ortho outline (1)

7/29/2019 Ortho Outline (1)

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Primary Dentition 9/2/2012 10:12:00 PM

Outline

Anterior relationship and Angle classification Development of primary dentition Ideal occlusion in primary dentition Deviations from normal Maturation of oral function

Anterior relationship

Overbite:o vertical overlap of the incisorso Max always overlaps in normal occlusion, primary and perm.

Overjet:o horizontal overlap of the incisors

Anterior crossbiteo or reverse overjeto when Man are in front of Max incisors

Open biteo No overlap of the anterior teeth

Angle classification

Normal occlusion

Class I molar relationship:o Mesiobuccal cusp of Mx 1st M occludes buccal groove of Mn

1st M

Class I malocclusiono Molar relationship is correct, but there is

Crowding or Space Crossbite Open bite

Class II molar relationship:o Buccal groove of Mn 1st M is distally positioned relative to

mesiobuccal cusp of Mx 1st M

o Convex profile Class III molar relationship:

o Buccal groove of Mn 1st M is Mesially positioned relative tomesiobuccal cusp of Mx 1st M


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o Concave profileDevelopment of Primary Dentition

Mineralization or calcification of primary teeth occurs in utero Ground section of enamel has lines (similar to circles in wood)

o Reflect appositional growth of the enamel layersStriae of Retzius & Neonatal line

A line forms if any disturbance or insult occurs.o The darker the line, the more severe the disturbance; like

birthing. (neonatal line)

More obvious in perm. dentitiono b/c the child is more susceptible to things outside the womb

Location of neonatal line

Neonatal lines are not in the same positiono Primary incisors have a line closer to gingival 3rdo Primary 2nd molars are closer to occlusal surface

Calcification:

All primary teeth start calcification before birth S eq u e n c e o f c a l c i f ic a t i o n ( 2 n d t r i m e s t e r ):

o centrals (14wks iu),o 1st M, laterals, canines, and 2nd molars (18-19wks iu)o Primary Crowns are complete 1.5-11 mos. Pp (postpartum)o Permanent calcification begins (3-28 mos) ; 4yrs = crown

finished on M1

Age Terminology: Perinatal Period

There are two ways to determine perinatal ageo LMP last menstrual periodo Conception / Fertilization

This is usually 2 weeks after LMP What orthos use to determine starting points Problems with tooth development

2nd trimester = all primary 3rd trimester = all primary + 1st Molars

o Other growth disturbance examples


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Just after birth prior to 1 month = All primarys + M1

Disturbance ~ 3yrs No primarys, ALL Permanents

Development of primary dentition

P r im . in b o y s a r e g e n e r a l l y l a r g e r t h a n t h o s e i n g i r l s , genderdifference is not as marked as in the perm.

o Did you get that, he said Perm have a greater differencemale to female than in Primarys

Anomalies less frequently in prim. than in perm. Less than 1% have congenitally missing prim. Most frequently missing:

o M x l a t e r a l s > M x c en t r a l s > 1 s t p r i m M .Eruption:

The precise time of each tooth eruption is not too important unlessit deviates greatly from the average.

Boys start earlier than girls on average. Which is opposite of thepermanent dentition

Teething

In infant, tooth eruption may be accompanied by a slighttemperature increase, mild irritation of gums, and general malaise.

Holy crap, thats putting it mildly.

Severe symptoms should not be associated. How about severecrying, staying up all night letting the poor kid chew on a cold

washcloth or carrot til they finally fall asleep around 2am?

Precocious erupted primary teeth familial tendencies

Mn incisors (enamel hypoplasia) Natal: present at birth Neonatal: erupt during 1st Mo

o So this could be a problem for nursingum yeah ya think? pre-erupted: 2nd to 3rd Mo KEEP if normal, not supernumeraries REMOVE if loose and aspirate


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o Which begs the question: What definition of aspirate do wehave here? Think about it, its been used in a lot of classes all

meaning different things: swallowing something, pulling back

on the syringe etc.

