Orthodontic Diagnosis and Treatment Planning in the Primary Dentition PDF

25 JANUARY-FEBRUARY 1995 JOURNAL OF DENTISTRY FOR CHILDREN Orthodontic diagnosis and treatment planning in the primary dentition...

25 JANUARY-FEBRUARY 1995 JOURNAL OF DENTISTRY FOR CHILDREN Orthodontic diagnosis and treatment planning in the primary dentition Peter Ngan, DMD Henry Fields, DMD, MS Early recognition of conditions predisposing young tial steps in determining the nature of problems include children to malocclusions is in the hands of primary care a complete medical and dental history; extraoral and in- providers who, for practical purposes, are the general traoral examination; and appropriate radiographs, usually practitioner and the pediatric dentist. It is important that consisting of bitewings and a maxillary occlusal radio- conditions that predispose one to develop a malocclusion graph.3 In the primary dentition years, evaluation of fa- of the permanent dentition, be detected early in the pri- cial profiles can be difficult and should be approached mary dentition. This allows either intervention or mon- carefully.®” Before active tooth movement, or as a basis itoring on an effective basis. In general the reasons to for monitoring a problem, study casts should be made. advocate early treatment are better stability, reduction A lateral cephalometric radiograph is suggested, if an- in percentage of permanent tooth extraction, reduction teroposterior or vertical skeletal discrepancies are sus- in overall treatment time, and better functional or es- pected. A systematic description of the malocclusion thetic end results. While this is still an area of contro- should be performed, including alignment and symme- versy in the orthodontic profession and the time for try, facial esthetics, and occlusal and jaw relationship in beginning treatment is still a subject of debate, the rec- all three planes of space.® The following are examples of ognition of conditions that are known to interfere with conditions that should be noted during intraoral exami- growth and development of a child should be familiar to nations: any primary care practitioner.* This paper outlines [ Early loss of primary teeth and/or crowding (arch strategies for dealing with problems commonly seen in length considerations) the primary dentition. The purpose of this paper is to [ Mesioclusion or distoclusion (anteroposterior con- provide perspective on those orthodontic conditions siderations) most related to the primary dentition as the point of [ Crossbite of individual teeth or in segments (trans- intervention. verse considerations) [0 Openbites (including nonnutritive sucking habits) DIAGNOSIS OF ORTHODONTIC and deep bites (vertical considerations) PRORILEMS IN THE PRIMARY DENTITION A rationale for determining the extent of the practiti- oner’s concern for this view will be presented. The diagnosis and treatment planning in the primary dentition begin with an adequate data base. The essen-  26 JANUARY-FEBRUARY 1995 JOURNAL OF DENTISTRY FOR CHILDREN Figure 1A, A five-year-old male with early loss of the maxillary right primary second molar. A reverse band and loop space maintenance appliance was placed to guide the eruption of the permanent first molar. Figure 1B. A removable appliance with finger spring was used to regain space where loss was due to mesial drifting of the masillary first molar. TREATMENT PLANNING FOR EARLY LOSS OF PRIMARY TEETH Preventive dentistry and essentially preventive ortho- struction of the appliance and its constant presence as a dontics should begin during pregnancy. This is largely foreign body can make its use difficult. An alternative an educational phase, but one that can pay substantial approach that requires more mechanotherapy and cor- dividends. Parents should be counseled on the advan- rective action is a reverse band and loop placed at the tages of postnatal, supplemental fluoride and oral hy- time of eruption of the permanent first molar. This ap- giene to reduce dramatically the premature loss of proach requires that one plan for regaining space if primary teeth by caries.” needed, when the permanent first molar is erupted. Fig- Space maintenance alone is not the appropriate treat- ure 1A shows a five-year-old male with early loss of the ment, if space is insufficient. Other types of treatment primary maxillary right second molar. A reverse band (extraction, expansion or space regaining) are indicated and loop appliance was placed to guide the eruption of occasionally, but usually not in the primary dentition. the permanent first molar. As the permanent molar The early loss of primary molars