Interceptive Orthodontics: A Practical Guide to Occlusal Management

Table of Contents

Dedication

Title page

Copyright page

Preface

CHAPTER 1: Introduction

What Do We Know about Growth?

References

CHAPTER 2: Recognising the Problem

Is an Attractive Smile Important?

CHAPTER 3: Investigations

Radiographs

Cone-Beam Computed Tomography

Study Models

Photographs

What Is the Scope of Orthodontic Change?

References

CHAPTER 4: Managing the Developing Occlusion

Thumb/Finger Sucking

Crowding of the Permanent Lateral Incisors

Serial Extraction: a Modern Approach

The Unerupted Central Incisor

Submerging Deciduous Second Molars

Fusion, Gemination and Morphology Issues

Upper Labial Fraenum

Leeway Space and the Use of Intraoral Anchorage Arches

Sagittal Problems: Class II

Sagittal Problems: Class III ()

Ectopic and Impacted Teeth

Missing Teeth

References

Index

End User License Agreement

List of Illustrations

Figure 1.1  Directions of facial growth.

Figure 1.2  Growth is genetically controlled and largely not under our influence.

Figure 2.1  Essential clinical assessment tools.

Figure 2.2  Clinical assessment of the A–P skeletal relationship.

Figure 2.3  Clinical assessment of the maxillary mandibular angle.

Figure 2.4  Clinical assessment of the lower anterior face height.

Figure 2.5  Clinical assessment of facial symmetry.

Figure 2.6  Facial asymmetry can be caused by mandibular displacement due to crossbites with displacements. (a) Displaced position; (b) first contact with condyles in retruded axis position.

Figure 2.7  Clinical assessment of overjet.

Figure 2.8  Lip trap (upper right incisor resting on lower lip).

Figure 2.9  Lip apart posture at rest.

Figure 2.10  Forward tongue position causing an anterior open bite.

Figure 3.1  OPG radiograph: Simple assessment of the space requirements for the developing dentition.

Figure 3.2  (a) OPG radiograph to identify maxillary canine position using vertical parallax. (b) Standard occlusal radiograph.

Figure 3.3  Lateral cephalograph and analysis.

Figure 3.4  CBCT images in the X, Y and Z planes showing buccally placed ectopically positioned upper left and right canines overlying the roots of the upper lateral incisors. The images show significant resorption of the roots of these teeth and enlarged canine crown follicles. The reconstructed slices are also shown in 3D. Using these images it is possible to make a judgement in all planes as to the likely long-term prognosis for the lateral incisors. The difficulty at the present time is the lack of evidence for or understanding of what happens to the resorption once the canines have been moved away from the incisors. It is important within the treatment planning process to know if the resorption will continue or remain stable. These images demonstrate both the good visualisation of the area and our limitations in interpreting this information.

Figure 3.5  (a) Section from a DPT showing the presence of a supernumerary tooth associated with the upper left central incisor – the diagnostic information is limited, as accurate localisation is not possible. (b) CBCT images in the X, Y and Z planes showing the position in 3D of a supernumerary palatal to the ectopically positioned upper central incisor. These views provide excellent positional information for this tooth and the morphology of both its crown and root and the surrounding alveolar bone. This information is particularly important to the orthodontic surgeon as it allows removal with maximum accuracy and therefore minimal trauma. By assessing the orientation of the unerupted tooth, a view can be reached as to whether it will move away from the other teeth (and can therefore be left to be reviewed) or whether it is likely to be an obstruction that requires removal.

Figure 3.6  CBCT imaging at different heights showing the talon cusp and clearly demonstrating the degree of extension of pulpal tissue into the cusp.

Figure 3.7  (a) Periapical radiograph (2D image) showing fusion of the incisor teeth. (b) CBCT image (3D) showing accurately the extent of root and crown contact.

Figure 3.8  CBCT images in the X, Y and Z planes, allowing comprehensive analysis of the root fracture affecting the UR1. The level of the root fracture, any shelving and any microfractures can be visualised. This allows accurate treatment planning and assessment of any repair. Progressive resorption can also be monitored accurately.

Figure 3.9  (a,b) A simple space analysis on plaster study casts.

