2. orthodontie interceptive.slideshare english oct 25 jm2

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2. orthodontie interceptive.slideshare english oct 25 jm2

  1. 1. Interceptive Orthodontics Dr Jean-Marc Retrouvey Dr Donald Taylor
  2. 2. Objectives• Discuss most common orthodontic problems in young patients• Present different modalities of treatment.• Identify the proper timing of treatment
  3. 3. Topics to be addressed …..1. Dental crowding2. Eruption problems3. Posterior crossbites4. Increased overjet5. Anterior crossbites6. Oral habits
  4. 4. 1. Dental crowdingA. Space maintenanceB. Control of Leeway spaceC. Dental extractions
  5. 5. A. Space maintenance
  6. 6. Indications Why maintain space?– Allow optimal dental alignment– Allow permanent teeth to erupt into their normal space– Conserve an acceptable occlusion– Prevent supra eruption of antagonists
  7. 7. Bilateral Space maintenance: Lingual archIn this case we use the primary second molars to compensate for theloss of a deciduous cuspid
  8. 8. Space maintenance on the upper arch: Fixed Nance appliance
  9. 9. B. Control of Leeway space Very important in interceptive orthodontics Most predictable way to reduce the need for bicuspid extractions
  10. 10. Note the difference in width between #75 and #45
  11. 11. A lower lingual arch acts as a space maintainer• If the Leeway space is maintained 75 % of cases can be treated without extractions and without proclination of the lower incisors. (Dr Gianelly)
  12. 12. Premature loss of the deciduous cuspids
  13. 13. A. Passive lingual archExpansion of the maxillary arch done concurrently
  14. 14. Result…..
  15. 15. B. Reduction of mesial aspect of the second deciduous molars• Another way to take advantage of the Leeway space• Allows spontaneous alignment of the lower incisors• Simple and efficient procedure (Cozzani: JCO 1994)
  16. 16. Indications• Moderate crowding of the lower arch (example: loss of a deciduous cuspid) – Timing is most important • wait until there is almost total resorption of the roots of the deciduous second molars
  17. 17. Too soon!
  18. 18. Proper timing!
  19. 19. Results
  20. 20. C. If Leeway space is notsufficient for proper alignment •Selective extractions •Enucleation of bicuspids
  21. 21. Example: Serial Extractions
  22. 22. 1. Extraction of primary cuspids
  23. 23. 2. Improvement in the position of the incisors
  24. 24. The incisors are well positioned
  25. 25. Enucleation
  26. 26. 2. Dental Eruption ProblemsA. Early or delayed eruptionB. Ectopic eruptionC. Missing teethD. Ankylosed teethE. Impacted teeth (maxillary cuspids)
  27. 27. A. Early or delayed eruptionA panorex is indicated at the age of 7 to 8
  28. 28. Abnormal sequence of eruption: Take a panorex please….supernumary upper cental incisors
  29. 29. B. Ectopic eruption
  30. 30. Ectopic # 45
  31. 31. Follicular cyst
  32. 32. Example: Nine year old patient presenting with #34 erupting ectopicallyPatient complaint : my front teeth are too far ahead
  33. 33. Treatment: extract # 75 and place an active lingual arch • Spring to tip the crown of # 34 mesially • The cuspid had already began to drift distally
  34. 34. Retention
  35. 35. C. Missing teeth
  36. 36. Agenesis• This problem is seen relatively frequently• Which teeth are most often missing? – Third molars – Upper lateral incisors (Caucasian) – Lower central incisors ( Asian) – Lower second premolars
  37. 37. Thirteen year old girl
  38. 38. Panorex
  39. 39. This case is one which will require a combination of orthodonticsand prosthodontics. It will require extensive planningTreatment options:• Extract the deciduous second bicuspids and protract the permanent molars or maintain thedeciduous bicuspids long term, Replace absent #22 with an implant•Increase the width of #12 reduce #23, intrude and crown #24 to make it look like a cuspid It is also imperative to conserve the profile
  40. 40. D. Ankylosed Primary teeth Often found with congenitally absent permanent bicuspids and lack of growth of the corpus of the mandible
  41. 41. Ankylosed teeth should be extracted when… The permanent molar begins to tip mesially A periodontal problem begins to develop at the mesial of the permanent molarAn open bite develops at the bicuspid and molar area
  42. 42. Ankylosed deciduous second premolarThis is a case where #65 should have been removed
  43. 43. Ankylosed teeth may be maintained…• …If the ankylosed teeth are in the plane of occlusion. …Especially if the roots are not resorbing.
  44. 44. E. Impacted teethDifficult to treat. Prognosis is guarded
  45. 45. 16 impacted teeth!
  46. 46. Impacted upper central incisors• Most often caused by trauma to the deciduous tooth. Root can become dilacerated• Infection of deciduous central• Cyst• Supernumary tooth
  47. 47. Case treated at MCH
  48. 48. Nine year old patient presented at MCH for a routine dental exam: What would you do? If the sequence of eruption is altered you need to ask questions and investigate radiographically
  49. 49. Space maintenance wasprescribed by the family dentist
  50. 50. Oups! • An upper central incisor was impacted • The parents did not recall a history of trauma…
  51. 51. Maintained for three months 24 months later!