due to caries requires erupted into occlusion, a removable appliance with fin- space maintenance, if space is adequate. This is partic- ger spring was used to regain space lost to mesial drifting ularly important, if a primary second molar is lost during of the permanent first molar (Figure 1B). the active eruption of the permanent first molar, causing In the normal primary dentition, especially by age five the latter to tip mesially. Also, distal drifting of the pri- or six, spacing between the incisors is normal and in fact mary canine is likely, if the loss occurs during the active is necessary, if the permanent incisors are to be properly eruption of the permanent lateral incisors. aligned, when they erupt. If the primary incisors contact Often the treatment of choice for unilateral loss of the each other proximally, one can confidently predict that primary first molar is a band and loop space maintainer. the permanent incisors will be crowded and irregular. For bilateral loss of primary first molars, the authors rec- Early expansion of the primary arches has been advo- ommend a Nance maxillary holding arch or bilateral cated by some in order to alleviate crow n the per- band and loops. manent dentition. The most aggressive method for early A difficult problem occurs when the primary second expansion uses maxillary and mandibular removable lin- molar is lost before the eruption of the permanent first gual arches in the complete primary dentition.!” This molar. An intra-alveolar fixed space maintainer (a distal produces an increase in both arch perimeter and width. shoe) has been advocated to preserve the space; but ma- The expansion is maintained for variable periods during jor complications, such as difficulty in the accurate con- the mixed and permanent dentition years. Lutz and  27 NGAN AND FIELDS ORTHODONTICS FOR PRIMARY DENTITION Poulton examined long-term results of this approach, fore, more easily deformed; sutures and ligaments are and found little change in intercanine width, however, more cellular and are more responsive to mechanical when control and treated patients were compared, but forces; and growing tissues are generally more respon- they did observe a small amount of buccal segment ex- sive to external forces."® There are no data, however, pansion and arch-perimeter increase.!! The effectiveness specifically addressing relapse of preadolescent treat- of this technique in meeting the challenge of anterior ment of Class II problems.** Recent studies on the crowding is questionable and unsubstantiated. long-term effect of using the Herbst appliance in early treatment of Class II patients indicated that dentofacial TREATMENT PLANNING FOR MESIOCLUSAL orthopaedics had only a temporary impact on the exist- AND DISTOCLUSAL PROBLEMS ing skeletofacial growth pattern.®2 For this reason, ex- cept in the most severe cases, it is unwise to begin According to a longitudinal study by Bishara et al, cases treatment for a skeletal Class II problem in the primary with a distal step occlusion in the primary dentition re- dentition.. sulted in a Class II permanent first molar malocclusion, Moyers classified Class 111 malocclusion in three dis- which will not self-correct with growth.? In cases with tinct types: The true skeletal Class IIT malocclusion a flush terminal plane, 56 percent became Class I occlu- characterized by skeletal dysplasia involving mandibular sions and 44 percent became Class II occlusions in the hypertrophy, maxillary retrusion or shortening of the permanent dentition. In contrast, 76 percent of cases cranial base; the pseudo or apparent Class 11 malocclu- with a 1 mm mesial step became Class I, whereas only sion that involved a positional relationship brought about 23 percent changed to Class 11, and 1 percent to Class by early interference with the muscular reflex of man- IIL In cases with a mesial step of 2 mm or more in the dibular closure; the third condition involved simple lin- primary dentition, 68 percent became Class 1, 13 per- guoversion of one or more maxillary anterior teeth.> cent Class II, and 19 percent Class III. Thus, a more While dental crossbites can be corrected using remova- favorable molar relationship in the primary dentition ble or fixed appliances with relatively stable results, true (flush or mesial step) lessens the chance for a Class 1T skeletal Class III malocclusion requires long-term mon- occlusion in the permanent dentition. itoring throughout puberty.