Examination, Diagnosis, and Treatment Planning










384 Part 3 The Primary Dentition Years: Three to Six Years
tooth is extracted. In the former situation the gingiva must be
incised when the appliance is placed if the extraction site has
healed. In the latter situation the construction cast must be modied
to simulate loss of the primary second molar, but placement in
the extraction site at the time of surgery is straightforward. e
appliance is constructed very much like the band and loop. e
primary rst molar is banded and the loop extended to the former
distal contact of the primary second molar. A piece of stainless
steel is soldered to the distal end of the loop and placed in the
extraction site. e stainless steel extension acts as a guide plane
for the permanent rst molar to erupt into proper position and
should be positioned 1 mm below the mesial marginal ridge of
will be a void in the cement. Next, the band is placed on the clean,
dry abutment tooth (teeth), and the excess cement is cleaned.
ere are several types of cement from which to choose, but glass
ionomer cement is recommended. is type of cement releases
uoride over time to protect the tooth from demineralization. e
appliance should be checked every 6 months to ensure it still ts
properly, cement has not washed out, and the abutment teeth are
nonmobile. Eruption of the permanent tooth is an easily recognized
indication for removal.
e distal shoe has some variation in the process. e appliance
can be constructed from an impression taken after removal of the
primary second molar or from an impression taken before the
A
B
C
E
D
Figure 26.9 (A) The initial step in fabricating a band and loop device is to t a band on the abutment
tooth. Band selection is a trial-and-error procedure and continues until a band can be nearly seated on
the tooth with nger pressure. (B) A band pusher is used to seat the band to a nearly ideal position. The
dentist should maintain a good nger rest because soft and hard tissue injury can occur if the pusher
slips without proper support. (C) Final occlusogingival position is achieved with a band biter. In the maxil-
lary arch the band biter should be placed on the distolingual portion of the band for nal positioning. In
the mandibular arch the band biter should be placed on the distofacial portion of the band. (D) A properly
tted band is seated approximately 1 mm below the mesial and distal marginal ridges. (E) If a tight inter-
proximal contact prevents the band from seating properly, orthodontic separators are placed to create
space for the band material. The separators are removed within 7 to 10 days, and the band is tted.

CHAPTER 26 Space Maintenance in the Primary Dentition 385
the unerupted rst permanent molar in the alveolar bone. After
the molar has erupted, the extension can be cut o or a new band
and loop appliance can be constructed. To ensure that the stainless
steel extension is in the proper position and in close proximity to
the permanent rst molar, a periapical radiograph is recommended
before the appliance is cemented (Fig. 26.10).
An alternative to the two-step process is the prefabricated appli-
ance, which comes in band and loop and distal shoe variations. ese
are fabricated intraorally and save chairside time and laboratory
expense. ere is extra chairside time and equipment needed to
t and place the appliances. ese are a practical alternative to the
traditional unilateral space maintainers but may lack durability.
10
Summary
Space maintenance in the primary dentition should be considered
in terms of anterior and posterior space loss. Space maintenance
Figure 26.10 A periapical radiograph is recommended before cement-
ing the distal shoe appliance to ensure that it is properly positioned in
relation to the unerupted permanent rst molar.
is generally not required for missing primary incisors but can be
placed if esthetic concerns are a factor. Posterior space maintenance
is a necessity in this age group and should be undertaken when
primary molars are lost prematurely and the space is adequate.
e band and loop appliance is used most often; other appliances
can be used as dierent situations dictate. Judicious space main-
tenance benets the child patient and may prevent future alignment
and crowding problems.
References
1. Prot WR, Fields HW, Sarver DM. Treatment of nonskeletal problems
in preadolescent children. In: Contemporary Orthodontics. 5th ed. St
Louis: Elsevier; 2012.
2. Ngan PH, Fields HW. Orthodontic diagnosis and treatment planning
in the primary dentition. ASDC J Dent Child. 1995;62(1):25–33.
