Early age orthodontic treatment

www.ajlobby.com Early-Age Orthodontic Treatment www.ajlobby.com EARLY-AGE ORTHODONTIC TREATMENT Aliakbar Bahreman, DDS, MS Clinical Professor Orthodontic and Pediatric Dentistry Programs Eastman Institute for Oral Health University of Rochester Rochester, New York www.ajlobby.com Library of Congress Cataloging-in-Publication Data Bahreman, Aliakbar Early-age orthodontic treatment / Aliakbar Bahreman p ; cm Includes bibliographical references ISBN 978-0-86715-566-2 I Title [DNLM: Malocclusion therapy Adolescent Child Orthodontics, Corrective methods WU 440] 617.6’45 dc23 2013001198 © 2013 Quintessence Publishing Co, Inc Quintessence Publishing Co, Inc 4350 Chandler Drive Hanover Park, IL 60133 www.quintpub.com 54321 All rights reserved This book or any part thereof may not be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, or otherwise, without prior written permission of the publisher Editor: Leah Huffman Design: Ted Pereda Production: Angelina Sanchez Printed in China www.ajlobby.com Contents Foreword by J Daniel Subtelny Preface and Acknowledgments Introduction Part I Clinical and Biologic Principles of Early-Age Orthodontic Treatment Rationale for Early-Age Orthodontic Treatment Development of the Dentition and Dental Occlusion Examination, Early Detection, and Treatment Planning Part II Early-Age Orthodontic Treatment of Nonskeletal Problems Space Management in the Transitional Dentition Management of Incisor Crowding Management of Deleterious Oral Habits Orthodontic Management of Hypodontia Orthodontic Management of Supernumerary Teeth Diagnosis and Management of Abnormal Frenum Attachments 10 Part III Early Detection and Treatment of Eruption Problems Early-Age Orthodontic Treatment of Dentoskeletal Problems www.ajlobby.com 11 Management of Sagittal Problems (Class II and Class III Malocclusions) 12 Management of Transverse Problems (Posterior Crossbites) 13 Management of Vertical Problems (Open Bites and Deep Bites) Bonus Cases www.ajlobby.com Foreword This book is a compendium of significant and pertinent information related to earlyage orthodontic treatment, a subject that seems to have evolved into one of considerable controversy, with as many orthodontists expressing a negative reaction as a positive reaction to its benefits Dr Bahreman is a believer in early-age orthodontic treatment, and he expresses some cogent arguments founded in years of experience in practice and teaching to back up his beliefs In developing his treatise, Dr Bahreman outlines the development of the occlusion and/or malocclusion from the embryonic stages, when the foundation of the jaws and thereby the position of the dentition is first established Early-age orthodontics is not about the time it takes to orthodontically treat a problem; it is a story of growth, of variation in anatomy, and of muscle function and influences, a realization that it is the jaws that contain the teeth and that where the jaws go, the teeth will have to go, and both undergo varying influences as well as grow in varying directions Early-age orthodontics necessitates recognition of this process and aims to alter and redirect it whenever feasible and possible Dr Bahreman has undertaken a monumental effort in directing efforts along this path An extensive exploration of the literature is an added bonus, as the mechanical approaches are based on this literature In fact, the extensive review of the literature and its application to diagnosis and varying forms of therapy are worth a veritable fortune You may or may not agree with the basic premises, but you will have access to important information that will widen your scope of vision and thereby widen your treatment horizons To my mind, an ounce of prevention, if possible, is worth a pound of cure The reality of prevention can exist at the earliest stages of development www.ajlobby.com J Daniel Subtelny, DDS, MS, DDSc(Hon) Professor Emeritus Interim Chair and Director of Orthodontic Program Eastman Institute for Oral Health University of Rochester Rochester, New York www.ajlobby.com Preface After obtaining a master’s degree in orthodontics in 1967, I began my career at a newly founded dental school in Tehran My responsibilities included teaching and administrative duties at the university and maintenance of a very busy private practice In addition, I established both the orthodontic and pediatric dentistry departments at the university Many patients were being referred to the orthodontic department, and there were no qualified faculty members to help me provide care To rectify the situation, I designed an advanced level, comprehensive curriculum in