*2*” Most clinicians prefer Table shows the frequency of treatment of various to delay treatment of this type of malocclusion until the classes of malocclusion at different stages of tooth erup- permanent dentition is intact, because mandibular tion. By the use of growth modification treatment meth- growth is difficult to control. On the other hand, Class ods, it is possible to correct distal step relationships in 1II treatment in the permanent dentition has often con- children relatively easily.”® Animal studies using func- sisted of producing dental compensations for the skeletal tional jaw orthopedics and extra oral forces have shown disharmony by proclining maxillary incisors and retract- that craniofacial modifications can be effected in young ing the mandibular anterior segment. Class 111 elastics animals with greater rate and magnitude.*'® This is due are often used in conjunction with mandibular first pre- to the fact that the bones are less mineralized and, there- molar extraction. This approach can result in increased Table (J Frequency and recommended treatment during primary dentition years. Class T " ClassIi- ClassTll___— Stage of eruption __Age SRR 3 e 1. Pritary 36 Space maintainance +++ Space maintainance +++ Space mantamance +++ management. - — Space management ~ — - Space management = — - tepa;-nn/m) (eqhn:‘odm) : ; (xnshnlm) s Orthopedics: Orthopedics: L gu@enr/?m;flbnll mhudgm ‘ase specific] therapy 3 (O,uelpl:&) Crossbites. ++ Crosshites ++ Pseudo Class INl g ‘Nonoutritive ? Nonnutritive v Noonutritive ? habits s habits - * sucking habits (openbite) : { ) {openbite) - : Deep bite — Deepbite ~ Deepbite 2  28 JANUARY-FEBRUARY 1995 JOURNAL OF DENTISTRY FOR CHILDREN Figure 2A. A five-year-old girl presented with anterior and pos- terior crossbites in the primary dentition. Figure 2B. Lateral cephalometric radiograph of the same pa- tient immediately after insertion of maxillary expansion appli- ance, revealing a Class I skeletal malocelusion with maxillary deficiency Figure 2C. Rapid palatal expansion appliance was used for transverse expansion and served as anchorage unit for maxil- lary protraction. Figure 2E. Lateral view of the same patient after six months of orthopedic treatment. Note the correction in anterior and posterior crossbites. Figure 2D. Elastics delivering 380gm on each side was attached from the protraction headgear to the expansion appliance for maxillary protraction,  29 NGAN AND FIELDS ORTHODONTICS FOR PRIMARY DENTITION and D). The objectives of early expansion and protrac- tion of the maxilla are to create an environment favor- able to subsequent growth and development. Figures 2E and F show the results after six months of orthopedic intervention. TREATMENT PLANNING FOR TRANSVERSE PROBLEMS: POSTERIOR CROSSBITES Transverse problems in the primary dentition are seen usually as posterior crossbite associated with a narrow upper arch. Sucking habits tend to be associated with some constriction of the upper arch, particularly in the primary canine region, and occlusal interferences may then lead to a functional shift of the mandible anteriorly and laterally. In a study by Lindner and Modeer, 97 percent of the seventy-six patients with unilateral pos- terior crossbites showed a forced bite with a functional shift on closure.® Lateral shift of the mandible to the Figure 2F. Lateral cephalometric radiograph of the same pa- crossbite side results in lower midline discrepancy, tient after six months of orthopedic treatment. Note the im- asymmetric condylar positioning, contralateral dental- provement in maxillo-mandibular skeletal relationship arch asymmetry (crosshite side toward Class 1T sagittal relationship, noncrossbite side toward Class T relation- ship) and facial asymmetry with chin deviation to cross gingival recession and tooth mobility in the anterior seg- bite side in occlusion?7 Soft tissue discrepancies also ment, along with compromised facial esthetics have been associated with long-s anding transverse prob- Another approach begins treatment after growth has lems™ This is judged to be the first dimension of the been fully expressed and invariably involves a combina- face to cease growth, based on the interdigitation of the tion of orthognathic surgery and comprehensive ortho- midpalatal suture, which complicates mechanical manip- dontic treatment. Although such an approach is ulation of the transverse dimension generally effective in resolving the underlying skeletal In treatment planning for patients with posterior and dental malrelationships, patients throughout child- crossbite, it is important to distinguish between skeletal hood have to endure poor esthetics, poor function, and and dental contributions to the malocclusion. A bilateral concomitant psychosocial problems associated with this posterior crossbite could be due to a narrow maxilla or type of malocclusion> a wide mandible or a combination of both. The diagnosis Early intervention for some Class 111 skeletal maloc- can be confirmed by analyzing a posteroanterior ce- clusions can at least temporarily improve skeletal rela- phalometric radiograph.”” ip by influencing the increment and directi The diagnosis of posterior crossbite often is compli- facial growth. Protraction headgears, for example, cated by skeletal and dental discrepancies in the sagittal used in treatment of early Class III malocclusions with and vertical dimensions. Patients with severe anteropos- maxillary deficiencies.