3. National Institutes of Health, National Institute of Dental and
Craniofacial Research. Dental caries (tooth decay) in children (age
2 to 11). https://www.nidcr.nih.gov/DataStatistics/FindDataByTopic/
DentalCaries/DentalCariesChildren2to11.htm. Accessed August 16,
2017.
4. Centers for Disease Control and Prevention, National Center for
Health Statistics. Oral and dental health. https://www.cdc.gov/nchs/
fastats/dental.htm. Accessed August 16, 2017.
5. Holan G, Needleman HL. Premature loss of primary anterior teeth
due to trauma—potential short- and long-term sequelae. Dent
Traumatol. 2014;30(2):100–106.
6. Law CS. Management of premature primary tooth loss in the child
patient. J Calif Dent Assoc. 2013;41(8):612–618.
7. Tunison W, Flores-Mir C, ElBadrawy H, et al. Dental arch space
changes following premature loss of primary rst molars: a systematic
review. Pediatr Dent. 2008;30(4):297–302.
8. Reggiardo P. Coding and Insurance Manual: A Comprehensive Resource
for Reporting Pediatric Dental Services. Chicago: American Academy
of Pediatric Dentistry; 2016.
9. Mayhew MJ, Dilley GJ, Dilley DCH, et al. Tissue response to
intragingival appliances in monkeys. Pediatr Dent. 1984;6(3):148–152.
10. Brill WA. e distal shoe space maintainer chairside fabrication and
clinical performance. Pediatr Dent. 2002;24(6):561–565.

CHAPTER 26 Space Maintenance in the Primary Dentition 385.e1
Case Study: Ankyloglossia Classication
Audrey Jung-Sun Yoon
Ankyloglossia is a broad denition encompassing individuals with decreased
tongue mobility caused by a shortened lingual frenulum. The commonly
referred “tongue-tie” has been reported to cause breastfeeding difculties,
oromyofacial dysfunction, speech problems, swallowing impediments, and
predisposition to sleep breathing disorders.
1
Systematic reviews show an
association between treatment rendered for ankyloglossia and mother-
reported improvements in breastfeeding and nipple pain.
2,3
Some have suggested that ankyloglossia may affect jaw skeletal
development during childhood growth.
4–7
A simple lingual frenectomy
performed early can prevent many undesirable consequences.
8
Due to
continuing controversies over the diagnostic criteria and management, a
systematic assessment should be conducted on each patient to determine
treatment needs.
9,10
Clinical Assessment in the Infant
A comprehensive intraoral dental exam should include inspection of the
tongue and its function. As the infant cries or extends the tongue, the
anterior edge of the tongue should be inspected. While lifting the infant’s
tongue, the frenulum should be palpated and its elasticity determined. The
attachment of the frenulum to the tongue should be approximately 1 cm
posterior to the tip of the tongue. The attachment of frenulum to the inferior
alveolar ridge should be inserted proximal or into the genioglossus
muslcle.
9,11
The Hazelbaker score can be calculated after scoring the
appearance and function items.
12
Clinical Assessment in a Child or Adolescent
An assessment of the lingual frenulum should include position of the muscle
insertion and tongue mobility. Two classication systems, developed to help
the clinician determine treatment options, may also contribute to long-term
studies of nonintervention versus intervention.
Tongue Range-of-Motion Ratio
A simple and quick grading scale of measuring tongue mobility has been
developed.
12
1. Maximal interincisal mouth opening (MIO) (in mm) (Fig. E26.1A). Patient
is instructed to “open your mouth” (but not as wide as possible).
2. Interincisal mouth opening with tongue tip to maxillary incisive papilla at
roof of mouth (MOTTIP) (in mm) (see Fig. E26.1B). Patients are instructed
to “touch the tip of tongue to the back of the upper two front teeth and
open mouth.”
3. Tongue range-of-motion ratio (TRMR) (%) calculated as the proportional
variance of MOTTIP divided by MIO.
The functional ankyloglossia was classied into four categories using
TRMR, based on ratios derived from clinical measurement. Grade 1 patients
exhibit the greatest range of motion, whereas grade 4 patients are the most
restricted (Fig. E26.2).