Primary tooth resorption

Eruption of perm. is not the only factor to cause prim. toothresorption.

o Can resorbed w/out permanent successors Primary tooth resorption can be expedited by inflammation and

occlusal trauma,

delayed by splinting and absence of a permanent successorIdeal occlusion in primary dentition

20 Primary Teeth Ovoid arch form Midline coincide All Mx teeth overlapping Mn Spacing (spaced anterior teeth & primate space)

o Generalizedo Primate Space alleviates later crowding

Mesial to canine Distal to canine

Near vertical relationship of anter. (0-2mm overbite/overjet) Straight/mesial step terminal plane

o If the 2nd molar is positioned distally to the = can lead toClass II relationship

o Straight plane exists b/c the 2M is larger MD than 2MDeviations from normal

Crossbiteo Anterior or Posterior

Bilateral True (narrow compared to ) True - This means there is no jaw shift when in

centric occlusion

Unilateral True


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True have a straight Frontal View; and a curved LateralView

o Functional Crossbite (Pseudo) Mn shifts laterally and anteriorly Needs early correction, asymmetry of jaw Have a stepped Frontal and Lateral View

Ankylosis (of Primary Molars)o Fusion of bone to dentin and /or cementumo Clinically

- tooth fails to erupt; bone fails to develop - almost impossible to move orthodontically - usually involve primary (Mn) molars - 20% related to congenitally missing teeth Occurs 2x more often with than

o The earlier occurs, the more occlusion is affected Need to consider:

1) loss of arch perimeter or length 2) extrusion of opposing teeth 3) interference with the eruption of perm. 4) inhibition of alveolar bone development

Problem with arch perimetero arch perimeter or arch circumference (A)o arch length/depth (B)o arch width (C/D) distal of 2M across

o


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o caries of primary teetho loss of individual or multiple primary teeth

Exfoliation problemo Exfoliation should be:

- bilaterally within 6 mos of contralateral teeth - should occur before the perm. tooth erupts - in same order as eruption of permanent teeth

Eruption problemo Asymmetric eruption

Number - congenitally missing 0.1-0.4% prim (3.9-6.3% perm. Excluding 3rd M) - supernumeraries 0.5%-prim (1%-perm)

Excessive Spaceo Potential causes

- frenum attachment - supernumerary teeth

yeah, I diagnosed a kid with a mesioden, thisdude had a HUGE friggin gap b/t his incisors.

Maturation of oral function Physiologic functions of the oral cavity:

o respiration,o swallowing,o mastication, ando speech

Chewing patterns

Adult: opens straight down Baby: opens laterally Transition occurs when perm. canine erupts Op e n b i t e c a se s r e t a in i n f a n t i le ch e w i n g p a t t e r n and they

might still suck their thumbno joke

Speech


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Gradient from anterior to posterior First sounds are m, p and b t & d later s & z even later with some posterior tongue control r is the last and requires more tongue control -

o which reminds mecan you trill your rs?


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Mixed Dentition 9/2/2012 10:12:00 PM

Outline

Dev. of mixed dentition Ugly duckling stage

o Can have space in the incisors, and crowding in the incisorso Deformities may improve or eliminate during eruption of the

permanent teeth

Leeway Spaceo Differences between 1 and 2 molars that can lead to class I

relationship in perm dentition.

Transition of molar relationship The eruption pattern is more important than the eruption sequence.

M i x e d D e n t i t i on

Prim. And Perm teeth in the mouth Early eruption of1st M and/or permanent incisors

o 6-8yr erupt as a groupo ~ 8 no perm eruption for a couple of years then @ 11 you go to

late

Late eruption of at least one PM or Cano ~ 11yr, eruption of PM and cano one two phase ortho tx.

One phase starts at late mixed Two Phase starts at earlymixed; then monitor growth;

then start second phase

Perm. teeth eruption

Dental age vs. chronological ageo Weak correlationo Ex. could reach dental age of 12, but could be chonologically 10F or

14M

Eruption sequences more important than timeo Mx - M1, I1, I2, P1, P2, C, M2, M3 (6,1,2,4,5,3) 7,8*o Mn - M1, I1, I2, C, P1, P2, M2, M3 (6,1,2,3) 4,5,7,8*

Root formation at time of eruption

Root completion2-4yrs after eruptiono How long do they take? ~ Inc & PM 3yr; C 2yr; M 4yr


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o At the time of eruption Inc & PM about formed C about 2/3 formed

Variation of eruption

If Eruption of M2 before C or PMo Decrease of available space

Asymmetrical eruptiono Normal if < 6mos.