®* Thus, it can be argued that in terior skeletal discrepancy such as in the case of Class borderline or minimal Class 11T malocclusions localized 11 division 1 malocclusion can present with a complete in the maxilla, current opinion favors early correction in buccal crossbite. Conversely, patients with Class 11T mal- the absence of long-term data. occlusion can have bilateral posterior crossbite with nor- Figure 2A shows the occlusion of a five-year-old girl mal maxillary and mandibular arch-widths. who presented with anterior and posterior crossbites in In a study by Kutin and Hawes, primary dentition the primary dentition. Cephalometric measurements re- crossbites observed longitudinally without intervention vealed a Class 111 skeletal pattern with maxillary defi- show only 8.65 percent (3 out of 33) self-correction in ciency (Figure 2B). A combination of maxillary expan- the mixed dentition.* On the other hand, correction in sion and protraction headgear was used to correct the primary dentition ing es the chance of no cross- maxillary deficiency and crossbite problems (Figures 2C bite in the permanent dentition, and recurrence of cross-  30 JANUARY-FEBRUARY 1995 JOURNAL OF DENTISTRY FOR CHILDREN bite is low. According to the study by Schroeder and preferred treatment is to increase the width of the max- Schroeder, thirty-two children ages three to six years illary arch by the use of a fixed appliance such as a lin- with high and narrow palatal vaults and functional pos- gual arch type appliance (W-arch or quadhelix) or a terior crossbites of the primary dentition who were removable appliance with a jackscrew (Figure 5). treated by transverse expansion showed no relapse when Bilateral posterior crossbite generally results from sig- the permanent first molars were in occlusion." In an- nificant skeletal maxillary constriction. Crossbites that other study by Thilander, Wahlund and Lennartsson, result from bilateral maxillary constriction can be cor- twenty-six of the thirty-three patients with posterior rected by opening the midpalatal suture, which widens crossbites were corrected by expansion plates and only the roof of the mouth and the floor of the nose. Patients six of twenty-eight patients who had no corrective treat- with bilateral posterior skeletal constriction, with no lat- ment showed spontaneous correction. It is reasonable, eral mandibular shift, can be treated by a rapid palatal therefore, to begin treatment of the primary crossbite in expander. In the primary dentition, lingual-arch-type ap- the primary dentition, unless eruption of the permanent pliances also usually accomplish skeletal changes. first molars is imminent and could require additional Occasionally, a patient may present with a true uni- treatment following eruption. lateral maxillary posterior constriction. These cases can Figure 3 shows a flow chart for determining the ap- be diagnosed by the presence of a unilateral posterior pliance to be used for treating individual or segments of crossbite in centric relation and centric occlusion and teeth in crossbite. The simplest form of posterior cross- the absence of a lateral shift to compensate. These pa- bite observed in the primary dentition is caused by in- tients can be treated by a fixed appliance, such as an terferences of the primary canines leading to a lateral asymmetric W-arch, or an asymmetric split-plate remov- mandibular shift, and in some cases, to a forward posi- able appliance that incorporates a wire spring or jack- tion of the mandible. This problem can be treated by screw for force generation. A subset of these patients grinding or equibration of the primary canines. If no have true facial asymmetry and asymmetric growth that correction results, expansion of the maxillary arch is require more complex treatment. Generally they have needed to eliminate the canine interferences. symmetric maxillary arches, and simple crossbite correc- Unilateral posterior crossbite accompanied by a lateral tions will