orthodontics for undergraduate students, including classroom instruction, laboratory research, and clinical demonstrations Once the students completed the course, they could work in the clinic, thus temporarily solving the issue of the heavy patient load in the orthodontic clinic With additional staff now available, I could select patients, mostly children in the primary or mixed dentition, for some interceptive treatment Despite my difficulties in performing all of the aforementioned duties, this situation had a fortunate outcome It helped me to understand and discover the advantages of early-age orthodontic treatment, which was not common in those years During my more than 40 years of practice and teaching, especially in early orthodontic treatment, I have accumulated a considerable amount of educational data for teaching purposes I would like to share this experience and information with readers The public’s growing awareness of and desire for dental services, especially at an early age, have encouraged our profession to treat children earlier Despite the recommendation by the American Association of Orthodontists that orthodontic screening begin by the time a child is years old, many orthodontists still not treat children prior to the complete eruption of the permanent teeth I believe that this inconsistency is due to the educational background of orthodontists as well as a lack of familiarity with recent technical advancements and the various treatment options that are available for young patients www.ajlobby.com The therapeutic devices available for this endeavor are not complex, but deciding which ones to use and when to employ them are important steps As we make these decisions, we should also remember not to treat the symptom but rather to treat the cause My goal is to present the basic information necessary to understand the problems, to differentiate among various conditions, and to review different treatment options Case reports are examined to facilitate clinical application of the theory in a rational way To understand the morphogenesis of nonskeletal and skeletal occlusal problems, to detect problems early, and to intervene properly, we must look at all areas of occlusal development, including prenatal, neonatal, and postnatal changes of the dentoskeletal system, and explore all genetic and environmental factors that can affect occlusion at different stages of development In other words, we must have a profound understanding of the fundamental basis and morphogenesis of each problem and then apply this knowledge to clinical practice Thus, the goals of this book are: • To provide a comprehensive overview of all areas of dental development, from tooth formation to permanent occlusion, to refresh the reader’s memory of the fundamentals necessary for diagnosis and treatment planning • To emphasize all the important points of the developmental stages that must be recognized during examination of the patient to facilitate differential diagnosis Each tooth can become anomalous in a number of ways and to different degrees Occlusion and maxillomandibular relationships can vary in the sagittal, transverse, and vertical directions • To discuss the application of basic knowledge to practice by presenting several cases with different problems and different treatment options • To demonstrate the benefits of early-age orthodontic treatment, achieved by intervention in developing malocclusion and guidance of eruption Materials are presented in three parts: In Part I, “Clinical and Biologic Principles of Early-Age Orthodontic Treatment,” three chapters introduce and explain the concept of early-age treatment, describe its necessity and advantages, and discuss the controversies surrounding this topic; discuss the basic foundation of occlusal development, empowering the practitioner to detect anomalies and intervene as necessary; and illustrate the procedures, tools, and techniques available for diagnosis, emphasizing differential diagnosis and treatment planning for early-age treatment Part II, “Early-Age Orthodontic Treatment of Nonskeletal Problems,” consists of 10 Harris EF, Johnson MG Heritability of craniometric and occlusal variables: A longitudinal sib analysis Am J Orthod Dentofacial Orthop 1991;99:258–268 10 Subtelny JD Examination of current philosophies associated with swallowing behavior Am J Orthod 1965;51:161– 182 11 Proffit WR Lingual pressure patterns in the transition from tongue thrust to adult swallowing Arch Oral Biol 1972;17:555–563 12 Huang GJ, Justus R, Kennedy DB, Kokich VG Stability of anterior openbite treated with crib therapy Angle Orthod 1990;60:17–24 13 Van der Linden