Ideal occlusion in primary dentition

Midline conincide All teeth overlapping teeth Near vertical relationship of anteriors Spacing b/t teeth Straight/ mesial step terminal plane Ovoid arch form 20 primary teeth

Spacing is normal in primary dentition

Abnormal : no spaces

Ug l y d u c k l i n g s t a g e

Mx incisors flare laterallyo Normally a mesial inclination

Due to lateral Inc influence Diastema

o Tend to close with eruption of laterals or canineso 2 mm or less may close spontaneously

Mild crowdig of Inco Permanent Inc are much bigger

IncisorLiability discrepancy in size b/t the primary and permanent incisor teeth

May be overcome by:o 1) Interdental spacingo 2) Incisors & canines erupt labially, esp. Mx


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o 3) Incisors procline labially,4) Repositioning of canine

Decrease of Arch l en g t h & p e r im e t e r

Both Arches show perimeter & length decrease during the transition stageo Especially Mandibular

Decrease of 2-3 mmo Maxillary, length remains close to same,

B u t w i d t h i n c r ea se s o Due to perm inc and canines increase of 5mm o And about 2-3 mm

Changes in Arch Dimensions

The dental arch perimeter are used toA l ig n t h e p e r m a n e n t i n c is o r s w h i ch t y p i ca l ly a r e c r o w d e d u p o n e r u p t i o n

Leeway Spaceo Difference b/t prim molars and perm premolars (mesial-distally)o After loss of prim. 2nd molars there is a late mesial shift of perm 1st

molars

(larger in ) As the larger incisors erupt, they find space by increasing the arch width

by pushing the primary canines distal

o H o w e v e r l en g t h o f a r c h d o e s n o t c h a n g e This is possible in the mandible because the space is distal of the primary

canines (space meaning, primate space)

In the maxilla, the primate spaces are mesial of the primary caninesS p a ce f o r c u s p i d s a n d p r em o l a r s

A d j u s t m e n t o f t h e m o l a r o cc lu s io n

Transition of molar relationshipo Straight / mesial step / distal step = terminal plane Stepso b/c the lower primary 2nd molar is larger than the upper

Shift of teeth b/c of leeway space helps to achieve Class I Growth of Mandible

o Growth graph Growth spurts : height > mandible > maxilla @ age 14


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o Minimal Growth > Differential Growth Distal Step

Class II > End to End relationship Flush

End to End > Class I Mesial Step

Class I > Class II >Class III


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Body Changes 9/2/2012 10:12:00 PM

Late Mixed / Early Permanent Dentition

Occlusal developmento Primary canines and molars are exfoliatingo Perm canines and molars are erupting

Secondary sexual chracteristics appear & adolescent growth spurttakes place

o Accelertion in overall facial growth differential growth of jaws

Growth Prediction

Need to know when the growth spurt is taking place to maximizeeffect of ortho tx on skeletal malocclusion

o Prognathic Cl III skeletalo Retrognathic Cl II skeletal

Ortho Tx. Late Mixed Dentition

Effect of puberty on ortho tx.o Prepubertal growth spurt physical changes affect the face and

dentition

Make retrognath pt easier to work on Make prognath pt harder to work on

64% chance of predicting developmental age from real age 50% chance of predicting dental development from real age

Developmental Parameters

Correlation b/t real age and developmental age Physical growth status correlates well w/ skeletal age

o Varies from real age Dental age is a poor correlation w/ other dev. indicators & real age Must assess

o Skeletal, behavioral, and other dev. ages in planning dentaltx.

Methods of Determining maturity


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1 . S e co n d a r y S e x c h a r c t e r i s t i c s

Adolescent Hormonal Changes

Hypothalamus Releasing Factor to Ant Pituitary Gonadotropinsto adrenal glands & sex organs Sex hormones (estrogen andtestosterone) produced in varying quantities depending on gender

Sex hormones stimulate 2nd sex characteristicso Acceleration of body growth

Genital growth, Jaw growth Shrinkage of lymphoid tissue

o Neural growth essentially done at age 6, not effected bygrowth hormones

BoardPearls

Growth of jaw is intermediate b/t neural and general body curves follows the general body curve more closely than acceleration in general body curve parallels an increase in sexual

organ and involution of lymphoid tissue

Adolescence Velocity Curves

Boys are two years later than girls Timing of Puberty

o Puberty longer for boys than girlso 2nd sex charac provide physiologic calendar of adolescence

that correlates w/ individuals growth status

not all characteristics are readily visible, but most canbe evaluated in a normal, fully clothed exam

