Ortho Sheet #2 By Shatha Al-Soudi

by **Sura** 2/10/2012, 9:34 pm

http://www.4shared.com/file/0ezaFCDO/Ortho_Sheet2_By_Shatha_AlSoudi.html

by **Shadi Jarrar** 18/12/2012, 4:07 pm

بسم الله الرحمن الرحيم

Ortho lec #2

Dr.Zaid Al Bitar

24/9/2012

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Interceptive Orthodontics 2 …

The definition of Local Factors : the factors affecting one or two adjacent /opposing teeth and usually there is interception !

These local factors are classified into …

· Variation in Teeth Number (Supernumerary, Hyperdontia , Hypodontia /missing teeth, Premature loss of primary teeth , Retained deciduous teeth)

· Variation in Teeth Form(Double teeth, Macrodontia , Microdontia ,Dens in Dent, Dilacerations)

· Variation in Teeth Position

· Soft Tissue Anomalies

· Local Pathology

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Supernumerary Teeth frequently cause Median Diastema , and sometimes they cause nothing ,they have just found incedently in the palate .

1. Conical shape (peg-shaped)>> Rarely interfere the eruption of the Central incisors and we could leave them without extraction if they are not causing any problems.

2. Tuberculate (barrel-shape)>> this type is associated with failure of central incisors eruption(impaction).

3. Supplemental >> causes usually localized crowding , bcoz it erupts adjacent to the original tooth.

The original tooth & the Supplemental one are Similar to each other , so for ortho treatment we could remove the most displaced one .

4. Odontome >> haphazard –shape ,not a frequent finding !

** In case of Supernumerary teeth , the decision of extraction a tooth is done according to the age of the patient (the eruption age for each tooth) , if there is delay or inhibited eruption for any permanent tooth then we have to do extraction !!

Anomalies in Shape	Anomalies in Position
Conical (peg-shape)	Mesiodens
Tuberculate (barrel-shape)	Distomolar
Supplemental	Paramolar
Odontome

Retained Deciduous teeth ; as we know after certain stage of development , primary teeth shed .. normally the shedding occur after the formation of 3/4 the root of permanent one .

In this case the primary teeth stays in mouth beyond the expected time of shedding .

>> we don't extract or remove every retained tooth ,, provided that the permanent successor tooth is present,, the retained primary tooth should be extracted especially if it's causing deflection or displacement for the permanent one .

>> Timing of extraction for the retained tooth is when the root of the permanent tooth is 3/4 formed ,, before that time delay of eruption for the successor tooth might occur !!

** there is a special condition of retained deciduous teeth , which is " Infra-Occluded Molars " (Submerged tooth)…

Examination of this type by >>

1.Check the Mobility… this tooth is usually Ankylosed

2. Check the Extent … a. Mild (above the contact point)

b. Moderate (at the contact point )

c. Sever (below the contact point)

**this infra-occluded tooth is not submerged ,but it haven't complete it's eruption like the other teeth (not fully erupted) and in this case the opposing permanent tooth is Over-erupted .

3. Percussion test … this tooth upon percussion will give a Tin-can sound !

>> we have to check for the presence of underlying Permanent Premolars .

The most important Diagnostic Feature is the "Dipping of the Marginal Bone Contour Apically">> by that your are sure that the bone level is below !!!

** Treatment … we have to look for the Age & the Gender of the patient ,, as it's diagnosed early it's effect will be less ,, and for the gender ; the growth spurt for the female is earlier than the male so the effect of such anomalies on females is less !

SooooOo, * we have to check for the presence of the 5's ,, * check for the severity of the infra-occlusion (more sever >> have a strong indication for extraction ) ,, * check for the adjacent teeth , if tipping is occurred or not .

2 options for Management >>>

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if the 5 is erupted /present , we just let the E to exfoliate by itself BUT you have to keep it under observation .

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if the 5 is present and the primary tooth is progressively Infra-occluded , we might extract it with the assistant of the Surgery .

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Infra-occluded …

1. Ankylosed : detected early >> extraction //// detected late >> if it's in normal position just build it up BUT if it has poor position extract it .

