Early Treatment of Occlusal Relationship Problems in Children
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Treatment of occlusal relationship problems
in preadolescent children
Presented by:
Dr Somayeh Heidari
Orthodontist
Reference:
Contemporary Orthodontics
Chapter 12
William R. Proffit, Henry W. Fields, David M.Sarver. 2007. Mosby
Special considerations in early treatment
The
goals
of treatment must be clearly outlined and understood
Problems of
too long
treatment:
patient can be
“burned out”
the chance of
damage
to the teeth
Fewer
options are available, and patient
cooperation
is more critical
There are important
biomechanical
differences between complete and partial
appliances
Typical
fixed
appliance for
mixed
dentition treatment:
2 × 4
2 × 6
( 2 molar bands, 4 or 6 bonded anterior teeth)
2 × 4
or
2 × 6 :
longer
archwire span
more
springy
and
less strong
wire
light
forces ( easier
intrusion
of teeth)
appropriate
moments
more prone to
breakage
,
distortion
and
displacement
Anchorage
control is both more
difficult
and more
critical
Extraoral
support ( Headgear or Facemask) and maxillary and mandibular
lingual arches
can be used
Implant
supported anchorage usually is
not
practical:
unerupted
teeth
reduced
density
of the bone
Beware of
unerupted
teeth
Space closure
must be managed with particular care
Teeth without attachments may tend to be
displaced
and
squeezed out
of the arch
Interarch
mechanics must be used sparingly if at all
Interarch forces are
not
recommended under must circumstances with
one
exception
:
Cross elastics
(in treatment of unilateral cross bite)
Final
results are dictated largely by the
untreated
arch
Retention
often is needed between mixed dentition treatment and eruption
of the permanent teeth
wires can
interfere
with eruption of permanent teeth
need to patient
cooperation
increase the chance of patient
burn-out
Occlusal relationship problems
Crossbite
Crossbites of dental origin
usually affect only
some
of the teeth
less
sever
than skeletal crossbites
occlusal
interferences
often are present (increased chance of
shift on closure
)
Treatment in the mixed dentition is
recommended
because:
Eliminates
functional shift
wear
of erupted permanent teeth
possibly dentoalveolar
asymmetry
Increase
arch circumference
Relapse
is
unlikely
in the absence of a skeletal problem
Simplifies
future treatment
Posterior Crossbite
treatment differs depending on its underlying
cause
dental
crossbites are treated by moving the
teeth
with
light
forces
heavy
force and
rapid
expansion are
not
indicated in the
primary
or
early
mixed
dentition significant risk of
nose distortion
Basic approaches to the treatment of
moderate
posterior crossbite in children:
equilibration
to eliminate mandibular
shift
expansion
of a constricted maxillary arch
repositioning
of
individual
teeth to deal with intra-arch asymmetries
A
shift
into posterior crossbite:
in a
few
cases
in
primary
or
early mixed
dentition
due solely to interference caused by the
primary canines
diagnosed
by careful positioning of the mandible
require only limited
equilibration
of the primary canines
A greater
maxillary constriction
:
allow the maxillary teeth to fit
inside
the mandibular teeth
without shift
on closure
reduced
arch
circumference
crossbite
correction
will provide more
space
small
constriction creates dental
interferences
that force the mandible to
shift
Whether or not
a mandibular shift is present, a crossbite due to a
narrow
maxilla
should be corrected
when it is noted
, in the primary or mixed dentition,
unless
the
permanent first molars
are expected to erupt in
less than
6 months
.
It is possible to treat posterior crossbite with a
split-plate
type of removable
appliance, there are two
problems
:
this relies on patient
compliance
for success
the appliance can be
displaced
easily
The
preferred
appliance for modest expansion of the maxillary arch in a
preadolescent
child is an
adjustable lingual arch
.
Both the
W-arch
and the
quad helix
are reliable and easy to use.