Kotlow Classication
“Free tongue” is dened as the length from base of tongue insertion of the
lingual frenulum to the tip (in mm) (see Fig. E26.1C). The length of the ventral
surface of the tongue is measured from the insertion of the lingual frenulum
to the tongue tip. In the Kotlow classication scheme based on the “free
tongue” measurement, normal is considered to be greater than 16 mm. Four
other classications are based on millimeter measures of the tongue length.
13
Summary
Clinicians should continue to follow the development of ankyloglossia
classications used to measure treatment indications and treatment
effectiveness. Treatment options for ankyloglossia include observation,
speech therapy, frenotomy without anesthesia, and frenectomy and
frenuloplasty using a laser, scalpel, or surgical scissors with anesthesia often
under general anesthesia,
14
based on ndings derived from the
classications. This online content will be updated as studies are published.
AB C
Figure E26.1 Measuring the tongue function and length using a Quick Tongue-Tie Assessment Tool.
(A) Maximal interincisal mouth opening (example: 46 mm). (B) Mouth opening with tongue tip to incisive
papilla (example: 34 mm). (C) Kotlow free tongue measurement (Kotlow, example: 16 mm).
Continued

385.e2 Part 3 The Primary Dentition Years: Three to Six Years
Questions
1. Why is it important to identify ankyloglossia, especially at an earlier age?
Answer: Ankyloglossia, or “tongue-tied,” often leads to varying
degrees of oromyfacial dysfunction, breastfeeding difculties,
speech and swallowing impediments, and even predisposition to
sleep breathing disorders.
2. What are two classication systems used for lingual frenulum in a child
or adolescent?
Answer:
a. TRMR grading: TRMR (%) has been developed for measuring tongue
mobility. TRMR is calculated as the proportion variance of MOTTIP
(interincisal mouth opening with tongue tip to maxillary incisive
papilla at roof of mouth) divided by MIO. Based on TRMR, functional
ankyloglossia was classied into four categories—grade 1 (TRMR
>80%) shows the greatest range of motion, whereas grade 4 (TRMR
<25%) shows the most restricted mobility.
b. Kotlow classication: “Free tongue” is dened as the length from
base of tongue insertion of the lingual frenulum to the tip (in mm). In
the Kotlow classication, free tongue greater than 16 mm is
considered to be normal. Four other classications are based on
millimeter measures of the free tongue length.
3. What are the treatment options for ankyloglossia?
Answer: Treatment options for ankyloglossia include
observation, speech therapy, frenotomy without anesthesia,
and frenectomy and frenuloplasty using a laser, scalpel, or
surgical scissors often under general anesthesia.
References
1. Guilleminault C, Huseni S, Lo L. A frequent phenotype for paediatric sleep
apnoea: short lingual frenulum. ERJ Open Res. 2016;2(3).
2. O’Shea JE, Foster JP, O’Donnell CP, et al. Frenotomy for tongue-tie in
newborn infants. Cochrane Database Syst Rev. 2017;(3):CD011065.
3. Francis DO, Krishnaswami S, McPheeters M. Treatment of ankyloglossia
and breastfeeding outcomes: a systematic review. Pediatrics.
2015;135(6):e1458–e1466.
4. Meenakshi S, Jagannathan N. Assessment of lingual frenulum lengths in
skeletal malocclusion. J Clin Diagn Res. 2014;8(3):202–204.
5. Defabianis P. Ankyloglossia and its inuence on maxillary and mandibular
development. (A seven year follow-up case report). Funct Orthod.
1999;17(4):25–33.
6. Northcutt ME. The lingual frenum. J Clin Orthod. 2009;43(9):557–565,
quiz 581.
7. Whitman CL, Rankow RM. Diagnosis and management of ankyloglossia.
Am J Orthod Dentofacial Orthop. 1961;47(6):423–428.
8. Ballard JL, Auer CE, Khoury JC. Ankyloglossia: assessment, incidence, and
effect of frenuloplasty on the breastfeeding dyad. Pediatrics.
2002;110(5):e63.
9. Messner AH. Lalakea ML. Ankyloglossia: controversies in management. Int
J Pediatr Otorhinolaryngol. 2000;54(2–3):123–131.