  52. 52. Another case of an impacted upper central incisor • Young patient followed by his family dentist presented at the emergency of the MCH because of swelling of the upper lip • No history of trauma or pain • The treating dentist found no problems during a routine exam 3 months previously and apparently the swelling increased gradually
  53. 53. Extent of the lesion • The central incisor is impacted • The lateral incisor is displaced laterally and distally • The cuspid is severely impacted mesially
  54. 54. Transverse cut: CT scan
  55. 55. Surgery prior to orthodontic treatment
  56. 56. Intraoral view• Altered sequence of eruption• Severe swelling
  57. 57. Second problem: Canine is resorbing the lateral incisor
  58. 58. Progression:
  59. 59. Final Result Surgical scar
  60. 60. E. Ectopic eruption of upper canines Be attentive of buccally impacted upper cuspids as resorption of the roots of the lateral incisors is seen frequently
  61. 61. Impacted cuspids• Upper cuspids are the teeth most often impacted (3 to 4%)• Treatment is difficult and costly• Can we reduce the incidence of this problem?
  62. 62. Etiology (Theories)1. Narrow upper arch causes a strong probability of impaction. Not valid in the majority of cases2. A combination of genetics and familial tendencies3. Missing or small lateral incisors, but a normally sized arch
  63. 63. Excellent result but a lot of work required
  64. 64. Prevention of palatally impacted cuspids• Early diagnosis: palpation at age 9 . Should feel a bulge at the labial of the deciduous upper cuspids• Screening Panorex at age 9 years• Extraction of primary canines if necessary• Extraoral traction in Class II cases• Palatal expansion if the upper arch is narrow
  65. 65. Potential Treatment Options1. Dr Kurol demonstrated that 65% of canines presenting with a mesial angulation will erupt normally once the deciduous cuspids have been removed2. Dr Taylor showed that 85% of canines will erupt normally if , in Class II cases, molars are distalized into a Class I relationship3. Dr Baccetti found similar results after palatal expansion
  66. 66. Normal cephalometric values
  67. 67. Extraction 53 Extraction 83
  68. 68. Extraction 63
  69. 69. Date of removal of braces
  70. 70. 3. Posterior crossbites Bilateral Unilateral • Functional • Non functional
  71. 71. Bilateral posterior crossbite• This type of malocclusion does not have a functional origin
  72. 72. Unilateral Crossbite Centric occlusion
  73. 73. Centric relation
  74. 74. Rapid Palatal Expansion• The best method to open the midline palatal suture and increase the width of the maxilla orthopedically• Maxillary expansion is now being prescribed in younger patients – Some authors are proponents of RPE therapy in the primary dentition…..
  75. 75. Types of appliances:Hyrax, Hass or Bonded
  76. 76. Correction of aposterior unilateral crossbite
  77. 77. At the 24 month follow-up this patient willmost likely not require further orthodontics
  78. 78. Expansion without a crossbite• Potential Indications: – Narrow and triangular maxilla – Lack of transverse development – Moderate crowding – Teeth of normal width
  79. 79. Crowding in the mixed dentition: What would you do? 1. I don’t know much… 2. Extraction of deciduous canines? 3. Expansion of the maxilla?
  80. 80. Expansion only! (18 months later) No treatment on the lower arch
  81. 81. 4. Oral habits• Thumb sucking• Low tongue posture• Oral respiration Photographie: Dre Stéphane Schwartz MCH
  82. 82. Deformation of the alveolarprocesses even in the deciduous dentition
  83. 83. Treatment options• Psychology• Speech therapy• Treatment – Fixed appliance – Removable appliance
  84. 84. Anterior position of the tongue. Mother wanted something fixed….