FPGM Vertical dimension In: McNamara JA, Brudon WL (eds) Orthodontics and Dentofacial Orthopedics Ann Arbor, MI: Needham Press, 2001:111–148 14 Subtelny JD, Sakuda M Open-bite: Diagnosis and treatment Am J Orthod 1964;50:337–358 15 English JD Early treatment of skeletal open bite malocclusions Am J Orthod Dentofacial Orthop 2002;121:563–265 16 Erverdi N, Keles A, Nanda R The use of skeletal anchorage in open bite treatment: A cephalometric evaluation Angle Orthod 2004;74:381–390 17 Strang RHW A Textbook of Orthodontia, ed Philadelphia: Lea & Febiger, 1950 18 Nanda R The differential diagnosis and treatment of excessive overbite Dent Clin North Am 1981;25:69–84 19 Neff C Tailored occlusion with the anterior coefficient Am J Orthod 1949;35:309–313 20 Diamond M The development of the dental height Am J Orthod 1944;30:589–605 21 Wylie WL The assessment of anteroposterior dysplasia Angle Orthod 1947;17:97–109 22 Baume LJ Physiological tooth migration and its significance for the development of the occlusion J Dent Res 1950;29:440–447 23 Flemming HB An investigation of the vertical overbite during the eruption of the permanent dentition Angle Orthod 1961;31:53–62 24 Canut JA, Arias S A long-term evaluation of treated Class II division malocclusions: A retrospective study model analysis Eur J Orthod 1999;21:377–386 25 Wasilewsky H Three Dimensional Evaluation of Overbite Relapse [thesis] Rochester, NY: University of Rochester, 1985 26 Popovich F Cephalometric evaluation of vertical overbite in young adult J Can Dent Assoc 1955;21:209– 222 27 Alexander TA, Gibbs CH, Thompson WJ Investigation of chewing patterns in deep-bite malocclusions before and after orthodontic treatment Am J Orthod 1984;85:21–27 28 Wragg PF, Jenkins WM, Watson IB, Stirrups DR The deep overbite: Prevention of trauma Br Dent J 1990;168:365– 367 29 Bollen AM Effects of malocclusions and orthodontics on periodontal health: Evidence from a systematic review J Dent Educ 2008;72:912–918 30 Nasry HA, Barclay SC Periodontal lesions associated with deep traumatic overbite Br Dent J 2006;200:557–561 31 Sonnesen L, Svensson P Assessment of pain sensitivity in patients with deep bite and sex- and age-matched controls J Orofac Pain 2011;25:15–24 32 Bell WH, Jacobs JD, Legan HL Treatment of Class II deep bite by orthodontic and surgical means Am J Orthod 1984;85:1–20 712 713 Chapter An 8-year-old boy with a long-term, chronic thumb-sucking habit developed a callus on his thumb (Figs 1A to 1D) He exhibited a Class II division malocclusion, an 8- to 10-mm open bite, contact only on the primary second and permanent first molars, and an overjet of about 17 mm Treatment: The patient was a very cooperative and determined boy, and after consultation with his parents, a removable appliance was planned for the first phase of treatment (Fig 1E) The patient’s level of compliance was excellent, and the habit was stopped after months The use of the appliance was continued for 12 months: He wore it 24 hours a day for months and at night only for months The habit was completely discontinued, and the open bite and overjet were reduced significantly, but the patient stopped treatment and returned years later Figures 1F and 1G show the patient’s occlusion during the permanent dentition He had a Class II division occlusion, 9-mm overjet, 2- to 3mm open bite, acceptable mandibular dentition, and severe maxillary anterior crowding with the canines out of the arch In accordance with the parents’ wishes and the patient’s age, the second phase of treatment was limited to the maxillary arch and extraction of two first premolars Figures 1H and 1I show the results of phase treatment Fig Treatment of an 8-year-old boy with a severe, long-term thumb-sucking habit He has a Class II division malocclusion, an 8- to 10-mm open bite, and a 17-mm overjet Only the primary second and permanent first molars make contact (A to C) Pretreatment occlusion (D) Calluses developed as a result of the sucking habit (E) Removable habit breaker (F and G) Occlusion of the permanent dentition 30 months after habit control (H and I) Posttreatment occlusion after phase therapy 714 Chapter An 18-year-old man presented with oligodontia He was missing 10 teeth, including third molars, and five remaining submerged primary molars had arrested the growth of the alveolar process The extreme spacing and tipping of all dentition, including distal tipping of the anterior teeth, had resulted in a bizarre occlusion (Fig 1A to 1F) Orthodontic problems included an anterior deep bite, severe open bite affecting the buccal segments (no bite), interdental spacing, mesial tipping of all molars, and distal tipping