Phase I Orthodontic treatment


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This lecture is for dental professionals requesting more information on when to refer young patients for orthodontic tretment

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Phase I Orthodontic treatment

  1. 1. Early Orthodontic Treatment Victoria J Lynskey, DMD, MDS Associate Clinical Professor, UCSF
  2. 2. Objectives•Define Early Tx•When you should refer a patient•Who is (and is not) a good candidate for Early tx•What common problems are addressed in Early tx•What options are available to treat Early Patients•How to determine success
  3. 3. Definitions of Early treatment• Phase Therapy: early dental problems that left alone will create an unhealthy environment for the growth and development of the teeth, gums, bone and jaws• Preventative/ Prophylactic: Prevent a problem from happening• Interceptive Orthodontics: Intercept a developing problem• Growth Modification: timing treatment to maximize and guide the growth of the jaw bones that support the teeth
  4. 4. Treatment Phases for Early/Interceptive Orthodontics• Phase I (12-15 months)• Maintenance Phase (12-24 mo)• Phase II (12-15months) Phase I active treatment Maintenance Phase II active treatment 12-15 months 12-24 months 12-18 months The Big Question is …When and Who is a candidate for Early Treatment
  5. 5. What is normal in a 7-year oldClass I Dental & Skeletalocclusion“Ugly-duckling” stage(spacing and or minorOB/OJ concernsDuring transitional dentition,perfect tooth alignment isnot to be expected and isnot cause for alarm.
  6. 6. Transition from Primary to Permanent Dentition
  7. 7. What is NOT Normal• Sagital relationships such as – Class II, dental and skeletal – Class III, dental, skeletal and functional shifts
  8. 8. Class II Skeletal Relationship• 32% of malocclusions are Class II, butthey are 70% of what orthodontists treat•The upper jaw is ahead of the lower jaw(XS OJ or “buck teeth)•In skeletal Class II, the jaws aremalaligned. Treatment can includeredirecting the eruption of teeth during jawgrowth Extraction Plan + FFA; or HPHG•Excessive OJ leads to risk of trauma inprotrusive teeth.•The upper jaw may be over developed,but more often, the lower jaw is under-developed.•Untreated, skeletal malocclusions mayrequire orthognathic surgery to correct thejaw position after growth is complete Growth Plan: Herbst/Forsus, HG
  9. 9. Class III Skeletal Relationship Mandibular Prognathism usually dx in adult (permanent dentition) Midface deficiencies and maxillary constriction is usually dx in the• Characterized by anterior crossbite mixed dentition•Approximately 3% of the malocclusions•Can be caused by lack of growth in the upper jaw or excessive growth in the lowerjaw (seen later in development)•Early treatment of maxillary sagital problem often includes a transverse component•Early Class III treatment is best at age 7-10 as it requires significant compliancewith extra-oral headgear
  10. 10. Protraction Headgear•Early Txt for Class III is primarily to affect maxillary growth.•Requires RPE plus PHG and often FFA. Class III: Protraction/ reverse Pull(often used with an RPE to aid in skeletal movement)
  11. 11. Functional ShiftsThe position of the teeth affect the position of the jaw. When there is apremature contact (see the canine) it can cause the jaw to shift so thatthe teeth can contact. This can be habit forming and may result inunwanted asymmetric growth.
  12. 12. Habits, Medical Problems• Finger, thumb, Tongue thrust• Speech discrepancies• Mouth breathing due to airway constriction (tonsils, adenoids)• TMJ dysfunction, rheumatoid arthritis, and growth hormone abnormalities may cause orthodontic problems
  13. 13. Vertical Relationships-Open bites• Dental vs Skeletal• Habits such as finger/thumb sucking, tongue thrust, or airway obstruction• May result in chewing difficulty and speech problem• Tx may require ENT, habit therapy and habit appliances
  14. 14. Vertical Relationships- Deep Bites• Potential for abnormal tooth wear and gingival impingements• May be skeletal cause: vertical maxillary excess or excessive curve of Spee• This can be one of the most damaging of malocclusions
  15. 15. Crossbite: Anterior• Skeletal vs dental• Can result from orthopedic problems or functional shifts• All of these may damage the teeth and can cause long term gingival problems• These need to be corrected early to avoid damage to teeth and gums
  16. 16. Crossbite: Posterior• Often found in patients with a narrow maxilla• A posterior crossbite may also cause a functional shift• It may also appear as a unilateral crossbite• These are easily treated in the growing child
  17. 17. Arch Length - crowding• Causes – Early loss of primary teeth – Decay, genetics – Tooth size problems – Missing teeth – Eruption problems
  18. 18. Arch Length-crowding Premature loss of Primary Teeth• Missing primary teeth, but adequate space for secondary dentition= space maintainer – Band and loop – Lingual Arch – Distal Shoe – Nance
