Age Appropriate Orthodontic

Treatment
 Who needs treatment?
• With few exceptions (e.g., disfiguring dental–
facial conditions), the only patient who
actually needs orthodontic treatment is the
patient(parent) who wants orthodontic
improvement!
 Liability
• Jimmy’s anecdote
• All (almost) orthodontic treatment is elective
• Cost-benefit ratio
 Initial examination—Pre-records
orthodontic checklist
• Record 4 key areas:
1. Occlusion and function:
– Primary cuspid and molar relationships
– Symmetry
– Anterior and/or posterior crossbite
– Functional shift
– Full range of motion
– TMJ evaluation and TMJ/ TMD history. This includes any
specific history of dental and/orofacial trauma.
2. Space available: evaluate if “reasonable” amounts of
dental space are available. Extraction /non-
extraction?
 Initial examination—Pre-records
orthodontic checklist
3. Facial balance and symmetry:
– Frontal /profile
– Dynamic smile
– Overall facial impression of dental and facial
balance
4. Chief complaints and expectations of the
patient and parents
 Remember!
• You are not allowed to tell patients (parents)
what to do. Your obligation is to explain
options and answer questions. The
parent/patient must be allowed ample
information and discussion to decide the best
treatment options for their child.
 Cost-benefit ratio of early treatment
Benefits
1. What are the benefits of starting treatment now?
2. Predictability?
3. Will performing “early” treatment negate the
need for or reduce the over all amount of time
the patient will require treatment?
4. Will having the patient undergo comprehensive
treatment at a later date remove or minimize any
potential iatrogenic injuries?
5. Psychosocial benefit?
 Cost-benefit ratio
Risks
1. What is the potential for negative clinical
sequelae to occur as a result of one prolonged
phase, or two (or more) phases of treatment
extended overtime?
2. Co-operation/ burnout
3. Financial implications
4. Will extending treatment over time negatively
impact patient’s lifestyle?
 Cost-benefit ratio
• Remember that only the parent/patient can
characterize any potential benefit as actual
benefit
• Be wary of educating decision makers into
coercing them
• Just because something can be done does not
mean it should be done
 Indications for early treatment
1. Unilateral crossbite
2. Single anterior tooth crossbite with lip-trap
3. Mild crowding: mandibular deciduous
canines placed buccal to incisors and the
space of E is insufficient to resolve crowding
if it can be preserved
4. Significant lip incompetence
5. Traumatic bite
 Indications for early treatment
• Openbite
• Psychosocial aspects of malocclusion
• Skeletal and dentofacial anomalies that if
treated early negate or lesson the need for
surgical intervention later
“Perceived benefit when applied against
perceived minimal risk is dangerous in that it
is essentially meaningless.”
 Psychological Considerations
• Attractive facial appearance in young children
was found to be the most influential of 33
different characteristics for social acceptance
and popularity among peers by Young and
Cooper.
 Indices
• Several indices have been developed to assess
psychological impact of malocclusion

1. Eastman esthetic index

2. Dental-facial attractiveness (DFA)
3. Dental esthetic index

• None have proved reliable at predicting the

degree of psychosocial limitation due to
malocclusion
 Psychological Considerations

