Clinical Problem Solving in Orthodontics
Clinical Problem Solving in Orthodontics
&Paediatric
Dentistry
To my parents (Declan) and to Philly, Izzy, Ollie, Mum and Dad (Peter) or their enduring love and support.
For Elsevier
Content Strategist: A lison Taylor
Content Develop m ent Sp ecialist: Sally Davies
Project Manager: Louisa Talbott
Designer/ Design Direction: Christian Bilbow
Illustration Manager: Lesley Frazier
CLINICAL P ROBLEM S OLVIN G IN DENTISTRY
SERIES
THIRDEDITION
Orthodontics
&Paediatric
Dentistry
Declan Millett
BDSc DDS FDSRCPS(Glasg) FDSRCSEng DOrthRCSEng
MOrthRCSEng FHEA
Pro essor o Orthodontics
Cork University Dental School and Hospital
University College Cork
Cork, Ireland
Peter Day
BDS PhD FDS(Paeds)RCSEng MPaedDent(RCSEng) MFDS(RCSEng)
FRCD(Canada) FIADT PGCLTHE FHEA
Associate Pro essor and Consultant in Paediatric Dentistry
School o Dentistry at the University o Leeds and Brad ord District Care NHS
Foundation Trust Salaried Dental Service
Leeds, UK
With contributions rom
Caroline Campbell
BDS MSc MPaedDent(Ed) MFDS RCPS(Glasg) FDSPaedDent(Glasg)
Consultant in Paediatric Dentistry, Honorary Senior Clinical Lecturer
Department o Paediatric Dentistry
Glasgow Dental Hospital and School
University o Glasgow
Glasgow, UK
Edinburgh London New York Ox ord Philadelphia St Louis Sydney Toronto 2017
© 2017 Elsevier Ltd . All rights reserved .
Previou s ed itions:
© 2005, 2010, reprinted 2011 (tw ice) and 2013 Elsevier Ltd . All rights reserved .
N o part of this p ublication m ay be rep rod u ced or transm itted in any form or by any m eans,
electronic or m echanical, inclu d ing p hotocopying, record ing, or any inform ation storage and
retrieval system , w ithou t p erm ission in w riting from the p u blisher. Details on how to seek
perm ission, fu rther inform ation about the Pu blisher ’s perm issions p olicies and ou r arrangem ents
w ith organizations such as the Cop yright Clearance Center and the Cop yright Licensing Agency,
can be fou nd at ou r w ebsite: w w w.elsevier.com / p erm issions.
This book and the ind ivid u al contribu tions contained in it are p rotected u nd er cop yright by the
Pu blisher (other than as m ay be noted herein).
ISBN 978-0-7020-5836-3
N otices
Know led ge and best p ractice in this eld are constantly changing. As new research and exp erience
broad en ou r und erstand ing, changes in research m ethod s, professional p ractices, or m ed ical
treatm ent m ay becom e necessary.
Practitioners and researchers m u st alw ays rely on their ow n exp erience and know led ge in
evalu ating and using any inform ation, m ethod s, com p ou nd s, or exp erim ents d escribed herein. In
u sing su ch inform ation or m ethod s they shou ld be m ind fu l of their ow n safety and the safety of
others, includ ing parties for w hom they have a p rofessional resp onsibility.
With respect to any d ru g or p harm aceutical prod u cts id enti ed , read ers are ad vised to check the
m ost current inform ation provid ed (i) on p roced ures featu red or (ii) by the m anu factu rer of each
prod u ct to be ad m inistered , to verify the recom m end ed d ose or form u la, the m ethod and d u ration
of ad m inistration, and contraind ications. It is the resp onsibility of practitioners, relying on their ow n
exp erience and know led ge of their p atients, to m ake d iagnoses, to d eterm ine d osages and the best
treatm ent for each ind ivid u al p atient, and to take all ap p ropriate safety precau tions.
To the fullest extent of the law, neither the Pu blisher nor the au thors, contribu tors, or ed itors,
assum e any liability for any injury and / or d am age to p ersons or prop erty as a m atter of p rod u cts
liability, negligence or otherw ise, or from any use or op eration of any m ethod s, p rod u cts,
instru ctions, or id eas contained in the m aterial herein.
The
publisher’s
policy is to use
Printed in China paper manufactured
from sustainable forests
The fond ness of stu d ents for this p roblem -solving form at face of orthod ontic and p aed iatric d entistry clinical practice.
and their encou raging feed back have led u s to being asked Three new orthod ontic append ices d eal w ith classi cation
by the p u blishers to d o a third ed ition. The passage of tim e and d e nitions, im plications of com m on m ed ical problem s
has brou ght a new co-au thor, Peter Day, to the Paed iatric and referral gu id elines. In ad d ition, one new paed iatric d en-
Dentistry section and a new contribu ting au thor, Marie- tistry append ix provid es a structured d ental trau ma history
Therese H osey. It is w ith great regret that Richard Welbury, form . Tw o new chap ters ad d ress m anagem ent of the physi-
w ho co-authored the rst and second ed itions, w as u nable cally and m ed ically com prom ised child . In p romotion of
to continue in this role and w e thank him m ost sincerely for evid ence-based best p ractice and to d irect further learning,
his form er involvem ent. We are ind ebted to ou r colleagues reference lists have been u pd ated throughou t to includ e
w ho have p rovid ed valu able su ggestions regard ing this Cochrane review s, w here these have been d evelop ed .
revision. It is ou r hope that this text w ill continu e to be of use to
The stru ctu re of the chap ters rem ains u nchanged , w ith u nd ergrad u ates and to those in the early years of post-
the presentation of a clinical problem follow ed by a step-by- grad u ate training.
step lead -through assessm ent, d iagnosis and treatm ent
planning. All chap ters and related Mind Map s®, w here rel- DTM
evant, have been u p d ated . Ad d itional cases are inclu d ed in PFD
several chap ters to re ect the contem p orary and changing Cork and Leeds 2016
• viii
Problem solving is a core skill w hich the d ental und ergrad u - Mind Map s ® are also given for each topic to provid e a
ate m u st d evelop and re ne for exam inations and everyd ay focused fram ew ork for learning and revision. Each Mind
clinical p ractice. As orthod ontics and p aed iatric d entistry Map ® links key w ord s, or key points, w hich are highlighted
interface broad ly, com bined clinical teaching and exam ina- throu ghou t the text, to create an overview of the su bject and
tions in these d isciplines are linked increasingly to encour- is d esigned to trigger inform ation recall.
age holistic p roblem solving of d ental and occlu sal p roblem s Intend ed p rim arily for the u nd ergrad u ate, w e hope this
in the child and ad olescent p atient. book w ill be of valu e also to the ju nior postgrad u ate and to
This book aim s, therefore, to ad d ress a range of com m on those p rep aring for m em bership exam inations.
clinical p roblem s encou ntered in orthod ontic and p aed iatric
d ental p ractice. The form at p rom otes a logical ap p roach to DTM
problem solving throu gh history taking, clinical exam ina- RRW
tion and d iagnosis, w hich u nd erp in the princip les of treat- Cork and Glasgow 2004
m ent p lanning for both d iscip lines. A short reference list is
provid ed w ith each chap ter to facilitate fu rther d irected
learning.
ix •
Acknowledgements
We are p articu larly gratefu l to Mrs K Shep herd and Mrs G of the illu strations. Mr K Evans also kind ly assisted w ith the
Drake for their help and su p p ort in the p rep aration of p ho- p rod uction of the app liances show n in Figs 9.4 and 13.8. Ms
tograp hic m aterial. We w ou ld also like to thank especially N Kelly is thanked esp ecially for the ed iting and com p ila-
Dr G McIntyre, Ms R Bryan, Mr J C Aird , Dr A Shaw, Miss tion of photograp hic m aterial. Thank you to stud ents and
D Fu ng, Dr T Ubaya, Dr C Cam p bell, Dr K O’Rourke, Dr P staff w ho have u nd ertaken som e or all of the care on w hich
Mu rray, Dr T McSw iney, Dr P Mu rp hy, Dr M Mead e, Dr L the cases are based on. We are also gratefu l to Buzan Centres
Darby, Dr S McMorrow, Dr S Littlew ood , Dr A Garry, Dr E Ltd for the style for the Mind Map s ®. Ou r gratitud e is
Salloum , Dr D Morris, Dr S Fayle, Dr A Mighell and Cork extend ed to the staff of Elsevier w ho have been very help fu l
University Dental School & H ospital for provision of som e throu ghout.
1
History o complaint
Brian’s p rim ary front teeth had a p leasing ap p earance w ith
a sm all m id line space in the u pp er arch; the low er p rim ary
front teeth w ere not spaced . There is no history of trau m a.
The permanent incisors erupted in their p resent positions.
Brian’s p erm anent m olars started to eru p t over a year ago
and there is no d iscomfort from any of them .
permanent molar
Brian’s father had an u p p er m id line sp ace that w as closed
w ith a xed ap pliance.
Examination
Extraoral examination
Brian has a Class I skeletal p attern w ith average FMPA and
SUMMARY no facial asym m etry. Lip s are com petent w ith the low er lip
resting at the incisal third of the up p er central incisors.
Brian is almost 8 years o age. He presents with a There are no tem porom and ibu lar joint signs or sym ptom s.
gap between his upper ront teeth and crooked
lower ront teeth (Fig. 1.1); an ‘adult’ upper back Intraoral examination
tooth also does not appear to be coming through Soft tissu es are healthy and the d entition is caries-free. The
properly. What are the causes o these problems intraoral view s are show n in Figs 1.1 and 1.2.
and what treatment would you recommend? ■ What do you observe?
Low-lying maxillary labial renum.
History 6 E D C B1 1B C D
The ollowing teeth are visible:
6 E D C 21 12 C D E 6
Complaint
(note E6 present, but 6 erupting into E).
Brian’s m other noticed the gap betw een his u p p er front
teeth and the irregu larity of his low er front teeth. She is Mild lower labial segment crowding with distolabial rotations
anxiou s abou t his ap p earance and is keen for treatm ent to o 1| 1; slight spacing distal o 2 | 2.
be provid ed . Recently she has also noticed that one of his Upper median diastema with the crowns o 1 1 f ared distally.
new ‘ad u lt’ u p p er back teeth is not com ing throu gh p rop -
Class III incisor relationship.
erly com pared w ith his other u pper back tooth on the oppo-
site sid e. B| B
Crossbites .
C| C
Fig. 1.1 Anterior occlusion at presentation. Fig. 1.2 Lower occlusal view (note 6 | 6 erupted but not shown).
•2
1 MEDIANDIASTEMAANDECTOPICERUPTIONOFANUPPERFIRSTPERMANENTMOLAR
■ Wha t is the aetiology o the 1 | 1 rotations? d istal tilt and rotations of 1| 1 m ay ind icate inherent crow d -
ing. Also, there is no low er prim ate (anthropoid ) sp ace
Incisor rotations are usu ally a m anifestation of inherent
betw een the p rim ary canines and rst p rim ary m olars.
crow d ing in the arch, w hich is genetic in origin. The lack of
Spacing betw een the up per perm anent central incisors
primary low er incisor sp acing rep orted by the child ’s
( ared d istally and form erly d escribed as the ‘u gly d u ck-
m other is p red ictive of likely crow d ing of the p erm anent
ling’ stage, term s best avoid ed w ith concerned p arents) is
successors. Incisor rotations may also resu lt from ectopic
also norm al at this stage, but generalized sp acing of the
position of the tooth germ s or from the p resence of a su p er-
up p er prim ary teeth inclu d ing the u p per prim ate spaces
nu merary tooth.
(located betw een the u p p er p rim ary lateral incisors and the
■ Wha t are the possible causes o the upper up p er prim ary canines) shou ld exist.
median dia stema? Although the prim ary incisor relationship is com m only
These are listed in Table 1.1. ed ge-to-ed ge at 5–6 years w ith incisor attrition, it is not
usu al for the perm anent incisor relationship to be sim ilar.
■ Is the dental and occlusal development normal?
Rather a Class I incisor relationship should be present.
Dental d evelopm ent is norm al. Erup tion d ates of the B B
A crossbite shou ld not exist on || .
prim ary and p erm anent d entition are given in Table 1.2. C C
It is com m on for som e crow d ing to be present as the The rst perm anent m olars shou ld norm ally be in a half-
low er incisors eru pt, w hich u su ally m anifests itself as slight unit Class II relationship d u e to the ‘ ush term inal p lanes’
lingual p lacem ent and / or rotation of the teeth, bu t the slight relationship of the second p rim ary m olars.
Fig. 1.3 Dental panoramic tomogram. Fig. 1.5 Anterior occlusion ollowing eruption o 2’s.
•4
1 MEDIANDIASTEMAANDECTOPICERUPTIONOFANUPPERFIRSTPERMANENTMOLAR
Table 1.3 Causes o impaction (ectopic eruption) o 6
Factor Cause
Local Signifcantlylarger 6 and more pronounced mesial angle o eruption o 6
Hereditary Familial tendency
Small maxilla
Examination
Extraoral examination
N eil has a m ild Class II skeletal p attern w ith slightly
Unerupted upper
increased FMPA. H is lip s are com p etent. N o facial asym -
m etry or abnorm al tem p orom and ibu lar joint signs or sym p -
tom s w ere d etected .
SUMMARY
Neil, a 9-year-old boy, presents with 1 unerupted
(Fig. 2.1). What are the possible causes and how
would you manage the problem?
History
Complaint
N eil’s m other is very concerned abou t the u neru p ted 1 as
he is 9 years old and the tooth has not yet ap peared ; 2 is
also eru p ting over B, and she d islikes the ap p earance.
History o complaint
A w as lost at abou t 6 years of age, and 1 eru p ted norm ally A
at 6.5 years of age. Unfortu nately, N eil fell over w hile
playing soccer w ith his class team 4 m onths ago and frac-
tu red 1, exp osing the p u lp, w hich w as treated by a coronal
pu lp otomy and p lacem ent of calciu m hyd roxid e.
■ Is there anything else you would wish to elicit rom the
history?
N eil’s m other shou ld be asked abou t any history of trau m a
to the prim ary incisors, p articu larly intru sion of BA .
There is no history of traum a to the prim ary d entition.
B
Fig. 2.1 Upper labial segment at presentation. Fig. 2.2 (A) Right buccal occlusion. (B) Anterior occlusion. (C) Le t
buccal occlusion.
•6
2 UNERUPTEDUPPERCENTRALINCISOR
Mild plaque deposits on most teeth associated with marginal
Box 2.1 Causes o unerupted or missing upper permanent
gingival erythema. central incisor
6 ED C 2 BA 1 2 C D E6 Missing
Early mixed dentition with present.
6 ED C 2 1 1 2 C E6 • Congenitally absent.
Restored incisal edge o 1, which also appears to be darker • Avulsed.
than the other incisors. • Extracted.
Class I malocclusion with mild lower and moderate upper Present but unerupted
labial segment crowding. • Ectopic position o the tooth germ.
Upper centreline to the right; lower centreline to the le t. • Dilaceration and/or displacement due to trauma.
Potential crowding lower le t quadrant. • Scar tissue.
Buccal segment relationship Class I bilaterally. • Supernumerary tooth.
• Crowding.
■ Why are the centrelines displa ced?
• Pathology, e.g. cyst, odontogenic tumour.
An im balance of u pper anterior tooth size (the retained A
is consid erably sm aller than an 1 ) has p rom oted the u p p er
centreline shift, bu t this has been aggravated by inherent
u pper arch crow d ing.
The low er centreline shift is d u e to early u nbalanced loss Box 2.2 Classifcation o supernumerary teeth (s/n) by
of D in a p otentially crow d ed arch. morphology and e ects on the dentition
• Conical or peg-shaped – most o ten lies between 1 1 and mayproduce no
■ Could the lower centreline shi t have been prevented?
e ect, a median diastema, incisor rotation or ailure o 1 eruption (Fig. 2.3A);
Follow ing rem oval of D the low er centreline shou ld have 75–78%o s/n.
been m onitored at review visits. D shou ld have been • Tuberculate or barrel-shaped – most usually associated with unerupted 1; ~12%
extracted to balance for loss of D w hen the centreline o s/n.
appeared to be m igrating. • Supplemental – resembles and lies adjacent to the last tooth o a series (2’s, 5’s,
■ With unilatera l loss o what other primary tooth, would you 8’s); likely to produce crowding, centreline shi t (Fig. 2.3B).
consider a balancing extraction to prevent a centerline shi t? • Odontome – may be either compound or complex; compound is more common
in the anterior maxilla; complexis more common in the premolar and molar
Where u nilateral loss of a p rim ary canine has occu rred (or areas; associated with unerupted/displaced teeth.
is planned as in the case of a p alatally ectop ic canine; see
Chap ter 6) and the contralateral tooth is not m obile, consid -
eration should be given to its rem oval to prevent loss of
the centreline. A balancing extraction of another second
Dilaceration and/or displacement due to trauma can be
primary m olar to p revent a potential centerline shift is
excluded due to the absence o a relevant history.
u nnecessary.
Scar tissue can be excluded also as this would result rom
trauma.
A supernumerary tooth (Box 2.2) is the most likely cause o
Key point unerupted 1. With an incidence o 1 3% in the premaxilla,
Always balance or unilateral loss/extraction o a primary supernumerary teeth (particularly the late- orming
canine. tuberculate type) are associated with delay or noneruption o
an upper permanent central incisor.
Crow d ing is an unlikely cau se. Althou gh the u pp er labial
segm ent is crow d ed , only very severe crow d ing w ou ld
■ Wha t are the possible causes o the unerupted 1 ? prevent 1 eru pting 2 years follow ing its expected eru ption
tim e.
These are listed in Box 2.1. Pathology is also an u nlikely cau se. There is no evid ence
■ How would you ra te the likelihood in this case o each o of alveolar exp ansion in the p rem axilla, w hich w ou ld m ost
the potential causes o unerupted 1 listed in Box 2.1? likely be d u e to cyst form ation p ossibly arising from 1, a
sup ernu m erary or od ontom e. Other rarer lesions w ou ld
Congenital absence o 1 is highly unlikely. It would be very
need to be exclud ed .
rare or 1 to be absent without other congenitally missing
teeth.
Avulsion o 1 can be excluded as there is no history o 1
having erupted or o incisor trauma.
Extraction o 1 can be excluded also. Key point
Ectopic position o the tooth germ is a possibility but is more A supernumerary tooth is the most common cause o
likely to be secondary to some pathological cause or the ailure o eruption o 1.
presence o a supernumerary tooth.
7•
UNERUPTEDUPPERCENTRALINCISOR 2
Radiographic The follow ing view s are required to d eter-
m ine the p resence/ absence of 1 and / or p ossible su p ernu -
m erary teeth:
• Dental panoramic tomogram gives a general screen o
the developing dentition allowing detection o the
presence/absence o unerupted teeth.
• Upper anterior occlusal or periapical views provide greater
detail o the anterior maxilla. In particular, the ollowing
can be assessed: the crown and root morphology o
unerupted 1, the presence o supernumerary teeth and/
or other pathology and their relation to the incisor roots,
the root and periapical status o traumatized 1. On a
panoramic radiograph these structures may be poorly
de ned due to superimposition o other anatomical
A eatures or by lying outside the ocal trough o the
tomogram. Periapical radiographs should include the
roots o adjacent teeth to determine i they were
damaged during previous trauma to 1.
Used in com bination and em ploying the principle of
vertical parallax, the d ental panoram ic tom ogram and the
u pper anterior occlu sal or periapical view s can be u sed to
localize the p osition of any u neru p ted tooth and / or su p er-
nu m erary relative to the d ental arch.
Key point
• Two radiographic views are required to localize an
B
unerupted tooth in the premaxilla using parallax.
Fig. 2.3 (A) Two conical supernumerary teeth between 1 1. • A lateral view may be required to aid localization o a
(B) Supplemental 2. dilaceration, i visible on either the dental panoramic
tomogram or on the upper anterior occlusal/periapical
■ What is the aetiology o supernumerary teeth? views.
Treatment
A ■ What a re your aims o treatment?
• Restore gingival and dental health.
• Relie o crowding.
• Correction o centrelines.
• Alignment o 1. De nitive restoration o 1.
■ What is your treatment plan?
For treatment planning, you shou ld make arrangements for
N eil to be referred for joint consu ltation by an orthod ontist,
oral surgeon and paed iatric d entistry colleague regard ing
management of unerupted 1 , associated su pernu merary, the
prognosis of 1 and the cariou s molars. The plan agreed w as:
1. Oral hygiene instruction.
2. Dietary advice with the aid o a diet diary.
B 3. Provision o a custom-made mouthguard or soccer
Fig. 2.4 (A) Dental panoramic tomogram. (B) Upper anterior practice. The t may need to be modi ed with regard
occlusal radiograph. to some aspects o the treatment given below.
4. Determine the prognosis o 1. The likelihood o apical
closure was deemed to be good, and 1 was to be
monitored radiographically at 3-month intervals.
Application of vertical p arallax to these rad iographs 5. Determine the prognosis o the second primary molars
ind icates that 1 and the sup ernum erary tooth are palatally rom bitewing radiographs. E’s were deemed to be o
p ositioned . reasonable prognosis, but E’s require ormocresol
pulpotomy and stainless steel crowns or extraction in
■ Is there any other a lternative radiographic investigation
view o the pulpal carious involvement. More than hal
you might consider? I so, why?
the root length o E| E remains, and in view o the space
Althou gh a cone beam com puted tom ographic (CBCT) loss that already exists in the lower arch, it would be wise
view m ay be consid ered in the assessm ent of u neru pted to minimize any urther extractions except in an attempt
tooth p osition, and if a su p ernu m erary tooth, or teeth, is to correct the centreline shi t.
present, a risk/ bene t analysis need s to be u nd ertaken 6. Open space or 1 and correct the upper centreline.
on a case-by-case basis. Only w hen conventional rad io- D
grap hic view s fail to provid e suf cient d iagnostic infor- 7. Taking the poor prognosis o into account, and to
D
m ation shou ld CBCT be requested . In this case it w as allow relie o upper arch crowding at this stage, to
reckoned to be u nnecessary based on the view show n in create space or centreline correction and or 1 to
Fig. 2.3. be accommodated, the ollowing extractions are
D C BA C D
indicated .
Diagnosis D
Removal o D is required to balance the extraction o
■ Wha t is your diagnosis? D. Extraction o D will balance the loss o D and tend to
Class I malocclusion on a mild Class II skeletal base with encourage correction o the lower centreline shi t.
slightly increased FMPA. 8. The supernumerary tooth will also need to be surgically
Generalized mild marginal gingivitis. removed and an attachment with a length o gold chain
should be bonded to 1, ollowed by f ap replacement
D
Caries in ; trauma to 1 involving the pulp. (closed technique). 1 should not be surgically exposed
ED E
with an open technique.
Upper and lower arch crowding. 9. In this case it will be necessary to await urther eruption
BA retained; 2 erupting labially; 1 unerupted with associated o 2 ollowing removal o BA be ore moving 2 and 12
tuberculate supernumerary. distally to create space or 1.
9•
UNERUPTEDUPPERCENTRALINCISOR 2
■ How ma y space be created or 1?
Space m ay be created u sing an u pper rem ovable appliance
or by a xed ap p liance.
■ Are there any adva ntages to use o an upper removable
appliance over a f xed a ppliance in this case and at
this stage?
A rem ovable ap p liance has the follow ing ad vantages in this
case at this stage:
There are few p erm anent teeth eru p ted , and m any of the
prim ary teeth are to be extracted ; this leaves very few teeth
on w hich the ap p liance m ay be anchored . Althou gh a xed
ap pliance cou ld be bond ed to the p erm anent incisors and
band s p laced on the rst p erm anent m olars, anchorage
w ou ld need to be reinforced by m eans of linking the rst Fig. 2.5 Upper removable appliance to open space or 1 .
m olars on either sid e of the arch by m eans of a N ance trans-
palatal arch w ith an acrylic bu tton w hich contacts the ante-
rior vau lt of the p alate. There w ill be long sp ans of the
archw ire u nsu p p orted and liable to d istortion. As the base-
plate covers the p alate, anchorage is better w ith a rem ovable
ap pliance for the tooth m ovem ents requ ired .
If d esired , a p rosthetic tooth cou ld also be ad d ed w hen
BA have been rem oved and colou r-m atched to 1; this w ou ld
enhance app liance aesthetics. It cou ld be progressively
trimm ed as 1 is brou ght into alignm ent.
The appliance m ay also be rem oved for cleaning and for
sp orts.
■ What design o upper remova ble a ppliance would you use
to achieve the desired tooth movements? Fig. 2.6 Following extraction o our rst premolars, xed
appliance therapy and urther restorative treatment to 1.
The ap p liance shou ld be d esigned w ith the aid of the
acronym ARAB (activation, retention, anchorage, baseplate)
w hile the p atient is still in the d ental chair, so that nothing
is overlooked . case at this stage. It is likely that fu rther treatm ent, p robably
• Activation: Palatal nger springs (0.5 mm stainless steel loss of a p rem olar u nit from each qu ad rant and xed ap p li-
wire) to 2 12. ance therap y, w ill be required at a later d ate, and then d etail-
• Retention: Adams clasps (0.7 mm stainless steel wire) to ing of 1 p osition can be u nd ertaken (Fig. 2.6).
6 6 . Recurved labial bow (0.7 mm stainless steel wire) ■ Wha t is the recommended root f lling ma terial or 1 during
rom mesial o each E. orthodontic tooth movement?
• Anchorage: From baseplate. When ap ical closu re is evid ent on 1, no root canal treatm ent
• Baseplate: Full palatal acrylic coverage (Fig. 2.5). is requ ired as the tooth has vital p u lp tissu e.
When sp ace for 1 has been created , a hook m ay be sol- ■ Does orthodontic tooth movement pose any risk to 1?
d ered to the labial bow to allow attachm ent of the gold
chain for 1 extru sion or the bow m ay be m od i ed to create There is an increased risk of root resorp tion. N eil and his
a bu ccal arm for this p u rp ose. m other shou ld be w arned abou t this d u ring the inform ed
consent p rocess. 1 m ay also becom e non-vital and requ ire
Key point end od ontic treatm ent.
■ Are there any precautions you would take during
Sequence in design o an upper removable appliance:
orthodontic treatment to minimize this risk?
ARAB acronym
• Activation. As w ith all orthod ontic tooth m ovem ent, excessive forces
• Retention. should be avoid ed . Sensibility testing and a periapical rad i-
ograph shou ld be taken p rior to starting treatm ent and sub-
• Anchorage.
sequ ently, for m onitoring, at 6 m onths into treatm ent. N eil
• Baseplate.
and his m other should be inform ed of this also d uring the
consent p rocess. N eil shou ld be ad vised to w ear the m ou th-
gu ard provid ed d uring contact sports to m inim ize the risk
■ Will an upper removable applia nce achieve a ll the
of repeat trau m a.
treatment objectives?
1 becam e non-vital nearing com pletion of 1 alignm ent
An up per rem ovable ap pliance w ill achieve the simp le and required end od ontic treatm ent w ith gu tta percha. This
tooth m ovem ents (tipp ing and extrusion) requ ired in this w as com pleted uneventfully.
• 10
2 UNERUPTEDUPPERCENTRALINCISOR
■ How would you ensure long-term stability o 1 ollowing Primary resources and
alignment?
recommended reading
Bond ed p alatal retention w ill be requ ired to gu arantee long- Becker A, Brin I, Ben-Bassat Y et al 2002 Closed -eru p tion su rgical
term alignm ent of 1 . techniqu e for im p acted m axillary incisors: a postorthod ontic
Labial gingivoplasty m ay be requ ired at a later stage in p eriod ontal evalu ation. Am J Orthod Dentofacial Orthop
relation to 1 to obtain coincid ence of the gingival m argins 122:9–14.
of 1 1. Flem ing PS, Xavier GM, DiBiase AT et al 2010 Revisiting the
su p ernu m erary: the ep id em iological and m olecu lar basis of
extra teeth. Br Dent J 208:25–30.
Key point Kap ila S, Conley RS, H arrell WE Jr 2011 The cu rrent status of
cone beam com p u ted tom ograp hy im aging in orthod ontics.
Sequence in management o unerupted 1: Dentom axillofac Rad iol 40:24–34.
• Obtain oral surgical/orthodontic opinion (and possibly Kind elan SA, Day PF, Kind elan JD et al 2008 Dental trau m a: an
paediatric dental opinion); i prognosis or 1 alignment overview of its in uence on the m anagem ent of orthod ontic
judged satis actory then, treatm ent. Part 1. J Orthod 35:68–78.
• Open space or unerupted 1 (may involve extractions o Mason C, Azam N , H olt RD et al 2000 A retrosp ective stud y of
primary teeth). u neru p ted m axillary incisors associated w ith su p ernu m erary
teeth. Br J Oral Maxillofac Su rg 38:62–65.
• Remove supernumerary.
Yaqoob O, O’N eill J, Gregg T et al 2010 Managem ent of
• Bond attachment to 1.
Uneru pted Maxillary Incisors. Facu lty of Dental Su rgery of
• Do not surgically expose 1. the Royal College of Su rgeons of England . Available at:
• Align 1 with appropriate appliance. http :/ / w w w.rcseng.ac.u k/ fd s/ p u blications-clinical
• Maintain 1 correction with bonded retainer. -gu id elines/ clinical_gu id elines/ d ocu m ents/
ManMaxIncisors2010p d f.
• Reassess malocclusion regarding urther treatment
needs.
For revision, see Mind Map 2, page 222.
3
Family history
Sarah’s m other also has a sm all space betw een her upp er
front teeth d u e to one m issing tooth (2 ).
Social history
Sarah is a keen clarinet player and is not m otivated to w ear
a xed ap pliance.
■ How will her instrument pla ying impa ct on
lateral incisors
her m u sical p erform ance, but w ith p ractice and m otivation,
m ost w ind instru m ent players ad ju st. With a w ood w ind
instru m ent su ch as a clarinet, it is likely that Sarah w ill
ad ju st very qu ickly to w earing an orthod ontic appliance
and that p laying w ill retu rn to norm al w ithin a few
w eeks. It w ould , how ever, be ad visable to avoid tting
an ap pliance close to d ates of m u sic exam s, au d itions
or p erform ances. Any orthod ontic ap pliance, p articularly
SUMMARY xed app liances, m ay ru b the insid e of the lips and cheeks
Sa rah, aged 12 years, presents with spacing o her w hen tted , bu t w ax m ay be app lied to m inim ize this. As
upper anterior teeth (Fig. 3.1). What are the possible Sarah is not keen for a xed appliance and provid ed treat-
causes, and how may it be treated? m ent is possible w ith a rem ovable ap p liance, this could be
removed w hile p laying. In ad vance of any orthod ontic treat-
m ent, it w ould be u sefu l for the orthod ontist to ascertain
History how m any hou rs Sarah p ractises per d ay, as leaving the
app liance out for long period s is likely to imp ed e treatm ent
Complaint progress.
Sarah d oes not like the gap s betw een her u p p er front teeth.
She has ju st m oved to a new school and feels self-consciou s
abou t the ap pearance of her teeth.
Examination
History o complaint Extraoral
All p rim ary teeth w ere p resent and w ere lost norm ally. Sarah has a Class I skeletal pattern w ith average FMPA;
When her u p p er p erm anent front teeth eru p ted , there w as there is no facial asym m etry. H er lips are com petent w ith
consid erable sp acing betw een them , and this has not altered the low er lip covering the incisal third of the u p per incisors.
m u ch since then. The p erm anent teeth eru p ted at a normal The tem porom and ibular joints are sym ptom -free.
age, and none have been extracted or avu lsed .
A B
C D
Fig. 3.2 (A) Lower occlusal view. (B) Upper occlusal view. (C) Right buccal occlusion. (D) Le t buccal occlusion.
Radiographic
Table 3.1 Possible causes o the upper labial segment spacing • A dental panoramic tomogram is required to determine
Cause Aetiology the presence/absence o 2’s, 8’s, supernumerary teeth or
Absence o 2 2 Hypodontia (a ects ~2%o Caucasians) – also associated with any pathology.
cle t lip and palate, Down syndrome and ectodermal dysplasia Sarah’s dental panoramic tomogram showed:
Avulsion
• Normal alveolar bone height.
Extraction
• Absence o 2 2 and third molars; short root on C.
Failure o /delayed Crowding
eruption o 2’s Ectopicposition • No pathology associated with any erupted or unerupted
Supernumerarytooth teeth.
Scar tissue Occlusal
Dilaceration • Impressions and a wax registration should be taken or
Cyst/tumour
study models to allow urther assessment o the occlusion.
13 •
ABSENTUPPERLATERALINCISORS 3
■ Wha t genes have been linked to hypodontia ?
Key point
MSX1 and PAX9 have been linked .
Management options with absent 2’s are to
■ How would you ra te the severity o the hypodontia? • Maintain or close 2 space.
Sarah has m issing 2’s and thu s has m ild hyp od ontia (one • Open space or 2 replacement.
or tw o teeth m issing). Mod erate or severe hypod ontia
ind icates three to ve or m ore than six teeth m issing,
respectively. ■ What a ctors would you consider in deciding between space
closure or space opening?
■ Are there other acial/dental/occlusal eatures associated
with hypodontia? Sarah should be seen w ith a restorative colleagu e w ho w ill
provid e inp u t regard ing the restorative im plications of each
Red u ced low er facial height, d elayed d ental d evelop m ent,
treatm ent op tion. Then, it is often w ise to u nd ertake a trial
retained p rimary teeth, sm all teeth and an increased over-
set-u p of the optim al treatm ent option using d u plicate
bite have been associated . Thinning of the hair and absence
stud y m od els and to show this to the patient, to allow a
of palm ar sw eat gland s are featu res of anhid rotic ectod er-
fu ller ap p reciation of the likely treatm ent ou tcom e.
m al d ysp lasia, w hich is associated w ith severe hyp od ontia
The follow ing factors should be consid ered :
(see Chap ter 37).
The patient’s attitude to orthodontic treatment. I the patient is
not keen to wear xed appliances, it may necessitate a
Diagnosis change in treatment plan.
■ What is your diagnosis? The anteroposterior and vertical skeletal relationships. In Class II
cases with an increased overjet, space closure is desirable as it
Class I m alocclu sion on a Class I skeletal base w ith average will eliminate the overjet, whereas in Class III cases this would
FMPA. Well cared for mou th. Mild ly im bricated low er inci- tend to worsen the incisor relationship. Space opening is
sors bu t otherw ise u ncrow d ed low er arch; sp aced u p p er optimal in Class III cases where proclination o the incisors is
arch w ith absent 2 2 and retained C. Bu ccal segm ent rela- likely to correct an anterior crossbite. Where the FMPA is
tionship is half-unit Class II bilaterally. reduced, space opening is pre erable to space closure, and
■ What is the IOTN DHC gra de (see p. 264)? Explain why. the converse is true where an increased FMPA exists.
4h – d ue to absence of 2 2 . The colour, size, shape and angulation o the canine and incisor
teeth. Where the maxillary canine is considerably darker than
the incisors and/or it has a marked canine orm, space closure
Treatment is not advisable as considerable recontouring o 3’s will be
required to enable them to resemble 2’s. Where the canine and
■ What are the trea tment options?
incisor teeth are so angulated that it is possible to reposition
These are: them into their desired locations by tipping movements, a
1. Accept the spacing not a realistic option as Sarah is removable rather than a xed appliance may be used.
concerned by it. Whether the arches are spaced or crowded, and the buccal
2. Build up the mesiodistal width o 1’s and 3’s with segment occlusion. In uncrowded or mildly crowded arches,
composite or by veneering to reduce the spacing, but where the buccal segment occlusion is Class I or at most
not to close it completely. The median diastema is too hal -unit Class II, space opening is best. Space closure is
large or restorative build up o 1 1 to look aesthetic. pre erable where more crowding exists and the buccal
Some recontouring o the cusp tips o 3’s would also be segment relationship is a ull-unit Class II.
required to improve the nal appearance.
In this case it w as d ecid ed to p roceed w ith sp ace op ening
3. Orthodontic space closure. This would require a for rep lacem ent of 2 2 , u ltim ately on resin-retained brid ges.
considerable amount o tooth movement along with C This requ ired an initial phase of d istal m ovem ent of the
extraction, the wearing o a xed appliance and reverse u pper bu ccal segm ents to achieve a Class I m olar relation-
headgear or the placement o TADs may be considered ship, extraction of C, follow ed by retraction of 3’s to a Class
to assist space closure. I relationship w ith 3’s and space op ening for 2’s replace-
4. Orthodontic space opening (this would require m ent. Im p ortantly, overbite red u ction w as also u nd ertaken
extraction o C) or replacement o 2’s on resin-retained in conju nction w ith these tooth m ovem ents to p rovid e sp ace
bridges, by xed bridgework or by implants in late for the m etal fram ew ork of the resin-retained brid ges.
teenage years. Replacement o 2’s by autotransplantation Id eally, a xed ap pliance w ould be ind icated to achieve
o lower premolars (see Chapter 2) is not a viable these objectives, bu t as Sarah w as not keen for this form of
consideration as (i) the lower arch does not warrant treatm ent, an accep table thou gh not op tim al outcom e w as
premolar extractions and (ii) root ormation on lower d eem ed achievable by u p p er rem ovable ap p liance therap y.
premolars is in advance o the ideal stage (two-thirds to
three-quarters complete). ■ Could treatment time ha ve been shortened by an earlier
interceptive measure?
As op tion 2 w ill only partly ad d ress Sarah’s concerns it
has to be ru led ou t. The choice then is betw een the tw o Rem oval of C’s is a u sefu l intercep tive m easu re in the
orthod ontic op tions. early m ixed d entition w hen sp ace closu re is p lanned as it
• 14
3 ABSENTUPPERLATERALINCISORS
encou rages 3’s to eru p t m ore m esially. In this case, how ever, ■ What design o upper removable applia nce would you
space op ening for 2’s rep lacem ent w as p lanned . H ence consider or these tooth movements?
rem oval of C at age 10 is likely to have allow ed 3 to erupt
Palatal nger springs to 31|13 (0.5 mm stainless steel wire).
in a m ore d istal p osition than it is now bu t w ou ld also have
encou raged m esial d rift of the u p p er left buccal segm ent. So Adams clasps 6 6 (0.7 mm stainless steel wire) with
on balance, this extraction at an earlier stage is u nlikely to headgear tubes soldered to the clasp bridges.
have shortened treatm ent tim e. Long labial bow with ‘U’loops (0.7 mm stainless steel wire)
rom 4 to 4 .
Key point Flat anterior biteplane to hal the crown height o 1 1 and
extended 3 mm urther palatally than the maximum overjet
With absent 2’s consider:
measurement. This is an important component o the
• Patient’s attitude to orthodontic treatment.
appliance to ensure that overbite reduction is maintained,
• Skeletal relationships. creating su cient interocclusal clearance or placement o
• Colour, size, shape and angulation o 3 and 1. the metal ramework on the resin-bonded bridges.
• Crowding/spacing.
■ When space has been created or 2 2 , what should
• Buccal segment occlusion.
be done?
The p atient shou ld be seen again w ith a restorative col-
■ How could the upper buccal segments be moved dista lly leagu e to ensure that the tooth m ovements achieved w ill
using a removable appliance to achieve a Class I molar allow restorative treatm ent to proceed as planned . Then a
relationship? removable retainer shou ld be tted for 6 m onths carrying
replacem ent 2 2 and ensu ring that space for them is main-
An u pper rem ovable ap pliance w ith bilateral screw s to
tained by p lacing w ire sp u rs in contact w ith the ad joining
m ove 6 5 4 and 4 5 6 d istally is an op tion. Anchorage need s
teeth (Fig. 3.3).
to be reinforced by allow ing provision for head gear to
be attached to the ap pliance. The app liance shou ld also
incorp orate: Key point
• Adams clasps (0.7 mm stainless steel wire) with headgear
tubes soldered to 6’s clasp bridges; Adams clasps (0.7 • Always place wire spurs on the removable retainer, to
mm stainless steel wire) to 4’s also. the teeth adjoining the 2 space a ter space opening.
• Short labial bow 3 to 3 (0.7 mm stainless steel wire). • Retain or 6 months be ore replacing 2 on resin-retained
bridge (underline 2).
• Flat anterior biteplane to hal the crown height o 1 1
and extended 3 mm urther palatally than the maximum
overjet measurement.
When there is evid ence of fu ll-tim e ap p liance w ear, head - ■ What design o resin-retained bridge is required?
gear should be tted for anchorage w ith an up w ard d irec-
tion of p ull to prevent the appliance becom ing d islod ged Maintenance of closu re of the m ed ian d iastem a requ ires
w hen the head gear is being w orn. perm anent retention. A bond ed p alatal retainer fram ew ork
linking 1 1 together is ind icated along w ith resin-retained
■ Wha t orce and dura tion o headgear wear is required or
brid ges w ith single w ing, off 3 3 . It is better that 1 1 are
anchorage?
retained as a sep arate u nit rather than risk the retention
A force of 250–350g p er sid e for 8–10 hou rs p er d ay is integrity and su ccess of the brid ges by incorporating 1 1
requ ired . retention in the brid ge d esign.
■ Wha t precautions must be adhered to when Im p lant rep lacem ent of 2 2 later is u nlikely as the roots
prescribing hea dgea r? of 31 13 are tipp ed tow ard the 2 2 sp ace, com p rom ising
access for im plant p ositioning. The nal resu lt w ith 2 2
Tw o safety m echanism s m u st be tted to the head gear
replaced on ad hesive brid gew ork is show n in Fig. 3.4.
assem bly, p referably a safety release sp ring m echanism
attached to the head cap and a facebow w ith a locking
d evice. Verbal and w ritten safety instru ctions m ust be
issued to both p atient and p arent(s)/ gu ard ian. The head -
gear should be checked at each visit.
When com p liance w ith head gear w ear is evid ent, then
Sarah shou ld be instru cted to turn each screw once per
w eek. C shou ld be extracted and acrylic relieved to allow
for p otential d istal d rift of 3 as the bu ccal segm ents are
retracted to Class I. Som e over-retraction is ad visable to
allow for any slight anchorage slip d u ring the next p hase of
treatm ent w hen 3’s w ill be retracted to a Class I relationship
w ith 3’s ; 1’s w ill be ap p roxim ated and overbite red u ction
w ill be m aintained . Fig. 3.3 Upper removable appliance retainer with replacement 2’s.
15 •
ABSENTUPPERLATERALINCISORS 3
Carter N E, Gillgrass TJ, H obson RS et al 2003 The
interd iscip linary m anagem ent of hyp od ontia: orthod ontics.
Br Dent J 194:361–366.
H arrison JE, Bow d en DE 1992 The orthod ontic/ restorative
interface. Restorative p roced ures to aid orthod ontic treatm ent.
Br J Orthod 19:143–152.
Khalaf K, Miskelly J, Voge E, et al 2014 Prevalence of hypod ontia
and associated factors: a system atic review and m eta-analysis.
J Orthod 41:299–316.
Kohich KO Jr, Kinzer GA, Janakievski J, 2011 Congenitally
m issing m axillary lateral incisors: restorative rep lacem ent. Am J
Fig. 3.4 Final restorations. Orthod Dentofac Orthop 139:435–445.
Mossey PA 1999 The heritability of m alocclu sion: p art 2. The
in u ence of genetics in m alocclu sion. Br J Orthod 26:195–203.
■ What additional actors would need to have been
considered i replacement o 2’s by implants was the Qad ri S, Parkin N A, Benson PE 2016 Sp ace closing versu s sp ace
opening for bilateral m issing up per laterals - aesthetic
pre erred pla n?
ju d gm ents of layp eop le: a w eb-based su rvey. J Orthod 43
It w ould be necessary to w ait u ntil facial grow th has red u ced (2):137–146.
to ad u lt levels. In a girl, grow th of the m axilla is com p lete Robertsson S, Mohlin B 2000 The congenitally m issing u p per
by abou t 15 years of age and m and ibu lar grow th u su ally 2 lateral incisor. A retrosp ective stu d y of orthod ontic space
years later, w hereas in boys m axillary grow th u su ally con- closu re versu s restorative treatm ent. Eu r J Orthod 22:697–710.
tinues to about 17 years of age and m and ibu lar grow th Silveira GS, De Alm eid a N V, Pereira DMT et al 2016 Prosthetic
until 19 years or later. This is esp ecially im p ortant as an rep lacem ent vs sp ace closu re for m axillary lateral incisor
agenesis: A system atic review. Am J Orthod 150, 228–237.
im plant has no eruptive potential and w ill be left behind if
erup tion of ad jacent teeth is still continu ing, com p rom ising Zachrisson BU, Rosa M, Toreskog S 2011 Congenitally m issing
m axillary lateral incisors: canine su bstitu tion. Am J Orthod
aesthetics.
Dentofac Orthop 139:434–444.
Asid e from su f cient d istance betw een the roots of the
ad jacent teeth, sp ace m u st also exist betw een the tooth
crow ns w ith su f cient interocclu sal clearance. Ad d itionally, For revision, see Mind Map 3, page 223.
am p le bu ccopalatal w id th and height of the alveolar bone
is requ ired in the 2 area.
upper canines
she w as 3 years old bu t has not u nd ergone any active d ental
treatm ent.
Examination
Extraoral
CASE1 Gem m a has a Class I skeletal p attern w ith average FMPA.
There ap p ears to be slight facial asym m etry w ith the chin
point d eviated m ild ly to the right. The lips are com petent.
SUMMARY N o temp orom and ibu lar signs or sym p tom s w ere d etected
Gemma, an 11-year-old girl, attends or a 6-month or rep orted .
dental assessment at your practice with both upper Gem m a and her m other w ere u naw are of Gem m a’s
slight facial asym m etry and have noticed no change in her
permanent canines erupting buccally (Fig. 4.1).
facial ap p earance over recent years.
What is the cause, and how may it be treated?
■ Would you be concerned by the mild acial asymmetry?
History A mild d egree of facial asym m etry is norm al, and as facial
appearance is rep orted ly u naltered for several years, there
Complaint is no cau se for concern.
Gem m a d oes not like the ‘squint’ ap pearance of her top and
bottom teeth, in p articular the p osition of the u p p er eye Intraoral
teeth, w hich she says ‘look like fangs’. ■ Gemma’s intraoral views are shown in Figs 4.1 and 4.2.
What do you notice?
History o complaint Generalized marginal gingival erythema.
The crooked ness of Gem m a’s teeth has been getting w orse
Plaque deposits visible on several teeth, notably both 3’s.
for the p ast year. The ap p earance of her u p p er teeth has
becom e of m ore concern to her in recent m onths w hen both There are no restorations, and there is no obvious caries.
u pper eye teeth started to eru p t. She is now teased at school Gemma is in the late mixed dentition stage with the
and called ‘Fangs’, w hich annoys her. 6 5 4 C3 2 1 1 2 3 4 5 6
Gem m a’s m other rep orts that her d au ghter ’s baby teeth ollowing teeth present: (note 5
7 6 5 4 3 2 1 1 2 3 4 E6 7
w ere also slightly crooked . Both she and Gem m a are very and 7 7 are partially erupted).
keen for treatm ent.
The lower labial segment is moderately crowded with 2 | 2
bodily displaced lingually and 1| 1 slightly mesiolabially rotated.
3 is distally angulated; 3 is mesially angulated.
The lower right buccal segment is also crowded with
insu cient space or 5 ; the lower le t buccal segment is
uncrowded with E present.
The upper labial segment is moderately crowded with 1 1
slightly mesiolabially rotated and 3 3 erupting buccally; C is
present.
3 is upright and 3 is slightly distally angulated.
The upper buccal segments are aligned.
In occlusion, there is a Class I incisor relationship.
The overbite is average and complete.
Fig. 4.1 Anterior occlusion at presentation. The lower centreline is slightly to the right.
17 •
CROWDINGANDBUCCALUPPERCANINES 4
Key point
Buccal displacement o 3 is more usual in a crowded arch.
Investigations
B ■ Wha t investigations would you request and why?
A d ental panoram ic tom ogram is requ ired to provid e a
general view of the d evelop ing d entition and to con rm the
p resence and position of all u neru pted perm anent teeth.
■ Gemma’s dental panoramic tomogram is shown in
Fig. 4.3. What do you notice?
Alveolar bone level is normal.
Presence o a ull complement o developing permanent
teeth, including third molars.
C All teeth appear caries- ree.
Diagnosis
■ Wha t is your diagnosis?
Class I malocclusion on a Class I skeletal base with average
FMPA, with the chin point displaced slightly to the right.
Generalized marginal gingivitis.
Moderate upper and lower arch crowding with the lower
centreline shi ted slightly to the right.
Right molar relationship is Class III; le t molar relationship is
D
Class I.
Fig. 4.2 (A) Lower occlusal view. (B) Upper occlusal view. (C) Right
■ What is the IOTN DHC grade and why (see p. 264)?
buccal occlusion. (D) Le t buccal occlusion.
Expla in why.
4d – d ue to severe d isplacements of teeth, greater than 4 mm.
The right molar relationship is Class III, and the le t molar
relationship is Class I.
Treatment
■ What are the possible reasons or 3’s erupting buccally?
■ Wha t treatment is likely to be required in this case?
• Crowding buccal displacement o 3’s is o ten a
Expla in why.
mani estation o inherent crowding in the upper arch. A
contributory actor is 3 being the last tooth to erupt Extractions are requ ired to relieve the m od erate crow d ing.
anterior to the rst permanent molars. Fixed app liance therap y is ind icated in view of the d istal
• 18
4 CROWDINGANDBUCCALUPPERCANINES
angu lation of m ost canines, the rotations of the central inci- As Gem m a has m od erate low er labial segm ent crow d ing,
sors, the bod ily lingu al d isplacem ent of 2’s and the cen- sp ace w ill be requ ired to achieve alignm ent.
treline shift. ■ What possible means are there o creating space?
■ Wha t would you do now?
Extractions.
Explain to the patient the likely plan or correction o her Arch expansion (laterally and/or anteroposteriorly).
malocclusion.
Distal movement o the molars.
Arrange or several visits o oral hygiene instruction by the
Enamel stripping.
practice hygienist, and assuming that oral hygiene improves
satis actorily, take upper and lower impressions and a wax Any combination o the above.
registration or study models. Expansion of the low er intercanine w id th is unstable as
Arrange re erral to an orthodontist and enclose the study is forw ard m ovem ent of the low er labial segm ent (w ith a
models and dental panoramic tomogram. few excep tions w hich w ill be d ealt w ith elsew here); d istal
m ovem ent of the low er rst p erm anent m olars is d if cu lt
Write a re erral letter to the orthodontist (Fig. 4.4).
w ithout extraction of low er second perm anent m olars and
■ Wha t aims o treatment do you think will be proposed by is und ertaken rarely. Enam el stripp ing is u sually only con-
the orthodontist? sid ered in ad u lts to gain 1–2 m m of space in total. In view
of these consid erations, extractions are the only realistic
Relie o crowding.
op tion of gaining sp ace in Gem m a’s case.
Upper and lower arch alignment.
Correction o lower centreline.
Correction o right molar relationship.
Key point
Closure o any residual spacing. Always consider the lower arch f rst in treatment planning.
Key point
Demineralization with f xed appliances:
• Is common (2 96% prevalence).
• Mostly a ects 2′s and 3 ’s.
• Is best prevented by care ul patient selection and
dietary advice.
CASE2 B
SUMMARY Fig. 4.6 (A) Dental panoramic tomogram. (B) Upper anterior
Aoi e, a 12-year-old girl, presented with crowded occlusal radiograph.
upper teeth. Her mother reported a possible
nickel allergy.
■ How would you deal with the history o a possible The u p p er anterior occlu sal rad iograp h reveals:
nickel a llergy?
Tapered roots o the upper incisors.
Aoife shou ld be referred to a d ermatologist for assessm ent 3 to be in contact with 2 root which is distally angulated.
and patch testing.
Fortu nately, no allergy to nickel w as rep orted . ■ Where is 3 located? Expla in how this assessment is made
and your reasoning.
■ How common is nickel allergy?
3 is buccally p laced . This assessm ent is m ad e by com paring
N ickel allergy is m ore comm on in fem ales (10–30%) than
the p osition of 3 on the panoram ic lm and the occlusal lm
m ales (~2%), p ossibly d u e to increased contact from nickel-
using vertical parallax. The x-ray tube has m oved u p
containing jew ellery.
betw een the panoram ic (taken at −10° to the occlu sal plane)
■ What implica tions does a nickel allergy ha ve or and the occlu sal (taken at 65–70° to the occlu sal p lane). This
orthodontic mana gement? w ou ld be a 75–80° tu be shift. The position of 3 relative to
These are su m m arized in Append ix 4. the ad jacent 2 is then assessed . An object closer to the x-ray
beam (bu ccally p laced ) w ill seem to m ove in the op posite
d irection as the tube shift. This is evid ent for 3.
■ What do you notice in Fig. 4.7?
Key point
Right bu ccal occlusion show ing:
A suspected nickel allergy:
• Should be assessed by a dermatologist. Mild marginal gingival erythema with apparent bulge over 2 .
• Is more common in emales. No caries.
• May require use o nickel- ree appliance components. Crowded lower arch with mesially angulated 3 (lower arch
was overall moderately crowded).
Spacing between 4 and 2 but insu cient or 3 ; 2 distally
angulated and mesiopalatally rotated.
■ Wha t do you notice on the radiographs shown in Fig. 4.6?
Class 1 incisor and molar relationship; average overjet; overbite
The d ental p anoram ic tom ogram show s: average (1 covers hal lower incisor crown) and complete.
Normal alveolar bone height.
7 6 5 4 C2 1 1 2 3 4 5 6 7
■ What a re the aims o treatment?
erupted.
76543211234567 The aim s of treatm ent are to:
Four third molars developing. Improve oral hygiene.
All permanent teeth o good quality; some root shortening o Relieve upper and lower arch crowding with alignment o 3 .
C but o reasonable length. Closure o residual spaces.
21 •
CROWDINGANDBUCCALUPPERCANINES 4
B
A
Fig. 4.10 (A) Right buccal occlusion. (B) Anterior occlusion. (C) Le t buccal occlusion. (D) Upper occlusal. (E) Lower occlusal.
m and ibu lar p lanes resp ectively). Only in the broad est sense rad iograp hs of 2 to ensu re that the root statu s rem ains
m ay com m ent be m ad e regard ing how the inclination of the unchanged .
incisors ‘ap p ears’. This w as found to be the case.
■ Wha t clinical assessment should you underta ke o 2? A lateral cep halom etric rad iograph is required to
provid e m ore inform ation abou t the severity of the Class
2 should be checked for m obility in case it is being resorbed III m alocclu sion and the extent of any d entoalveolar
by 3. If this is su spected , sensibility tests shou ld also be com p ensation.
u nd ertaken.
■ What is your interpretation o the ollowing
cephalometric f ndings?
Investigations SN A = 81°; SN B = 79.5°; SN -m axillary p lane = 8°; 1 to m axil-
lary p lane = 105°; 1 to m and ibu lar p lane = 90°; m axillary
■ The patient presented with a denta l panoramic radiograph
m and ibu lar p lanes angle (MMPA) = 28°; facial prop ortion
taken 6 months previously by her general dental
= 57%.
pra ctitioner. What radiographic investiga tions would you
The skeletal p attern is m ild ly Class III (AN B = 1.5°; SN A-
request and why?
SN B) d u e to very slight m and ibu lar p rognathism. Com -
It is not necessary to rep eat the p anoram ic lm . This revealed pared w ith m ean valu es, the u p per and low er incisors are
all perm anent teeth to be d evelop ing norm ally and to be of somew hat retroclined , bu t w ithin the norm al range, and the
good qu ality. The root statu s of 2 also app eared to be sou nd 1 angle is not com p ensating for the MMPA (shou ld be
w ith no evid ence of root resorp tion from 3. 120−28° = 92°). Both the MMPA and facial proportion are
As 6 m onths has elap sed since the last rad iograp h w as slightly increased from norm al values, but both are w ithin
taken of 2, it w ould be sensible to take tw o p eriap ical the norm al range.
23 •
CROWDINGANDBUCCALUPPERCANINES 4
• Arch expansion and extractions expansion will
Diagnosis reduce the need to extract 4 4 , so 5 5 may be
considered.
■ What is your orthodontic diagnosis?
• Arch expansion and distal movement o the le t buccal
Class III malocclusion on a mild Class III dental base with segment the ormer is as previously outlined; the latter
slightly increased acial proportions. may be achieved by placing a TAD between and pushing
Mild marginal gingivitis. Mild lower arch and severe upper against it with coil spring on a xed appliance to move
arch crowding with 3 excluded buccally. 4 5 6 distally.
Upper centreline shi t o 2 mm to the le t. Triona’s m other w as keen to avoid extractions, if p ossi-
ble. Follow ing consid eration of all op tions, it w as agreed to
Right molar relationship is slightly Class II, and le t molar
p roceed w ith an initial non-extraction ‘therap eutic d iagno-
relationship is slightly Class III.
sis’ ap proach (Fig. 4.11).
■ What is the IOTN DHC grade? Expla in your reasoning. ■ What a ppliance is shown in Fig. 4.11A? How is it constructed
4d – d u e to severe d isp lacem ent of teeth greater than 4 m m and how is it activated?
(betw een 2’s and 3’s bilaterally). This is a qu ad helix ap p liance and has been cu stom -m ad e in
the laboratory; p reform ed types, how ever, also exist. The
qu ad helix is attached to band s cem ented to a m olar on each
Treatment sid e of the arch. For a cu stom -m ad e app liance, an im pres-
■ What are your aims o treatment? sion m u st be taken w ith the band s in p lace, then the band s
are rem oved and located carefu lly in the im pression before
Improve oral hygiene. being d isinfected and sent to the laboratory. For the p re-
Relie o upper and lower arch crowding. formed typ es, attachm ents are w eld ed to the palatal sur-
Establish a positive overjet and overbite. faces of the band s into w hich slot the arm s of the qu ad helix;
this facilitates rem oval for ad ju stm ents. Both ap pliance
Correction o the upper centreline.
types are m ad e of 1 m m stainless steel w ire. Typ ically, acti-
Correction o the molar relationships to Class I. vation is achieved by ‘expand ing’ the app liance around half
Retain the correction. a tooth w id th on each sid e. Although activation m ay be
achieved intraorally w ith triple-beak p liers, it is d if cu lt to
Monitor third molars.
gauge the am ou nt of activation by that m ean; it is u su ally
■ What possible options are there to relieve the upper arch p referable to rem ove the appliance every second visit and
crowding and correct the upper centreline? activate it extraorally.
Sp ace is required in ord er to ad d ress these treatm ent aims. ■ Wha t is the most likely initial a ligning archwire shown
Possible m eans to provid e this are: in Fig. 4.11C? What a vourable properties ha s it got or
• Extractions removal o a premolar on either side o alignment?
the upper arch. Removal o 5 5 is usually considered This is most likely a nickle–titaniu m archw ire of sm all d iam -
in Class III camouf age, but anchorage would need to eter, probably 0.012-in. Its p roperties inclu d e exibility
be rein orced (with either a palatal arch or TADs) i w ithout und ergoing d eform ation, and it exerts a light force
their removal was considered. Removal o 4 4 , situated w hen tied into d isp laced teeth.
right beside where space is needed, would acilitate
alignment o 3 3, and although not all the 4 space ■ How would you re-evaluate treatment progress ollowing
is required or relie o crowding in the upper right upper arch expa nsion a nd a lignment?
quadrant, the residual space will be utilized or Interim record s should be taken for further treatm ent
upper centreline correction. With both extraction planning. These are clinical photographs (extraoral and
options, the upper arch would be aligned inside intraoral view s), stu d y m od els, and a lateral cep halom etric
the lower. rad iograp h.
• Arch expansion both anteroposterior and lateral The lateral cephalom etric m easurem ents shou ld be com -
expansion o the upper arch would correct the anterior pared w ith those taken at the start of treatm ent. Any change
crossbites as well as the tendency to buccal crossbite. It in SN B, AN B and MMPA shou ld be noted . The incisor incli-
will also provide urther space or 3, which may erupt. nations shou ld also be assessed relative to the m axillary and
Care is required as arch expansion may cause the palatal m and ibular planes resp ectively. 1 inclination w ill ind icate
cusps o the maxillary molars to tip buccally, which will how m u ch their inclination has changed d u ring u p p er arch
compromise the already tenuous overbite. A potential alignm ent, and 1 inclination w hen consid ered w ith the AN B
advantage o this approach is that extractions are and MMPA angles w ill ind icate if any d entoalveolar com -
delayed while urther mandibular growth is observed p ensation has occu rred since treatm ent started and w hether
when it will become more apparent whether fu rther orthod ontic com p ensation is feasible or d esirable. If
orthodontic correction is possible or not. Such a there has been m inim al/ no change in SN B, AN B and MMPA
‘therapeutic diagnosis’approach to treatment is o ten then the p rospect of orthod ontic correction is good . Other-
advisable in a Class III malocclusion where the extent o w ise any attem p t at orthod ontic cam ou age should be con-
urther mandibular growth is unknown. sid ered w ith cau tion d u e to the likely guard ed prognosis;
• 24
4 CROWDINGANDBUCCALUPPERCANINES
A A
Severe crowding Amy’s card iologist should be consulted regard ing the
card iac statu s and the p ossible need for antibiotic p rop hy-
laxis for p roced u res likely to p rod u ce bacteraem ia becau se
of the potential risk of infective end ocard itis. The N ational
Institute for H ealth and Clinical Excellence (N ICE, w hich
governs clinical practice in England and Wales) guid elines
(2016) d o not recom m end rou tine antibiotic p rophylaxis for
those und ergoing d ental p roced ures; the American H eart
Association (AH A) recom m end s antibiotic cover only for
those at high risk.
CASE1 Am y’s card iologist con rm ed that her card iac m u rm u r
had fu lly resolved and that antibiotic p rop hylaxis w as not
requ ired prior to any d ental or orthod ontic (separator p lace-
SUMMARY
m ent, tting/ removal of band s) proced u res.
Amy, an almost 11-year-old girl, presents with As excellent oral hygiene is essential w ith any orthod on-
marked space shortage or both unerupted 3′s tic treatm ent, the im p act of lack of optim al w rist m obility
(Fig. 5.1). What has caused this problem and how on oral hygiene shou ld be assessed . Assistance w ith tooth-
may it be treated? brushing by a parent m ay be requ ired until w rist m obility
is fully restored ; com p ared w ith m anual bru shes, pow ered
brushes w ith a rotation oscillation action provid e better
History plaque rem oval in the short term and better protection
against gingivitis in the short and long term .
Complaint Am y’s m other is alread y assisting w ith her d au ghter ’s
Am y d oes not like the appearance of the upp er ‘sid e teeth’ toothbru shing u sing a pow ered toothbrush.
being besid e her upp er front teeth; the ‘sid e teeth’ she thinks
‘look like tw o row s of teeth’. She also d oes not like the Dental history
crooked ness of her low er front teeth.