10. Suter VG, Bornstein MM. Ankyloglossia: facts and myths in diagnosis and
treatment. J Periodontol. 2009;80(8):1204–1219.
11. Hazelbaker AK. The assessment tool for lingual frenulum function (ATLFF):
Use in a lactation consultant private practice. 1993.
12. Yoon A, Zaghi S, Weitzman R, et al. Toward a functional denition of
ankyloglossia: validating current grading scales for lingual frenulum length
and tongue mobility in 1052 subjects. Sleep Breath. 2017;21(3):767–775.
13. Kotlow LA. Ankyloglossia (tongue-tie): a diagnostic and treatment quandary.
Quintessence Int. 1999;30(4):259–262.
14. Kupietzky A, Botzer E. Ankyloglossia in the infant and young child: clinical
suggestions for diagnosis and management. Pediatr Dent.
2005;27(1):40–46.
Grade 1 functioning
TRMR >80%
Grade 2 functioning
TRMR 50%–80%
Grade 3 functioning
TRMR <50%
Grade 4 functioning
TRMR <25%
Figure E26.2 Clinical examples of varying degrees of ankyloglossia categorized by tongue range-of-
motion ratio grading (ratio of interincisal mouth opening with tongue tip to maxillary incisive papilla at roof
of mouth to maximal interincisal mouth opening). Higher grade indicates decreased tongue mobility and
increased severity of compromised tongue function.

386
27
Oral Habits
CLARICE S. LAW
CHAPTER OUTLINE
Thumb and Finger Habits
Treatment
Pacier Habits
Lip Habits
Tongue Thrust
Mouth Breathing
Nail Biting
Bruxism
Summary
mouth. e frequency of digit sucking throughout a routine day
will also have an impact on tooth movement. Clinical experience
suggests that 4 to 6 hours of force per day is probably the minimum
necessary to cause tooth movement.
3
erefore a child who sucks
intermittently with high force may not produce much tooth
movement at all, whereas a child who sucks with less force but
continuously (for more than 6 hours) can cause signicant dental
change, which is consistent with the equilibrium theory. However,
it is the duration of time sucking (in months and years) that
probably plays the most critical role in tooth movement caused
by a digit habit.
1,2,4,5
e most frequently reported dental outcomes
of an active digit habit are the following
3
:
1. Posterior crossbite
2. Anterior open bite
3. Increased overjet
Some studies have also reported dierences in canine and molar
relationship, but these are not present with the same frequency.
e maxillary arch constriction associated with a posterior
crossbite is probably due to the change in equilibrium balance
between the oral musculature and the tongue.
1,2,4,5
When the thumb
is placed in the mouth, the tongue is forced down and away from
the palate. e orbicularis oris and buccinator muscles continue
to exert a force on the buccal surfaces of the maxillary dentition,
especially when these muscles are contracted during sucking. Because
the tongue no longer exerts a counterbalancing force from the
lingual surface, the posterior maxillary arch collapses into crossbite
(Fig. 27.1).
Anterior open bite, or the lack of vertical overlap of the upper
and lower incisors when the posterior teeth are in occlusion, develops
because the digit rests between the maxillary and mandibular incisors
(Fig. 27.2). is prevents complete or continued eruption of the
incisors, whereas the posterior teeth are free to erupt. Anterior
open bite may also be caused by intrusion of the incisors. However,
inhibition of eruption is easier to accomplish than true intrusion,
which would be the result of a habit of greater duration.
Faciolingual movement of the incisors depends on how the
thumb or nger is placed and how many ngers are placed in the
mouth. Some consider this positional variable to be a confounding
factor related to force and duration of the habit. Usually, the
thumb is placed so that it exerts pressure on the lingual surfaces
of the maxillary incisors and on the labial surfaces of the mandibular
incisors (Fig. 27.3). A child who actively sucks can create enough
force to tip the upper incisors facially and the lower incisors lingually.
e result is an increased overjet and, by virtue of the tipping,
decreased overbite.