Secondary Sex Characteristics

Females pubertal growth 3.5 yearso Stage 1 start to year 1

breast buds and pubic hair Peak velocity of physical growth occurs about 1

year after stage 1 around beginning of stage 2

o Stage 2 year 1-2.5


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Bigger boobs, darker hair down there, armpit hairgrowth

Purchase of a personal razoro Stage 3 year 2.5-3.5

Onset of menstruation g r o w t h s p u r t a l m o s t d o n e Broadening of hips, adult fat distribution, boobs done

growing

Male pubertal growth 5 yearso Stage 1 start to 1st yr

Fat spurto Stage 2 year 1-2

Fat , pubic hair, growth of penis, growth spurtbegins

o Stage 3 year 2,3 year 4 Aux. hair, facial hair on upper lip, muscle growth,

less fat, harder body form, peak velocity in height

o Stage 4 years 3,4 year 5 Height growth ends, hair on chin, darker hair down

there, and more muscle strength

Impact of Puberty

Growth in height endochondral bone growth at epiphyseal plates Sex hormones

o Stimulate cartilage to grow fastero Increase rate of skeletal maturation

Earlier sexual maturation relates to early cessation of growth Ortho needs to be earlier in girls to take advantage of the growth

palate

Growth in jaw usually correlates w/ growth in heighto Cephalocaudal gradent of growth evident at puberty

Differential jaw growth More growth in lower jaw than in upper

o Height chart Growth in jaw similar ~ easier to track in office


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2 . H a n d W r i s t F i l m s

boneso ossification of bones ~ standard for skeletal developmento 30 small bones w/ a predictable sequence of ossification

yeah, so theyre all numbered, but I cant figure out apattern to it, so I am not going to remember which is

which.

Information gathered from filmso Maturity progresso Repeated films can graph developmento Final stage = epiphyseal diaphysial fusion of the last bone

in which it occurs

o Distinguish nutritional statuso Reveals imbalances in skeletal developmento Discloses scars of interrupted growth record of past illness

Correlationso Maturational stages and statural heighto Facial growth and general skeletal growth

Esp. mandibular growth Max rate of circumpubertal facial growth occurs slightly

later than peak growth in statural heightwtf

SMA Skeletal Maturation Assessment 1982o Correlated skeletal growth of hand and wrist to facial,

maxillary and mandibular growth peak velocities

o 4 stages of bone maturation 6 anatomical sites thumb, third & fifth fingers and radius 11 discrete adolescent SMIs covering the entire period

of adolescent development are found on these 6 sites

o 4 Stages of SMA Width of Epiphysis Ossification Capping of Epiphysis Fusion

o 6 anatomical sites


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o Skeletal maturity Indicators SMI

Width of epiphysis as wide as diaphysis

Third finger Proximal phalanx Middle phalanx

Fifth finger Middle phalanx

Ossification Adductor of sesamoid of thumb

Capping of epiphysis Third finger

distal phalanx middle phalanx

Fifth finger


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Middle phalanx Fusion of Epiphysis and Diaphysis

Third finger Distal phalanx Proximal phalanx Middle phalanx

Radius Hand Wrist Observation Scheme

o Ossification Y Fusion

Y Fusion N Capping

N Width Results

o Maxilla and mandible growth tend to lag behind skeletalgrowth

o Acceleration of growth velocity Mx and Mn Males b/t SMI levels 6 & 7 Females b/t SMI levels 5 & 6

o Maximum growth rate Males level 7 Females level 6

Current Literatureo Flores 2004 says yep hand wrist does correlateo Verma 2008 says no it doesnto Basically, why do you need to do hand wrist exams when the