Am y is a regular attend er at her general d ental p ractitioner.
She had several of the baby back teeth extracted a few years
History o complaint ago and has som e ssu re sealants placed in the rst perm a-
Am y has become aw are of the w orsening app earance of her nent molars. She brushes her teeth tw ice p er d ay, but her
teeth over the p ast year. In that tim e, she has lost som e baby m other says that she need s remind ing abou t toothbru shing,
teeth and the new teeth have com e throu gh crooked . w ith w hich her m other cu rrently assists her.
Am y’s m other reports that her d aughter ’s baby teeth
looked good w ith only mild irregularity of the low er front
teeth. Both she and Am y are keen for treatm ent. Examination
Medical history Extraoral
Am y has a Class I skeletal pattern w ith average FMPA,
Am y’s m other reports that her d au ghter had a heart m u rm ur
average low er facial height and no facial asym m etry. H er
as a baby and attend ed a card iologist at the local hospital.
lip s are com p etent w ith the low er lip resting in the m id labial
third of the u pper central incisors.
N o abnorm al tem p oromand ibu lar joint signs or sym p -
tom s w ere d etected .
Intraoral
■ The intraoral views are shown in Figs 5.1 and 5.2. Describe
what you see.
Poor oral hygiene with plaque deposits visible on several
teeth and associated generalized marginal gingival erythema.
Stained occlusal ssures in 6 , brown staining on the mesial
Fig. 5.1 Anterior occlusion at presentation. o 6 and decalci cation at the gingival margin level on the
• 26
5 SEVERECROWDING
Table 5.1 Factors a ecting the rate o space loss ollowing early loss
o a primary molar
Factor Ef ect*
Age at loss The younger the age at loss, the greater the potential or space loss
Degree o crowding The more crowded the arch, the more space that will be lost
Tooth extracted Earlyloss o an E, rather than o a D,is likelyto lead to more space
loss (see belowregarding arch). 5’s mayerupt and be excluded
palatally/linguallyor be impacted; 5 maybe in crossbite; centreline
shi t i asymmetrical extraction and in case o E, i earlyloss be ore
age 7
Arch romwhich Greater loss is likelyin the upper, rather than in the lower arch, as
A tooth is lost mesial dri t tendencyis greater in the ormer
Type o occlusion Less space loss will occur where good buccal interdigitation exists
*The e ects listed above are those that are, in general, likelyto result romeach o the actors
given. Individual variation with regard to outcome is, however, possible.
Key point
Where anchorage is at a premium, always rein orce
anchorage be ore any extractions or relie o crowding.
Fig. 5.3 Nance button palatal arch.
29 •
SEVERECROWDING 5
effectiveness betw een the ap p liances in term s of anchorage
su pp ort, bu t there w ere m ore problem s reported w ith head -
gear and N ance bu ttons than w ith TADs.
■ Are there any risks with TADs?
Risks inclu d e:
• Screw breakage during insertion (5%).
• Root contact during placement (should heal
unevent ully).
• Failure necessitating TAD replacement/removal (~14%).
• In ection (unlikely i the area around the screw is brushed
gently with a small headed toothbrush and f uoride
toothpaste and chlorhexidine mouthrinse (0.2%) is used
or rst 5 days a ter insertion).
• Screw loosening (may be replaced in original or di erent
Fig. 5.4 Lingual arch. position).
sid e and u se it to keep the 6’s and second prem olars from ■ I Amy were issued an upper removable space mainta iner
m oving m esially. with headgear support, how would you know at her
2-week review whether the a pplia nces were being worn
■ I all the spa ce rom lower premolar extra ctions ha d been
as instructed?
required or lower labial segment a lignment, how could
anchorage have been rein orced there? Amy shou ld be speaking norm ally w ith the u pper rem ov-
able ap pliance in p lace; she shou ld also be able to rem ove
A low er rem ovable ap p liance is not w ell tolerated d u e to
and insert the app liance u naid ed by a m irror. The baseplate
encroachm ent on tongu e sp ace, interference w ith sp eech
should have lost its shine; there shou ld be evid ence of m ild
and d if cu lty w ith achieving good ap p liance retention d u e
gingival erythem a along the palatal m argins of the app li-
to the lingu al inclination of the m olars. A low er lingual arch
ance and at the posterior extension of the basep late (if the
sold ered to band s on the rst p erm anent m olars is a better
app liance had a bite p latform , there w ou ld be m arks from
op tion (Fig. 5.4). Alternatively, the second perm anent
the occlu sion also). She should also be able to insert, assem -
m olars cou ld be bond ed or band ed and ligated to the rst
ble and rem ove the head gear easily. If it is being w orn as
perm anent m olars. Another op tion is to p lace a TAD into
instru cted , the head cap w ill have signs of w ear and the
the retrom olar area on each sid e and use it to keep the rst
head gear tu bes in the rem ovable ap p liance shou ld be free
perm anent m olars and second p rem olars from m oving
of any food d ebris from insertion of the facebow.
m esially w hile p rovid ing anchorage for canine retraction.
The occlusion follow ing appliance w ear w ith head gear
support and extraction of four rst premolars is show n in
Key point Fig. 5.5. The lower centreline shift corrected without appli-
ance treatment. At this stage, Amy indicated that she was
Options or rein orcing anchorage in upper arch:
suf ciently pleased w ith the improvement in her dental
• Upper removable appliance space maintainer with appearance that she did not wish to proceed to further xed
headgear support. appliance therapy. This was fortunate as she was not keen on
• Headgear to molar bands. assisted tooth brushing by her mother and had struggled, due
• Nance button palatal arch (with/without transpalatal to continuing problems w ith right w rist mobility, to maintain
arch). a high standard of oral hygiene during removable appliance
• TAD. treatment, despite the use of a pow ered toothbrush.
Options or rein orcing anchorage in lower arch: An Essix retainer w as tted in the u p p er arch only; Am y
• Lingual arch. w as instru cted to w ear this at night-tim e only for 12 m onths
• Bond/band 7 ’s and ligate to 6 ’s. initially. Arrangem ents w ere m ad e to review her occlu sion
at that stage.
• TAD.
■ Wha t is an Essix reta iner, and what are its potential
adva ntages over a Ha wley retainer in the upper a rch? Aside
■ How e ective are TADs a t rein orcing anchorage? How do rom the usual advice regarding reta iners, what specif c
they compare to other methods o anchora ge advice should the pa tient be given regarding this retainer?
rein orcement? An Essix retainer is a clear vacu u m-form ed therm oplastic
retainer. Som e of its potential ad vantages over a H aw ley
Evid ence ind icates that TADs are an effective, non-com p liant
retainer are:
m eans of reinforcing anchorage or of m oving u p p er rst
perm anent m olars d istally. A recent rand om ized clinical • Better aesthetics.
trial com pared anchorage sup plem entation w ith head gear • Less di culty with speaking.
or N ance button p alatal arch or TADs, in cases that requ ired • Cheaper.
m axim u m anchorage su p p ort; there w as no d ifference in • Easier to make.
• 30
5 SEVERECROWDING
Fig. 5.6 (A) Right buccal occlusion. (B) Anterior occlusion. (C) Le t buccal occlusion. (D) Upper occlusal view. (E) Lower occlusal view.
Key point
6 rotates mesiopalatally with mesial dri t ollowing early
loss o E.
Diagnosis
■ Wha t is your diagnosis?
Class I malocclusion on a Class I skeletal base with
average FMPA.
Generalized mild marginal gingivitis.
Moderate lower and severe upper arch crowding with the
lower centreline shi ted to the le t.
Right buccal segment relationship is Class II; le t buccal
Fig. 5.8 Digital simulation o potential outcome ollowing
segment relationship is Class I.
extractions and 3 alignment.
Buccal crossbite 6 and 5 .
A B
C
D
Fig. 5.9 (A) At presentation: right buccal occlusion. (B) Anterior occlusion. (C) Le t buccal occlusion. (D) Lower occlusal view. (E) Upper
occlusal view.
■ What is the IOTN (DHC) gra de (see p. 264)? Explain why. A lateral cep halom etric lm is also requ ired to assess
m ore fu lly the Class III skeletal p attern and the angu lations
4d – d u e to contact p oint d isp lacem ent >4 m m (present on
of the u pp er and low er incisors to their resp ective d ental
several teeth, bu t greatest w ith 3 and ad jacent teeth).
bases. This revealed the follow ing: SN A = 81°; SN B = 81°;
SN -m axillary plane = 5°; MMPA = 29°; 1 to m axillary plane
Investigations = 112°; 1 to m and ibu lar plane = 91°; interincisal angle = 130°;
facial p rop ortion = 58%.
■ What investigations would you request and why?
■ How would you assess the long term prognosis o 6 ?
A d ental p anoram ic view w ou ld be ad visable to check the
cond ition of all eru p ted teeth and to ascertain if third m olars As the patient’s general d ental p ractitioner, you shou ld
are d evelop ing. check the clinical notes regard ing the last tim e 6 w as
This revealed all teeth includ ing third m olars to be d evel- restored . This shou ld have record ed w hether an ind irect
op ing norm ally and in the correct p ositions w ith no ap p ar- p ulp cap w as u nd ertaken or w hether the pu lp w as exposed
ent resorp tion of the 2’s by 3’s. The restoration in 6 w as d u ring the restorative p roced u re. You should also ask Conal
d eep . A su bsequent periap ical rad iograp h of 6 ind icated if he is having any sym p tom s associated w ith 6 , then check
second ary caries. the bu ccal su lcu s for any sw elling or sinu s related to 6 , as
• 34
5 SEVERECROWDING
w ell as the restoration for integrity of the m argins, and 3. Upper and lower xed appliances.
assess w hether 6 is tend er to p ercu ssion. 4. Upper and lower vacuum ormed retainers.
The clinical notes record ed a p u lp exp osu re and a d irect 5. Monitor third molars.
pu lp cap , so althou gh the tooth has been sym p tom -free, the
■ How may anchorage be rein orced in the upper and
prognosis w ou ld be som ew hat gu ard ed .
lower arches?
■ What is your interpretation o the cephalometric f ndings?
Means to reinforce anchorage in the up per and low er arches
Relative to Caucasian norm s, SN A is average and SN B is have been ou tlined on p age 29.
slightly increased , ind icating m ild m and ibu lar prognath- A lingual arch and a N ance palatal arch w ith transpalatal
ism. The skeletal p attern is m ild ly Class III (SN A − SN B = bar from 7 to 6 w ere placed (Figs 5.10 and 5.11).
AN B = 0°). SN to m axillary p lane is slightly less than
■ Are there any means by which anchorage demands may be
average; MMPA is slightly increased ; 1 to m axillary p lane is
reduced in the upper arch?
slightly increased , and 1 to m and ibu lar p lane is slightly
red u ced . The interincisal angle is red u ced and facial p ropor- Extraction of 4 in ad d ition to 6 w ou ld red u ce anchorage
tion is increased . The 1 angu lation is com p ensating for the d em and s in the u p p er right bu ccal segm ent.
m ild ly increased MMPA (120° − 91° = 29°). ■ Does this option ha ve a ny other potential benef ts? Are
there any risks?
Treatment
■ What are the aims o treatment?
Improve oral hygiene.
Relieve crowding.
Align upper and lower arches.
Correct centrelines.
A
Maintain Class I buccal segment relationship.
Dental history
Diane is a regu lar attend er at her general d ental p ractitioner
bu t has never had any d ental treatm ent.
CASE1
4
Intraoral
SUMMARY ■ The intra oral views are shown in Figs 6.1 a nd 6.2. Describe
what you see.
Diane, a 15-year-old girl, presents with both upper
primary ca nines retained (Fig. 6.1). What is the Oral hygiene is air with mild marginal gingival erythema
related to 2 2 and the upper le t buccal segment teeth.
cause and what treatment possibilities are there?
No obvious buccal swellings in the C areas, but there seem to
be mucosal swellings palatal to C2 2C, perhaps indicating
History the position o unerupted 3’s.
Diane is concerned about the size of the baby u pper ‘eye’ Slight enamel demineralization buccally on 6 6.
teeth that are present and by the spaces on either sid e of her
7 6 5 4 C2 1 1 2 C4 5 6 7
u pper tw o front teeth. She is not bothered by the sm all sp ace erupted.
7654321 1234567
betw een the u pp er front teeth. C is also slightly loose, and
she is w orried in case it is lost, p rod u cing a big sp ace. Mild lower labial segment crowding; 1| 1 very slightly
mesiolingually rotated; lower buccal segments spaced.
History o complaint Upper arch uncrowded; spacing in the upper labial
Diane has been aw are that the baby ‘eye’ teeth shou ld have segment.
been lost a few years ago. H er p reviou s general d ental prac- Class I incisor relationship with a centreline shi t (clinically the
titioner, w ho retired last year, ad vised her that these teeth lower centreline was 1.5 mm to the le t).
w ou ld eventu ally fall ou t by them selves and that w hen
Buccal segment relationship is Class I bilaterally; lingual
the new ‘eye’ teeth cam e throu gh, she w ou ld then need a
crossbite o 4 with 4 ; buccal crossbite o 6 with 6.
brace to close the sp aces betw een her top teeth. There is no
history of trau m a to C C areas, and all other prim ary teeth ■ What a re the potential causes o C’s being retained?
w ere lost natu rally. All p erm anent teeth have eru p ted on
Absence o 3’s this is highly unlikely (0.3% o Caucasians).
sched u le.
She has noticed that C has been loose interm ittently for Ectopic position o 3’s this is the most likely cause (1 2% in
the p ast 18 m onths. It d oes not app ear to have got looser in Caucasians with 8% o these being bilateral).
recent m onths. Diane is very keen to im p rove the appear- ■ What a ctors are implicated in pa la tal ca nine ectopia?
ance of her u p p er teeth.
The aetiology of p alatal canine ectop ia is obscu re bu t m ost
probably mu ltifactorial. Possible cau sative factors are:
1. Genetic palatally displaced 3 appears to result rom a
polygenic mode o inheritance, with associated
anomalies including incisor-premolar hypodontia,
peg-shaped 2 (see below), in raoccluded primary molars,
impacted 6, other ectopic teeth and transposition (see
Chapters 1, 7 and 8). Class II division 2 malocclusion is
also associated with an increased incidence o palatal 3.
Lending urther support to a genetic aetiology is that
palatal 3 has a predilection or those o European origin
Fig. 6.1 Anterior occlusion at presentation. as well as those with a amilial tendency, with emales
37 •
PALATALCANINES 6
3. 3 has the longest path o eruption o any permanent
tooth.
4. Arch length discrepancy palatal displacement o 3’s has
been mostly associated with an uncrowded or spaced
arch. Note the spacing present in Diane’s upper arch.
5. Trauma to the maxillary anterior area at an early stage o
development this has been suggested, but there is no
history o trauma in this case.
6. Peg-shaped, short-rooted 2’s or absent 2’s guidance or
3 is reduced where these eatures are evident, doubling
the incidence o palatal impaction o 3.
A
Key point
Palatal displacement o 3:
• A ects Europeans, emales and both sides o the arch
more commonly.
• Is more common in an uncrowded arch.
• Is associated with small, absent or abnormal ormation
o 2’s, hypodontia, impacted 6 in raoccluded primary
molars, other ectopic teeth and Class II division 2
malocclusion.
A
A
In planning treatment or a palatally ectopic canine, assess These are sum m arized in Table 6.1.
the ollowing on radiograph:
• The root length o C and root status o incisors. Key point
• The vertical and mesiodistal position relative to the Surgical exposure and orthodontic alignment o a palatal 3
incisor roots. requires a well-disposed patient with good oral hygiene
• The axial angulation. and dentition.
• The apex location.
Mild lower labial segment crowding but spaced buccal Correction o crossbites on 4 6 .
segments; uncrowded upper arch with C’s retained (3’s Correction o lower centreline shi t.
Table 6.1 Management options, with indications, or palatally displaced unerupted 3’s*
Option Indications Comments
Earlyremoval o C’s See comments in the text in relation to interceptive treatment Not a viable option in this case as Diane is 15 years old
Retain 3 and observe Patient not keen or treatment Need to monitor radiographicallythe unerupted 3 or cystic degeneration and/or
Pathologyor resorption o adjacent teeth not evident root resorption o incisors
Anchorage
From baseplate. Key point
Surgical exposure o 3, whether by open or closed
Baseplate technique, has no signif cant e ect on:
Full palatal acrylic coverage. • Periodontal health.
• Dental aesthetics.
Posterior bite plat orms ~2 mm in thickness to acilitate
crossbite correction on 4 6. The acrylic needs to be relieved
palatal and occlusal to 4 .
■ What instructions would you give the patient regarding ■ How may the 3’s be aligned?
turning o the screw?
Elastic traction m ay be ap p lied from the attachm ent bond ed
It should be turned one qu arter tu rn once per w eek (this is to 3’s to the archw ire (Fig. 6.5) or to a TAD. Light forces
~0.25 m m ). (20–60 g) shou ld be used . When m ovem ent of 3’s is evid ent,
■ When the crossbites on 4 6 ha ve been corrected, what C’s should be extracted . Once 3’s are close to the line of the
would you do? arch, a bracket shou ld be bond ed to the m id -bu ccal aspect
of each tooth. It is essential that the roots of 3’s are ad e-
Red u ce the posterior capping to half its height at one visit qu ately torqu ed to nalize their p ositioning.
and then rem ove it com p letely at the follow ing visit to allow
■ Wha t actors may you consider or reta ining 3’s in their
the p osterior occlusion to settle. It w ould then be ad visable
corrected positions?
to place an upp er xed appliance u nless this w as placed at
the outset for the initial m ovem ents outlined above. A trans- Asid e from fu ll correction of torqu e, early correction of rota-
palatal arch, attached to band s on 6’s, shou ld be cem ented tions shou ld be u nd ertaken, follow ed by circum ferential
for anchorage. Brackets should be bond ed to all other up per breotom y to 3’s and then the p rovision of a bond ed
teeth except 7C C7 and alignm ent continu ed u ntil a retainer.
• 42
6 PALATALCANINES
A
B
Fig. 6.6 (A) Anterior occlusion at presentation. (B) Right buccal occlusion. (C) Le t buccal occlusion. (D) Upper occlusal view. (E) Lower
occlusal view.
A B
Fig. 6.7 (A) Dental panoramic tomogram at presentation. (B) Upper anterior occlusal radiograph.
• 44
6 PALATALCANINES
p rocline unrestrained by the u p p er incisors. This w ill ■ What procedure would you pre er?
p rovid e som e space for relief of low er arch crow d ing, bu t
Cu rrent evid ence ind icates that it is a m atter of personal
the alignm ent of the teeth w ill require a xed appliance.
preference w hether to u se an op en or closed su rgical tech-
As a non-extraction approach is being ad opted in the
niqu e. In this case, after d iscu ssion betw een the orthod ontist
low er arch, a sim ilar strategy shou ld be consid ered for the
and oral su rgeon, open exp osure w as favoured .
u pper arch.
■ How may 3 be brought across the occlusion?
■ How could you create space or 3 a lignment?
When su f cient sp ace has been created for 3 and a m inim u m
This w ou ld involve d istalizing the u p p er rst p erm anent
of an 0.018-in stainless steel archw ire has been in place
m olars initially follow ed by retraction of the p rem olars to
(assu m ing an 0.022 × 0.028-in slot), orthod ontic traction m ay
op en sp ace for 3. This cou ld be accom p lished by head gear,
be ap p lied to 3 either by an au xillary w ire attached over the
TADs or head gear in com bination w ith a rem ovable (Ten
base archw ire or by elastic chain (Fig. 6.9A). The form er
H ove ap p liance; Fig. 6.8A) or xed ap p liance (Fig. 6.8B).
involves ‘p iggy-backing’ an 0.012-in or 0.014-in nickel–tita-
■ When should 3 be surgically exposed? nium archw ire on an 0.018-in stainless steel w ire, or one of
The typical treatm ent sequ ence w ou ld be to rstly create greater d im ensions.
space for 3 and then to organize for su rgical exposu re of It w ill also be necessary to d isengage the occlu sion to
3, follow ed by a 2–3-m onth p eriod to allow 3 eru p tion p rior allow 3 to be free of occlu sal interference d u ring m ovem ent
to the app lication of traction to align 3. H ow ever, in this across the low er arch. This can be achieved by one of the
case, as no extractions are p lanned for the u p per arch, it follow ing short-term m easu res: p rovision of a low er rem ov-
w ou ld be bene cial to have 3 su rgically exposed at the start able app liance w ith buccal cap ping of 2–3 m m to ‘clip over ’
of treatm ent so 3 can then eru p t w hile other asp ects of the the low er xed ap p liance; bond ing of glass ionom er cem ent
treatm ent are p rogressing. Op en or closed exp osure shou ld to the occlu sal su rfaces of the rst p erm anent m olars or
be d iscussed w ith the surgeon. bond ing of stainless steel ‘bite turbos’ to the palatal aspect
of the u p p er central incisors (Fig. 6.9B). The last option
given is the m ost favourable in this case as it d oes not com -
prom ise overbite red u ction.
More canine problems Mild marginal gingival erythema related to most teeth, more
marked interproximally.
654C21 12
visible with 4 erupted orward o 3 and
654321 123
displaced palatally.
Moderate lower and upper arch crowding; mesiopalatal
rotation o 3 ; distopalatal rotation o 2 ; mesiolabial rotation o
1 . Class I incisor relationship.
Molar relationship is Class I (4 was in buccal crossbite
CASES1 AND2 with 4 ).
A A
B B
Fig. 7.1 (A) Case 1 at presentation: right buccal occlusion. (B) Case Fig. 7.2 (A) Case 2 at presentation: right buccal occlusion. (B) Case
1 at presentation: lower sectional occlusal view. 2 at presentation: upper sectional occlusal view.
47 •
MORECANINEPROBLEMS 7
■ Which arch and which teeth are a ected mostly? Is there a Table 7.1 Factors to consider in treatment planning or transposition
gender di erence in incidence? Factor(s) Reason(s)
Transp osition is m ore com m on in the u pp er arch, w here it Underlying malocclusion, acial These will in uence need or extraction(s)
m ost com m only affects the canine and rst p rem olar, fol- aesthetics, degree o crowding
low ed by the canine and lateral incisor. In the low er arch, it Stage o dental development When root development is complete, interception (by
seem s to affect exclu sively the canine and lateral incisor. The and position o root apices extraction o primaryteeth) is unlikelyto lead to
left sid e seem s to be favoured in the u pper arch and the spontaneous improvement in tooth position
right sid e in the low er arch. With complete transposition and root apices closed,
A fem ale p red ilection has been highlighted in som e acceptance o transposition maybe best due to the root
stud ies, w hereas others have ind icated either no d ifference resorption and periodontal risks (e.g. gingival recession,
in gend er p revalence or a m ale pred ilection. alveolar dehiscence) involved in correction
Dental morphology I transposition is to be maintained, reshaping is
■ What is the aetiology o this anomaly?
necessaryto disguise or incorrect tooth position
Althou gh several theories have been p rop osed – inter- Occlusal considerations Judicious grinding o the palatal cusp o a maxillary
change of d evelop ing tooth bu d s, altered eru p tion paths, frst premolar will be required where it is aligned in the
presence of retained p rim ary teeth, trau ma – the aetiology canine position
is now su ggested to be m u ltifactorial w ith involvement
of comp lex relationship s betw een genetic and environm en-
tal factors. There is evid ence of associated gend er pred ilec-
tion, hypod ontia, p eg-shap ed m axillary lateral incisors and
retained prim ary teeth.
Key point
Management options or transposition:
• Intercept.
• Accept/tooth reshaping.
Key point
• Extract most displaced tooth.
Transposition: • Align orthodontically: consider relative position o root
• In maxilla: more commonly a ects 3 and 4 than 3 and 2. apices.
• In mandible: a ects 3 and 2 almost exclusively.
• Prevalence: less than 1%.
• Aetiology: genetic and environmental.
■ How would you ma nage Ca se 1 and Case 2?
Requ est a p eriap ical rad iograp h of the transp osed teeth to
■ Could you classi y this anomaly? d eterm ine p osition of the root ap ices.
• Case 1: this indicated that the apex o 2 was slightly
The transposition may be partial or comp lete, the ap ices of ahead o the long axis o 3 ; root ormation was nearing
the affected teeth being transposed in the latter. completion. No root resorption was observed.
■ What actors would you consider in treatment? • Case 2: this indicated that hal the root length o C was
remaining; root apices o 4 were marginally ahead o 3
These are given in Table 7.1.
root; no root resorption was visible.
■ What are the trea tment options?
Treatm ent options are to align the transposed teeth in
These are as follow s: their transp osed position or to correct the transp ositions.
Interceptive treatment: i detected early (on average, between • Case 1: in view o the relation o the 2 apex to the 3
6 and 8 years o age), extraction o primary teeth may be root, it was decided to proceed with orthodontic
undertaken in an attempt to guide the transposed teeth to alignment, correcting the transposition.
their normal positions while ensuring that space is • Case 2: a periodontal specialist’s opinion deemed that as
maintained by either an upper removable appliance/palatal 4 was quite markedly palatal (almost in line with the
bar or lingual arch. This approach is only possible where the palatal cusp o 5 ), there was adequate alveolar bone to
teeth a ected are tilted so their roots are near the desired align 3 in its correct position without risk o gingival
positions (sometimes called pseudotransposition). recession/alveolar dehiscence. To encourage 3 to move
Acceptance: especially i transposition and root ormation are mesially, C was removed initially and an upper
complete, ollowed by reshaping o incisal/occlusal sur aces removable space maintainer was tted. It was decided to
and/or composite additions to camouf age or tooth position. commence treatment on a non-extraction basis and to
review need or extractions based on urther
Extraction o the most displaced tooth: this strategy has been
cephalometric evaluation o pro le and incisor
recommended where the arch is crowded or or caries;
inclinations when the arches were aligned.
appliance therapy may be required therea ter.
■ What appliance type will be required? Explain why.
Orthodontic alignment: whether the a ected teeth are aligned
in their transposed positions or whether these are corrected, Fixed ap p liance therap y is ind icated in both cases in view
depends on the relative position o the root apices. of the need for bod ily m ovem ent. These are: Case 1: the
• 48
7 MORECANINEPROBLEMS
Fig. 7.3 (A) Case 1 ollowing xed appliance alignment. (B) Case 2
ollowing xed appliance alignment.
CASE3
SUMMARY
positions of 3 and 2 to be corrected ; rotational correction of Adrienne, an 11.5-year-old girl, presents with
3 ; sp ace closure. Case 2: p ositions of 43 to be corrected ; mobile 2’s and C’s with 3’s unerupted and not
rotational correction of 321 ; correction of incisor relation- palpable buccally (Fig. 7.5). You order a dental
ship; space closu re. panoramic tomogram and upper anterior occlusal
In Case 1, the u pp er arch also required xed ap pliance radiograph.
therap y to close the m ed ian d iastem a. In Case 2, the low er
arch requ ired xed ap pliance alignm ent.
■ What do you notice in Fig. 7.5?
■ How would you check that the positions o the corrected Mild marginal gingival erythema.
transposed teeth are optimal? 654C21 12C456
Palpate the labial/ bu ccal su lci for root p osition of the cor- 654321 123456 .
rected teeth (Case 1: 3 and 2 ; ad d itional labial crow n torqu e Attrition o C’s.
m ay be requ ired in a rectangu lar steel or TMA archw ire to
Uncrowded upper and lower arches.
m axim ize root p ositions; Case 2: 4 and 3 ; ad d itional bu ccal
root torque m ay be required to 4 and palatal root torqu e to Class I (tending toward Class III) incisor relationship.
3 in rectangu lar steel or TMA w ires for m axim u m Molar relationship Class I bilaterally.
correction).
■ Why are radiographs requested?
Take a periapical radiograph to check root alignment and any
root resorption o the corrected teeth. To localize the position of the unerup ted 3’s and to d eter-
m ine the cau se of m obility of 2’s.
Check unctional occlusion, lateral and protrusive movements,
to ensure no occlusal inter erences. ■ What do you notice on the radiographs (Fig. 7.6)?
The occlusion ollowing xed appliance alignment or Case 1 Normal alveolar bone height.
and Case 2 is shown in Fig. 7.3A and B, respectively. All permanent teeth present except or third molars; all
An example o a case where the transposition o 3 and 2 was erupted permanent teeth appear to be caries- ree with
accepted is shown in Fig. 7.4. possible exception o 6.
49 •
MORECANINEPROBLEMS 7
■ Wha t is the most likely ca use o root resorption o the
incisors?
It is probably cau sed by a com bination of inherent pressure
d u e to m igration of the d isp laced , eru p ting canines and
their p hysical contact w ith the incisor roots.
■ Wha t is the incidence o root resorption o 2’s by ectopic
3’s? What sites a re most commonly a ected? Is there a
gender predilection?
Key point
Incisor resorption by an ectopic maxillary canine:
• Has an incidence o 12 68%.
• Is more common in emales.
• Risk increases by 50%, i angulation o 3 to the midline
is greater than 25°.
Key point
Detection o incisor root resorption may be:
• Di cult on conventional radiographs.
• Facilitated by CBCT.
Key point
Swi t intervention is required or incisor resorption by an
ectopic 3.
molars
She is a regu lar attend er at the fam ily’s general d ental prac-
titioner. N o d ental treatm ent has been requ ired to d ate.
Family history
Aileen’s m other has several p erm anent teeth m issing, and
these have been replaced by brid gew ork.
SUMMARY Examination
Aileen is 11 years old. She is re erred by her general Extraoral examination
dental practitioner or in raoccluded lower primary
Aileen has a m ild Class II skeletal pattern w ith average
molars (Fig. 8.1). What is the cause, and how would FMPA and no facial asym m etry. The lip s are incom p etent
you treat it? w ith the low er lip lying at the incisal ed ges of the u pper
incisors. There are no tem p orom and ibular joint signs or
History sym ptom s.
Investigations
■ What investigations would you undertake? Explain why.
Clinical
Assess:
1. Mobility o –E’s i these are mobile, this tends to indicate
that they are close to ex oliation and that the permanent
successors are present.
2. Extent o in raocclusion o –E’s i these teeth are in
danger o submerging below gingival level, their removal
A is indicated.
3. I –E’s are ankylosed typically a ‘tin-can’sound is audible
when the occlusal sur ace is percussed with the stainless
steel handle end o a dental mirror and the sound
compared with that obtained rom percussion o
adjacent ully erupted teeth.
4. Overeruption o opposing teeth this could lead to
inter erences in unctional occlusion and present
di culties i prosthetic replacement o –E’s spaces is
required in the absence o 5’s.
B
Key point
–
With in raoccluded E’s, assess:
–
• Mobility o E’s.
• Extent o in raocclusion.
–
• I E’s are ankylosed.
• Overeruption o opposing teeth.
• I 5’s are present.
C
Radiographic
1. A dental panoramic tomogram to determine i
unerupted teeth are present, in normal developmental
position and o normal orm and size.
2. A lateral cephalometric radiograph may be required later
i xed appliance therapy is planned and the patient is
keen to proceed. It would allow more accurate
determination o the skeletal pattern in the
D
anteroposterior and vertical dimensions and or the
Fig. 8.2 (A) Upper occlusal view. (B) Right buccal occlusion. incisor inclinations to be assessed.
–
(C) Anterior occlusion. (D) Le t buccal occlusion. Both E’s w ere fou nd to be non-m obile and w ere not
infraocclu d ed below gingival level, bu t clinically both w ere
ankylosed .
■ Why does in raocclusion o prima ry molars occur?
■ The dental panoramic tomogram is shown in Fig. 8.3. What
Separate phases of resorption and repair occu r in the exfolia- are the f ndings o note?
tion of p rim ary teeth. Althou gh resorp tion p red ominates in
m ost cases, som etim es rep air p revails tem p orarily lead ing to • Dental development corresponds with chronological age.
ankylosis of a p rim ary m olar. As alveolar grow th and erup- • Extensive resorption o the roots o E’s; short roots on –E’s.
tion of the ad jacent teeth continu e, the tooth infraocclu d es. • Absent 5’s and all third molars.
• Absence o periodontal ligament space related to E E.
Key point ■ What is the prevalence o hypodontia in the permanent
In raocclusion o a primary molar is due to ankylosis o the dentition? Which teeth and gender does hypodontia a ect
tooth while alveolar growth and eruption o the adjacent most commonly?
teeth continues. A recent system atic review found the prevalence of hypo-
d ontia in the perm anent d entition to be around 6% w ith a
53 •
INFRAOCCLUDEDPRIMARYMOLARS 8
Fig. 8.5 Another case with Ni-Ti coils used or the closure o
premolar extraction spaces.
• 5 present, no reinclusion: allow Ē to ex oliate. Patel A, Burd en DJ, Sand ler J 2009 Med ical d isord ers and
orthod ontics. J Orthod 36:1–21.
• 5 present, and reinclusion: extract or surgically
remove Ē.
• 5 absent: retain and place onlay: For revision, see Mind Map 8, page 228.
• extract and space close.
• extract and prosthetic replacement.
9
■ How common is bullying among school children? What
in uence do prominent teeth have, and does bullying have
any long-term consequences?
Using a valid ated m easu re, the prevalence of bullying
among 8–18-year-old s in 11 European cou ntries w as found
to be 20.6%. In a recent UK stu d y, nearly 13% of child ren
aged 10–14 w ho w ere assessed for orthod ontic treatment
had been bullied d u e to their m alocclu sion, and bu llying
Examination
Extraoral
Em m a’s fu ll facial and p ro le view s are show n in Fig. 9.2.
■ How would you assess Emma’s skeletal pattern?
The skeletal pattern is the relationship of the m and ibular to
the m axillary d ental base in all three p lanes of sp ace – anter-
oposterior, vertical and lateral. Assessm ent shou ld be mad e
w ith Em ma seated u p right in the natu ral head position (the
p osition in w hich the head is supp orted naturally w hen
Fig. 9.1 Right buccal occlusion at presentation. looking straight ahead at a d istant object); the lip s shou ld
• 56
9 INCREASEDOVERJET
ront o chin) acial thirds; this may be increased
(Class II; convex pro le), average (12° + 4°; Class I) or
reduced (Class III; concave).
Emma has a Class II skeletal pattern.
2. Vertical.
Lower acial height. The distance rom the mid-eyebrow
level to the base o the nose (upper acial height) should
equal that rom the base o the nose to the in erior aspect
o the chin (lower acial height). The lower acial height is
reduced when the latter measurement is reduced, and
the converse is true when this distance is increased.
Frank ort-mandibular planes angle (FMPA). With a nger
along the lower border o the mandible and a ruler placed
along the Frank ort plane (lower border o the orbit to the
superior aspect o the external auditory meatus), project
both o these lines backwards in the imagination to
A estimate the FMPA. The FMPA is then classi ed as average
(both lines intersect at the back o the skull, occiput),
reduced (both lines meet beyond occiput) or increased
(both lines meet anterior to occiput).
Emma has a slightly reduced lower acial height and
FMPA.
3. Transverse. Stand directly behind the patient and look
down across the ace, checking the coincidence o the
midlines o the nose, upper and lower lips and midpoint
o the chin. Alternatively assess the ace rom the ront. It
is important to note that slight acial asymmetry is
common. The location (upper, middle or lower acial third)
and extent o any asymmetry should be recorded. Emma’s
chin point is marginally to the right. As this is very mild
and has not been noticed by her or her mother be ore
now, and as a slight degree o acial asymmetry is
regarded as normal, there is no cause or concern.
No mandibular deviation on closure or
B temporomandibular signs/symptoms were detected.
The lips are habitually competent with the lower
Fig. 9.2 (A) Full ace view. (B) Pro le.
lip tending to lie under the upper incisors at rest
(Fig. 9.2B).
be at rest and the teeth in m axim u m interd igitation. Assess-
m ent shou ld be as follow s: Intraoral
1. Anteroposterior. Viewing the so t tissue acial pro le in
most cases allows the ollowing classi cation to be made: ■ The intra oral views are shown in Figs 9.1 a nd 9.3. Wha t do
these show?
Class I: the mandible lies 2 3 mm behind the maxilla.
Class II: the mandible lies more than 2 3 mm behind the There are plaque deposits on several teeth and overall mild
maxilla. marginal gingival erythema.
Class III: the mandible lies less than 2 3 mm behind the All teeth appear to be o good quality.
maxilla. Emma is in the permanent dentition with
Due to variation in lip thickness, this method is not 654321123456
present. (Note 7 7 are erupting.)
always reliable and palpation o the alveolar bases over 654321123456
the apices o the upper and lower incisors in the midline The upper and lower arches are uncrowded.
has been claimed to give a better estimate o skeletal There is a Class II division 1 incisor relationship with increased
pattern. overjet (measured 7 mm clinically); the overbite is increased
Two other assessments may also be made: and complete. The buccal segment relationship is a hal -unit
1. The relationship o the lips to zero meridian (a true Class II bilaterally. There is a lingual crossbite (scissors bite)
vertical rom so t tissue nasion): the upper lip should a ecting 4.
be on, or slightly ahead, and the chin just behind.
■ What a re the causes o an increa sed overjet?
2. The angle o acial convexity o the middle (mid-
eyebrow to base o nose) to lower (base o nose to These are given in Table 9.1.
57 •
INCREASEDOVERJET 9
Investigations
■ What radiographs are indica ted?
A d ental p anoram ic tom ogram is requ ired to check the pres-
ence, p osition, d evelop m ental stage and any abnorm alities
of crow n and root of uneru p ted teeth. Untreated caries
should also be noted and bitew ing rad iographs requ ested ,
if necessary. In view of the history of trau m a to the u pper
incisor area, a p eriap ical view or an u pp er anterior occlu sal
rad iograp h shou ld be taken and exam ined for p ossible
ap ical p athology.
A A lateral cephalom etric rad iograph is ind icated as there
is an anteroposterior and a vertical skeletal d iscrep ancy. In
ad d ition, anterop osterior m ovem ent of the incisors is
p lanned .
The nd ings of the cep halom etric analysis are:
SN A = 82°; SN B = 76°; SN to m axillary p lane = 9°; MMPA
= 22°; 1 nomenclatu re to m axillary p lane = 114°; 1 to m an-
d ibu lar p lane = 92°; facial p roportion = 52%.
■ Wha t do these indicate (see p. 270)?
ANB value o 6° (SNA minus SNB) indicates a Class II skeletal
pattern.
Reduced MMPA and acial proportion.
B
Relative to m ean Cau casian valu es, the upp er incisors are
proclined (bu t w ithin the norm al range) and the low er inci-
Fig. 9.3 (A) Anterior occlusion. (B) Le t buccal occlusion. sors are slightly retroclined . Although w ithin the norm al
range the 1 to m and ibu lar p lane m ust be consid ered w ith
the MMPA as there is an inverse relationship betw een the
tw o valu es. 1 to m and ibu lar p lane (93°) and MMPA (27°)
should total 120° or, alternatively, 1 to m and ibu lar p lane
angle shou ld be 120° – MMPA. H ence in this case, the 1 to
Table 9.1 Causes o an increased overjet m and ibu lar p lane angle shou ld be 120° – 22° = 98°. At 92°,
Cause Aetiology it is retroclined .
Skeletal pattern Maybe Class I, IIor III ■ Wha t other important in ormation rega rding growth
potential may be obtained rom the lateral cephalometric
I Class II, mandibular defciencyis almost entirely
the primarycause but maybe excessive horizontal f lm? How is this assessed?
maxillarygrowth or a combination o the two actors It may also be u sed to d eterm ine skeletal m atu rity. This is
So t tissues* Lower lip lying under the upper incisors to create an assessed by the cervical vertebral m atu ration (CVM) ind ex
anterior oral seal will procline the upper incisors and w hich has ve stages, each w ith m orphological changes in
retrocline the lower incisors (likelyi there is a Class II the second , third and fourth cervical vertebrae. The peak in
skeletal pattern, reduced lower acial height and lip m and ibu lar grow th occu rs betw een CVM stage II and CVM
incompetence)
stage III; CVM stage V occurs 2 years after the p eak.
Hyperactive lower lip will retrocline the lower incisors
■ How valid and reliable is the CVM index?
Primaryatypical swallowing pattern (endogenous
tongue thrust) will tend to procline upper (but also CVM has been show n to have high valid ity and
lower) incisors reprod ucibility.
Digit sucking habit I present or more than 6 hours out o 24, it will ■ Would you consider a ny other investigations?
procline upper incisors, retrocline lower incisors,
It w ou ld be w ise to d o sensibility tests of 1 1. These proved
create an anterior open bite and a tendencyto buccal
segment crossbite
p ositive for all tests, w ith no m arked d ifference in record -
ings betw een teeth.
Overjet increase is o ten asymmetrical due to digit
positioning
Crowding Labial displacement o upper incisors and/or lingual
displacement o lower incisors Diagnosis
Anycombinationo the above
■ Wha t is the diagnosis?
*E ects determined principallybythe skeletal pattern, and therea ter bythe manner in
Emma has a Class II division 1 malocclusion on a mild Class II
which an anterior oral seal is produced.
skeletal base with reduced FMPA.
• 58
9 INCREASEDOVERJET
There is generalized marginal gingivitis. gests that earlier treatm ent red u ces the incid ence of incisor
1 1 have su ered recent trauma. trau m a bu t does not offer any other ad vantages com p ared
w ith treatm ent in early ad olescence. Em m a has recently
There is no crowding o the upper and lower arches.
su ffered u p per incisor traum a, and starting treatm ent earlier
The buccal segment relationship is a hal -unit Class II m ay have averted this; how ever, she is still w ithin the scope
bilaterally with a lingual crossbite o 4. of the ages d eem ed ‘early treatment’. Although this review
rep orted no p sychosocial bene ts of early or later treatm ent,
■ Wha t is the IOTN (DHC) grade (see p. 264)? Explain why.
recent longitu d inal d ata from a UK stu d y on bu llied chil-
4a – d u e to overjet >6 m m bu t ≤9 m m. d ren fou nd that intercep tive treatm ent for an increased
overjet red u ced the p revalence of bu llying and im p roved
oral health–related qu ality of life.
Treatment
■ What types o unctional appliances are there? Which is the
■ Wha t actors other than increased overjet predispose to most popular?
upper incisor trauma?
Fu nctional app liances m ay be classi ed as tooth-borne (e.g.
The risk is doubled where the overjet exceeds 9 mm. Tw in-Block appliance, m ed iu m op ening activator, H erbst)
Lip incompetence due to the absence o lip protection. or soft tissu e borne (e.g. Frankel). The H erbst is a xed
Gender o the patient boys experience more upper incisor fu nctional ap pliance; all others are rem ovable, although the
trauma than girls. Tw in-Block appliance m ay also be cem ented in p lace. In
the UK, the Tw in-Block app liance is m ost p op u lar, bu t the
■ What are the aims o treatment? H erbst ap p liance is favou red in N orth Am erica.
To reduce the overbite and overjet to establish a Class I ■ Describe the records you would take to allow abrication o
incisor relationship. a Twin-Block a ppliance?
To correct the buccal segment relationship to Class I. The record s required are w ell-extend ed u pper and low er
4 alginate im p ressions as w ell as a w ax registration taken
To correct the crossbite on .
4 w ith the m and ible postu red forw ard , usu ally to an ed ge-to-
ed ge incisor relationship , the bite op en abou t 8 m m in the
■ Wha t treatment would you advise? Explain why. p rem olar areas w ith no appreciable shift in the u pper and
Em m a’s m alocclu sion shou ld be am enable to correction by low er d ental m id lines. This ‘w orking bite’ may be record ed
grow th m od i cation w ith fu nctional ap pliance therap y. by softening several layers of w ax in w arm w ater, form ing
Favou rable features are that Em m a is likely to be grow ing this to a horseshoe shape ind exed rm ly over the u pper
and is ap p roaching the p u bertal grow th sp u rt. The skeletal teeth and nally gu id ing the m and ible to the correct antero-
pattern is m ild ly Class II d u e to m and ibu lar retrusion rather p osterior, vertical and lateral position by checking the
than m axillary protru sion. The arches are u ncrow d ed and relationship of the centrelines and the incisal op ening. Alter-
aligned ; the low er incisors are slightly retroclined ; the natively, layers of w ax m ay be ad apted to a proprietary
bu ccal segm ent relationship is a half-u nit Class II, so a bite registration fork, w hich has grad u ated m arkings to
m od est shift of the arch relationship is requ ired for it to be facilitate assessm ent of the p ostu red m and ibu lar position.
corrected to Class I. The w ax registration shou ld then be chilled , exam ined for
Fu nctional ap pliances are u su ally contraind icated w here ad equ ate d ental registration and re-checked for accuracy in
the low er incisors are p roclined , as they ind u ce fu rther the m outh before forw ard ing w ith the im pressions to the
proclination throu gh generation of Class II interm axillary laboratory. Where the overjet is large, the m and ible m ay be
traction. Follow ing fu nctional ap p liance therap y, xed ad vanced to 70–80% of m axim um protrusion to facilitate
appliances m ay be requ ired to d etail the occlu sion. It w ou ld p atient com fort.
be ad visable then to retain the resu lt by night-only w ear of ■ On issuing the Twin-Block appliance, what instructions
a functional ap pliance u ntil grow th is com p lete. would you give Emma ?
The instructions w ould be as follow s:
Key point • The appliance should be worn ull-time, including at
mealtimes, rom insertion. The only times it is removed
A unctional appliance:
are a ter meals or cleaning and or contact sports, during
• Aims to ‘modi y’ growth.
which times it should be stored in the hard plastic tub
• Is only e ective in growing children, pre erably just provided.
prepubertal.
• Speaking and eating will be di cult or the rst ew days
but will improve i you persevere.
• Avoid eating hard or sticky oods or consuming zzy
■ Should Emma have been treated earlier? What evidence is drinks while wearing the appliance as these are likely to
available regarding this? damage the appliance and/or your teeth. The appliance
A recent Cochrane review com p ared the effects of orthod on- and the teeth should be cleaned thoroughly a ter every
tic treatm ent for child ren w ith prom inent upp er front teeth meal.
w hen treatm ent is started betw een 7 and 11 years com p ared • Mild jaw discom ort and muscle tenderness are common
w ith treatm ent started in early ad olescence. Evid ence su g- or the rst ew days but reduce a ter that. It may be
59 •
INCREASEDOVERJET 9
necessary to take a mild analgesic, as required, during Dentoalveolar (~70–80%)
this ‘settling-in’period. Retroclination o upper incisors/proclination o lower incisors.
• Should a sore spot develop or there be any breakage o
Promotion o mesial and upward eruption o lower posterior
the appliance, you should contact us immediately by
teeth (see below).
telephone to arrange an appointment to have any
adjustments carried out. Distal movement o the upper molars.
■ How does a Twin-Block work a nd wha t e ects does it Upper arch expansion.
produce?
The Tw in-Block ap p liance consists of u p p er and low er
Key point
ap pliances incorporating bu ccal blocks w ith interfacing
inclined p lanes (at abou t 70°), w hich p ostu re the m and ible A unctional appliance or Class II correction:
forw ard on closu re (Fig. 9.4). This ap p liance w orks by u sing • Postures the mandible downward and orward.
the forces generated by the orofacial m u scu lature, tooth • Generates intermaxillary traction.
erup tion and d entofacial grow th. The u p p er m id line expan- • Uses, removes or modif es orces o the oro acial
sion screw is u su ally ad ju sted once p er w eek by the p atient musculature, tooth eruption and dento acial growth.
until the arch w id ths are coord inated w ith the m and ible
postu red forw ard in a Class I incisor relationship . In this
case, no exp ansion w as requ ired in view of the scissors bite
4 ■ How do the e ects produced by a Twin-Block a ppliance
on . The effects are u su ally as follow s:
4 di er rom those o other unctional applia nces?
Skeletal (~20–30%) The recent Cochrane review also assessed the effect of
Forward growth o the mandible. orthod ontic treatm ent for p rom inent u p per front teeth
w hen u nd ertaken by d ifferent orthod ontic app liances.
Increase in lower anterior acial height.
Fu nctional app liance treatm ent, irresp ective of type, in early
ad olescence app ears to prod u ce som e m inor bene cial skel-
etal changes. When the Tw in-Block w as com pared w ith
other ap pliances, there w as no d ifference in overjet, bu t the
Tw in-Block p rod u ced a statistically signi cant greater
red u ction in AN B, althou gh this w as sm all. There w ere no
ad vantageou s effects of other fu nctional app liances com -
pared w ith the Tw in-Block.
■ Following overjet correction by Twin-Block therapy, wha t
occlusa l anomaly is usually mani est posteriorly in the
dental arches?
A posterior op en bite is u su ally p resent bilaterally d u e to
the buccal blocks.
■ How may this be corrected?
There are three possible m eans available to allow for correc-
A tion of the posterior open bite by eru ption of the bu ccal
segm ent teeth:
• The patient may be instructed to proceed to part-time
wear o the appliance.
• The Adams’clasps on the lower molars may be removed
initially and then acrylic trimmed progressively over a
period o a ew months, rom the undersur ace o the
lower block and the lower sur ace o the upper block,
until a posterior occlusion is established.
• Wear o the Twin-Block appliance may be ceased and the
patient tted with an upper Hawley retainer (Adams
clasps 0.7 mm on 6 6, labial bow 0.7 mm 3 to 3) with a
‘steep and deep’anterior inclined biteplane, which aims
to maintain overjet correction by posturing the mandible
orward while encouraging eruption o the lower buccal
segment teeth. Full-time wear o the appliance is
B required, except or contact sports and teeth cleaning,
until a well-interdigitating posterior occlusion is
Fig. 9.4 Twin-block appliance. (A) Upper occlusal view. (B) Lower established. Then night-only wear o the appliance, until
occlusal view. The design is modi ed rom the original growth has ceased or until a second phase o treatment
developed by Clark. commences, is permissible.
• 60
9 INCREASEDOVERJET
■ I there is no progress at 6 months, what action would interincisal angle is created. A use ul rule o thumb with
you take? tipping movement is that each millimetre o upper incisor
retraction approximates to a 2.5° change in angulation. With
Lack of overjet correction cou ld be d u e to p oor p atient
an original overjet o 7 mm and a target overjet o 3 mm
response to the ap pliance, im p rop er d esign or p oor
(representing a 4 mm reduction), this would equate to a 10°
comp liance. Treatm ent shou ld be d iscontinu ed and a re-
change producing a nal incisor angulation o 104°. This value
evalu ation m ad e. The p atient’s stand ing height shou ld be
is just within the normal range (109° ± 6°), and the incisors
record ed and com pared w ith the pre-treatm ent m easure-
would be quite upright. An upper incisor angulation o 95° to
m ent. This w ill give an ind ication of grow th over the inter-
the maxillary plane is regarded as the limit or acceptable
vening p eriod . Provid ed Em m a rem ains keen for orthod ontic
retraction by tipping movements.
treatm ent, new record s, includ ing a p rogress cep halom etric
rad iograp h, shou ld be taken and analysed to allow for a ■ What a ctors govern stability o the corrected overjet?
new treatm ent p lan to be d evised . For the best p rospects of stability the interincisal angle
■ What other treatment options are there? shou ld be w ithin norm al lim its (135° ± 10°) and the overjet
comp letely red uced w ith the incisors in soft tissue balance,
I a design problem with the appliance is identi ed as the i.e. no tongu e thru st and the low er lip covering at least
cause o lack o treatment progress, then remaking the one-third of the labial su rface of the u pp er incisors. A
appliance to incorporate appropriate design modi cations period of retention w ill nonetheless be requ ired , and this
could be undertaken and treatment recommenced. shou ld extend u ntil grow th is com p lete follow ing fu nctional
I poor compliance is to blame or no progress, then the appliance therapy. Most p atients, how ever, usu ally p roceed
reason(s) should be ascertained rom discussion with the d irectly to a second p hase of xed ap p liance therap y to
child. I lack o motivation or interest in treatment is the d etail the occlu sion follow ed by retention.
cause, it would be prudent to avoid any urther appliance
therapy until such time as the child has a change o heart
Key point
regarding orthodontic treatment.
A ter unctional appliance therapy with or without
Orthodontic camou age by retraction o the upper incisors
subsequent f xed appliance therapy:
into rst premolar extraction spaces, accepting the Class II
skeletal pattern. Importantly, this treatment should not be • Ensure the upper incisors are in so t tissue balance and
detrimental to acial aesthetics. Although some amount o controlled by the lower lip.
tipping movement o the upper incisors is permissible, xed • Retain until growth is complete.
appliances would be required to ensure an optimal
Fig. 9.5 (A) A ter unctional appliance therapy: pro le. (B) A ter unctional appliance therapy: le t buccal occlusion. (C) A ter unctional
appliance therapy: anterior occlusion.
61 •
INCREASEDOVERJET 9
The p ro le and occlu sion follow ing fu nctional ap p liance Petti S 2015 Over tw o hund red m illion inju ries to anterior teeth
therapy are show n in Fig. 9.5. attribu table to large overjet: a m eta-analysis. Dent Trau m atol
31:1–8.
Primary resources and Seehra J, Flem ing PS, N ew ton T et al 2011 Bu llying in orthod ontic
p atients and its relationship to m alocclu sion, self-esteem and
recommended reading oral health-related qu ality of life. J Orthod 38:247–256.
Baccetti T, Franchi L, McN am ara JA Jr 2005 The cervical vertebral Shah AA, Sand ler J 2009 H ow to … take a w ax bite for a Tw in
m aturation (CVM) m ethod for the assessm ent of optim al Block ap p liance. J Orthod 36:10–12.
treatm ent tim ing in d entofacial orthopaed ics. Sem in Orthod
Thiru venkatachari B, H arrison JE, Worthington H V et al 2013
11:119–129.
Orthod ontic treatm ent for p rom inent u p p er front teeth (Class II
Clark W 2010 Design and m anagem ent of Tw in Blocks: re ections m alocclusion) in child ren. Cochrane Database of Syst Rev Issu e
after 30 years of clinical u se. J Orthod 37:209–216. 11. Art N o: CD003452. DOI: 10.1002/ 14651858.CD003452.p ub3.
DiBiase AT, Sand ler PJ 2001 Malocclu sion, orthod ontics and Wolke D, Lereya ST 2015 Long-term effects of bu llying. Arch Dis
bullying. Dent Up d ate 28:464–466. Child 100:879–885.
Flem ing PS, Scott P, DiBiase AT 2007 H ow to … m anage the
transition from fu nctional to xed app liances. J Orthod
34:252–259. For revision, see Mind Map 9, page 229.
10
Examination
Extraoral
The skeletal pattern is Class I w ith an average FMPA. There
is no facial asym m etry. The lip s are com petent.
There are no abnorm al tem p orom and ibular joint signs or
sym p tom s.
History
Complaint
Matthew ’s m other is concerned that her son’s u p p er front
teeth are not straight and is anxious for treatm ent to be
u nd ertaken soon.
History o complaint
A
1 eru p ted insid e the low er teeth. There is no history of a fall
or other trau m a to the prim ary p red ecessor or to 1 . A w as
lost over a year ago, a little later than A.
Medical history
Matthew is in good health.
Dental history
D w as extracted uneventfully u nd er local anaesthesia 8
m onths ago.
Fig. 10.1 Anterior occlusion at presentation. Fig. 10.2 (A) Upper occlusal view. (B) Right buccal occlusion.
(C) Le t buccal occlusion.
63 •
INCISORCROSSBITE 10
slightly palatally, and there is a sm all m ed ian d iastem a.
Otherw ise the u p p er arch app ears uncrow d ed . The incisor
Key point
relationship is Class I and 1 is in crossbite; 2 is p artially Where an incisor crossbite is present, check:
erup ted w ith the d istoincisal aspect in crossbite w ith C . • Periodontal status o lower incisors.
■ What is the prevalence o anterior crossbite reported • I an edge-to-edge incisor occlusion is achievable.
in the literature? • I mandibular displacement is present.
Dep end ing on the racial grou p , age at assessm ent and if an • Amount o overbite.
ed ge-to-ed ge incisor relationship w as inclu d ed or not, the • Incisor inclination.
reported p revalence varies from 2.2–11.9%. • Amount o space required or correction.
■ What specif c ea tures would you check? Explain why.
1. The periodontal status o 1 degree o mobility and
pocket probing depth associated with 1 should be
assessed to determine its prognosis as it is being
displaced labially by def ecting occlusal contact Investigations
(see below) and gingival recession is present. ■ What special investigations would you request? Why?
1 exhibited grade 2 mobility, but probing pocket
depth was less than 2 mm, indicating good periodontal As a d ental p anoram ic tom ogram taken 6 m onths prior to
prognosis in the event the crossbite relationship is this visit by a previou s general d ental p ractitioner (see
corrected. below ) w as available for inspection, a rep eat lm of this
1 nature w as not ind icated on clinical grou nd s. From this
2. Is it possible to achieve an edge-to-edge relationship on ?
1 rad iograp h it w as possible to check the presence/ absence
I so, this indicates that only a small amount o labial of p erm anent teeth and w hether there w as a su pernu m erary
movement o 1 is required to correct the crossbite tooth p resent in the up p er m id line. Shou ld there have been
1 any susp icion of the latter, a m axillary anterior occlu sal
relationship. An edge-to-edge relationship o was view w ould be ind icated to note the relation of the su per-
1
easily achievable. nu merary tooth to the roots of the u p per incisors. N o su per-
nu merary tooth w as evid ent in the u pp er m id line. A
3. Is there a mandibular displacement on closure? I the
p eriap ical rad iograph of the low er central incisors is not
mandible is shi ted anteriorly or laterally on closure
requ ired as the clinical exam ination d oes not lend signi -
1 2
rom initial tooth contact, on or into maximum cant cau se for concern to the p rognosis of these teeth.
1 C
Bitew ing rad iographs should be taken to d iagnose accu -
interdigitation, early treatment to eliminate the
rately the extent of carious involvem ent of the prim ary
displacement is indicated on dental health grounds. The
m olars.
rationale or this approach is that in susceptible
individuals, mandibular displacement on closure due to ■ The dental panoramic tomogram taken 6 months prior to
premature tooth contact(s) may lead eventually to this visit is shown in Fig. 10.3. What does it show?
temporomandibular joint dys unction syndrome. A 3 mm Normal alveolar bone height, except or apparent angular
anterior mandibular displacement on closure was bone de ects related to the mesial aspects o 6 6. (Both teeth,
1 however, were not mobile, and pocket depths were <2 mm
detected rom initial contact on ; there was no lateral
1 on the mesial and distal aspects o 6 6.)
mandibular displacement associated with the crossbite
D CD
2 D absent; caries in .
a ecting . E DE
C
4. The amount o overbite on 1 as the amount o All permanent teeth (except 8’s) present, o normal size and in
overbite post-treatment is a major actor governing normal developmental positions.
stability o incisor crossbite correction and as overbite
reduces when the incisor edge is moved upwards
and orward during incisor proclination, a deep
overbite pre-treatment is a avourable eature. In this
case, the overbite was 3.5 mm on 1 and there is a good
prospect o adequate overbite ollowing crossbite
correction.
5. The inclination o 1 an upper incisor that is upright or
retroclined (1) is better or proclination than an incisor
that is already labially inclined. Further proclination o the
latter may not be possible or could result in un avourable
occlusal loading.
6. The amount o space required to procline 1 space already
exists in the upper incisor area, and there is no need or
any extractions. Fig. 10.3 Dental panoramic tomogram.
• 64
10 INCISORCROSSBITE
Diagnosis
■ Wha t is your diagnosis?
Matthew has a Class I malocclusion on a Class I skeletal base
with average FMPA.
Mild marginal gingivitis related to the incisor teeth.
Gingival recession related to 1 labially.
D CD
Caries in .
E DE
Crossbite on 1 with associated mandibular displacement.
Misalignment o upper and lower labial segments. Fig. 10.4 Upper removable appliance to procline 1.
■ Wha t is the IOTN DHC grade (see p. 264)? Explain why.
4c – d u e to m and ibu lar d isp lacem ent >2 m m betw een the
retrud ed contact position (RCP) and the intercu spal posi-
tion (ICP).
■ Wha t would you deem to be the prognosis or the la bial
recession related to 1 ?
For accu rate assessm ent of the extent of the labial recession,
the soft tissu es shou ld be healthy, and at p resent gingival
in am m ation is evid ent. There ap p ears, how ever, to be
some attached gingiva labially, and the recession d oes not
Fig. 10.5 Post-treatment.
extend to the sulcu s re ection. It is also not associated w ith
a frenal p u ll. At this stage, p rovid ed oral hygiene im proves
and the crossbite is corrected , the gingival recession shou ld Retention: Adams clasps 6D D6 (clasps on 6 6 in 0.7 mm
not w orsen, although the w id th of attached gingiva w ill not stainless steel wire; clasps on D D in 0.6 mm wire).
increase.
Anchorage: rom baseplate.
■ Why is 1 in crossbite?
Baseplate: acrylic baseplate with ull palatal coverage
This is m ost likely d u e to a slightly p alatal ectop ic p osition incorporating posterior capping (~2 mm in height).
of 1 tooth bud . The appliance is show n in Fig. 10.4.
■ What will determine stability o crossbite correction on 1 ?
Treatment
Provid ed there is 2–3 m m of overbite on 1 follow ing p rocli-
■ What treatment would you provide and why? nation, the p rospect of stability is good . Su bsequ ent m an-
d ibu lar grow th m u st also be favou rable.
1. Oral hygiene instruction this is required to improve
The occlu sion follow ing crossbite correction on 1 is
gingival health and to remove the plaque insult to the
show n in Fig. 10.5.
gingival recession related to 1.
2. Caries management a diet diary should be completed
over 3 consecutive days (one o which should be a Key point
weekend day) and then appropriate dietary advice
Early treatment o an incisor crossbite is advisable i there
should be given based on the ndings (see Chapter 22).
is associated mandibular displacement and/or periodontal
Although several primary molars are carious, none have
trauma.
associated symptoms. Restorative management o
carious primary teeth is dealt with in Chapters 22
and 24.