W-arch
fixed
appliance
constructed of
36 mil
steel wire soldered to
molar bands
activated simply by
opening the apices
of the
W
easily
adjusted
to provide
more
anterior
than posterior expansion, or vice
versa
delivers proper force when
opened 4-5 mm
wider than passive width
should be adjusted
before
being inserted
it is not uncommon for the teeth and maxilla to move
more
on
one side
Quad helix
more flexible
version of W-arch
the
bulk
of the anterior helices can effectively serve as a
reminder
to stop habit
combination
of a posterior crossbite and a sucking habit is the
best
indication
greater range of action
than the W-arch but the
forces
are
equivalent
Both
appliances:
leave an
imprint
on the tongue, that will
disappear
when the appliance is removed
some opening of the
midpalatal suture
can be expected in a
young
child
expansion should continue at the rate of
2 mm
per
month
( 1 mm on each side)
until the crossbite is slightly
overcorrected
intraoral
appliance
adjustment
may lead to
unexpected
changes
require
2 to 3
months
active
treatment and
3
months of
retention
True unilateral crossbite:
ideal
treatment is to move
selected
teeth on the constricted side
to a
limited
extent, this can be achieved by using
different length arms
, but some
bilateral
expansion must be expected
an
alternative
is to use a mandibular
lingual arch
to
stabilize
the lower teeth
and attach
cross-elastics
to the maxillary teeth
this is more
complicated
and requires
cooperation
, but is more
unilateral
in its
effect
a third
alternative
is to use a
removable
appliance that
sectioned asymmetrically
this appliance has the same
restrictions
as all removable appliances
If teeth in
both
arches contributed to the problem:
Cross-elastics
between banded or bonded attachments in both arches
the force has a
vertical
vector which will
extrude
the posterior teeth and
reduce the overbite
caution
in child with increased
lower face height
or
limited overbite
crossbite should be
overcorrected
, and attachments
left
in place immediately
after active treatment
when the
occlusion
is
stable
after
several weeks
without elastic force, the
attachments can be
removed
.
the
most common
problem is lack of
cooperation
from the child.
Anterior Crossbites
most
children with anterior crossbite, especially if
more
than one or two teeth
are in crossbite, have a
skeletal
problem
the
most common
etiologic factor for nonskeletal anterior crossbite is
lack of
space
for the permanent incisors
if the developing crossbite is discovered
before
eruption is complete and
overbite
has
not
been established, the
adjacent primary teeth can be extracted
to provide the necessary space.
only
occasionally
the anterior crossbite treatment is indicated in the
primary
dentition
dental anterior crossbites typically develop as the
permanent incisors
erupt
those diagnosed
after
overbite is established require
appliance
therapy
the
first
concern is adequate
space
bilateral
disking
extraction
of the adjacent primary teeth
opening
space
if teeth are
tipped
when
bodily
movement is
required
,
stability
of the result is
questionable.
in a young child, the
best
method for
tipping
anterior teeth out of crossbite is a
removable
appliance
finger springs
for facial movement of maxillary incisors
one
22 mil
double helical
cantilever
spring
multiple
clasps
for retention
labial bow is usually
contraindicated
active labial bow
for lingual movement of
lower
incisors (less frequently)
Biteplate
to reduce the overbite:
usually is
unnecessary
in children unless the overbite is
exceptionally
deep
it would be needed only in a child with a
clenching
or
grinding
habit
using a biteplate
risks
the chance that the teeth
not
in contact with the
appliance or opposing arch will
erupt excessively
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This removable appliance :
requires nearly
full time
wear
if the springs are activated
1.5 to 2 mm
, the teeth will move
1 mm
in a month
the offending teeth should be slightly
overcorrected
the teeth should
retained
until
overbite
is adequate to retention
one
or
two months
of retention with a
passive
appliance
The most common
problems
:
lack of patient
cooperation
poor design leading to lack of
retention
improper
activation
The simplest
fixed
appliance for correction of anterior crossbite:
a
maxillary lingual arch
with
finger
spring (
whip spring
)
indicated
for a child with
compliance
problems
the springs usually are soldered on the
opposite side
of the arch
it will increase their
length
most effective if the length is approximately
15 mm
3 mm
activation , will produce optimum rate of movement:
1 mm per
month
the
greatest problems
are distortion, breakage and poor oral hygiene
2 × 4 appliance:
the
best
choice for an
older
patient with
crowding
,
rotations
and
more
permanent
teeth in crossbite in mixed dentition
forces
and
moments
produced on the anterior teeth by a
rectangular
archwire
the
torque
and the
coil springs
tip the incisors
facially
multiple incisors can be readily corrected in a