CVM measures it close enough

3 . Ce r v i c a l M a t u r a t i o n

Measuring Maturity

Skeletal Age based on cervical vertebrae Advantage

o Separate radiograph not needed less radiationo As accurate as hand wrist films

Cervical Vertebraeo Change from birth full maturity


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o Vertebral growth Cartilaginous layer on the superior and inferior surfaces

of each vertebrae

1928 Study on cervical vertebrae growth 1972 Skeletal age assessment utilizing cervical vertebrae

o mapped maturation stages of cervical vertebrae 1995 skeletal maturation evaluation

o developed indexo Six stages of maturation

Initiation, Acceleration, Transition, Deceleration, Maturation, Completion

2002 Baccetti improved version of CMV for Assessment ofMandibular growth

o based on C-2,3,4o analyzed at the six intervals T1-T6 (combined first stage)o Peak occurs b/t stage II and III

Peak at green line


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Growth Timing in Ortho

Futureo Molecular kits personalized medicine

Dx. growth problems Personalized developmental status & growth factors and

signaling molecules

o Specific growth discrepancies presicesly targeted Orthopedic approaches alone

Combination systemic and local interventions


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Early Permanent Dentition years 9/2/2012 10:12:00 PM

Growth Pattern in the dentofacial complex

Nasomaxillary Complexo Passive displacement

Primary dentition years Sutural growth b/t Cranial base and NMC pushes the

NMC Forward

Slows w/ completion of neural growth ~ age 7o Active growth of maxillary structures and nose

Surface remodeling resorption and apposition Grows downward and forward

Bone added in posterior and superior Nasal Growth

o Passive displacement Nose grows more rapidly than the rest of the face in size of nasal cartilaginous septum Proliferation of lateral cartilages alters the shape of the

nose and adds to the overall increase in size

o Nasal dimensions increase at a rate about 25% greater thangrowth of the maxilla

Mandibular Growtho Relatively steady rate before puberty

Ramus 1-2 mm/yr Body length increases 2-3 mm/yr

o Juvenile and pubertal growth spurts demonstrate growthacceleration

o Prominence of chin due to forward translation of mandibleand resorption above the chin

Timing of Growtho Sequence - growth is completed in maxilla and mandible

Width before adolescent growth spurt Length during / after puberty Height during / after puberty

Boys 20; girls 16


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Dental Changes During Facial Develoment

Path of eruption of maxillary teetho Downward and forward

Translocationo Teeth moving with jawo of total maxillary growth during adolescent growth spurt

Path of eruption of mandibular teetho Upward and forwardo Both jaws rotate upward in front

Mandible > maxilla Mandible decreases in arch length more than

maxilla

Short face individuals - DEEP biteo Due to excessive (forward,upward) rotation of the mandibleo Low mandibular plane angle

Long Face individuals open biteo Mn backward rotation

Perm pulp chamber size; eruption > older age Gingival attachment is above CEJ at eruption Downward migration of gingival attachment results from vertical

growth of the jaws and eruption of the teeth as opposed to

downward migration of the gingival attachment from perio dz.


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Active vs Passive Eruption

Passive Eruption old theoryo Gingival migration of the attachment w/o any eruption of the

tooth

o As long as gingival is healthy, this does not occur Active eruption current theory

o Eruption of the dentition that is compensating for thesimultaneous vertical jaw growth

Facial types: Class I, II, III Growth Patterns

Classifying Facial Typeso Common Systems

Headform Type Facial Profile

o Dolicephalics Long narrow facial pattern Nasomaxillary complex (NC) is in a more protrusive

position relative to mandible

NC is lowered relative to mandibular condyle whichcauses downward and backward rotation of mandible

high angle Occlusal plane rotated in a downward-inclined

alignment

Tendency towards mandibular retrusion and a Class IImolar

o Brachycephalics Relative posterior position of maxilla Horizontal length of NC is relatively short Overall, tendency toward a prognathic (concave) profile

and a CL III molar


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Mesocephalicso Intermediate headformo Tendency toward a Cl I molar

Facial Profiles

Convex Cl IIo Retrognathic

Concave Cl IIIo Prognathic

StraightOrthognathic

Ortho: Growth and Development


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12/1/2009

Etiology of Orthodontic Problems

Dr. Ingrid Reed

Malocclusion

35% of the population has a normal occlusion

5% of the population have a malocclusion of known cause

60% cause unknown

Relative discrepancy b/t size of teeth & size of jaws Disharmon facial skel probs Environmental factors

Causes

Specific causes

Disturbances in embryonic development

Skeletal growth disturbances

Muscle dysfunction

Any force on the teeth and bone will cause movement

Acromegaly & Hemimandibular Hypertrophy (Endocrine Problems)