3. Upper removable appliance therapy to procline 1 due to ■ What other treatment possibilities are there? What
the mandibular displacement that is producing evidence is there in relation to their e ectiveness?
periodontal trauma to 1, correction o the crossbite on 1 Other treatm ent op tions includ e xed appliances incorpo-
is required urgently. rating the incisors and rst p erm anent m olars (‘2 × 4’;
4. Monitor the lower centerline consider removal o D i a although 2 is only partly erup ted p resently and w ill need
centreline shi t develops. to have the bond ed attachm ent rep ositioned as treatm ent
■ Describe the a pplia nce design you would use to align 1 . progresses), u se of an inclined comp osite slop e bond ed to
the opp osing low er incisor (at about a 45° incline and
The ap p liance w ou ld have the follow ing d esign: 3–4 m m in height), a com bination of these techniques, elas-
Activation: Z spring (0.5 mm stainless steel wire) to tics attached to bond ed brackets/ bu ttons or m od i ed fu nc-
procline 1. tional app liances. A system atic review p u blished in 2011
65 •
INCISORCROSSBITE 10
ind icated that the evid ence level w as low w ith regard to Gravely JF 1984 A stu d y of the m and ibu lar closu re p ath in Angle
anterior crossbite correction, bu t evid ence favou red the u se Class III relationship . Br J Orthod 11:85–91.
of xed ap pliances. A recent rand om ized controlled trial Joss-Vassalli I, Grebenstein C, Top ou zelis N et al 2010
cond u cted in Sw ed en fou nd m inim al d ifferences betw een Orthod ontic therap y and gingival recession: a system atic
xed and rem ovable appliances for anterior crossbite cor- review. Orthod Craniofac Res 13:127–141.
rection; treatm ent d u ration w as slightly shorter (1.4 months) McCom b JL 1994 Orthod ontic treatm ent and isolated gingival
recession: a review. Br J Orthod 21:151–159.
w ith a xed ap p liance (brackets bond ed to the m axillary
incisors, p rim ary canines, prim ary rst m olar or rst prem o- Wied el A, Bond em ark L 2014 Fixed versu s rem ovable orthod ontic
ap p liances to correct anterior crossbite in the m ixed d entition –
lar, if erup ted ) than w ith a rem ovable app liance, bu t the
a rand om ized controlled trial. Eu r J Orthod 37:123–127.
latter treatm ent cost m ore. At 2-year follow -u p , stability w as
sim ilar in both grou p s.
For revision, see Mind Map 10, page 230.
Primary resources and
recommended reading
Borrie F, Bearn D 2011 Early correction of anterior crossbites: a
system atic review. J Orthod 38:175–184.
11
Medical history
Alistair is t and w ell.
Family history
Alistair ’s father reports that his ow n teeth m eet in a m anner
sim ilar to his son’s, and he also has a slightly prom inent
chin bu t is u nconcerned by it. H e had orthod ontic treatm ent
w ith extraction of tw o low er teeth and xed ap p liances
Examination
Extraoral
Alistair has a m ild Class III skeletal pattern w ith average
FMPA (Fig. 11.2) and no facial asym m etry.
Fig. 11.1 Right buccal occlusion at presentation. Fig. 11.2 Pro le.
67 •
REVERSEOVERJET 11
to the mean (109°) bu t are w ithin the norm al range. Taking
account of the MMPA, the 1 angle shou ld be 120° − 25° =
95° but is 2° proclined at 97°. The MMPA and facial propor-
tions are slightly red u ced from average values bu t are
w ithin the norm al range.
Diagnosis
■ What is your orthodontic diagnosis?
Alistair has a Class III m alocclu sion on a Class III skeletal
Fig. 11.3 Le t buccal occlusion. p attern w ith slightly red u ced facial p roportions. There is an
anterior m and ibu lar d isp lacem ent on closu re on 1 1. Mar-
Table 11.1 Causes o reverse overjet ginal gingivitis related to the u p per and low er incisors.
Upper and low er arches exhibit m ild incisor crow d ing; the
Cause Aetiology
u pper incisors are in crossbite. Up p er and low er centrelines
Skeletal UsuallyClass IIIdue to anyo the ollowing: long mandible; are slightly d isp laced . The bu ccal segm ent relationship is
orward placement o glenoid ossa positioning the mandible Class III bilaterally.
more anteriorly; short and/or retrognathicmaxilla; short
anterior cranial base ■ What is the IOTN (DHC) grade (see p. 264)? Explain why.
Anterior mandibular Apremature contact maydisplace the mandible orward on 4c – d u e to >2 m m m and ibular d isp lacem ent betw een the
displacement on closure closure into maximuminterdigitation RCP and ICP.
Retained primaryupper These mayde ect the eruption path o their successors ■ Wha t dental health reasons a re there or
incisors palatallyinto crossbite orthodontic treatment?
Pattern/excessive Forward pattern o mandibular growth will exacerbate a
Mand ibu lar d isplacem ent on closu re m ay increase the like-
mandibular growth Class IIIskeletal pattern
lihood of tem porom and ibu lar joint d ysfunction in su scepti-
Excessive mandibular growth maybe due to excess growth
ble ind ivid u als. In ad d ition, d isplacing occlusal contacts
hormone resulting roma pituitaryadenoma
m ay lead to low er incisor m obility and contribu te to gingi-
Restraint o maxillary Found in repaired cle t lip and palate and attributed to the val recession.
growth e ect o post surgical scar tissue
■ What a ctors would you assess in orthodontic
treatment planning?
Upper and low er incisors are very m ild ly crow d ed and These are given in Table 11.2.
in crossbite. The overbite is average to slightly increased
and com plete. Up p er and low er centrelines are d isp laced .
The bu ccal segm ent relationship is Class III bilaterally.
Treatment
■ What are the possible causes o the reverse overjet? ■ Wha t orthodontic treatment would you undertake
and why?
These are listed in Table 11.1.
■ What radiographic investigations would you request In view of the alread y app arent Class III skeletal pattern,
and why? the ability of the patient to ju st achieve an ed ge-to-ed ge
incisor relationship , the inherent tend ency for d ow nw ard
A d ental p anoram ic tom ogram w ou ld be requ ired to accou nt and forw ard m and ibular grow th and the fam ily history, a
for the p resence and p osition of all the rem aining p erm a- sensible option w ould be to accept the m alocclusion for the
nent teeth. present and reassess in the light of fu rther m and ibular
A lateral cep halom etric rad iograph is ind icated to assess grow th. Alistair has not yet entered the p u bertal grow th
m ore accu rately the m agnitu d e of the Class III skeletal spurt, w hich is likely to exacerbate the Class III m alocclu -
pattern and the incisor inclinations, w hich w ill facilitate sion and chin prom inence as m and ibu lar grow th p roceed s.
treatm ent p lanning. It w ill also form a baseline from w hich On average, m and ibu lar grow th continu es until 19 years of
treatm ent progress/ grow th changes can be evaluated by age in boys, bu t it m ay progress for longer.
comp arison w ith fu tu re cep halom etric lm s.
The panoram ic rad iograph show ed all perm anent teeth
to be d evelop ing. Key point
■ What is your interpretation o the ollowing cephalometric Class III malocclusion in the mixed dentition is likely to
f ndings? worsen with mandibular growth, especially in boys.
SN A = 80°; SN B = 82°; 1 to m axillary plane = 106°; 1 to
m and ibu lar p lane = 97°; maxillary m and ibu lar planes
angle = 25°; facial p rop ortion = 53%. As the p arents are keen for treatm ent if possible, to try
The skeletal pattern is Class III (SN A − SN B = AN B = −2°) to red u ce any fu rther teasing at school, another op tion to
d u e to m ild m axillary retrognathism and m and ibu lar p rog- consid er w ou ld be grow th m od i cation by fu nctional ap p li-
nathism . The u p per incisors are slightly retroclined relative ance therapy (Fränkel III or FR III, w here FR stand s for
• 68
11 REVERSEOVERJET
Table 11.2 Factors to assess in treatment planning continu ing grow th and of the need for reassessm ent in the
Factor light of ensuing grow th. This form of treatm ent shou ld only
Degree o anteroposterior and Most important actor be u nd ertaken by a specialist and only w hen Alistair ’s oral
vertical skeletal discrepancy hygiene has im proved .
Re ected directlyin acial and dental appearance;
patient’s perception o these will in uence complexity ■ How would you take a wax registration or this appliance?
o treatment undertaken The m and ible is rotated d ow nw ard and backw ard u ntil the
Potential direction and extent o Assess relevant amilyhistory, age and gender o the incisors are brought to an end -to-end relationship or better,
uture acial growth patient and vertical acial proportions w ith the bite open about 2 m m . Alistair m ay be instructed
Reverse overjet is likelyto worsen with a orward to place the tip of his tongu e at the back of the hard p alate
growth rotation and horizontal pattern o mandibular and to m aintain it there w hile closing slow ly into a horse-
growth, usuallyobserved when the anterior acial shoe of softened w ax p laced over the u p p er teeth u ntil the
height is reduced or average d esired p osition is reached . This w ax registration should
The converse is likelywhere there is an increased then be chilled in cold w ater and its accu racy re-checked
vertical acial height in the m ou th before forw ard ing to the laboratory w ith
Incisor inclinations I dentoalveolar compensation is alreadymarked, im pressions of the d ental arches to allow for appliance
urther orthodonticcompensation is unlikelyto be constru ction.
stable or to produce an aesthetic result ■ How much should Alista ir wear this appliance?
Amount o overbite The deeper the overbite, the better the likelihood o
stable correction o the reverse overjet H e shou ld bu ild up w ear over the rst w eek so that it is
w orn for at least 14 hou rs ou t of 24. Encou ragem ent shou ld
Abilityto achieve edge to edge I this is not possible, correction o the incisor
be given to increase w ear to fu ll-tim e w ith the exception of
incisor contact relationship bysimple means is unlikely
m ealtim es and d u ring sports, althou gh this may prove d if-
Degree o upper and lower arch Delayupper arch extractions until the reverse overjet cult for som e child ren. As its nam e im p lies, the Fu nction
crowding is corrected, as this mayprovide space or relie o
Regu lator w as d esigned w ith the intention of altering fu nc-
mild/moderate crowding
tion of the circu m oral and m asticatory m u scu lature. For this
I extractions are undertaken in the upper arch only, reason, the p atient shou ld be instru cted to ‘exercise’ these
the reverse overjet mayworsen bythe upper labial
m uscles by gently op ening and closing into the ap pliance.
segment moving palatally
Alistair shou ld be given a tim e sheet to allow him to record
I mid upper arch extractions are necessary, extraction the nu m ber of hou rs of w ear per d ay. This shou ld be
o 4 4 is usuallyadvisable to allow or correction o inspected at each visit and u sed to encou rage p rogress.
the incisor relationship
■ What e ects will this appliance have?
The resp onse is a d ow nw ard and backw ard rotation of the
m and ible accom panied by an increase in facial height. Evi-
d ence su ggests that m and ibu lar grow th m ay be constrained
by the FR3 bu t it d oes not prom ote forw ard m axillary
grow th. The low er incisors are up righted , and the upp er
incisors m ay be proclined slightly. The upp er molars shou ld
erupt m ore than the low er ones.
Key point
The FR3 appliance or correction o Class III malocclusion:
• May constrain mandibular growth.
• Does not promote orward maxillary growth.
• Produces mostly dentoalveolar changes.
Fig. 11.4 Fränkel Ill appliance.
CASE2
SUMMARY
A Daniel, a 9.1-year-old boy, presents with all o the
upper incisors in crossbite. Daniel is unconcerned
by this. He is in good health. His mother is keen or
treatment to correct Daniel’s bite.
History
History o complaint
All of the perm anent upper front teeth eru pted insid e the
low er teeth; the ‘baby’ teeth had the sam e bite.
B
Fig. 11.5 (A) Post-treatment: pro le view. (B) Post-treatment: Medical history
occlusion. Daniel is in good health.
Dental history
H e has not had any p reviou s d ental treatm ent.
If the p atient is not keen to try grow th m od i cation or
the parents express concern abou t the need for p rolonged Examination
retention of the corrected incisor relationship , the m alocclu -
sion should be accep ted for the present. Arrangem ents Extraoral
shou ld be m ad e to review occlu sal d evelop m ent and to Daniel has a Class III skeletal pattern with average FMPA and
m onitor facial grow th. In Alistair ’s case it w ou ld be w ise to no facial asymmetry. The Class III pattern appears to be
review his occlu sion in 18 m onths (at age 10) to check par- mostly maxillary rather than mandibular in origin, with
ticularly on the position of the u nerupted perm anent m axil- mid face attening rather than a prominent chin. Lips are com-
lary canines and to m easure the reverse overjet. petent. There is no mandibular displacement on closure and
Once the p erm anent d entition is established , provid ed no abnormal temporomandibular joint signs or symptoms.
the reverse overjet has not w orsened m arked ly and the chin
■ Wha t do you notice in Fig. 11.6?
prom inence has not increased greatly, consid eration cou ld
be given to rem oval of 4 4 only, in conju nction w ith up p er Oral hygiene is poor with plaque deposits on most teeth and
and low er xed app liance therapy to correct the incisor associated generalized mild marginal gingival erythema. The
relationship . If the u pp er arch is crow d ed , 5 5 m ay be dentition appears caries- ree. EDC21 are visible in each
rem oved also, bu t it is w ise to d elay the d ecision regard ing quadrant. (6’s were erupted but not shown).
the need for any u pper arch extractions until the reverse Upper and lower incisors are very mildly crowded and in
overjet has been corrected . It is im p ortant to assess the crossbite as is the mesial aspect o C. The overjet is reversed
pattern of m and ibu lar grow th from an u p d ated cep halom - (measured 2 mm); the overbite is average to slightly reduced
etric rad iograp h p rior to this treatm ent ap p roach, and if and appears complete on 2 . The buccal segment relationship
there is any concern abou t it, treatm ent shou ld be d elayed is slightly Class III.
u ntil grow th is alm ost com plete.
■ Wha t radiogra phic investigations would you request
If the reverse overjet increases consid erably w ith fu rther
and why?
grow th, a com bined orthod ontic and su rgical app roach m ay
be requ ired for correction, d epend ing on the p atient’s con- A d ental p anoram ic tom ogram shou ld be requ ested to
cerns. This treatment w ou ld not be u nd ertaken u ntil m an- ascertain the p resence and p osition of all the uneru pted
d ibu lar grow th is com p lete in the late teens. perm anent teeth.
• 70
11 REVERSEOVERJET
B
Fig. 11.9 Rail-style acemask.
Fig. 11.10 Seven months later on removal o RME (A) pro le and
(B) right buccal occlusion.
Key point
Facemask (reverse pull headgear) treatment may be SN B change 0.7°) w ith an overall m ean skeletal change
considered or: (AN B) of abou t 2°. The occlusal plane rotates u p w ard and
forw ard w ith a d ow nw ard and backw ard rotation of the
• Mild to moderate Class III malocclusion due to maxillary
m axilla. Dentally, the overjet is increased and the low er
retrusion.
incisors are retroclined by about 5°.
• ≤10 years.
The facial and occlu sal ou tcom es show n 7 m onths later
and at 1-year follow -u p are show n in Figs 11.10 and 11.11,
respectively.
■ How does this work? ■ Does treatment pose any risk to the ja w joints? Are there
any psychologica l benef ts?
Forces of abou t 400 g p er sid e are app lied by elastics for 14
hou rs p er d ay from the vestibu lar hooks on the bond ed In the one rand om ized controlled trial that record ed tem po-
m axillary splint/ exp and er to the crossbow of the facem ask. romand ibu lar joint signs and sym ptom s w ith facem ask
These p u ll at 30° in a d ow nw ard and forw ard d irection to treatm ent com pared w ith an u ntreated control grou p, no
ad vance the m axilla. ad verse effects w ere reported at 15-m onth and 3-year
follow -up . The sam e trial found no im provem ent in the
■ What e ects does it have?
child ’s self-esteem at either point in tim e. At 15-m onth
Cephalom etric nd ings ind icate that, com p ared w ith an review, a signi cant red u ction w as record ed in the im pact
u ntreated control grou p, facem ask treatm ent p rod u ces a of malocclu sion scores relative to controls, w hich allud es to
sm all am ou nt of m axillary p rotraction (m ean SN A change less u nease abou t d ental app earance, bu t this effect w as not
1.4°), slight backw ard m ovem ent of the m and ible (m ean present at 3-year review.
• 72
11 REVERSEOVERJET
Complaint visible: 6E4321 124E6 (21 1 2 are erupted but are covered
6E43 3456
H arry d oes not like the ap p earance of his u p p er teeth and by the upper incisors).
has recently com p lained abou t the gu m behind his u p p er
Mild upper labial segment crowding.
front teeth being sore. H is m other is keen for treatm ent.
Class II division 2 malocclusion with deep complete overbite.
History o complaint Buccal segment relationship is a hal -unit Class II bilaterally.
H is p rim ary teeth w ere m ild ly irregu lar. H is perm anent
u pper front teeth erup ted in a ‘crooked ’ p osition and have
not changed since.
Medical history
H arry is t and w ell.
Dental history
H arry is a regu lar attend er at his general d ental p ractitioner
and has not requ ired any d ental treatm ent so far.
Fig. 12.4 (A) Post-treatment. Pro le. (B) Post-treatment: le t buccal occlusion. (C) Post-treatment: anterior occlusion.
B
A
Fig. 12.5 Case 2 at presentation. (A) Anterior occlusion. (B) Right buccal occlusion. (C) Le t buccal occlusion. (D) Upper occlusal view.
(E) Lower occlusal view.
A A
B B
Fig. 12.7 (A) Post-treatment: anterior occlusion. (B) Post-treatment: Fig. 12.9 (A) Pre-treatment: right buccal occlusion. (B) Pre-
le t buccal occlusion. treatment: le t buccal occlusion
• 80
12 INCREASEDOVERBITE
A A
B
B
Fig. 12.12 (A) Post-treatment: right buccal occlusion.
Fig. 12.10 Following retraction o 6’s: (A) right buccal occlusion; (B) Post-treatment: le t buccal occlusion.
(B) le t buccal occlusion.
Key point
A non-extraction approach is avoured in management o
Class II division 2 malocclusion.
Examination
Extraoral
Anterior open bite ■ Gera ld’s acia l prof le is shown in Fig. 13.2. What do
you notice?
Gerald has a m ild Class II skeletal pattern w ith increased
FMPA and increased low er anterior facial height. The lip s
are com p etent.
There w as no facial asym m etry. Mou th op ening w as
w ithin norm al d im ensions, and there w as no tem porom an-
d ibu lar joint tend erness or crepitu s. N o m asticatory m u scle
tend erness w as noted .
SUMMARY ■ Wha t other eatures should you assess? Explain why.
Gerald is 11 years old. He presents with no contact 1. The swallowing pattern. Where there is a space between
o his incisor teeth (Fig. 13.1). Identi y the cause(s) the upper and lower anterior teeth, swallowing is likely
and discuss the treatment options. to be achieved by orward positioning o the tongue
between the anterior teeth to achieve an oral seal. This is
particularly so where the vertical acial proportions are
History increased as the likelihood o lip incompetence is greater.
Although such behaviour o the tongue is in most cases
Complaint adaptive, in rare instances an endogenous (primary)
Gerald com p lains that his front teeth d o not m eet. This tongue thrust exists. It has been suggested that this is
em barrasses him w hen eating as he cannot bite into food . associated with lisping and some proclination o the
H is p arents are also concerned by this and by lisp ing d u ring upper and lower incisors. Any attempt in these cases to
sp eech, w hich they attribu te to the p osition of his front close the open bite is doomed to ail as the tongue will
teeth. They are anxiou s for treatm ent. return the incisors to their original positions.
2. Speech. By asking Gerald to count rom 60 to 70 aloud or
History o complaint to say ‘Mississippi’, the degree o sibilance (lisping) can be
Gerald ’s p arents rep ort that his p rim ary incisors d id not detected. The tongue position during speech should also
m eet either, bu t the sp ace betw een the u pp er and low er be observed.
p erm anent incisors app ears to have increased in the past
year. H is lisp has also becom e m ore noticeable. H e has no
history of thu m b or d igit su cking.
Medical history
Gerald is t and w ell.
Investigations
■ Wha t special investigations would you require? Explain why.
Adental panoramic tomogram is required to indicate what
other teeth have yet to erupt and to check their
A
developmental position and orm.
Alateral cephalometric radiograph is required to assess more
ully the extent o the anteroposterior and vertical skeletal
discrepancies, as well as the relationship o the incisors to the
underlying dental bases.
The d ental p anoram ic tom ogram show ed :
Normal alveolar base height.
A normal dentition. The developmental age matches Gerald’s
chronological age.
B
Third molars are present.
Fig. 13.7 (A) Anterior open bite due to thumb sucking. The cephalom etric analysis revealed :
(B) Following cessation o the habit and xed appliance therapy. SN A = 82°; SN B = 76°; AN B = 6°; MMPA = 34°; 1 to m axil-
Note that acid pumice microabrasion was used to improve the lary p lane = 111°; 1 to m and ibu lar plane = 86°; interincisal
appearance o 11 (see Chapter 36). angle = 126°; facial p rop ortion = 60%.
• 84
13 ANTERIOROPENBITE
■ What is your interpretation o these f ndings? crib associated w ith high-p u ll chincu p are able to correct
anterior op en bite.
Relative to m ean valu es for Cau casians, SN A is slightly
increased and SN B is slightly red u ced , but both are w ithin
the norm al range; AN B is increased , ind icating that the skel- Key point
etal p attern is m ild ly Class II; 1 to m axillary p lane show s
Unless an anterior open bite is due to a habit, treatment is
that it is proclined relative to the m ean but w ithin the
complex.
norm al range; 1 to m and ibu lar p lane show s that it is retro-
clined relative to the m ean, bu t it is at the correct angle to
comp ensate for the increased MMPA (120° − 34° = 86°); rela-
tive to m ean valu es, the interincisal angle is red u ced ■ What mea ns have been tried in a n a ttempt to stop a
but w ithin the norm al range and the facial proportion is digit-sucking ha bit?
increased .
These range from sim ple strategies, su ch as covering the
d igit w ith a p laster or p ainting the d igit w ith an u np leasant-
Diagnosis tasting su bstance, to attem pts to m od ify behaviou r w ith
cognitive behavioural therapy, rew ard -based strategies and
■ Wha t is your diagnosis? the use of positive reinforcem ent. The u se of intraoral app li-
Class I malocclusion on a mild Class II skeletal base with ances has also been tried either to stop the d igit being pu t
increased FMPA. in the habit p osition or to lessen the satisfaction felt in
u nd ertaking the habit.
Marginal gingivitis related to the incisors and 4 .
■ I the anterior open bite had been due to digit sucking,
Mild mesiolabial rotations o 1 1 with spacing o the upper what treatment would you recommend?
and lower labial segments. Anterior open bite.
A recent Cochrane systematic review conclud ed that p rovi-
Buccal segment relationship is Class III bilaterally.
sion of a xed habit breaker (palatal crib or arch; Fig. 13.8A
■ Wha t is the IOTN (DHC) grade (see p. 264)? Explain why. and B), p sychological intervention (p ositive or negative
reinforcem ent) or both seem to be effective in assisting chil-
4e – d u e to the anterior op en bite.
d ren w ith stop p ing a N N SH ; this, how ever, w as based on
low -qu ality, highly biased evid ence. If the habit ceases, the
Treatment
■ What treatment would you consider?
As the anterior op en bite is not d u e to d igit su cking, treat-
m ent is likely to be com p lex. Gerald has anterop osterior and
vertical skeletal p roblem s, the latter being m ore m arked ,
w ith a d ow nw ard and backw ard p attern of facial grow th
that has p rod u ced the anterior op en bite. An attempt, there-
fore, to achieve incisor contact m ay be by grow th m od i ca-
tion aim ing for effective control of m axillary vertical skeletal
and d ental grow th.
This w ou ld requ ire sp ecialist care. A fu nctional ap p liance
w ith p osterior bite blocks, e.g. a Tw in-Block app liance,
w ould be op tim al. As the incisor relationship is Class I and
the m olar relationship s are Class III, no forw ard p osturing
A
of the m and ible for the registration bite is ad visable. The
bite, how ever, m u st be op ened beyond the norm al resting
vertical d im ension so that m olar eru p tion is prevented . As
the app liance hold s the m and ible in this position, a vertical
intru sive force is exerted on the p osterior teeth m ed iated by
the stretch of the m u scles and other soft tissu es. Gerald
should be instructed to w ear the app liance fu ll-tim e, inclu d -
ing for m eals. The anterior teeth are allow ed to eru p t w hile
eruption of the p osterior teeth is inhibited , thereby red u cing
the anterior op en bite. This is su p p lem ented by a tend ency
for m and ibu lar grow th to be p rojected anteriorly w hile
vertical control of m axillary skeletal and d ental grow th
is effected . In this case, high-p u ll head gear should not be
ad d ed to the ap p liance. As the m olar relationship s are Class
III, any m olar d istal m ovem ent is not ind icated . B
Cu rrently, there is w eak evid ence that both the Fu nction
Regu lator IV (FR IV) w ith lip -seal training and the p alatal Fig. 13.8 (A) Palatal crib. (B) Modi ed palatal arch.
85 •
ANTERIOROPENBITE 13
anterior open bite w ill u su ally red uce sp ontaneou sly, guard ed . Gerald and his parents should be m ad e aw are of
althou gh this is likely to take several years. this before treatm ent com m ences. Provid ed there is excel-
lent coop eration w ith ap p liance w ear and vertical facial
grow th is favou rable, functional ap pliance treatm ent has
Key point a reasonable chance of success at this stage. H ow ever, a
Currently, low-quality evidence indicates that e ective second phase of treatm ent w ith xed app liances is likely to
strategies to assist a child in stopping a digit-sucking habit be requ ired to d etail the occlu sion. As these app liances d o
include: not control eru p tion so favou rably, posterior bite blocks or
• Fixed habit breaker. sim ilar com ponents w ill also be required d uring that phase
• Positive or negative rein orcement. of treatm ent to m aintain the correction achieved in the
earlier p hase. Thereafter, bite blocks w ill also need to be
• Both.
incorporated in any retainer. Long-term retention w ill be
requ ired to avert the possible unfavourable effects of su b-
sequent vertical facial grow th.
■ How would you manage a parent who is concerned a bout
The lisp m ay imp rove w ith closu re of the anterior open
an anterior open bite produced by either a dummy or digit
bite, but Gerald and his p arents should not have high expec-
sucking habit in the prima ry dentition (Figs 3.4 and 3.5)?
tations regard ing this.
It w ould be pru d ent to ad vise the parent of the child that ■ Are there any other treatment options?
this is a very com mon issue at this stage of d evelopm ent
and that, as the incid ence of N N SH s d ecreases throu ghou t If Gerald d oes not cooperate w ith functional appliance
the m ixed d entition, a ‘w ait and see’ ap p roach w ou ld be w ear, treatment for the anterior open bite by a speci c typ e
bene cial. Gentle p ersu asion to d iscontinu e the habit may of xed appliance m echanics w ith m u ltiloop archw ires
also be consid ered , bu t as m ost child ren are likely to ou tgrow (Kim m echanics) m ay be consid ered , m ost likely in conjunc-
the habit, it w ou ld be im portant not to m agnify the issu e for tion w ith the rem oval of the second or third m olars. This
the child . If either habit stop s, the anterior op en bite w ill ap proach to ap p liance treatm ent requ ires specialist training.
red u ce. Many changes w ill occu r w ith grow th of the face The objective is to correct the cant of ind ivid ual occlusal
and the eru ption of the p erm anent teeth, so the m alocclu - p lanes, u p righting the teeth in relation to the bisecting
sion can be reassessed in light of these changes at age 8 occlu sal plane. As this hap p ens, there is a red u ction in pos-
(w hen the incisors and rst p erm anent m olars eru p t); terior facial and d entoalveolar heights, w hich red uces the
shou ld there be a d isp lacem ent of the low er jaw d u e to nar- anterior open bite; anterior vertical elastics then bring the
row ing of the u pp er arch by the habit, it can be assessed and incisors into contact. Im p ressive and stable correction of
corrected at that tim e. Any concerns regard ing sw allow ing m arked anterior op en bite, in ad olescents and ad u lts, has
pattern and sp eech are also likely to change as the p erm a- been reported u sing this techniqu e. Sim ilar results can be
nent teeth eru p t and cou ld be assessed by a sp eech thera- achieved w ith ‘rocking horse’ archw ires u sed in com bina-
pist, also at that tim e, if d esired . tion w ith anterior vertical elastics.
Molar intru sion m ay also be achieved u sing tem p orary
■ What is the likely prognosis o treatment in Gerald’s case?
anchorage d evices (TADs; Fig. 13.9) in the form of either
As the anterior open bite is qu ite m arked and the vertical screw s or plates. To m axim ize m olar intrusion and p revent
skeletal p attern is m od erately increased , the prognosis is u nw anted bu ccal tipping of the m olars, use of bu ccal and
A B C
Fig. 13.9 TADs used to close anterior open bite: lateral cephalometric radiograph (A) pre-treatment; (B) ollowing molar intrusion with
TADs (arrowed) and palatal arch; (C) nearing the completion o xed appliance treatment with extraction o our premolars.
• 86
13 ANTERIOROPENBITE
palatal im p lants has been ad vised ; the skeletal anchorage, m axillary teeth. Am J Orthod Dentofacial Orthop
how ever, for m olar intru sion need s to be maintained d u ring 138:396–398.
the early retention phase in an attem p t to red u ce relap se. Borrie FBP, Bearn DR, Innes N PT et al 2015 Interventions for the
Shou ld the anterior op en bite w orsen consid erably, a cessation of non-nu tritive su cking habits in child ren. Cochrane
com bined orthod ontic su rgical ap p roach m ay be sou ght Database of Syst Rev Issu e 3. Art N o: CD008694. DOI: 10.1002/
14651858.CD008694.p u b2.
w hen grow th is com p lete.
British Orthod ontic Society 2012 Du m m y and thu m b
su cking habits. Patient inform ation lea et. Available at:
w w w.bos.org.u k.
Johnson N C, Sand y JR 1999 Tooth p osition and sp eech – is there a
Key point relationship ? Angle Orthod 69:306–310.
Management options or anterior open bite may be: Kim YH 1987 Anterior openbite and its treatm ent w ith m u lti-loop
• Accept. ed gew ise archw ire. Angle Orthod 57:290–321.
• Habit breaker. Lentini-Oliveira D, Carvalho FR, Qingsong Y et al 2007
Orthod ontic and orthop aed ic treatm ent for anterior op en bite in
• Growth modif cation.
child ren. Cochrane Database of Syst Rev Issu e 9. Art N o:
• Orthodontic camou age, with or without TADs. CD005515. DOI: 10.1002/ 14651858.CD005515.p u b3.
• Surgery. Lop ez-Gavito G, Wallen TR, Little RM, et al 1985 Anterior
op en-bite m alocclu sion: a longitu d inal 10-year p ostretention
evalu ation of orthod ontically treated p atients. Am J Orthod
87:175–186.
Mizrahi E 1978 A review of anterior op en bite. Br J Orthod 5:21–27.
Primary resources and N gan P, Field s H W 1997 Op en bite: a review of etiology and
recommended reading m anagem ent. Ped iatr Dent 19:91–98.
Posterior crossbite joint tend erness or crep itu s, and m outh opening is not
restricted .
■ What other eature would you check or, bearing in mind
the history? Explain why.
It is im p ortant to check if there is m and ibular d isplacem ent
on closu re as this w ou ld ind icate that the facial asym m etry
is more an app arent than a true skeletal asym m etry. For the
former, orthod ontic correction of an associated crossbite
should be straightforw ard , bu t for the latter, fu rther inves-
tigations w ou ld be required to d etermine if the asym m etry
SUMMARY is p rogressive and more com p lex treatm ent w ou ld be
Kirsten is 7 years old. She presents with a crossbite requ ired to ad d ress the facial and occlu sal problem s.
o the right buccal segments (Fig. 14.1). What will be Early correction of a crossbite w ith a m and ibu lar d is-
your assessment and management options or this placem ent is ind icated to allow the occlu sion to d evelop
in an u nd isplaced p osition. It is likely also to red u ce the
problem?
possibility of d evelop m ent of tem porom and ibu lar joint d ys-
fu nction synd rom e, w hich m ay occur in su scep tible ind i-
History vid u als in w hom this occlu sal d iscrep ancy exists.
An anterolateral m and ibu lar d isp lacem ent on closu re
Complaint C
w as d etected on w ith an associated 3 m m shift betw een
Kirsten’s m other is concerned abou t the w ay her d aughter ’s C
teeth bite together. She has noticed that Kirsten’s jaw m oves retrud ed contact position (RCP) and intercusp al position
to one sid e as she closes her m ou th. This m akes her face (ICP).
ap pear crooked , a fu rther cause of anxiety for her m other.
History o complaint
Kirsten u sed to su ck her thu m b u ntil 5 months ago w hen Key point
1 1 started to eru p t. H er m other has becom e m ore aw are of Early correction o a posterior crossbite with associated
her d au ghter ’s ‘d eviated bite’ in the p ast year and w on- mandibular displacement is advisable.
d ered if the thu m b-su cking habit cou ld have contribu ted to
the problem .
Medical history
Kirsten is t and w ell. Intraoral
■ Wha t eatures are evident on the intraoral views (Figs 14.1
Family history and 14.2)?
There is no fam ily history of facial asym m etry.
Mild marginal gingival erythema related to the erupting
permanent incisors, but otherwise the so t tissues appear
healthy. There is no caries visible.
Upper arch seems V-shaped anteriorly; lower arch is more
U-shaped anteriorly.
6EDCB1 are present in both upper quadrants and in the lower
right quadrant; 12CDE6 are present in the lower le t quadrant.
Spacing o the upper and lower incisors with distopalatal
rotation o 1.
Class III incisor relationship.
Anterior open bite.
Fig. 14.1 Anterior occlusion at presentation. Lower centreline shi t to the right.
• 88
14 POSTERIORCROSSBITE
Table 14.1 Causes o buccal segment crossbite
Cause Aetiology
Skeletal Mismatch in the widths o the dental arches and/or an anteroposterior
skeletal discrepancy– buccal and anterior crossbites are most
commonly ound in Class IIImalocclusion. Rarely, mandibular growth
restriction ollowing condylar trauma or hemimandibular hypertrophy
maybe implicated, both producing asymmetry
So t tissues/habit With a digit sucking habit, the tongue position is lowered with the
teeth apart, and cheekcontraction is unopposed during sucking,
narrowing the upper arch slightly
A
B
Key point
Fig. 14.2 (A) Right buccal occlusion. (B) Le t buccal occlusion. A digit-sucking habit may lead to posterior crossbite with
associated mandibular displacement.
These are listed in Box 14.1. In this case it is d u e to the lateral All permanent teeth developing apart rom third molars.
aspect of the m and ibu lar d isp lacem ent on closu re. No apparent caries or other pathology.
89 •
POSTERIORCROSSBITE 14
Treatment
■ Wha t treatment plan would you propose?
Oral hygiene instruction to improve gingival health.
Correction o the right buccal segment and anterior
crossbites.
Regular review o the developing occlusion.
■ How may the crossbites be corrected? Describe the design
A o any a ppliance you would use.
Possible ap proaches to treatm ent are as follow s:
1. As the digit-sucking habit has been abandoned and the
mandibular displacement arises rom premature contact
C
on , judicious grinding o their cusp tips may remove
C
the occlusal inter erence and correct the buccal segment
crossbite, although the success rate with this treatment
has varied considerably, rom 27 64%. Placing composite
onlays to allay mandibular shi t where occlusal
inter erences exist has also been tried but with outcomes
in erior to active appliance therapy.
B The permanent incisors are erupted insu ciently, at
present, to consider their proclination and which means
Fig. 14.3 (A) Dental panoramic tomogram. (B) Repeat o right hal will be best.
dental panoramic tomogram. 2. As the upper buccal segment teeth are not tilted
buccally, upper arch expansion by a midline screw in an
■ What is the most likely reason or the blurred image on the upper removable appliance may be considered. The
right hal o the dental pa noramic tomogram? appliance may be clasped on 6D D6 (Adams clasps: 6 6
0.7 mm stainless steel wire; D D 0.6 mm stainless steel
Movem ent of the p atient d u ring im age cap tu re, m ost p rob-
wire). Buccal capping will acilitate tooth movement by
ably d ue to sw allow ing, is the likely cau se.
disengaging the posterior occlusion. Kirsten should be
■ Why wa s a right hal , rather than a ull, dental panora mic encouraged to turn the screw one quarter turn twice
tomogram retaken (Fig. 14.3B)? weekly (0.25 mm o activation with each turn) until the
In line w ith cu rrent rad iology gu id elines, the rad iation crossbite is corrected. A small amount o overexpansion
d osage to the p atient shou ld be as low as reasonably achiev- is advisable as some relapse is to be expected. Then the
able for the d iagnostic p u rp oses requ ired . Retaking the capping should be reduced to hal its height at one visit
right-half im age only satis es d iagnostic need s here. and removed completely at the ollowing visit to allow
the buccal segment teeth to erupt into occlusion.
Provided there is a well-interdigitating buccal segment
Diagnosis occlusion, the appliance should then be worn as a
retainer at night or several months; 6 months o
■ What is your diagnosis?
retention will likely su ce.
Class III malocclusion on a mild Class III skeletal base The nal occlusion ollowing crossbite correction by
with slightly increased FMPA; anterolateral mandibular an upper removable appliance is shown in Fig. 14.4.
C Correction o the incisor relationship and improvement
displacement on closure on .
C in 1 alignment occurred spontaneously.
Mild marginal gingivitis related to the erupting incisors. 3. Alternatively, upper arch expansion may be undertaken
Spacing o the upper and lower incisors with 1 distopalatally using a quadhelix (see Fig. 4.11A). This consists o bands
rotated. cemented to the rst permanent molars with soldered
Anterior open bite; lower centreline shi t to the right. arms, which in this case should extend orward to the
palatal aspects o the C’s. Alternatively, a pre ormed
Buccal segment relationship hal -unit Class II on the right and quadhelix may be employed that ts into sheaths
Class III on the le t. soldered to the palatal aspects o the molar bands,
Buccal crossbite o the right buccal segments associated with allowing easy removal or adjustment. Activation is
the mandibular displacement. usually hal a tooth width on each side. To acilitate
crossbite correction, it may be necessary to disengage
■ What is the IOTN (DHC) gra de (see p. 264)? Explain why.
the buccal occlusion temporarily by placing glass
4c – d u e to m and ibu lar d isp lacem ent >2 m m betw een the ionomer cement on the occlusal sur aces o the molars.
RCP and the ICP. Once the crossbite has been corrected, the cement may
• 90
14 POSTERIORCROSSBITE
A A
B B
Fig. 14.4 Post-treatment (A) Right buccal occlusion. (B) Anterior Fig. 14.5 (A) Pre-treatment: anterior occlusion (note C retained
occlusion. and mobile; 3 unerupted). (B) Post-treatment: anterior occlusion.
be removed and the quadhelix should be rendered over another w ith regard to the other ou tcom es assessed
passive prior to cementation or 3 6 months as a (intercanine exp ansion, stability of crossbite correction,
retainer. signs and sym p tom s of tem p orom and ibu lar joint d ysfu nc-
Another case treated by a quad helix is show n in tion, signs and sym ptom s of resp iratory d isease and quality
Figs 14.5A and B. of life).
■ What will determine i the corrected buccal segment
crossbite is likely to be stable?
Key point
Good buccal segm ent interd igitation and absence of any
Management options or a unilateral posterior crossbite d isp lacing occlu sal contacts.
with associated mandibular displacement in the mixed
dentition:
• Grind C’s. Key point
• URA with midline screw.
Correction o a unilateral buccal segment crossbite in the
• Quadhelix.
mixed dentition may be more success ul with a quadhelix
than with a removable expansion plate.
Examination
Extraoral
Jean has a Class I skeletal p attern w ith slightly increased
FMPA and no facial asym m etry. Lip s are incom p etent. There
are no signs or sym ptom s associated w ith the tem porom an-
d ibu lar joints.
Intraoral
■ The appearance o the teeth on presentation is shown in
Figs 15.1 and 15.2. Describe wha t you see.
Fair oral hygiene with generalized marginal gingival
Fig. 15.1 Case 1: anterior occlusion at presentation. erythema.
• 92
15 BILATERALCROSSBITE
Table 15.1 Possible causes o bilateral buccal crossbite
Bilateral buccal
crossbite Possible causes
Skeletal Mismatch in relative widths o arches or anteroposterior discrepancy
(commonlyassociated with Class IIImalocclusion)
So t tissues Possible role o adenoids/tonsils (see text)
Lowtongue position possiblydue to altered head posture
associated with mouth breathing
Scar tissue o cle t repair restraining growth in upper arch width
A
Radiographic
A d ental p anoram ic tom ogram w ou ld be u sefu l to d eter-
m ine the presence, p osition and form of u neru pted third
m olars. A lateral cephalom etric rad iograp h w ill also be
requ ired to ascertain the inclination of the u p p er and low er
incisors to their respective d ental bases.
The d ental panoram ic tom ogram ind icated fou r third
m olars of good form and p osition to be p resent.
The cephalom etric nd ings w ere as follow s:
SN A = 81°; SN B = 79°; MMPA = 28°; 1 to m axillary plane
= 113°; 1 to m and ibu lar plane = 93°; interincisal angle = 138°;
facial prop ortion = 56%.
B ■ What is your interpretation o these f ndings?
Fig. 15.2 (A) Case 1: right buccal occlusion. (B) Case 1: le t buccal Relative to m ean valu es for Cau casians, SN A is norm al; SN B
occlusion. is slightly increased ; AN B (SN A − SN B) = 2°, ind icating a
Class I skeletal p attern; MMPA is slightly increased ; 1 to
m axillary p lane is increased , so the up per incisors are
slightly proclined ; 1 to m and ibu lar p lane is norm al; interin-
654321 123456 cisal angle is slightly increased ; facial proportion is slightly
visible (please note 7 7 are also erupted).
7654321 1234567 increased .
All teeth visible appear caries- ree; amalgam restoration in 6 . All valu es are w ithin the norm al range for Cau casians.
Molar relationship is Class I on right and Class III on le t with Generalized marginal gingivitis.
6543 456 Moderate lower labial segment crowding: mild upper labial
bilateral buccal crossbite a ecting .
6543 56 segment crowding with 2’s in crossbite; upper and lower
centreline shi ts.
■ What are the possible causes o bilateral buccal crossbite?
Molar relationship is Class I on the right and Class III on le t
Factors im plicated in the aetiology of a bilateral bu ccal
6543 456
crossbite are given in Table 15.1. with bilateral buccal crossbite a ecting .
6543 56
■ What is the IOTN (DHC) grade (see p. 264)? Expla in why.
Investigations
3d – d ue to contact point d isp lacem ent betw een 1 and 2;
■ What investigations would you underta ke in relation to the also betw een 2 and 3.
bilateral buccal crossbite? Explain why.
Clinical Treatment
It w ou ld be imp ortant to ascertain if there is an associated ■ What a re the aims o treatment?
m and ibu lar d isp lacem ent, althou gh this is rare w ith bilat-
To improve oral hygiene.
eral crossbites. It is m ore u su al to have a m and ibu lar d is-
placem ent associated w ith a u nilateral bu ccal crossbite. To correct the bilateral buccal crossbite.
N o m and ibu lar d isp lacem ent w as noted . To relieve upper and lower arch crowding.
93 •
BILATERALCROSSBITE 15
Table 15.2 Management options or bilateral buccal crossbite
Management option Indications Comments
Accept and monitor Patient not keen or correction. Not an option here as Jean is keen or correction
Part o underlying skeletal IIIproblemwhich is likelyto
worsen with mandibular growth, especiallyin males
Removable appliance with midline Primary/earlymixed dentition Rate o expansion must be quite slowand orce employed low: otherwise retention o
screwor heavymidline spring appliance compromised byhigher expansion orces
Compliance with wear and activation maybe problematic
Not cost e ective as o ten lengthytime required to produce desired expansion
Quadhelix Pre erred approach in earlymixed dentition Made o 1 mmstainless steel wire attached to bands cemented to molar tooth on each side
3–5 mmmaxillaryexpansion required (mainlydental but Delivers ewhundred grams o orce
some skeletal expansion)
Teeth pre erablytipped palatallybut molar inclination maybe Produces e cient slowexpansion
adjusted with fxed appliances later Mayderotate molars
Maybe adjusted to give more expansion posteriorlyor anteriorly
Maybe custom made or pre ormed types available
Activation hal a tooth width each side
Rapid maxillaryexpansion (RME) Child/adolescent Produces ~ equal amounts o dental/skeletal expansion
Minimal/no palatal tipping o the buccal segment teeth, i.e. Maybe undertaken using a banded or bonded appliance (the latter limits the amount o
skeletal crossbite downward backward rotation o the mandible)
>5 mmtransverse maxillaryexpansion required
Mild anterior maxillarycrowding The older the age at expansion, the less likelythe increase in vertical acial height will be
recovered bysubsequent growth
Surgicallyassisted rapid maxillary Skeletallymature patient with severe skeletal crossbite in Not an attractive option i urther maxillaryrepositioning in the anteroposterior or vertical
expansion (SARPE) whomsegmental expansion in Le Fort Iosteotomymight plane is required later
compromise blood supplyto segments
>5 mmtransverse maxillaryexpansion required
Key point
Rapid mid-palatal suture expansion:
• Exerts a orce o 10 20 lb (approximately 4.5 9 kg) over
2 3 weeks.
Fig. 15.3 Case 1: rapid maxillary expansion appliance with Hyrax • Produces ~0.5 mm movement per day.
screw. • Creates a median diastema.
• Has a strong relapse tendency, requiring overcorrection.
History
Complaint
Aid an has been concerned for som e tim e regard ing his B
d ental ap pearance. H e now has a new job w ith a retail rm
and feels embarrassed w hen he sm iles. A p revious ortho- Fig. 15.6 (A) Case 2: expansion appliance in situ a ter surgery.
d ontist told him that he w ou ld need to w ait u ntil he w as in (B) Case 2: completion o alignment by xed appliances.
his late teens before anything cou ld be d one regard ing the
bite of his front teeth.
■ What makes a smile attractive?
Treatment
On sm iling, the full height of the u p per incisors shou ld be
seen (usu ally at rest, there is 1 m m incisor show in m ales ■ Why is RME not easible?
and 3 m m incisor show in fem ales). Although som e gingival
In ad u lts the m id -p alatal and lateral m axillary su tu res are
d isp lay is accep table, the interp roximal gingivae only
w ell-interd igitated , w hich afford increased resistance to the
shou ld be visible for op tim al aesthetics. The contou r of the
orthop aed ic-typ e p alatal exp ansion (RME) that m ay be used
u pper incisor ed ges should m atch that of the low er lip
in ad olescents.
(smile arc), w ith no u p p er incisor/ low er lip contact. In the
transverse d im ension, the sm ile shou ld inclu d e at m inim um ■ How is SARPE undertaken?
the u p per rst p rem olars. The d istance betw een the insid e Originally, surgically assisted rapid p alatal exp ansion
of the cheek and the m axillary p osterior teeth (bu ccal cor- (SARPE) w as u nd ertaken u sing bone cu ts only in the lateral
rid or), p articu larly the p rem olars, shou ld be narrow. m axillary bu ttress to d ecrease resistance su ch that in ad u lts
the m id -palatal suture cou ld be m icrofractu red by forced
opening. Althou gh this is com m only successfu l in p atients
u nd er 30 years old , in old er patients there is a risk of
Key point u nw anted fractures in other areas. Currently, the p roced u re
is often u nd ertaken u sing cu ts as for a Le Fort I osteotom y
An attractive smile comprises:
bu t w ithou t m axillary d ow n-fractu re. The m axilla is thu s
• Full length o the upper incisors. able to w id en in a p rocess akin to d istraction osteogenesis
• Related interproximal gingivae. (see p. 97) as resistance is provid ed by the soft tissues only.
• Upper incisor edges contour matches that o the The RME appliance is cem ented p rior to su rgery, and activa-
lower lip. tion of the screw u su ally com m ences w ithin 2 d ays at the
• Extends laterally to include no less than upper f rst same rate as for non-su rgically assisted RME. Fixed appli-
premolars. ances are required to com plete alignm ent (Fig. 15.6).
• Narrow buccal corridors. The im p roved occlu sion on com p letion of treatm ent is
show n in Fig. 15.7.
■ How stable is SARPE?
SARPE app ears to be m ore stable than su rgical w id ening of
the m axilla. The latter has a high relap se tend ency d u e to
Medical and dental history elastic rebou nd of the stretched p alatal m u cosa. Even after
Aid an is in good health. H e is u nable to breathe throu gh SARPE, w ear of a palate-covering retainer for at least the
his nose. rst p ost-su rgical year is recom m end ed to control relap se.
• 96
15 BILATERALCROSSBITE
A A
Key point
SARPE:
C
• Is indicated or bilateral posterior crossbite correction in
adults.
• Allows widening o the maxilla against only so t tissue
resistance.
• Appears to be more stable than surgical widening o
the maxilla.
CASE3
SUMMARY
Simon is 13 years old. He presents complaining
D
about the prominence o his top teeth and the
crooked lower back teeth (Fig. 15.8). What are the Fig. 15.8 (A) Case 3 at presentation: right buccal occlusion.
causes, and what options are there or (B) Case 3 at presentation: anterior occlusion. (C) Case 3 at
management? presentation: le t buccal occlusion. (D) Case 3 at presentation:
lower occlusal view.
■ What are the main eatures o note in Fig. 15.8?
Enamel racture in incisal third o 1 with composite
restoration ( 1 had su ered trauma 2 years previously but was Bilateral lingual crossbite (also re erred to as scissors bite or
symptom- ree). Brodie bite) a ecting 54 5.
Caries 5 distally.
■ Given the position o 5 45, what would you enquire about?
Mild upper arch crowding; moderate lower arch crowding.
It w ou ld be u sefu l to know if there had been early loss of
Class II division 1 malocclusion; increased overjet; slightly –
both low er E’s w hich w ou ld encourage m esial d rift of 6s
increased overbite. and lingu al d isp lacem ent of 5s.
Canine relationship hal -unit is Class II bilaterally. Sim on had E DE rem oved w hen he w as 7 years old .
97 •
BILATERALCROSSBITE 15
clip (Speed ) or retaining springs (Sm art-Clip ). These replace
Key point the stainless steel ligatures or elastom eric m od ules that are
Lingual crossbites are associated with Class II malocclusions. u sed (the latter m ainly) to retain the archw ire in the bracket
slot w ith conventional non-self-ligating system s. Claim ed
ad vantages inclu d e faster ligation, low er friction, faster
treatm ent, less pain and few er app ointm ents. Com p ared
w ith conventional pre-ad ju sted ed gew ise brackets, cu rrent
Extraoral p rospective evid ence for self-ligating brackets ind icates
Sim on has a Class II skeletal pattern w ith slightly red u ced no clinically signi cant d ifference in treatm ent d u ration
FMPA; there is no facial asym m etry. betw een the tw o system s; sim ilar effects on arch form for
N o m and ibular d isplacem ent or tem poromand ibu lar
joint signs or sym p tom s w ere d etected .
■ What are the causes o bilateral lingual crossbite? Table 15.4 Management options or bilateral lingual crossbite
These are given in Table 15.3. In Sim on’s case, a com bina- Option Possible indications
tion of local and skeletal causes are im plicated in the bilat- Extraction Single tooth on either side a ected and completelyexcluded
eral lingu al crossbite. lingually
■ What treatment options are there or correction o bilateral Reciprocal movement o Depends on inclination o teeth, number o teeth a ected and
lingua l crossbite? a ected upper and lower presence/absence o underlying Class IIskeletal discrepancy
teeth Fixed appliances required
It is im portant to ascertain the nu m ber of teeth affected and
to check the inclination of the affected teeth. These w ill help Growth modifcation An appliance that in uences so t tissue orce balance maybe
to ind icate the severity of any u nd erlying skeletal com po- use ul, eg, Frankel II
nent and w hether recip rocal m ovem ent of the affected teeth Orthodontic camou age Extraction/non extraction therapydepending on local/skeletal
w ith the op posing teeth only w ill su f ce for correction. components
Managem ent op tions are given in Table 15.4. An appliance that acilitates lower interpremolar expansion
In view of the u nd erlying Class II skeletal problem , maybe help ul, eg, Damon appliance
Simon w as treated rst by grow th m od i cation w ith a Midline distraction Severe mandibular crowding with well aligned upper arch,
Frankel II appliance follow ed by non-extraction u pper and osteogenesis v shaped mandible and narrowmandibular arch with bilateral
low er xed ap p liance therap y (Fig. 15.9). scissors bite a ecting several teeth
Orthognathic surgery Adult skeletal Class IIwith mandibular defciency
Key point
Correction o a bilateral lingual crossbite:
• Single tooth a ected on each side: consider extraction
o displaced teeth.
• Several teeth a ected on each side: consider
combination o buccal movement o a ected lower
teeth/palatal movement o a ected upper teeth.
Medical history
Graham is t and w ell.
Dental history
Tw o years ago Graham had a course of xed appliance
Fig. 16.1 Lower occlusal view at presentation. Fig. 16.2 Le t buccal occlusion.
• 100
16 LATELOWERINCISORCROWDING
initial m ild crow d ing tend s to becom e w orse. Low er labial
segm ent crow d ing also occu rs in patients in w hom extrac- Investigations
tions for relief of crow d ing and xed appliance therapy
■ What investigations would you undertake? Explain why.
have been u nd ertaken (u nless a bond ed lingu al retainer has
been placed ). Radiographic
■ Wha t are the possible causes o late lower incisor A d ental p anoram ic tom ogram w ou ld be u sefu l to assess the
crowding? position and inclination of the p artially eru pted low er third
The aetiology is m u ltifactorial and the m ajor theories p ro- m olars. As a rad iograp h w as taken prior to com m encing
posed are as follow s: orthod ontic treatm ent, this shou ld be consu lted rst, and
the need for a fu rther rad iograp h shou ld be assessed based
Late mandibular growth. Forward mandibular growth,
on the clinical assessm ent and the rad iograp hic nd ings.
especially i a growth rotation is also present, and where
maxillary growth has stopped, aided by lip pressure, tends to
Study models
reposition the lower incisors lingually, reducing arch length
and causing anterior crowding. Currently it is thought that as Upper and low er im pressions and a w ax registration in
the lower incisors, and perhaps the whole lower dentition, centric occlu sion shou ld be taken for stu d y m od els to record
move posteriorly relative to the mandibular body late in accu rately the current m alocclu sion and to aid fu rther treat-
mandibular growth, lower incisor crowding almost always m ent p lanning.
develops. The greater the magnitude o late mandibular ■ What do you notice on the denta l panoramic tomogram
growth when other growth has essentially stopped, the taken pre-orthodontic treatment (Fig. 16.3)?
greater the likelihood o developing late lower incisor Normal alveolar bone height.
crowding. On average, in a male patient, as is the case here,
mandibular growth is complete by 19 years o age, but it may All teeth present and o good quality.
continue or longer. 8 is slightly mesioangularly impacted.
Gingival and/or occlusal orces. Pressure rom the transseptal 8 is upright.
bres and/or the anteriorly directed component o occlusal Bone overlies the distal hal o the crown o both lower third
orces lead to mesial migration o the dentition. molars.
Lack o approximal attrition in modern diet. This was thought to
explain absence o lower labial segment crowding in Diagnosis
Australian aborigines but has not been borne out by research
ndings. ■ What is your dia gnosis?
Reduction in intercanine width. The mandibular intercanine Class I malocclusion on a Class I skeletal base with average FMPA.
width reduces gradually during the teenage years, and this
Lower incisor crowding.
decrease progresses at a reduced rate into adult li e. The
result is an increase in lower labial segment crowding, most Impacted third molars.
marked during the late teens. Le t buccal segment relationship is Class III.
The presence o third molars. Their role is controversial. Two ■ What is the IOTN DHC grade (see p. 264)? Explain why.
theories abound:
3d – based on the 2.5 m m w orst contact p oint d isplacem ent
• They may exert mesial pressure on the lower dentition betw een the low er incisor teeth.
during eruption, tending to produce lower labial ■ What a re the management options or la te lower incisor
segment crowding. crowding?
• They may prevent the lower teeth rom moving distally
in response to orces generated by mandibular growth or Accept and monitor. As this is a normal maturational change in
so t tissues. the lower arch, it would be sensible in a late teenager, and
However, late lower incisor crowding develops even when
third molars are absent so their presence is not the critical
actor in the aetiology o the problem. The amount o late
mandibular growth is paramount.
Key point
Possible actors in the aetiology o late lower incisor
crowding include:
• Late mandibular growth.
• Gingival and/or occlusal orces.
• Reduction in intercanine width.
• Third molars?
Fig. 16.3 Dental panoramic tomogram.
101 •
LATELOWERINCISORCROWDING 16
where the crowding is mild, to keep it under observation. low er labial segm ent alignm ent w hile p reserving the integ-
Where more marked crowding is present, intervention may rity of the bu ccal segm ents.
be considered. ■ Would you advise removal o the lower third molars?
Interproximal stripping. This is only acceptable in an adult with
Low er third m olars shou ld not be rem oved in an attem pt to
mild lower incisor crowding. By removing 0.25 mm at most
p revent further increase in low er labial segm ent crow d ing,
rom the mesial and distal aspects o each incisor, up to 2 mm
as their relation to this aspect of m alocclusion is u nproven.
o space can be obtained or relie o crowding. Incisor
Current gu id elines ad vise rem oval of low er third m olars
alignment may then be achieved by either a sectional xed
only if they are associated w ith recurrent ep isod es of peri-
appliance or a removable appliance. For ultimate aesthetics, a
coronitis or other p athology. In this case, as neither of these
lingual xed appliance may be used. A removable appliance
ap ply at p resent, the low er third m olars should be retained
clasped on the rst permanent molars, with an acrylated
and their p osition review ed if sym ptom s d evelop.
labial bow or Invisalign®(a clear vacuum- ormed
thermoplastic aligner) made to t a duplicate study model
with the incisors aligned with their mesial and distal sur aces
reduced, are alternative approaches. With Invisalign®, however, Key point
several appliances will be required to achieve incremental Management options or late lower incisor crowding:
change (~0.25 0.3 mm per aligner worn or about 20 hours • Accept and monitor.
per day and changed about every 2 weeks) until the nal • Interproximal stripping with appliance therapy.
alignment has been realized. A bonded retainer will be
• Lower incisor extraction with appliance therapy.
required to maintain the result long term.
■ Are there any possible undesirable e ects rom extraction H arrad ine N W, Pearson MH , Toth B 1998 The effect of extraction
of third m olars on late low er incisor crow d ing: a rand om ized
o one permanent lower incisor?
controlled trial. Br J Orthod 25:117–122.
The p atient shou ld be w arned of the p ossibility of tw o Little RM, Ried el RA, Artu n J 1988 An evalu ation of changes in
und esirable sequ elae: the u p p er labial segm ent m oving m and ibu lar anterior alignm ent from 10 to 20 years
palatally, w ith resu ltant m isalignm ent, in resp onse to the p ostretention. Am J Orthod Dentofacial Orthop 93:423–428.
low er labial segm ent being aligned slightly lingu ally and / N H S Centre for Review s and Dissem ination, York 1999
or a slight increase in overjet. Prop hylactic rem oval of im p acted third m olars: is it ju sti ed ?
Extraction of lower premolars. Where the bu ccal segm ent Br J Orthod 26:149–151.
occlu sion is w ell interd igitated and crow d ing is con ned to Richard son ME 2002 Late low er arch crow d ing: the aetiology
the low er labial segm ent, it is p referable to avoid low er review ed . Dent Up d ate 29:234–238.
m id -arch extractions becau se these w ill d isru p t the bu ccal
occlu sion. Instead rem oval of a low er incisor w ill exped ite For revision, see Mind Map 16, page 236.
17
History o complaint
Jocelyn has been m ore aw are of her p rom inent chin and her
bite since she w as in her last year at school. After consu lta-
tion w ith an orthod ontist at age 12, she had tw o u pper teeth
rem oved to p rovid e sp ace for the u p p er eye teeth (she had
both low er rst perm anent m olars extracted at age 8 becau se
of d ecay.) She d id not w ear any braces on her teeth. She w as
ad vised to w ait u ntil she w as in her late teens to have the
Prominent chin bite of her front teeth reassessed . In the past 6 m onths she
has becom e qu ite self-consciou s abou t her facial ap pear-
ance, althou gh she feels that her chin d oes not app ear to
andTMJDS
have becom e m ore prom inent in the past 4 years.
■ What questions would you ask a bout the
temporomandibula r joint pa in?
When and how the pain started.
Type and duration o pain.
Frequency.
SUMMARY Is it localized? Site o radiation.
Jocelyn, aged 23, is re erred by her general dental Associated symptoms, e.g. muscle pain, click, jaw locking,
practitioner because o her prominent chin (Fig. trismus.
17.1) and pain in her le t temporomandibular joint Aggravating actors, e.g. stress.
(TMJ). What are the causes and how would you Any habits, e.g. nail-biting, bruxism, pen-chewing.
manage these problems? Relieving actors, e.g. heat, analgesics (type and amount).
The p ain started su d d enly w hen Jocelyn w as p rep aring
History for exam inations in her rst year at u niversity. She has had
interm ittent d iscomfort in her left jaw joint since then, but it
Complaint has been of a m ild natu re. The d iscom fort is an ache that is
Jocelyn’s m ain concern is that she d oes not like the p rom i- p rincipally in the left jaw joint area but rad iates to the jaw
nent ap p earance of her chin and her u p p er teeth biting m uscles on that sid e. It d oes not keep her aw ake at night, bu t
insid e her low er teeth. She has pain in her left jaw joint and she feels it is w orse in the m orning. Typ ically it lasts for a few
has som e d if cu lty chew ing. She is also aw are that she has hours and then d isap p ears. It tend s to retu rn w hen Jocelyn
a lisp , w hich she d islikes. is stressed by w ork. She is aw are of grind ing her teeth w hen
stressed . She d oes not engage in chew ing pencils or p ens or
nail-biting. She feels that in the past year the p ain has
recu rred m ore frequ ently and has becom e w orse. Chew ing
hard food or op ening her m ou th too w id e m akes the p ain
w orse; one or tw o p aracetam ol tablets usually relieves the
ache. Jocelyn is also aw are that she has a jaw click.
Medical history
Jocelyn is t and w ell.
Dental history
Jocelyn is a regu lar attend er at her general d ental p racti-
tioner and bru shes tw ice d aily.
Family history
Jocelyn’s sister also has a prom inent chin, bu t not as m arked
as hers, and her sister ’s bite w as corrected w ith xed braces.
Examination
Extraoral examination
■ What do you observe rom Jocelyn’s prof le view (Fig. 17.1)?
Class III skeletal pattern w ith average FMPA. Com -
Fig. 17.1 Pro le at presentation. p etent lips.
103 •
PROMINENTCHINANDTMJDS 17
■ Based on the history, what other aspects would you
assess extraora lly?
Temporomandibular joints. Opening and lateral mandibular
movements should be assessed by rst observing the patient
rom the ront and second by palpation o the condylar heads
while listening or the presence o crepitus or a joint click. As
symptoms are present, the masticatory muscles should also
be palpated. A le t TMJ click and le t masseteric tenderness
were detected.
Mandibular path o closure. The path o closure rom rest
position to maximum interdigitation should be assessed,
noting any anterior or lateral mandibular displacement A
produced by a premature contact.
In this case there is an anterior m and ibu lar d isp lacem ent
7
on closu re on contact of (centric relation to occlusion
8
shift of ~3 m m ).
