Recognizing and Correcting Developing Malocclusions
Description
Comprehensive reference providing an evidence-based approach to the early treatment, recognition, and correction of developing malocclusions
Recognizing and Correcting Developing Malocclusions, Second Edition provides an evidence-based approach to early treatment of developing malocclusions, presenting treatment protocols for mixed-dentition patients with various malocclusions and other orthodontic problems. Class I, Class II, and Class III malocclusions are covered extensively, along with eruptive deviations and different malocclusions.
The literature is comprehensively reviewed to ensure that the reader thoroughly understands the development, phenotypic characteristics, and etiology of each type of malocclusion. Taking a problem-oriented approach, the authors provide detailed information for each case, develop comprehensive problem lists, and then present evidence-based treatment solutions.
This newly revised and updated Second Edition contains comprehensive updates to all chapters and sections, including dental trauma and its consequences and sleep apnea in children.
Containing figures, tables, patient pictures, and 3D rendered illustrations throughout to elucidate key concepts, Recognizing and Correcting Developing Malocclusions, Second Edition explores topics including:
- Assessing the degree of severity of a developing malocclusion and recognizing and correcting intra-arch deviations
- Genetics of dental occlusions and malocclusions and mixed dentition orthodontic mechanics
- Strategies for managing missing second premolar teeth in young patients and principles and techniques of premolar autotransplantation
- Abnormal eruption, function, and aesthetics, congenitally missing teeth, autotransplantation, and habits
- Construction of a diagnosis, treatment plan, and estimation of prognosis based on available diagnostic records produced by both old and new technologies
Practical in approach but grounded in the literature, Recognizing and Correcting Developing Malocclusions, Second Edition is equally useful as a patient-side guide for clinicians and as a detailed reference for orthodontic and pediatric specialists and residents.
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Persons
The editors
Eustáquio A. Araújo, DDS, MDS, is an Emeritus Professor of Orthodontics at Saint Louis University in Saint Louis, Missouri, USA.
Peter H. Buschang, MA, PhD, is a Regents Professor Emeritus, the Peter H. Buschang Endowed Chair of Orthodontics, and former director of research in the Department of Orthodontics at the Texas A&M University College of Dentistry in Dallas, Texas, USA.
Content
List of Contributors xiii
Foreword xv
Preface xvii
1 A guide for timing orthodontic treatment 1
Eustáquio A. Araújo, DDS, MDS and Bernardo Q. Souki, DDS, MSD, PhD
1.1 Occlusal deviations with indications for interceptive orthodontic treatment 3
1.2 Ideal timing for early treatment 5
1.2.1 Psychological aspects 5
1.2.2 Severity of the malocclusion 5
1.2.3 Effectiveness and efficiency concepts 6
1.2.4 Maturational stage of development 7
References 7
2 Development of the occlusion: what to do and when to do it 9
Bernardo Q. Souki, DDS, MSD, PhD
2.1 Stage 1-eruption of deciduous teeth 9
2.1.1 Biogenesis of the deciduous dentition 9
2.1.2 Dimensional changes of the dental arches at stage 1 11
2.1.3 Management of occlusal development at stage 1 11
2.2 Stage 2-completion of the deciduous dentition 11
2.2.1 Dimensional changes in the dental arches at stage 2 13
2.2.2 Management of occlusion development at stage 2 14
2.3 Stage 3-eruption of first permanent molars 16
2.3.1 Management of occlusion development at this stage 17
2.4 Stage 4-eruption of permanent incisors 18
2.4.1 Dimensional changes in the dental arches at this stage 18
2.4.2 Management of occlusal development at this stage 19
2.5 Stage 5-eruption of mandibular canines and first premolars 20
2.5.1 Management of occlusal development at this stage 21
2.6 Stage 6-eruption of second premolars 21
2.6.1 Management of occlusal development at this stage 23
2.7 Stage 7-eruption of maxillary canines and second molars 23