Figure 3.10  Extraoral photographs.

Figure 3.11  Intraoral photographs.

Figure 4.1  Effect of thumb sucking on the dentition.

Figure 4.2  Asymmetric open bite due to digit sucking.

Figure 4.3  Fixed thumb guard to prevent digit sucking.

Figure 4.4  Clinical effects of the thumb guard. (a) Start. (b) At 3 months. (c) At 6 months. (d) At 9 months.

Figure 4.5  (a) The Quadhelix appliance. (b) Using a Quadhelix appliance to expand the upper dental arch and correct the lateral arch dimensions, as well as acting as a thumb guard.

Figure 4.6  (a) Before extraction of the primary canines. (b) After extraction of the primary canines, space is created to allow the upper permanent lateral incisors to erupt, and the crowding is seen to shift distally in the arch.

Figure 4.7  Early expansion can be used to create an effective environment for the permanent teeth to develop into.

Figure 4.8  Using fixed appliances to close anterior incisor spacing early can be useful when guiding the developing dentition into the correct alignment.

Figure 4.9  Anterior crossbite of the upper right central incisor.

Figure 4.10  Anterior crossbite causing forward displacement of the lower central incisors and leading to reduced labial bone coverage.

Figure 4.11  Case showing potential damage involving tooth wear and periodontal involvement.

Figure 4.12  When correcting an anterior crossbite, posterior coverage is needed to open the bite beyond the depth of the crossbite.

Figure 4.13  Simple removable appliances can provide effective treatment for anterior crossbites.

Figure 4.14  Extraction of the lower canines eliminates the crossbite.

Figure 4.15  Upper arch expansion with a removable appliance to eliminate a unilateral crossbite.

Figure 4.16  A Quadhelix appliance can eliminate the need for patient compliance as it is not removable from the mouth.

Figure 4.17  Serial extraction. (a) Start. (b) 6 months after primary canine extraction. (c) First premolars erupted and ready for extraction. (d) Second premolars erupting, ready for alignment if required.

Figure 4.18  Series of OPG radiographs showing the management of severe crowding with interceptive extractions alone, thus avoiding the need for orthodontic treatment. (a) 2009; (b) 2011; (c) 2014.

Figure 4.19  Tuberculate supernumeraries preventing the eruption of the central incisors.

Figure 4.20  Mesiodens supernumeraries preventing the eruption of the central incisors.

Figure 4.21  Managing the impacted incisor: the treatment sequence.

Figure 4.22  Severely ectopic teeth can be effectively treated with complex orthodontic treatment. Bringing the teeth into the line of the dental arch preserves alveolar bone.

Figure 4.23  Lateral incisor moved into central incisor position and restored showing poor emergence profile.

Figure 4.24  Submerging lower right second deciduous molar and impacted second premolar.

Figure 4.25  Submerging lower left second deciduous molar causing a food trap.

Figure 4.26  A band and loop is rarely successful in preventing the medial tipping of the first molar after loss of primary molars. (a) Before extraction of the primary second molar. (b) Band and loop in place, but not controlling mesial movement of the adult molar. (c) Loss of space leading to impaction of the developing premolars.

Figure 4.27  A lingual arch is effective at stabilising the molar position and arch length after loss of a primary second molar.

Figure 4.28  A geminated central incisor.

Figure 4.29  Large upper central incisors (megadont teeth) cause occlusal issues and crowding due to their size, and benefit from early management.

Figure 4.30  Orthodontic tooth movement and restorative management of one megadont tooth to allow space for normal occlusal development of the remaining incisors.

Figure 4.31  A large labial fraenum.

Figure 4.32  Lip trap causing proclination of incisors.

Figure 4.33  Lip trap causing proclination of the upper central incisors and retroclination of the lower incisors.

Figure 4.34  Using palatal and lingual arches to preserve the leeway space.

Figure 4.35  Proclination of the upper incisors increases the risk of trauma.

Figure 4.36  Result of a fall, fracture and luxation of the anterior teeth.

Figure 4.37  A treatment sequences for the management of an increased overjet. (a) Start. (b) With the appliance in place. (c) Post treatment with the overjet reduced.

Figure 4.38  Functional appliances come in many