Disturbances of Dental Deveelopment

Genetic Influences

Environmental Influences

Teratogens

Cleft lip and palate maternal use of

Aspirin

Cigarette smoke (hypoxia)

Dilantin

6 Mercaptopurine (immunosuppressive drug)

Valium

Central midface deficiency Fetal alcohol syndrome

Ethyl alcohol

Disturbances of Dental Development

Congenitally missing teeth


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Sometimes runs in families but there is no known gene that is the cause of this

congenitally missing teeth

Malformed and supernumerary teeth

Inteference with eruption

Ectopic Eruption = tooth bud itself is not in the right place

Early loss of primary teeth

Traumatic displacement of primary teeth affects the permanent tooth buds

Genetic Influences

Familial tendencies

There hasnt been a genetic link but you usually see it in more than one member of a family.

Class III 1/3 of children with Class III had parent with same problem

There are genetic links but not specific genes that can be associated with it.

**Malocclusions

Relative discrepancy between size of teeth and size of jaws

Biggest most common = discrepancy

Results in crowding or spacing

Disharmonous facial skeletal problems = maxilla and mandible dont grow at the same rate

Tongue thrust results in an open bite

Disproportion between teeth and jaws

Class II/III superimposed crowding or spacing

Figure 1-4

Classified by the MB cusp of the maxillary first molar

Class I MB cusp is in the B groove of the mandibular first molar, if this doesnt happen theother teeth wont fit together

Class I Malocclusion molar Class I but other problems in the anterior Class II Malocclusion maxillary molar mesial to the mandibular molar, increase in overjet

usually

Class III Malocclusion maxillary molar distal to the mandibular molarFunctional Components of the Face

The cranium and cranial base is considered a stable point after the age of 7, it runs from sella in

sella turcica to the junction of the nasal and frontal bone. Grows until age 6.


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Where the maxilla grows the teeth go with it, so if the maxilla grows forward the maxillary teeth

will be forward

No teeth = no alveolar process (alveolar process and the teeth go hand in hand)

All of these parts must fit together to have a good facial profile and for the teeth to be in the right

occlusion.

Disharmonious Skeletal Relationships

Class I Bimaxillary protrusion = both jaws are forward, molars in Class I relationship buteverything else if forward

Class II disharmony between the maxilla and the mandibleo Maxillary excess, normal mandibleo Normal maxilla, retruded mandibleo Combo (maxillary excess with retruded mandible)

Class III o Normal maxilla, prognathic mandibleo Retruded maxilla, normal mandibleo Combo

Class I/II/III look at the skeleton in a A-P direction

Looking in the transverse direction: look at the maxilla ( you can change it, you cant change the

mandible)

Constricted = maxilla too narrow compared to the mandible Deep bite/Open bite

Class I

Straight, orthonagthic facial profile Class I dental relationship and Class I skeletal relationship-Cephalometrics Harmony of the face and teeth

Bimaxillary Protrusion

Class I molar relationship but everything else forward resulting in convex facial profile Whole anterior complex forward even though Class I molar relationship and Class I skeletal

relationship

Both jaws too far forwardClass I Crowding

Constricted Maxilla and Crowding Cross bite on one side


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Skeletal harmony but disharmony between size of the teeth and the size of the arch (toothto jaw relationship)

Tx: Ext of 4 PMs

Class II Division 1

Skeletal Problems maxilla and mandible not in harmony (maxillary excess or mandibularretrusion)

Division 1 = protruding incisiors and large overjeto Overjet = horizontal overlap of the teeth

Class 1 Class 2 increase overjet Tx: corrected to Class I molar relationship and has better facial profile

Class II Division 2

Disharmony between maxilla and mandible in the A-P direction Maxillary incisors define it as this the teeth are retruded (tucked in)

o Difference between Division 1 and 2: Incisor position Division 1: teeth protruded, large overjet Division 2: teeth retruded, associated with deep bite