2.7.1 Management of occlusal development at this stage 23
2.8 Conclusions 24
References 24
3 Mixed dentition diagnosis: assessing the degree of severity of a developing malocclusion 27
Eustáquio A. Araújo, DDS, MDS
3.1 Assessing treatment need, complexity, and outcome 27
3.1.1 Summers' Occlusal Index 28
3.1.2 Dental Aesthetic Index (DAI) 28
3.1.3 Peer Assessment Rating (PAR) 28
3.1.4 Index of Orthodontic Treatment Need (IOTN) 28
3.1.5 Index of Complexity, Outcome, and Need (ICON) 29
3.1.6 The American Board of Orthodontics complexity index and outcome assessment 29
3.2 Assessing interceptive treatment outcome 31
3.2.1 Class I 31
3.2.2 Class II 31
3.2.3 Class III 32
References 33
4 The genetics of the dental occlusion and malocclusion 35
Robyn Silberstein, DDS, PhD and Mary MacDougall, PhD
4.1 Introduction 35
4.1.1 Personalized medicine 35
4.1.2 Clinical examination 35
4.1.3 Principles of dysmorphology: variable expressivity and etiologic heterogeneity 36
4.2 Chromosomal abnormalities 37
4.3 Single gene defects 38
4.4 Multifactorial inheritance 38
4.5 Genetics of nonsyndromic malocclusion 40
4.6 Altered tooth number 42
4.7 Altered tooth structure 43
4.8 Altered eruption 43
4.9 Radiographic deviations associated with genetic conditions 45
4.10 Conclusion 47
References 47
5 Class I: Recognizing and correcting intraarch deviations 51
5.1 Section I: The development and etiology of a Class I malocclusion 51
Peter H. Buschang, MA, PhD
5.1 Introduction 51
5.2 Prevalence of Class I malocclusion and changes in arch form 52
5.3 Class I malocclusion and the dental compensatory mechanism 58
5.4 What is anterior mandibular malalignment is related to? 60
5.4.1 Predisposing factors 60
5.4.2 Eruption problems associated with space loss 61
5.4.3 Contact displacements associated with relapse and tooth movements 62
References 63
5.2 Section II: Intercepting developing Class I problems 67
Eustáquio A. Araújo, DDS, MDS
5.5 Tooth size arch length discrepancy (TSALD) 67
5.6 The assessment of crowding in the mixed dentition 68
5.6.1 Zero to minor TSALD 68
5.6.2 Small to moderate TSALD 69
5.6.2.1 Taking advantage of the transitional dentition 69
5.6.3 Gaining spaces in the dental arches 71
5.6.3.1 The importance of the leeway space/E space 71
5.6.3.2 Etiology of maxillary transverse deficiency 72
5.6.3.3 Maxillary expansion and headgear 73
5.6.3.4 Gaining space in the mandibular arch 83
5.6.3.5 Arch dimensions changes 84
5.6.3.6 Arch length and mandibular molar/MP 84
5.6.3.7 Arch length and mandibular incisors/MP 84
5.6.3.8 Transverse changes 84
5.6.3.9 Incisor irregularity changes 84
5.6.3.10 The Schwarz appliance 86
5.6.3.11 Two-by-four fixed therapy 86
5.6.4 Severe TSALD: fundamentals of serial extraction 92
5.6.5 Indications and contraindications for serial extraction (SE) 93
5.6.5.1 Additional important fundamentals in serial extraction 94
5.6.5.2 Sequence and timing of extractions 95
5.6.5.3 Alternative extraction sequences 95
References 102
6 Recognizing and correcting Class II malocclusions 107
6.1 Section I: The development, phenotypic characteristics, and etiology of Class II malocclusion 107
Peter H. Buschang, MA, PhD
6.1 Introduction 107
6.1.1 Prevalence 109
6.2 Characterization of the Class II, division 2 phenotype 110
6.3 Characterization of the Class II division 1 phenotype 111
6.3.1 Hyperdivergent vs. hypodivergent Class II division 1 malocclusion 114
6.4 Developmental changes of Class IIs 115
6.5 Class II developmental changes 118
6.6 Etiology 119
References 123
6.2 Section II: Class II treatment: problems and solutions 131
Eustáquio A. Araújo, DDS, MDS
6.7 Early Class II adjustment 132
6.8 Treatment 136
References 158
7 Recognizing and correcting Class III malocclusions 161
7.1 Section I: The development, phenotypic characteristics, and etiology of Class III malocclusion 161
Peter H. Buschang, MA, PhD
7.1 Introduction 161
7.2 Characterization of the Class III phenotype 163
7.3 Class III development 168
7.4 Etiology 170
References 175
7.2 Section II: Class III treatment: problems and solutions 179
Eustáquio A. Araújo, DDS, MDS
7.5 Diagnosis 183