Data on the amount of skeletal change are not clear. Some
believe the maxilla and its alveolar process are moved anteriorly
T
he presence of an oral habit in a 3- to 6-year-old child is
an important nding during the clinical examination. e
most common oral habits—digit and pacier sucking—
generally cease spontaneously between 3 and 4 years of age at the
beginning of the age range.
1
By 6 years of age, most children begin
the transition into the permanent dentition, making habit cessation
more important. us the 3- to 6-year age range is a very important
period for facilitating the transition out of an oral habit. In this
chapter, we will consider the various oral habits that may be
associated with either malocclusion or oral health.
Thumb and Finger Habits
umb and nger habits make up the majority of oral habits.
Approximately two-thirds of such habits end by 5 years of age,
decreasing from a prevalence of approximately 30% at 12 months
of age to approximately 10% at 5 years.
2
Dentists are often
questioned about the kinds of problems these habits may cause if
they are prolonged. e malocclusions caused by nonnutritive
sucking may be more of an individual response than a highly
specic cause-and-eect relationship. e types of dental changes
that a digit habit may cause vary with the amount of force applied
to the teeth (force magnitude), the manner in which the digit is
positioned in the mouth (force direction), how much time the
child engages in the habit (frequency in hours per day), and how
long the habit persists (duration in months or years).
Research and clinical experience have shown that as little as
35 g of force can tip a tooth.
3
It is apparent that children vary in
the amount of force applied during sucking. Some suck with a
great deal of intensity, and others essentially rest the digit in their

CHAPTER 27 Oral Habits 387
and superiorly.
6
Certainly, if the teeth are moved, some alveolar
change occurs. Whether this is translated to the skeletal maxilla
is not as well known. In one study a signicantly higher per-
centage of distal step molar relationships in 5 year olds was
noted among digit suckers compared with children with no
sucking habit.
7
Treatment
Timing of treatment must be gauged carefully. If parents or the
child does not want to engage in treatment, it should not be
attempted. e child should be given an opportunity to stop the
habit spontaneously before the permanent teeth erupt. If treatment
is selected as an alternative, it is generally undertaken between the
ages of 4 and 6 years. Delay until the early school-age years allows
for spontaneous discontinuation of the habit by many children,
often through peer pressure at school. As long as the habit is
eliminated before full eruption of the permanent incisors, the
eruption process will spontaneously reduce the overjet and open
bite as the permanent teeth occupy new positions. It is generally
agreed that interception of a digit-sucking habit does no harm to
the child’s emotional development, nor does it result in habit
substitution. However, the dentist should evaluate the child for
psychological overtones before embarking on habit elimination.
Such procedures might best be postponed for children who have
recently undergone stressful changes in their lives, such as a new
sibling, separation or divorce of parents, moving to a new com-
munity, or changing schools. Four dierent approaches to treatment
have been advocated, depending on the willingness of the child
to stop the habit. It is important to select the approach that is age
appropriate and acceptable to parents to increase the odds of
successful treatment.
Counseling
e simplest yet least widely applicable approach is counseling
with the patient. is involves discussion between the dentist and
the patient of the problems created by nonnutritive sucking. ese
adult-like discussions focus on the changes that have occurred
because of the sucking and their impact on esthetics. Usually an
appeal is made to the children on the basis of their maturity and
responsibility. Clearly, this approach is best aimed at older children
who can conceptually grasp the issue and who may be feeling
social pressure to stop the habit. Some children are captured by
this approach and successfully eliminate their habit.
Reminder Therapy
e second approach, reminder therapy, is appropriate for those
who desire to stop the habit but need some help. e purpose of
any treatment should be thoroughly explained to the child. An
adhesive bandage secured with waterproof tape on the oending
nger can serve as a constant reminder not to place the nger in
the mouth (Fig. 27.4). e bandage remains in place until the
habit is extinguished. ere are some parents who are reluctant
to use the bandage as a reminder. ey are concerned that it may
come o during sleep and the child may swallow or aspirate the
bandage. erefore some clinicians use a mitten or a tube sock to
cover the ngers of the hand. is is especially useful during sleeping
hours. Other commercial products such as shirts that cover the
hand or plastic sleeves that cover the thumb are available. Another
approach is to paint a commercially available bitter substance on
the ngers that are sucked. However, sometimes this type of therapy
is perceived as punishment and may not be as eective as a neutral
Figure 27.1 This patient exhibits a right maxillary posterior crossbite.