2. Not-Ankylosed : Root resorption >> extraction /// no root resorption >> we might just leave it there !!

If the 5 is absent , sometimes we choose to keep the E's in order to preserve the underlying bone and it's(E) providing some sort of function >>> so , Retain the E and place Onlay , OR if there is crowding extract it and use space to align the teeth ,, OR do prostho treatment (Extraction and placement of Implant / auto transplantation ) .

Anomalies in the Size of the tooth … (Root & Crown )

**Macrodontia >> when the crown size is more than normal , in this case the decision should be done soon after eruption , either to keep it or to extract it . the size of this tooth might cause crowding , so the management could be by extraction of the enlarged tooth >> displacement of the lateral and the canine /for e.g./ to the place of the central , then we can do reshaping for them !!

Anomalies in the Crown Form ..

1. Double teeth

2. Accessory cusps

3. Dental invagination

In Root Form .. Dilacerations

1) Double Teeth : In Primary stage usually it’s associated with a missing permanent tooth , so you have to count the teeth ,it also may cause delay in eruption .

Double teeth in permanent incisors >>

*Gemination : partial splitting of a tooth germ

* Fusion : fusion of two tooth germs

If the tooth has one root its preferred to extract it !! but if it has two roots just divide it and remove the other!!

2) Accessory Cusps >> causes occlusal interferences & increase the caries risk ,,,,, Management >>

a. Do selective grinding to the cusp to allow the secondary dentine to form .

b. Remove the cusp & make pulpotomy

c. Aseptic removal of the cusp(with the help of the endodontist) .

3) Dens Invagination >> in such cases it's difficult to seal it properly , it's considered as a rout of infection and caries , So we need a prophylactic management as soon as the tooth erupts , if it's not possible we have to extract it .

ROOT FORM Anomalies … Dilacerations >> there are two conditions depending on the etiology ,,

** Developmental : crown turned upward and labially , regular enamel and dentine .

** Traumatic : crown turned palatally , disturbed enamel and dentine (caused by the intrusion of the primary incisor resulting in displacement of the developing permanent incisor tooth germ).

>> if the dilacerations is Mild /not causing any problems either to the soft tissue or to the adjacent teeth/ we just choose to align the tooth . BUT , if the case is sever it's better to remove the dilacerated tooth ,, there are some case reports said that Apecictomy could be done in such cases.

Anomalies in tooth Position ;

>> in general we have to remove any local factor and provide space ,,

>> you have to differentiate between Impacted(ectopic) and Unerupted teeth !!!! =)

Special case >> unerupted central incisor , usually we diagnose it early , bcoz the eruption age of it is around 7years ,so if it's delayed we had to notice that !

Factors causes uneruptive /delayed eruption of the central incisor :

1. Hereditary factor

2. Supernumerary teeth

3. Cleft lip/palate

4. Cleido-Cranial Dysplasia

5. Environmental factors ( Stroma?!!)

6. Retained deciduous teeth

Diagnosis >> ** Proper History ,clinical examination and radiographic assessment .

** Inspection (like ; if a central incisor tooth erupts the other one should erupts within 6 months , if not so there is a problem ,,, also if a change in the sequence of eruption happened,, inspection for the inflammation of the teeth ) , Palpation (if a tooth is not erupted we have to palpate the labial and palatal mucosa ) .

X-ray assessment ; we want to check the condition of the teeth ,the cause of delayed eruption also to Localize the tooth .

A) Parallix/ Parallism method … two periapical x-rays with two positions ,, we shift or move the x-ray tube from one position to another ,, Explanation >> the reference in the Ex. Is the central incisor , and the supernumerary tooth is lying against the mesial side of the central incisor , if we move the tube to 2^nd position it will appear as overlapping the central incisor.. this concept is called SSL "Slope Same Lingual/palatal" .