7.5.1 Facial diagnosis 183
7.5.2 Cephalometric diagnosis 183
7.5.3 Dental diagnosis 183
7.5.4 Functional diagnosis 184
7.5.5 Hereditary diagnosis 185
7.6 Communication 187
7.7 Early intervention 188
7.8 Orthopedic maxillary expansion 188
7.9 Face mask and/or chincup orthopedics 191
7.9.1 The face mask 191
7.9.2 The chincup 193
7.10 Leeway space control 194
7.11 Orthodontic mechanics 194
7.12 Finishing 194
7.13 Retention 194
7.14 Growth reevaluation 195
References 221
8 Special topics 225
8.1 Section I: Habit control: the role of function in open-bite treatment 225
Ildeu Andrade, Jr., DDS, MS, PhD and Eustáquio A. Araújo, DDS, MDS
8.1 Nutritive vs. nonnutritive sucking habits 225
8.2 Tongue physiology 226
8.3 Tongue thrusting and forward resting posture of the tongue 227
8.4 Breaking the habit 227
8.4.1 How and when should a clinician intervene? 227
8.4.2 The Araújo approach 227
8.5 Treatment 229
References 235
8.2 Section II: Eruption deviations 239
Bernardo Q. Souki, DDS, MSD, PhD and Eustáquio A. Araújo, DDS, MDS
8.6 Eruption deviations 239
8.7 Eruption deviation and PIOM: what are the most frequent eruption disturbances in each stage of dental development? 241
8.7.1 Stage 2 - Completion of deciduous dentition 241
8.7.2 Stage 3 - Eruption of the first permanent molars 241
8.7.3 Stage 4 - Eruption of the permanent incisors 241
8.7.4 Stage 5 - Eruption of the mandibular canines and the first premolars 242
8.7.5 Stage 6 - Eruption of the second premolars 247
8.7.6 Stage 7 - Eruption of maxillary canines and second molars 247
References 253
8.3 Section III: Strategies for managing missing second premolar teeth in the young patient 255
David B. Kennedy, BDS, LDS (RCSEng), MSD, FRCD(C)
8.8 General concepts 255
8.9 Longevity of the second deciduous molar, resorption, and infraocclusion 256
8.9.1 Resorption 256
8.9.2 Infraocclusion 257
8.10 The alveolar ridge in extracted deciduous molars 257
8.11 Overall dental health and cost 258
8.12 Case histories 258
8.13 Summary 270
References 270
8.4 Section IV: Principles and techniques of premolar autotransplantation 273
Ewa M. Czochrowska, DDS, PhD and Pawel Plakwicz, DDS, PhD
8.14 Class II malocclusion with congenitally missing lower second premolars 274
8.15 Traumatic loss of upper incisor/s 274
8.16 Uneven tooth distribution with multiple agenesis 274
8.17 Surgery 277
8.18 Selection of anesthesia (local vs. general) 277
8.19 Premolar to premolar transplantation 277
8.20 Premolar to anterior maxilla transplantation 279
8.21 Postoperative instructions 279
8.22 Follow-up 279
8.23 Pulp healing 280
8.24 Periodontal healing 281
8.25 Root growth 281
8.26 Reshaping to incisor morphology 281
8.27 Alveolar bone after autotransplantation 281
References 282
8.5 Section V: Dental trauma: revisiting posttrauma protocols and long-term follow-ups 285
Eustaquio A. Araújo, DDS, MDS and Gabriel Miranda, DDS, MS
8.28 An overview of dental trauma 285
8.29 Orthodontic treatment and dental trauma 286
8.30 Managing traumatized teeth and preserving bone width - The decoronation approach 288
8.31 Final considerations 295
References 297
8.6 Section VI: Sleep-disordered breathing (SDB) in the growing child 299
Juan Martin Palomo, DDS, MDS and Luciane M. de Menezes, PhD
8.32 The need for sleep 299
8.33 Diagnosis and management of sleep-disordered breathing (SDB) and obstructive sleep apnea (OSA) in children 300
8.34 Risk factors for OSA in children 302
8.34.1 Enlarged tonsils and adenoids 302
8.34.2 Obesity 304
8.34.3 Allergies and respiratory infections 304
8.34.4 Structural abnormalities and craniofacial anomalies 305
8.35 Consequences of SDB in children 305
8.36 Treatment options for the dental and skeletal consequences of SDB in children 309
8.37 New technologies: the use of apps and devices for SDB and OSA in children 310
8.38 Conclusion 310
References 311
8.7 Section VII: Mixed dentition orthodontic mechanics 313
Gerald S. Samson, DDS
8.39 Definitions and terminology 314
8.39.1 Center of mass and center of resistance 315
8.39.2 Orders of tooth movements and orthodontic terminology 316
8.39.3 Force systems 316
8.39.4 Single-point force and moment of force 316