short time
the roots of lateral incisors should
not
repositioned into the canine
path
of
eruption
Anterior Open Bite
Deep Bite
before treatment, it is necessary to establish its
cause
:
reduced
lower face height
lack of eruption
of posterior teeth
over eruption
of the anterior teeth
Removable
biteplate
appliance:
for children who have
less
than normal
eruption
of the posterior teeth (usually
associated with reduced face height)
an
anterior
biteplate
is incorporated into removable appliance
mandibular incisors occlude with the plastic plane, this
prevent
the posterior
teeth from occluding
treatment may take
several months
appliance must be worn
full time
during active treatment
biteplate must continue to be worn at
night
as a
retainer
If the maxillary or mandibular
anterior
teeth have
erupted excessively
:
more
challenging
approach
the task is to
stop
the eruption (
relatively intrude
) or
actually intrude
the incisors
this type of tooth movement requires
light continuous
forces and careful
management of the
anchorage
(posterior teeth)
intrusion as a part of early treatment is
seldom
indicated
Thanks for your attention
Dr. Somayeh Heidari, an orthodontist, discusses the treatment of occlusal relationship issues in preadolescent children. The importance of clear treatment goals, challenges in early intervention, and considerations for biomechanical differences in appliance types are highlighted. Anchorage control, space closure management, and potential risks like unerupted teeth are also addressed to ensure effective orthodontic care for young patients.
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Presentation Transcript
Treatment of occlusal relationship problems in preadolescent children Presented by: Dr Somayeh Heidari Orthodontist
Reference: Contemporary Orthodontics Chapter 12 William R. Proffit, Henry W. Fields, David M.Sarver. 2007. Mosby
The goals of treatment must be clearly outlined and understood Problems of too long treatment: patient can be burned out the chance of damage to the teeth
Fewer options are available, and patient cooperation is more critical
There are important biomechanical differences between complete and partial appliances Typical fixed appliance for mixed dentition treatment: 2 4 2 6 ( 2 molar bands, 4 or 6 bonded anterior teeth)
2 4 or 2 6 : longer archwire span more springy and less strong wire light forces ( easier intrusion of teeth) appropriate moments more prone to breakage, distortion and displacement
Anchorage control is both more difficult and more critical Extraoral support ( Headgear or Facemask) and maxillary and mandibular lingual arches can be used Implant supported anchorage usually is not practical: unerupted teeth reduced density of the bone
Space closure must be managed with particular care Teeth without attachments may tend to be displaced and squeezed out of the arch
Interarch mechanics must be used sparingly if at all Interarch forces are not recommended under must circumstances with one exception: Cross elastics (in treatment of unilateral cross bite)
Retention often is needed between mixed dentition treatment and eruption of the permanent teeth wires can interfere with eruption of permanent teeth need to patient cooperation increase the chance of patient burn-out
Crossbites of dental origin usually affect only some of the teeth less sever than skeletal crossbites occlusal interferences often are present (increased chance of shift on closure)
Treatment in the mixed dentition is recommended because: Eliminates functional shift wear of erupted permanent teeth possibly dentoalveolar asymmetry Increase arch circumference Relapse is unlikely in the absence of a skeletal problem Simplifies future treatment
Posterior Crossbite treatment differs depending on its underlying cause dental crossbites are treated by moving the teeth with light forces heavy force and rapid expansion are not indicated in the primary or early mixed dentition significant risk of nose distortion
Basic approaches to the treatment of moderate posterior crossbite in children: equilibration to eliminate mandibular shift expansion of a constricted maxillary arch repositioning of individual teeth to deal with intra-arch asymmetries
A shift into posterior crossbite: in a few cases in primary or early mixed dentition due solely to interference caused by the primary canines diagnosed by careful positioning of the mandible require only limited equilibration of the primary canines
A greater maxillary constriction: allow the maxillary teeth to fit inside the mandibular teeth without shift on closure reduced arch circumference crossbite correction will provide more space small constriction creates dental interferences that force the mandible to shift
Whether or not a mandibular shift is present, a crossbite due to a narrow maxilla should be corrected when it is noted, in the primary or mixed dentition, unless the permanent first molars are expected to erupt in less than 6 months.