of all remaining permanent teeth The patient’s major complaint was a chewing problem; because of financial problems he did not consider esthetics to be an issue This is a clear example of the necessity for general practitioners to understand the importance of early detection of and intervention in ankylosed primary molars as well as hypodontia Timely extraction of the ankylosed teeth and proper space maintenance, instead of placement of amalgam restorations, would have restored the integrity of the occlusion of this patient earlier and more easily Treatment: After extraction of all primary ankylosed molars, the treatment plan for this young man included orthodontic treatment first and then prosthodontic restoration The comprehensive orthodontic approach included leveling, correction of rotation, uprighting, space closure, anterior retraction, torque control, and overbite reduction The prosthetic approach was limited to fixed partial dentures because implants were not common at that time Considering the patient’s age and skeletal maturation, it was recommended to restore the occlusion toward some bite opening Figures 1G to 1J show the final occlusion after prosthodontic restoration 715 Fig Treatment of an 18-year-old man with oligodontia He is missing 10 teeth, including third molars Some submerged primary molars remain (A to D) Pretreatment occlusion (E) Pretreatment panoramic radiograph ( F ) Pretreatment cephalometric radiograph (G to J) Posttreatment occlusion, after prosthetic restoration (K) Posttreatment panoramic radiograph (L) Posttreatment cephalometric radiograph Chapter A 9-year, 7-month-old boy in the early mixed dentition had a Class I malocclusion and two mesiodentes preventing eruption of the maxillary right central and lateral incisors (Fig 1A) Damage to the central incisor crown and space loss had resulted from the neglected supernumeraries Figure 1B, taken after removal of the mesiodentes, clearly demonstrates the space closure in the anterior segment that has resulted from the failure to maintain the necessary space for the unerupted central incisor Figure 1C was taken during the initial stage of orthodontic treatment for space opening The lateral incisor had erupted, but the central incisor was still highly positioned The central incisor was exposed for traction attachment The crown damage and pulp exposure were restored first with hydroxyapatite (Figs 1D to 1G) and later, after completion of orthodontic movement, with a composite resin restoration (Figs 1H to 1K) Undiagnosed or neglected mesiodentes that delay eruption of the central incisors can result in the mesial movement of erupted lateral incisors and space loss even before removal of the mesiodentes Therefore, an important consideration in management of hyperdontia is maintaining the space between erupted teeth after removal of the supernumerary Space maintenance for unerupted teeth is especially a factor when unerupted teeth are located deeply, and, even after extraction of the supernumerary tooth, their eruption is delayed and slow 716 Fig Treatment of a 9-year, 7-month-old boy with mesiodentes preventing eruption and damaging the maxillary right central incisor crown (A) Pretreatment panoramic radiograph (B) Panoramic radiograph after extraction of the supernumerary teeth and lateral incisor eruption (C) Panoramic radiograph taken during the initial stage of orthodontic treatment and space opening (D to G) Traction of the central incisor Note the damage to the crown and pulp exposure caused by the supernumerary teeth; a hydroxyapatite restoration has been placed (H to J) Posttreatment occlusion, after orthodontic treatment and final composite restoration ( K ) Post-treatment panoramic radiograph Chapter 11: Case A 9-year, 3-month-old boy in the middle mixed dentition had a history of previous thumb sucking He presented with a severe Class II division malocclusion, an 11.3-mm overjet, and a 2.6-mm open bite He exhibited severe maxillary and mild mandibular incisor proclination, a convex profile, and a retrognathic chin caused by mandibular clockwise rotation (Figs 1A to 1D) 717 Treatment: Because of his vertical growth tendency and aligned mandibular incisors, the only appliance used in the mandibular dentition was a heavy lower holding arch to preserve leeway space and prevent vertical molar eruption, thereby controlling clockwise mandibular rotation In the maxillary arch, a combined tongue crib–transpalatal arch appliance was inserted first to control anterior tongue movement and achieve some intrusion of the maxillary molars (for more detail on the tongue crib–transpalatal arch appliance, see chapter 6) Then