Intraoral examination
The intraoral view s are show n in Fig. 17.2.
■ Wha t do you see?
Gingival tissues appear healthy; gingival recession related
63 356 B
to .
7
Oral hygiene appears overall good, apart rom slight plaque
765321 12356
deposit on 3 are visible.
8754321 123457
No obvious caries.
Very mild lower incisor crowding with spacing between the
4’s and 5’s.
Very mild upper arch crowding with slight mesiolabial
rotations o 2 2.
Class III incisor relationship with reverse overjet (measured
4 mm clinically), reduced overbite and coincident dental
centrelines. C
Class I canine relationship bilaterally. Fig. 17.2 (A) Right buccal occlusion. (B) Anterior occlusion. (C) Le t
7 buccal occlusion.
Buccal crossbite a ecting .
8
■ What is the most likely cause o the considerable spacing
in the lower premola r area s with 5’s dri ted into contact
with 7 ’s?
w hich m ay transm it its effect by a p arafu nctional habit,
Early rem oval of 6E E6 in an u ncrow d ed arch is the m ost stem m ing from a d isplacing occlusal contact in su scep tible
likely exp lanation for the sp acing. An uncrow d ed low er 7
ind ivid u als. In this case a d isp lacem ent exists on on
arch is com m on in Class III m alocclu sion. 8
■ What occlusal eatures ma y predispose to closu re. There are also anterior and p osterior crossbites
temporomandibula r joint dys unction syndrome? p resent.
■ Why was Jocelyn advised to wa it until her late teens
Crossbites, Class III m alocclu sion and anterior open bite
or reassessment?
have been show n to have a signi cant association w ith tem -
porom and ibu lar joint d ysfu nction synd rom e (TMJDS) in In a Class III m alocclu sion, the am ou nt of reverse overjet
some stu d ies w hile others have fou nd no link betw een tend s to increase w ith forw ard m and ibu lar grow th d u ring
signs and sym p tom s of TMJDS and m and ibu lar d isp lace- teenage years. Waiting u ntil m and ibu lar grow th is essen-
m ent. The aetiology of TMJDS is m ultifactorial w ith the tially com pleted , w hich is generally abou t 17 years of age
im plicated involvem ent of psychological, trau m atic and in girls and 19 years of age in boys, has three ad vantages.
occlu sal elem ents. The m ost salient factor is p robably stress, First, it allow s treatment planning to be und ertaken w ith
• 104
17 PROMINENTCHINANDTMJDS
reasonably stable facial and occlu sal characteristics. Second , Table 17.1 Investigations required in combined orthodontic-surgical
if treatm ent is und ertaken, it safegu ard s against relap se d u e planning*
to further grow th. Third , the m agnitu d e of occlu sal change Investigation required Reason
d u e to m and ibu lar grow th in u ences w hether treatm ent Thorough clinical assessment o acial To locate anycranial, maxillary, nasal, mandibular
can be u nd ertaken by orthod ontic m eans alone or w hether ormin ull ace and profle or chin de ormities
a com bined orthod ontic-su rgical ap p roach is necessary.
To assess the height and width proportions o the
Orthod ontic treatm ent involves ind ucing d entoalveolar ace, interalar distance, nasolabial angle, upper
com p ensation for the und erlying skeletal p attern, bu t if incisor exposure, relation o upper dental midline
u nsuccessfu l d u e to continu ed ad verse m and ibu lar grow th, to other acial midlines, the ormand tone o the
the com pensation w ou ld need to be u nd one as p art of pre- so t tissues
surgical orthod ontics. This m ay involve op ening up low er Assessment o TMJ To record signs and/or symptoms o TMJ
prem olar extraction sp aces. H ence the d ecision to treat a dys unction. Treat these conservativelyi possible
Class III m alocclu sion in early teenage years by orthod ontic prior to treatment; i marked occlusal problems
cam ou age that inclu d es low er arch extractions m u st be contributing to dys unction, aimto correct these
m ad e w ith great cau tion. with treatment
In this case the severity of the anteroposterior skeletal Dental panoramictomogram(DPT) To assess the general dental status and prognosis
pattern, the likely pattern of mand ibu lar grow th, the am ou nt o the dentition as well as the position o
of d entoalveolar com p ensation, the am ou nt of overbite and unerupted third molars (bitewing or periapical
the relative absence of crow d ing (follow ing the rem oval of radiographs maybe required depending on
u pper rst prem olars and low er rst perm anent m olars) clinical and/or DPTfndings)
w ou ld all have been consid erations in d elaying any fu rther Lateral cephalometric radiograph To ascertain the aetiologyo the malocclusion
orthod ontic intervention. Whether the patient cou ld achieve and to acilitate surgical planning
an ed ge-to-ed ge incisor relationship w ou ld also need to Facial and dental photographs To record the acial and dental characteristics o
have been assessed . the malocclusion
To allowsurgical planning bymatching the
digital profle acial image with the lateral
cephalometrictracing
Studymodels and duplicates mounted To allowthorough orthodontic/occlusal
Key point on an articulator assessment and model surgery
Waiting until at least the late teens be ore considering an *Three dimensional (3D) acial images, where possible, and when combined with cone beam
orthodontic-surgical approach is desirable, as: computed tomography, allow3Dsurgical planning, although urther development is required to
• Facial and occlusal characteristics stabilize. optimize this.
A B C
Fig. 17.3 Another case: (A) Pre-treatment: pro le. (B) Super-imposition o lateral cephalometric radiograph tracing on a digital pro le
view and morphing using Dolphin®so tware to simulate the post-treatment pro le. (C) Post-treatment: pro le.
automatically morph the image in response to planned ■ Describe the phase o pre-surgica l orthodontics.
surgical and orthodontic movement undertaken virtually
This p hase of xed ap p liance treatm ent aim s to allow the
on the computer. The likelihood o di erent treatment
jaw s to be m oved to their d esired location w ithou t interfer-
options can thus be explored. In addition, the patient
ence from tooth positions. The u p per and low er arches are
can view the nal computerized prediction to appreciate
aligned and coord inated as w ell as establishing the vertical
more clearly the possible likely outcome on pro le
and anteroposterior p osition of the incisors. This involves
aesthetics, although it should be understood that this is
d ecom p ensating for any existing d entoalveolar com p ensa-
not guaranteed (Figs 17.3A–C). Using re erence lines to
tion. For Jocelyn, this w ill involve p rim arily labial m ove-
measure distances, planned surgical movements should
m ent of the low er incisors, w hich w ill elim inate the
then be trans erred to a duplicate set o study models,
m ild crow d ing and slight up righting of the upp er incisors.
mounted on a semi-adjustable articulator in this case as
The fu ll extent of the skeletal d iscrep ancy is thu s revealed ,
maxillary surgery is planned. The ability to plan
m axim izing the extent of possible su rgical correction.
orthognathic surgery in 3D (superimposing 3D acial
Class II interm axillary traction m ay be required to aid
images and CBCT scans) is being developed and o ers
d ecom p ensation. N o extractions are ind icated in this case to
exciting possibilities.
achieve the d esired tooth m ovem ents. The gingival statu s,
4. The nal plan should be explained to Jocelyn, ensuring
labial to the low er incisors, shou ld be m onitored d u ring
that she is aware that her pro le will be worsened by
d ecom p ensation to ensu re that gingival recession d oes not
pre-surgical orthodontics and that she realizes what her
ensu e.
nal acial appearance is likely to be. Provision o an
When the requisite tooth m ovem ents have been achieved ,
in ormation leaf et and DVD on orthognathic surgery will
rigid rectangular stainless steel archw ires shou ld be u sed to
also assist in recognizing the ull consequences o what
passively stabilize tooth position. Final p re-su rgical record s
treatment involves and are an important part o
– stu d y m od els, photograp hs and a cep halom etric lm –
obtaining in ormed consent.
w ill then be taken to assess the changes that have occu rred
and to d ecid e if the original surgical plan w ill be follow ed
or requ ire som e am end m ent. H ooks shou ld be attached
to the archw ires ju st p rior to su rgery u nless brackets w ith
Key point an integrated hook on each tooth have been u sed . The
Planning orthodontic-surgical treatment: hooks facilitate interm axillary xation and / or elastic trac-
• Requires a team approach. tion p ost-op eratively.
• May be assisted by matching the digital acial prof le
■ What surgical procedures are likely to be required?
image with the lateral cephalometric tracing and using
computer prediction so tware. Le Fort I advancement.
Mandibular setback.
107 •
PROMINENTCHINANDTMJDS 17
Key point
Pre-surgical orthodontics:
• May involve extractions.
• Usually involves decompensation or any dentoalveolar
compensation.
• Aligns and coordinates arches or arch segments.
• Establishes the vertical and anteroposterior position o
the incisors.
• Place rigid rectangular archwires with ball-hooks (unless
brackets with integrated hooks are used) immediately
pre-surgically.
Dri ting incisors extracted , and he w ore rem ovable retainers for 1 year (6
months fu ll-tim e and 6 m onths part-tim e) follow ing treat-
ment. After he stopped w earing the retainers, his bite
changed and his orthod ontist said it w as d u e w as d u e to his
low er jaw grow ing m ore.
Medical history
Iain has d iabetes w hich is w ell controlled by insulin. H e is
otherw ise t and w ell.
A B
C D
Fig. 18.2 (A) Lower occlusal view. (B) Upper occlusal view. (C) Right buccal occlusion. (D) Le t buccal occlusion.
■ With loss o periodontal attachment, how ma y labial ■ How would you describe the prognosis o Iain’s dentition?
dri ting o the incisors occur?
Prognosis d epend s on the response to initial therap y and
Alveolar bone loss compromises the ability o the teeth to p atient factors such as m otivation tow ard s m aintenance of
deal with so t tissue and occlusal orces, thereby leading to a very high stand ard of oral hygiene and cessation of the
tooth movement. sm oking habit.
A traumatic occlusion may result rom extrusion as a Based on the am ou nt of alveolar bone loss, the prognosis
consequence o periodontal disease. Dri ting may occur of the u pp er incisors is likely to be better than that of the
where periodontal support is also reduced. low er incisors.
Labial shi t o periodontally involved upper incisors may result ■ Wha t are the treatment options or the upper labial
also rom a displacing occlusal contact on closure producing segment spacing?
a orward mandibular slide. 1. Orthodontic alignment o the upper labial segment teeth
Undue orces may be placed on the incisors, where posterior with space closure. Six months a ter completion o
tooth support is lacking due to tooth loss, and these can lead periodontal therapy, the periodontist should re-evaluate
to upper incisor proclination. the periodontal status. Provided it has not deteriorated
and Iain is not averse to the prospect o wearing an
orthodontic appliance, orthodontic treatment could be
considered.
Key point 2. Extraction o 2 or o 2112 and replacement on a partial
Migration o periodontally involved incisors may be upper denture or adhesive bridgework. Extraction o 112
exacerbated by: may be required also with similar prosthetic replacement
• A orward mandibular displacement on closure. to the extracted upper units.
• Def cient posterior occlusal support. Iain op ted for xed ap p liance therap y to align the u p p er
teeth (Fig. 18.4).
■ Wha t options are there with regard to improving appliance
aesthetics in an adult pa tient?
■ What is the signif cance o the medical history a nd social
Options are aesthetic brackets (p olycarbonate or ceram ic),
history to the diagnosis?
clear aligner therap y (Invisalign ®) and lingu al orthod ontics.
Diabetes affects the host resp onse to p eriod ontal p athogens Each, how ever, is not w ithout its shortcom ings (Table 18.1).
by altering polym orph chemotaxis. Althou gh Iain’s d iabetes
is w ell controlled , p eriod ontal d isease is chronic and gener-
alized d u e to inad equ ate oral hygiene m easu res aggravated
by the host resp onse.
Sm oking contribu tes signi cantly to p eriod ontal d isease
throu gh a variety of m eans. Gingival blood ow is red uced ;
salivary ow is slow ed also, lead ing to p oorer rem oval
of p eriod ontop athic bacteria and encou raging calcu lu s
bu ild -up .
Treatment
■ What treatment would you advise?
Cessation of smoking. The patient should be encouraged to
stop sm oking to p revent any fu rther insu lt to his p eriod on-
tal health im posed by this habit. Fig. 18.4 Upper xed appliance.
• 112
18 DRIFTINGINCISORS
Table 18.1 Shortcomings o aesthetic orthodontic appliances
Treatment option Shortcomings
Aestheticbrackets
Polycarbonate brackets Stain, de orm, poor torque control (improved with metal insert)
Ceramic brackets Cannot bond to composite unless a silane coupling agent is
used, which increases bond strength and risko enamel
damage at debond (overcome bydi erent base designs to
allowmechanical bond)
Enamel damage at debond (problemovercome with di erent
base design but must ollowmanu acturer’s instructions
specifc or di erent bracket designs)
Fig. 18.5 Final occlusion (bonded palatal retainer in place).
Bracket breakage
Wear o opposing enamel
Increased riction compared with metal (overcome byinsertion Regu lar p eriod ontal recall shou ld be u nd ertaken
o metal slot) throu ghou t orthod ontic treatm ent.
Clear aligner therapy Control o root movement and possible intermaxillarycorrection
Due to the loss of p eriod ontal attachm ent and alveolar
limited unless bonded attachments added appropriately bone, p erm anent bond ed retention w ill be required .
The nal occlu sion is show n in Fig. 18.5.
Extraction site space closure di cult
Lingual appliances Tongue discomort
Speech adjustment Key point
Di cult to place (indirect bonding required) and adjust For orthodontic treatment in a periodontally involved
(operator/patient time and cost implications)
dentition:
• Avoid bands.
• Use light orces.
■ Wha t specia l considerations are there with orthodontic • Ensure regular periodontal recall during treatment.
treatment in a periodontally compromised dentition? • Retain permanently.
CASE1
SUMMARY
Owen, an 8-year-old boy, presents or a routine
check o his upper removable appliance. You notice
a reddened palate (Fig. 19.1A). What is your
diagnosis and how would you manage this?
History
B
Complaint
Ow en’s only com plaint is that his up per rem ovable ap pli- Fig. 19.1 (A) Appearance o the palate at presentation. (B) Upper
ance is loose. H e is not aw are of any p roblem w ith his removable appliance.
p alate.
■ Describe the appearance o the palate.
History o complaint
The lesion affecting the p alate can be d escribed as follow s:
Ow en has been w earing the upp er rem ovable appliance for
the p ast 8 w eeks to correct a crossbite on 1. The current Site palatal mucosa and attached gingivae.
ap pliance has been getting progressively looser over the Size area a ected relates primarily to that covered by the
p ast m onth. baseplate o the upper removable appliance (Fig. 19.1B).
Shape the outline is de ned by, and posteriorly extends
Medical history slightly beyond, the shape o the baseplate.
Ow en is asthm atic and has used a salbutam ol (Ventolin)
Colour uni ormly reddened appearance o the palate and
inhaler for the p ast 4 years. H is asthm a is w ell controlled .
attached gingiva primarily underlying the baseplate.
Background mucosa and gingivae not covered by the
Examination baseplate appear o normal colour except an area in the
palatal midline beyond the baseplate.
Extraoral ■ Wha t are your observa tions rega rding the upper removable
Ow en has a Class I skeletal pattern w ith average FMPA appliance?
and no facial asym m etry. H is lips are com p etent, w ith
the low er lip ju st covering the incisal third of the u pper The appliance has Adams clasps on 6 6 and D D with a Z
anterior teeth. There are no tem p orom and ibu lar joint signs spring to 1. The distal arrowhead on D clasp and the
or sym p tom s. mesial arrowhead on 6 clasp do not engage the undercuts
optimally.
Intraoral The baseplate has posterior capping over 6ED DE6.
The soft tissu es ap p ear norm al excep t for generalized m ild Appliance hygiene does not appear as it should ood debris
m arginal gingivitis and the p alatal m u cosa, w hich is show n and plaque deposits are visible, through the baseplate, on the
in Fig. 19.1A. Oral hygiene is fair. tting sur ace o the appliance.
• 114
19 APPLIANCE-RELATEDPROBLEMS
■ Wha t is the most likely diagnosis based on the in orma tion Saliva sampling or Candida counts.
you have so a r? Culturing or accurate identi cation and sensitivity testing
Palatal (d entu re) stom atitis, as the p atient is sym p tom - may also be undertaken.
free. ■ What stains identi y Ca ndida?
■ Wha t other condition would produce a similar appea rance?
Gram stain: Candida is strongly Gram positive.
Acrylic allergy. This, how ever, is u nlikely as a ‘bu rning’ Periodic acid Schi (PAS): the magenta stain locates
sensation of the m ucosa und erlying the baseplate w ou ld carbohydrate in ungal cell walls.
have been rep orted early after insertion of the ap p liance and
there w ou ld be erythem a of all of the soft tissu es ad jacent
to the acrylic. Treatment
■ What is the aetiology o ‘denture’ stomatitis?
■ How would you treat this condition?
Candida is the princip al cause. Althou gh a norm al oral com -
m ensal, p roliferation of Candida is facilitated by local envi- Ow en shou ld be ad vised to:
ronm ental or system ic factors, thereby allow ing it to becom e 1. Leave the appliance out at night. Due to the in ection, it
pathogenic (Table 19.1). would be wise to wear the appliance throughout the day
but remove it at night until the palatal mucosa returns to
health.
Key point 2. Improve appliance hygiene brush the tting sur ace
and soak it in a 1% hypochlorite solution.
Candida is the principal cause o palatal stomatitis related
to an upper removable appliance. 3. Improve oral hygiene teeth, gingivae and palatal
mucosa should be brushed thoroughly a ter every
meal.
4. Reduce sugar intake alter diet to low carbohydrate
■ Wha t actors in this case ma y have predisposed Owen to consumption.
‘denture’ stomatitis?
5. Anti ungal agents (nystatin or amphotericin suspension
The u se of a steroid inhaler, p oor app liance hygiene and or miconazole oral gel) should be applied to the tting
fu ll-tim e w ear of the ap p liance are likely to be the m ain sur ace o the appliance our times daily. A 0.2%
contribu tory factors. A d irect relationship has been show n chlorhexidine mouthwash may also be bene cial due to
betw een the p resence of an up p er rem ovable ap p liance, its anti ungal e ect.
Candida and low salivary p H levels. In ad d ition, u p per As the asthm a is w ell controlled , there is no need to refer
removable ap p liance therap y has a p ositive, thou gh tran- Ow en to his general m ed ical p ractitioner.
sient, in u ence on the p revalence of Candida and d ensity of
oral cand id al carriage, su ggesting that the carrier state m ay
be initiated by the appliance.
Key point
Management o palatal stomatitis:
Investigations
• Leave appliance out at night.
■ How would you conf rm the diagnosis? • Improve appliance and oral hygiene.
The ideal investigation is a smear rom the palatal mucosa • Reduce carbohydrate consumption.
underlying the baseplate or microbiological testing. • Anti ungal agents.
}
Systemic Ironandvitamindefciencies Two common f xed appliance problems are shown.
Steroids What is the cause o each, and what treatment
predispose to
Drugs that cause xerostomia Candida in ection would you provide?
Endocrine abnormalities, e.g. diabetes ■ What problem do you notice in Fig. 19.2A?
Antibiotictherapy
A bracket has becom e d ebond ed from 5 .
115 •
APPLIANCE-RELATEDPROBLEMS 19
Table 19.2 Causes o bracket bond ailure
Factor Aetiology
Operator Insu cient etch time
Poor etch pattern*
Poor moisture control during bonding
Non adherence tomanu acturer’s instructions with the bonding adhesive
chosen
Movement o the bracket a ter initial placement, which inter eres with bond
ormation within the adhesive
Application o high orce to the bracket to accomplish archwire engagement
Patient Eating hard/sticky oods
Possiblyuse o phenolic containing mouthrinses that so ten composite
Occlusal trauma/bruxing habit
A Pen chewing/nail biting
*Etch pattern is poorer on premolars than on canine or incisor teeth. This contributes to the greater
bond ailure rate on premolars (note ailure in Fig. 19.2Ais on 5).
Fig. 19.2 (A) Lower occlusal view. (B) Following removal o ligature
wire and 5 bracket. (C) Following replacement o ligature wire
B
and rebonding o a 5 bracket.
Fig. 19.3 (A) Upper occlusal view. (B) Following shortening and
adjustment o upper archwire.
Enqu ire from the p atient w hen the exp osed w ire on 2 w as
rst noticed , w hether there are p resently or have been any
problems w ith this, how long the retainer has been in p lace Key point
and if the orthod ontist still sees the p atient for review. Emergency treatment or:
The patient rst noticed this 2 w eeks ago after chew ing
• Broken vacuum- ormed retainer: arrange replacement.
a toffee; it rubs the tongu e and has p rod u ced a sm all u lcer.
• Bonded retainer: composite repair/smooth wire end or
The retainer fractu red in the m id line 2 years ago, at w hich
arrange replacement.
time it had been in p lace for 1 year; the w ire end s w ere
sm oothed and covered w ith comp osite. Since then there
have been no problem s. The p atient is d u e for a review w ith
the orthod ontist next year. As such, the p atient should
contact the orthod ontist to have the retainer assessed w ith Primary resources and
regard to repair or replacem ent as soon as possible.
recommended reading
■ In the meantime, what would you do to improve Arend orf T, Ad d y M 1985 Cand id al carriage and p laqu e
patient com ort? d istribu tion before, d u ring and after rem ovable orthod ontic
ap p liance therap y. J Clin Period ontol 12:360–368.
As 2 is still aligned w ith the ad jacent teeth and com posite
remains attached to the enam el and und ersurface of the H obson RS, Ru gg-Gu nn AJ, Booth TA 2002 Acid -etch p atterns on
the bu ccal su rface of hu m an p erm anent teeth. Arch Oral Biol
w ire, a sm all com p osite ad d ition cou ld be m ad e to the w ire
47:407–412.
on 2 . The w ire su rface should be cleaned gently w ith
Mand all N A, Millett DT, Mattick CR et al 2002 Orthod ontic
pu mice, the com p osite rou ghened slightly on 2 w ith a green
ad hesives: a system atic review. J Orthod 29:205–210.
stone, then resin and com p osite ap p lied and light-cu red . An
Patel A, Sand ler J 2010 First aid for orthod ontic retainers. Dent
ap pointm ent shou ld be arranged w ith the orthod ontist in
Up d ate 37:627–730.
the near future.
Wilson J 1998 The aetiology, d iagnosis and m anagem ent of
■ What urther trea tment do you think will be required? d entu re stom atitis. Br Dent J 185:380–384.
In light of the m inor shifts in alignm ent that are now visible
on several teeth (Fig. 19.5A and B), rem oval of the retainer, For revision, see Mind Map 19, page 239.
20 B
A
A
CASE1
SUMMARY
Darren, a 13-year-old boy, has been undergoing Key point
upper removable appliance therapy or 6 months Tipping movement, typically, requires orces o 30 50 g or
to retract and align 3 , ollowing extraction o 4 . 0.3 0.5 N.
Tooth movement has been very slow with no
movement recorded at the last two visits.
■ What are the possible reasons or a slow rate o orthodontic
tooth movement?
These can be d ivid ed broad ly into p atient, ap p liance and Pressure zones The cellu lar response d epend s on w hether
op erator factors. a light or heavy force is ap plied . With a light sustained force,
Patient actors Non-compliance with instructions regarding tooth m ovem ent occu rs w ithin a few second s as p eriod ontal
wear o the appliance. ligam ent uid is squeezed ou t and the vascu lar sup ply is
Incorrect positioning o the spring on appliance insertion or com pressed , setting off a com p lex biochem ical response.
distortion o the spring. Within 2 d ays, osteoclast invasion occu rs and frontal resorp -
tion follow s.
Contact o the tooth with the buccal cortical plate or with a
When a heavy sustained force is app lied , the period ontal
retained root part o 4 .
ligam ent is com p ressed to su ch a d egree that the blood
Occlusal inter erence rom the opposing arch. su p p ly is cu t off com p letely, prod ucing an area of sterile
necrosis (hyalinization). Sm all areas of hyalinization are
Appliance actors Acrylic and / or w ire m ay be interfering
inevitable, even w ith light forces, bu t the area of hyaliniza-
w ith tooth m ovem ent.
tion is extend ed w ith forces of greater m agnitu d e. Osteo-
Operator actors Design aw s, u nd eractivation, overacti- clast d ifferentiation is im p ossible w ithin the necrotic
vation or activation of the sp ring su ch that 3 is d irectly period ontal ligam ent space, bu t after several d ays osteo-
buccally into contact w ith the cortical plate rather than clasts app ear ad jacent to and w ithin the ad jacent cancellou s
through the cancellous corrid or of bone. sp aces. From there they invad e the bone ad jacent to the
■ What orce ra nge is optima l or retraction o 3 by tipping hyalinized area and tooth m ovem ent eventually occurs by
movement? und erm ining resorp tion.
The op tim al force range is 30–50 g or 0.3–0.5 N . Tension zones Follow ing initial ap plication of a light force,
the blood vessels vasod ilate and the p eriod ontal ligam ent
■ What cellula r response is there ollowing activation o the
bres are stretched w hile broblast and preosteoblast p ro-
spring to retract 3 by tipping movement?
liferation occu rs. The stretched bres become em bed d ed in
The consequ ence of activating the spring is to set u p zones osteoid , w hich later m ineralizes. The norm al period ontal
of pressu re and tension w ithin the period ontal ligam ent. ligam ent w id th is eventu ally regained by sim u ltaneous col-
H alf of the p eriod ontal ligam ent is stressed w ith m axim u m lagen bre rem od elling.
pressu re created at the alveolar crest in the d irection With heavy forces, rup tu re of blood vessels and severing
of m ovem ent and at the d iagonally op posite ap ical area of the p eriod ontal ligam ent bres are likely, bu t both are
(Fig. 20.1). restored w ith the rem od elling p rocesses.
119 •
TOOTHMOVEMENTANDRELATEDPROBLEMS 20
Key point
Application o a sustained orce to a tooth creates areas
o pressure and tension within the periodontal ligament
which ultimately lead to bone resorption and deposition,
respectively.
Key point
Root resorption:
• Increases in incidence and severity with comprehensive
orthodontic treatment.
• Is promoted by the use o heavy orces.
A
CASE3 Fig. 20.4 (A) Right buccal occlusion at presentation. (B) Anterior
occlusion at presentation
SUMMARY
Lisa, an 18-year-old girl, had previous extraction o
lower f rst premolars and f xed appliance therapy ■ Why has this occurred?
to success ully correct her Class III malocclusion.
The follow ing factors are likely to d estabilize the nal ortho-
Both upper second premolars were congenitally d ontic resu lt.
absent. On removal o the f xed appliances 1 year
Forces rom the supporting tissues Reorganization of p rin-
ago, a palatal bonded retainer was placed rom 3 cipal p eriod ontal ligam ent bres and su p p orting alveolar
to 3; she was also issued an upper Hawley retainer, bone occu rs w ithin 4–6 months after cessation of active
designed to f t over the bonded retainer, and a tooth m ovem ent. At least 7–8 m onths, how ever, are requ ired
lower vacuum- ormed retainer. Both removable for the su p racrestal bres to reorganize becau se of the
retainers were to be worn at night only. slow tu rnover of the free gingival bres. Rotational correc-
tion and sp ace closure are, therefore, liable to relap se.
■ What do you notice in Figure 20.4 A and B?
Pre-treatm ent view s of Lisa’s m alocclusion are show n in
So t tissues appear healthy; 6 seems to be restored with an Figs 20.5A and B. N ote the rotated teeth and spacing of the
amalgam restoration. arch.
Lower arch is reasonably aligned with a small space between Forces rom the oro acial so t tissues Follow ing ap pliance
5 and 3 . therapy, the teeth shou ld be in a p osition of soft tissu e
Right upper buccal segment and labial segment aligned with balance. The original m and ibu lar arch form shou ld rem ain
the possible exception o 6 . u nchanged as m arked alteration in the inclination of the
low er incisors w ill prom ote relapse. Lim ited p roclination
Spacing between 1 1 and 1 and 2 with slight mesiolabial
rotation o 1 and 2. of the low er labial segm ent, how ever, m ay be stable in
Class II d ivision 2 m alocclu sion, or if the low er incisors
Average overjet; overbite average to slightly reduced but w ere retroclined by a thu m b-sucking habit or by a low er
complete; mild centreline discrepancy (lower appears shi ted lip trap .
to the le t by about 2 mm). If a thu m b- or d igit-su cking habit is not ceased before
Molar relationship is Class I with crossbite a ecting the treatm ent com m ences, its p ersistence w ill prom ote overjet
mesiobuccal cusp o 6 . relapse.
One-third to half of the labial su rface of the u p p er inci-
■ What does this indica te?
sors should be covered by the low er lip to give the best
There has been relap se in the p osition of Lisa’s teeth follow - chance of stable overjet correction. Where the lips are grossly
ing treatm ent. incom p etent post-treatm ent, the u pp er incisor position w ill
• 122
20 TOOTHMOVEMENTANDRELATEDPROBLEMS
Key point
Relapse may be due to:
• Forces rom:
• Supporting tissues.
• Oro acial so t tissues.
• Occlusion.
• Facial growth.
• Inappropriate retainer design or retention regime, and/
or patient compliance.
A
Pre-treatment:
• Discuss relapse and retention as part o in ormed
consent.
• Highlight patient’s responsibility to adhere to long-term
retainer wear.
Lisa ind icated that she had w orn the rem ovable retainers
for a few m onths at night but then had d iscontinu ed w ear.
The u p p er bond ed retainer had com e aw ay from 13 2 w eeks
B ago, and the w ire had fractu red betw een 1 1. She w as now
concerned abou t the sp aces that had d evelop ed and that her
Fig. 20.5 (A) Right buccal occlusion (pre-treatment); note rotations front teeth w ere ‘tw isting’ back to the w ay they u sed to be.
o 621 1 and spacing. (B) Anterior occlusion (pre-treatment); note
■ What designs a re there o f xed and removable retainers?
incisor spacing and rotations.
Several d esigns of xed retainers exist, althou gh in the
low er arch this is m ost com m only either a sm ooth, rou nd
w ire w ith sand blasted end s bond ed to the canines only or
a mu ltistrand / spiral w ire bond ed to each of the incisors and
be inherently u nstable, and the mechanism by w hich an canines ind ivid u ally (Fig. 20.6). In the upp er arch, a m ulti-
anterior oral seal is achieved w ill aggravate this further. strand w ire is com m only bond ed to the incisors only or to
the canines and incisors. For either arch, a 020 in m u lti-
Occlusal actors A poor buccal segm ent interd igitation w ith
strand w ire is recom m end ed . Bond ing is u sually w ith light-
d isp lacing occlu sal contacts and an u nfavou rable interin-
cu red com posite. Rem ovable retainers m ay either be
cisal angu lation w ill encou rage instability.
vacu um -form ed (Fig. 20.7) or have a w ire labial bow
Post-treatment acial growth Facial grow th continues into (u su ally H aw ley or Begg typ e: Fig. 20.7; Fig. 20.8A); the
ad u lt life and , althou gh of lesser m agnitu d e than that latter m ay be acrylated to im prove app earance (Fig. 20.8B).
observed d uring child hood , it varies am ong ind ivid u als. On ■ What does current evidence indicate with regard to
average, fem ales tend to d em onstrate a backw ard m and ibu- post-orthodontic retention?
lar rotation, and this w ill not aid overjet stability. Late facial
grow th also im pacts on the d evelopm ent of late low er A recent upd ate of a Cochrane review found that m ost
incisor crow d ing. stud ies on types of retainers and d u ration of retainer
w ear w ere of low qu ality. Based on a sm all nu m ber of
Retention plan An inap p rop riate d esign of retainer, reten- p articip ants in one w ell-cond ucted short term (6 m onths)
tion regim en and / or inad equ ate com pliance by the patient stud y, mod erate qu ality evid ence ind icates that there is no
w ith the prescribed retainer w ear w ill facilitate relap se. d ifference in stability betw een fu ll-tim e or p art-tim e w ear
Firm ru les, how ever, d o not exist for retention follow ing of therm oplastic retainers. There is, how ever, insu f cient
active tooth m ovem ent; instead the retention plan should high qu ality evid ence w ith regard to retention p rotocols and
be d ecid ed ind ivid u ally for each case. H ow long this shou ld p roced ures follow ing orthod ontic treatm ent to m ake rm
be for is unknow n at present and probably unlikely to be recom m end ations.
ascertained d u e to the m u ltip licity of com p lex factors
■ How ca n relapse be prevented long-term?
involved in m alocclu sions and their treatm ent, as w ell as
the inherent d if culties in u nd ertaking clinical trials on the N ight-tim e w ear of a rem ovable therm oplastic retainer
m any likely retention strategies. It is acknow led ged that the shou ld continu e long-term , althou gh w ear on alternate
only m eans of guaranteeing that the p ost-treatm ent resu lt nights red uced to biw eekly m ay be suf cient w ith the onu s
rem ains u nchanged long-term is to ad vise long-term reten- on the p atient to m onitor occlu sal change.
tion. This should be exp lained to the patient by the ortho- Du e to the u npred ictability, bu t high likelihood , of late
d ontist before treatm ent starts as a p art of inform ed consent; low er incisor crow d ing d eveloping post-treatm ent (see
im portantly, the p atient’s resp onsibility in the retention Chapter 16), instead of ad vising long-term w ear of a rem ov-
process m u st also be em phasized . able retainer, a bond ed lingu al retainer m ay be tted to the
123 •
TOOTHMOVEMENTANDRELATEDPROBLEMS 20
Fig. 20.8 (A) Upper Begg retainer. (B) Upper Hawley retainer with
an acrylated labial bow.
Key point
A bonded retainer is indicated ollowing correction o :
• Severely rotated teeth and spaced dentitions.
Following placement o a bonded retainer, instruction Jonsson A, Malm gren O, Levand er E 2007 Long-term follow -u p of
tooth m obility in m axillary incisors w ith orthod ontically
must be provided in relation to interdental cleaning.
ind u ced ap ical root resorp tion. Eu r J Orthod 29:482–487.
Kotescha S, Gale S, Kham asha–Led ezm a L et al 2015 A
m u lticenter au d it of GDPs know led ge of orthod ontic retention.
Br Dent J 218:645–653.
■ What management options are there or Lisa’s problem?
Littlew ood SJ, Millett DT, Dou bled ay B et al 2016 Retention
The follow ing options exist: p roced u res for stabilising tooth p osition after treatm ent w ith
1. Accept and monitor study models should record the orthod ontic braces. Cochrane Database of Syst Rev Issu e 1.
current tooth position and occlusion to allow or Art N o: CD002283. DOI: 10.1002/ 14651858.CD002283.p u b4.
comparison with the pre- and post-treatment study casts Little RM 2009 Clinical im p lications of the University of
and to act as a baseline rom which to assess any urther Washington p ost-retention stu d ies. J Clin Orthod 43:645–651.
occlusal change. I there is urther relapse, then consider Melrose C, Millett DT 1998 Tow ard a p ersp ective on orthod ontic
retention? Am J Orthod Dentofacial Orthop 113:507–514.
options 2 or 3 below.
Pand is N , Vlahopou los K, Mad ianos P et al 2007 Long-term
2. Re-treatment ull case assessment is required with
p eriod ontal statu s of p atients w ith m and ibu lar lingual xed
study models and photographs; radiographs are not
retention. Eu r J Orthod 29:471–476.
indicated. For comprehensive recorrection, xed
Ren Y, Maltha JC, Ku ijp ers-Jagtm an AM 2003 Op tim u m force
appliance therapy is an option, but clear aligner therapy
m agnitu d e for orthod ontic tooth m ovem ent: a system atic
with Invisalign is also likely to produce a satis actory literatu re review. Angle Orthod 73:86–92.
outcome due to the mild nature o the relapse; the slight Roberts-H arry D, Sand y J 2004 Orthod ontics. Part II: orthod ontic
centreline shi t could be accepted with the latter tooth m ovem ent. Br Dent J 196:391–394.
treatment option. Long-term bonded retention will be Walker SL, Long DT, Flores-Mir C 2013 Rad iograp hic com p arison
required, therea ter, to the upper labial segment; it would of the extent of orthod ontically ind u ced external apical root
also be advisable to provide a vacuum- ormed retainer to resorp tion in vital and root- lled teeth: a system atic review. Eu r
t over the bonded retainer. Although this dual retention J Orthod 35:796–802.
( xed and removable retainer) strategy was adopted Weltm an BJ 2011 External root resorp tion and orthod ontic
ormerly, it must be emphasized to Lisa that should the treatm ent—assessm ent of the evid ence. In: H u ang GJ,
bonded retainer partially debond, then the vacuum- Richm ond S, Vig KWL (ed s), Evid ence-based orthod ontics.
ormed retainer must be worn to maintain tooth Wiley-Blackw ell, Chichester, p p. 63–88.
alignment prior to repair or replacement o the bonded
retainer. For revision, see Mind Map 20, page 240.
21
■ How common is a a mily history with cle t lip and palate? Is
this the same or cle t palate (CP) only?
In arou nd 40% of cases w ith CLP, there is a fam ily history.
For CP alone, how ever, a fam ily history is less (arou nd 20%).
■ Wha t is the preva lence o cle t lip and palate?
It affects abou t 1 in 700 live births am ong Cau casians, but
the prevalence varies betw een racial grou ps as w ell as geo-
Medical history
Karen w as born w ith a cleft lip and p alate (CLP), w hich has
been repaired . ■ Wha t genetic risk is there o CLP? How does this compare to
CP alone?
Family history As in this case of CLP, w here neither parent has a cleft and
Karen’s parents have no fam ily history of cleft lip and one child is affected , there is a sm all (4%; 1 in 25) risk that
p alate. H er old er brother and sister are also unaffected . the follow ing child w ill be affected ; if the m other or father
is affected , there is a 2% (1 in 50) likelihood of the rst child
having CLP. Due to the lesser genetic involvem ent in clefts
of the second ary palate, for u naffected parents of a child
w ith isolated CP, the risk of a su bsequ ent cleft-affected child
is 1 in 80.
Key point
There is a greater genetic risk with CLP than there is with CP.
■ Why is this? What treatment will have been provided to On the cle t side, 2 is either absent, o abnormal size and/or
date, a nd what role have you to play as her general shape, hypoplastic or present as two conical teeth on either
dental practitioner? side o the cle t.
Due to the interd isciplinary care required , treatment is facili- A supernumerary or supplemental tooth may exist on either
tated for the patient and family by coord inating m anagement side o the cle t.
in a specialized centre w ith a team com prising an orthod on- 1 is o ten rotated and tilted toward the cle t and may be
tist, speech therapist, health visitor and clinical psychologist hypoplastic.
as w ell as plastic, EN T and maxillofacial su rgeons. Eruption is delayed.
Treatm ent u ntil now is likely to have been as follow s:
Tooth size elsewhere in the mouth is small.
Neonatal period to 18 months
Class III incisor relationship is common with crossbite o one
Parental counselling by a member o the Cle t Lip and Palate or both buccal segments and a lateral open bite on the
Association (CLAPA) and/or clinical psychologist, as well as cle t side.
reassurance o the uture treatment by an orthodontist and
member o the surgical team.
Key point
Advice and support to the parents by a specialized health
visitor, particularly in relation to eeding. In this case eeding Incisor and buccal segment crossbites are common in
problems are likely to have been modest, as the cle t only repaired CLP.
involves the primary palate.
Planning o lip repair: this usually occurs at 3 months,
although neonatal repair is being assessed. In this case
closure o the alveolar de ect may be undertaken at the same
Examination
time. Where a palatal cle t exists, on average, this is repaired Extraoral
between 6 and 9 months.
■ What do you notice rom Fig. 21.2?
Primary dentition
Karen has a Class I skeletal p attern w ith average FMPA and
First ormal speech and hearing assessment at around 18
no obviou s facial asym m etry. The lips are com petent w ith a
months and then speech therapy as required.
scar on the right sid e of the u p p er lip .
Regular speech and hearing assessments should be N o clicks, locks or crep itu s of the tem porom and ibu lar
undertaken; consider closure o any palatal stulae to assist joints w ere d etected .
speech development. Consider pharyngoplasty to reduce
■ How is lip closure a chieved?
velopharyngeal incompetence at 4 5 years, thereby
attempting to improve any nasal intonation to speech. A Millard rep air w ith or w ithou t its m od i cations is the
Consider lip revision at 4 5 years only i clearly indicated. m ost pop ular, aim ing, after d issection, to p lace the lip
m uscles and alar base in their correct anatom ical location.
As a general d ental p ractitioner you r role is to: Whether subperiosteal or su p raperiosteal d issection and
Liaise with the CP team. skin-lengthening cuts are u sed , to obtain tissue m ovem ent,
Provide dietary advice and oral hygiene instruction to the remains controversial. The extent of alar cartilage d issection
parents, at regular intervals, rom eruption o the primary or the u se of a vom er ap also rem ains u nresolved .
incisors.
Consider the use o f uoride tablets i the level o f uoride in
Intraoral
the local domestic water supply is below 1 ppm. ■ The appea rance o the teeth is shown in Figs 21.1 and 21.3.
Attend to any dental treatment required. What are your observa tions?
Your particular aim in dental care is to promote and maintain Oral hygiene is air. Plaque deposits are visible on several teeth.
excellent dental health or Karen, thereby avoiding the need There is marginal gingival erythema related to most teeth.
or restorative treatment or en orced loss o primary teeth EDCB1 12CDE
visible (6 6 were erupted but not shown).
through dental caries. 6EDC21 12CDE6
E restored; possible caries in E DE; 1 slightly hypoplastic.
Key point
Mild lower labial segment crowding.
Management o CLP requires a team approach.
Spaced upper labial segment with 1 distolabially rotated.
The cle t repair involves the right upper lip and alveolus a
■ Wha t skeletal/dental/occlusal problems a re commonly bony depression is evident in the 2 area.
ound with CLP? Class III incisor relationship with average overbite; B in
Skeletally, there is a tendency or the maxilla and mandible to crossbite; lower centreline shi t to the right.
be retrognathic, the upper acial height to be reduced and Right molar relationship hal -unit Class II with buccal segment
the lower acial height to be increased. A Class III skeletal crossbite involving CDE ; (6 was also involved but not shown);
pattern is common. le t molar relationship is Class I.
127 •
CLEFTLIPANDPALATE 21
B C
Fig. 21.2 (A) Pro le. (B) Full ace. Fig. 21.3 (A) Lower occlusal view. (B) Right buccal occlusion.
(C) Le t buccal occlusion.
A
Fig. 21.5 Right buccal occlusion ollowing crossbite correction
with quadhelix.
Key point
Secondary alveolar bone gra ting:
• Provides bone or 3 eruption.
• Restores arch integrity.
• Improves alar base support.
• Aids oronasal f stula closure.
• Allows orthodontic space closure.
22
■ What is the cause o this pattern o decay?
‘N ursing caries’, or ‘nursing bottle m ou th’ or ‘bottle m outh
caries’.
■ What can cause this?
Consum ption of a sw eetened d rink or fruit- avoured d rink
from a bottle or d inky feed er, esp ecially if the feed er is
constantly in the m ou th or the child falls asleep w ith it in
childhood caries
m onths of age (child is allow ed to sleep on the breast) m ay
cause caries. There are many biological and social variables
that confou nd this com p lex relationship .
As can be seen, the term ‘nu rsing caries’ is p robably the
m ost accu rate as it encom p asses both breastfeed ing and
bottle feed ing.
■ Why are the teeth a ected in this pattern?
SUMMARY Teeth become carious in the ord er in w hich they eru pt (Fig.
22.2), w ith the exception of the low er p rim ary incisors,
Kelly-Ann is only 3 years old. She has been brought
w hich are p rotected by tw o m ajor m echanism s: the p osition
to the dentist by her mother because her upper of the su bmand ibu lar d u cts that op en ad jacent to these teeth
ront teeth are ‘wearing away’ (Fig. 22.1). What has and the position of the tongu e in su ckling, w hich covers the
caused this, and how may it be treated? low er incisors.
■ What additional actors make the upper prima ry incisors
History more predisposed to ca ries?
The teeth apparently never cam e throu gh properly and High bow-shaped upper lip in in ants which does not cover
w ere never w hite like the rest of her teeth. There has been the upper incisors and results in an increased evaporation o
no p ain from the teeth, and Kelly-Ann is eating and d rink- any saliva on these teeth.
ing norm ally. Gravity, which keeps submandibular saliva pooled around the
lower incisors and less likely to reach the upper incisors.
Medical history Any liquid with sugar that is allowed to bathe the teeth on a
Kelly-Ann is a healthy child . She has had all her vaccina- requent basis will cause caries. This is especially so at night
tions and has had no illnesses. She has never taken any when the protective unction o saliva reduces as less saliva is
m ed ication. produced. Even breast milk, ormula milk or cows’milk with
their lowered natural sugars can still be cariogenic on this
basis.
Examination
Extraorally there is no sw elling and no facial asym m etry.
Intraorally she is in the fu ll prim ary d entition w ith the
second p rim ary m olars having ju st eru p ted . There is caries
affecting the u p per incisors and cavitation in all rst p rim ary
m olars.
Treatment
Prevention
■ Wha t should be your advice about night-time eeding? ■ Kelly-Ann is at high risk or caries. List all the main actors
you ca n think o or placing someone in the high risk group
Only w ater should be given d uring the night after 12 m onths
or denta l ca ries.
of age.
The term early child hood caries (ECC) is a further term See Table 22.1.
u sed to d escribe caries presenting in one or m ore p rim ary ■ Wha t preventive a dvice would you provide or Kelly-Ann’s
teeth of child ren u nd er the age of 5. Som e child ren p resent mother?
w ith extensive caries that d oes not follow the ‘nu rsing
caries’ pattern and often p resent later, betw een 3 and 5 years Preventive ad vice shou ld follow the DoH Prevention Toolkit
old (Fig. 22.4). gu id ance. This provid es ad vice for child ren of d ifferent ages
(in Kelly-Ann’s case, 0–3 years old ) follow ing placem ent in
■ How could you identi y pre-school children in need o
the high risk for caries category.
denta l ca re?
Home based advice Although m any parents are fully aw are
Encou rage p arents to bring their child ren for a d ental
of the cau ses of d ental caries in their child or child ren,
check-u p as soon as the rst p rim ary tooth eru p ts.
changing family behaviou r to u nd ertake healthier rou tines
Develop good w orking relationships w ith local health
is more com plex. Consequently, carefu l consid eration is
visitors, baby clinics, m other and baby grou p s, nu rseries
need ed in how preventive ad vice is given and w ho d elivers
and their local general m ed ical practice to encou rage w id er
it. All m em bers of the d ental team shou ld have a basic
health and nu rsery staff to p rovid e ap p rop riate oral health
u nd erstand ing of how they can support parents and chil-
ad vice. This ad vice shou ld follow the gu id ance of the
d ren to und ertake these changes, and those d elivering these
Dep artm ent of H ealth (DoH ) Prevention Toolkit. Pu blic
preventive m essages shou ld have a m ore d etailed know l-
health p rogram m es in som e cou ntries encou rage and train
ed ge of behaviou r change strategies.
general health p rofessionals, su ch as health visitors, to ‘lift
the lip’ to id entify early caries affecting the u p p er m axillary Toothbrushing and f uoride toothpaste Kelly Ann’s p arents
incisors. shou ld u nd ertake toothbru shing for her last thing at night
• 132
22 NURSINGANDEARLYCHILDHOODCARIES
Table 22.1 ‘High-risk’ actors or caries scores (w ith or w ithou t a d isclosing agent) allow s the d ental
Risk actor Aetiology professional to m onitor p arental com p liance w ith the tooth-
Clinical evidence Newlesions bru shing ad vice.
Premature extractions ■ What advice should be given i Kelly-Ann does not like
strong, mint- avoured toothpaste?
Anterior caries or restorations
Multiple restorations Some child ren struggle w ith the strong m int avours u sed
in ad ult toothp aste. As a d ental care p rofessional, you
Fixed appliance orthodontics
shou ld be able to ad vise on alternative child -friend ly tooth-
Partial dentures
p astes. These shou ld have a mild , non-m inty avour that
Dietaryhabits Frequent sugar intake still have the required levels of u orid e. Other child ren m ay
Social history Social deprivation struggle w ith the foam ing action of the toothp aste, and
High caries in siblings again you shou ld be able to p rovid e ad vice on the availabil-
ity of toothpastes w ithou t these agents (for exam p le, sod iu m
Lowknowledge o dental disease
lauryl su lp hate-free toothp astes).
Irregular attendance
■ Is there a role or uoride supplements?
Readyavailabilityo snacks
Lowdental aspirations Fluorid e sup plem ents althou gh still recom m end ed are no
longer consid ered a m ainline intervention. The reason for
Use o uoride Drinking water not uoridated
this relates to the p oor com p liance w ith these su p p lem ents
No uoride supplements
in the families w ith child ren at high risk. All uorid e prod -
No uoride toothpaste ucts, inclu d ing toothp aste, shou ld be treated as a m ed icine
Plaque control In requent, ine ective cleaning and kep t ou t of reach of you ng child ren to prevent excessive
Poor manual control ingestion. The DoH Prevention Toolkit provid es fu rther
read ing and ad vice on preventing u orosis, especially for
Lacko parental involvement in brushing
child ren at low caries risk living in areas w ith u orid ated
Saliva Low owrate
w ater su p p lies.
Lowbu ering capacity
Diet advice The only w ay to effectively u nd ertake d ietary
High Streptococcus mutans and Lactobacillus counts
ad vice is to ask p arents to com plete a 4-d ay d iet d iary. From
Medical history Medicallycompromised this a w ritten analysis can be p rod uced . It is im portant to
Physical disability try to obtain 1 d ay’s history from a w eekend , as they are
Intellectual disability invariably d ifferent from w eekd ays. In m od ern society it is
Xerostomia comm on for m ost p arents to w ork and the child to be looked
after by a carer or nu rsery. It is critical to establish w ho is
Long termcariogenic medicine
the carer on w eekd ays and w eekend s. Ad vice need s to be
clear at all tim es, bu t if it has to be relayed from a p arent in
the su rgery to a carer, then it need s to be clear, su ccinct and
w ritten. Frequ ent consu m ption of sugar-containing d rinks
and at least on one other occasion every d ay. On each and food s is the key aetiological featu re in m any pre-school
occasion, a sm ear of 1350–1500 p p m toothp aste shou ld child ren w ith caries. Red u cing the frequency of sugar-
be u sed . containing snacks is an imp ortant m essage. If the child is a
‘poor eater ’, there is need to bu ild u p the am ount of food at
■ Why is parental involvement important?
m ealtim es and , therefore, red u ce the need for frequent
Child ren need help from their p arents if effective oral snacking. Child ren d o not need zzy d rinks or fru it-based
hygiene is to be achieved . This help shou ld extend u p to at d rinks. These d rinks often m ake u p for calories m issed at
least 7 years old . Bru shing need s to start as soon as the rst m ealtim es. Only m ilk and w ater should be taken betw een
tooth eru pts. Stand ing or kneeling behind the child in front m eals. A sm all am ou nt of fru it-based d rink can m ore
of a sink or m irror is often the best w ay to bru sh a you ng safely be taken w ith a m eal. As p reviou sly m entioned , it is
child ’s teeth. Other su ccessfu l w ays inclu d e the child lying critical to stop the night-tim e bottle w ith anything other
on his or her p arents’ legs. Su pervision of bru shing is than w ater.
im portant so that an ap p rop riate am ou nt of p aste is p laced In you r d ietary ad vice you m u st be practical, personal and
on the bru sh to p revent/ red u ce ingestion of p aste. Carefu l positive. Avoid m aking the p arent feel excessively gu ilty, but
qu estioning of p arents and hand s-on d em onstration of concentrate on p ractical strategies. It is p robably unreason-
how to u nd ertake toothbru shing is im p ortant. Qu alitative able to give ou t m ore than fou r pieces of w ritten ad vice.
research has reported a num ber of barriers that parents These should concentrate on d ay-tim e d rinks, night-time
d escribe w hen trying to u nd ertake their child ’s toothbru sh- d rinks, betw een-m eal snacks, and m aking sure the child has
ing. A nu m ber of these barriers relate to p arenting skills, no food or d rink for 1 hou r before going to bed and cleans
such as m anaging tod d lers w ho w ant to bru sh them selves, their teeth just before bed . Furtherm ore, d ietary ad vice
or establishing and maintaining routines. Consequ ently shou ld not be lim ited to su gary snacks bu t also brie y eval-
ad vice and gu id ance need s to ad d ress these w id er p arent- uate the d iet as a w hole and assess if it is in line w ith the
ing issu es. The use of sim p le serial p laqu e and gingivitis eat w ell plate.
133 •
NURSINGANDEARLYCHILDHOODCARIES 22
Medication For child ren on regu lar m ed ication, this shou ld , either a d irect com p osite or a com p osite crow n u sing a
w here p ossible, be su gar free. Often this w ill requ ire liaison p lastic strip crow n. Follow ing the tem p orary GIC restora-
w ith their general m ed ical p ractitioner. A carefu l m ed ical tions, Kelly-Ann’s coop eration im proved signi cantly to
history–taking is essential, as som e p arents m ay not p erm it the placem ent of d irect com posite restorations und er
perceive regu lar nu tritional su p p lements or laxatives as local anaesthetic several m onths later.
m ed ication.
■ How would you restore the early cavita tion in the f rst
Pro essional interventions For Kelly-Ann, cu rrent ad vice is primary mola rs?
that u orid e varnish shou ld be ap plied to her teeth three to
Similar to the incisors, d ifferent options are available:
fou r tim es a year. Site-sp eci c ap p lication of u orid e varnish
can be very valu able in the m anagem ent of early, sm ooth- Prevention only namely to modi y the cavity to permit
su rface and ap p roxim al cariou s lesions. The m ost com - plaque removal using a toothbrush and regular application o
m only u sed varnish – 5% sod iu m u orid e – has 22 600 p pm . f uoride varnish. Regular plaque scores will allow you to
Before ap p lying the varnish the child ’s asthm a statu s and monitor how well parents are complying with your
any history of allergy to colop hony shou ld be checked . In toothbrushing instructions.
cases w here child ren have been hosp italized for their Seal with partial or no caries removal namely to seal the
asthm a or have a history of an allergic reaction to sticky caries with composite and/or ssure seal ollowing limited
plasters (w hich can contain colop hony), the u se of coloph- caries removal with a slow handpiece.
ony containing u orid e varnishes are contraind icated . Complete caries removal using local anaesthetic, rubber
Alternative, non-colophony-containing varnishes are avail- dam and handpieces to remove caries ollowed by composite
able. When ap plying the varnish, ensure the correct d ose restorations.
and instru ctions are given.
The recall interval betw een d ental clinic visits w ill red u ce Initially a p reventive ap p roach w as taken w ith the
to 3 m onths. This w ill enable the m ore frequ ent ap plication cariou s rst p rim ary m olars. As Kelly-Ann’s coop eration
of u orid e varnish, m ore intense preventive su p port and im proved , a com plete caries removal ap p roach w as und er-
the exam ination of Kelly-Ann’s d entition for caries progres- taken, as both her and her m um w anted w hite coloured
sion or new lesions. llings rather than stainless steel crow ns.
Why can Kelly-Ann not have f uoride mouthwash? These ■ What method o caries removal, without a handpiece, may
are contraind icated in child ren less than 6 years of age be applica ble here?
because m ore than half the m ou thw ash w ill be sw allow ed , With the ad vent of the H all techniqu e (see Chapter 24)
increasing the risk of u rosis. This is also the reason w hy chem ical caries rem oval has had lim ited u se. An exam ple of
parents are ad vised to u se only a sm ear-sized (for 0–3-year- chem o-m echanical caries rem oval is the u se of Carisolv. It
old s) or pea-sized (for 4–6-year-old s) am ou nt of toothpaste consists of a p ink gel that contains m ainly the am ino acid s
and w hy the child is encou raged to sp it ou t the excess leucine, lysine, glu tam ic acid and hypochlorite. In ad d ition,
resid ue of the toothpaste as soon as he or she is able to there is cellulose and a colou ring agent, erythrocin. The
d o so. amino acid s and hypochlorite w ork to sep arate carious
d entine from sou nd d entine, and the cariou s d entine is
Treatment removed w ith the aid of special hand instrum ents that have
d ifferent cu tting ed ges and hand actions to excavators. They
Restorative care are used in a w hisking, rotating or u p-and -d ow n m ove-
(Please see Chapter 24, w hich p rovid es greater d etail of m ent. Because the sou nd d entine is not stim u lated by the
treatm ent op tions and treatm ent p lanning.) temperatu re or vibration of a hand piece, or the tem perature
Kelly-Ann has caries involving her u pper incisors (Fig. changes of a three-in-one sp ray, it is a p ainless p roced u re.
22.1) and cavitated occlu sal caries in her rst prim ary The cavity shou ld be d ried by saline-d am pened cotton
m olars. Treatment can be p rovid ed in a nu m ber of w ays and w ool, then d ry cotton w ool, prior to restoring w ith an ad he-
relates to parental expectations and w illingness to com ply sive m aterial. Bond strengths to ad hesive m aterials are the
w ith the hom e-based p reventive ad vice, p arents’ expecta- same as conventionally p repared cavities. The d isad van-
tions and w ishes, child ’s coop eration and any history of tages of the techniqu e inclu d e the taste of Carisolv if it
toothache or other sym p toms. Child coop eration can change should leak ou t of the cavity, the tim e taken to rem ove caries
rap id ly as the child grow s, and consequ ently, over a few and the noises and sensation of the hand instru m ents.
m onths, d ifferent treatm ent op tions m ay be ap prop riate ■ How is pain relie best achieved in the child with nursing
w ith im proving behaviou r and cooperation. In Kelly-Ann’s ca ries in Fig. 22.2?
case, w ith no history of p ain, tim e w as available at rst to
tem porize and seal in the caries w ith glass ionom er cem ent This is a case w here general anaesthesia for tooth rem oval
(GIC) u ntil coop eration im p roved . is ju sti ed . This is covered in Chapter 26. Depend ing on the
type of the general aneasthetic (extraction only or com p re-
■ How would you restore the upper incisors?
hensive care), d ental care w ou ld consist of either extracting
There are a nu m ber of d ifferent op tions and m aterials avail- all cariou s teeth (DBA ABD) or extracting irreversibly
able. These inclu d e the p revention-only ap p roach w ith no in am ed and non-vital p rimary teeth and restoring other
caries rem oval or d isking, tem p orarization w ith GIC or teeth affected by caries together w ith ssu re sealants of
comp lete caries rem oval w ith d e nitive restoration u sing other p rim ary m olars.
• 134
22 NURSINGANDEARLYCHILDHOODCARIES
Primary resources and H ealth England . Available at: http s:/ / w w w.gov.u k/
governm ent/ u p load s/ system / u p load s/ attachm ent
recommended reading _d ata/ le/ 367563/ DBOH v32014OCTMainDocu m ent
Am erican Acad em y of Ped iatric Dentistry 2014 Guid eline on _3.pd f.
caries-risk assessm ent and m anagem ent for infants, child ren, Scotish Dental Clinical Effectiveness Program m e (SDCEP) 2010
and ad olescents. Ped iatr Dent 36 (6):127–134. Prevention and Managem ent of Dental Caries in Child ren:
Am erican Acad em y of Ped iatric Dentistry 2014 Policy on early Dental Clinical Gu id ance. Du nd ee, SDCEP. Available at:
child hood caries (ECC): unique challenges and treatm ent http :/ / w w w.sd cep .org.u k/ w p-content/ u p load s/
op tions. Ped iatr Dent 36 (6):53–55. 2013/ 03/ SDCEP_PM_Dental_Caries_Fu ll_Gu id ance1
.p d f.
Deery C 2013 Caries d etection and d iagnosis, sealants and
m anagem ent of the p ossibly cariou s ssu re. Br Dent J 214 Marshm an Z, Ahern S, McEachan R et al Parents exp eriences of
(11):551–557. tooth bru shing w ith child ren: a qu alitative stu d y. Accepted for
p u blication in Jou rnal of Dentistry Clinical and Translational
H ealthcare Im provem ent Scotland 2014 SIGN 138: Dental
Research, 2016.
Interventions to Prevent Caries in Child ren. Ed inbu rgh, SIGN .
Available at: http:/ / w w w.sign.ac.u k/ p d f/ SIGN 138.p d f.
Public H ealth England 2014 Delivering Better Oral H ealth: An
For revision, see Mind Map 22,
Evid ence-Based Toolkit for Prevention, 3rd ed . Lond on, Public page 242.
23
Dental history
At the age of 5 years he had a num ber of his p rim ary teeth
extracted u nd er general anaesthetic.
H e has su bsequ ently requ ired restorative care and an
extraction of his u p p er right rst p erm anent m olar u nd er
local anaesthetic several years ago. You have not seen Peter
for at least 3 years (Fig. 23.1).
■ Which aspects o his presenta tion and history help to
adolescents
aspirations to date (high caries risk).
• Fluoridated water living in an area with no f uoride in
the drinking water (high caries risk).
• Medical history t and well (low caries risk).
• Dental history primary tooth extractions under general
anaesthesia and subsequent permanent tooth extraction
and restorations with local anaesthetic (high caries risk).
SUMMARY
Peter is 13 years old. He is concerned about the Examination
appearance o his teeth, especially the spaces Extraoral
between his ront teeth, and would like this N othing relevant is revealed .
improved (Fig. 23.1). He is not very keen on the
prospect o complex restorative or orthodontic Intraoral
treatment. On assessment he is diagnosed as high Peter ’s oral hygiene is poor. Basic Period ontal Exam ination
caries risk. How would you plan preventive (BPE) scores of one in each sextant are record ed . N orm al
treatment or this patient? saliva levels are noted . Caries is evid ent in the low er left
second p erm anent m olar. H e is in the perm anent d entition
w ith missing both low er central incisors and a retained
History low er left prim ary central incisor. H is u pper right rst p er-
m anent m olar w as extracted p reviou sly and the u p p er and
Complaint low er left rst p erm anent m olars and low er right rst and
Peter attend s your su rgery for the rst tim e in a nu m ber of second m olars restored . N o ssu re sealants are present.
years. H e ad vises you he w ou ld like the sp aces betw een his There is evid ence of m ild buccal crow d ing in the low er arch
front teeth corrected (Fig. 23.1). w ith low er left second perm anent prem olar lingually
p laced . The u pper left second p erm anent p rem olar is
History o complaint u nerupted and palatally d isplaced (Figs 23.2 and 23.3).
Peter is a sp orad ic attend ee. H e rep orts no p ain from any of ■ Which urther a spects o his clinical presentation help
his teeth. H e is now keen on having the app earance of his determine his ca ries risk status?
front teeth im p roved and is eager to learn how this can be
Clinical evidence
achieved .