  85. 85. Four months of treatment with apalatal expansion appliance and a tongue crib
  86. 86. The occlusion and smile haveimproved including in the vertical dimension (smile line)
  87. 87. 5. Excess overjet• Etiology:• Oral habits: upper incisors proclined and spaced• Class II skeletal with dentoalveolar factors – Growth modification • HG • Twin block , bionator • Forsus• Genetic origin. Patient in which growth is or has been unfavorable – Surgery or camouflage
  88. 88. Cephalometric analysis is very important Differential Diagnosis • Skeletal relationship – Maxillary – Mandibular – Vertical • Dentoalveolar relationship – Inclination of the upper and lower incisors
  89. 89. Dentoalveolr protrusion or skeletal dysplasia?Dentoalveolar Protrusion : •Normal skeletal measurements •Excess overjet •Space between the upper incisors •Proclined upper incisors
  90. 90. Dentoalveolar protrusion or skeletal dysplasia?Skeletal dysplasia: • Abnormal skeletal measurements •Excess overjet •No space present between the upper incisors •Full cusp Class II molars
  91. 91. Dentoalveolar Protrusion Case • 10 mm overget • Mainly of dentoalveolar origin (ANB=3.5)
  92. 92. Treatment• Compromised treatment• Bands on permanent molars• Brackets on the 6 upper anteriors• Cervical extra oral traction It was necessary to avoid the use of a removable appliance because the upper incisors would extrude, an unfavorable result even if the overjet was reduced
  93. 93. 12 months post treatment
  94. 94. Skeletal Class II
  95. 95. Skeletal Class II• Should we intervene at a young age? – Two phase treatment vs single phase • Scientific literature supports a single phase treatment –However many clinicians still practice 2 phase treatment • Clinical judgment is important because each case Is different
  96. 96. ClassII division 1 ,11 year old female patient
  97. 97. Retrusive mandible • Deficient lip seal • Good facial proportions • Favorable growth potential
  98. 98. Myofunctional Appliance• Promotes – Protraction of the mandible – Maximum expression of mandibular growth – Bite opening – Maxillary expansion
  99. 99. Twin Block Appliance• Appliance to protract • Other myofunctional the mandible appliances perform• Maxillary expansion essentially the same• Bite opening functions
  100. 100. Excellent response by the patient• Compliant patient• Favorable mandibular growth• Good dentoalveolar response
  101. 101. Same type of response in our patient (12 months of Twin Block)
  102. 102. Types of treatment• « Timing is almost everything »• Dentoalveolar compensations must be favorable• Whatever we do, optimal mandibular growth is primordial• Disclusion of the dentition is extremely important
  103. 103. Fixed appliances• Type « Herbst » or Forcus…• Pistons position the mandible in an anterior position• Generally slightly more efficient than myofunctional appliances• Correction is mainly dentoalveolar
  104. 104. Genetic mandibular retrusion • Regardless of the type of appliance used ythe chances of success are limited • The family must be aware that mandibular advancement surgery will most likely be necessary if a reasonable result is contemplated
  105. 105. 6. Anterior crossbite• Functional origin – Easily corrected with a removable appliance• Dentoalveolar origin – Palatal expansion and traction• Skeletal origin – Surgery probably required
  106. 106. Differential diagnosis• Anterior crossbite: Class III vs pseudo Class III – Manipulation: centric occlusion – centric relation – Facial profile (concavity of middle third of face) – Dentoalveolar compensations : • Verify the angulation of the upper and lower incisors
  107. 107. Functional anterior crossbite Centric occlusion Centric relation Manipulate the condyles in their physiologic rest position. If the occlusion is end to end it is probable that the crossbite is functional
  108. 108. Appliance of choice to correct a functional anterior crossbite• Hawley with posterior bite pads• Finger springs or microscrews on the lingual of the upper incisors
  109. 109. Skeletal Class III TreatmentExamination Treatment1. Analysis of records • Rapid maxillary Expansion2. Estimation of the severity • Maxillary traction with of the malocclusion Delaire facemask or bone3. Prediction of growth plates (new approach) – Direction • Brackets on upper incisors – Potential, amplitude • Long term retention
  110. 110. 2008 Mainly, a retruded maxilla The lower incisors are not retroclined
  111. 111. Rapid Palatal Expansion21 to 28 days of activation, 1 turn of screw per day
  112. 112. Sleep Apnea in the child and adolescentLe rôle de l’orthodontiste dans l’amélioration de la respiration chez l’enfant et le jeune adulte affligé d’apnée du sommeil Dr Jean Marc Retrouvey Director of Orthodontics McGill University
  113. 113. Snoring: Benign condition andannoying but without danger(snoring) UARS: Disturbance of sleep without oxygen desaturation (no cardiopathy OSA: Trouble sleeping + oxygen desaturation of (cardiac disorders, vascular accidents, hypertension, arythmia s, death) C*Collpo N. Semin Respir Crit Care Med 2005; 26(1): 13-24 Irit Care Med 2005; 26(1): 13-24
  114. 114. Most frequent contributing factors1. Environment – Diet = Obesity – Allergies2. Genetic – Skeletal malocclusion3. Combination
  115. 115. Observations frequently seen• Hypertrophied tonsils and adenoids seen in young patients presenting with UARS or OSA http://kidshealth.org.nz/index.php/ps_pagename/contentpag e/pi_id/303
  116. 116. Obesity
  117. 117. Typical appearance of a childwho suffers from sleep apnea 1.Extraoral exam  Facial type  “Saucers” under the eyes  Retrusive mandible (Classe II malocclusion)  Retrusive maxilla?
  118. 118. Normal Apneic•Retrusive mandible•Increased anterior faceheight•Underdeveloped ramusof mandible•Obtuse gonial angle
  119. 119. Role of the dentist: Rapid palatal expansion• Literature supports RPE at a young age for OSA• A skeletal expansion of an average of 4,5 to 6 mm is obtained• The earlier the intervention, the greater the benefits
  120. 120. Conclusions• A detailed orthodontic examination is essential for every child• Interceptive orthodontics is one of the most important aspects of pediatric dentistry• Simple, well coordinated treatment regimen, will be very beneficial for your patients.• This presentation was an overview of interceptive orthodontics. Hopefully it has given information to allow better communication with your patients, parents and friendly orthodontist!

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