8.39.5 Additive and subtractive couples 316
8.39.6 Equilibrium and tooth movement - Newton's third law 317
8.39.7 Force systems and tooth movements 318
8.39.8 Mixed dentition example of one tube (bracket) and one couple system 319
8.39.9 Mixed dentition: maxillary anterior root convergence 320
8.39.10 Orthodontic treatment of teeth with open apices 320
8.39.11 Two brackets - two equal and oppositely directed couples 320
8.39.12 Two brackets - two unequal oppositely directed couples 321
8.39.13 Two brackets - two "same direction, additive" couples including increased anterior incisor root torque 322
8.39.14 Clinical application - mixed dentition openbite, two "same direction, additive" couples including increased anterior incisor root torque 324
References 326
Index 327
1
A guide for timing orthodontic treatment
Eustáquio A. Araújo, DDS, MDS1 and Bernardo Q. Souki, DDS, MSD, PhD2
1 Department of Orthodontics, Center for Advanced Dental Education, Saint Louis University, St. Louis, MO, USA
2 Department of Dentistry, Pontifical Catholic University of Minas Gerais, Belo Horizonte, Brazil
When the decision was made to work on this book, the heavy responsibility of embracing the topic without bias or radicalism increased. Clinicians and academicians were initially consulted and asked to provide questions that would help establish priorities for early interventions. The responses came rapidly and contained all the sorts of questions one would imagine. Recognizing and Correcting Developing Malocclusions will try to address the collected questions and themes.
The term "early treatment" has been used for a long time, and it seems now to be fixed. Although "early" could suggest "too soon," for the sake of practicality it will be used in this book. The text will eventually also refer to timely or interceptive treatment.
Initiating orthodontic treatment during the growth spurt was often used to be considered the "gold standard" for treatment timing. The pendulum that regulates the initiation of orthodontic treatment has been swinging in different directions for many years. At present, this balance seems to have been shifting, as the pendulum appears to be swinging toward an earlier start, preferably at the late mixed dentition. The possibility of successfully managing the E-space has dramatically influenced the decision-making on the timing of orthodontic treatment [1].
At the beginning of the 20th century, some consideration was given to early treatment. A quote from Lischer [2] in 1912 says,
Recent experiences of many practitioners have led us to a keener appreciation of the "golden age of treatment" by which we mean that time in an individual's life when a change from the temporary to the permanent dentition takes place. This covers the period from the sixth to the fourteenth year.
Soon after, in 1921, a publication [3] titled "The diagnosis of malocclusion with reference to early treatment," discusses the concepts of function and form and gives notable consideration to the role of heredity in diagnosis-so the topic with its controversies is an old one.
"The emancipation of dentofacial orthopedics," an editorial by Hamilton [4] supports early treatment. In summary, he states that:
- healthcare professionals must do everything possible to help their patients, including early treatment;
- it is irresponsible and unethical to prescribe treatment for financial betterment and for the sake of efficiency;
- if the orthodontist is not willing to treat patients at a young age, others in the dental profession will, and it is in the patients' best interest that we, as specialists, treat these patients. After all, our flagship journal includes "Dentofacial Orthopedics" in its title;
- it is the highest calling of healthcare professionals to incorporate prevention as a primary means of treatment, and therefore early treatment is important;
- pediatric dentists and other health professionals are incorporating early treatment in their practice because orthodontists are waiting too long to initiate treatment;
- orthodontic programs have the responsibility to educate orthodontists about early treatment.