New caries in the lower le t second permanent molar,
Medical history previous restorations and a missing permanent tooth which
Fig. 23.1 Anterior view o teeth at presentation. Fig. 23.2 Upper occlusal view at presentation, with upper right six
previously extracted.
• 136
23 HIGHCARIESRISKADOLESCENTS
was extracted are all noted (high caries risk). This caries risk separate time to brushing his teeth, or example a ter coming
category will have the largest weighting in scoring overall in rom school or a ter dinner is well remembered by many
caries risk. high caries risk patients.
Plaque control Dietary history
Oral hygiene poor, BPE scores all one. His oral hygiene is Frequency a nd timing o a ll ood a nd drinks including
especially poor in the upper anterior region (high caries risk). milk a nd wa ter? Carbonated drinks are consumed at least
Saliva our times a week with diluted juice consumed on a daily
basis.
Normal saliva levels noted (low caries risk).
Frequency a nd timing o ood. Peter is a grazer and likes to
For a fu ll list of caries risk factors, see Chap ter 22, Table
eat well into the evening. Peter is advised to complete a
22.1. This w ill help bu ild u p a p ictu re of caries risk and
4-day diet diary (at least 1 day should be completed over the
form u late a p revention p lan that is tailored to the p atient’s
weekend; high caries risk).
requ irem ents.
■ At present what ca ries risk status would you assign Peter Peter ’s history, clinical assessm ent and fu rther qu estion-
to? ing com bine to give a nal caries risk assessment, w hich
ind icate a high caries risk statu s (Table 23.1).
H igh caries risk.
■ What urther in ormation would you ask Peter to complete
his ca ries risk assessment? Key point
Fluoride history Caries risk assessment:
Wha t strength/type o f uoride toothpa ste does he use? I • The largest weighted caries risk assessment category is
Peter is not aware o the f uoride strength o the toothpaste clinical evidence.
he uses, he should be shown how to determine this on a • The completion o a caries risk assessment helps
toothpaste tube. He should be using toothpaste strength at ormulate an enhanced prevention plan specif c to this
least 1350 1500 ppm F (children 6 and older). He is presently patient.
using a brand which is the correct strength/type or a low
caries risk child o his age.
How ma ny times a da y does he brush his teeth? He
presently brushes twice daily, but not e ectively. Twice daily
or 2 minutes should be recommended and the technique
Preventive care and treatment
demonstrated. Peter is presently high caries risk. Prior to restorative w ork
Does he presently rinse with wa ter a ter brushing? He being u nd ertaken, the preventive treatm ent p lan shou ld
rinses his teeth with water a ter brushing. The ‘spit but don’t ensure that his caries risk status is red uced and he remains
rinse’with water guidance should be recommended. caries free in the fu tu re.
■ What else might you suggest when Peter is older that could
help urther reduce his caries risk status or the uture?
Higher st rengt h uoride t oot hpa st e (5000 ppm F). The
effect of uorid e toothpaste is concentration d ep end ent.
The m axim al over-the-cou nter prod u ct is 1500 p pm uo-
rid e. Prescrip tion-only toothp astes containing 2800 and
5000 p pm u orid e allow s the d ental p rofessional to target
high caries risk ad olescents. The resu lts of a nu m ber of
rand om ized clinical trials su ggest that in the range 1000–
2500 p pm u orid e, every ad d itional 500 p pm u orid e, over
and above 1000 pp m u orid e, w ould provid e a cu m u lative
6% red uction in caries increm ent. This d ose resp onse is
highest in high caries risk child ren and those aged over 11
Fig. 23.7 Final restorative treatment o the upper incisors. years. H ow ever, this w ou ld only be p rescribed after assess-
ing su itability and com p liance w ith instru ctions for the u se
of higher strength u orid e toothp aste. It shou ld be em p ha-
sized that such high-strength u orid e toothpastes should be
kept ou t of reach of you nger child ren. Ind ivid uals for w hom
this toothp aste is p rescribed should be encouraged to expec-
torate after bru shing. The 5000 pp m u orid e toothp aste is
u sed for ad olescents over 16 years of age and ad u lts.
Toot h mousse or t oot h mousse plus (CP P -ACP or CP P -
ACFP ). Tooth m ou sse is a w ater-based cream containing
Recald ent (casein p hosp hop ep tid e-am orp hou s calciu m
p hosphate or CPP-ACP). Tooth m ou sse plus, a stronger
tooth m ou sse, is recom m end ed at night only for p atients
w ho either have m arked salivary d ysfu nction or increase
risk of m ineral loss from d ental caries or erosion of teeth.
Child ren should be at least 6 years of age before u sing tooth
m ousse plu s. The p rop osed anticariogenic m echanism of
CPP-ACP involves the enhancem ent of rem ineralization
Fig. 23.8 Final restorative care o the anteriors. throu gh the localization of bioavailable calcium and phos-
p hate ions at the tooth surface. Casein p hosp hop eptid es
(CPPs) stabilize high concentrations of calciu m and p hos-
p hate ions as em bryonic ACP nanoclusters together w ith
central incisor w as assessed and d u e to lim ited root length, u orid e ions at the tooth su rface by bind ing to p ellicle and
he w as ad vised of its p oor long-term p rognosis. The p rim ary p laque and act as a d elivery vehicle to the tooth su rface. The
incisor w as extracted and a one-u nit Maryland brid ge p ro- ions are freely bioavailable to d iffu se d ow n concentration
vid ed w ith fu rther related oral hygiene instru ction. This grad ients into enamel su bsurface lesions, thereby effectively
includ ed the u se of su p er oss to clean beneath the p ontic. p rom oting rem ineralization. Tooth m ou sse m ay not be
At a later stage, shou ld Peter d ecid e he w ou ld like m ore ap propriate for all p atients ow ing to its cost. This is ap proxi-
com p lex treatm ent su ch as xed orthod ontics or im plants, m ately 5–10 tim es as expensive as a stand ard tu be of uo-
this can still be provid ed . rid e toothpaste.
Suga r-free chew ing gum. Many chew ing gum s are now
available as sugar-free w ith 50% sw eetened w ith su gar su b-
stitutes. Oral bacteria d o not u se these su gar substitutes to
prod u ce the acid s that d em ineralize enam el and d entine.
Key point
Fu rtherm ore, the act of chew ing stim u lates saliva ow,
Preventive care: w hich increases bu ffering cap acity and enhances clearance
• The evidence to date suggests an additional benef t of food d ebris and m icro-organism s from the oral cavity.
rom application o uoride varnish 3 4 yearly in high Chew ing gu m containing xylitol, a p olyol 5 carbon sw eet-
caries risk children. Apply twice yearly in low caries risk ener, red uces p laqu e salivary Streptococcus mutans levels and
children. tooth d ecay, as w ell as enhancing rem ineralization.
• Fluoride mouthwash at 0.05% sodium uoride is
recommended or daily use at a separate time to Primary resources and
toothbrushing.
• For high caries risk children (age 10 and over) and
recommended reading
Cochrane N J, Saranathan S, Cai F et al 2008 Enam el su bsu rface
adolescents, higher strength prescription uoride
lesion rem ineralisation w ith casein phosphopep tid e stabilised
toothpaste (2800 ppm F) is recommended. solu tions of calciu m , p hosp hate and uorid e. Caries Res
42:88–97.
139 •
HIGHCARIESRISKADOLESCENTS 23
Facu lty of General Dental Practice (FGDP) 2013 Selection Criteria Walsh T, Worthington H V, Glenny A-M et al 2010 Flu orid e
for Dental Rad iograp hy, third ed . Lond on, FGDP. toothpastes of d ifferent concentrations for p reventing d ental
H ealthcare Im provem ent Scotland , 2014. SIGN 138: Dental caries in child ren and ad olescents. Cochrane Database of
Interventions to Prevent Caries in Child ren. Ed inburgh, SIGN , System atic Review s 2010, Issu e 1. Art. N o.: CD007868. DOI:
sections 2–8. Available at: http :/ / w w w.sign.ac.uk/ p d f/ 10.1002/ 14651858.CD007868.pu b2.
SIGN 138.p d f.
Kiet AL, Milgrom P, Rothen M 2008 The potential of d ental- For revision, see Mind Map 23, page 243.
p rotective chew ing gu m in oral health interventions. J Am Dent
Assoc 139:553–563.
Public H ealth England 2014 Delivering Better Oral H ealth: An
Evid ence-Based Toolkit for Prevention, third ed . Lond on, Pu blic
H ealth England , sections 2–5.
24
Place a glass ionomer cement (GIC) or other temporary
restoration (Kalzinol or Intermediate Restorative Material.). I
the pain settles, a more de nitive restoration will be required
when time permits and as part o a comprehensive treatment
plan (see later).
Irreversible pulpitis i possible, gently excavate the so test
layer o coronal caries, then, place a poly-antibiotic and
steroid paste (e.g. Ledermix or Odontopaste) beneath the GIC.
treatment planning or
permits and as part o a comprehensive treatment plan.
Acute apical periodontitis i a tooth is abscessed, there is
o ten signi cant coronal destruction. The pulp chamber o
carious primaryteeth
such teeth can o ten be accessed, and a dressing o Ledermix
or Odontopaste on some cotton wool placed within the
chamber and sealed with a GIC will o ten lead to temporary
resolution o symptoms and swelling. Again, more de nitive
treatment (extraction or pulpectomy) will be required or this
tooth when time permits and as part o a comprehensive
treatment plan.
Where tim e and p atient cooperation p erm it, d ress-
SUMMARY
ing open cavities has a nu m ber of ad vantages (see Key
Paul is 5 years old. He is in pain rom one o his upper Point box and Fig. 24.1):
right back teeth. He has never had any treatment Simple introduction to dental procedures.
be ore. How would you manage Paul’s problem? Oral mutans streptococci count is reduced when excavation
■ What questions do you need to ask rega rding the pain? o gross caries is accomplished. I the cavity is then
completely sealed by a GIC, there is evidence that the viability
Site ask Paul to point to the tooth.
o the remaining organisms decreases and caries progression
Severity does the pain stop him rom playing, eating or is greatly reduced. This buys the dentist time to institute
sleeping? This question you o ten have to ask both Paul and preventive and behaviour management programmes be ore
his parents. reassessing teeth with temporary restorations.
Onset what makes the pain worse? Is it in response to hot, GICs act as a f uoride reservoir.
cold or sweet stimuli, or does it occur spontaneously? Does it
Makes toothbrushing and eating more com ortable.
wake him up rom sleep?
Character is it a sharp pain or is it dull and throbbing?
Table 24.1 Pain characteristics
Duration how long does it last when the pain is present?
Reversible Irreversible
How long has Paul su ered rom pain? What makes the pain
worse or better (e.g. painkillers) Transient or short duration (minutes) Long duration
Response to hot, cold, sweet Response to pressure (chewing)
A sim ple m nem onic can help you to rem em ber the d if-
ferent questions, SOCRATES (Site, Onset, Character, Rad ia- Sharp Spontaneous
tion, Association, Tim e cou rse, Exacerbating and relieving Does not stop playor sleep Throbbing
factors, Severity). You ng child ren m ay how ever nd som e Stops playor sleep
of these qu estions d if cu lt to answ er, su ch as rad iation and
association. Moreover, care need s to be taken to u se the m ost
approp riate langu age. For exam ple, even thou gh child ren
m ay not u nd erstand sensitivity, they or their p arents are
likely to rep ort if they avoid cold d rinks or ice cream .
The d ifferent characteristics of reversible and irrevers-
ible p u lp itis are show n in Table 24.1. The initial m anage-
m ent of a child attend ing in p ain is often constrained by
the lack of sleep on behalf of the child or tim e available
to the d entist to treat this extra ‘em ergency p atient’. An
accu rate d iagnosis is essential before any treatm ent can be
provid ed .
■ Wha t dressings ca n help mana ge pulpitis initia lly?
Reversible pulpitis i possible, gently excavate the so test Fig. 24.1 Temporary GIC restoration placed, the bene ts o which
layer o coronal caries: are described in the text.
141 •
PAINCONTROLANDTREATMENTPLANNINGFORCARIOUSPRIMARYTEETH 24
Key point
Advantages o dressing (stabilization) open cavities are:
• Introduction to dental procedures and usually does not
involve local analgesia or complete caries removal.
• Reduction o Streptococcus mutans count. The
temporary restoration deprives the bacteria in the
active lesion o sugar and oxygen.
• GIC acts as a uoride reservoir.
• Eating and toothbrushing are more com ortable.
A
An acute and / or spread ing infection or sw elling m ay
requ ire the p rescrip tion of antibiotics. This is d iscu ssed in
Chap ter 25. Antibiotics shou ld only be p rescribed for pain
in the absence of sw elling for im m u nosu ppressed p atients.
Ad vice abou t analgesics for pain w ill be necessary to
su p p ort the em ergency treatm ent (Table 24.2).
Maximumo our doses in a 24 hour period Fig. 24.2 (A&B) Paul’s upper and lower arches.
Ensure adequate hydration
Ibupro en (non steroidal 10 mg/kg every8 hours
anti in ammatorydrug (NSAID)) Can be used in conjunction with paracetamol
Best given with ood and drink
History
Questioning su ggested an irreversible p ulpitis in the u pper
right qu ad rant.
Examination
Pau l has no extraoral sw elling or asym m etry. Intraorally he
has all his prim ary teeth. There is occlu sal caries of E and A
m esial caries of A A. The E is grossly cariou s (Fig. 24.2A).
There is no associated soft tissu e sw elling.
■ What investiga tion is essential to allow you to ormula te a
treatment plan?
Bitew ing rad iograp hs are necessary to d iagnose ap p roxi-
m ate caries in p rim ary m olars w ith their w id e contact areas
and to con rm the d ep th of d entine caries. Rad iograp hs w ill
increase the d iagnosed yield of caries by 50%. Frequ ency of
su bsequ ent bitew ing rad iograp hs w ill d ep end on the clas-
si cation of caries risk: high risk p atients shou ld have rad io-
grap hs taken every 6–12 m onths; m ed iu m risk 12–18
m onths; low risk 18–24 months. In Pau l’s case, the low er B
arch (Fig. 24.2B) and bitew ing rad iograp hs (Figs 24.3A and
Fig. 24.3 (A&B) Paul’s bitewing radiographs.
B) show extensive caries of E involving the p u lp. There is
E
also caries extend ing into the m id -d entine for .
E DE ■ Wha t is your def nitive trea tment plan or E ?
The E w as u nrestorable w ith the d istal m argin of the
Treatment caries extend ing su bgingivally. Therefore the only option
Initial tem porization of Pau l’s E w as w ith w ith Od onto- for the E w as extraction. The tem porary d ressing alleviated
p aste and GIC. fu rther p ain from this tooth and allow ed for behaviou r
• 142
24 PAINCONTROLANDTREATMENTPLANNINGFORCARIOUSPRIMARYTEETH
m anagem ent and acclim atization to the d ental su rgery to be Table 24.3 Paul’s proposed treatment plan
u nd ertaken. Extracting p rim ary teeth on a child ’s rst visit Teeth af ected
to a d entist should be avoid ed w here possible. If an extrac- by caries Extent o caries Restorative plan
tion is u nd ertaken on the rst visit, it is likely to lead to E Into pulp Extraction
signi cant d ental anxiety and relu ctance to attend further
AA Outer 1/3rd dentine Disk
d ental visits.
E Mid 1/3rd dentine Hall crown
■ Will local a naesthetic be needed or extracting E ?
EE
Where the d ecision has been m ad e to extract E , local anaes- Outer 1/3rd dentine Partial caries removal, ollowed bycomposite
D
thetic is essential. It is tim e consum ing to give local anaes- restoration and fssure sealant
thetic in a p ain free and child -friend ly w ay and ensu re the
entire tooth is anaesthetized p rior to the extraction. Often
Table 24.4 How preventive and restorative treatment was provided
child ren and p arents are su rp rised how qu ickly the tooth is
or Paul on a visit by visit basis
extracted in com parison to the tim e taken for the local
anaesthetic stage. Visit Preventive plan Restorative plan
1 Pain control E temporary
■ Wha t are the consequences o extracting E ?
2 Bitewing radiographs
Extracting the E is likely to lead to localized sp ace loss, w ith
Toothbrushing instruction
the 6 d rifting m esially into this sp ace. This esp ecially is the
case w hen the extraction is u nd ertaken p rior to the eru p tion Fluoride advice
of the rst p erm anent m olar. The d rifting w ill exacerbate Hand out diet diary
any tend ency for crow d ing and can frequently lead to the Plaque score
palatal exclu sion of the m axillary p erm anent second prem o- Apply uoride varnish
lar in ad olescence. Althou gh sp ace m aintainers have been
DD
ad vocated to p revent sp ace loss follow ing p rem atu re extrac- 3 Collect in diet diaryand give advice Fissure seal
DD
tion of primary m olars, there is a lack of robu st evid ence to
support their longevity and cost effectiveness in you ng chil- DiskAA
d ren w ith extensive d ental caries. 4 Toothbrushing instruction Plaque score
■ I the E was restorable, what other treatment options Restore D
would be available? Place separators E
The only other option for a tooth d iagnosed w ith irrevers- 5 Rein orce diet advice Hall crown E
ible p u lp itis or w here it is necrotic and non-vital is a p u lp ec-
Place separators EE
tomy. A p u lp ectom y is sim ilar to a root canal treatm ent in
6 Toothbrushing instruction Plaque score
perm anent teeth. It is m ad e m ore com p lex by the ared and
irregu lar shap e of the root canals, as w ell as the need for the Hall crowns EE
roots to resorb, thu s allow ing natu ral exfoliation of the 7 Post extraction pain control Extract E
primary tooth. Althou gh hand les are u sed for gentle
shap ing, the m ost im p ortant stage of the proced u re is d is-
penetration. Table 24.3 shows such a list or Paul based
infection of the root canal w ith carefu l u se of hyp ochlorite.
on his clinical examination and bitewings.
Like in the perm anent d entition, a ru bber d am is essential
to prevent salivary ingress into the root canal and the escap e C. Develop a robust and rigorous preventive plan as
of the hypochlorite into the oral cavity. Once the w orking described in Chapters 22 and 23 and shown in Table 24.4.
length is established and the root canals d isinfected , canals D. Evaluate Paul’s cooperation to treatment ollowing the
are lled w ith either zinc oxid e cem ent or a calciu m delivery o behaviour management strategies described
hyd roxid e-iod oform p aste w hich w ill resorb w ith the root in Chapter 26. Although several visits may be required to
as part of the p hysiological root resorp tion. develop the child’s cooperation, it is not acceptable to
leave an in ected tooth untreated or longer than 3
months.
Treatment planning E. There are multiple options available or treating primary
■ How do we underta ke treatment pla nning and devise a teeth, and f exibility in approach is needed as treatment
plan which is appropriate or ea ch and every pa tient? options may change in response to parental expectations
and willingness to comply with the home-based
There are several im p ortant stages to treatm ent p lanning: preventive advice, the child’s cooperation and the
A. The rst priority is to relieve pain. Where pain relie can development o urther toothache or other symptoms. In
be provided, even over a short time rame, this permits addition, the choice o how the treatment is undertaken,
time to develop a holistic treatment plan described in e.g. local anaesthetic, sedation or general anaesthetic,
steps B E. described in Chapter 26, may dictate what treatment is
B. Identi y all pathology. Bitewings (Figs 24.3A and B) and available and appropriate. For example, all carious teeth
other radiographs are essential to support the detection may be extracted even when some are restorable where
o caries. A list should be drawn up o each tooth an ‘extraction-only general anaesthetic’is the only
a ected by caries together with the depth o caries method available or an uncooperative child in pain.
143 •
PAINCONTROLANDTREATMENTPLANNINGFORCARIOUSPRIMARYTEETH 24
E was extracted. This was provided towards the end o
Key point his course o treatment. Earlier, simpler visits (Table 24.4)
The ollowing considerations will in uence the treatment had developed his cooperation and con dence, thus
provided: permitting this more di cult procedure to be
• Parental expectations and willingness to comply with undertaken without the need to use sedation or general
home-based preventive advice. anaesthesia (see Chapter 26).
• Child’s cooperation.
• Development o urther pain and symptoms.
• Dental care pro essional’s expertise and training in
Key point
di erent treatment procedures.
Advantages and disadvantages o di erent restorative
approaches:
• Preventive
Di erent restorative philosophies These d ifferent ap - Advantages: limited child cooperation needed, some
proaches can be used at a p atient level or at a tooth level cooperation is needed to modi y carious cavities to
w ith several em p loyed w ithin one p atient. Table 24.4 show s improve toothbrushing access.
Paul’s treatm ent plan and includ es several d ifferent ap- Disadvantages: high levels o parental cooperation, as
proaches to m anage his cariou s teeth. they will need to undertake a rigorous preventive plan,
• Prevention only. This approach requires a high level o more requent clinic visits, accurate diagnosis o the
engagement and cooperation rom the parents as extent o caries to ensure these teeth are at low risk o
treatment is predicated on their compliance with the pain or in ection.
preventive advice provided. Preventive advice as • Sealing in caries with partial or no caries removal
discussed in Chapters 22 and 23 is provided with regular Advantages: moderate child cooperation, no local
clinic visits or f uoride varnish application. To support anaesthetic and minimal or no drilling.
daily plaque removal, carious cavities can be adjusted to
Disadvantages: more requent clinic visits to monitor
acilitate toothbrush access to remove plaque. For Paul,
seal, more radiographs to monitor any caries
early dentinal caries was identi ed on the mesial aspects
progression, accurate diagnosis o the extent o caries
o A A. The mesial aspects o these teeth were ‘disked’to
with a low risk o irreversible pulpitis, short term
allow or better toothbrush access. This decision was
occlusal disturbance ollowing Hall crown placement.
made based on the short time these teeth had to be
• Complete caries removal
retained be ore they ex oliated, the dark appearance o
Advantages: high levels o child cooperation, can
the caries suggesting it was arrested, the low likelihood
directly assess pulpal health at time o pulpotomy,
o caries progression or pain and parent satis action with
permits treatment o more extensive caries, can modi y
this approach.
crown to ensure f t o stainless steel crown, permits
• Sealing in caries with no or partial caries removal. This
tooth coloured restorations or caries involving the
approach is based on the biological principle that by
outer and mid third o dentine.
sealing the cavity, the carious process cannot progress
Disadvantages: risk o iatrogenic damage to adjacent
without nutrients and will there ore either slow down or
teeth, requires high levels o clinical expertise and
arrest completely. There ore ensuring a good seal is
e ciency, local anaesthetic and rubber dam needed.
essential. This can be achieved using a number o
di erent materials and with or without partial caries
removal. Best examples o these techniques in the
primary dentition are the Hall technique, sealing in
dentinal caries and indirect pulp therapy. For Paul, his
cooperation was limited and there was little likelihood o Hall crowns and indirect pulp therapy
him cooperating or our separate visits o complete
caries removal under local anaesthetic. There ore Hall ■ Wha t are Hall crowns?
crowns were provided on the three other a ected Stainless steel crow ns are a very effective m ethod for restor-
E ing cariou s p rim ary m olars. H istorically, it w as only felt that
second primary molars ( ) and a composite restoration
EE these crow ns cou ld be placed u sing a com plete caries
on D. The D used simple hand and slow handpiece removal approach to ensure a good t w as achieved thereby
excavation to remove only the in ected dentine. optim izing the coronal seal. Furtherm ore, this approach
• Complete caries removal. This approach involves complete m inim ized any occlu sal d istu rbance. Using this conven-
caries removal and necessitates the need or local tional approach (inclu d ing occlusal red uction and m esial
anaesthetic, rubber dam and ast and slow handpieces. and d istal slices) excellent long-term outcom es w ere
Consequently it requires signi cant levels o cooperation achieved .
rom the child. All in ected carious dentine is removed. In the last ten years, an alternative (H all crow n) ap proach
Only once this is completed is the tooth restored. Where to their application has em erged . This involves no caries
caries extends into the pulp, a pulpotomy is undertaken. removal or local anaesthetic. The correct size of crow n is
Paul coped with one visit o local anaesthetic where the chosen and lled w ith GIC. The crow n is then p u shed onto
• 144
24 PAINCONTROLANDTREATMENTPLANNINGFORCARIOUSPRIMARYTEETH
the tooth using the child to bite it d ow n into p lace. The sym p tom s su ggesting irreversible p u lp itis (see Table 24.1)
coronal seal generated by the crow n and cem ent lead s to the or p ulp al necrosis. This includ es the absence of a sinu s,
arrest of the u nd erlying caries. Fu rther inform ation on sw elling, peri-furcation rad iolucency, internal resorption,
the H all techniqu e is provid ed in a sp eci c m anu al w ith the tend erness to p ercu ssion or a clinical history of irreversible
w eblink p rovid ed in the Prim ary Resou rces and Recom - pu lpitis.
m end ed Read ing section. The in am ed coronal pulp is rem oved u nd er local anaes-
■ When ca n I use Hall crowns? thesia (LA) and ru bber d am w ith the healthy non-in am m ed
pu lp stum ps d ressed for 15 second s w ith 15.5% ferric su l-
There are several im p ortant caveats to H all crow ns, and like phate. Follow ing this ap plication, bleed ing from the pu lp
all restorative techniqu es, they have ad vantages and d isad - stu m p s shou ld stop . The technique allow s one fu rther
vantages to their u se. Most im p ortantly, a carefu l pain ap plication of ferric su lphate if the bleed ing has not stop ped
history and bitew ing rad iograp hs are im p ortant stages in entirely after the rst ap plication. The cham ber is then lled
id entifying p u lpal health. Where caries is w ithin the inner w ith zinc oxid e eu genol cem ent or Mineral Trioxid e Aggre-
third of d entine or there is history of pain or signs and gate. The d efau lt restoration for a pu lpotom ised p rim ary
symp tom s of p u lpitis or p u lp al necrosis, it is u nw ise to m olar is a stainless steel crow n to facilitate an excellent
u nd ertake a H all crow n. For Pau l, the caries w as lim ited to coronal seal. If the pu lp stu m p s d o not stop after tw o appli-
the outer half of the d entine and there w ere no sym p toms cations of ferric su lp hate, treatm ent shou ld p roceed to either
E a vital p ulpectom y (a variation of the p u lpectom y techniqu e
from .
E E d escribed earlier in the chap ter) or the tooth shou ld be
Ow ing to the tight contacts seen in the p rim ary d entition, extracted . This continu ed bleed ing d em onstrates in am m a-
pu shing the crow n throu gh these contacts can take signi - tion extend ing into the p u lp stu m p s and early tooth loss is
cant force. Where tight contacts are seen, an alternative likely if a p ulp otom y is u nd ertaken (as a resu lt of internal
approach is to place orthod ontic sep arators for u p to 2 resorp tion).
w eeks to p rovid e sp ace for p lacem ent of the crow n. Pu lpotom ies are an area of active research as show n by
■ Wha t will happen to the child’s occlusion ollowing the the recent Cochrane review on the su bject. This id enti ed
placement o a Hall crown? 47 rand om ized controlled trials on the su bject. Current areas
of active research inclu d ed how haem ostasis is achieved
As there is no occlu sal red uction as p art of the H all tech-
and alternatives to ferric su lphate and old er agents such as
niqu e, the crow n w ill be p rou d and cau se occlu sal interfer-
form ocresol. Althou gh form ocresol has show n long-term
ence. Research has show n that after a few w eeks, there is
su ccess and is still u sed in som e parts of the w orld , there
occlu sal ad ju stm ent w ith the crow n no longer sitting p rou d .
have been international concerns over its toxicity both
A post-op erative bitew ing is ad visory once all H all
locally and system ically. These concerns have grow n in the
crow ns have been p laced to ensu re the crow ns are fu lly
past 15 years w ith form ald ehyd e, one of the im portant com -
seated and have sealed the cariou s cavity. This esp ecially is
ponents of form ocresol being associated w ith nasop haryn-
tru e for proxim al caries.
geal cancer. Form ocresol is no longer ad vocated as a
■ How does indirect pulp therapy (IPT) di er rom front-line m ed icam ent for p u lp otom ies and is no longer
a Hall crown? tau ght in UK u nd ergrad u ate cu rricu la.
IPT is a proced ure requ iring local anaesthetic and ru bber
d am. Infected caries is rem oved from the m argins of the
cavity. At the cavity base, carefu l caries rem oval is u nd er-
Primary resources and
taken to rem ove as m u ch soft infected d entine as possible recommended reading
bu t to ensure there is no pu lp al exp osu re. Calciu m hyd rox- Am erican Aced em y of Ped iatric Dentistry 2014 Policy on
id e is then p laced over the d eep caries before a d e nitive p ed iatric p ain m anagem ent. Reference Manu al 36 (6):78–79.
restoration is placed . It is essential that the restoration Pain control for child ren 2013 In: Cam eron A, Wid m er R (ed s),
provid e an excellent coronal seal. H and book of Ped iatric Dentistry, 4th ed n. Mosby, Ed inbu rgh,
IPT and H all crow ns are sim ilar in that they both requ ire p p . 25–46.
an excellent d iagnosis of p u lp al health. In both techniqu es Deery C 2013 Caries d etection and d iagnosis, sealants and
infected caries is left, and both rely on an op tim al coronal m anagem ent of the p ossibly carious ssu re. Br Dent J 214
(11):551–557.
seal to p revent caries p rogression. The d efau lt restoration
m aterial for both techniqu es is a stainless steel crow n. In the Du ggal MS, Day PF 2005 Op erative treatm ent of d ental caries in
the p rim ary d entition. In: Welbu ry RR, Du ggal MS, H osey MT
perm anent d entition, step w ise caries rem oval (of w hich IPT
(ed s), Paed iatric Dentistry, third ed . Oxford University Press,
is a form of) has show n very p ositive resu lts in red u cing the Oxford , p p . 149–174.
need for root canal treatm ent.
Evans D, Innes N 2010 The H all Technique: A Minim al
Intervention, Child Centred Ap proach to Managing the Cariou s
Prim ary Molar. University of Du nd ee. Available at: http s:/ /
Pulpotomies d entistry.d u nd ee.ac.u k/ sites/ d entistry.d u nd ee.ac.u k/ les/
3M_93C%20H allTechGu id e2191110.p d f.
■ Wha t is a pulpotomy?
Facu lty of General Dental Practice (FGDP) 2013 Selection Criteria
Pu lpotom y is a proced u re for d eep caries involving or for Dental Rad iograp hy, third ed . Lond on, FGDP.
in close ap p roxim ation to the p u lp . Carefu l p re-op erative Franzon R, Gu im araes LF, Magalhaes CE et al 2014 Ou tcom es of
d iagnosis is essential to ensu re the absence of signs and one-step incom plete and com plete excavation in prim ary teeth:
145 •
PAINCONTROLANDTREATMENTPLANNINGFORCARIOUSPRIMARYTEETH 24
a 24-m onth rand om ized controlled trial. Caries Res 48 http :/ / w w w.sd cep .org.u k/ w p -content/ u p load s/
(5):376–383. 2013/ 03/ SDCEP_PM_Dental_Caries_Fu ll_Gu id ance1
Ricketts D, Lam ont T, Innes N P, et al 2013 Op erative caries .p d f.
m anagem ent in ad u lts and child ren. Cochrane Database of Sm ail-Fau geron V, Courson F, Du rieu x P et al 2014 Pu lp treatm ent
Syst Rev Issue 3. Art N o: CD003808. DOI: 10.1002/ 14651858. for extensive d ecay in p rim ary teeth. Cochrane Database of Syst
CD003808.pub3. Rev Issu e 8. Art N o: CD003220. DOI: 10.1002/ 14651858.
Scotish Dental Clinical Effectiveness Program m e (SDCEP) 2010 CD003220.p u b2.
Prevention and Managem ent of Dental Caries in Child ren:
Dental Clinical Gu id ance. Du nd ee, SDCEP. Available at: For revision, see Mind Map 24, page 244.
25
Acu te infections tend to present w ith facial cellulitis
rather than a facial abscess w ith p us. Danny w as febrile,
althou gh he w as not in any signi cant pain, because the
infection had perforated the cortical plate. The m ainstay of
treatm ent is rem oval of the cause – either p ulpal extirpation
or extraction of the tooth.
History
Facial swelling and Danny traum atized his u pper right lateral incisor 3 w eeks
ago, su staining a d eep enam el d entine fractu re. The d entine
dental abscess
w as d ressed w ith calciu m hyd roxid e and a glass ionom er
cem ent w as p laced over the exp osed d entine and enam el.
H e had a review appointm ent w ith his d entist the follow ing
w eek.
On Saturd ay m orning his m other noticed that his cheek
w as sw ollen and the tissu es arou nd his right eye w ere ‘p u ffy
and red ’. H e attend ed the accid ent and em ergency d epart-
m ent of the local hosp ital, w here he w as prescribed Am oxi-
SUMMARY cillin 250 m g tablets to be taken three tim es d aily for 5 d ays.
Danny is 12 years old. He attended with a large Unfortu nately, by Sund ay evening Danny had becom e list-
less and his sw elling had increased . H e felt hot.
acial swelling a ter an episode o trauma 3 weeks
previously. He eels unwell, and his right eye is
closing (Fig. 25.1). Examination
The presentation o acute in ection, as Extraorally there w as facial asym m etry w ith a sw elling of
demonstrated by Da nny, is very di erent rom the right m axillary canine fossa. The overlying skin w as red
chronic in ection. and hot. The right eye ssure w as partially closed . Danny’s
■ List our symptoms and signs specif c to each type o temp erature w as 39°C. Maxillary canine fossa infections can
in ection sp read via em issary veins, w hich have no valves, to the
intracranial venou s system causing either a cavernou s sinus
Acu te: throm bosis or a brain abscess. The pathw ays of the IIIrd
• Sick, upset child. and VIth cranial nerves lie in the w alls of the cavernou s
• Raised temperature. sinu s. Throm bosis in the cavernou s sinu s can present w ith
• Red, swollen ace. a squ int d u e to involvem ent of the IIIrd and VIth cranial
• Reduced intake o ood and drink nerves, w hich are involved in control of the extraocu lar
Chronic: m u scles.
• Buccal sinus may be present. ■ What is the major problem with mandibula r in ections?
• Mobile tooth. Spread alongside the ascial planes that surround the airway
• Halitosis. with subsequent narrowing o the airway and stridor.
• Discoloured tooth.
Spread via the ascial planes to the mediastinum to cause a
Other signs and sym ptom s can be seen in both acu te and mediastinitis.
chronic infection, includ ing pain and lym p had enop athy.
■ What is the basic mana gement o a ny in ection?
Removal o the cause extraction or root canal therapy.
Local drainage and debridement via root canal or incision
and drainage.
Oral antibiotics i systemic involvement (see Table 25.1)
Amoxicillin or Penicillin V are usually the drugs o rst choice.
Amoxicillin has the advantage that it is given with ood and
only needs to be taken three times per day. Metronidazole,
which is active against anaerobes, can be added to either
Amoxicillin or Penicillin i the in ection is severe. O ten the
extraction o the abscessed tooth alone will bring about
resolution without antibiotic therapy. It is important that
antibiotics alone should not be considered as a rst line o
treatment unless there is systemic involvement. In a child a
temperature o 39°C or higher can be considered signi cant
Fig. 25.1 Severe in ection o canine ossa. (normal 37°C). Immunosuppressed patients and those with
147 •
FACIALSWELLINGANDDENTALABSCESS 25
Table 25.1 Common antibiotics used in paediatric dentistry
Drug Route Dose Frequency Notes
Antibiotics
Amoxicillin PO 25–50 mg/kg/day tds Syrup or chewable tablets or young children
IV 100–400 mg/kg/day tds
Amoxicillin plus clavulanic acid PO 20–40 mg/kg/day tds For beta lactam resistant organisms only
Ampicillin IV 50–100 mg/kg/day qds
IV 50 mg/kg stat
Benzyl penicillin IV 15–350 mg/kg/day
20000–500000 U/kg/day qds First IVdrug o choice or odontogenic in ections
PenicillinV PO < 5 years 500 mg/day
> 5 years 1–2 g/day qds Give 1 hour be ore meals
Cephalexin PO 25–50 mg/kg/day qds
Cephazolin IV 25–50 mg/kg/day
Erythromycin PO 25–40 mg/kg/day qds Ethylsuccinate is readilyabsorbed
Metronidazole IV 22.5 mg/kg/day tds Not in pregnancy
Gentamicin PO 10–15 mg/kg/day tds
Clindamycin PO,IV 15–40 mg/kg/day qds Risko pseudomembranous colitis
cardiac disease should receive antibiotics immediately i any d azole shou ld be ad d ed as anaerobic organism s p lay a sig-
in ection is suspected. ni cant role.
Maintenance uid s w ill be given until the child is d rink-
■ What are the criteria or hospital a dmission with oro acial
ing norm ally again.
in ection?
Warm saline m ou thw ashes.
Dehydration. Ask whether the child has had a decreased Ad equ ate pain control com m only w ith paracetam ol or
requency o micturition (urine output) in previous 12 hours. ibu p rofen (Table 24.2).
Signi cant in ection or temperature greater than 39°C. If the eye is shu t d u e to a sw elling in the canine fossa,
it may be necessary to give chloram p henicol eye d rop s
Floor o mouth swelling.
0.5% or chloram p henicol ointm ent 1.0% to prevent
■ What will the hospital mana gement o a severe in ection conju nctivitis.
involve?
Extraction of involved teeth. It is im p ossible to d rain a sig-
ni cant infection solely throu gh the root canals of a tooth. Key point
Drainage of any p u s. In ad d ition to extractions, there m ay Hospital admission in oro acial in ection is necessary with:
be a need to incise and d rain p u s, often leaving a d rain in
• Dehydration.
situ for a few d ays to enhance d rainage. With severe m an-
• Temperature >39°C.
d ibular sw ellings or w here the oor of the m ou th is raised ,
it may be necessary to have an extraoral d rain throu gh a • Floor o mouth swelling.
skin incision or a ‘throu gh and throu gh’ d rain, w hich p asses • Trismus or signif cant swelling around the eye leading
comp letely throu gh the area of infection. Extraoral incisions to complete closure.
are to be avoid ed if at all p ossible d u e to p ost-op erative • Breathing and swallowing di culties.
scarring. Sw abs of p u s for laboratory cu lture to establish
accu rate sensitivities of the organism s concerned to com mon
antibiotics.
Intravenou s antibiotics. Benzyl p enicillin is the d ru g of Treatment
rst choice, or Am oxicillin. Cep halosp orins are effective if
there is a p enicillin allergy, bu t there is som e cross-reactivity Danny w as treated by the follow ing regim en:
in those patients allergic to penicillin and so cephalosporins 1. Extirpation o 2 . The tooth was immature and good
shou ld be u sed w ith care, esp ecially w hen there w as a drainage o pus was achieved through the root canal.
severe reaction to p enicillin. In severe infections, m etroni- 2. Open drainage o the tooth or 2 days.
• 148
25 FACIALSWELLINGANDDENTALABSCESS
3. Amoxicillin 250 mg three times daily, metronidazole Primary resources and
200 mg twice daily or 5 days each.
4. Hot saline mouthwashes.
recommended reading
Cam eron A, Wid m er R (ed s), 2013 Paed iatric oral m ed icine and
After 2 d ays Danny w as review ed . The sw elling w as
p athology. In: H and book of Ped iatric Dentistry, 4th ed n. Mosby,
red u ced around his right cheek, and his right eye w as Ed inbu rgh, p p . 209–268.
norm al. The 2 w as cleaned and led and non-setting
Am erican Acad em y of Ped iatric Dentists 2015 Guid eline on u se
calcium hyd roxid e placed into the canal. The access cavity of antibiotic therap y for p ed iatric d ental p atients. Ref Man 36
w as sealed w ith cotton w ool and glass ionom er cem ent. The (6):284–286.
non-setting calciu m hyd roxid e w as rep laced once after a
m onth. Once the root canal w as free from any signs or
symp tom s of infection, the tooth w as obu rated w ith a For revision, see Mind Map 25,
Mineral Trioxid e Aggregate p lu g and w arm gu tta p ercha. page 245.
26
be m ore d if cu lt to treat. They often give up becau se they
‘never succeed ’ and are often called ‘failures’ by their
p arents or peers.
Communicative management. This is the m ost fu nd am ental
form of behaviour m anagem ent. It is the basis for establish-
ing a relationship w ith a child that w ill allow you to su c-
cessfu lly com p lete d ental p roced u res and help the child
d evelop a p ositive attitu d e tow ard d ental health.
Liam had inhalational sed ation, w hich enabled com p le- Id eally, w e w ou ld all hop e that by ad olescence a child is
tion of his treatm ent and helped him overcom e his fear of d isease free and therefore w ill need little op erative treat-
local anaesthesia. m ent. H ow ever, there are ad olescents w ho have caries or
other d ental problems, su ch as non-caries tooth tissu e loss;
Key point perhap s d ue to acid erosion, or period ontal d isease; or w ho
have aesthetic need s that require orthod ontic treatm ent,
The patient’s record in inhalational sedation should w hich p erhap s inclu d e p rem olar extractions as p art of the
include: treatm ent plan. Ad olescents w ho need orthod ontic extrac-
• In ormed consent. tions, in p articu lar, may not have had very m uch d ental
• Indications or use. treatm ent in the past, esp ecially if they are low caries
• Nitrous oxide dosage. risk. On the other hand the ad olescent w ho has high caries
risk (ap p roxim ately 14% of the ad olescent p op ulation,
• 152
26 THEUNCOOPERATIVECHILDANDADOLESCENT
Child Dental H ealth Su rvey 2013) often has a heavy bu rd en shou ld also includ e habits su ch as sm oking, experim ental
of d isease requiring m any visits to com p lete their restora- d ru g and alcohol frequ ency; e.g. ‘alco-p ops’ and also ‘rec-
tive treatm ent. reational’ d ru gs that cau se thirst lead ing to increased acid ic/
To overcom e the bu rd en of d isease, p reventive action is su gary d rink consu m p tion.
need ed . This is a tw o-pronged ap p roach that involves good ,
clear, evid ence-based p reventive ad vice from the d entist
Key point
and the active agreem ent to im p lem ent the ad vised behav-
iour changes from the ad olescent. The Dep artm ent of H ealth • Adolescents are sel -conscious and can have a ragile
(DoH ) Oral H ealth Preventive Toolkit contains evid ence- sel -esteem.
based prevention ad vice inclu d ing tw ice d aily tooth- • They want to be able to determine and make their own
bru shing w ith 1450 p p m u orid e toothp aste, the need for choices in li e.
regu lar d ental check-u ps and red u cing su gar frequency. • They have concerns about their looks.
In Maria’s case, 2800 p p m u orid e toothp aste shou ld be • They want to f t in with their peers.
recomm end ed . This is su itable for child ren over 10 years of
• Question or habits such as smoking, experimental
age w ho m ay be at risk for tooth d ecay, inclu d ing p atients
drugs and alcohol.
w ith active tooth d ecay or a history of tooth d ecay, exp osed
• Be alert to bullying and sa eguarding issues.
root surfaces, high-su gar d iets, orthod ontic ap pliances or
d ry m ou th.
Ad vice given should be evid ence based and given in a
know led geable context of ad olescent m ind -set and behav- ■ Ca n a nxiety be measured, and what questions should
iour change p sychological theory, su ch as u sing m otiva- be asked?
tional interview ing and cognitive behaviou r therap y. These There are variou s anxiety scales that help alert a d entist to
theories are generally based on ad olescents und erstand ing d ental anxieties. Thou gh these are not sensitive enou gh to
their ow n d ental need s and the challenges that they face in tease ou t the d ifferences betw een these tw o possible aetiolo-
imp lem enting recom m end ations and then taking action, gies, they m ay be of valu e. The com m on ones are the Mod i-
and ‘rew ard ing’ them selves for d oing so. ed Child Dental Anxiety Scale (MCDAS) and the Child
This ap p roach to p revention w ill also help in Maria’s Fear Su rvey Sched u le (CFSS). A sim p ler m easure, w hich can
anxiety m anagem ent becau se she w ill feel that she has a role also be valu able in younger child ren, is the Facial Im age
and a say in her ow n d ental m anagem ent. In this w ay, the Scale (FIS); this is sometim es com bined w ith the MCDAS to
d entist and Maria w ill alread y be w orking together; ‘on the assist you nger child ren’s com prehension. An exam ple is
sam e sid e’ against the d ental d isease. show n in Fig. 26.1.
H ow ever, these also need to be au gm ented by carefu l
Key point and thou ghtful qu estioning, especially relating to p ast
d ental history and p ossible p erceived traum atic events.
• Prevention o urther dental caries is essential, provided Those w ho report that they have a need le phobia should be
the caries that is already present is managed. asked if they m anaged to accept their vaccinations at school;
• Adherence to preventive advice is key to progression to e.g. the tetanu s/ polio booster is usu ally given at arou nd 13
orthodontic treatment a terwards. years of age in the UK.
• The DoH toolkit gives clear, evidence-based preventive
recommendations.
Treatment
■ What are the anxiety management options?
■ Wha t is the aetiology o dental a nxiety? N on-pharm acological behaviou r m anagem ent is just as
There are tw o reasons behind ad olescent anxiety. The rst effective w ith ad olescents as it is w ith you nger child ren, so
is d ental anxiety that is learnt over the p reced ing years and positive reinforcem ent, tell-show -d o and enabling a hand
cau sed by real or p erceived trau m a of p reviou s d ental or signal to ‘stop ’ to enhance Maria’s sense of control shou ld
m ed ical treatm ent. The second is d ental anxiety that is part all be u sed . Giving information abou t w hat w ill hap pen,
of a d eep er p sychological d istu rbance that is beginning to w hat it w ill feel like and how to cop e beforehand and d u ring
emerge. the p roced u re are all im p ortant. Psychological interventions
su ch as cognitive behaviou ral therap y can also p lay a key
■ Why should a n a dolescent be ma naged di erently orm a
role. The id ea behind this technique is to help Maria recon-
younger child?
sid er her belief that a fu tu re d ental extraction w ill be as
There are som e fu rther d etails that a d entist cannot overlook trau m atic as that rem em bered from her child hood .
w hen m anaging an anxiou s ad olescent. These relate to the Maria has alread y u nd ergone a d ental extraction at an
m ind -set and to the em erging character of the ad olescent earlier age, and in her m emory this w as traum atic. It is not
them selves. Ad olescents have a rather fragile self-esteem uncom m on for a child to perceive a p ast experience as ‘trau-
yet w ant to be able to d eterm ine and m ake their ow n choices m atic’, even if in reality it w as not. The fact is that in Maria’s
in life. They have concerns abou t their looks, especially ow n m ind the event w as d am aging to her, so this has to be
d ental aesthetics, and w ant to t in w ith their p eers. A taken into accou nt. In Maria’s case, she w ill need to u nd ergo
d etailed history, perhap s based on som e subtle qu estioning, extractions as part of her orthod ontic treatm ent p lan. It is
153 •
THEUNCOOPERATIVECHILDANDADOLESCENT 26
Modified Child Dental Anxiety Scale – MCDAS
For the next eight questions I would like you to show me how relaxed or worried you get about the dentist and what
happens at the dentist. To show me how relaxed or worried you feel, please use the simple scale below. The scale is
just like a ruler going from 1, which would show that you are relaxed, to 5, which would show that you are very worried.
… having a filling? 1 2 3 4 5
… having a mixture of ‘gas and air’ which will help you feel
1 2 3 4 5
comfortable for treatment but cannot put you to sleep?
likely that d iscu ssing Maria’s fears w ith her and p u tting to assess treatm ent progression and to evalu ate w hither the
them into a d ifferent context, in line w ith a cognitive p lan is likely to su cceed .
behaviou ral therap y ap proach, and u sing excellent behav-
iou ral m anagem ent skills, giving her a locu s of control, and ■ Wha t treatment plan would you propose?
ensu ring ad equ ate analgesia w ill enable her to proceed to The treatm ent plan:
accep t her p lanned orthod ontic extractions. Resou rces and
fu rther gu id ance on the u se of cognitive behaviou ral therap y VISIT 1
are listed in the fu rther read ing section. 1. Preventive advice (this is discussed in greater detail in
■ What is the commonest conscious sedative in children Chapter 23) ollowing the DoH toolkit, so including:
and adolescents? a. Prescription o twice daily brushing with 2800 ppm
f uoride toothpaste.
For m od erately anxiou s child ren, nitrou s oxid e inhalation
b. Handing out a 4-day diet diary.
sed ation is the m ost com m only u sed sed ative and is effec-
2. Ask Maria to sign a contract to:
tive in ad olescents w ho requ ire p rem olar extractions. Maria
m ay need this in ad d ition to the behaviou ral techniqu es a. Reduce dietary sugar intake requency based on
alread y d escribed . The key is to carry ou t a thorou gh assess- tailored advice derived rom her diet diary.
m ent based on a frank d iscu ssion w ith her and her p arent(s) b. Implement twice daily toothbrushing with a
before the treatm ent p lan is d evelop ed , to inclu d e inhalation 2800 ppm f uoride toothpaste.
sed ation from the start if it is need ed , rather than have a c. Attend pre-agreed and booked dental
‘failed ’ behavioural m anagem ent visit before consid ering appointments.
consciou s sed ation as an option. It is also w ise to bu ild in a d. Conduct a discussion between dentist, parent(s) and
reassessment of the agreed plan after the rst or second visit patient that leads to written parental consent and
• 154
26 THEUNCOOPERATIVECHILDANDADOLESCENT
adolescent assent o sedative choice and operative ■ What other sedation techniques are availa ble?
treatment.
Other sed ation techniqu es su ch as oral or intravenou s m id a-
e. Document the consent and assent process and
zolam are effective. Dental sed ationists w ho offer this type
document written in ormed consent.
of treatm ent have to show that they have u nd ergone fu rther
. Disclose dental plaque and modi y toothbrushing training in the technique, as w ell as continu ed com petency
technique and choice o toothpaste regarding and experience in line w ith contem porary national gu id e-
f uoride dose; consider 2800 ppm f uoride lines and recom m end ations.
toothpaste. For young child ren oral sed ation is a viable option u sing
g. Introduce her to the inhalation sedation nasal mask m id azolam . A num ber of recent stud ies have show n that its
and technique. use in a d ose of 0.3–0.5 m g/ kg, d epend ing on age, has been
h. Fissure seal a maxillary rst permanent molar and therap eu tically effective in p rod u cing sed ation that has
introduce topical analgesia. allow ed su bsequ ent d ental treatm ent.
For ad olescents w ho require m ore invasive p roced ures
VISIT 2 (preventive advice will continue and expand on 2a,
or w ho are m ore severely p hobic, m id azolam intravenou s
2b, 2 )
sed ation is an op tion becau se it has the ad d ed bene t of
3. Use inhalation sedation or the rst time: causing am nesia. Am nesia also occu rs w ith oral m id azolam .
a. Fissure seal the remaining rst permanent molars. The p atient cannot rem em ber u nd ergoing the proced u re.
b. Introduce topical analgesia. They m ay rem em ber the start of the d ental visit and the
c. Reassess Maria’s caries risk by checking compliance beginning of the sed ation, bu t nothing u ntil after the sed a-
with dietary changes and toothbrushing, and tive effect has begu n to w ear off.
con rm premolar extraction plan with the
■ What a re the indications or general anaesthesia?
orthodontist. Reassess the use o nitrous oxide
inhalation sedation. Does Maria still need it? Patients who are unable to cooperate due to a lack o
psychological or emotional maturity and/or mental, physical
VISIT 3 AND 4 (preventive advice will continue and expand
or medical disability.
on 2a, 2b, 2 )
Patients or whom local anaesthesia is ine ective because o
4. Begin orthodontic premolar extractions perhaps in two
acute in ection, anatomical variations or allergy.
quadrants per visit. O ten an extraction in maxillary and
mandibular quadrant is undertaken rather than The extremely uncooperative, ear ul, anxious or
extracting both mandibular premolars on the same visit. uncommunicative child or adolescent.
For mandibular extractions, in ltrations using Articaine Extensive dental caries involving dental treatment in multiple
local anaesthetic rather than in erior dental blocks with quadrants.
Lidocaine is an e ective but less invasive method. Patients requiring signi cant surgical procedures ( or example,
■ Wha t ollow-up does Maria need now? the extraction o all rst permanent molars or a severely
in raoccluded primary molar).
Maria has su ccessfu lly u nd ergone the p rem olar extractions
and has red u ced her su gar frequ ency and is toothbrushing Patients or whom the use o general anaesthesia (GA)
w ith 2800 p pm u orid e tooth p aste. Therefore she is pro- may protect the developing psyche and/or reduce medical
ceed ing to have orthod ontic xed ap p liance treatm ent. As risks.
such, her caries risk is still high and she w ill need regular, Patients requiring immediate, comprehensive oral/
four-m onthly follow -u p s d u ring her orthod ontic treatm ent. dental care.
She w ill also need fu rther bitew ings to assess for new d ental
caries once yearly (once her orthod ontic ap p liance is ■ What a re the contra indications or general anaesthesia?
removed , u ntil no fu rther caries is seen and she is d eem ed
A healthy, cooperative patient with minimal dental need.
to be at low caries risk).
Maria feels hap py and p roud to have u nd ergone the Predisposing medical conditions that would make GA
extractions. She now enjoys visiting the d entist for check- inadvisable.
u ps and is excited abou t her new sm ile. General anaesthesia is a controlled state o unconsciousness
accompanied by a loss o protective ref exes, including the
ability to maintain an airway independently and respond
CASE3 purpose ully to physical stimulation or verbal command. It
should only be provided in premises with resuscitation
SUMMARY capability and intensive care back-up (e.g. an acute hospital
setting). All equipment must ollow current guidelines (please
Un ortunately, there are some children and see re erence section).
adolescents or whom inhalational sedation is Parental or legal guard ian inform ed consent m ust be
unable to overcome their anxiety, and alternative obtained and d ocu m ented prior to the u se of general anaes-
sedation agents or general anaesthesia is the only thesia. The p atient’s record should inclu d e:
option that will allow relie o pain and completion • In ormed consent.
o dental treatment. • Indications or the use o GA.
155 •
THEUNCOOPERATIVECHILDANDADOLESCENT 26
Therefore agreeing to a contract w ith an ad olescent
In ormed consent p atient, w here they sign-u p to agree to d ietary behaviou r
Regard less of the behaviour m anagem ent techniques u ti- changes and regu lar toothbru shing w ith the correct d osage
lized by the ind ivid u al p ractitioner, all m anagem ent d eci- of u orid e toothp aste, not only p rovid es them w ith a sense
sions m u st be based on a su bjective evalu ation w eighing of self d eterm ination and esteem but also tailors and clari-
bene t and risk to the child . Consid erations regard ing es the preventive practices that und erp in the d ental treat-
need of treatm ent, consequ ences of d eferred treatm ent and m ent p lan.
p otential p hysical/ em otional trau m a m u st be entered into It is alw ays p ru d ent to involve both the ad olescent and
the d ecision-m aking equ ation. the ad u lt w ith parental responsibility. Child ren u nd er 16
Delivery of d ental treatm ent is often a com p lex d ecision. years of age can consent for treatm ent if they u nd erstand
Decisions regard ing the u se of behaviou r m anagem ent tech- w hat is proposed . ‘It is u p to the d entist to d ecid e w hether
niqu es other than com m u nicative m anagem ent cannot be the child has the m atu rity and intelligence to fu lly und er-
m ad e solely by the d entist. Decisions m u st involve a legal stand the natu re of the treatm ent, the op tions, the risks
gu ard ian and , if app rop riate, the child . The d entist serves involved and the bene ts. A child w ho has su ch u nd er-
as the exp ert abou t d ental care, i.e. the need for treatm ent stand ing is consid ered Gillick com petent.
and the techniqu es by w hich treatm ent can be d elivered .
The legal gu ard ian shares w ith the p ractitioner the d ecision
w hether to treat or not to treat and m u st be consu lted
regard ing treatm ent strategies and p otential risks. Therefore Key point
the successful comp letion of d iagnostic and therapeutic • It is good practice to gain consent rom the adult with
services is view ed as a p artnership of d entist, legal gu ard ian parental responsibility and assent rom the child up to
and child . 16 years o age.
Althou gh the behaviou r m anagem ent techniqu es
• Where a child is considered Gillick competent, they can
inclu d ed in this chap ter are u sed frequ ently, p arents m ay
consent or their own dental treatment.
not be entirely fam iliar w ith them . It is im p ortant that the
• Di erent ages and rules apply in di erent parts o
d entist inform the legal gu ard ian abou t the natu re of the
the UK.
technique to be u sed , its risks, bene ts and any alternative
techniques. All qu estions m u st be answ ered . This is the
essence of inform ed consent.
Children with disabilities and w ith social services to have his ed u cational and
social need s assessed . As a resu lt of these assessm ents,
Sanjeev now has better access to health care, social and
and learning di culties ed ucational sup port, and his p arents have been in touch
w ith other parents w ho have child ren w ith Asperger ’s
synd rom e.
Sanjeev has tw o healthy brothers w ho also need su p p ort
and attention in their ow n right. Sanjeev’s m other gave
u p her p art-tim e job to look after him . Although she is
p leased that she has achieved stability, su pport and
m ed ical care for her child , she is w orried abou t his teeth.
SUMMARY She has previously p rioritized the m any ed u cational and
Sa njeev is an 8-year-old boy with Asperger’s school assessm ents, w hich led to Sanjeev’s irregu lar d ental
syndrome. You receive a letter rom a community attend ance.
dentist who has undertaken a routine school
inspection. The letter reports that Sanjeev has
caries in his f rst and second primary molars. On
entering the clinic, Sa njeev’s mother gives the
receptionist a communication passport (http://
www.autism.org.uk/living-with-autism/out-and
-about/my-hospital-passport.aspx). She asks the
dentist to read the passport be ore seeing her son
(Fig. 27.1).
■ How will you ma nage him?
History
Complaint
Sanjeev’s m other reports that she d oes not think
he is in p ain. H e has been eating and sleep ing normally.
Sanjeev says, bu t only w hen he is p rom p ted , that he has
occasional p ain w hen he eats sw eets.
History o complaint
There is no relevant history.
Medical history
Sanjeev is t and w ell. H e w as d iagnosed w ith Asp erg-
er ’s synd rom e last year. H e d oes not take any m ed ica-
tion. Asp erger ’s synd rom e is a typ e of high-fu nctioning
au tism .
Social history
Sanjeev is in a m ainstream school and receives ad d itional Fig. 27.1 Sanjeev’s communication passport where he describes
su p p ort d u ring his lessons from a teaching assistant. how best to manage his dental visit. Passport originated by
H is m other rep orts that she had to ght very hard for National Autism Society. See http://www.autism.org.uk/about/
this su pport and w ent through nu m erou s ed ucation health/hospital-passport.aspx.
assessments – esp ecially before the Asp erger ’s synd rom e Reproduced with permission.
• 158
27 CHILDRENWITHDISABILITIESANDLEARNINGDIFFICULTIES
and level of tru st. Parents w ill be grateful for ap pointm ents
Key point and treatm ents that m inim ize the am ou nt of tim e out of
Key eatures o Autism, Asperger’s syndrome and Attention school and aw ay from w ork.
Def cit Hyperactivity Disorder (ADHD):
• Please see http://www.autism.org.uk or urther Examination
in ormation.
Autism is a spectrum o disorders with children ■ How will you examine Sanjeev?
showing varying levels o severity in three key categories: Sanjeev has provid ed consid erable help and guid ance on
• Communication children show delayed language how best he can cope w ith the d ental exam ination. Follow -
development and limited comprehension o non-verbal ing his ad vice w ill only help w ith the appointm ent. Many
communication. Severely a ected children may have child ren w ith d isabilities and learning d if culties can read ily
rudimentary or no speech. accep t a d ental examination. H ow ever, some can have more
• Social interaction children o ten live in their own challenging behaviour and even a d ental examination can be
world and have limited interest and interaction with d if cult to perform. Some of these d if culties can be over-
other children and adults. come by a sequence of short introd uctory visits, each one set
• Social imagination children may struggle to interpret up in exactly the same w ay as the previou s but just build ing
other people’s eelings and actions. on the examination; this can w ork w ell w ith a child w ith
Asperger’s syndrome, as already described, is at the autistic spectrum d isord er. Other d istractions arou nd the
high- unctioning end o the autistic spectrum. It is surgery should be minimized , e.g. noise or interruption.
characterized by normal spoken language development, Keep ing instru ction sim p le and d irect help ed Sanjeev
and the child can have average or above average sit in the d ental chair and allow ed for a qu ick d ental
intelligence. He or she o ten does not have learning delay exam ination.
but can have specif c learning di culties. There are three
key eatures o the diagnosis:
Extraoral
• Love o routines. There w ere no relevant nd ings.
• Intense interests.
Intraoral
• Sensory impairment which can be either under or over
Caries w as id enti ed in the occlusal surfaces of all fou r
unctioning, or example taste, sound, sensation,
second p rim ary molars. There w ere d istal cavities on both
hearing or sight.
m and ibu lar rst p rim ary m olars.
ADHD is a diagnosis made be ore the age o 7 with
children demonstrating a triad o symptoms, which can be
treated with medication or therapeutic interventions.
Radiographic investigation
• Inattention. ■ What is the best radiographic investigation?
• Impulsivity. With carefu l and sim p le explanation, Sanjeev tolerated
• Hyperactivity. bitew ing rad iographs.
Although many children are diagnosed with high- If this was not possible, a ‘teeth-only dental panoramic
unctioning autism and ADHD, they are two separate tomogram (DPT)’ or a standard DPT (depending on what
conditions. settings are available) is an alternative. A trial run to familiar-
ize Sanjeev with the equipment and what is expected is a very
helpful halfway step. This w ill increase the likelihood of
Sanjeev staying still for the DPT. Although the radiation expo-
■ Wha t ca n dentists do to a ssist the a mily and help them sure is higher for a DPT, w here a radiograph of the carious
overcome ba rriers o access to dental care? primary teeth w ill in uence the treatment provided , this DPT
Managing child ren w ith d isabilities and learning d if cu lties radiograph is still justi ed if bitewings are not possible.
can som etim es seem to be a challenge, bu t it is alw ays The bitew ings show ed that the:
rew ard ing. For m any of these fam ilies, being able to access • First permanent molars have no caries.
d ental care in a p rim ary setting is a w elcom e resp ite from • Occlusal caries in the second primary molars was into
the other specialist services that they attend . Many d entists the inner hal o the dentine.
w ho begin to treat a child w ith a d isability often continu e • Caries in the mandibular rst primary molars appears
to d eliver care for the w hole fam ily and provid e a continu ed close to the pulp with the roots almost completely
source of su pport. For m any child ren w ith Asp erger ’s syn- resorbed by the permanent successors.
d rom e, rou tine is very im p ortant and being seen by the
■ What is Sa njeev’s dental dia gnosis?
sam e d entist in the sam e su rgery help s w ith fam iliarization
and their cooperation. Sanjeev appears to have reversible pulpitis rom his
From a d ental p oint of view, it is not u ncom m on to have carious and restorable second primary molars.
a ‘w arrior-m u m ’ w ho has becom e cond itioned to ght for The mandibular rst primary molars may also be causing
her child ’s care and so can ap p ear overly d em and ing or him some annoyance, especially as they become more
imp atient. H ow ever, being aw are of these other challenges mobile. In common with other children his age,
that the fam ily is facing can help d evelop a strong af nity he may be xated by his ex oliating teeth.