high-pull headgear was applied to correct the Class II molar relationships and intrude the molars in order to achieve more counterclockwise rotation of the mandible Treatment provided significant results in correcting all dentoskeletal aberrations and improving the profile (Figs 1E to 1J) Treatment resulted in a Class I dentition; a significant change in the A-B discrepancy from 9.1 to 4.3 degrees; correction of the overjet, from 11.3 to 2.1 mm; and a change in incisor overlap from a –2.6 to 1.4 mm In addition, significant changes in the retruded chin were achieved by mandibular growth and counterclockwise rotation of the mandible; these changes were confirmed by cephalometric improvement in the facial angle, lower facial height, and profile convexity Fig Management of severe overjet and overbite in a 9-year, 3-month-old boy with a history of thumb sucking He has a Class II division malocclusion, severe maxillary incisor proclination, and a retrognathic chin (A to C) Pretreatment occlusion (D) Pretreatment soft tissue profile (E to G) Posttreatment occlusion (H) Posttreatment soft tissue profile 718 Fig (cont) (I) Pretreatment (left) and posttreatment (right) cephalometric radiographs and tracings (J) Changes in cephalometric measurements and superimposition of pretreatment (black) and posttreatment (green) tracings Chapter 11: Case 719 An 11-year, 3-month-old girl in the late mixed dentition presented with a Class II division malocclusion, an 11.6-mm overjet, impinging deep bite, and maxillary and mandibular incisor crowding The maxillary incisors were crowded and proclined, and the mandibular incisors were retroclined and overerupted, creating a two-step occlusion (Figs 2A to 2D) Treatment: Because of the patient’s severe maxillary incisor crowding, the HLH approach was modified to include an inclined bite plane and, instead of a labial bow, × bonding, plus cervical headgear and a mandibular lip bumper The first goal of treatment was to align the maxillary incisors by bonding The second goal was to distalize and extrude the maxillary molars by the use of cervical headgear in conjunction with an anterior inclined bite plane to disocclude the posterior segments to reduce the overbite Third, the curve of Spee was reduced by use of the lip bumper to upright the proclined mandibular incisors After some reduction of overbite was achieved by the previous three steps, × bonding of the mandibular incisors was started Later, a utility arch was placed to intrude the mandibular incisors for complete leveling of the mandibular arch The treatment approach was a one-phase treatment that consisted of the aforementioned steps, which were continued until normal interdigitation was achieved and the crowding, overjet, and overbite were corrected Active treatment was finished with × bonding followed by placement of a maxillary Hawley retainer and mandibular fixed retainer extending from canine to canine Figures 2E to 2J show the results of treatment Fig Management of severe overjet, impinging deep bite, and incisor crowding in an 11-year, 3month-old girl with a Class II division malocclusion (A to C) Pretreatment occlusion (D) Pretreatment soft tissue profile (E to G) Posttreatment occlusion (H) Posttreatment soft tissue 720 profile Fig (cont) (I) Pretreatment (left) and posttreatment (right) cephalometric radiographs and tracings (J) Changes in cephalometric measurements and superimposition of pretreatment (black) and posttreatment (green) tracings 721 Chapter 11: Case A 14-year-old girl presented with a neglected pseudo–Class III malocclusion, space deficiency for the maxillary second premolar, and a mandibular shift that was causing temporomandibular dysfunction (Figs 3A to 3D) She exhibited some damage to the incisor structure and minor spacing in the mandibular anterior segment The patient’s chief complaint was temporomandibular joint pain Treatment: The treatment approach involved use of only one removable appliance in the maxilla and no treatment in the mandible The appliance was a modified Hawley appliance with a special labial bow with two horizontal loops on the buccal side of the canines to provide good retention in the anterior segment without touching incisors; occlusal coverage; two Z-springs for labial movement of the maxillary incisors out of crossbite; and a jackscrew for distalization of the maxillary left molars (Fig 3E) Figures 3F to 3I show the posttreatment occlusion The crossbite was corrected, the maxillary second premolar was aligned, and minor mandibular incisor spacing was spontaneously closed \ Fig Management of a neglected pseudo–Class III malocclusion with mandibular shift and space