  19. 19. Arch Length-crowding Irregular lower incisors• Irregular Incisors, no arch-length/space discrepancy.• Large Incisors + large primary molars +small premolars= no space issues, but transient crowding & rotations of the permanent incisors• Up to 2mm of crowding may resolve spontaneously• For 3-4mm of anterior crowding, IPR lower C’s and place lingual arch **
  20. 20. Arch length-Crowding: Delayed/blocked premolar development• Aligned Incisors, no arch-length/space discrepancy.• Erupting canine width+ erupting 1stPM width + large primary 2nd molar width=transient crowding & rotations of the erupting canines and premolars• For posterior arch crowding, IPR lower E’s, hemi-section or extract and place lingual arch
  21. 21. Arch Length-crowding Localized space loss• Localized space loss (3mm or less); Space Regaining• Maxillary Regaining: tipping vs bodily movement – Headgear or intra-oral appliance – FFA
  22. 22. Arch Length-crowding Localized space loss• Localized space loss (3mm or less); Space Regaining• Mandibular Regaining – FFA or lip bumper
  23. 23. Arch Length-crowding Midline discrepancy• Premature loss of a primary tooth results in a midline shift• Tx with fingerspring or FFA
  24. 24. Arch Length-crowding Severe• Serial/Guided eruption (>10mm) – No skeletal abnormality exists (Class I) – >10mm crowding – Influence first premolars to erupt prior to canines. For mandible this means ext D’s at ½ to 2/3 root formation on 4’s. – Overbite might increase during guidance but can be tx after eruption of all permanent teeth in a comprehensive phase.
  25. 25. Arch Length - Spacing Maxillary Midline Diastema• Normal diastema = “ugly duckling stage”• Larger diastema: >2mm =FFA – Supernumeraries – Missing permanent lateral incisors – Tooth size discrepancy – Tongue thrust – Excessive tissue in the frenum Tx indicated for 1) when the centrals inhibit eruption of the laterals or canines, or 2) esthetic issues (behavioral), 3) protrusion and trauma risk Studies prove that stability of the end result is improved if a large diastema is corrected before the full eruption of the permanent dentition
  26. 26. Abnormal eruption sequence Ectopically-erupting teeth• Lateral incisor/canine• First molar
  27. 27. Congenitally missing permanent teeth
  28. 28. Congenitally missing permanent teeth• Mandibular second premolars: – Retention – Ankylosis •Delayed eruption •Manage until it interferes with eruption or drift of other teeth, then extracting and placing space maintainer if necessary •Monitor 1) tipping of molars over distal marginal ridges of the ankylosed teeth 2) super-eruption of opposing teeth
  29. 29. Ankylosed TeethAnkylosis: Fusion of the tooth to the bonePrimary Failure of eruption: Failure of permanent teeth to grow normallyResult: 1) Adjacent teeth continue to erupt & can tip forward, over theprimary teeth resulting in space loss; 2) the primary molars appear to sinkas the rest of the teeth and jaws continue to grow and develop. This willcause a significant discrepancy in the alveolar bone height, an issue duringreplacement when permanent teeth are missing
  30. 30. Early Treatment Rationale• Phase I (12-15 months)• Maintenance Phase (12-24 mo)• Phase II (12-15months) Phase I active treatment Maintenance Phase II active treatment 12-15 months 12-24 months 12-18 months The Big Question is …When and Who is a candidate for Early Treatment
  31. 31. Crossbite: Posterior• Skeletal vs Dental• Unilateral/ bilateral
  32. 32. Orthodontic Terminology Sagital Dimension (AP)• Dental (Angle Classification): – Overjet(OJ): distance between the upper & lower front teeth(mm) – Molar position – Canine position• Skeletal: relation of maxilla and/or mandible to the skull• Goal: to “affect mandibular growth” or dental compensation. OJ Class II, Div 1 Class II, Div.2
  33. 33. Jaw Deformities• Class II: Growth modification Extraction Plan + FFA Growth Plan: Herbst/Forsus, HG
  34. 34. Craniofacial Anomalies• Cleft Lip & Palate• Syndromes: Hemifacial Microsomia, Craniosynostosis, Crouzon’s, Treacher-Collins, etc.
  35. 35. Benefits of Early Treatment• Young patients may be more cooperative and follow instructions• Increased stability• Habit modification• Reduce extractions• Reduced risk of tooth trauma (protruded teeth)• Reduced periodontal trauma (crossbites and guiding eruption into attached gingiva)• Growth modification (sagitally, transverse, asymmetric jaw growth)
  36. 36. Benefits of Early Treatment
  37. 37. Benefits of Early Treatment• RPE + FFA to create space for U2’s and LR2
  38. 38. Benefits of Early Treatment
  39. 39. Benefits of Early Treatment
  40. 40. Disadvantages• Time: most patients that require a phase I for moderate to severe dental or jaw growth modification will require a second phase.• Money: increased cost to staging treatment into 2 phases is approximately $600• OHI: poor motor skills may require more parental involvement.• Emergencies: higher risk of working on the weekend
  41. 41. Questions
  42. 42. Thank You!