B) Occlusal x-ray / Panorama >> as the Dr. is explaining a slide !! let's assume that the supernumerary tooth at this level ,and the occlusion is at a higher level , so when we move the panorama to occlusal /as if we're moving up (the crown in the panorama is overlapping the middle of the root of central incisor)>> but after moving the panorama it's overlapping the apex of the central !! O.o

There are many options for the management of unerupted central incisors :-

1] Do frequent observation , y3ni just observe O.o

Advantage > preserving the alveolar bone

Disadvantages > we have to see the patient regularly , bcoz we want to make sure that the central incisor is not making any problems ,,, This option is done for a limit time .

2] Interceptive treatment , which means removing the obstacles (supernumerary teeth) to create space (by using removable appliance or we wait until it erupt by itself >>> just preserve the space that you create ) .

>> Disadvantages ;

· Delay of eruption

· No eruption of the tooth

· Alignment , that we need ortho treatment

up to 78% of the incisors erupts spontaneously within 20 months .

>> 25% needs surgical episodes > y3nii needs another surgery , then put brackets to pull the tooth and 4% of these teeth will require ortho treatment .

The Dr. prefer to do interceptive treatment , and at the same time he places bracket (cold/mold chain Low profile!!) .

3] Surgical removal of the incisor that we can't save it …

Indications ; Ankylosed tooth,,, Ectopic tooth ,,, the tooth that is beyond our capabilities to align it ,,, Pathology/ risk on the adjacent teeth[resorption].

^^ Disadvantages ;

· Damage to the adjacent tooth during the surgery

· Loss of bone , which might affect any other treatment modalities (implants…) .

4] Exposure and ortho alignment .. the patient should be cooperative and the incisor have a good chance to erupt .

If it was severely displaced or have poor prognosis we choose not to align the tooth .

Canines >>there is an evidence have been shown by Erikson & Cuerel >> if the canines are palatally ectopic from the age of 10-13 years , the extraction of C's [primary canines] will give a good chance (78%) for the permanent canines to erupt spontaneously .

Ectopic eruption of the First Molars , they are impacted against the E's , so they are not fully erupted in this case .

Before the age 8 years ,this condition could be reversible , can align by itself , but after that age there is a little chance that they will erupt by themselves .

Management …

1. Extraction of the E's >> there will be definite space loss ,that will need treatment by removable or fixed appliance .

2. Non-extraction ,, we have to put something between the E & 6 so to push the 6 backward (brace wire separator) or to make disking for the E's , But the problem in this case is that there will be Space Loss that we need to regain it !

Local Anomalies in Soft Tissue …

Like Median Diastema , which is caused by ?

1. Developmental causes

2. Dento-alveolar dis-proportion (small teeth in relation to the jaws )

3. Supernumerary tooth

4. Proclined upper incisors

5. High frenal attachment (migration )

6. Pathology(Naso-palatine duct cyst)

>> in Infants the frenum is attached to the incisive papillae and with age apical migration occurs , if it's stays it will cause diastema , interrupting the periodontal fibers that connects the two centrals together.

Diagnosis …

Clinically , by the presence of Blanching , we pull the upper lip by two fingers and observe the blanching around the area of the incisive papillae

On the X-ray , you will notice Radiolucent line between the centrals .

Treatment …

1. We start it after the eruption of the Canines , bcoz we are going to align the laterals (which are the eruption guidance of the canines) unless the Diastema is less than 3mm can close it conservatively .

In the treatment of Diastema it will be on long term basis bcoz of frequent relapse! >> we have to use Retainer for a long-term to prevent Relapse .

2. The other option is Surgery (Frenectomy ) which improves Retention , there is a controversy when to do frenectomy before ortho treatment or after [at the end of treatment /after the closure of diastema >> bcoz the surgery will result in a scar tissue wish causes contraction that prevents Relapse of diastema ] .

The last thing is about the pathology or cysts , the treatment is according to another department (perio, surgery , endo…. Etc.) .

That's it … I'm Sooo sorry for any mistakes .

Done by : Shatha Al-Soudi .

Ortho Sheet #2 By Shatha Al-Soudi

Ortho Sheet #2 By Shatha Al-Soudi

Re: Ortho Sheet #2 By Shatha Al-Soudi