159 •
CHILDRENWITHDISABILITIESANDLEARNINGDIFFICULTIES 27
Guid ance for the u se of H all crow ns (see Chapter 24) w ou ld
Key point ad vocate their u se at an earlier stage of the caries process,
• Parents o a child with a learning disability will have before sym ptom s d evelop. H ow ever, in som e situ ations,
many competing demands on their time. and after carefu l d iscu ssion w ith the parents, treatment m ay
• Routine is key and there ore it is important that the be u nd ertaken if there is a clear und erstand ing of the poor
child sees the same sta , in the same surgery to p rognosis and the need for one or m ore teeth to be extracted
develop amiliarity. if fu rther signs and sym p tom s show irreversible p u lp itis or
• Keep instructions simple and direct. ap ical p eriod ontitis (e.g. non-vital).
For som e child ren w ith d isabilities, especially w here
• Children may not always sit in the dental chair and
there are signs of bruxism and tooth w ear, great thou ght
there ore take whatever opportunity arises to examine
shou ld be taken before ap plying H all crow ns. The p ropp ing
their teeth (e.g. sitting on their parents’ lap, in the
op en of the occlusion m ay exacerbate their grind ing and
waiting room, on the surgery oor).
increase the risk of a p erforated crow n.
• Clear communication with a parent is essential to
identi y how much support and/or restraint they are ■ When will these prima ry teeth exo oliate?
happy to provide to permit a dental examination. Any This is an im portant consid eration w hen treatm ent p lan-
restraint must be proportionate with the history and ning. For Sanjeev, the m and ibu lar prim ary rst m olars are
the need or a dental examination. likely to exfoliate very shortly and therefore, u nless sym p-
tomatic, can be left to exfoliate. For the second prim ary
m olars, these teeth exfoliate arou nd the age of 12. Therefore
any restorative plan w ill requ ire m aterials w ith good evi-
■ What are the trea tment options or Sanjeev? d ence of longevity over this 4-year tim e p eriod . Such m ate-
The m anagem ent of the d ental d isease is the sam e as rials inclu d e com posite, am algam or stainless steel crow ns.
d escribed in Chap ter 24. bu t it is the m ethod of d elivery The longer the restoration need s to survive the m ore likely
than can be d ifferent. Prevention is the key. The DoH Preven- a stainless steel crow n w ill be the restorative op tion as these
tion Toolkit is a valu able sou rce of gu id ance. Every visit have the greatest longevity.
presents an op p ortu nity to p revent caries: w hether this is ■ Does beha viour management work with children with
ad vice to red u ce sugar frequ ency, to u se 1450 p p m u orid e Asperger’s syndrome?
toothp aste or to ap ply top ical u orid e. There are a nu m ber
N on-p harm acological behaviou r m anagem ent can w ork
of w ays p arents can be su p p orted to ensu re they are u nd er-
w ell in child ren w ith Asp erger ’s synd rom e. H ow ever, this
taking toothbru shing for their child . This includ es m od i ed
m ay need to be au gm ented w ith voice control to gain San-
toothbru shes (three-sid ed toothbru sh), nger-gu ard s or
jeev’s attention if he becomes d istracted , so p ositive rein-
u sing a tw o toothbru sh techniqu e. The second toothbru sh
forcement, tell-show -d o and enabling a hand signal to ‘stop’
can be u sed to keep the teeth ap art, thus p erm itting the
should all be u sed . Giving sim ple inform ation abou t w hat
other to bru sh the occlu sal su rfaces of the teeth.
w ill happ en, w hat it w ill feel like and how to cope before-
■ Ca n Sa njeev be managed in a primary ca re setting? hand and d u ring the proced u re are all im p ortant. The lan-
The answ er to this qu estion d ep end s on the d e nitive treat- gu age u sed should be ap propriate for his level of
m ent p lan and the p atient’s level of coop eration. Referral to u nd erstand ing and experience. A constant sim ple and rep -
a specialist (com m u nity) or hosp ital-based paed iatric d en- etitious d ialogu e need s to be maintained , otherw ise Sanjeev
tistry u nit m ay be requ ired , esp ecially if general anaesthesia w ill get d istracted .
is need ed .
■ What are the dental management options?
Key point
Sanjeev m ight m anage to have the carious second prim ary
• Behaviour management techniques should be used.
m olars restored w ith com p lete caries rem oval, bu t he w ill
• A constant dialogue should be maintained to keep the
need to accep t local analgesia ow ing to the d ep th of caries
child engaged and ocused on the dentist.
in all fou r of these teeth and their sym p tomatic history.
Conventional caries rem oval is likely to take at least a • Voice control may sometimes be required to ocus the
fu rther ve visits. Therefore, in the rst instance, stabilizing child’s attention.
the caries using glass ionom er cem ent (GIC) tem p orary res-
torations is the best op tion. It also p rovid es Sanjeev w ith
fu rther acclim ation to the d ental su rgery and gives an ind i-
cation of how he w ill cop e w ith m ore invasive treatm ent. In ■ Does nitrous oxide inhalation sedation work or children
these earlier visits, ad d ressing the causes of caries is essen- with Asperger’s syndrome?
tial as d escribed in Chap ters 22 and 23. Many au tistic chil-
d ren can stru ggle w ith som e of the sensations of d entistry N itrou s oxid e inhalation sed ation is the m ost com m only
su ch as the tastes, sm ells, noises and textu res. u sed sed ative in child ren. The key is to carry out a thorou gh
assessm ent based on a frank d iscu ssion w ith Sanjeev and
■ Would Hall crowns be an a ppropriate treatment option?
his m other. The su ccess of the technique is d epend ent on
The extent of the caries and the history of p ain w ou ld red u ce Sanjeev’s ability and w illingness to breathe in and ou t
the chances that the H all ap p roach w ou ld be effective. through his nose. Many child ren w ith Asp erger ’s synd rom e
• 160
27 CHILDRENWITHDISABILITIESANDLEARNINGDIFFICULTIES
enjoy the active engagem ent of this activity. It is also w ise a non-vital central incisor and a general anaesthetic m ight
to assess progress after the rst or second visit and to evalu - be requ ired to m anage the trau m atized tooth. While asleep,
ate w hether Sanjeev w ill m anage to accep t local analgesia. any other d ental care w ould also be carried ou t, su ch as
■ Does Sa njeev need a general anaesthetic? ssu re sealants, extractions or restorations.
■ Are there more complica tions to genera l anaesthesia or
This d ecision is a balance as there are a nu m ber of d isad -
children with a disa bility?
vantages of this ap p roach. The w hole general anaesthetic
event can be trau m atic for the child , and research has Many child ren w ith a d isability or learning d if cu lty are
show n that child ren are m ore d entally anxious afterw ard s. otherw ise p hysically healthy and can u nd ergo d aycase
H ow ever, for som e parents the ability to treat the d ental general anaesthesia w ithou t fu rther concern. N evertheless,
caries ef ciently (e.g. all d ental care is p rovid ed in one go) the w hole general anaesthesia event can be anxiety provok-
and their child ’s lim ited ability to rep ort any p ain and su f- ing, and so p rep aring the child and fam ily can help red uce
fering can m ake a general anaesthetic an attractive option. the psychological anxiety that su rrou nd s the event. Psycho-
Other consid erations w hich in uence the d ecision includ e logical su p p ort inform ation m ay help ; one su ch online and
the likelihood of the child coop erating d u ring treatm ent, the freely available p ackage that has increased fam ily satisfac-
pain history and the w aiting tim e for this treatm ent. tion can be fou nd at w w w.scottga.org.
Sanjeev d oes not need u rgent treatm ent, and he is not in Som e m ay not have the cop ing skills to coop erate w ith
severe p ain. Therefore a general anaesthetic is not cu rrently the anaesthetic ind uction and m ay need pre-m ed ication
ju sti ed esp ecially as in Sanjeev’s case there is tim e to stab- beforehand . The com m onest pre-m ed ication is m id azolam
lise his caries and see how he and his sym ptom s resp ond to 0.5 m g/ kg given app roxim ately 30 m inutes before the
this initial treatm ent. general anaesthetic ind uction.
■ Wha t treatment plan would you propose? ■ What medical comorbidities can children with a disability
commonly present with?
Using the principles d iscussed in Chap ter 24, a treatm ent
plan should be d raw n u p together w ith a visit-by-visit p lan. Apart from his Asperger ’s synd rom e, Sanjeev is otherw ise
As for all child ren, it is essential to ensu re a rigorou s p reven- healthy. H ow ever, som etim es d isabilities are linked w ith a
tive plan. Sanjeev may alw ays need extra su p p ort w hen m ed ical com orbid ity. An exam p le of this is a child w ith
attend ing the d entist and therefore keep ing him caries free Dow n synd rom e, w ho m ight not only have a card iac d efect
is a key p riority. bu t also be p rone to acu te lym phoblastic leu kaem ia, espe-
By follow ing Sanjeev’s instru ctions, he cop ed w ith the cially if the Philad elp hia chrom osom e is carried together
temporary restorations and both his m um and he engaged w ith trisom y 21.
in the p reventive regim e (d iscu ssed in Chap ters 22 and 23). The m anagem ent of these child ren w ith com p lex cond i-
Sanjeev’s cooperation w as good bu t limited . H ow ever, he tions need s liaison w ith paed iatricians and is best referred
respond ed w ell to nitrou s oxid e sed ation. Conventional to a hospital p aed iatric d entistry team .
caries rem oval w as u nd ertaken u nd er local anaesthetic and
nitrou s oxid e sed ation. This w as very effective, and Sanjeev
Key point
comp leted treatm ent. While the m and ibu lar second p rim ary
m olars w ere anaesthetized , the alm ost exfoliated m and ibu- • Learning disabilities can be linked to epilepsy, cardiac
lar p rim ary m olars w ere extracted . de ects and other medical problems.
• There needs to be liaison with the child’s paediatrician.
Common disabilities • Re erral to a community or hospital based paediatric
■ Wha t are the common disabilities? dentistry specialist team may be needed, especially i
general anaesthesia treatment is required and their
There are m any other physical d isabilities and learning d if- medical comorbidity will complicate the general
culties. These can be grou p ed into sensory, p hysical, anaesthesia.
m ental and m ed ical d isabilities. The com m onest of these are
show n in Table 27.1. Som etim es these can be intertw ined .
The im p act of m ed ical cond itions on d ental care is d iscu ssed ■ How does a dentist communicate with children with
in Chap ter 28. a disa bility?
■ How would this plan be altered i Sa njeev’s disability had
Com m u nication w ith child ren w ith com p lex need s inclu d es
been more severe?
a mixtu re of m ethod s and technologies that can sup plem ent
Sanjeev coped w ell w ith a d ental p lan that w as based on the spoken and w ritten w ord and gestu re. For som e, ges-
prevention, stabilization and then d e nitive care. As su ch, tu res, facial exp ressions, bod y p ostu res, eye gaze and m ime
it d id not challenge him too m u ch and it also incorp orated is need ed . For others, sign langu age, e.g. British sign lan-
very good behaviou ral management. H ow ever, for som e gu age, or other hand signals and pictures and sym bols or
child ren, their p hysical and learning d isability is m ore other m ed ia su ch as a sou nd board m ay be u sed . The best-
severe and their d ental need s m ore u rgent. A typical know n technique is MAKATON , d evelop ed in the 1970s to
exam ple is a child w ith epilep sy and cerebral p alsy w ho is help p eop le w ith learning d isabilities to com m unicate. It
u nable to control his or her m ovem ents. This child m ay have u ses som e British sign langu age signs com bined w ith
had a seizu re and fallen, thu s trau m atizing a tooth. In su ch sp eech, facial expression, eye contact and bod y langu age
a case, the child m ay be u nable to cop e w ith treatm ent for along w ith gestu res and sym bols. N ow ad ays, MAKATON
161 •
CHILDRENWITHDISABILITIESANDLEARNINGDIFFICULTIES 27
Table 27.1 Types o disability
Type Example(s) Dental implications Solutions
Physical Cerebral palsy Bruxism Oral hygiene support
Varying degrees o Reduced vertical dimension Modifed brushes
paralysis/muscular Anterior open bite Teaching carers howto brush
dys unction Drooling 2800 ppm uoride toothpaste or children aged 10 and over
Epilepsy Inabilityto per ormadequate oral hygiene Regular check ups and scaling
Behavioural problems Phenytoin induced gingival hyperplasia Corsodyl gel applied via a toothbrush daily, separate rom uoride toothbrushing
Visual and/or hearing Wheel chair access Reduce sugar requency
impairments Wherever possible consider re erral to interdisciplinaryteam or assessment o
Compromised speech and drooling to avoid surgeryto relocate submandibular salivarygland outlet, as
learning skills this will signifcantlyincrease caries riskespeciallylower anterior teeth
Augmentive and alternative communication skills
Learning Down syndrome Class IIIocclusion Oral hygiene support
Macroglossia Modifed brushes
Hypodontia Teaching carers howto brush
Microdontia 2800 ppm uoride toothpaste or children aged 10 and over
Delayed exoliation o primaryteeth Regular check ups and scaling
Predisposition to periodontal disease Corsodyl gel applied via a toothbrush daily, separate rom uoride toothbrushing
Reduce sugar requency
Medical problems:
Cardiac de ect
Leukaemia
Recurrent chest in ection
Severe developmental delay Di cult to examine or to provide dental care Consider gentle holding to prevent harm– known as‘clinical holding’
Mouth props (thimble)
Towels
Pillows
Sa etybelts
Pharmacological restraint
Pre medication
General anaesthesia
Sensory Hearing Di cultygiving a history Lip reading
disabilities Di culty ollowing instructions while in the dental chair, Do not over emphasize mouth and lips when speaking – it causes di culties
especiallyi the dentist is behind with lip reading
Hearing aids and cochlear implants maydistort sounds and Find out the best means o communication
enhance the volume o dental drills and scalers so much Take time to askthemto showit to you and agree howyou will use it to
that it is pain ul and distressing collaborate together to communicate
Uses other means o communication Give child a hand mirror so that theycan see you
Sign language Warn to switch o hearing aid or turn down volume be ore drilling or scaling
Lip reading Agree on hand signals or gestures to allowcontinued communication while
Other communcation aids or media such asVOCA hearing aids are o
Cochlear implants
Avoid monopolar electrosurgery
Vision Needs toothbrushing instruction that is not based on visual
cues such as disclosing
Bright lights can hurt Use sunglasses and avoid shining light into eyes
No visualization o surroundings or gestures o dentists or sta Give verbal cues
Access challenges Use and allowtouch shake hands/touch hands and shoulder
Stairs Use Braille in li ts and in signage
Guide dog Thinkabout where the guide dog can be during treatment
Directional signage
has been au gm ented by new technologies and m ed ia tressing m e’. Other lea ets and storybooks can help chil-
(for exam p le http :/ / w id git-health.com / easy-read -sheets/ d ren p rep are for their d ental visit and w hat to exp ect.
p d fs/ H ealthy%20teeth.p d f). Speech and language thera-
p ists u se all of these techniqu es and tailor them to each Key Point
child ’s need s so that every child can achieve som e level of
com m u nication. As can be seen from Sanjeev’s case, the • Children with disabilities communicate by gestures,
com m u nication p assp ort can w ork very w ell. The fu ll pass- symbols, signing and multimedia.
p ort contains other help fu l sections su ch as ‘things I can’t • Many have their own ‘communication passport’.
cop e w ith and m ake m e d istressed ’ and ‘how to avoid d is-
• 162
27 CHILDRENWITHDISABILITIESANDLEARNINGDIFFICULTIES
Primary resources and Peninsu la Cerebra Research Unit 2013 Dentistry for child ren and
you ng p eop le w ith learning d isabilities and challenging
recommended reading behaviou r. Available at: http:/ / w w w.p encru .org/ evid ence/
Facu lty of Dental Su rgery 2012 Clinical Guid elines and Integrated d entistry/ .
Care Pathw ays for the Oral H ealth Care of Peop le w ith Pu blic H ealth England 2014 Delivering Better Oral H ealth: An
Learning Disabilities. Lond on: Facu lty of Dental Su rgery, The Evid ence-Based Toolkit for Prevention, 3rd ed n. Lond on: Pu blic
Royal College of Su rgeons of England . H ealth England . Available at: http s:/ / w w w.gov.u k/
Makaton®. Available at: w w w.m akaton.org. governm ent/ u p load s/ system / u p load s/ attachm ent_d ata/
le/ 367563/ DBOH v32014OCTMainDocu m ent_3.p d f.
Mencap . Available at: https:/ / w w w.m encap.org.u k/ cqcrep orts.
Research Au tism . Available at: http :/ / researchautism .net
The N ational Au tistic Society. Available at: http :/ / w w w
.au tism .org.uk. RN IB Know led ge and Research H u b. Available at: http :/ / w w w
.rnib.org.u k/ know led ge-and -research-hu b.
N u nn J, Foster M, Master S et al 2008 Consent and the Use of
Physical Intervention in the Dental Care of Child ren. Lond on: Scott’s H ospital Dental Visit. Available at: w w w.scottga.org.
Royal College of Su rgeons of England . Available at: http s:/ /
w w w.rcseng.ac.u k/ fd s/ p ublications-clinical-gu id elines/
clinical_gu id elines/ d ocu m ents/ p aed _d ent_intervention.p d f. For revision, see Mind Map 27, page 248.
28
Dental history
She had a p reviou s lling in the E w ith no local anaesthetic
abou t a year ago. N o bitew ing rad iograp hs w ere taken.
Examination
Extraorally there is no sw elling and no facial asym m e-
try. There is left-sid ed su bm and ibu lar lym phad opathy.
problems in children At the tim e of the lling, no bitew ing rad iograp hs w ere
taken to id entify the d epth of the caries, the p roxim ity of
the caries to the pu lp and the p ulpal resp onse to the caries.
Moreover, the lack of local anaesthetic w hen u nd ertaking
conventional caries rem oval often resu lts in incom p lete
removal, as the child nd s the d rilling uncom fortable. The
Cell number
bone marrow recovery
0 5 21 28 42 47 63 68
Chemo Chemo Chemo Chemo
Day
Fig. 28.1 E with a temporary restoration, D distal caries with Fig. 28.2 A schematic and simple diagram to explain the e ect o
buccal swelling. chemotherapy on bone marrow and cancer cell numbers.
• 164
28 COMMONMEDICALPROBLEMSINCHILDREN
taking H annah’s tem p eratu re is essential. H er tem peratu re w ill u nd ergo a lu m bar p u nctu re and bone m arrow asp ira-
is 38.5°C. tion. These are invariably carried ou t u nd er general anaes-
The oral assessment should include bitewings and a d ental thetic and m ay therefore p rovid e an op p ortu nity to
panoramic tomogram, when the patient can tolerate these und ertake any acu te extractions.
radiographs (Fig. 28.3). Follow ing the clinical and radio-
graphic examination, a complete problem list and treatment
plan (see Chapter 24, Table 24.3) should be drawn up. Any
Treatment
primary teeth with a poor prognosis, including those with ■ What acute treatment does Hannah need?
deep caries, should be extracted rather than restored. For
necrotic and infected permanent teeth, either they should be The presence of a tem peratu re, together w ith the bu ccal
extracted or rst stage end odontics should be und ertaken sw elling associated w ith the E and / or D, need s to be d is-
w here there is con d ence that the infection can be eliminated. cu ssed w ith the m ed ical team im m ed iately. Treatm ent w ill
inclu d e the u se of approp riate antibiotics (for exam ple,
Medical in ormation Close collaboration is required w ith amoxicillin and m etronid azole or sim ilar antibiotics given
the m ed ical team coord inating H annah’s chemotherapy. intravenously or orally d ep end ing on the severity of the
There are only a few short w ind ow s in w hich invasive infection) and painkillers (these are frequ ently paracetam ol
d ental treatm ent can be p rovid ed as a resu lt of the anaem ia, and opioid s, as non-steroid al anti-in am m atories such as
leukopenia and throm bocytopenia associated w ith her ibuprofen are avoid ed ow ing to the low p latelet cou nt and
treatm ent. Therefore it is essential to nd ou t the cu rrent fu ll the risk of bleed ing). H annah w as ad m itted to the oncology
blood cou nt (red cell cou nt, w hite cell cou nt, neu trophil w ard and started on intravenou s antibiotics.
cou nt and p latelet cou nt) and w hether the cou nt w ill At the m ost ap prop riate tim e, in relation to the chem o-
im p rove or get w orse in the im m ed iate fu tu re. Moreover, at therap y regime and fu ll blood cou nt, the DE w ill need to
d ifferent points of ALL chem otherap y regim ens, child ren be extracted . Althou gh sw elling is m ost likely to arise from
the E, for H annah the safest option w ou ld be to extract both
DE to elim inate all potential sou rces of infection. In id enti-
fying the m ost ap p rop riate tim e for this treatm ent, consid -
eration shou ld be given to how long it w ill take the socket
to heal p ost-extraction becau se her cou nts w ill start to d rop
again w ith the next cou rse of chem otherap y.
■ What other denta l care does Hannah require?
H annah requires an intense preventative regim e against any
fu rther oral d isease. For som e child ren u nd ergoing chem o-
therap y, their d iet w ill change signi cantly d u ring treat-
m ent. This is fu rther exacerbated by the sid e effects of
chem otherapy, such as m ucositis and the need to m aintain
ad equ ate calori c oral intake. On occasions w here child ren
A
are failing to eat su f cient calories, they m ay be fed via a
nasogastric tu be, gastrostom y or intravenou sly.
■ What are the oral implica tions o childhood
ca ncer treatment?
Treatm ent for leukaem ia and solid child hood cancers can
includ e chem otherapy, rad iotherap y and su rgery. Boxes
28.1 and 28.2 list the short- and long-term oral com plica-
tions of chem otherapy and rad iotherapy.
required to m onitor any signs of infection as a result of the Primary resources and
tooth becom ing non-vital. Avoid ance of non-vital and
infected teeth is essential to m inim ize the increased risk of recommended reading
infective end ocard itis. H arriet’s p arents, follow ing this d is- RCS Guid eline for Oral Managem ent of Oncology Patients
Requ iring Rad iotherap y, Chem otherap y and / or Bone Marrow
cu ssion, op ted for the H all crow n and very carefu l follow -
Transp lantation 2012 Available at: http s:/ / w w w.rcseng.ac.u k/
u p . They felt that if she d id have a general anaesthetic, they fd s/ p u blications-clinical-gu id elines/ clinical_gu id elines/
w ou ld elect to have E extracted . d ocu m ents/ clinical-gu id elines-for-the-oral-m anagem ent-of
Where a general anaesthetic is requ ired for d ental care, chil- -oncology-p atients-requ iring-rad iotherap y-chem otherap y-and
d ren w ith com p lex congenital heart d efects (rep aired or -or-bone-m arrow -transp lantation.
u nrep aired ) or w ith rhythm ic d isord ers (for examp le Wolf Dayer MJ, Jones S, Prend ergast B et al 2015 Incid ence of infective
Parkinson White synd rom e) should be referred to special- end ocard itis in England , 2000–13: a secu lar trend , interru p ted
ized card iac hospitals. tim e-series analysis. Lancet 385 (9974):1219–1228.
Exam p les of other com m on m ed ical p roblem s and how they N ICE Guid eline (CG 64) 2008 Prop hylaxis against Infective
im pact d ental care is provid ed in Table 28.1. End ocard itis: Antim icrobial Prop hylaxis against Infective
End ocard itis in Ad u lts and Child ren Und ergoing Interventional
Proced u res. Available at: https:/ / w w w.nice.org.u k/ gu id ance/
Key point cg64.
AAPD gu id elines 2015 Gu id eline on d ental m anagem ent of
With all medical conditions: p ed iatric p atients receiving chem otherap y, hem atop oietic cell
• Enhanced prevention is essential to prevent or minimize transp lantation, and / or rad iation therap y. Ped iatr Dent 37 (6):
caries 298–306.
• Care ul liaison with the medical team leading the
patient’s care For revision, see Mind Map 28,
page 249.
29
■ What specif c questions would you ask a nd why?
Was there any loss o consciousness? I so how long? I there was,
then this signi es intracranial trauma and the child should be
re erred to an accident and emergency department. The
duration o loss o consciousness can provide an indication to
the severity o the head injury.
When did the accident occur? Delay in seeking help might
arouse suspicions o a non-accidental injury.
The displaced Where did the accident occur? An accident outside raises the
additional problem o potential wound contamination. Any
primaryincisor
child brought up in the UK should be immunized against
tetanus. I a child has not been immunized, seek the advice o
a local general practitioner or accident and emergency
department.
What was the sur ace on which the accident occurred? Newly
constructed playgrounds have to con orm to British Standards
and should be either o an energy-absorbing polymer or bark
chippings. Older playgrounds and normal pathways will have
SUMMARY non-yielding sur aces and are likely to produce greater
James, who is 3 years old, tripped over while damage and potentially greater risk o more underlying
playing outside. He hit his ront teeth on the injuries. Dirt or gravel can contaminate extra- and intra-oral
ground. How do you manage the immediate wounds, and these oreign bodies will need to be care ully
removed to prevent in ection and reduce scarring.
problem, and what do you advise his parents about
potential damage to the permanent teeth? How did the accident occur? This gives an indication o the
orce that produced the injury. The clinician needs to be
highly suspicious o the high-impact injury that looks simple.
History Always suspect a deeper underlying injury until proven
otherwise.
Complaint
Fragments, where are they? Where a tooth or teeth have been
Jam es has been brou ght to you r su rgery straight from hom e
ractured, these ragments need to be identi ed. Although in
by his mother. She says his u p p er front tooth has been
many cases they will have been spat out, there is a risk o
pu shed back (Fig. 29.1).
these being swallowed, inhaled or incorporated into oral so t
tissues (e.g. lacerated lips or tongue). Suspicion o inhalation
History o complaint o ragments is increased i there was any history o loss o
Jam es trip p ed and fell forw ard hitting his teeth on the consciousness, where the accident was not witnessed by an
grou nd . One tooth is ‘p u shed backw ard s’. adult or i there was coughing or choking ollowing the injury.
I in any doubt, re erral to an accident and emergency
Medical history department to investigate this urther is needed and may
Jam es is a healthy boy w ho has had no signi cant child hood necessitate a chest x-ray.
illnesses and w ho is u p to d ate w ith all his vaccinations. What other parts o the body were injured? Frequently other
parts o the body will also be injured such as abrasions to
Dental history hands, elbows or knees. I visible they should be brief y
Jam es has been a regu lar attend er at his d entist since the examined to establish the extent o these injuries. Again,
age of 2 years. H e has had his teeth p olished and has no concerns o more signi cant injury, or example bony
caries. ractures, should be assessed at an accident and emergency
department.
Examination
Extraoral
James is d istressed , bu t there is no obviou s extraoral sw ell-
ing or facial asym m etry.
Intraoral
■ The a ppea rance o the upper anterior teeth is shown in
Fig. 29.1. What ca n you see?
Fig. 29.1 Palatal luxation o A. Palatal d isp lacem ent of A and associated gingival traum a.
169 •
THEDISPLACEDPRIMARYINCISOR 29
■ What specif c signs will you look or in your exa mina tion? an intruded tooth may occur, and close review is necessary. I
re-eruption has not occurred within 4 6 months, an intruded
The mobility o the teeth. Are they a danger to the airway?
primary incisor should be removed to minimize eruptive
The occlusion. Do the injured teeth prevent normal problems in the permanent dentition.
occlusion?
An adult periapical lm used as an anterior occlusal is the
Mobility o a segment o teeth, e.g. the injured teeth move easiest way to obtain a periapical view o the upper anterior
together rather than individually. This indicates a region in a young child. James’s radiograph did not reveal any
dentoalveolar racture. root ractures or dentoalveolar ractures.
■ What question should dentists keep at the back o their Vitality testing o primary teeth is not indicated, as young
minds when examining children? children are o ten unreliable in reporting any sensation elt.
Are the injuries consistent with the history, and i you eel Direction o displacement provides important in ormation on
they are, is this normal behaviour? the likelihood o any damage to the underlying permanent
successor. Displacement o the crown labial indicates the root
Child physical abuse presents with oro acial signs o bruising,
has moved palatally towards the permanent successor and
abrasions and lacerations, burns, bites and ractures in
vice versa.
approximately 65% o cases.
Radiographic assessment with periapical and/or occlusal lms
Dentists should have a copy o their local area Child
is essential: a palatal intrusion o the root toward the
Protection Committee guidelines. This will tell them who they
successor moves away rom the x-ray source and yields an
should contact or advice.
elongated image.
■ What ea tures in the history and examination would lead to A labial intrusion o the root away rom the successor moves
suspicions o child physical abuse? near the x-ray source, yielding a oreshortened image and a
There are 10 item s to consid er. Five are qu estions to ask gap between the apex o the primary incisor and crown o its
you rself, and ve are observations abou t the behaviou r of successor. Extraoral lateral radiographs have been shown to
the child and the p arent(s): have a limited value in showing labial positioning, especially
in cases o intruded lateral incisors or multiple intrusions.
Could the injury have been caused accidentally and i
so, how?
Does the explanation or the injury t the age and the clinical Diagnosis
ndings?
■ Wha t is your diagnosis?
I the explanation o the cause is consistent with the injury,
James has a palatal luxation injury to his upper le t primary
is this itsel within the normally acceptable limits o
behaviour? central incisor.
The child’s reactions to any medical or dental examinations. Pain. Either spontaneous or on eating suggests pathosis.
The general demeanour o the child. Mobility. Is the tooth a danger to the airway?
Any comments made by the child and/or parent that Occlusal inter erence. A luxation injury that has prevented
give concern about the child’s upbringing or li estyle. For normal intercuspal occlusion will prevent normal eating.
example, lack o parental supervision or a history o repeated
■ Wha t treatments are usua lly required or displaced
trauma.
prima ry incisors?
Concussion and subluxation: observation.
Investigations
Lateral luxation: i no occlusal inter erence, the tooth is
■ What investiga tions would you per orm or James? Expla in allowed to reposition spontaneously; i occlusal inter erence,
why or each. extract.
Radiographs are required to visualize the traumatized area and Intrusion: i the apex is displaced toward the labial bone plate,
assess whether there are any root ractures to either then leave or spontaneous repositioning. I no movement
the traumatized or adjacent teeth. In addition, is a within 4 6 months, extract. In addition, i the root has
dentoalveolar racture evident? Are permanent successor per orated the buccal plate o bone, as identi ed by palpating
teeth present? the area, extract. I the apex is displaced into the developing
tooth germ, extract.
In an intrusive injury a child may have been re erred as an
‘avulsed’incisor. It is imperative always to check in these Extrusion: extract or reposition i only a minor extrusion.
circumstances that the tooth is not intruded. Re-eruption o Avulsion: replantation is not indicated.
• 170
29 THEDISPLACEDPRIMARYINCISOR
Key point
Traumatized primary teeth may need to be extracted i :
• Pain interrupts eating or sleeping.
• Excessive mobility causes a danger to the airway.
• There is occlusal inter erence.
• Tooth becomes non-vital and child is uncooperative or
a pulpectomy. I the tooth is le t in situ, urther damage
to the developing permanent successor can result.
The ractured
traumatic amnesia are key indicators or the severity o the
head injury.
Was the ractured piece o tooth located?
incisor crown When, where and how did the injury occur? A clear and
detailed description o the injury is essential.
What other injuries were sustained at the time o the injury?
The time rom the injury to presentation may a ect the
treatment options.
Did Shay cope well with his previous experience o local
SUMMARY anaesthetic? The answer to this will dictate what behaviour
management techniques (see Chapter 26) may be required to
Shay is 8 years old. While saving a penalty or his
acilitate treatment.
school team, he collided with the goalpost and
sustained enamel-dentine-pulp and enamel-
dentine ractures to his upper central incisors. How Examination
would you manage the injuries? Outline a
Extraoral
ollow-up treatment plan.
■ Why is the presence o lip swelling together with a mucosal
lacera tion important?
History
This cou ld ind icate that the m issing tooth fragm ent is
Complaint retained in the lip.
The u p p er right and left p erm anent central incisors are frac- ■ How would you demonstrate there was a ragment o tooth
tured (Fig. 30.1). in the lip?
Take soft tissu e rad iograp hy u sing tw o view s at right angles
History o complaint to each other. A sim p le anterop osterior view using a p eriapi-
The inju ry w as su stained d u ring a gam e of soccer. There cal lm p laced behind the lip and in front of the teeth, fol-
w ere no other inju ries. low ed by a lateral soft tissu e view u sing a lateral occlu sal
lm (Fig. 30.2). Unless exp erienced and trained in nd ing
Medical history these fragments, it is sensible to refer to a su rgical colleague
Shay is a healthy boy w ith no history of illness. H e has had to retrieve them .
all his vaccinations, inclu d ing a pre-school booster for
tetanu s.
Key point
Missing tooth ragments could:
• Be within the so t tissues i there is a laceration.
• Have been inhaled i there was loss o consciousness.
• Have been spat out at the site o the accident.
• Have been swallowed.
Intraoral
■ Wha t injuries are visible in Fig. 30.1?
Fig. 30.1 Trauma to the central incisors. Pulp exposure can be There is an enam el-d entine fractu re of 1 and an enam el-
seen a ecting 1 . d entine-p u lp fractu re of 1 of greater than 1 m m in d iam eter.
• 172
30 THEFRACTUREDIMMATUREPERMANENTINCISORCROWN
also approp riate to brie y check the posterior teeth as they
can on rare occasions be inju red as w ell.
Investigations
• Radiographs (previously mentioned) or:
— Foreign body in so t tissues i applicable.
— Root maturity and apical status o teeth.
— Presence or absence o root or alveolar ractures.
• Vitality testing o all upper and lower incisors.
Treatment
■ What is the prime consideration or both the upper
centra l incisors?
Fig. 30.2 Fragments o tooth in lower lip (di erent case). To m aintain a vital p ulp w ithin the root, w hich w ill allow
ongoing p hysiological d entine d eposition. This w ill resu lt
It is essential that p eriod ontal inju ries are also d iagnosed . in fu ll root grow th w ith norm al d entinal w all thickness,
Unless special tests su ch as m obility or tend erness to per- w hich w ill red u ce the chance of late stage crow n root
cu ssion are u nd ertaken, d iagnoses su ch as concu ssion or fractu re.
sublu xation w ill be m issed . Crow n fractu res com bined w ith ■ What is the appropria te immedia te treatment or 1 (tha t
a period ontal injury have p oorer p u lp su rvival ou tcomes ha s an enamel-dentine racture)?
than those w ith no associated period ontal inju ry.
Reattachment o the ragment.
■ Are the roots o 1 and 1 likely to have open or closed apices?
or
Open. Apices are not u su ally closed on u p per p erm anent
central incisors before the age of 11 years. A bonded restoration/‘bandage’, which will produce a
hermetic seal. Glass ionomer cement is not an adequate
■ How would you conf rm apical status?
material or a ‘bandage’and will be lost shortly a ter
Periapical rad iograph. placement resulting in bacterial ingress and thermal damage
■ Wha t other injuries must you exclude on the periapical to the pulp rom hot and cold stimuli. A layer o setting
ra diograph? calcium hydroxide cement should be placed over dentine
where a pulpal shadow is visible prior to placement o an
Root fractu res. adhesive (composite) bandage.
■ What other eatures o the anterior teeth are important at
■ What are the treatment options or 1 (that ha s
examination?
a pulpal exposure)?
Mobility. In a buccopalatal direction. Excessive mobility
• Direct pulp capping.
suggests either a periodontal ligament injury or a root
racture. • Pulpotomy Cvek, coronal or radicular (depth
determined by level o inf ammation).
Colour. This will indicate whether any direct pulpal damage
Direct pu lp capp ing, the placem ent of w ou nd d ressings
causing haemorrhage into the dentinal tubules has occurred.
on an exp osed p u lp, is consid ered less unp red ictable by
Percussion. Tenderness suggests periapical damage and m any au thors. Partial p ulp otom y (Cvek) is the rem oval of
oedema. A dull note may suggest a clinically undiagnosed only the ou ter layer of d am aged and hyp eraem ic tissu e in
vertical crown racture or root racture. the exposed p ulps. This w ill leave healthy p ulp , w hich w ill
Vitality. Following trauma there may be a period o apparent perm it continu ed fu ll root grow th. Partial pu lpotom y is a
loss o vitality on testing with hot and cold stimuli or the highly su ccessfu l techniqu e. Where d am age to the pu lp has
electric pulp tester even in teeth without obvious crown been more extensive (e.g. size of exp osu re or increased
ractures. Nevertheless, the readings serve as a baseline d u ration betw een inju ry and treatm ent), fu rther in am ed
against which subsequent tests can be compared. Teeth, pu lp al tissue w ill have to be rem oved . Where this extend s
which respond to vitality testing at the time o injury, have an to the root canal ori ce, this is called a cervical pulp otom y
excellent chance o maintaining pulp vitality. For teeth that or a rad icu lar p u lp otom y w hen extend ing d ow n the root
do not respond at this time point, the pulp may be still be canal. The im portant asp ect of this treatm ent is to ensu re
vital and respond at subsequent clinic visits. that all in am ed p u lp is rem oved leaving healthy (u nin-
amm ed ) tissue behind .
■ Wha t teeth should be examined a ter trauma a ecting only
■ What a re the indica tions or permanent tooth pulpotomy?
the upper centrals?
No history o spontaneous pain.
All u pper and low er incisors should be includ ed in an
exam ination after any trau m a to the anterior region. It is Acute minor pain that subsides with analgesics.
173 •
THEFRACTUREDIMMATUREPERMANENTINCISORCROWN 30
No discom ort to percussion, no sulcus swelling, no
mobility.
Radiographic examination shows normal periodontal
ligament.
Tissue appears vital.
Bleeding rom the pulp excision site stops within 2 5
minutes.
Examination
The root ractured Extraoral
There is som e sw elling of the up per lip and som e bru ising
Key point
Splinting in dentoalveolar trauma:
• Flexible 2 weeks or avulsions.
• Flexible 4 weeks or luxations, dentoalveolar ractures
and apical and middle third root ractures.
• Flexible 4 months or coronal third root ractures.
For 4 w eeks in apical and m id d le third fractures u ntil the 4. Remove the wax or cotton wool rolls, and with a
m ajority of p eriod ontal ligam ent bres have healed . This nonworking hand, bring 1 and 1 into an accurate
time can be extend ed to 4 m onths in coronal third fractu res. position against the wire splint. Hold them in this
The old regim en of rigid splinting for root fractu res has been position while etching, washing, bonding and adding
show n to have no bene t. Rigid splinting w as m eant to give composite with the working hand. Cure the composite.
the fractu re its best chance of a hard tissu e union. Research 5. Smooth any rough areas with sandpaper discs.
has show n that hard tissu e u nion is m ost likely to occu r if ■ What materials could be used or splinting?
there w as little d isplacem ent at the tim e of the original
injury rather than being a fu nction of the typ e of sp lint An ideal splint should be simple and quick to place and
emp loyed . In other w ord s, the larger the d isp lacem ent at remove, easy to bend to ensure it is passive, biologically com-
the fracture line at the tim e of the injury, the sm aller the patible and relatively cheap. The splint must allow for func-
chance of a hard tissu e u nion betw een the fractu re end s tional movement of the teeth while holding the teeth in their
after red u ction and splinting. new position and allow ing thorough cleaning around the gin-
gival margins. The most common materials used are pieces of
■ Do a ny orms o dentoa lveolar injury need to be
orthod ontic w ire, for example 0.014-in or 0.016-in stainless
rigidly splinted?
steel or twist ex (w hich is three pieces of 0.010-in wire twisted
N o. H istorically, rigid sp linting w as used for d entoalveolar around each other). Each of these wires requires moderate
fractures. A rigid sp lint involved tw o sou nd abu tm ent teeth skills in wire bending to achieve a passive splint. New materi-
on either sid e of the inju ry and a stiffer arch w ire. It w as als such as titanium are now available for splinting, and these
prop osed that this style of sp linting w ou ld ensu re no m ove- have the bene t of being much easier and therefore quicker
m ent betw een bony fragm ents, thereby allow ing healing. to passively ad apt to teeth (Chapter 32, Fig. 32.1B).
177 •
THEROOTFRACTUREDPERMANENTINCISOR 31
■ On removal o the splint how o ten would you Place non-setting calcium hydroxide 1 mm short o racture
review Andrea? line with aim o inducing barrier ormation.
After 1 m onth, 3 m onths, 6 m onths and then yearly. Change non-setting calcium hydroxide 3-monthly until
barrier orms, or alternatively use MTA to generate a 4 5-mm
■ What tests would you complete at each o these reviews?
barrier.
For all trau m atized teeth, a stand ard regimen shou ld be Obturate with gutta percha to barrier.
follow ed . If this is carried ou t in every case, then om issions
are less likely to be m ad e. Annual radiographic review.
• Clinical:
■ What ha ppens to the a pical ragment?
Colour (palatal sur ace best).
In nearly all cases this w ill u nd ergo pu lp canal obliteration
Buccal sulcus sensitivity to digital pressure.
and w ill not need treatm ent. If there is infection of the apical
Sinus or swelling presence.
fragm ent, it m ay requ ire su rgical removal. Root canal
Tenderness to percussion.
therapy across a root fracture is frau ght w ith d if cu lty
Percussion sound. becau se of p roblem s keeping the d istal canal d ry.
Mobility.
■ Is the prognosis good in coronal or gingival third
Sensibility testing.
root ractures?
• Radiography: long cone periapicals.
N o. Decisions need to be m ad e early regard ing options.
■ Is sensibility testing accurate?
Long-term stability and long-term retention of the w hole
N o form of sensibility testing on its ow n is accu rate. Electric tooth in these inju ries are uncom m on. Research show s a
pu lp testing (EPT) is p robably the m ost accu rate, bu t its real survival rate of one-third at 10 years post-traum a, w ith
valu e lies in successive num erical read ings w ith the sam e m any of these teeth being lost as a resu lt of fu rther trau m a
type of EPT. N u m erical valu es can then be comp ared . or excessive m obility. These consequ ences relate to the u nfa-
At each visit, resp onses (both positive and negative) vourable crow n root ratio.
shou ld be com p ared against u ninju red teeth and also if each
■ Wha t are the treatment options in coronal or gingival third
tooth is consistent in its response and the d u ration before
root ractures?
any p ositive sensation is acknow led ged . Cu rrent sensibility
testing relies on sensation of stim u li, w hereas true pu lp al Retain crown temporarily with an endodontic post across the
vitality is m ore appropriately tested by the presence of racture line.
blood ow. In the fu tu re, the w id espread u se of Dop pler in Remove coronal ragment. Root treat apical ragment and
d etecting blood ow in a trau m atized tooth w ill inform all orthodontically extrude prior to post, core and crown
d ecisions regard ing p u lp al necrosis and the necessity for placement.
extirp ation.
Remove coronal ragment. Cover, ‘bury’, the apical ragment
with a mucoperiosteal f ap. The width and height o the
alveolus are thus retained or uture implant placement.
Key point
Prosthetic replacement required.
What types o healing occur in root ractures?
Remove all portions o tooth. Prosthetic replacement
• Hard tissue. required. Future implant placement.
• Connective tissue (see Fig. 31.2). This type o healing is
o ten combined with osseous healing. As the two ■ Ca n root ra ctured teeth maintain vitality?
ragments grow apart over time, bone will f ll in the gap
Yes. The m ajority d o so (literatu re rep orts betw een 72% and
that was originally only f lled with connective tissue.
90% m aintain their vitality). Figs 31.2 and 31.3 show
• Granulation tissue. Technically this is not a type o And rea’s teeth 3 years after the original injury. The teeth
healing but is seen when the coronal ragment is m aintained vitality and u nd erw ent p rogressive p u lp canal
in ected. Once the in ection is treated, healing will take obliteration. In ad d ition, the d istal fragm ents are resorbing.
place by connective tissue. Im portantly, there has been no infection.
■ Ca n root ractured teeth be moved orthodontically?
Yes, bu t w ith cau tion. If there is not a hard tissu e u nion
■ Wha t is the likely radiographic appearance at the racture
betw een the fractu re end s, then the apical p ortion w ill
line i the coronal tooth portion becomes non-vital?
remain static and only the coronal portion w ill m ove.
There w ill be increasing w id ening and translu cency su r- Regu lar rad iograp hic review w ill be necessary d u ring any
round ing and betw een the fractu red end s of the root. orthod ontic treatm ent. Orthod ontic m ovem ent m ay cau se
■ I the coronal portion o an apical or middle third root fu rther root resorption, w hich w hen com bined w ith an
ra ctured tooth beca me non-vita l, how would you root treat alread y com prom ised crow n root ratio can lead to long-
the tooth? term m obility of the coronal fragm ent at the end of ortho-
d ontic treatment. Consequently, great care is need ed w ith
Extirpation to the racture line only. the orthod ontic treatm ent to m inimize the risk of further
Establish working length to racture line. root resorp tion.
• 178
31 THEROOTFRACTUREDPERMANENTINCISOR
The avulsed incisor 8. Bend a titanium trauma splint (or alternative splinting
material as discussed in Chapter 31) to include one
uninjured tooth on either side o the avulsed tooth
CC
( ) and ollow guidance described in this chapter or
CASE1 10.
hygiene.
Arrange a review appointment or 14 days.
SUMMARY ■ What a ctors a re important when deciding whether root
ca nal treatment is necessary in Ka thryn’s case?
Kathryn is 9 years old. She was playing with her
riends at a brownie camp with a skipping rope, Root development.
when the rope caught behind one o her upper How long the tooth was out o the mouth
central incisors and avulsed it. Her teacher has got (extra-alveolar time).
the tooth. How would you manage this problem? A tooth that has com pleted root d evelopm ent w ill not
■ Kathryn’s teacher phones your surgery or advice. She ha s u nd ergo revascu larization. The only tooth that has a chance
the tooth in a handkerchie . The accident occurred 10
minutes ago. Wha t is your a dvice?
Check that Kathryn has no other injuries, i.e. head injuries that
require re erral to an accident and emergency department.
Check or any known medical history.
Hold tooth by crown and wash gently under cold water to
remove any debris or 10 seconds.
Replant in socket ideally.
Hold tooth in socket by biting on a handkerchie . Come to
surgery.
I replantation is not possible, place the tooth in either milk or
normal saline ( rst aid box) and bring it to surgery with
Kathryn as quickly as possible. A
B CASE2
Fig. 32.2 (A) A post-replantation radiograph taken at 14-day SUMMARY
review, 1 showing an immature root orm. (B) 1 radiograph
taken at 6-month review showing continued root development. Justin is 11 years old. He ell o his scooter, avulsing
his 1 . His riends at the park ran home to get his
parents, who arrived within 15 minutes. They took
Justin and his tooth to an accident and emergency
Follow ing splint rem oval, Kathryn’s 1 w as carefully department. At hospital his tooth was placed in
review ed at 6 w eeks, 3 m onths, 6 m onths and 12 m onths. milk. Three hours later his tooth was replanted and
At each visit, special tests (d escribed in Chap ter 31) and splinted. The EAT was 4 hours, and the EADT 1 hour.
rad iographs w ere taken. This w as to ascertain the type of ■ Justin’s parents book a n emergency a ppointment so see
period ontal healing and to look for signs of p u lp al necrosis you the ollowing day, what will you do?
and or infection-related resorp tion. As can be seen in Fig.
32.2, continu ed root form ation w as seen d em onstrating Fig. 32.4 show s a su tu re splint. This typ e of splint is inap-
pu lp revascu larization. At 12 m onths (Figs 32.3A and B) prop riate, as the patient w ill nd it very d if cu lt to m aintain
there w as clear clinical and rad iographic signs of period on- good oral hygiene. Moreover, this typ e of sp lint is unable to
tal healing (re-establishm ent of a norm al period ontal liga- hold the tooth in the rep lanted p osition w ith the 1 slightly
m ent w ith a few sm all areas of rep air-related resorp tion) extru d ed on presentation. The sp lint w as rep laced for
and continu ed root grow th and ap ical closu re (signs of a more conventional sp lint (d iscu ssed in Chapter 31);
revascu larization). Kathryn w as therefore d ischarged back how ever, Ju stin w ou ld not tolerate fu rther rep ositioning of
to her general d ental practitioner w ith the prognosis that the tooth to im p rove its p osition. Ad vice d escribed earlier
the 1 w ill be retained as a fu nctional tooth for the rest of in this chap ter is reiterated , and Ju stin w as booked for a
her life. review appointm ent 8 d ays after his accid ent.
• 182
32 THEAVULSEDINCISOR
resorp tion. Therefore early referral to an interd iscip linary
team is essential. At this interd iscip linary clinic they w ill
d iscu ss the d ifferent treatm ent op tions w ith Ju stin and his
parents.
BSPD and IADT gu id elines d iffer slightly w ith their cu t
off p oints of w hen ankylosis-related resorp tion is highly
likely. Beyond EADT of 30 m inu tes and EAT of 90 m inutes,
BSPD gu id elines rep ort that there is less than a 10% chance
of p eriod ontal healing. For IADT, beyond EADT of 60
m inutes there is less than a 1% chance of p eriod ontal
healing. Justin is beyond both of these cu t off p oints, and
therefore ankylosis-related resorption is almost guaranteed .
H ow ever, m aintaining a tooth w hich w ill u ltim ately fail is
very im p ortant over the short to m ed iu m term . The tooth
Fig. 32.4 Showing 1 replanted with an inappropriate suture w ill help m aintain good aesthetics for the p atient as w ell as
splint. Reproducedwith permission romthe RCSEDen project, Royal College o Surgeons o England. the height and w id th of the alveolus. Careful follow -u p is
essential to d iagnose infraocclu sion as soon as it becom es
■ Wha t is the cha nce o pulp survival? ap parent.
Rad iograp hs show 1 has com p lete root d evelop m ent. There- ■ What long-term treatment options are available?
fore there is no chance of p u lpal revascu larization. In ord er
There are a nu m ber of d ifferent op tions w hich w ere assessed
to prevent infection-related resorp tion, root canal treatm ent
for Ju stin. These inclu d ed d ecorontation, orthod ontic space
is com m enced at this visit. It is good practice to extirp ate
closure and cam ou age of the lateral incisor, d entu re, resin
the necrotic pu lp and d isinfect the root canal before rem ov-
retained brid ge and p rem olar transplant. In a grow ing
ing the splint. Justin w as booked for a fu rther review and
patient (e.g. a child or ad olescent) an osseointregrated
d isinfection of the root canal 1 m onth later.
im plant is contraind icated as they have not com p leted their
■ Wha t intracana l medicament should be pla ced in the facial grow th.
extirpated tooth? The d ifferent op tions w ere d iscu ssed w ith Ju stin and his
There has been som e anim al-based research that has show n parents at the interd iscip linary clinic. Justin had crow d ing
that w hen non-setting calciu m hyd roxid e is placed too in his u pper and low er arches and w as keen on und ergo-
early after rep lantation (w ithin the rst 7 d ays) in a tooth ing orthod ontics to im prove his app earance. As p art of the
w ith a d am aged p eriod ontal ligam ent, this can aggravate treatm ent p lan a p rem olar w as to be extracted in each
favou rable p eriod ontal healing and lead to ankylosis-related qu ad rant. The best prognosis for prem olar transp lant is
resorp tion. With this in m ind som e au thorities ad vocate that w hen the root form ation is betw een three-qu arter and
a steriod / polyantibiotic p aste shou ld be the rst d ressing comp lete root length d evelopm ent bu t w ith an open ap ex.
placed in root canals of avu lsed teeth as soon after the Ju stin tted the criteria for a p rem olar transp lant and both
inju ry as p ossible. They argued that the steroid / antibiotic he and his parents w ere keen to pu rsu e this option (see
paste w ill d am pen the im m u ne resp onse p rom oting favou r- Figs 32.5 A-D).
able healing. Cu rrently there is no d e nitive research su p- Ju stin had a tooth extracted in each qu ad rant includ ing
porting one app roach over another. Therefore gu id elines the 5 w hich w as u sed for the p remolar transp lants. This w as
ad vocate either ap proach. For Ju stin’s tooth, a non-setting bu ilt up initially d u ring the healing p hase of the transplant
calcium hyd roxid e d ressing w as p laced at his d ay-8 review before the orthod ontic treatm ent w as u nd ertaken. On the
appointm ent. comp letion of his orthod ontic treatm ent, a nal com posite
bu ild u p w as p rovid ed . The transplant d em onstrated both
■ Wha t are the cha nces o periodontal healing?
pu lp al and period ontal healing. The prognosis for the trans-
There is very little chance of period ontal healing w ith the plant is that it w ill be retained as a fu nctional u nit for the
tooth almost gu aranteed to heal by ankylosis-related rest of Ju stin’s life.
183 •
THEAVULSEDINCISOR 32
Fig. 32.5 (A) 1 week a ter the premolar transplant procedure with initial composite build up. (B) Radiograph o the premolar transplant
taken 1 week a ter the premolar transplant procedure. Reproduced with permission romthe RCSEDen project, Royal College o Surgeons o England. (C) Radiograph o
premolar transplant taken 6 months a ter the premolar transplant, showing periodontal and pulpal healing (continue root growth).
Reproduced with permission romthe RCSEDen project, Royal College o Surgeons o England. (D) Premolar transplant (1 ) a ter orthodontic treatment and nal composite
build up. Reproducedwith permission romthe RCSEDen project, Royal College o Surgeons o England.
Primary resources and Day PF, Kind elan SA, Sp encer J et al 2008 Dental trau m a: p art 2.
Managing poor prognosis anterior teeth - treatm ent options for
recommended reading the su bsequ ent sp ace in a grow ing p atient. J of Orthod
And ersson L, And reasen JO Day P et al 2012 International 35:143–155.
Association of Dental Trau m atology gu id elines for the Trope M 2011 Avu lsion of p erm anent teeth: theory to p ractice.
m anagem ent of traum atic d ental inju ries: 2. Avu lsion of Dent Traum atol 27 (4):281–294.
p erm anent teeth. Dent Trau m atol 28 (2):88–96.
And reasen JO, Laurid sen E, Bakland L et al 2014 Dental trau m a For revision, see Mind Map 32,
gu id e. Available at: http :/ / w w w.d entaltraum agu id e.org/
Exam ination.aspx. page 253.
Day P, Gregg T 2012 Treatm ent of avu lsed p erm anent teeth in
child ren. British Society of Paed iatric Dentistry. Available at:
http :/ / bspd .co.u k/ Resou rces/ BSPD-Gu id elines.
33
■ What a re the main problems associated with natal and
neona tal teeth?
Mobility.
Ulceration o ventral sur ace o tongue.
Nipple soreness (breast eeding mothers).
The teeth are m obile becau se the d evelop m ent of the
tooth is consistent w ith age. Only abou t ve-sixths of
Disorders o eruption the crow n, and u sually no root, is form ed . Ad d itionally, the
crow n is occasionally d ilacerated and the enam el hypoplas-
tic or hypom ineralized .
and exoliation
Excessive mobility is a d anger to the airw ay from aspira-
tion, and the tooth should be rem oved . Care shou ld be taken
to ensure that the entire tooth inclu d ing the p ulpal tissue is
removed , otherw ise d entine and a root w ill form , w hich w ill
requ ire eventual rem oval. If teeth can be left, then continued
root d evelopm ent w ill occu r. N ipp le soreness m ay occasion-
ally necessitate tooth rem oval.
Medical history
Lisa is a healthy child w ho has never been in hosp ital.
Dental history
Lisa and her fam ily are regu lar d ental attend ers. The fam ily
m em bers all have a low caries risk. Lisa has had no restora- Fig. 34.1 Hypomineralized and hypoplastic upper rst permanent
tions in her p rim ary d entition. She u sed a child ren’s tooth- molars.
p aste (1050 p p m) u ntil recently and is now u sing the sam e
ad u lt toothp aste as her p arents (1450 p p m ).
Examination
Intraoral examination revealed that all fou r rst perm anent
m olars (FPMs) w ere hyp om ineralized w ith areas of brow n
enam el. In ad d ition, there w ere areas of post-eru ptive
breakd ow n (hypoplasia) w here the enam el had chipped
aw ay, exp osing the u nd erlying d entine. The m axillary
m olars w ere the w orst affected by p ost-eru p tive break-
d ow n. 6 had a large atyp ical am algam restoration. In ad d i-
tion, some cream y hyp om ineralized areas w ere visible on Fig. 34.2 Hypomineralized upper and lower permanent incisors.
• 188
34 POORQUALITYFIRSTPERMANENTMOLARS
■ Do you think that the enamel hypomineralization and ■ What other di erential diagnoses might you consider?
hypopla sia noted on the f rst perma nent molars and the
• Caries. Newly erupted teeth are particularly prone to
permanent incisors ollows a chronological pattern? I so, a t
dental caries until their enamel maturation is complete.
what time wa s the a ected enamel ormed?
However, it seems very unlikely, even in the presence o
Yes, it is p ossible that there is a chronological pattern. The particularly deep ssures, that Lisa, who has no caries in
cu sp tip s of the rst p erm anent molars begin mineralizing her primary teeth, should develop such caries in her
from the eighth m onth of p regnancy, and the cu sp tips of permanent teeth. In addition, the overall colour o the
the incisors and cu spid s (canines) from abou t 3 m onths of permanent molars is not consistent with caries in a tooth
age (the u pp er lateral incisor slightly later at 10–12 m onths). o normal morphology. The exposed dentine is slightly
Mineralization d ates for the p erm anent d entition are given so tened and does have caries, but the overall pattern
in Table 34.1. o destruction o the tooth suggests that caries is
■ Wha t specif c questions would you like to ask Lisa’s mother? secondary to some other predisposing actor, such as
hypomineralization/hypoplasia. Another actor to
Pre-natal. Mother’s health during pregnancy. Were there any consider that is against a diagnosis o caries is the creamy
concerns such as high blood pressure, proteinuria or hypomineralized areas on the incisors. They are neither
preeclampsia? the shape nor the distribution o white spot or precarious
Peri-natal. Di cult birth. Was the delivery prolonged? Was lesions that one would expect with poor oral hygiene.
there a need or assisted delivery by orceps, ventouse or • Amelogenesis imper ecta. Although the presenting
caesarean? All o these can be associated with etal distress. eatures could be a hypomature orm o amelogenesis
Post-natal. Did Lisa spend any time in the special care baby imper ecta, there are several actors that suggest this is
unit (SCBU)? not the case: there is no amily history; the primary
dentition is not a ected; the pattern o the de ects is
Illnesses in the f rst 2 years o li e, e.g. meningitis, measles,
chronological. All o these combined make an inherited
respiratory in ections, chickenpox. These disturbances may
abnormality unlikely.
mani est as enamel de ects distributed in the enamel that
• Fluorosis. The severe enamel de ects on the molar teeth
was orming around birth and in the rst 2 years o li e.
could only occur i there was a history o very high
Fu rther qu estioning revealed that Lisa w as born after endemic f uoride levels, probably in excess o 6 ppm.
a norm al p regnancy and d elivery bu t had a signi cant Such levels do not occur in the UK. Mild f uorosis is seen
nu mber of respiratory infections d u ring the rst year of life. where children have swallowed toothpaste or have been
This con rm s you r d iagnosis of chronological hyp op lasia. given supplementation in addition to swallowing
The correct nam e for this cond ition is m olar incisor hypom - toothpaste. However, in such cases there are usually ne,
ineralization (MIH ). Post-eru ptive breakd ow n and atyp ical opaque, white lines ollowing the perikymata and small
restorations are consistent w ith this d iagnosis. irregular enamel opacities or f ecks that merge into the
background enamel colour. Fluorosis does not produce
well-demarcated opacities like those seen on the incisors.
Tooth discoloration,
nent teeth that had started to m ineralize before birth (arou nd
the eighth m onth of pregnancy). Cond itions that m ay
suggest som e fetal d istress and d ysm ineralization m ay be
hypomineralization
raised m aternal blood p ressu re; early ad m ission to hosp ital;
prematu re d elivery; p rolonged d elivery; assisted d elivery,
e.g. forcep s or ventou se, em ergency caesarean section; or
and hypoplasia
ad mission to the sp ecial care baby u nit (SCBU).
Childhood illnesses. These m ay resu lt in a ‘chronologi-
cal hyp op lasia’ affecting those p arts of the teeth that w ere
m ineralizing at the time of the illness. Although ‘chrono-
logical hyp op lasia’ u su ally involves som e failu re of d evel-
opm ent of enam el m atrix giving obvious lines or rid ges on
the teeth, there m ay be m ild er form s that can only be felt
CASE1 w ith a p robe and that p resent for care becau se they attract
extrinsic stain.
Tablets or medications taken during childhood. Tetra-
SUMMARY cycline staining shou ld not occu r now in child ren w ho have
Simon is 8 years old. He has been brought to your been brought u p in d evelop ed cou ntries. It is still com m on
in child ren from d evelop ing cou ntries w here tetracycline
surgery by his mother because his teeth are very
is still u sed becau se it is a very effective, cheap , broad -
dark and he is being teased at school. How would spectru m antibiotic. The only child ren w ho m ay still be
you determine the origin o the discoloration? affected in d eveloped countries are those w ith cystic brosis
w ho have d evelop ed mu ltip le d ru g resistances as a resu lt
History of recu rrent resp iratory infection.
Sim on w as born w ith prim ary biliary atresia. This
Sim on says that the colou r of his perm anent teeth has resulted in progressive liver failure, increasing levels of cir-
rem ained the sam e since they erupted (Fig. 35.1). cu lating biliru bin and eventu ally a liver transp lant at the
■ What other questions do you need to ask about the teeth? age of 2.5 years. All the perm anent teeth d eveloping prior
to the transp lantation w ill have intrinsic d iscoloration as a
Do they chip or wear?
result of the high circu lating biliru bin. The p rim ary d enti-
Are all the teeth a ected? tion w ill be affected to a lesser extent as a resu lt of staining
Was the primary dentition a ected? in second ary d entine. Althou gh not seen w ith Sim on, som e
Has anyone else in the amily got, or had, similar teeth? child ren can have gingival overgrow th as a resu lt of im m u -
Positive answ ers to the last three qu estions m ay su ggest nosu p p ressive treatm ent w ith cyclosp orine.
an inherited abnormality of the teeth su ch as am elogenesis The colour of the second perm anent m olars is likely to
or d entinogenesis im p erfecta. be entirely norm al as these teeth started m ineralizing
arou nd the age of 3 w hen there w as a fu nctioning new liver
and norm al levels of biliru bin.