deficiency The neglected problems have caused temporomandibular dysfunction and pain (A to C) Pretreatment occlusion in centric occlusion (D) Pretreatment occlusion in centric relation (E) Modified Hawley appliance with occlusal coverage, modified labial bow, and jackscrew to regain space for the maxillary left second premolar (F to I) Posttreatment occlusion 722 Chapter 11: Case A 5-year-old girl in the primary dentition presented with a complete unilateral and anterior crossbite as well as a mandibular functional shift (Figs 4A to 4F) Treatment: This patient was treated with a removable Hawley appliance The maxillary primary second molars were bonded with a buccal tube and C-clasps over the tube for better retention of the appliance Two Z-springs were constructed to procline the maxillary incisors out of crossbite, while posterior occlusal coverage was used to disocclude the anterior segment Figures 4G to 4I show different stages of anterior crossbite correction The posterior segments exhibited open occlusion before settling Figure 4J shows the appliance after removal of the occlusal acrylic resin By 10 months after the end of retention, all mandibular permanent incisors and the maxillary central incisors had erupted (Figs 4K to 4O) The type of appliance used in this patient must be worn 24 hours a day except during toothbrushing As mentioned earlier, the first tactic in such cases is to jump the incisors out of crossbite In some patients, after the maxillary incisors are corrected, open occlusion may result in the posterior segments if the appliance is worn continuously In this situation, the occlusal acrylic resin should be left in place and gradually reduced in thickness at each visit Once the posterior dentition has erupted and settled, the occlusal coverage can be removed or the appliance can be stopped, if required 723 Fig Management of complete unilateral and anterior crossbite and mandibular functional shift in a 5-year-old girl in the primary dentition (A to E) Pretreatment occlusion ( F ) Pretreatment cephalometric radiograph ( G ) Occlusion after correction of anterior crossbite but before correction of posterior occlusion (H and I) Occlusion after more occlusal contact has been established in the posterior segments (J) Appliance used in treatment, after removal of occlusal coverage Fig (cont) (K to N) Posttreatment occlusion (O) Posttreatment cephalometric radiograph 724 About the Author Aliakbar Bahreman, DDS, MS, currently serves as a clinical professor in the Pediatric and Orthodontic Programs at the Eastman Institute for Oral Health at the University of Rochester in New York After graduating from dental school at Tehran University of Iran in 1961 he completed a pediatric dentistry fellowship (1964) and a master's degree in orthodontic and dentofacial orthopedics (1967) at the Eastman Institute He then started his career at the dental school at Shahid Beheshti University (former National University of Iran) as founder and chairman of the Departments of Orthodontics and Pediatric Dentistry Later, as the dean of the dental school, he presented complete postgraduate curriculum to the Iranian Ministry of Higher Education and, for the first time in Iran, started postgraduate training He returned to the Eastman Institute for Oral Health as a visiting professor in 1999 and started as a full-time clinical professor and clinical supervisor of the orthodontic, pediatric dentistry, and advanced education of dentistry programs in 2003 Dr Bahreman is the founder of the Iranian Orthodontic Association and was the first president of the Iranian International Orthodontic Meeting, and he is a fellow of the International College of Dentists, the American Association of Orthodontists, and the International Federation of Orthodontics He received many awards and medals both as a student and as a faculty member in Iran, and in June 2010, he received the Iranpour Award for excellence in clinical education from the University of Rochester 725 Learn more about Quintessence Publishing Co., Inc www.quintpub.com 726 ... of Early- Age Orthodontic Treatment Rationale for Early- Age Orthodontic Treatment Development of the Dentition and Dental Occlusion Examination, Early Detection, and Treatment Planning Part II Early- Age. ..www.ajlobby.com Early- Age Orthodontic Treatment www.ajlobby.com EARLY- AGE ORTHODONTIC TREATMENT Aliakbar Bahreman, DDS, MS Clinical Professor Orthodontic and Pediatric Dentistry... Hypodontia Orthodontic Management of Supernumerary Teeth Diagnosis and Management of Abnormal Frenum Attachments 10 Part III Early Detection and Treatment of Eruption Problems Early- Age Orthodontic Treatment