Ortho alone cannot fix a retruded mandible, you would need surgery

Class III

Maxillary molar is distal to the mandibular molar Not just the teeth but everything changes usually have a long face with a cross-bite or

edge-to-edge occlusion

Will have a protruded chin Anterior crossbite = maxillary incisors behind the mandibular incisors Even when corrected these people have somewhat of the same appearance because you

cant change the bone, but you can correct the relationship of the teeth

Class III with Spacing

Jaw too big, there isnt enough tooth mass to fill the whole space Two problems: skeletal disharmony between the maxilla and mandible, and the teeth are

too small to fill the jaws

Esthetically close the space in the anterior but leave the space in the posterior because wecant increase tooth mass or make the jaws smaller


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Esthetics with a class III in women is a big problem that is why some choose surgeryClass I Unilateral Posterior Crossbite

Transverse problem Constricted maxilla

Posterior Crossbite and Anterior Openbite

Upper arch inside the mandible in the posterior and no vertical overlap in the anterior Anterior openbite is usually associated with tongue thrust

o They cant swallow properly so they put it between the teeth to create a seal, thisperpetuates the problem

o You also have to do some tongue retraining to make sure the tongue thrust goesaway

Deep Biteo Overbite, 100% = dont see lower teeth at all; related to Cephalometrics

Cleft Lip

Cleft lip failure of fusion of median and lateral nasal processes and maxillary prominence 6th week of development

Usually notch in alveolar process of central and lateral Affects anterior development

o Once corrected scar tissue (not as bouncy) restricts the development of thepremaxilla

60% of patients with cleft lip have a cleft palateCleft Palate

Closure of the secondary palate elevation of the palatal shelves Palate closes from the anterior to the posterior so you can have various levels of failure of

fusion

Most minor = cleft uvula


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Cleft Palate

Constricted maxilla may be due to the surgery

Etiologic Factors

Maternal use of aspirin Cigarettes Dilantin Valium Use of immunosuppresent drugs

Cleft Lip

Scar tissue resilience will affect the anterior tooth development

Have all teeth because no cleft palate

Cleft Lip and Palate

See larger problems The whole maxilla tends to be constricted which leads to anterior cross bite or rotation in

the area between the central and lateral

The cleft affects the eruption of the canine because there is no bone there for it to comethrough

Bilateral Cleft Lip and Palate

The premaxilla is quite small but the mandible is fine There is an affect on the eruption of the teeth and the width of the maxilla

Interesting Case: DOB 5-17-1995 Unrepaired cleft palate

They never treated the cleft palate so he will have eruption problems on that side

He has a fairly good A-P relationship between the maxilla and the mandible

There is a cross bite in the area of the cleft

Tx: tried to develop the arch form and move the teeth so that he could later have the cleft closed

The lower teeth werent terribly out of alignment but there was some expansion due to a crossbite

The appliance has a screw in the middle that is turned to push the two sides apart

The midpalatal suture doesnt fuse until about age 15 or 16 so with a patient with a constricted

maxilla you can widen it with an appliance as wide as you need until that age

Skeletal A-P relationship is good


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Disturbance of Dental Development

Congenitally missing teetho Anodontia (none), oligodontia (missing more than 6), hypodontia (less than 6)

Malformed teetho 3rd molars, maxillary laterals incisors (peg lateral or malformed), 2nd premolarso Rotated 180 degrees affects occlusion because wrong cusp is occluding

Supernumerary teetho Mesiodens most commono Other places

Affect eruption of permanent teethAnkylosis bone is no longer growing because the bone grew to the tooth

Ankylosed teeth appear to submerge, why? Because as the child grows the ramus increasesin height and the teeth and the alveolar bone grow with it (it grows 10.25 cm between

eruption and age 18). When you have a tooth that is ankylosed the cementum is attached to

the bone and everything stops. The bone can no longer grow in that area. The teeth and

bone adjacent to this area continue to grow and make it appear that the tooth has

submerged. It will be below the margin of the occlusal plane. The problem with this is that

when there is not interproximal contact the tooth behind it tips over and screws with the

occlusion.

Supernumerary Teeth

There is a color difference between the permanent and primary teeth the primary teethare whiter (milk teeth)

EctopicEruption tooth is not coming in the right place

Malposition of a permanent tooth bud Can lead to eruption in the wrong position Can also be caused by retained primary tooth, crowding


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Could also mean resorption of a tooth other than the primary that is supposed to beresorped

Example: permanent lateral is causing the resorption of both the primary lateral and canine Most common Maxillary first molar

o Causes resorption of the primary second molar and it doesnt come into the mouth Other common tooth that erupts ectopically and/or impacts Maxillary canine (second

most)

If it doesnt have the right vertical area and crosses over the lateral it causes a problem, itwont come into the right path

o The canine can move palatally where it will stay impacted or buccally where it mayerupt a little bit

The second primary molar is larger than the premolar that replaces it.