• Kleck et al “friends” study

• 10 % higher rule
 Psychological Considerations

“Ask a parent what it is worth to them if they

could potentially improve, by a measure of
10% or more, their child’s academic, athletic,
and social performance to influence a more
successful future lifetime of opportunities!”
 Early Class III treatment
• Mandibular excess delay treatment
• Maxillary deficiency  start early
• Treat maxillary deficiency with protraction
• Optimal time
– 6 -8 years
– After the eruption of maxillary first permanent
molars and incisors
 Early Class III treatment
• Advantages of earlier orthopedic treatment
include
– More consistent patient (and parent) compliance
– Less patient discomfort
– No loss of root structure
Early Class III treatment - appliance
• Typically, a heavy .036-in wire is usually
soldered to the buccal side of the molar band
and extends forward to the canine area for
protraction.
• A new design that utilizes a stainless steel
crown and a removable arm for maxillary
protraction may overcome this problem
 Posterior Crossbite
• One of the most common malocclusions in
primary and mixed dentitions
• Prevalence 5-8% children 3-12 years old
• Upto 90 percent have lateral mandibular shift
• Diagnosis: abnormal buccolingual transverse
relationship
• Unilateral or bilateral
 Posterior Crossbite
1. Localized problem in tooth eruption
– Single tooth crossbite
– Atypical eruption patterns
– No alteration of basal bone or functional
deviation of the jaws
– Usually molars/premolars
 Posterior Crossbite
2. Unilateral crossbite
– Edge to edge in centric relation
– Functional shift of mandible in central occlusion
– Chin and lower midline deviated towards affected
side
– Crossbite side in class II
– Non-crossbite side in class I or III
 Posterior Crossbite
3. Bilateral posterior crossbite
– True basal skeletal discrepancies
– Severe maxillary constriction
– Midlines On
– No functional shift
– Increased risk of crowding and open bite
– Cause can be inherited or environmental
Posterior Crossbite
Posterior Crossbite
 Posterior Crossbite

Dimburg et al reported 13% prevalence of

unilateral posterior cross-bites in the primary
dentition of 386 children followed
longitudinally into the mixed dentition where
the unilateral presentation showed a
prevalence rate of 14%.
Bilateral Crossbites
 Posterior Crossbite
• 90 % of posterior crossbites have a functional
shift
• Canine interference factors
1. Eruption sequence
2. Positioning
3. Insufficient arch dimensions
 Habits
• 48% to 97% of patients with posterior
crossbites have oral habits
– Pacifier use
– Thumb and finger sucking
– Mouth breathing

• Habits lasting longer than 48 months cause significant

oral changes resulting in an increased incidence of
anterior openbites, posterior crossbites, and
excessive overjet
 Posterior Crossbites
• All pediatric patients of suitable age should be
screened for such habits
• Similar to extraoral habits forward tongue
positioning, open-mouth breathing patterns,
and other atopic related disease problems
may be related to maxillary constriction, open
bite, and crossbites.
 Posterior Crossbites
Volk et al:
• Using 3d ultrasonography found 83% crossbite
patients held their tongue low
• Compared to 43% control
• Incorrect tongue position may be cause or
effect
 Posterior crossbite
Incorrect tongue position leads to
• Imbalance between the force of cheeks and
tongue on teeth
• Displacement of teeth in palatal direction

Mouth breathing
• Mandibular muscles develop exaggerated
downwards and backwards component
 Posterior Crossbites
• Over-eruption of posterior teeth
• Unrestrained vertical alveolar growth
• Upper lips become flaccid due to decreased tonicity
and retract upwards, decreasing labial influence of
upper anteriors
• In swallowing tongue is trust forward to compensate
for incompetent lip position
• Lower lip interpositions behind the upper incisors to
create seal
• Proclination of upper incisors and retroclination of
lower incisors
 Posterior Crossbites
• If mouth breathing is identified, the patient
should be referred to ENT before starting
orthodontic therapy
 Treatment
• Treatment usually requires maxillary
expansion
• If canine interferences are present they should
be selectively ground only if
– Maxillary intercanine width is 2 to 3 mm than
mandibular arch width.
– If it is edge to edge or smaller then selective
grinding would not be effective and upper canine
expansion is required
 Treatment protocols
• Unilateral crossbite, primary dentition: 4 Quad-
helix, band/crown Hyrax, second primary molars.
• Unilateral crossbite, mixed dentition: 4 Quad-helix,
band/crown Hyrax, first permanent molars.
• Bilateral crossbite, primary dentition: 4band/ crown
Hyrax, second primary molars.
• Bilateral crossbite, mixed dentition: 4 band/ crown
Hyrax,2-point to first permanent molars or 4-point to
first permanent molars and second primary molars.
• Unilateral posterior crossbite, late mixed to
adolescent permanent dentition: 4 band Hyrax, 2-
point to first permanent molars, 4-point to 6-year
molars, and selected premolar.
– Girls upto age15–17 years
– Boys uptoage17–18 years
• Adult dentition: surgically assisted maxillary
expansion with band Hyrax—2 or 4 point.
THE END