Dental history
■ Wha t other lines o questioning do we need to explore i we
are considering all the possible causes o intrinsic
discoloration?
Was there a history o in ection and/or extraction or decay o
any o the primary teeth?
Localized infection on p rim ary teeth can cau se local-
ized abnorm alities of enam el form ation and m ineraliza-
tion of p erm anent teeth (Tu rner ’s tooth).
Visit 2
4. Check that the bleaching tray ts and trim back any
5.
rough edges that may irritate the gingival margin.
Place rubber dam, isolating the a ected tooth. Ensure
CASE2
adequate eye protection or the patient, operator and
SUMMARY
dental nurse.
6. Remove the palatal restoration to permit access to the Tony is 14 years old. He has come to your surgery
root canal. because he is concerned by the colour o his teeth
7. Remove root lling to 1 2 mm below the dentogingival and his bad breath (Fig. 35.2).
junction you may need to use adult burs in a
miniature contra-angle head.
History
8. Place 1 mm o glass ionomer cement over the gutta
percha. H e has noticed his teeth changing colou r over the p ast year.
9. Use an ultrasonic to remove debris blocking the H is friend s have also com mented on his bad breath over
dentinal tubules on the labial sur ace. Alternatively, very this period of tim e.
lightly use a slow hand piece with a round bur. Do not The colour of the teeth in Fig. 35.2 is a resu lt of extrinsic
remove excessive dentine. staining from chrom ogenic bacteria d u e to inad equate oral
hygiene. The staining is classically in the gingival and cervi-
10. Show the patient (or parent) how to ll up the access
cal areas of the teeth.
with 10% carbamide peroxide and then seat the
bleaching tray. A small amount can also be placed in ■ Are there any other causes o extrinsic staining?
the well o the bleaching tray around the discoloured Food and drink. Tea, co ee and dishes such as curry can cause
tooth. staining o the teeth. Most commonly this occurs in the
11. Provide written and verbal instructions. In summary gingival or cervical areas initially, but i oral hygiene is poor,
advise the patient to remove the bleaching tray and then it can a ect a signi cant part o the whole tooth sur ace
replace the bleach 3 5 times a day. This should (Fig. 35.3).
continue or several days up to 2 weeks until the
Arrested caries. This produces a brown stain as a result o
patient is happy with the colour. It is sensible to provide
chromogenic bacteria.
the patient with a maximum o two tubes o bleach so
that they are orced to return or a review appointment
a ter a week. The bleaching tray should be worn at all
times except or tooth brushing. Phoning the patient a
couple o days a ter their visit is sensible to check how
they are getting on. O ten at this point they will not
have seen any change in colour.
Visit 3
12. Check that the patient is happy with the colour. Wash
out the access cavity and place a cotton wool ball
and a temporary restoration (glass ionomer cement). Fig. 35.2 Extrinsic chromogenic staining.
• 194
35 TOOTHDISCOLORATION, HYPOMINERALIZATIONANDHYPOPLASIA
be ore school, and then last thing at night with a 2800 ppm
f uoride toothpaste based on a high caries risk.
Show him the ‘white spot’lesions. Explain that these will
progress to decay i the brushing is not corrected.
Daily f uoride mouthwash (0.05% sodium f uoride) used at a
separate time to brushing to encourage enamel
remineralization.
Mottled teeth
p lem ents, type and am ount of toothp aste used and any
history of eating toothp aste.
It transp ired that Sop hie had never received any su p p le-
m ents or u sed toothpaste excessively. H ow ever, she lived
on a farm w ith its ow n ‘w ell’ w ater sup p ly. This w as su b-
sequ ently analysed and w as fou nd to be over 1 ppm uo-
rid e. The d iagnosis w as one of u orosis.
Examination
■ Wha t is the distribution o the mottling that you can see in
SUMMARY Fig. 36.1?
Sophie is 8 years old. Her main concern is that White and brow n m ottling of the incisal half of the labial
some o her permanent teeth have white patches, surface of 1 1 and w hite m ottling of the incisal third of the
especially the upper central incisors. She is getting labial su rface of 2 2.
teased at school because the upper centrals also ■ Do you know why the labia l sur aces o the upper
have brown patches. What are the causes o the permanent central incisors are o ten more a ected
by mottling?
white patches? How may they be treated?
Research has show n that these teeth are p articu larly su scep -
tible to an excess ingestion of uorid e betw een 24 and 30
History m onths of age.
Sophie noticed that the p erm anent teeth cam e through w ith Mild uorosis gives a d iffu se m ottling that m ay m anifest
the w hite and brow n patches (Fig. 36.1). They have not as d iffu se lines or patches that m erge into the backgrou nd
changed in ap p earance since eru p tion. enam el. When the uorosis becom es m ore severe the lines
■ What important questions would you now a sk her mother? and patches coalesce to p rod u ce a con u ent w hite su rface.
In very severe cases there is also p itting of the enam el. Well-
Were the p rim ary teeth norm al? d e ned or w ell-d em arcated p atches (su ch as m olar incisor
If the answ er to this is yes, then it is u nlikely to be an hypom ineralization; see Chapter 34) that d o not follow a
inherited d efect and m ore likely to have a system ic origin. system ic or chronological d istribu tion, or are localized , are
■ Is anyone else in the a mily a ected? u nlikely to be d ue to u orosis.
Unless siblings are subjected to exactly the sam e systemic ■ Which part o the enamel does mild uorosis a ect?
d iseases and cond itions it is likely that an affected sibling The ou ter 200–300 µm .
w ill ind icate an inherited d efect.
■ How ca n you use this knowledge to your adva ntage during
Sop hie’s p rimary teeth w ere norm al, and she has no sib-
your clinica l examination?
lings. N either her m other ’s nor her father ’s fam ily has
anyone w ith sim ilar d ental ap pearance. Look for areas of the d entition that are su bject to erosion or
attrition, e.g. the occlusal su rfaces of the rst perm anent
m olars. If the m ottled enam el has been rem oved on these
surfaces then that con rm s that the m ottling is in the outer
aspect of the enam el and the d iagnosis is likely to be one of
u orosis.
Key point
History taking in suspected uorosis:
• Fluoridated water in places o residence.
• Amount o paste and age brushing started.
• Type o toothpaste used and uoride concentration.
• Flouride supplements.
Fig. 36.1 Dis guring f uorotic mottling a ecting upper • Toothpaste eating habits.
permanent central incisors.
• 196
36 MOTTLEDTEETH
Treatment
■ What treatment options or Sophie would you consider or
uorotic mottling?
Fig. 36.2 A ter acid pumice microabrasion.
Microabrasion.
Composite veneers. 5. Mix 18% hydrochloric acid with pumice into a slurry and
apply a small amount to the labial sur ace on either a
Vital Bleaching.
rubber prophylaxis cup rotating slowly or a wooden
Microabrasion can be carried ou t in a variety of w ays and stick rubbed over the sur ace or 5 seconds, be ore
is a controlled rem oval of the su rface layer of enam el in washing or 5 seconds directly into an aspirator tip.
ord er to im p rove d iscolorations that are limited to the ou ter Repeat until the stain is reduced, up to a maximum o
enam el layer. It is not su itable for d eep enam el or d entine 10 × 5 second applications per tooth. Any improvement
d iscoloration. One of the m ost reliable m ethod s that has that is going to occur will have done so by this time.
been u sed extensively since 1986 is the hyd rochloric acid 6. Apply the f uoride drops to the teeth or 3 minutes.
(H Cl)-pu m ice m icroabrasion techniqu e. It is achieved by a
7. Remove the rubber dam.
combination of abrasion and erosion – the term ‘abrosion’
8. Polish the teeth with the nest sandpaper discs.
is som etim es u sed . In the clinical technique that w ill be
d escribed , no m ore than 100 µm of enam el is rem oved . Once 9. Polish the teeth with f uoridated toothpaste or 1
comp leted the p roced u re shou ld not be rep eated again in minute.
the fu ture. Too m u ch enamel rem oval is p otentially d am ag- 10. Review in 1 month or vitality tests and clinical
ing to the p ulp , and cosm etically the u nd erlying d entine photographs (Fig. 36.2).
colou r w ill becom e m ore evid ent. 11. Review biannually, checking pulpal status.
Ind ications: Critical analysis of the effectiveness of the techniqu e
• Fluorosis. shou ld not be m ad e im m ed iately but d elayed for at least 1
• Idiopathic speckling. m onth, as the appearance of the teeth w ill continu e to
• Post-orthodontic treatment demineralization. im prove over this tim e. Exp erience has show n that brow n
m ottling is rem oved m ore easily than w hite, bu t even w here
• Prior to veneer placement or well-demarcated stains.
w hite m ottling is incom p letely rem oved it nevertheless
• White/brown sur ace staining, e.g. secondary to primary
becomes less percep tible. This phenom enon has been attrib-
predecessor in ection or trauma (Turner’s teeth).
uted to the relatively prismless layer of com p acted su rface
Materials: enamel p rod u ced by the ‘abrosion’ techniqu e, w hich alters
• Bicarbonate o soda/water. the op tical p rop erties of the tooth su rface.
• Copalite varnish/Vaseline. Long-term stu d ies of the techniqu e have found no asso-
• Fluoridated toothpaste. ciation w ith p u lpal d am age, increased caries su sceptibility
• Non-acidulated f uoride (f uoride drops). or signi cant p rolonged therm al sensitivity. Patient com pli-
• Pumice. ance and satisfaction is good , and any d issatisfaction is
• Rubber dam. usu ally d ue to inad equ ate pre-op erative explanation. The
techniqu e is easy to p erform for the op erator and p atient
• Rubber prophylaxis cup.
and is not tim e consum ing. Removal of any m ottled area is
• Sandpaper polishing discs.
perm anent and achieved w ith an insigni cant loss of surface
• 18% hydrochloric acid. enamel. Failu re to im p rove app earance by the H Cl-p u m ice
Technique: m icroabrasion techniqu e has lim ited harm fu l effects bu t
1. Per orm pre-operative vitality tests; take radiographs w ill be less d estru ctive than localized or fu ll-face com posite
and photographs. veneers.
2. Clean the teeth with pumice and water, wash and dry.
3. Isolate the teeth to be treated with rubber dam, and Key point
paint Copalite varnish around the necks o the dam
(alternatively place Vaseline around the necks o the Microabrasion:
teeth under the rubber dam). • Will improve sur ace de ects, e.g. uorosis.
4. Place a mixture o sodium bicarbonate and water on • Will not improve deeper de ects ( ull thickness o
the dam behind the teeth, as protection in case o enamel lesions), e.g. amelogenesis imper ecta.
spillage.
197 •
MOTTLEDTEETH 36
Fig. 36.2 show s the appearance of Sophie’s 1 1 1 m onth allow them to d iffu se rap id ly throu gh enam el and d entine
after H Cl-p u m ice m icroabrasion. and thus explains the transient pu lp al sensitivity occasion-
ally exp erienced w ith hom e bleaching system s.
■ Is vital bleaching lega l or children?
Pulpal histology w ith regard to these m aterials has not
Changes in EU legislation in 2012 perm it d ental bleaching been assessed , bu t no clinical signi cance has been attrib-
to be u nd ertaken for ad u lts. This gu id ance sp eci ed that the u ted to the changes seen w ith 35% hyd rogen peroxid e over
m axim u m concentration of 6% hyd rogen p eroxid e w as p er- 75 years of usage, except w here teeth have been overheated
m itted for d ental bleaching; 10% carbam id e p eroxid e breaks or trau m atized . By extrapolation, 3.4% hyd rogen peroxid e
d ow n to 3.4% hyd rogen p eroxid e. For child ren u p to the age in the hom e system s is therefore safe.
of 18 it is illegal. It w as only in 2014, that the General Dental Althou gh m ost carbamid e peroxid e m aterials contain
Council changed its gu id ance for d entists. Their statem ent trace am ounts of p hosphoric and citric acid s as stabilizers
id enti ed that d entists cou ld bleach child ren’s d iseased and p reservatives, no ind ication of etching or a signi cant
teeth w ithout fear of d iscip linary action. It is alw ays sensi- change in the su rface m orp hology of enam el has been
ble to check w ith you r d ental d efence organization on the d em onstrated by scanning electron m icroscopy analysis.
latest p osition. N o matter w hich treatment op tion you There w as early concern that bleaching solutions w ith a low
choose, you r d iscu ssions w ith the p arents need to be p H w ou ld cau se d em ineralization of enam el w hen the pH
record ed in the patient’s clinical record s and w ritten consent fell below the ‘critical’ p H of 5.2–5.8. H ow ever, no evid ence
taken. of this process has been noted to d ate in any clinical trials
■ Has blea ching o teeth any part to play in the treatment o or laboratory tests, and this m ay be d ue to the u rea (and
sur ace enamel discoloration? subsequ ently the am m onia) and carbon d ioxid e released on
d egrad ation of the carbam id e p eroxid e elevating the p H .
Yes, external vital bleaching has been u sed as an initial treat- There is an initial d ecrease in bond strength of enam el to
m ent for u orotic m ottling and as a second ary treatm ent for com p osite resin im m ed iately after hom e bleaching, bu t this
resid ual brow n staining after m icroabrasion. It is, how ever, retu rns to norm al w ithin 7 d ays. This effect has been attrib-
usually associated w ith the bleaching of the yellow d iscol- u ted to the resid ual oxygen in the bleached tooth surface,
oration of ageing – so-called ‘nightgu ard vital bleaching’. w hich inhibits p olym erization of the com posite resin. The
This technique involves the d aily p lacem ent of 10% car- hom e bleaching system s d o not affect the colou r of restora-
bam id e p eroxid e gel into a cu stom - tted tray of either the tive m aterials. Any perceived effect is p robably d ue to
up per or the low er arch. As the nam e su ggests it is carried super cial cleansing.
ou t by the p atient at hom e and is initially d one on a d aily Minor u lceration or irritation m ay occu r d u ring the
basis. initial treatm ent. It is im p ortant to check that the m ou th-
Materials: gu ard d oes not extend on to the gingivae and that the ed ges
• Upper impression and working model. of the gu ard are sm ooth. If u lceration persists, a d ecreased
• So t mouthguard avoiding the gingivae. exposu re time m ay be necessary. If there is still a problem
• 10% carbamide peroxide gel. then allergy is a possibility.
Techniqu e: The exact mechanism of bleaching is u nknow n. Theories
of oxid ation, photo-oxid ation and ion exchange have been
1. Take an alginate impression o the arch to be treated and
su ggested . Conversely, the cau se of red iscoloration is also
cast a working model in stone.
u nknow n. This m ay be a com bination of chem ical red u ction
2. Relieve the labial sur aces o the teeth by about 0.5 mm
of the oxid ation p rod ucts previou sly formed , m arginal
and make a so t, pull-down, vacuum- ormed splint as a
leakage of restorations allow ing ingress of bacterial and
mouthguard. The splint should be no more than 2 mm
chem ical byp rod ucts, and salivary or tissu e uid contam i-
in thickness and should not cover the gingivae. It is only
nation via p erm eable tooth stru ctu re.
a vehicle or the bleaching gel and not intended to
protect the gingivae. ■ Wha t are the indica tions or composite veneers?
3. Instruct the patient on how to f oss the teeth thoroughly. Com p osite veneers m ay be requ ired to m ask d ense w hite
Per orm a ull mouth prophylaxis and instruct them how u orotic p laqu es that are refractory to m icroabrasion and
to apply the gel into the mouthguard. bleaching. Most com p osite veneers p laced in child ren and
4. Note that the length o time the guard should be worn ad olescents are the d irect type fashioned at the chairsid e
depends on the product used. rather than the ind irect or laboratory-m ad e typ e.
5. Review about 2 weeks later to check that the patient is Before p roceed ing w ith any veneering techniqu e, the
not experiencing any sensitivity, and then at 6 weeks, by d ecision m u st be m ad e w hether to red u ce the thickness of
which time 80% o any colour change should have labial enam el before placing the veneer. Certain factors
occurred. Sensitivity occurs in almost all patients, and should be consid ered :
reducing the duration o mouthguard wear is e ective • Increased labiopalatal bulk makes it harder to
at minimizing symptoms. However, around 14% maintain good oral hygiene. This may be courting
may stop this technique owing to the sensitivity it disaster in the adolescent with a dubious oral hygiene
causes. technique.
Carbam id e p eroxid e gel (10%) breaks d ow n in the m ou th • Composite resin has a better bond strength to
into 3.4% hyd rogen p eroxid e and 7% urea. Both u rea and enamel when the sur ace layer o 200 300 µm is
hyd rogen p eroxid e have low m olecu lar w eights, w hich removed.
• 198
36 MOTTLEDTEETH
• I a tooth is very discoloured, some sort o reduction will instrument, then use a brush lubricated with un lled
be desirable, as a thicker layer o composite will be resin to ‘paddle’and smooth it into the desired shape.
required to mask the intense stain. Cure or 60 seconds gingivally, 60 seconds mesioincisally,
• I a tooth is already instanding or rotated, its appearance 60 seconds distoincisally, and 60 seconds rom the
can be enhanced by a thicker labial veneer. palatal aspect i incisal coverage has been used. Di erent
N ew generation, highly p olishable, hybrid com posite shades o composite can be combined to achieve good
resins can replace relatively large am ou nts of m issing tooth matches with adjacent teeth and a transition rom a
tissu e and be u sed in thin sections as a veneer. Com bina- relatively dark gingival area to a lighter more translucent
tions of shad es can be u sed to sim ulate natu ral colour gra- incisal region. For some darkly stained dentine, a thin
d ations and hu es. Within these system s, op aqu ers can be layer o composite opaquer is an alternative to removing
very u sefu l at blocking ou t the transm ission of the d iscol- urther enamel and dentine. This is placed as the rst
ou red enam el d efect throu gh the com p osite. layer beneath the incremental composite build-up o
Ind ications for com posite veneers: di erent composite shades.
• Discoloration. 7. Flick away the un lled resin holding the contour strip
• Enamel de ects. and remove the strip.
• Diastemata. 8. Finish the margins with diamond nishing burs and
interproximal strips and the labial sur ace with graded
• Malpositioned teeth.
sandpaper discs. Characterization should be added to
• Large restorations.
improve light ref ection properties.
Contraind ications:
The exact d esign of the com posite veneer w ill d ep end on
• Insu cient available enamel or bonding. each clinical case, bu t w ill u su ally be one of fou r types:
• Oral habits, e.g. woodwind musicians. intra-enam el or w ind ow preparation; incisal bevel; over-
■ How do you undertake a composite veneer? lapped incisal ed ge; or feathered incisal ed ge.
Tooth preparation w ill not u su ally expose d entine,
The m aterials required are: bu t this w ill be u navoid able in som e cases of localized hypo-
• Rubber dam/contoured matrix strips. plasia or caries. Sou nd d entine m ay need to be covered by
• Preparation and nishing burs. glass ionom er cem ent p rior to placem ent of the com posite
• New generation, highly polishable, hybrid composite veneer.
resin.
• So -Lex polishing discs and interproximal polishing strips. Primary resources and
Technique: recommended reading
1. Use a tapered diamond bur to reduce labial enamel by Bu rrow s S 2009 A review of the ef cacy of tooth bleaching. Dent
0.3 0.5 mm. Identi y the nish line at the gingival margin Up d ate 36:537–538, 541–544, 547–548.
and also mesially and distally just labial to the contact Bu rrow s S 2009 A review of the safety of tooth bleaching.
points. Dent Up d ate 36:604–606, 608–610, 612–614.
2. Clean the tooth with a slurry o pumice in water. Wash Kilp atrick N M, Bu rbrid ge LA 2012 Anom alies of tooth form ation
and dry and select the shade. and eru p tion. In: Welbu ry RR, Duggal MS, H osey MT (ed s),
3. Isolate the tooth either with rubber dam or a contoured Paed iatric Dentistry, 4th ed n. Oxford University Press, Oxford ,
p p . 174–198.
matrix strip. Hold the latter in place by applying un lled
resin to its gingival side against the gingiva and curing Poyser N J, Kelleher MG, Briggs PF 2004 Managing d iscoloured
non-vital teeth: the insid e/ ou tsid e bleaching techniqu e. Dent
or 10 seconds.
Up d ate 31:204–210, 213–214.
4. Etch the enamel or 60 seconds, wash and dry.
5. Where dentine is exposed, apply dentine primer.
6. Apply a thin layer o bonding resin to the labial sur ace For revision, see Mind Map 36,
and roughly shape it into all areas with a plastic page 257.
37
■ There are a signif cant number o syndromes o the head
and neck tha t mani est with missing teeth. Can you
name some?
Ectodermal dysplasia.
Cle t lip and/or palate.
Down syndrome.
Chondro-ectodermal dysplasia (Ellis van Creveld syndrome).
abnormallyshapedteeth
Oro- acial-digital syndrome (types I and II).
Ectodermal dysplasia d escribes a group of inherited d isor-
d ers involving ectod erm ally d erived stru ctures, i.e. hair,
teeth, nails, skin and sw eat gland s. The m ost com m on form
is the hyp ohid rotic X-linked form . The usu al p resentation is
a male child w ith:
Multiple congenital absence o teeth.
CASE1 Fine, sparse hair with sha t abnormalities.
Dry skin.
SUMMARY Frontal bossing.
Ellen is almost 11 years old. She is very concerned Maxillary hypoplasia.
by the gaps between her upper and lower ront
Thin lips showing little vermilion margin.
teeth. She is hoping to become an actress. She is a
Heterozygous emales can be identi ed dentally with
new patient to your surgery and has been brought
microdontia and hypodontia.
by her mother. What are the causes o the problem,
Down syndrome affects 1 in 700 births, is com m oner in
and how may it be treated?
offsp ring of old er m others and is a resu lt of chrom osom al
translocation. Ap art from the morphological featu res char-
History acteristic of the synd rome, there is com m only d elayed eru p-
tion and generalized m icrod ontia, as w ell as hypod ontia of
Ellen is a regu lar attend er w ith no caries. H er oral hygiene
some teeth.
is excellent. There is no history of tooth extraction in either
The d iagnosis and m anagem ent of all d ental anom alies
the prim ary or perm anent d entitions.
is extrem ely im p ortant and shou ld not be d elayed . Genetic
consu ltation is often d esirable to not only con rm the d iag-
Medical history nosis bu t also to help p arents u nd erstand the risk of fu tu re
Ellen has no m ed ical p roblem s. She is an active girl w ho is offsp ring and generations being affected . Conversely, genet-
involved in orienteering w ith her fam ily as w ell as partici- icists m ay requ ire help from p aed iatric d entists to clarify a
p ating in the local am ateu r d ram atic society. d iagnosis.
■ What question do you need to a sk Ellen’s mother?
Is there a fam ily history of m issing teeth or gaps?
Key point
As you are sp eaking to Ellen’s m other you notice that she
has a m issing u p p er right lateral incisor and the canine Hypodontia:
tooth is p rom inent. She con rm s your qu estion that not only • Prevalence is 3.5 6.5% in permanent dentition
has she got a missing tooth bu t her brother and her nep hew (excepting third molar).
(son of her brother) have either m issing or very sm all u p p er • May be associated with a number o syndromes.
lateral incisors. • Requires interdisciplinary care.
■ How prevalent are missing teeth in the population?
0.1 0.9% in the primary dentition.
3.5 6.5% in the permanent dentition (discounting third
■ What a ctors would you consider important in the
management o dental anomalies?
molars).
More common in emales than males (1.4 4×). The most Reassurance o child and parent.
common teeth to be absent are the last teeth in each series Elimination o pain.
(i.e. lateral incisor, second premolar, third molar). The presence
Prevention o caries and periodontal disease.
o a conical (peg) tooth is requently associated with a
missing tooth on the opposite side o the arch. There is Genetic counselling.
requently a amily history. Restoration o aesthetics.
• 200
37 MULTIPLEMISSINGANDABNORMALLYSHAPEDTEETH
Provision o adequate unction. • Fixed appliance to close the upper median diastema;
Maintenance o vertical dimension o occlusion. retain with a palatal bonded retainer.
• Poor prognosis B B. As the spaces are o concern to Ellen,
Interdisciplinary ormulation o de nitive treatment plan.
consider extraction o B B and replacement with an
upper partial denture with prosthetic 2 2. Alternative
Examination approaches include the extraction o the B B and the
provision o resin retained cantilever bridges. Another
Extraoral short- to medium-term option is to build up the primary
Ellen had a norm al facial ap p earance w ith a Class 1 skeletal lateral incisors with composite.
pattern. • In adulthood there will be the option o implants to
replace the missing maxillary and mandibular teeth.
Intraoral Hence the importance o interdisciplinary planning to
ensure short-term solutions do not compromise
The follow ing teeth w ere present:
long-term plans.
6E D C B1 1 BC D E 6
D D w ere m obile. The other
6E 321 234E6
prim ary teeth w ere rm . The p rim ary m olars w ere
infraocclu d ed . CASE2
■ Wha t special investigations are required?
SUMMARY
A d ental p anoram ic tom ogram (Fig. 37.1) to check on the
Cameron was 3 years old when his mother brought
presence/ absence of other p erm anent teeth.
him to the surgery because she was concerned that
■ Wha t is visible rom the radiograph?
two o his teeth were joined together (Fig. 37.2).
87532 234578 What is the cause, and how may it be treated?
Absence of: .
8754 1 57
Fig. 37.1 Severe hypodontia. ( romMillett andWelbury(2000) with permission). Fig. 37.2 Double incisor teeth.
201 •
MULTIPLEMISSINGANDABNORMALLYSHAPEDTEETH 37
The clinical m anifestation of the anom aly m ay vary con-
sid erably from a m inor notch in the incisal ed ge of an abnor-
m ally w id e incisor crow n to the ap p earance of tw o sep arate
crow ns. There m ay be hard tissu e continu ity betw een either
the crow ns or the roots of the tw o elements or betw een both.
Sim ilarly there m ay be one u ni ed p u lp cham ber and rad ic-
ular p u lp or sep arate ones.
In the prim ary d entition, d ou ble teeth m ore com m only
occu r in the labial segm ents of the arches and m ost fre-
qu ently in the m and ible. Double permanent teeth can occu r
anyw here in the arch and frequ ently involve the incisor
teeth.
■ What are the most important clinical aspects o a double
tooth in the prima ry dentition?
Fig. 37.3 Talon cusp.
Caries m ay occu r in the ‘join’ betw een the tw o coronal ele-
m ents if it is not easily accessible to a toothbru sh. This risk
can be red u ced by ssu re sealing the groove if there is food ■ What other types o crown abnormalities do you know?
stagnation, staining or enam el d ecalci cation.
The p resence of a nu m erical abnorm ality of the perm a- Accessory cusps.
nent d entition. Cou nting a d ou ble tooth as one u nit in the Invaginations.
primary d entition, w ith relation to the total nu mber of teeth
Evaginations.
present, m ay be help fu l in p red icting the typ e of nu m erical
abnorm ality of the p erm anent d entition. H ypod ontia is Ad d itional p rim ary cu sp s are seen on the m esiobu ccal
usually follow ed by m issing p ermanent teeth. A norm al aspect of maxillary rst m olars and the m esiop alatal asp ect
number of teeth in the p rim ary d entition is often associated of maxillary second m olars.
w ith p erm anent su p ernu m eraries. The overall frequency of The com m onest ad d itional cusp in perm anent teeth is
perm anent nu m erical abnorm alities follow ing prim ary often on the lingual cingulu m , m ore com m only in the
d ou ble teeth is betw een 30% and 50% in Caucasians and is m axilla than the m and ible. The nam e ‘talon cu sp’ is often
75% in the Jap anese p op u lation. given to the ad d itional cu sp (Fig. 37.3). The cu sp is com -
Rad iograp hy is therefore im p ortant at an ap p rop riate posed of enam el, d entine and a horn of p ulp tissu e. Talons
time, so the p arent can be ad vised of fu tu re treatm ent and in maxillary anterior teeth su ch as that show n in Fig. 37.3
prognosis and a treatm ent p lan formu lated . Extraction of can cau se a nu m ber of p roblem s:
d ou ble p rim ary teeth m ay be necessary if p hysiological Appearance.
root resorp tion is signi cantly retard ed . Su rgical rem oval of Occlusal inter erence.
su pernu m erary teeth m ay be requ ired to facilitate eru p tion Caries in the deep grooves between the cusp and the tooth.
of norm al u nits. Often treatm ent p lanning is m ost ap prop ri-
ately u nd ertaken w ithin an interd iscip linary team . The com m onest accessory cu sp in the perm anent d enti-
tion is the m esiopalatal sited tu bercle of Carabelli on the
m axillary rst m olar (10–60%).
Key point ■ Wha t are the treatment options or a talon cusp on a
Double primary teeth may: maxillary tooth?
• Be associated with numerical abnormalities o the Selective grinding o cusp to encourage obliteration o the
permanent dentition. pulp horn by secondary dentine.
• Be a caries risk. Aseptic removal o the cusp under rubber dam ollowed by a
• Not undergo normal physiological resorption. limited pulpotomy procedure (immature or mature root).
Aseptic removal o cusp and one-stage endodontic treatment
(mature root).
■ What are the important actors tha t will dictate whether Failure of a pu lp otomy techniqu e in an im m atu re tooth
you retain or extract double permanent teeth? w ill resu lt in the need for ind u ced ap ical closu re w ith
Space in the arch. Mineral Trioxid e Aggregate. Many clinicians favou r w aiting
u ntil fu ll root form ation has occu rred p rior to rem oval of
Aesthetics.
the cu sp. Invaginations or invagination of the enam el ep i-
Morphology o pulp chambers and roots. thelium into the d ental papilla of the u nd erlying tooth germ
If the coronal parts of the d ou ble teeth are joined bu t the has been d escribed as ‘d ens in d ente’, ‘gestant com posite
roots are sep arate, then it m ay be feasible to d ivid e the od ontome’ and ‘d ilated com posite od ontom e’. The correct
crow n and extract one p ortion of the crow n and its root, d escriptive term is ‘d ens invaginatus’ or ‘invaginated tooth’.
thereby retaining the other portion of the crow n w ith its The anom aly m ay vary clinically from a d eep cingulum pit
root. The retained p ortion w ill requ ire root canal treatm ent in a tooth of norm al form (Fig. 37.4) to a tooth w ith grossly
and su bsequ ent coronal restoration. d istorted crow n and root. Invaginated teeth are relatively
• 202
37 MULTIPLEMISSINGANDABNORMALLYSHAPEDTEETH
Evaginations consist of enam el, d entine and a pu lp al
extension. Evagination shou ld be su sp ected if a prem olar
w ithou t caries d evelop s a p eriap ical lesion shortly after
eruption.
Treatm ent is the same as ‘talon cu sp’.
■ What abnormalities o root orm do you know?
Taurodontism.
Accessory roots.
Pyramidal roots.
Tau rod ontism (bull-like teeth) ap plies to m u ltirooted
teeth in w hich the bod y of the tooth is enlarged coronoapi-
cally at the exp ense of the roots. Rad iographs show appar-
ent enlargem ent of the coronal p u lp cham ber, u su ally
extend ing below the level of the alveolar crest before root
d ivision. The norm al constriction at the level of the am el-
ocem ental ju nction is frequ ently absent in affected teeth.
The cond ition is uncom m on in p rim ary teeth but m ay occu r
in perm anent m olars in 6% of the p op u lation.
Fig. 37.4 Dens in dente o lateral incisor. ■ What conditions ma y taurodontism be associated with?
Amelogenesis imper ecta.
com m on, occurring in 1–5% of p erm anent teeth. Prim ary Trichodento-osseous syndrome.
invaginations are rare. Ectodermal dysplasia with hypodontia.
The m ain p roblem w ith invaginations is infection. The
Ellis van Creveld syndrome.
enam el lining of the invagination is either incom p lete or
very thin and easily breached , resu lting in d entinal caries Achondroplasia.
that qu ickly progresses to involve the pu lp cau sing a rapid ly Kline elter syndrome.
spread ing infection presenting w ith acu te facial cellu litis or Accessory roots can occu r in alm ost any tooth. Rarely
acu te d entoalveolar abscess. Rarely a large invaginated they m ay be d ue to early traum a to a form ing root. The
tooth m ay cause im paction and non-eru ption of an ad jacent m ajority are likely to be d u e to genetic factors that rem ain
tooth. to be speci ed .
There is an association betw een invaginated teeth and Pyram id al roots d escribe the red uction in root nu m ber in
supernu m erary teeth. A fu ll rad iograp hic exam ination is m ultirooted teeth. Any molar tooth m ay be affected .
ju sti ed if an invaginated tooth is id enti ed .
Invaginations in crow ns of norm al m orphology should Primary resources and
be sealed prop hylactically as soon as p ossible after eru ption.
If these ‘high’ invaginations d o become pu lpally involved recommended reading
then root treatm ent is p ossible, becau se the invaginated H olid ay R, Lu sh N , Chap ple J et al 2014 Aesthetics and fu nction
portion is accessible and can be rem oved w ith a crow n bu r p art 2: m anagem ent. Dent Upd ate 41:891–898.
allow ing access to the norm al root canal. All other invagina- Lu sh N , H ollid ay R, Chap ple J et al 2014 H ypod ontia: aesthetics
tions u su ally requ ire extraction ow ing to their com p lex root and fu nctions p art 1: aetiology and the p roblem s. Dent Up d ate
41:811–815.
m orp hology.
Millett D, Welbu ry R 2000 Orthod ontics and Paed iatric Dentistry:
‘Evaginated teeth’ or ‘d ens evaginatus’ or ‘tu bercu lated
Colou r Gu id e. Chu rchill Livingstone, Ed inbu rgh.
teeth’ occu rs com m only as a conical tu bercu lar p rojection
Tahm assebi JF, Day PF, Tou m ba KJ et al 2003 Paed iatric d entistry
arising from the occlu sal su rface of the central ssu re or the
in the new m illenniu m : 6. Dental anom alies in child ren. Dent
lingual p lane of the bu ccal cu sp . Prem olar teeth are the com -
Up d ate 30:534–540.
m onest teeth affected , w ith p erm anent m olars and canines
less com m only affected . The cond ition is m ainly seen in
people of Mongolian race (1–4%), althou gh rarely it is seen For revision, see Mind Map 37,
in Cau casians. page 258.
38
either hypop lasia, d ue to d e cient m atrix prod u ction, or
hypom ineralization, from im perfect m ineralization of the
m atrix proteins. In hyp op lasia the enam el m ay be thin,
grooved or p itted , w hereas in hyp om ineralization it m ay
ap pear m ottled bu t of norm al thickness. The com p lete range
of cau ses of d evelopm ental abnorm alities of enam el are
show n in Box 38.1.
Enam el d efects of genetic origin m ay occu r either as a
p henom enon p rim arily involving the enam el, w ith p ossible
imper ecta a com p onent of a m ore com p lex synd rom e in w hich d efec-
tive enam el is only one of a num ber of m ore generalized
abnorm alities.
Medical history
Mark has no m ed ical p roblem s. H e is d oing very w ell at
school and is a keen basketball player.
SUMMARY
Mark is 10 years old. He and his parents are Examination
concerned because his teeth seem rough. They also
Intraoral exam ination revealed that all the su rfaces of all the
stain easily. What is the cause o these problems?
eru p ted p erm anent teeth are affected by a rou ghness or
What treatment is possible? ‘p itting’ (Fig. 38.1). The second prim ary m olar teeth that are
■ Wha t ca n you see in Fig. 38.1? still p resent have a sim ilar roughness that, although not as
evid ent on visu al exam ination, w as obviou s on tactile exam -
All erup ted teeth have pitted hypoplastic enam el.
ination w ith a probe. There w as no tooth w ear.
■ Why is this pattern o enamel hypopla sia unlikely to be
History caused by systemic (chronological) in uences?
Mark’s m other says that she noticed w hen the teeth rst Primary and permanent teeth all a ected.
erupted that they w ere rough. They picked up stain and w ere
d if cult to clean. What key questions do you need to ask? All the enamel sur ace o the teeth is a ected.
■ Was there any systemic illness rom birth to early Positive amily history.
childhood? Am elogenesis im p erfecta (AI) occu rs as a resu lt of gene
m u tations that follow au tosom al-d om inant, au tosom al-
N o.
recessive or X-linked patterns of inheritance. The prevalence
■ Were the primary teeth similarly a ected? varies arou nd the w orld w ith rates of 1 in 718 in northern
There w as a slight rou ghening of the prim ary teeth, althou gh Sw ed en and 1 in 14 000 in Michigan, USA. A global qu oted
not as bad ly affected as the p erm anent teeth. gu re is often 1 in 10 000.
■ Is anyone else in the amily similarly a ected?
Mark’s father and his cou sin (father ’s brother ’s son) have Box 38.1 Di erential diagnosis o enamel de ects
similar rou ghness of their teeth. After obtaining this history General actors
it is m ost likely that Mark has an inherited enam el d efect • Genetic:
involving enam el – am elogenesis im p erfecta. H ow ever, • Primarily involving enamel – amelogenesis imper ecta.
d efective enam el form ation m ay be cau sed by genetic or • Associated with generalized de ects.
environm ental factors. The d efective enam el w ill exhibit
• Systemic (chronological):
• Nutritional defciencies.
• Metabolic or biochemical disorder.
• Toxic substances.
• In ectious illnesses: pre-natal; peri-natal; neonatal; in ancy; earlychildhood
(see Chapter 34).
• Excess Fluoride ingestion (see Chapter 36).
• Idiopathic.
Local actors
• Trauma.
• In ection.
Fig. 38.1 Hypoplastic amelogenesis imper ecta.
• 204
38 AMELOGENESISIMPERFECTA
Table 38.1 Treatment modalities or amelogenesis imper ecta
Restoration Aesthetics
Primarydentition: Adhesive restorations Minimal intervention
0–5 years Stainless steel crowns (SSCs) Composite veneers
especiallyon E’s
Mixed dentition: Adhesive restorations/SSCs on Composite veneers
6–16 years primarymolars
SSCs/adhesive castings on
permanent molars
Permanent dentition: Adhesive castings on premolars Porcelain veneers
Fig. 38.2 Hypomineralized amelogenesis imper ecta. 16+ years Full mouth rehabilitation ± Full crowns
crown lengthening
imper ecta
SUMMARY
Siobhan is 9 years old. She and her parents are
concerned because her permanent teeth are darker
than normal and she is getting teased at school.
What is the cause o the discoloration? How would A
you treat it?
History
Siobhan’s m other says she noticed that w hen the perm anent
teeth eru pted they looked d arker. Siobhan is very u nhapp y
at school and refu ses to sm ile for any photograp hs. When
she talks she has the habit of covering her mouth w ith a
hand so it is imp ossible to see her teeth. What can you see
in Fig. 39.1A? What key qu estions d o you need to ask?
■ Was there any systemic illness rom birth until early
childhood?
N o. Siobhan had no illness.
■ Were the primary teeth similarly a ected? B
The p rim ary teeth eru pted normally but very qu ickly
Fig. 39.1 (A) Dentinogenesis imper ecta. (B) Dentinogenesis
chip ped aw ay, becom ing w orn to gu m level (see Fig. 39.1B).
imper ecta.
■ Is anyone else in the a mily similarly a ected?
Siobhan’s brother and her father have a problem w ith their
teeth. Siobhan’s brother is 14, and he has need ed crow ns on
his back teeth and veneers on his front teeth. Siobhan’s
father need ed a lot of treatm ent w hen he w as you nger and
has had som e teeth crow ned . Many of his p osterior teeth,
how ever, w ere extracted .
Even before you have exam ined the m ou th, the history
suggests that Siobhan has an inherited d efect. Fig. 39.1A
con rm s you r su sp icion that this is d entinogenesis imp er-
fecta (DI).
■ Why is this DI and not amelogenesis imper ecta (AI)?
The teeth are translucent.
The enam el is poorly ad herent to the u nd erlying d entine
and easily chip s and w ears. The rem aining p rim ary canines
and m olars in Figs 39.1A and B are w orn to gingival level Fig. 39.2 Obliteration o root canals and pulp chambers in
and have a translu cent op alescent ap p earance. dentinogenesis imper ecta.
207 •
DENTINOGENESISIMPERFECTA 39
• Shell teeth. This is rare and seen in the primary dentition.
Box 39.1 Hereditary dentine de ects
The pulp remains large and the thin enamel and dentine
Limited to the dentine
rapidly ragments to cause pulpal in ection.
• Dentinogenesis imper ecta type II (hereditaryopalescent dentine). • DI type III (brandy wine type). This was rst described in
• Dentine dysplasia type I (radicular dentine dysplasia). Maryland, USA, and has been traced back to East Anglia
• Dentine dysplasia type II (coronal dentine dysplasia). in England. It was apparently taken to the USA by one o
• Fibrous dysplasia o dentine. the sailors who accompanied the Pilgrim Fathers to
Associated with generalized disorder Maryland. Type III de ect has been linked to the same
locus on chromosome 4q21 as DI type II.
• Osteogenesis imper ecta (dentinogenesis imper ecta type I).
• Ehlers-Danlos syndrome. DI type I associated with osteogenesis imper ecta Osteo-
• Brachioskeletogenital syndrome. genesis im perfecta is a grou p of connective tissu e d isord ers
• Vitamin Dresistant rickets. involving inherited abnorm alities of typ e I collagen.
Increased bone fragility is only one aspect of the cond ition
• Vitamin Ddependent rickets.
w hich m ay includ e lax joints, blue sclerae, opalescent teeth,
• Hypophosphatasia.
hearing loss and a variable d egree of bone d eform ity. The
inheritance p attern is either au tosom al recessive or d om i-
nant. The recessive form is often lethal arou nd birth.
Opalescent teeth are only rarely seen in surviving reces-
sive types. They are com m only a featu re of the d om inant
Family examination variety w ith accom p anying bone fragility, bone d eform ity
• Family examination o a ected members. and blu e sclerae. Ow ing to the bone fragility, frequently
• Dentine de ects like those o enamel may be subdivided child ren w ith osteogenesis im p erfecta are treated w ith
by cause into two main groups based on whether they bisphosp honates. In ad u lts bisp hosphonates, esp ecially
are o genetic or environmental origin. those given intravenou sly, are associated w ith osteonecro-
• Dentine anomalies that are genetically determined may sis. Although no cases of osteonecrosis have been reported
appear to be limited to the dentition or orm part o a in child ren, great care, thought and interd isciplinary
more complex generalized disorder (Box 39.1). w orking w ith m ed ical colleagu es is requ ired w hen m anag-
ing these com p lex child ren (see Chapter 28).
The m ost w ell d ocu m ented hered itary d entine d efects
The prim ary teeth in DI type I resem ble exactly those in
are DI type II (hered itary op alescent d entine), w hich only
DI typ e II. H ow ever, in the perm anent d entition the d efect
affects teeth, and DI typ e I, in w hich abnorm alities of teeth
is extrem ely variable. In m any cases the u pp er anterior teeth
are associated w ith osteogenesis im p erfecta.
m ay have a norm al colour and app earance, w hereas the
DI type II Both d entitions are u su ally affected . The severity low er incisors and canines are opalescent, d iscoloured
of the d efect varies consid erably betw een fam ilies and bluish-brow n and w ear at the incisal ed ges. In m ost cases
w ithin fam ilies. Prim ary teeth tend to be m ore severely the enam el d oes not chip aw ay from the und erlying d entine
affected than perm anent teeth, and the later form ing p er- as read ily as in typ e II.
m anent teeth m ay be the least affected . Enam el tend s to chip Rad iographic appearances are as alread y d escribed w ith
aw ay from the u nd erlying am elod entinal ju nction (ADJ), the excep tion that u pper teeth m ay retain their pu lp spaces
exposing the abnorm ally soft d entine that u nd ergoes rap id long after those in the low er jaw. H istological app earances
w ear. This is m ost m arked in the p rim ary d entition w here, are ind istingu ishable from type II.
w ithin 2 years, the crow ns m ay be w orn to the gingival Environm entally d eterm ined d entine d efects d o exist bu t
m argin and ap p ear as am ber-colou red rem nants (Fig. are less w ell d ocu m ented than correspond ing anom alies of
39.1B), w hich m ay be frequ ently infected and abscessed . In enam el: trau m a, nu tritional d e ciencies (m inerals, proteins
the p erm anent d entition, follow ing eru p tion, the enam el and vitam ins) and d ru gs (tetracycline, chem otherapeu tic
m ay look reasonably norm al, bu t histological stu d ies have agents – cyclophospham id e) w ill likely prod u ce increased
show n hyp om ineralized areas in ap p roxim ately one-third interglobular d entine, p red entine and osteoid .
of cases. Rad iograp hic signs are d escribed previou sly. H is-
tologically, the ADJ m ay ap p ear attened , and w hile the
su bad jacent p erip heral d entine m ay ap p roach normality, Key point
the rem aind er is grossly d isord ered w ith an am orp hous
Dentinogenesis imper ecta:
m atrix containing areas of interglobular calci cation, abnor-
• Occurs in 1 in 8000 o the population.
m ally shap ed and sized tu bu les and cellu lar inclu sions.
• May be associated with osteogenesis imper ecta.
■ Is DI more preva lent than AI?
Possibly, gu res of 1 in 8000 have been estim ated (AI
1:10 000).
■ Has DI got as many inheritance patterns as AI? Treatment
N o. Invariably it is au tosomal d om inant w ith m arked The m ain clinical problems associated w ith AI and DI
expressivity and good p enetrance. Tw o clinical variants of and the key points of treatm ent objectives are covered in
the cond ition have been d escribed : Chapter 38. The princip les of treatm ent for DI are the sam e
• 208
39 DENTINOGENESISIMPERFECTA
as those for AI w ith the excep tion that in the p ermanent ap propriate, and orthod ontic band s rather than brackets
d entition from age 16, crow n-lengthening p roced u res are w ill m inimize the risk of d am age to the abnorm al enam el.
m ore com m on in DI and the p rovision of overd entu res and The p roblem is tw ofold : there m ay be frequ ent bond failu re
fu ll d entu res is not u ncom m on. The role of imp lants in these d u ring active treatm ent or the enam el m ay be fu rther
patients has yet to be d e ned . d am aged d uring d ebond ing. Som e orthod ontists prefer to
Siobhan’s m ajor concern w as of the colour of her perm a- use band s even for anterior teeth, w hile others w ill use glass
nent incisors. There w as som e w ear of rst p erm anent ionom er cem ent as the bond ing agent in p reference to m ore
m olars. The rst p erm anent m olars w ere treated w ith conventional resin-based agents. In other instances, cos-
ad hesive castings w ith m icrom echanical retention to lu ting m etic restorative techniqu es (veneers and crow ns) m ay be
cem ent (Fig. 39.1B). The u p per and low er incisors w ere m ore ap p rop riate than orthod ontic treatm ent.
veneered w ith com p osite resin. This can be extend ed to
inclu d e the canines and p rem olars w hen the arches are com -
plete. The com p osite veneers can be rep laced by p orcelain
Primary resources and
veneers around the age of 18 years. recommended reading
You ng child ren w ith DI often pose the greatest p roblem s. Am erican Acad em y of Ped iatric Dentistry 2014/ 2015 Gu id eline
The p rim ary teeth und ergo su ch excessive w ear that they on d ental m anagem ent of heritable d ental d evelopm ental
becom e w orn d ow n to the gingival level and are unrestor- anom alies. Reference Manu al 36 (6):264–269.
able. Teeth affected by DI are also prone to sp ontaneous Barron MJ, McDonnell ST, Mackie I et al 2008 H ered itary d entine
d isord ers: d entinogenesis im p erfecta and d entine d ysplasia.
abscesses d u e to the p rogressive obliteration of the pu lp
Orp hanet J Rare Dis 20 (3):31.
cham bers. In these cases p u lp therapy is often u nsu ccessful
Dhaliw al H , McKaig S 2010 Dentinogenesis im p erfecta—clinical
and extraction of the affected teeth is necessary.
p resentation and m anagem ent. Dent Up d ate 37 (6):364–366,
Early consu ltation w ith an orthod ontist is ad visable in
369–371.
inherited abnorm alities of enam el and d entine in ord er to
keep the orthod ontic requ irem ents sim ple. Treatm ent for
these p atients is possible and in m any cases proceed s For revision, see Mind Map 39,
w ithou t p roblem s. The u se of rem ovable ap p liances, w here page 260.
40
su ch as titratable acid ity, the in uence of p laqu e pH and the
buffering capacity of saliva w ill all in u ence the erosive
p otential of a su bstrate. Fou r things, how ever, are clear w ith
erosive loss:
• It is worse i consumption is high.
• It is worse i consumption occurs at bedtime.
• It is worse i brushing occurs directly a ter consumption.
• It is worse i children undertake swishing or holding
Box 40.2 Conditions associated with chronic regurgitation ■ What advice would you give to Tom regarding his high
in children intake o f zzy drinks?
• Gastrooesophageal re ux. It is critically imp ortant w hen d ealing w ith child ren and
• Oesophageal stricture. ad olescents not to be too d ogm atic in your ad vice, and it is
• Chronic respiratorydisease, e.g. asthma. u nrealistic to expect youngsters w ho have been brought
• Disease o the liver/pancreas/biliary tree.
u p w ith a high intake of carbonated beverages to stop
altogether.
• Over eeding.
They shou ld be ad vised to erad icate betw een-m eal zzy
• Feeding problems/ ailure to thrive conditions. d rink consu m p tion bu t to have the zzy d rink w ith m eals
• Learning delay. and preferably to d rink it w ith a straw. The presence of food ,
• Anorexia. and the extra saliva that is generated at m ealtim es, w ill help
• Bulimia nervosa. neu tralize the acid ity. In ad d ition, a straw w ill d ep osit the
• Cyclic vomiting syndrome. m ajority of the carbonated beverage beyond the teeth.
Make su re that the betw een-m eal carbonated d rink is not
• Cerebral palsy.
su bstitu ted by som ething w ith a sim ilar erosive p otential,
• Rumination.
e.g. fresh fru it ju ice or a ju ice-based squash.
Milk and w ater are the m ost ap p rop riate betw een-m eal
d rinks. If either of these proves im possible, then an
oesop hageal sp hincter. In this case the qu estion about a extrem ely w ell-d ilu ted ‘no ad d ed su gar ’ squ ash can be
bitter taste in the m ou th shou ld have the suf x ‘w hen you accepted .
w ake u p ’. N o carbonated d rinks or fru it d rinks should be given last
■ What is the common pa ttern o erosive loss when there is thing at night.
chronic gastric regurgitation? Ad vocate the consu m p tion of a neu tral food im m ed i-
ately after a m eal, e.g. cheese.
Initially there is erosion of the palatal su rfaces of the up per
incisors, canines and prem olars. With time this extend s to
the occlu sal and buccal surfaces of the low er m olars and Management
prem olars.
The m ost im p ortant asp ect of the m anagem ent of Tom ’s
Whenever there is u nexp lained erosive loss, an eating
erosion w as early d iagnosis before there had been d am age
d isord er should be su sp ected . There are three su ch d isor-
to the p erm anent teeth, and su bsequently to establish the
d ers: anorexia nervosa; bulim ia nervosa; and ru m ination.
aetiology and elim inate the cau se.
The latter is a cond ition in w hich food is volu ntarily regu r-
gitated into the oral cavity and either expelled or sw allow ed
again.
Key point
■ Is there a specif c pattern o erosive loss in recurrent
vomiting? Management o erosion:
• Early diagnosis.
All tooth surfaces can be affected w ith the relative exception
of the lingu al su rfaces of the low er teeth, w hich are p ro- • Establish aetiology.
tected by the tongu e and the saliva from the sublingu al • Eliminate cause.
papillae. • Monitor or urther tooth sur ace loss.
■ Wha t would you do i you suspect, a ter questioning Tom
and his parents, that there may be asymptoma tic GORD?
Referral to a p aed iatrician w ith an interest in gastrointesti- ■ Tom only has occasional sensitivity. Wha t treatment, i a ny,
nal d isease w ou ld be ap p rop riate. The p aed iatrician w ill does he need?
seek to elim inate organic d isease and then attem p t to qu an-
Probably none. The follow ing w ou ld be realistic initially:
tify the p roblem . The latter m ay involve 24-hou r p H m oni-
Daily neutral sodium f uoride mouthwash (0.05%) to maximize
toring of the oesop hagu s, w ith p robes in the low er and
the resistance to remaining enamel and desensitize the
u pper oesop hagu s. An ad d itional p robe cou ld be ad d ed to
dentine.
an intraoral ap pliance to measu re m ou th p H . Med ical and /
or su rgical treatment m ay be requ ired to control GORD. High concentration sodium f uoride varnish (Duraphat) to be
Chronic regu rgitation can lead to scarring of the oesop ha- applied three to our times a year.
gu s and d ysp lastic change, and this is therefore an im p or- High f uoride toothpaste (2800 ppm or children aged
tant cond ition to d iagnose and treat. In su ch cases m ed ication 10 years and older, 5000 pmm or children aged 16 years
or su rgery are ind icated to p revent regu rgitation. and older).
Summary o Tom’s history There w as no evid ence of any If there is p rogressive sensitivity then the areas of enam el
gastrointestinal illness, bu t Tom d id consu m e a nu m ber of loss and d entine exp osu re cou ld be p rotected by an ad he-
zzy d rinks, especially betw een m eals and w hen he w as at sive restoration. In m any cases, if erosion is d iagnosed early
the local sp orts centre. In ad d ition to these, he rarely d rank then p reventive cou nselling and the above ad vice m ay be
w ater and m ilk. su f cient. It is a good id ea to take photographs and m ake
211 •
DENTALEROSION 40
stu d y casts of all p atients w ith signs of erosion or attrition
or abrasion to m onitor the rate of p rogression. In m ore
Key point
ad vanced cases than Tom ’s, as in Figs 40.2A and B, w here Treatment objectives or erosion:
there are signi cant sensitivity or cosm etic p roblem s, m ore • Resolve sensitivity.
active intervention is requ ired . Table 40.1 show s the m erits • Restore missing tooth sur ace.
of the d ifferent options available.
• Prevent urther tooth tissue loss.
• Maintain a balanced occlusion.
Table 40.1 Treatment techniques or tooth sur ace loss Those w ith signi cant p arafu nctional activity, e.g. cerebral
palsy and other p hysical and d evelop m ental d isord ers w ith
Technique Advantages Disadvantages
intracranial abnorm alities. Controlling attritional w ear in
Cast metal Fabricated in thin section – Maybe cosmeticallyunacceptable due these p atients can be very d if cu lt. Som e d rugs act to try
(nickel/chrome requires only0.5 mmspace to the‘shine through’o metallicgrey
to red u ce su ch p arafu nctional activity, bu t even if this is
or gold) Veryaccurate ft possible Cannot be simplyrepaired or added to successful in the lim bs, there is often still resid u al oral
intraorally parafu nction. This is p robably d u e to the neu ronal sensitiv-
Verydurable ity of the m outh and the structu res w ithin it. For child ren
Suitable or posterior w ith p rofou nd neu rological cond itions w ho stru ggle to
restorations in para unction comm u nicate, grind ing is very com m on. If p arents p resent
Does not abrade opposing w ith an increase in frequ ency or d urations of grind ing, a
dentition thorou gh oral exam ination is essential to elim inate any
Composite: Least expensive Technicallydi cult or palatal veneers
intraoral p athology and / or p ain w hich m ay have led to this
direct activity.
Can be added to and repaired Limited control over occlusal and
intraorally interproximal contour ■ Wha t restorative materials are the most durable or
Aestheticallysuperior to cast Inadequate as a posterior restoration attritional wear a s a result o para unction?
metal Amalgam and stainless steel crow ns. Carefu l consid eration
Composite: Can be added to and repaired Requires more space – minimumo w hen using these m aterials is necessary, as occlu sal d erange-
indirect intraorally 1.0 mm m ent m ay exacerbate parafu ctional habits. One research
Aestheticallysuperior to cast Unproven durability pap er id enti ed higher levels of stainless steel crow n failu re
metal in child ren w ith d evelopm ental d isabilities, w hich they su g-
Control over occlusal contour gested m ay related to bru xist habits.
and vertical dimension
Porcelain Best aesthetics Potentiallyabrasive to opposing
dentition Primary resources and
Good abrasion resistance In erior marginal ft recommended reading
Well tolerated bygingival Verybrittle – has to be used in bulk Kilp atrick N M, Bu rbrid ge LA 2012 Anom alies of tooth form ation
tissues section and eru ption. In: Welbu ry RR, Du ggal MS, H osey MT (ed s),
Paed iatric Dentistry, 4th ed . Oxford University Press,
Hard to repair
Oxford .
• 212
40 DENTALEROSION
N g MW, Tate AR, N eed lem an H L et al 2001 The in u ence of Su rgeons. Available at: <http :/ / w w w.rcseng.ac.u k/ fd s/
m ed ical history on restorative p roced u re failu re rates follow ing p u blications-clinical-gu id elines/ clinical_gu id elines/ d ocu m ents/
d ental rehabilitation. Ped iatr Dent 23:487–490. d iagnosis-prevention-and -m anagem ent-of-d ental-erosion.
O’Su llivan E, Barry S, Milosevic A, 2013 Diagnosis, Prevention
and Managem ent of Dental Erosion. Lond on: Royal College of For revision, see Mind Map 40, page 261.
41
been p oor, but generally her control is now good w ith a
stable regim en. She is seen every 2 m onths by her d octor,
and she monitors her blood glu cose and u rinary glu cose at
hom e herself.
Dental history
Kayleigh and her family are regu lar d ental attend ers and
have ju st m oved to the area w ith her father ’s job. This is the
Gingival bleeding
rst tim e you have seen her.
Examination
and enlargement Extraoral exam ination is norm al, w ith no signs of infection.
Intraorally there is w id espread m arginal gingivitis, w hich
is p articu larly bad in the u p p er right qu ad rant anteriorly
(Fig. 41.1). Clinical and rad iographic exam inations of the
teeth reveal a low caries rate, w ith only the need to replace
a cracked and d e cient restoration in a low er rst perm a-
nent m olar that has recu rrent caries.
SUMMARY ■ What periodontal screening should be underta ken
Kayleigh is 15 years old. She is concerned that her or Ka yleigh?
upper gums look abnormal, and they bleed Period ontal screening shou ld be und ertaken for all child ren
whenever she brushes them (Fig. 41.1). over the age of 7 years. For child ren in the m ixed d entition
(e.g. 7–12 years old ) a sim p li ed basic p eriod ontal exam ina-
History tion (BPE) is recom m end ed . BPE is m easu red at six points
(m esiobuccal, buccal, d istobu ccal, d istolingu al, lingual and
Kayleigh has noticed bleed ing w hen she has been bru shing 61 6
for the last year. She is frightened of bru shing becau se of m esiolingu al) on six ind ex teeth ( ), and only cod es 0,
6 16
the bleed ing and feels that it is getting w orse. She is also 1 and 2 are u sed . For old er child ren (13–17 years old ) the
very socially conscious of her gu m s because they look very same ind ex teeth are m easured in the sam e w ay, bu t a full
red and are ‘bigger ’ than norm al. range of cod es (0, 1, 2, 3 and 4) are used . Any scores over
2 require further investigation, inclu d ing a fu ll p ocket
Medical history charting for all teeth and , w here ind icated , referral to sp e-
Kayleigh has insu lin-d ep end ent d iabetes. She takes her cialist care.
insu lin by subcu taneou s injection at 07.30 and 17.30 hours. ■ Wha t actors are contributing to the chronic
She has a regu lated gram intake of carbohyd rate at 07.30, marginal gingivitis?
11.00, 13.00, 15.00, 17.30 and 21.00 hou rs. Ap art from this,
she is an active girl w ho p lays basketball and hockey at Poor oral hygiene.
school and has learnt to increase her carbohyd rate intake Hormonal changes o puberty.
ap prop riately to cover her sp orting activities. H er m u m Poorly controlled diabetes mellitus.
reports that Kayleigh has had the occasional ‘rebellion’
against her cond ition and at these tim es d iabetic control has
Key point
Gingival bleeding can be as a result o :
• Local causes.
• Systemic causes.
ap pointment either rst thing in the m orning or d irectly Karjalainen KM, Knu u ttila MLE, Kaar M-L 1997 Relationship
betw een caries and level of m etabolic balance in child ren and
after lunch. For any p rolonged su rgical p roced ure in a d ia-
ad olescents w ith insulin-d ep end ent d iabetes m ellitu s. Caries
betic p erson, or any treatm ent that requ ires general anaes-
Res 31:13–18.
thesia (GA), a referral to hospital is requ ired . GA w ill requ ire
ad m ission p re-op eratively to stabilize insu lin and glu cose
requirem ents via a d rip so that hypoglycaem ic com a d oes For revision, see Mind Map 41,
not occu r w ith p re-op erative GA starvation. page 262.
42
■ What is the diagnosis?
Prim ary herpetic gingivostom atitis.
There are tw o typ es of herp es sim p lex viru s: herp es
simplex type 1 (H SV-1) and herp es sim plex typ e 2 (H SV-2).
Classically H SV-1 cau ses oral d isease and H SV-2 cau ses
genital d isease. The viru ses, how ever, are very sim ilar, and
both can cau se both oral and genital d isease, althou gh there
are d ifferences in recu rrence rates. Prim ary exposure to H SV
Oral ulceration in the m outh cau ses acute prim ary herpetic gingivostom a-
titis (Fig. 42.1). The viru s cau ses a viraem ia, fever, m alaise
and lym phad enopathy. All the surfaces of the m ou th,
inclu d ing the hard p alate and attached gingiva, can be
involved initially w ith a vesicular rash that u lcerates and
can become su perinfected . The illness lasts for 10–14 d ays
before resolving spontaneou sly. Diagnosis is u sually m ad e
on clinical grou nd s but can be con rm ed by a threefold rise
in the convalescent antibod y titre over that seen in the acute
phase or by d irect im m u no uorescence of vesicular uid
using speci c antisera.
SUMMARY
Alan is 8 years old. He has been brought to the
surgery by his mother because his mouth is so Key point
pain ul he ca nnot eat (Fig. 42.1). What could cause Systemic signs in HSV:
this problem? How would you treat it? • Fever.
• Malaise.
History • Lymphadenopathy.
• Di culty eating and drinking.
Alan has not been w ell for a cou p le of w eeks. H e had a
‘viru s’ that resu lted in his being p ut to bed and m issing
school. Just as he w as im proving, his m ou th becam e very
sore. H e has been unable to eat solid food for 3 d ays and The primary infection m ay be m ild and subclinical in the
has been on liqu id s only. H e feels hot and lethargic. H is majority of you ng child ren w ho are exp osed to it, though
gu m s bleed w hen he tries to bru sh them . the cond ition m ay be severe and d ebilitating. In an im m u -
nocom prom ised ind ivid u al, it m ay lead to severe illness and
Medical history som etim es herp etic hepatitis or encep halitis, w hich m ay be
Alan is generally a healthy boy. H e has had a cou p le of fatal in the absence of treatm ent.
cou rses of antibiotics for ear infections bu t has had no real Oral infection arises from d irect contact w ith secretions
illnesses. H e has never been in hosp ital and is not on any from an ind ivid u al w ho has either p rim ary or recu rrent
tablets or m ed icines from his d octor. H SV infection. Direct inocu lation of the ngers or skin w ith
virally contam inated secretions or u id can lead to local
■ Describe the appea rance o the upper and lower gingiva e
infection, e.g. herp etic w hitlow of the nger.
in Fig. 42.1.
