approach of expansion; use maxillary and mandibular lingual arches in complete primary dentition.

o This will increase both; arch perimeter & arch width.

o This treatment is maintained for different period during mixed dentition years.

Conservative Approach of Expansion; extract primary canine & place lingual arch so that incisors can align

themselves.

o With this approach only labiolingual irregularity of incisors will be corrected during alignment if space is

available.

o If there are rotational irregularities, then instead of lingual arch, fixed appliance is needed along with

extraction of primary canine.

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.

EXPANSION FOR CROWDING IN THE LATE MIXED DENTITION: MOLAR DISTALIZATION

So, we saw that the methods for gaining space are;

o Facial movement of anterior teeth.

o Transverse expansion of jaw with lingual arch or jackscrew expansion device.

o By moving permanent 1st molars distally.

1st two are mentioned in previous topic, here we are going to learn molar distalization.

Molar distalization in maxilla can be achieved by two methods based on age;

o Before age 12 intra oral appliance like head gear. temporary anchorage devices cannot be used in this age because of reduced bone density.

o After age of 12, by temporary anchorage devices. (TAD)

Distal movement of the lower first molar is very difficult and in reality the best that can be achieved is uprighting

of the incisor teeth with fixed appliance.

INDICATIONS FOR MOLAR DISTALIZATION

o Less than 4 – 5 mm per side space gain is required, it should be gained by tipping. Extra-oral traction using headgear will usually produce up to 2–3 mm per side (creating 4–5 mm space in total).

o All anterior teeth should be erupted, ideally 1st premolars for anchorage.

o Lip & maxillary dental protrusion should be normal or retrusive.

Because 1/3rd of movement for molar distalization also occurs in anterior teeth.

o Overjet should also be normal.

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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

Major advantage of headgear is simplicity, while major disadvantage is patient compliance.

Force for distalizing the molar is applied via a facebow directly to molars, while reciprocal force is not distributed

on other teeth.

The force should be constant & moderate because it is applied & concentrated on two teeth only.

o 12 – 14 hours per day is minimal time for wear.

o Approx. 400 gm of force per side is appropriate.

o The molar should be moved at a rate of 1mm/month. Typically, approx. 3mm of movement is required for distalizing the molar. So child will have to wear approx. 3 months.

Cervical or high pull headgear can be used but, high – pull headgear is best option for molar distalization.

HIGH PULL HEADGEAR

OTHER APPLIANCES USED FOR DISTALIZING THE MOLARS & INCREASE THE ARCH CIRCUMFERENCE.

01) Bilateral coil springs

a. provide the force that is resisted by the anchorage of the primary molars

and the palate using a Nance arch.

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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PENDULUM APPLIANCE WITH BOTH A JACKSCREW FOR TRANSVERSE

EXPANSION AND MOLAR DISTALIZING SPRINGS (THIS MODIFICATION IS

CALLED THE T-REX APPLIANCE).

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.

After molar distalization, the retention will be given by lingual arch.

EARLY (SERIAL) EXTRACTION

It is timed extraction of primary, and ultimately, permanent teeth to relieve sever crowding.

Serial extraction makes lateral comprehensive treatment easier & quicker.

Serial extraction is reserved for severe crowding.

o space discrepancy greater than 10 mm per arch.

Serial extraction should be done in those child who does not have skeletal contribution to malocclusion.

STEPS of Serial Extraction

Extraction of four Primary canines

o Extraction of primary incisors if necessary, followed by extraction of primary canines to allow eruption of

& alignment of permanent incisors.

o Undertaken at the age of approximately 8 years in a child of average dental development, at the time of

eruption of the maxillary lateral incisors. This should allow spontaneous alignment of the incisors at the

cost of canine space.

Extraction of 1st Primary Molars

o This extraction is done so as to influence the permanent 1st premolar to erupt before canine so that

permanent 1st premolars can be extracted.

o Undertaken at the age of approximately 9 years when the roots of the first premolars are half – 2/3rd

formed. The aim is to encourage the first premolars to erupt before the canines, which is often not the

case in the lower arch.

Because in maxilla, premolars erupt naturally before canine, while in mandible, premolar erupt

after the canine.

Extraction of the first premolars

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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.

A complication of serial extraction is premature eruption of the permanent canines, because after the removal or primary 1st molar, if 1st premolar does not erupt before canine, then canine will come out because of space available for its eruption. When this occurs, the first premolars are impacted between the canines and the second premolars. In this situation the first premolars usually have to be surgically removed (a procedure often called enucleation).

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 BORDERLINE CROWDING CASE: WHAT TO DO?

Early extraction will be done only in few patients with severe crowding.

Early expansion provide benefit in later comprehensive treatment not in early mixed dentition.

So the best option in early mixed dentition for crowding is to maintain leeway space if the space is adequate or

borderline by;

o Extraction of primary canines followed by placement of lingual arch to maintain space.

THE END

Author: DR. SARANG SURESH HOTCHANDANI

Email: hotchandaniss@hotmail.com