relapse. mandibular shift is usually due to a width discrepancy Crossbite corrections in the primary dentition are uni- between the maxillary and mandibular arches. The dis- formly successful and also have an influence on arch- crepancy between the width of the maxilla and that of perimeter. The decision to treat is more obvious for the mandible causes the mandible to deviate to one side those patients with mandibular shifts and severe con- to occlude with the posterior teeth and is usually the strictions with related crowding. result of bilateral maxillary constriction (Figure 4). The DIFFERENTIAL DIAGNOSIS OF POSTERIOR CROSSBITE Unilateral posterior Unilateral posterior Bilateral posterior crossbite with no shift crossbite with shift crossbite. /N (maxilla constricted) (maxilla constricted) Unilateral True facial Unilateral ! Eliminate | Assess axial inclinations maxillary asymmetry mandibular canine constriction expansion I 7N\ interference l ! l Unilateral ~ Orthopedics/ Unilateral Bilateral Maxillary Mavillary maxillary Surgical mandibular maillary dental skeletal expansion Intervention constriction expansion expansion expansion Figure 3. A flow chart for determining the appliance used for treating individual or segment of teeth in crossbite.  31 NGAN AND FIELDS ORTHODONTICS FOR PRIMARY DENTITION Figure 5. A lingual arch type of appliance (W-arch) is recom- mended for bilateral expansion in the primary dentition. though many children who practice digital sucking habits have no evidence of malocclusion, Popovitch and Thompson have reported a high association of abnormal sucking habits with the malocclusion sample at the Bur- Figure 4. A fice-year-old male presented with unilateral pos- lington Orthodontic Research Center in Ontario, Can- terior erossbite and a mandibular shift on closure. Note the ada." Melsen et al found that both digital sucking and deviation of chin and dental midlines on closure. pacifier sucking increased the tendency toward abnormal swallowing.*” Sucking habits were related to an increase in severe malocclusion symptoms apart from the type of TREATMENT PLANNING FOR DEEP BITE swallow presented. Sucking habits were strongly corre- AND OPENBITE PROBLEMS lated with distoclusion and open bite and with crosshite and maxillary overjet. Usually sucking habits are spon- Deep-bite malocelusion is usually associated with the taneously stopped or reduced to a minimal level because skeletal proportions that predispose to this condition: a of peer pressure, before the appearance of permanent relatively short face with a square gonial angle and flat teeth. In general, up to age five or so, sucking habits are mandibular plane. This is classically the Class IT division unlikely to cause any long-term problems in children 2 patient for whom intervention for the Class II mal- with good skeletal patterns. Some data indicate that ul- occlusion would be delayed. Generally, treatment of timately the distortions promoted by nonnutritive suck- deep bites is not indicated in the primary dentition, un- ing habits in terms of openbite and overjet are resolved less clear functional problems or irritation of the palatal by the teenage years with no treatment. tissue from lower incisor impingement is noted. The dilemma for the practitioner, then, is either to Open bite can also occur as a result of a skeletal or intercept the habit, probably before the erption of the dental problem. Those with skeletal problems and dis- permanent teeth, by explanation, support, and use of a proportionately long lower ace: are difficult to treat be- reminder appliance if reward and explanation fail to cause the vertical dimension continues to change into bring about a response, or let the situation resolve nat- adolescence. On the other hand, open bite is often seen urally. Because both ways appear to bring an acceptable in children who have good skeletal proportions and suck- result at different times, much of this decision should ing habits. Recommendations regarding the use of be based on the perspective of the parent and child. “physiologic” and “natural” nursing bottle nipples and Some vertical problems and openbites have been pacifiers have been strongly supported by some, but blamed on breathing patterns.** ' The relationship be- there is no good evidence to support these claims.