On the other hand, Johnston [5] indicates in "Answers in search of questioners" that:
- little evidence exists that two-phase early treatment has a significantly greater overall treatment effect compared with treating in one phase and considering E-space preservation;
- treatment aimed at the mandible typically has an effect on the maxilla;
- early treatment is not efficient for the patient or doctor and results in an increased burden of treatment;
- functional appliances do not eliminate the need for premolar extraction, as bone cannot grow interstitially and arch perimeter is not gained with their use;
- patients occasionally endure psychological trauma due to dental deformity, but these isolated instances are not enough to "support what amounts to an orthodontic growth industry."
In an effort to establish grounds to initiate treatment earlier or later, we must try to answer two key questions:
- Should developing problems be intercepted and treated in two phases?
- Which malocclusions should receive consideration for treatment at an early age?
Undoubtedly, there is much agreement on what to treat, but there is still great disagreement on when to intervene.
What are achievable objectives for early treatment? Some of the most relevant ones are using growth potential appropriately, taking advantage of the transitional dentition, improving skeletal imbalances, eliminating functional deviations, managing arch development, improving self-esteem, minimizing trauma, and preventing periodontal problems.
Early orthodontic treatment offers several potential advantages, including better patient compliance, emotional satisfaction, and the ability to harness growth potential. It may also simplify the second phase of treatment and reduce the need for extractions. Additionally, early treatment can benefit practice management. However, there are also disadvantages, such as inefficiency, prolonged treatment time, patient immaturity, challenges with maintaining oral hygiene, difficulty in caring for appliances, and higher costs. It is crucial for orthodontists to carefully weigh these benefits and risks, providing evidence-based and well-reasoned recommendations on whether or not to initiate treatment. This chapter offers guidance on the optimal timing for orthodontic interventions.
The ideal timing for treating malocclusions in growing patients has been a controversial and widely discussed topic throughout the history of orthodontics [16-10]. One of the most important debates in our field is whether to interrupt the development of problems with early treatment or to postpone therapy until later [1, 9]. Such controversies are likely due to the lack of a scientific basis for therapeutic clinical decisions [8]. Historically, dentistry has been an empirical science. Even today, most dentists choose to employ solutions and techniques that were first learned in dental school or those that they believe will work [1, 9]. In such cases, there is a high probability of treatment failure or a low-quality treatment outcome.
During the search for excellence in orthodontics, the concepts of effectiveness and efficiency have been emphasized [1]. Orthodontic clinical decisions should be scientifically based. Accordingly, treatment must be postponed until strong arguments in favor of beginning the therapy are present [9].
A follow-up protocol in which patients are re-examined periodically during growth and the development of occlusion allows the clinician to decide whether the cost/benefit of early treatment is justifiable. At this time, the program "preventive and interceptive orthodontic monitoring," or simply PIOM, as devised by Souki [11] is introduced.
Conceptually, PIOM is a program of sequential attention that aims to monitor the development of "normal" occlusion and seeks to diagnose any factors that may compromise the quality or quantity of orthodontic treatment and the establishment of an appropriate occlusion. Seven objectives govern PIOM:
- Provide prospective monitoring with a minimal intervention philosophy;
- Provide comprehensive orthodontic care with functional and esthetically harmonious adult occlusion as the ultimate goal;
- Establish parameters so that orthodontists are not in a hurry to start treatment but are able to have a deadline to complete treatment;
- Establish scientific parameters as guidelines for beginning therapy at each stage of maturation;
- Respect the normal range of occlusal development;
- Reduce dependence on patient compliance;
- Delay phase II, if possible, until the time when second permanent molars can be included in the final occlusion.
During the years that separate the eruption of the first deciduous tooth and the full intercuspation of the second permanent molars, many morphogenetic influences and environmental factors act on the maturation of the dental arches and the occlusal pattern. Therefore, human occlusion should be viewed dynamically.
Clinicians must understand that during occlusal development, there is not just one line of ideal characteristics but a wide range of normal characteristics. In the mixed dentition, a larger variety of normal characteristics compared to the deciduous and permanent dentitions is encountered. Knowledge of normal features of occlusal maturation is important for the practice of orthodontics within PIOM. Throughout the history of medicine/dentistry, identifying signs or symptoms of a deviation from normal has been viewed as a situation requiring interceptive action. In lay terms, it has been thought that allowing a disease to evolve naturally (without therapy) may possibly make the disease more difficult to treat or even make it incurable [7]. This belief, when applied to orthodontics, may produce unnecessary...