It is possible to treat posterior crossbite with a split-plate type of removable appliance, there are two problems: this relies on patient compliance for success the appliance can be displaced easily
The preferred appliance for modest expansion of the maxillary arch in a preadolescent child is an adjustable lingual arch. Both the W-arch and the quad helix are reliable and easy to use.
W-arch fixed appliance constructed of 36 mil steel wire soldered to molar bands activated simply by opening the apices of the W
easily adjusted to provide more anterior than posterior expansion, or vice versa delivers proper force when opened 4-5 mm wider than passive width should be adjusted before being inserted it is not uncommon for the teeth and maxilla to move more on one side
Quad helix more flexible version of W-arch the bulk of the anterior helices can effectively serve as a reminder to stop habit combination of a posterior crossbite and a sucking habit is the best indication greater range of action than the W-arch but the forces are equivalent
Both appliances: leave an imprint on the tongue, that will disappear when the appliance is removed some opening of the midpalatal suture can be expected in a young child expansion should continue at the rate of 2 mm per month ( 1 mm on each side) until the crossbite is slightly overcorrected intraoral appliance adjustment may lead to unexpected changes require 2 to 3 months active treatment and 3 months of retention
True unilateral crossbite: ideal treatment is to move selected teeth on the constricted side to a limited extent, this can be achieved by using different length arms, but some bilateral expansion must be expected
an alternative is to use a mandibular lingual arch to stabilize the lower teeth and attach cross-elastics to the maxillary teeth this is more complicated and requires cooperation, but is more unilateral in its effect
a third alternative is to use a removable appliance that sectioned asymmetrically this appliance has the same restrictions as all removable appliances
If teeth in both arches contributed to the problem: Cross-elastics between banded or bonded attachments in both arches the force has a vertical vector which will extrude the posterior teeth and reduce the overbite caution in child with increased lower face height or limited overbite
crossbite should be overcorrected, and attachments left in place immediately after active treatment when the occlusion is stable after several weeks without elastic force, the attachments can be removed. the most common problem is lack of cooperation from the child.
most children with anterior crossbite, especially if more than one or two teeth are in crossbite, have a skeletal problem the most common etiologic factor for nonskeletal anterior crossbite is lack of space for the permanent incisors if the developing crossbite is discovered before eruption is complete and overbite has not been established, the adjacent primary teeth can be extracted to provide the necessary space.
only occasionally the anterior crossbite treatment is indicated in the primary dentition dental anterior crossbites typically develop as the permanent incisors erupt those diagnosed after overbite is established require appliance therapy the first concern is adequate space bilateral disking extraction of the adjacent primary teeth opening space
if teeth are tipped when bodily movement is required, stability of the result is questionable. in a young child, the best method for tipping anterior teeth out of crossbite is a removable appliance
finger springs for facial movement of maxillary incisors one 22 mil double helical cantilever spring multiple clasps for retention labial bow is usually contraindicated active labial bow for lingual movement of lower incisors (less frequently)
Biteplate to reduce the overbite: usually is unnecessary in children unless the overbite is exceptionally deep it would be needed only in a child with a clenching or grinding habit using a biteplate risks the chance that the teeth not in contact with the appliance or opposing arch will erupt excessively
Removable appliance without biteplate 2 months Teeth in the opposite arch are moving in the same direction Biteplate is indicated and can be added to the appliance
This removable appliance : requires nearly full time wear if the springs are activated 1.5 to 2 mm, the teeth will move 1 mm in a month the offending teeth should be slightly overcorrected the teeth should retained until overbite is adequate to retention one or two months of retention with a passive appliance
The most common problems: lack of patient cooperation poor design leading to lack of retention improper activation
The simplest fixed appliance for correction of anterior crossbite: a maxillary lingual arch with finger spring ( whip spring ) indicated for a child with compliance problems the springs usually are soldered on the opposite side of the arch it will increase their length most effective if the length is approximately 15 mm
3 mm activation , will produce optimum rate of movement: 1 mm per month the greatest problems are distortion, breakage and poor oral hygiene
2 4 appliance: the best choice for an older patient with crowding, rotations and more permanent teeth in crossbite in mixed dentition
forces and moments produced on the anterior teeth by a rectangular archwire the torque and the coil springs tip the incisors facially multiple incisors can be readily corrected in a short time the roots of lateral incisors should not repositioned into the canine path of eruption