** Al- tween these variables is difficult to quantify and i  32 JANUARY-FEBRUARY 1995 JOURNAL OF DENTISTRY FOR CHILDREN certainly more difficult to assign causality on the basis Wieslander, L.: Intensive treatment of severe Class IT malocclu- =] sions with a headgear-Herbst appliance in the early mixed den of the data. Before any surgical intervention involving tion. Am | Orthod, 86:1-13, July 1984 the tonsils and adenoid is undertaken, a thorough and. McNamara, |.A: Neuromuscular and skeletal adaptations to objective evaluation of respiratory mode should be un- tered function in the orofacial region. Am J Orthod, 64:578-606, December 1973 dertaken.* Moyers, R E.; Elgoyhen, ].C.; Riolo, M.L. et al: Experimental pro- duction of Class 11T in Rhesus monkeys. Rep Congr Eur Orthod Soc, -75, 1970. CONCLUSIONS. Stockli, P, and Willert, H.G.: Tissue reactions in the temporo- mandibular joint resulting from anterior displacement of the man- Treatment of orthodontic problems in the primary den- dible in the monkey. Am | Orthod, 60:142-155, August 1971. tition requires careful diagnosis and treatment planning,. Elder, JR. and Tuenge, RJ: Cephalometric and histologic changes produced by extraoral high pull traction to the maxilla of Proper orthodontic records and a systematic description Macaca Mulatta. Am ] Orthod, 66:599-617, December 1974, of the malocclusion should be performed, including Droschl, H.; The effect of heavy orthopedic forces on the masilla alignment and symmetry, facial esthetics, and occlusal in the growing Saimiri sciureus (squirrel monkey). Am J Orthod, 63:449-461, May 1973, and jaw relationships in all three planes of space. Strat- Glass, D.F.: Bone deformation caused by external pressure. Trans egies in treatment planning for early loss of primary Eur Orthod Soc, 37:302-310, June 1961 teeth, mesioclusal and distoclusal occlusion problems, Bridges, T ; King, G.J.; Mohammed, A.: The effect of age on taoth movement and mineral density in the alveolar tissues of the rat and transverse and vertical problems are discussed. Cer- Am ] Orthod Dentofac Orthop, 93:245250, March 1955 tain conditions such as early loss of primary teeth, an-. Riedel, RA.: A review of the retention probleni. Angle Orthod, © terior and posterior crossbites, and some Class 111 skel- 30:179-199, July 1960. etal problems warrant early intervention to facilitate 22, Salzmann, J:A.: An evaluation of retention and relapse following orthodontic therapy. Am J Orthod, 51 :779-781, October 1965. normal growth and development. Aggressive arch-length 23 Pancherz, H. and Fackel, U The skeletofacial growth patter pre- 8 modulation, Class II correction, and intervention for ver- and post-dentofacial orthopedics. A long-term study of Class 11 malocelusions treated with the Herbst appliance. Eur ] Orthod, tical problems, including nonnutritive sucking habits, are 12:200-218, July 1990. largely unwarranted.. Wieslander, Long-term effect of treatment with the headgear. Herbst appliance in the early mixed dentition. Stability or relapse? Am | Orthod and Dentofac orthoped, 104:319-329, October 1993. REFERENCES Moyers, R.E.. Handbook of orthodontics. Chicago: Year Book 1. Ackerman, ].L. and Proffit, W.R.: Preventive and interceptive or- Medical Publishers Incorporated, 1988, pp 189-191, 571. thodontics: strong in philosophy, weak in practice. Angle Orthod, 6. Allen, R.A; Connolly, LH.; Richardson, A.: Early treatment of 50:75-87, April 1980. Class 11 incisor relationship using chincap appliance. 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ACCELERATED WEIGHT GAIN IN PRESCHOOL CHILDREN The purpose of the current investigation was to determine the dietary, physical activity, family history, and demographic predictors of relative weight change in a cohort of 146 children over a 3-year period. Results indicated that boys of normal-weight parents or who had only one parent overweight showed decreases in their body mass index (BMI) while those with two parents overweight showed increases. Girls with an over- weight father showed BMI increases while others experienced de: n BMI. Ad- ditionally, baseline intake of kilocalories from fat as well as decre: in f at intake were related to decreases in BML. At higher levels of baseline aerobi activity, subsequent changes in BMI decreased. There was also a trend for changes in le ure activity— increases in children’s leisure activity was associated with decr in subsequent weight gain. Modifiable variables (ie, dietary intake, physical activity) accounted for more of the variance in changes in child BMI change than nonmodifiable variables (eg, number of parents obese). These results strongly suggest that encouragement of heart healthy dietary intake patterns and participation in physical activity can decrease accelerated weight gain and obesity, even in preschool children. Klesges, R.C. et al: A longitudinal analysis of accelerated weight gain in preschool children. Pediatrics, 95:126-130, January 1¢