If the premolar isnt lined up exactly under the primary molar it will fail to resorb the mesialroot of the primary tooth and the deciduous tooth will not exfoliate on its own and will need

to be extracted. Depending on the amount of root formation the tooth may have to be

brought in orthodontically.

Ectopic eruption can result in an impacted second molar.

Environmental Factors

Loss of arch perimetero Carieso Early loss of primary teeth

Thumb and digit sucking Tongue thrust Mouth breathing

Early Loss of Primary Teeth

Maintain symmetry Mesial drift of molars, distal of incisors and canines Avoid loss of arch perimeter

o Guaranteed to have crowding if you lose this lower ligual arch


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maxillary hayes nanceLoss of primary teeth without space maintenance creates a huge problem orthodontically

Ankylosis

Loss of perimeter as anterior teeth tip in

The opposing teeth can supererupt and the adjacent teeth can drift into the space. It can prevent

the eruption of the permanent tooth.

Thumbsucking

Causes anterior open bite and constricted maxilla Retroclining of mandibular teeth Tx

o Tongue cribs - remindersTraumatic Displacement of Teeth

Results of trauma Defect in crown Dilaceration


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9/2/2012 10:12:00 PM

Eriksons - Emotional

Development Stage

Age Range Common Characteristics Dental Considerations

Development of Trust Birth to 19 months Basic trust develops Depends on caring mother/mother

substitute

Physical growth can be retarded if emotionalneeds are not met

Strong bond creates separation anxiety

If dental work is necessary Parent present Parent holds child Children who havent developed basic trust

will need special effort by dentist and staff

Development of

Autonomy

18 months to 3 years Uncooperative behavior Child developing autonomy Child struggling to exercise free choice Still dependent on patents in times of

insecurity

Have child think whatever dentist wants ishis/her choice

Offer simple choices color of bib Allow parent to be present Complex dental treatment Sedation or General anesthesia

Development of

Initiative

3-6 years Continued development of autonomy Physical activity and motion Extreme curiosity and questioning Aggressive talking

Usually first visit Exploratory visit with mom present and little

treatment

After initial visit will tolerate separation frommother and usually behave better

Reinforce independence over dependenceMastery of Skills 7-11 years Acquiring academic, social skills

Learning rules Competitionwithin a reward system Decrease parents Increase peer groups

Often orthodontic treatment is started,phase I or functional appliances

Set attainable goals Positievely reinforce success Likely to faithfully wear headgear and/or

removable appliances

Instructions explicit and concreteDevelopment of

Personality

12-17 years Intense physical development Psychological development Can exist outside family Belonging to a larger group Complex stage Time of stress and rewards Establishment of ones own identity

Most orthodontics is done at this time Behavior management a challenge Motivation is key External Internal


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Development of

Intimacy

Young adult Development of relationships Factors of acceptance and success Appearance Personality Emotional qualities Intellect Others

Trying to correct a dental appearance theysee as flawed

Feel change in appearance will changeoutcome of relationships

Potential psychological impact oforthodontics should be explored from the

start

Guidance of the Next

Generation

Adult Successful parenting Supporting services for the next generation Opposite characteristics Stagnation Self-indulgence Self centered behavior

Attainment of

Integrity

Late Adult Individual has adapted to the combination ofgratification and disappointment that every

adult experiences

Opposite is despairCognitive

Development Theory

of Jean Piaget

Assimilation Accommodation Cognitive structures

Sensorimotor Birth to 2 years Goes from reflex activities to behavior tocope with new situations

Concept of objects Communication limited Little ability to interpret sensory data

Preoperational 2 to 7 years Literal nature of language Understand the world through senses Abstract ideas hard to grasp Egocentrism Animism

Period of concrete

operations

7-11 years Improved ability to reason Ability to see another point of view Animism declines Instructions must be very clear and concrete

Period of formal ~11 years to Abstract concepts and reasoning


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operations adulthood Imaginary audience Personal Fable

ortho outline (1)

Documents