H SV is a neu rogenic virus, and on recovery from the
There is erythem atou s gingival enlargem ent w ith sm all prim ary infection the viru s m ay becom e latent w ithin the
u lcerations of the gingival m argin. trigem inal ganglion or basal ganglia of the brain and m ay
subsequ ently be reactivated to cau se a second ary infection.
The second ary infection m ay cau se a ‘cold sore’ on the lip
or Bell’s palsy. Best p ractice for p atients presenting w ith a
cold sore for regu lar d ental treatm ent (e.g. not in acu te pain)
is to rebook them once the lesion has d isapp eared . When a
cold sore is present, there is increased risk to the p atient of
exacerbating the infection and infecting one or m ore
mem bers of the d ental team (eye infection).
Treatment
Alan resp ond ed w ell to rehyd ration and analgesia su ch as
paracetam ol, w hich is also antip yretic, and an antiseptic
m ou thw ash su ch as chlorhexid ine (Corsod yl) or benzyd am -
ine hyd rochlorid e (Dif am ). H ad Alan not been able to
Fig. 42.1 Gingival enlargement and ulceration. m aintain hyd ration, he w ou ld have had to be ad m itted for
217 •
ORALULCERATION 42
intravenous uid therapy. There is no evid ence that sys- Coxsackie viruses. These are RN A viru ses and resp onsi-
tem ic aciclovir is of any bene t at the relatively late stage of ble for herpangina and hand , foot and m ou th d isease.
the cond ition that he p resented . If he had been seen w ithin H erp angina is a Coxsackie A viru s that cau ses a herp es-
72 hou rs of the onset of the infection and the clinical severity like orop haryngitis w here the u lceration is p red om inantly
w arranted it, aciclovir cou ld have been p rescribed . The d ose on the tonsil, soft palate and u vula. The m ild illness is asso-
is 200 m g ve tim es d aily for 5 d ays in p atients over 2 years ciated w ith fever and m alaise bu t only p ersists for a few
of age and 100 m g ve tim es d aily for 2 d ays in patients d ays.
u nd er 2 years of age. Althou gh aciclovir can shorten the H and , foot and m ou th d isease is also Coxsackie A virus
cou rse of the prim ary infection, there is no evid ence that it and occurs pred om inantly in child ren and their fam ilies.
red u ces the incid ence of recurrent herpetic lesions. The cond ition is characterized by u lceration affecting the
■ What are the reasons given or the reactivation o HSV to gingiva, tongu e, cheeks and p alate. It is associated w ith
produce a cold sore (herpes labialis) (Fig. 42.2)? vesicles and u lcers on the p alm s and soles. It m ay persist
for 2 w eeks.
See Box 42.1. Human papilloma virus (HPV). An increasing num ber
■ How should herpes labialis be treated? of H PV typ es have been id enti ed . Typ es 2 and 4, the
common w art, occu r in child ren usually d u e to au toinocula-
App ly aciclovir 5% cream to the lip lesion as soon as tingling
tion by biting ngers or hand w arts. Cond ylom a acu m inata
or prickling of the prod rom al p hase is felt. This is u sually
or venereal w arts can occu r on the oral m u cosa and are
24 hou rs prior to vesicu lation and p ain.
associated w ith H PV types 6, 11 and 60.
■ What other viral in ection can occur in the mouths o There are a nu mber of other cau ses of oral u lceration in
paediatric patients? child ren and ad olescents that are not associated w ith infec-
Varicella zoster virus (VZV). VZV is a neu rogenic DN A tions. These are show n in Box 42.2.
virus that causes a prim ary infection in the form of chick- ■ What types o a phthae are there?
enpox. Thereafter it rem ains d orm ant u ntil reactivation as
Minor.
shingles.
Epstein–Barr virus (EBV). EBV is a herp es viru s w ith a Major.
pred ilection for infecting B lym p hocytes. This infection Herpeti orm.
causes the B lym p hocytes to becom e activated and p rod u ce
Behçet syndrome.
their ow n antibod ies. A p rim ary infection w ith EBV causes
gland u lar fever or infectiou s m ononu cleosis. Recurrent aphthae a ect up to 20% o the population.
Cytomegalovirus. This is associated w ith a gland ular M inor aphthae are com m onest and account for 85% of
fever-like illness in child hood . On occasion it is found in recurrent aphthae. Ulcers are less than 1 cm in d iam eter,
severe atyp ical oral u lceration in hu m an im mu nod e ciency u sually only 2–3 m m . They occu r singly or in crop s of u p to
virus (H IV). 10, last 3 d ays to 3 w eeks and heal w ithou t scarring. Ulcers
Herpes virus type 8. This has been d em onstrated in are round or oval w ith a yellow ish-grey base and su r-
Kaposi sarcom a in H IV infection. round ed by an erythem atous halo. They affect only non-
keratinized m u cosa.
M ajor aphthae are m ore severe and u su ally m ore than
1 cm in d iam eter w ith an irregular ou tline. They are u su ally
single and often affect the fau ces. They are often d eep er
and bleed , and m ay last for several w eeks or m onths
before healing w ith scarring. Again, they tend to affect non-
keratinized m u cosa.
Herpetiform aphthae look sim ilar to p rim ary herpes. The
u lcers are 1–2 m m in d iam eter and large nu m bers m ay
occu r sim u ltaneou sly. They last from 2 d ays to 2 w eeks
before healing w ithout scar form ation. Again they affect
Fig. 42.2 Recurrent herpes ‘cold sore’. only non-keratinized m u cosa.
Box 42.1 Reactivation o HSV Box 42.2 Other causes o oral ulceration
• Trauma. • Aphthae.
• Chemicals. • Gastrointestinal disease.
• Heat. • Haematological disease.
• Hormones. • In ections.
• Sunlight. • Mucocutaneous disorders.
• Emotion. • Radiotherapy.
• Immunosuppression. • Trauma.
• Concurrent in ection. • Carcinoma.
• 218
42 ORALULCERATION
Box 42.3 Common aetiological actors in recurrent aphthae Box 42.5 Therapy or recurrent aphthae
in children Topical
Host actors • Coating agents (Gelclair, Orabase).
• Genetics. • Antimicrobials (chlorhexidene mouthwash, tetracycline mouthwash).
• Nutrition. • Corticosteroids (beclomethasone inhaler spray, betamethasone mouthwash,
• Systemic disease. triamcinolone dental paste).
• Immunity. • Local analgesics (lidocaine spray, lidocaine ice lolly, topical benzocaine (20%).
Environmental actors Systemic
• Trauma. • Systemic corticosteroids.
• Allergy. • Colchicine.
• In ection. • Thalidomide.
• Stress.
Box 42.4 Dietary allergens in recurrent aphthae Patients u su ally d evelop fresh u lceration w ithin 12–24
• Cheese. hours of ingesting the su sp ect food . Food s m ay be id enti ed
• Chocolate.
more objectively by patch testing. Dietary avoid ance is often
attend ed by clinical im p rovem ent.
• Nuts.
• Tomatoes.
• Citrus ruits.
• Benzoates.
Key point
• Cinnamon aldehyde.
Aetiological actors in recurrent aphthae:
• Host related.
Behçet syndrome d escribes the triad of oral and genital • Environment related.
u lceration and anterior u veitis. It is rare in the UK and USA.
■ Wha t aetiological a ctors are importa nt in recurrent
aphthae?
See Box 42.3. Althou gh only 20% of the p op u lation experi- Treatm ent of recurrent aphthae can be grou ped into
ence recu rrent ap hthae, there is a p ositive fam ily history in topical and system ic m ed ication d ep end ing on the severity
50% of fathers and 60% of m others. There is, in ad d ition, a and frequ ency of the u lceration (Box 42.5).
w eak hu m an leu cocyte antigen (H LA) association w ith
H LA typ es A2 and B12. Primary resources and
N u tritional d e ciencies of iron, folic acid and B12 can
occu r singly or in com bination. Many of these are latent and recommended reading
have a normal p eripheral blood p ictu re. It is necessary to Al Johani KA, Moles DR, H od gson TA et al 2010 Orofacial
assay ind ivid u al levels of ferritin, folic acid and vitam in B12, granu lom atosis: clinical featu res and long-term ou tcom e of
therap y. J Am Acad Derm atol 62:611–620.
as w ell as d o a fu ll blood cou nt (FBC).
Montgom ery-Cranny JA, Wallace A, Rogers H J et al 2015
■ What systemic diseases in children are commonly Managem ent of recu rrent aphthou s stom atitis in child ren.
associated with aphthae? Dent Up d ate 42:564–566, 69–72.
Coeliac disease. Scu lly C, Welbu ry R, Flaitz C, et al 2002 A Color Atlas of
Orofacial H ealth and Disease in Child ren and Ad olescents, 2nd
Crohn disease. ed . Martin Du nitz, Lond on.
Ulcerative colitis. Scottish Dental Clinical Effectiveness Program (SDCEP) 2011
Dru g Prescribing for Dentistry, 2nd ed . SDCEP, Du nd ee.
In old er p atients and less com m only in child ren, aphthae
Available at: http:/ / w w w.sd cep .org.u k/ p u blished -gu id ance/
m ay also be associated w ith p erniciou s anaem ia, H IV infec-
d rug-p rescribing/ .
tion and m alabsorption.
There is an increasing aw areness of the role of d ietary
allergens in recurrent ap hthae in child ren. Dietary allergens For revision, see Mind Map 42,
imp licated in recu rrent ap hthae are show n in Box 42.4. page 263.
43
Mind maps
43
• 220
c
h e c
i
n
k c
c
s
f
h i
t
o
s
r e
r
e
i
v c
t
n
e
c k
o
b
h p
f
t
c
e
i
o
c n
a
h
t
h
r
w g
p
e
b
i e
c
i
l
o
n
t l
l
k
e
o
a
a f
i
n
o n
n
f
o
u
o
t c
t
1
h
p
n
e
r h
|
p
r s
1
/
i
u
n
d
e u
p
p
g
e
r
p a
w
n
l
e
o t
i
a
t
p
h r
f
a
r
n
o l
d
l
u b
o
m
o
g n
y
e
p
e r
f
a
l
a
r a
l
e
r
a b
n
y
t
d
i a
a
a
e l
l
l n
a
f
t a
t
a
t p
?
m
a
l a
c
p
c
a
i
m
i l
l
h
h
e
n
p
y
b m
o
m
a
r
c
a
o
s
h
i
c r
i
a
a
r
t
e
d
e
c i
t
i
e
s
p
y
o
i n
e
l
n
n
u
t
i n
c
t
n
c
t
o
b
g
s s
o
2
a
c
r
e
a u
y
m
e
’
l
s
l
p d
t
v
–
o
o
u
m 2
c
p
u
i
e
d
r
b
l %
l
e
h
i
e
o n
w
o
e
y
c
D
n
m
t
i n
r
a
c
p
o
o
c P
t
i
e
a
b
o
n
n
o
u d
T
n
l
s
d
i
m
l
c i
a
f
t
e
g
o e
a
a
t
e
n
i
n
e m
l
l
t
e
j
t t
u
r
s
i a
x
2
a
a
v
u
a l
’
d
t
e
e
s
c d
y
m
i
n
s
k
o
p e
i
i
i
g
h
d
n
l
e
v n
e
r
i
e
e
g
s
a s
a
a
c
p
l
p
n t
t
o
p
b
y
i
r
o e
t
o
o
p
s
h
o
s r
r
n
m
m
y
t e
i
a
i
c
o s
/
n
l
p
i
i
e
v
d n
n
u
t
t
r
e
n
u
o c
e
p
o
o
o
t
I
m
n
i n
e
c
a
n
s
r
l
t
a
t l
r
o
l
o
v
i
p
i t
n
n
r
l
(
r
i
u
e a
e
s
u
‘
s
a
d
u
s
r g
b
m
t
i
g
t
i
-
i
s o
a
i
s
l
e
ga
p y
n
l
h
r
p
r f
a
d
a
o
r
a
o t
r
e
u
p
p
i t
f
y
o
h
n c
e
o
u
n
o
k
u
t d
r
e
p
t
l l
m
s
i
o
i
e 2
p
n
o
g
t
’
e
g n
s
h
y
’
r ) A
e t
i o l
o g y M
a n
a g e m
e n
t r
m
e
d
e n
i
a
m
a
b c
s
y
e
o
o t
f
e
u
v
c o
c
s
e
l
m
r y
p
r
o
a
e s
a
s
s
a
g t
c
e
u
a e
/
>
e
n
p s
t
d
y
e
u
4 f
p
o
i
r m
g
o
o
n
m
r
i
n r
t
u
o
2
t m
t
h
s
m
u
a
’ s
u
o
r
n :
e
b
c
d b
e
c
r
e
k
o
a
e o
o
f
i
n
n
r
o
f
u n
o
y
t
g
r
s
s
i r
e
c
l
t
e
i y
h
o
d
3
t a
o
e
c
r
a
|
e b
l
t
r
3
s
o
h a
i
i
t
s
n 3
e
t
/
m
u t
t
’
r
o s
t
e
r
u
e e
e
r
p
p
s
e
p
e
d
a v
n
c
t
e
t
r
o
t
e
u
p
o
t o
p
h
u
r
a
s
n
r
p
n
p a
m
p
i
n
s
o
t
n
l
s l
i
t
i
i
a
d
a
o
a r
g
i
b
d t
t
n
n
n
l
l
a
o e
s
e
a
c
e
l p
r
c
e
2
n
r r
i
a
f
k
e
n
e
’ t
r
s
c s
e
t
t
b
o
e a
e
t
(
n
o
f
o r
?
f
i
r
e
n
i
c
c n
e
r
x
a
c
a
e
v
l d
m
e
o
e
t
t
n
r
e d
o
s
i
o
v
n
i d
u
m
n
e
v
e r
e
a
y
e
e t
b
r r
w
e
s l
e
i a
)
d t
t
m h e n
p
u
m
m
t r
s
i
i
i u
n
m
x
o
a
e a
r
l
d
l r
y
i
y n
d
c
c
e d
o
r
n
e e
m
t
n a
i
t
p
t i
s
i
o
t l
e
e
i n
o
t
:
t
n e
o
~
: ~
~
~
3 9
1
1
m 3
–
y
m
e
2 y
a
e
m i
r
n
a s
m
c
r s
r
e i
n a
c s
r e
e a s e
MINDMAP1A
M e d
i a n D
i a s t
e m
a
221 •
MINDMAP1B 43
significantly larger 6
local more mesial angle of eruption of 6
Indicative of crowding
small maxilla
Aetiology
non-cleft 2–6%
Prevalence
cleft lip and palate 20–25% 6 disimpacts
reversible 6 erupts spontaneously
rare after 8 years
Classification
until treated (see below)
6 remains impacted
irrreversible E lost spontaneously
Management
surgically expose and align orthodontically if 1 apex not destined to perforate cortical plate
mild
dilaceration prosthesis; bridge; implant later
severe surgical removal 1 replace 1
– 2 drift mesially; crown 2
– – –
tumour biopsy for further diagnosis
dentigerous cyst marsupialize
surgically expose 1–, closed technique: bond attachment activation
retention
design using ARAB
? start with URA anchorage
baseplate
surgical / orthodontic orthodontic alignment fixed appliance
bonded retainer open space for 1 always balance for unilateral loss/extraction of C
r
e p
l a n
r
e p
l a r
e p
o
l a
n n
r
e e
r o
o l
t
o o
n
n y
e
r r
n
r
e o
t
a
o
h
t a
r
m
m p
o
l
h r
r
n
a
e o
e
e
n
m t
t
h m
p
r
a
o
p a
l
a
n
a
e r
n
o
t e
r
r
a
o
e e
m
a
n
m r
o
t
a n
a
e
o
r
t r
o
t
e
l a
t
o
e
r e
r
n
r
l
a
m
e
o e
n
n
a
e l
t
p
a
a
o
t e
l
h
a
r e
r
l
r
l
e
r
o
m
a
o
n p
y
o
r
e
t
r
l
n
t
r
t h
e
l
a
o
o
r
p
a
e
m o
o
a
e
r
p
n
t
e
r a
e
n
a
e
t
r a
r
n
o
m a
o
p
t
a
e
n
a
h p
n
e
t
a
r
o
o
l
e
p e
l
r
t
t
o
m
o n
t
m
a
e
n e
l
l
t
t
o
l
a
m o
r
o
a
a
h
T
a
n
p
e r
r
n
r
a
o
e n
t
a
y
r
e
e l
m
n
p
m
a n
n
e
a
a
t
n
t r
n
e
p
m
e
n
p
l
m
e p
r
e
n
p
r
l
o n
e
a
a
a
n
e
e
y n
n
l
t
r
m
n
t y
t
t
o
a
a y
t
n
a
e
r
r
h e
e
n
t
i
y
p
o e
m
o
m
r
p
l
o
n n
r
t
l
a
h
s
a a
m
r
l
o
m l
p
o
e
e e
m
n
l
y
m
p
o
a p
n
r
p
n
m
t y
l
t
e
h e
n
a
a
t n
m
r
e
o p
t
a m
a
a
r
r o
M
y
m a
e
p
a
e
e n
l a
e
g o
n
p
n
e
r
e h
a
e
m
t
e a
r
y
n e
n
o n
t
t y
p e I
n H
v
y
e p
s o
t
i d
g
o a
t
n i
t
on i
a s r
a e
a
l e
n r
o a
m
s
m l
p
e
t y
a
i
o
r
l
v d
a
t
d
r
e
a o
p
e
(
r
l y
≤
e
h
r
t
n
e
a
e
e
a l
(
t
n
n
l
2
e >
e
t
t
)
t a
a
l
6
(
o l
3
t
l
a
)
a l
r
–
o t
e
l
r
t
n 5
n
o
o
l
a
a
) o
t
t
t t
h
p e
e
a
o o
r
r
n n
n
n
a
l
l
r
r
s
i
a
d n
e
e
o
m
n
e
e
c e
d
t
h
l
a r
m
a
p
a
t
h
u
e
i
o i
y
d
l
a
n
c l
e
a
e
r
a e
e
o
t
r
e
s
o
e
d l
a
d
d
r
p
e
n
t t
e
r
i
o
h d
d
t
c
p
l
y
h
t
o
h n
o
h
e
t
r
o
e
e
w
a e
i
n
n
m
y v
c
e
p
a
e
t
e
t a
t
e
a
t
r
o
o r
l
r
d
f
b
n y
t
d
a
e i
t
e
t
r
c t
e
r
e
e v
i
m
a e
e
p
l
a t
l
a
o
h
h l
t p
e
d
h
t m
i
y
r
o
g e
s
l
h
e
o a
p
t
n t
l
m
a t s
e
y i
a
n t t
a
h n
n e n n e o
o p
h
a a
l
m a
r r e
n o r
m a l p h e n
o t
y p e A e t
i ol og y
e n t p
p e r a t
e r
a l n o
r
223 •
MINDMAP3
43
• 224
43 MINDMAP4
refer to dermatologist
females > males nickel allergy medical history
if confirmed use nickel-free
appliance components arc usuall crowded
crowding spacing Buccal 3–'s las per anen oo o erup an erior o
angula ion o lower incisors re ainedC
canine inclina ion lower arc irs
o er i e dep
idline s i
ild
odera e degree o crowding
assess space
se ere increased o er i re e uire en s
cen reline s i
decide inal olar rela ions Crowding and Buccal Upper Canines
ip and rela ed ec anics
anc orage
re en ion
prognosis
si e o crowding
e racs ion
e en o crowding
indi idual oo posi ions
surgical e posure i re uired
crea e spac
e arc e pansion er rarel undern a e
in lower arc
dis al o e en
ena el s ripping
co ina ion
re o a le
Treatment id e
appliances
eadgear pala al arc
id e
re ainer
s
re o a le
incidenc
e
s and s
decalci ica ion
care ul pa ien selec ion
ain ris s
pre en iondie ar ade ic
applica ion o luo
wee l around rac e
roo resorp ion sodiu luoride e
relapse
225 •
MINDMAP5 43
inherent dentoalveolar
disproportion
age at removal
arch from which removed
Causes early loss of primary teeth space loss affected by: degree of crowding
tooth lost: greater if posteriorly in arch 6 rotates mesiopalatally following loss of E
occlusion
supernumerary teeth
megadont
space lost by mesial drift
premolar / molar rotation
possible effects premolar / canine impaction
crossbite of premolar with / without mandibular displacement
centreline shift
Severe Crowding
DPT
radiographic
Investigations
average space for 3,4,5 = 22 mm
space analyses
average space for 3,4,5 = 21 mm
o ilit
olour
lini al wear
palpate palatall
in lination
tooth with longest path of eruption
r pt ispla e ent he wi th of an for
in isor pre olar h po ontia erti al or hori ontal tu t e shif
two fil s
ost o on ou les paralla
feaf ts s in i en peg e or a sent
infrao lu e pri ar olar Aetiology
ost
usuall un row e ar h resorption of a a ent teeth
pol geni Investigations
i pa te geneti un ertaint a out position on stan sar fil
asso iate
other e topi teeth root length
ano alies
transposition ra iographi erti al position ofto roots of in isor
s
lass i ision assess esio istal position of to roots of ins isor
uropeans a ial in lination
fe ales ales ape lo ation
ilateral with greater fre uen than e pe te in isor root resorption esti ate higher wit
anterior a illar trau a than with on entio
patholog ra iographs
italit test
au asians
a sent
au asians of whi eh topi
Retained C
ilateral – alatal anines ean anterior ratio
olton anal s si
ean o erall ratio
re o e s ut no fir resear h e as
s ear
inter eption
o erlaps istal half root
a ti e treat ent if no h
onitor onths within onths
patient not een for treat ent
no patholog resorption
retain an o ser e prognosis goo
an in onta t goo s aestheti
se erel ispla e no patholog
highl oti ate patient
Management e pose an align e ellent ental healt
h
spa e for or possi le to reate spa e
position fa oura e l
no signifi ant ifferen e l enta
open lose te hni health
ue ental aestheti
s
patient not een for align ent
st for ation
poor prognosis to align
re o e
an goo t onta
goo aestheti s prognosis
earl resorption of a a ent
h teet
a e uate spa e
transplant inta t re o al possi le
a e uate u al palatal one
rarel signifi ant if
a ress
lini all signifi ant if s
e on olton ean alues
227 •
MINDMAP7 43
maxilla: a a m a a
ma i l :a a alm x l i l
la i i a i : a ial m l
al :
a i l : i a i m al
l i a l i a
i i i
i x a i ima
Transposition
a
i i
a mai ai
a i i a ma i m l
a
a m a
a a i
x a i i la
ix a lia i
i la i i i a i
i ali m
a i l m
i i
m mm i mal
i i a i a la i mi li
xi a i
m ili
li i al l
i i a i i ili
Associated incisor root resorption
i ll x l
i i l i al a i a
a i a i
i i i i
x a i a
a m i
x a i a ai i al x
a a m i
m i i a i a i all i a
ma al ll i ma a m a ia
l a i ma i i a i a
i i a m
• 228
43 MINDMAP8
ti li
o i tio it l t l to i
Aetiology i il t m o
ylo i
o ti l ol o t it
m t titio
i by o ti t Prevalence
y o o ti
f m l m l
f fo ll yt ti
Latex allergy?
if o fi m l t f
f o l im y ol
mobility of E
if
ob tio o
t t of i f o l io of E
li i l o o i oo o
ti o to io
Investigations
o tio of o o i t t t i o b t
Management l o l lo l y
b t l
io i o o i oo o t
bm b lol i i l
mo
oot fo m tio o o o
open or close space
229 •
MINDMAP9 43
e tea
a c ea e eate May predispose to a a
c pete t p ppe c t a a a a e c e c
e eta
ta t e ce ta a a
c e a a a a
e p e
Aetiology t t pe eact e e p
e e t e t t
t c a t
a a p ace e t
c a p ace e t
c at
t t e e
t pe
t t e
e et e e a a
t p e p e ta
accept c pete t p
ea a e a c
a e a c e
p t e a e
ct a a a a
c ea e e et app ea c app e a
te a a t act
e e e
e ac cea
e e ate t t e pt
e t ac a
e eta
pat e t t cat
e ect e t a e a
ate a cep a a ea t
e t te t Diagnosis e ce c e ce
t a a
pe ap ca a ap a e e e t act
a e app a ce
a a p t
ea ea
Management e
e eta
ct a ea ea
eta t e t c p
eate e eta
e t ca ac a p p
ca a e
a
c e a e
a e a t act e app a
pat e t a e e eta
e e ce c ea
t at c ac a pe p t
e
e et c p ete e ce
e p c e t t a
a a ace
ta e c ect
t e t t
te c a a e a
a e ate ete t
• 230
43 MINDMAP10
May predispose to
erio ont tr
Incisor Crossbite
o nt o oe erbit
Stability of correction
no n ib r is ce ent s bse ent n ib
no erio ont tr cce t n re ie
ini o erbite
n ib r is ce ent
Management
erio ont tr
e tr scttoCenco r e o erbite incre se o r b e o erbiteroc i ine
incisor e
s rin
consi er
osterior c in
o re o er
i e e i nc
cost ess t n
231 •
MINDMAP11 43
? familial tendency
profile
A-P
skeletal vertical
growth direction / extent extent greater in males
clinical
? mandibular displacement
periodontal trauma
Investigations gingival recession
amount of overbite
site and extent of crowding
ANB < 1º
long mandible lateral cephalogram growth pattern
anterior position of glenoid fossa radiographic ? dentoalveolar compensation
skeletal III
short and / or retrognathic maxilla tooth number
DPT
short anterior cranial base tooth position
mandibular displacement
Aetiology
retained BA | AB
excess
mandibular growth
forward pattern
restraint of maxillary growth
Reverse Overjet
i ed a iances it it t s inc de s
Increased Overbite
ti it arc incisor
es intrusion
di ic t
n molar eruption
cervica ead ear Methods of overbite reduction
ec anics t intr de incis rs molar
isted ab extrusion
ve
ass II III inter a i s ar e astic
lower incisor proclination
in re e A n e et
o n r n i r ro t p ttern
en o eno ton t e t r
i it in er p i ier
o on in e r i oo Aetiology
re e it non ne triti e in it ( ) in re e A n
oe not pre i t e n to o io e et
ini
etri AOB e i tit i
Assessment
e t ip n op ton et r t
ite e i re o eo r e e op ent
in re e A
r io r p i ter ep o r
in re e
AOB i
t i it n i eept
re ie e ro in i n r e on
i e r it re e
po iti e or ne ti e rein or e ent
ot
po terior o er e i r p int
e et i p ero t e or i i tion
n tion pp i n e it ppin
r AOB
e Treatment
r n e it ip e tr inin
i p in p
A it ppin
AOB i
re ie e ro in
o e
i e pp i n e it it o t A
oi e tr ion
AOB e ere
ro t o p eter er
t i it
• 234
43 MINDMAP14
lass
s eletal
emimandibular pertr
c ec centrelines mandibular displacement di it suc in
inclinati n p steri r teetclinical Aetiology cr din in sciss rs bite
cr din Assessment
earl l ss in
c ec c nd lar anat m radi rap ic cr ded arc buccal cr ssbite
unilateral
bilateral Classification
it it ut mandibular displacement
mandibular displacement
Treatment needed
ma predisp se t steri r r ssbite
eletal o o it la alo l io
o i le ole o a e oi to il
aetiology alte e ea o t e e to o t eat i g
o t ti e
lo to g e o itio
a ti e e to le t e ai
ll le gt o e i i o
a o e a
elate i te o i al gi gi ae
li i al eat e
att a ti e ile e i i o e ge o to at e lo e li
oo ile ae t eti
late al e te io at lea t to
a o al o i o
a o iate a i la i la e e t
i e tigatio i li atio o al eg e t teet
t i e o gi gi al ti e a al o e
Buccal
atie t ot ee o t eat e t
a e t a o eito lyi g eletal li ely to o e
it a i la g o t
i a y ea ly i e e titio
lo e a io
it i li e e o o ea lia
y ie li eit eai g a a ti atio ay e o le ati
ot o et tie e o e ti e e i e to o e e i e e
e e e ea ly i e e titio
a ti ate al ola toot i t
a age e t e a io e i e
to a e o e o e
a eli
a t to gi e o e e a io o te io ly o a te io ly
o ie ie et lo e a io
e otate ola g o
o e o a e a lia e o e e t e ay
ilate al o ite e ia ia te a al i te
i o e o e t
eletal o ite it e alatala io t e et o ei ei g al o
g a a tee e o e age etai o o
i e eaa lia
t o g ela ye e te
it alatal a
o e age o i
a ea y e
i e o t o teoto y ig t o o i e loo
eletally at e it e a io e i e
a e ate a o
e a io ally ta t y it i ay o ge
t a o e o t o teoto y t it o t
a illa y o a t e
i e i g o a illa agai t o ly o t ti e e i ta
o e ta le t a gi al i e i g o a illa
eletal o o it la alo l io
o e i le ig to g e o itio
o t ti
aetiology ea ly lo o
lo al
e ie e o i a o aly
a
Lingual o i e e t a tio o i la e toot
i gle toot e te
a o ea i e
o i e o i atio o ealatal
te o e e t teet
o a
al o e ee tet o lo ae teet
t eat e t
a el e a lia
g o t o i i atio
el ligati g i e a lia
ae ot a lage
tio o e t a tio
e e al teete te a o ea o it eo o ti
allo o teoge e i a i toge e i
ay late y e io
i lie et i e y e a
i t a tio o teoge
toot o e i t a to o e e
o li atio ai ly il a t a ie
o t og at i a i
ge y la at a e e
• 236
43 MINDMAP16
ti actoria
orward andi ar growt w ere a i ar
growt as sto ed aided e i ress r c inica se erit o crowding
transse ta i res s
Investigations radiogra ic
anterior co onent st d ode s
o occ sa gingi
orces a and or occ saAetiology
orces
ead to esia igration
o osterior teet
red ction in intercanine widt
e ert esia ress re d ring n er tio
re ent osterior teet ot ird
ing os ar
dista in res onse to ot er orces
c olog cal
auma c
ae olog mul fac o c alo e
occlu al la
a e o e o
lac g co ac
e
TMJDS a afu c o
e ma ageme
ma ula g o l e a
ae olog Prominent chin
a e o g o o a o occlu al e u l a o
ma ageme
o o o o c gua a ee
o o o c
o og a o c gua a ee
om e a
eam a oac
camouflage
full e e of ma ula g o
u ge
la e ee
fac al occlu al a l
ela e afegua e
fac al
o og a
e al
u l ca e fo
mo el u ge
f ma lla u ge u mo
la ele
a cula o mou e e ga o
dia ete
periodontal disease edi al in l en e on periodonti
periapi al pat olog istor attendan e
dental
st treat ent
t o r s or e
r ing Aetiology aries
lini al dental stat s
nail iting a it sin s
Investigations gingi al s elling le
pen e ing
andi lar displa e ent e a ination periodontal stat s toot o ilit
o l sal periodontal po eting
la o posterior teet
andi lar displa e ent
o l n sio
e tent o posterior s tppor
or periapi als
radiograp i
pat olog al eolar one le els
ri ting n isors
ling al applian es
239 •
MINDMAP19 43
Candida
Red palate
Bond failure
Overextended archwire T
T
T
• 240
43 MINDMAP20
too o
or e
operator e e e
a r ter ere e
app a e e
orre t re a eter o pr
ort a p ate o ta t
aet o o a ato a
reta e root
ter tte t re o e at ea
pat e app
t a e ear
orre t po t o o pr re tort o
o a ter ere e
a t
t pp
o
tr o
Slow / no tooth movement rotat o or e tr o
or e
pre re
p
te o
ta e
reorpt o
o e
epo t o
appropr ate or e e e
orre t app a e e
appropr ate app a e ear
a r
a a e e t re
re o e o tr o t o a
r a re o a or
reta e ea e
root a o tor
o ra e a t
e o e o
t a tor a
e ate ro e
pre treat e appropr
t ate ra o rap e p a r
p at o or
a o ea or e
a pra t e
o t pa e t
treat e t ear re orpt o o
o t pro re ra o rap
o tor o o r
e root
t a a t erap
e ere re orpt o o e
pport t e rea e treat e t ter
p a ate treat e t
e t e
oro a a o t t e a ra o rap
or e o tor
aet o o o o e ere re orpt o o ear
a a ro t po t treat e e t o treat e t ra root
o rapa a t erap
el e appropr ate rete t o re e o e p t
re ap e rete t o a part o or e o e t
pre
pre e t o treat e t
t re po t t ee or o ter rete t o
a ept a o tor
a or e po ret a e
ea
a a e e t re o a ea e t t o t a r ate a a o
t pe
rap aro e
p o pete t a ter o er et re t o
re treat o pro e pa e e t t o
ar e a terat o a tero po ter or po t o o o er
e e ere rotate teet
appropr ate rete t o re e pa te
per o o ta o e e t t o
e t p a pa ate
o ter
re o a e
t o
rat o
e o ter
CLP fa il i t
eneti left palate (CP fa il i t )
Aetiology
eate i it CLP t an CP
en i n ental
p i a e palat
e nda e palat
nilate al
Classification ilate al
Ca a ian eplet
ale Prevalence
e n in eplet
left ide t lef
clinical evidence
dietary factors
social history
use of fluoride Risk assessment
plaque control
saliva
medical history
c ri s
c inic i r nc ious nt tr ction
r ious r stors tion
h o stic n
nt ctors og n sis i r ct
oor or h g in
ntinog n sis i r ct
ti ing
r u nc
sug r Aetiology High caries risk i t r ctors
in u t uori r gi ns oor nt tt n nc
soci histor
i it nt s s ir tion
in ro ri t tooth st str
uori us
in ro ri t ti ing o uors
u contro
s i rosto i
ic histor
igh ri s is o sc nts
onstrn tio
toothbrushing instruction
isc osing t b ts
tooth st str ngth ic
high r str ngth tooth st
su nts n ti uori ing
rnish ic tion
oo
rin i t ic
ch ing gu s nt r s stor tion
issur s Treatment
nts / preventive care Restorative care nt rior co osit s
sth tic or
sug r r icin ic bri g or
• 244
43 MINDMAP24
paracetamol
pain control
ibuprofen
introduction to dental procedures
Acute treatment reduces Streptococcus mutans count
why
temporization cement fluoride reservoir
increase comfort for eating, brushing
dehydration
temp > 39ºC
culture and sensitivity
Hospital admission
trismus
complete closure of eye
breathing and swallowing difficulties
extraction
incision and drainage
culture and sensitivity
IV antibiotics
Hospital treatment
fluid maintenance
saline mouthwash
pain control
chloramphenicol eye drops
extract
remove cause
RCT
incision
dentist Management
RCT local drainage
extract
oral antibiotics if systemic involvement
• 246
43 MINDMAP26A
a l an io t
tain ntall h i all i all
in i ation o o i ati nt
a l int ith ntal a
inhalation h o o n
lo al ana th ia annot
ation h oni ti o t l ona i a
otional i t an
lat n n i
ont ain i ation
i t t i t o nan
ntal i l ll i a
i al ati nt t at ith l o in l hat
a il a
History ntal la o holo i al o
na l to oo at
ntal h i al o
lo nt la o nition a t in tion
lo al ana th ia tiin anato i al a iation
all
t l n oo ati a
in i ation
an io o n o ni ati
Pharmacological i ni i ant i al o
n al ana th ia ot t lo in h
an o i al i
i iat o h n i o al
h alth oo ati ati nt
ith ini al ntal n
in i ation an ati nt
non al
ont ain i ation non
in i ation an ati nt
t ll ho o
ont ain i ation non
mother
i iat l
father (if ...) who has parental
on i t nt
step-parents (if ...) responsibility Consent l a
relative, friends (if ...) Communicative
o iti in o ontin nt nt
social services (if ...)
in i ationan ati nt
in i ation an ati nt
i t a tion non
ont ain i ation
in i ation an ati nt
oi ont ol
non
ont ain i ation
in i ationan ati nt
a ntal n a non n
ont ain i ation
247 •
MINDMAP26B 43
lo el e tee
Peer pressure
tool it bullying ocial e ia
iet iary an tailore iet a vice
patient contract Preventing disease
cognitive behavioural therapy
behaviour change theorie recreational rug
otivational intervie ing
Habits o ing
alcohol
perio ontal i ea e
u ing concern to otivate Dental diseases carie carie ri a e ent
veneer aci ero ion
Concerns about aesthetics non carie tooth ur ace lo
bleaching attrition
previou entoalveolar trau a
ortho ontic treat ent
pre olar e traction Consent co petency
ea uring an iety
ealing ith parental eparation
an co ple a ily relation Changing
hip relationship with parents
groo ing
neglect
Self-guarding
abu e phy ical e ual e otional
orce arriag
e
43
• 248
f
s
l
a i a
n
n s
s o
i o
n
s
s i
l
n
o i
c a l s
s i
s f
a
l i
c a
a o
i
i
l
l o
i
c i i
o
a
o
n i
n i
l o
a
o
a n
o a
l l
a a
i a
i
s s
i s
o i
n i o
c
s s
s
s i
a
s s n s
n a s s s i
i c
o
i a l s c
l
l o
o
i s
s
n
o o l f
f
l
a i
n s
o
o s c o a
o o l s c o
o s
i i
c o
n a
l l
a s
c s a
f i
c
l l
i s n
i
a c
a
MINDMAP27
a
s s i
n a
l n
a
f
o
i s
n
n s a
l
a
o s o
a
n n
s
o
o a i
s
n a l
a n
a
a a
n f
i n
a
i n c
o
i l
a
n l i
o
l o
n s
o s s
o l
c s a a i
c a
a c
c c
c s
s s
s o c
a I n e q
u al i t
y S
c h o ol a n d s o c i
a l s u p p o r t s e r v
i c e s i
c a l a s s s s n s a o l
o i
n s
o n i
n c o
o
s f
a a i
a
f i
s i
l
i i
l
f
a
i c a
a n i
o o
i
s s
n
o
c i
f a n
l
o
i
n a
n
i
o
f s
i
c
s o
s
o
l n a
a
i
f
o i
a
l
l
n
l l
l o
a
i
c
l o
s
i
i
l
s
o a
s
i a
n
n
o
n
s a
f
f
n
o
n
o a
R
o
s E
n
n
n
e
a
a
i
B
l
s
c l
a
i
l
s
l
a
r
i
o
i
i
e a
n
c
i
l
a
s
o
c n
h
t
e
u
a
e s
a
s
s
l
d
t
i o
o
of
v
i
n
a
nc i
d
a
ou o
i
l
e
a
s
a e
a
i
s
l
c n
d
n
r
c
c
o
a
t
e a
n
a
a
o
a
e
a
l
n a
f
l
a
n
p
c
m f
t
a
s
a t
f
s
a
a
n l n
n
o
c
i
c
a a
o
m
a
e
g
r
o n
s
e
a
e of
o
l
o
m
i f
e
li
o e
c
sn i
n
o
c t
i
s
i c
i s
n a
i s s
i s
i
f a
f ic i
l i
l i s
a n
i
n i
l a n i n n
i
l a l i a c o o s o i
n o n s n o
C H
on i gh
s c i
c
ou a r
s i
e s s
e r
d i
s a k
t i
o n c
i
c
n a
l
o
c a
s i
s
l a
a
l i
i
a
a
a i
a
n
c
s
i s
s o
s n
n
a
n
o
i i
a
n l
c
o o
o o
c
f
i
i o
s
a
n i
n
i
n
c
c n
c
c i
a
s
i l
s i
a
o i
n
c
n c
l i
o
s i
l
o
s
f
a i
o l
i
n s
i c
c
o
s a
i
n f
o
l s
c
s
c i
i
o
a
n l l
l a n a
s
o
a i
o
n f s
a l
i
c
i
a
c a
a a l i
n l
i s s i
i
i
c
o s
n
n c a
i n a c a
n f
n
i
f
i
n
o s
a
f
n a
l
c
s n
a n
a
a l a n
s
a n s s
l s s
i i
a i
s
c i
s
c a s i
a
a i
i
n
c i
a n f
i n i s s f
o
M e d i
c a l c o m or b i
d i
t y
G e n
T
e
y r
p
a e
l s
a o
n f
a e
d s
i
s t
h a
e b
s
i l
i i
a
t y
249 •
MINDMAP28 43
histor
infecti e endocarditis clinical exa
leedin Identify extent of disease radio ra s h
i aired i nitBroad implications dia nosis
increase likelihood of extraction a oid infection hich a ro le list see ha ter
rather than co lex restorati e careco ro ise eneral health
toolkit
Comprehensive and rigorous prevention
a ha e to odif as
of edical treat ent
• 250
43 MINDMAP29
? accident, if so how
does injury fit the age and clinical findings
is explanation consistent with injury infection
? delay in seeking advice pain
required if
? story of accident mobility
relationship between parent and child ? Child physical abuse occlusal interference
to other people concussion and subluxation observation
reactions
to medical or dental examinations spontaneous reposition
demeanour of child lateral luxation
extract
comments by child / parent that give concern spontaneous reposition
about upbringing / lifestyle of child intrusion
extract
extrusion extract
general demeanour
tetanus status to other people
reactions
to medical / dental treatment
congenital heart disease / rheumatic fever Displaced Primary Incisor
immunosuppression Medical history bruising
bleeding disorders extraoral abrasions
allergies lacerations
Examination ? child physical abuse
burns
bites
fractures
tooth
mobility
intraoral dentoalveolar segment
occlusion
periapical concussion and subluxation
periapical lateral luxation
periapical intrusion radiographs may occur in 50% of cases
Investigations
periapical extrusion intrusive trauma most damaging
periapical avulsion enamel
hypomineralization
not indicated vitality testing
enamel hypoplasia
Effect on permanent successor crown dilaceration
crown / root dilaceration
root dilaceration
odontome formation
disturbance in eruption
sequestration of permanent tooth germ
251 •
MINDMAP30 43
swelling
previous treatment extraoral asymmetry
previous local anaesthetic occlusion
Dental history
attitude to lip laceration – check
treatment soft tissue for teeth fragments
Examination colour
mobility
intraoral teeth
percussion
congenital heart sensibility
disease / rheumatic fever occlusion
immunosuppression bone
bleeding disorders Medical history
allergies
tetanus status
how
when
where
check for root and alveolar fractures
fragments History Radiographs periapical
check periapical status
previous injury
smooth/restore clinically
enamel fracture monitor vitality
radiographically
reattach fragment Review monitor root
temporary adhesive bandage enamel / dentine fracture maturation
Treatment
acid etch tip monitor adjacent teeth
partial pulpotomy enamel / dentine /
complete coronal pulpotomy pulp fracture
calcium hydroxide pulpectomy
• 252
43 MINDMAP31
a ri i ec i e e car i i
pre i rea e
i ppre i
Medical history Dental history pre i l cal c a ae e i
lee i i r er
a i e rea e
aller ie
e
ere
History
pre i i r elli
l c ci e e ra ral
a e r
ccl i
e i
c l r
Examination
ili
ee
i ra ral perc
e r c re Structured
i r and examination
history r
rac re er a e ci r e i
ccl i
e
pli re al
i r e i ili Review rac re ee
periapical
i r e i ili a ace ee Radiographs
a eri r
re c i
i ili a i lile i le irepli e i
Treatment
c l r e i i e a
ie
253 •
MINDMAP32 43
previous treatment
at risk of infective endocarditis Dental history previous local anaesthetic
immunosuppression attitude to treatment
Medical history
bleeding disorders
allergies
how
swelling
when
extraoral asymmetry
where
occlusion
extra-alveolar dry time
History soft tissue
storage medium
colour
total extra-alveolar time Examination
intraoral mobility
previous injury adjacent teeth
percussion
contamination
sensibility
place in normal saline/milk
tooth in medium
establish apical status
decoronation
denture
The Avulsed Incisor 30 min DT
Early referral to
BSPD
resin retained bridge interdisciplinary team open apex replanted – may revascularize 90 min EAT
orthodontic space closure IADT 60 min DT
transplant
extirpate prior to splint removal
Endodontics
all others initial dressing antibiotic / steroid paste (days 0–10)
change non-setting calcium hydroxide 3 monthly
or initial dressing with non-setting
repair calcium hydroxide (days 7–10)
infection monitor resorption
ankylosis
Review
obturate if no progressive resorption
monitor sensibility of adjacent teeth
spontaneous
aetiology familial
syndromic
mobility
double primary teeth
problems tongue ulceration
hypodontia affecting
permanent successor Delayed exfoliation Natal / neonatal teeth nipple soreness
of primary teeth
ectopic successor mobility extract
abnormal physiological resorption nipple soreness extract
infraocclusion / ankylosis treatment carmellose paste
tongue ulceration smooth tooth
extract
familial
Generalized high birth weight
premature eruption race
of permanent teeth
sex
neutropenia maternal smoking in pregnancy
neutrophil defect reduced maternal physical exercise
histiocytosis Metabolic lower socioeconomic status
hypophosphatasia Premature loss
scurvy of primary teeth
Ehlers–Danlos syndrome periodontal disease
psychosis pre-term
self injury primary teeth
congenital insensitivity to pain very low birth weight
non-accidental injury
chromosomal
nutritional
hypothyroid
primary and permanent teeth hypopituitarism
hereditary gingival
Generalized delay in eruption fibromatosis (HGF)
acquired gingival overgrowth
generalized cleidocranial dysplasia
supernumerary / odontome
ectopic
permanent teeth
localized cystic follicular change
crowding
thickened mucosa
255 •
MINDMAP34 43
endemic F levels
Fluorosis
toothpaste ingestion
occlusal
interproximal
Caries recurrent caries
oral hygiene Poor Quality First Permanent Molars Restored
periapical pathology
diet
antisensitivity toothpaste
sensitivity toothmouse
discrete creamy or brown hypomineralized GIC temporary
areas affecting permanent molars and incisors preventive oral hygiene
Molar incisor hypomineralization
post-eruptive breakdown measures diet advice
atypical restorations ? fluoride supplements
composite
restoration stainless steel crown
adhesively retained copings
Treatment
assess all 6’s
buccal 6’s ensure all permanent teeth
check cervically
lingual 6’s caries dental status especially 5’s and 8’s present
diet diary clinical extraction
timing more critical for lower
first permanent molars
occlusion
Investigations compensate
6’s caries / hypoplasia
number, position, status of unerupted teeth DPT
radiographic
? furcation calcifying developmental state 7’s colour brown worse than creamy
periapical / bitewing What is the long-term prognosis? size of area
cusps affected
• 256
43 MINDMAP35
family history
primary teeth affected
Dentinogenesis imperfecta
permanent teeth affected maternal illness
generalized Pre-natal early admission to hospital
can affect primary molars and 6’s
type
duration and time (chronological)
drugs Childhood illness
can affect 6’s and other permanent teeth
generalized
amelogenesis
requires a primary predecessor inherited
dentinogenesis
trauma to primary teeth Localized Generalized
systemic illness
infection to primary teeth fluorosis
257 •
MINDMAP36 43
microabrasion
composite
Diffuse defect veneer
porcelain
external bleach
composite veneer
external bleach
leave defect
microabrasion (how superficial within the enamel is the defect?)
porcelain veneer in late adolescence Demarcated defect
composite veneer remove defect
• 258
43 MINDMAP37
taurodontism
accessory roots Root abnormalities
pyramidal roots
0.1–0.9% primary
prevalence
3.5–6.5% permanent (excluding 8’s)
1.4–4 times more common in females than males
hair, teeth, nails, skin, sweat glands
most common hypohidrotic X-linked
usually male
multiple congenital absence of teeth
fine, spare hair with shaft abnormalities ectodermal dysplasia
dry skin
frontal bossing accessory cusps
maxillary hypoplasia Other crown abnormalities invagination
syndromes
thin lips, little vermillion border evagination
cleft lip and / or palate
Multiple missing teeth
1:700
delayed eruption Down syndrome
microdontia / hypodontia
Ellis–van Creveld syndrome
Multiple Missing and
Reiger syndrome Abnormally Shaped Teeth
Orofacial digital syndrome (types I and II)
reassure child and parent
eliminate pain
genetic counselling
restoration of aesthetics management
provide adequate function
maintain vertical dimension
formulate interdisciplinary treatment plan
autosomal dominant
Inheritance autosomal recessive
X-linked
1 in 10000 Incidence
epidermolysis bullosa
tuberous sclerosis
pseudohypoparathyroidism
trichodento-osseous syndrome
occulodento-osseous dysplasia Generalized disorder association
vitamin D dependent rickets
Amelo-cerebrohypohidrotic syndrome
Amelo-onychohypohidrotic syndrome hypoplastic
mucopolysaccharidosis Main clinical types hypomineralized
mixed
Amelogenesis Imperfecta
adhesive restorations
alleviate symptoms SSCs
maintain / restore occlusal height cast onlays
improve aesthetics Treatment modalities
full crowns
maintain positive dental attitude Treatment principles composite veneers
prevention porcelain veneers
minimize likelihood of dental anxiety
interdisciplinary care
• 260
43 MINDMAP39
1 in 8000 Incidence
osteogenesis imperfecta
Ehlers–Danlos syndrome
brachio-skeletogenital syndrome
Generalized disorder association
vitamin D resistant rickets
vitamin D dependent rickets
hypophosphatasia
Dentinogenesis Imperfecta
shortened roots
progressive pulp chamber and canal obliteration
Complicating factors wear
spontaneous periapical abscesses
bulbous crowns
adhesive restorations
alleviate symptoms SSCs
maintain / restore occlusal height Treatment principles cast onlays
Treatment modalities
improve aesthetics full crowns
maintain positive dental attitude composite veneers
prevention porcelain veneers
minimize likelihood of dental anxiety
interdisciplinary care
261 •
MINDMAP40 43
diet diary
study models
Dental investigation antisensitivity toothpaste
photographs
high fluoride paste
diagnostic index
low abrasive paste
Desensitization fluoride varnish
fluoride supplements
sugar-free gum
bonding agents
bulimia / anorexia
drugs for reflux
Medical treatment and investigation
surgery
oesophageal monitoring
limit acids to meals
reduce frequency
finish meal with alkaline foods
Dietary advice
avoid acid foods at night
avoid toothbrushing after acid foods
check pH of medications / mouthwashes
eruption gingivitis
acute / chronic gingivitis
chronic periodontitis
foreign body entrapment
local
ANUG
haemangioma
reactive hyperplasia
factitial
Bleeding hormonal
diabetes mellitus
anaemia
leukaemia
systemic platelet disorder
clotting defects
anticoagulants
scurvy
HIV
coeliac disease
genetic Gastrointestinal disease Crohn disease
nutritional ulcerative collitis
host factors
systemic disease
immunity
trauma
cheese
chocolate Aetiology
nuts
tomatoes allergy
environmental factors
citrus fruits
benzoates
iron deficiency
cinnamon aldehyde
Haematological disease B12
infection
folic acid
stress
haematinic replacement
treat gastrointestinal disease
exclusion diet
minor treat infections
major topical anaesthesia
Aphthae Treatment
herpetiform Oral Ulceration topical antimicrobial oral rinse
Behçet topical anti-inflammatory paste
symptomatic
topical coricosteroid
medications/mouthwashes
systemic corticosteroids
reduced saliva
Radiotherapy
reduced life span of oral epithelium
FromHeasman P2008 Master DentistryVol. 2, Restorative Dentistry, PaediatricDentistryand Orthodontics, 2nd Edn. Edinburgh, Churchill Livingstone. Fig. 110, with permission.
A1
The indexo orthodontic
treatment need: dental
health component
Grade Characteristics
1. None Extremelyminor malocclusions including displacements <1 mm
2. Little a. Increased overjet >3.5 mmbut ≤6 mmwith competent lips
b. Reverse overjet >0 mmbut ≤1 mm
c. Anterior or posterior crossbite with ≤1 mmdiscrepancybetween retruded contact position and intercuspal position
d. Displacement o teeth >1 mmbut ≤2 mm
e. Anterior or posterior open bite >1 mmbut ≤2 mm
. Increased overbite ≥3.5 mmwithout gingival contact
g. Prenormal or postnormal occlusions with no other anomalies; includes up to hal a unit discrepancy
3. Moderate a. Increased overjet >3.5 mmbut ≤6 mmwith incompetent lips
b. Reverse overjet >1 mmbut ≤3.5 mm
c. Anterior or posterior crossbites with >1 mmbut ≤2 mmdiscrepancybetween retruded contact position and intercuspal position
d. Displacement o teeth >2 mmbut ≤4 mm
e. Lateral or anterior open bite >2 mmbut ≤4 mm
. Increased and complete overbite without gingival or palatal trauma
4. Great a. Increased overjet >6 mmbut ≤9 mm
b. Reverse overjet >3.5 mmwith no masticatoryor speech di culties
c. Anterior or posterior crossbite with >2 mmdiscrepancybetween retruded contact position and intercuspal position
d. Severe displacements o teeth >4 mm
e. Extreme lateral or anterior open bites >4 mm
. Increased and complete overbite with gingival or palatal trauma
h. Less extensive hypodontia, requiring prerestorative orthodontics or orthodonticspace closure to obviate the need or a prosthesis
l. Posterior lingual crossbite with no unctional occlusal contact in one or both buccal segments
m. Reverse overjet >1 mmbut <3.5 mm, with recorded masticatoryand speech di culties
t. Partiallyerupted teeth, tipped and impacted against adjacent teeth
x. Supplemental teeth
5. Verygreat a. Increased overjet >9 mm
h. Extensive hypodontia with restorative implications (more than one tooth missing in anyquadrant) requiring prerestorative orthodontics
i. Impeded eruption o teeth (with the exception o third molars) owing to crowding, displacement, the presence o supernumeraryteeth, retained deciduous
teeth and anypathological cause
m. Reverse overjet >3.5 mmwith reported masticatoryand speech di culties
p. De ects o cle t lip and palate
s. Submerged deciduous teeth
FromHeasman P2013 Master DentistryVol. 2, Restorative Dentistry, Paediatric Dentistryand Orthodontics, 3rd edn. Churchill Livingstone, Edinburgh, with permission.
A2
Classifcation and
defnitions
re erral guide
When to re er What to re er
Primarydentition • Gross skeletal discrepancy
• Markedlyslowdental development (see Chapters 1 and 33)
• Cranio acial anomalies, especiallycle t lip and/or palate (unless
care provided alreadybyspecialist team) (see Chapter 21)
Mixed dentition • Increased overjet with associated severe teasing or marked lip
incompetence (greater trauma risk1) (see Chapter 9)
• Severe reverse overjet2 (see Chapter 11)
• Anterior crossbite with marked mandibular displacement, with
or without associated periodontal trauma (see Chapter 10)
• Posterior crossbite with marked mandibular displacement
(see Chapter 14)
• Unerupted upper permanent incisor(s) (see Chapter 2)
• Ectopic eruption o 6 (see Chapter 1)
• Poor qualityfrst permanent molars (see Chapter 34)
• Developmentallyabsent permanent teeth (see Chapter 8)
• Palatal/ectopic canine (see Chapter 6)
• Pathology, e.g. root resorption o 2’s by3’s (see Chapter 6)
• Medicallycompromised (see Appendix4)
Permanent dentition • Mani est malocclusion with or without skeletal problem
(see Chapter 5)
• Dri ting incisors (see Chapter 18)
• Temporomandibular joint problem(see Chapter 17)
• Complexcombined orthodontic restorative or orthodontic
orthognathicproblems (see Chapter 17)
1
Earlygrowth modifcation indicated
2
Likelyto beneft romearlyorthopaedic intervention
Adaptedbypermission romScott JK&AtackNE, 2015The developingocclusiono childrenandyoung
people in general practice: when to watch and when to re er. Br Dent J. Macmillan
Publishers Ltd.
Adapted with permission o BOS.
A4
Implications o some
medical problems
or orthodontics
Problem Implications
Asthma • Risko intraoral candidiasis with steroid based inhalers
• Maintain excellent oral and appliance hygiene, especiallywith URA
Allergy
Latex • Re er or testing to confrm
• Avoid latexgloves and latex containing orthodontic products
• Treat earlymorning to avoid exposure to airborne latexproducts
Nickel • Uncommon or intraoral allergy
• Place plastic sleeving on headgear to avoid extraoral dermatitis; i intraoral atopyconfrmed, use nickel ree appliance components
Bleeding diathesis • Liaise with medical specialist regarding extractions/surgery
• Mayusuallyproceed with orthodontictreatment
• Avoid mucosal/gingival irritation romappliances
Biphosphonates • Discuss potential treatment with physician, especiallyi extraction is likely
• Assess risko osteonecrosis and advise on slowtooth movement/reduced bone healing
Cardiac de ect with IErisk • Current guidelines indicate ABCis not recommended routinely or procedures likelyto produce bacteraemia
• Consult patient’s cardiologist i anyconcern
Diabetes • Onlyconsider treatment i diabetes is well controlled
• Greater risko periodontal disease
• Time appointment to minimize inter erence with control regime and possible hypoglycaemic attack
Drugs • Sloworthodontic tooth movement
Steroids
NSAIDs
TSADs
Epilepsy • Treat onlyi epilepsyis well controlled
• Avoid headgear and removable appliances due to risks associated with seizure
• Phenytoin induced gingival hyperplasia
• Ensure patient has rested, eaten and taken antiepileptic medication be ore appointment to reduce risko seizure
Juvenile rheumatoid arthritis • Steroid injections intoTMJ mayreduce jawgrowth
• Prone to periodontal breakdown due to long termsteroids
• Controversywith regard to role o unctional appliances
• Avoid prolonged orthodontictreatment
Leukaemia • Delaytreatment to >2 years post BMT
• Mayhave short blunt roots and increased risko root resorption
• Reduced resistance to oral in ections
• Growth modifcation guarded prognosis, as growth maybe suppressed
URA, upper removable appliance; IE, in ective endocarditits; ABC,antibiotic cover; NSAIDs, non steroid anti in ammatorydrugs; TSADs, tricyclic antidepressants; BMT,bone marrowtransplant.
• 270
A4 IMPLICATIONSOFSOMEMEDICALPROBLEMSFORORTHODONTICS
Skeletal relationships
• A-P. I SNA is < or >81° and S N/maxillary plane is within
Lateral cephalometric
8° ± 3°, correct ANB as ollows: or every degree SNA is
>81°, subtract 0.5° rom the ANB value and vice versa.
• Vertical. MMPA and acial proportion should lend support
analysis
to each other usually.
Tooth position
• To assess i overjet reduction is possible by tipping
movement, do a prognosis tracing (Fig. A5.2), or or
every 1 mm o overjet reduction, subtract 2.5° rom 1
angulation. I the nal angulation is not <95° to maxillary
Aim and objective o plane, tipping is acceptable.
cephalometric analysis
Aim : To assess the anteroposterior and vertical relationships
of the up p er and low er teeth w ith su p p orting alveolar bone
to their respective m axillary and mand ibu lar bases and to
Table A5.1 De nition o commonly used cephalometric points
the cranial base.
and planes
Objective: To com p are the p atient to norm al p op u lation
stand ard s ap p rop riate to his or her racial grou p , id entifying Points and planes De nition
any d ifferences betw een the tw o. S Sella: midpoint o sella turcica
N Nasion: most anterior point o the rontonasal suture (may
use the deepest point at the junction o the rontal and nasal
Practice o cephalometric analysis bones instead)
Ensu re that teeth are in occlu sion and that the p atient is not P Porion: uppermost, outermost point on the bonyexternal
p ostured forw ard . auditorymeatus (upper border o the condylar head is at the
In a d arkened room , by tracing or d igitizing, id entify the same level, which helps location)
p oints and p lanes listed in Table A5.1 (Fig. A5.1); alw ays O Orbitale: most in erior anterior point on the margin o the
trace the m ost prom inent im age. For bilateral land m arks, orbit (use average o the le t and right orbital shadows)
u nless d irectly su p erim p osed , take the average. Calcu late ANS Tip o the anterior nasal spine
angu lar and linear measu rem ents.
PNS Tip o the posterior nasal spine (pterygomaxillaryfssure is
directlyabove, which helps location)
A Apoint: most posterior point o the concavityon the anterior
sur ace o the premaxilla in the midline belowANS
B Bpoint: most posterior point o the concavityon the anterior
sur ace o the mandible in the midline above pogonion
N Pog Pogonion: most anterior point on the bonychin
Me Menton: lowermost point on the mandibular symphysis in
S the midline
P FP O Go Gonion: most posterior in erior point at the angle o the
mandible (bisect the angle between tangent to the posterior
PNS ANS ramus and in erior bodyo the mandible to locate)
A
Planes S–Nline Line drawn through Sand N
Frankort plane Line connecting porion and orbitale
Go B Maxillaryplane Line joining PNSand ANS
Pog Mandibular plane Line joining Go and Me
G
M Functional occlusal plane Line drawn between the cusp tips o the frst permanent
molars and premolars/primarymolars
Fig. A5.1 Standard cephalometric points. FromHeasman P2013 Master DentistryVol. 2, Restorative Dentistry, PaediatricDentistryand
(FromHeasman P2013 Master DentistryVol. 2, Restorative Dentistry, PaediatricDentistryand Orthodontics, 3rd edn. Churchill Livingstone, Edinburgh, with permission.
Orthodontics, 3rd edn. Churchill Livingstone, Edinburgh, with permission).
• 272
A5 LATERALCEPHALOMETRICANALYSIS
Table A5.2 Normal Eastman cephalometric values or Caucasians
Holdaway line
Parameter Value (± SD)
Ricketts’ E-line
SNA 81 ± 3°
SNB 78 ± 3°
ANB 3 ± 2°
S–N/Max 8 ± 3°
1 to maxillaryplane 109 ± 6°
1 to mandibular plane 93 ± 6°
Interincisal angle 135 ± 10°
MMPA 27 ± 4°
Facial proportion 55 ± 2%
So t tissue analysis
• Holdaway line. Lower lip should be ±1 mm to this line.
Predicted
reduction • Ricketts’ E-line. Lower lip should be 2 mm (±2 mm)
in ront o this with the upper lip slightly behind
(Fig. A5.3).
Overjet reduction by tipping movement unacceptable
(note upper incisor root through labial plate)
Teeth Present
8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
• 274
A6 ASTRUCTUREDDENTALTRAUMAHISTORYFORM
Teeth Injured
Vitality Tests Transillu- Root dev
Tooth Clinical Injury Mobility TTP
Eth. Cl ETP mination stage
Radiographs Views
Report .............................................................................................................................................................
........................................................................................................................................................................
........................................................................................................................................................................
........................................................................................................................................................................
Diagnosis
Tooth Diagnosis
Treatment Plan
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................