A posterior crossbite is often the side effect of a thumb or pacier habit
because the tongue is displaced inferiorly and the orbicularis oris and
buccinator muscles exert a force on the upper teeth. When there is no
counterbalancing force from the tongue, the upper arch falls into
crossbite.
Figure 27.2 This patient’s anterior open bite is a direct result of an
active thumb sucking habit. An open bite results when the thumb impedes
eruption of the anterior teeth, moves them facially, and allows the posterior
teeth to erupt passively. Actual intrusion of the anterior teeth is possible
but unlikely.
Figure 27.3 With most thumb-sucking habits, the thumb exerts pres-
sure on the lingual surface of the maxillary incisors and on the facial
surface of the mandibular incisors. This causes the maxillary incisors to
tip facially and the mandibular incisors to tip lingually, resulting in increased
overjet.

388 Part 3 The Primary Dentition Years: Three to Six Years
An intraoral appliance approach can also be used in the adjunct
method. e two appliances used most often to discourage the
sucking habit are the quad helix and the palatal crib. e quad
helix is a xed appliance commonly used to expand a constricted
maxillary arch—a common nding accompanied by posterior
crossbite in patients who practice nonnutritive sucking (Fig. 27.6).
e helices of the appliance serve to remind the child not to place
the nger in the mouth if they are placed in the area where the
child places the thumb when sucking. e quad helix is a versatile
appliance because it can correct a posterior crossbite and discourage
a nger habit at the same time.
Figure 27.4 One or two adhesive bandages can be taped to a child’s
nger to serve as a reminder not to place the nger in the mouth. The
bandage is worn until the child stops sucking the nger.
Figure 27.5 A personalized calendar can be used to motivate a child
to stop a thumb sucking habit. Stick-on stars are applied to the calendar
on days when the child has successfully avoided the habit. At the end of
a month or a specied period of time, a reward and verbal praise can be
provided for discontinuing the habit.
Figure 27.6 The quad helix is a xed appliance used to expand a
constricted maxillary arch. The anterior helices also discourage a sucking
habit by reminding the child not to place a nger in the mouth. This appli-
ance is often used in children in whom there is an active sucking habit
and a posterior crossbite.
reminder. In conclusion, reminder therapy works by changing the
sucking sensation enjoyed by the child.
Reward System
A third treatment for oral habits is a reward system. A contract is
drawn up between the child and the parent or between the child
and the dentist. e contract simply states that the child will
discontinue the habit within a specied period of time and in
return will receive a reward. e reward does not need to be
extravagant but must be special enough to motivate the child.
Praise from the parents and dentist has a large role. e more
involvement the child takes in the project, the more likely it is
that the project will succeed. Involvement may include placing
stickers on a homemade calendar when the child has successfully
avoided the habit for a specied period of time, for example, an
afternoon or an entire day. At the end of the specied time period,
the reward is presented with verbal praise for meeting the conditions
of the contract (Fig. 27.5). e reward system is less successful if
the child uses the habit to fall asleep. Reward systems and reminder
therapy are often combined to improve the likelihood of success.
Adjunctive Therapy
If the habit persists after reminder and reward therapy and the
child truly wants to eliminate the habit, adjunctive therapy that
includes a method to physically interrupt the habit and remind
the patient can be used. is type of treatment usually involves
restraining the patients arm in an elastic bandage or some equivalent
so it cannot be exed and the hand brought to the mouth.
8
Another
treatment is to place an appliance in the mouth that physically
discourages the habit by making it dicult to suck a thumb or
nger. e dentist should explain to the patient and parent that
the appliance is not a punishment but rather a permanent reminder
not to place the nger in the mouth.
e elastic bandage method is usually applied only at night.
e bandage is snugly, but not tightly, wrapped over the arm
extending from below the elbow to above it. e elasticity of the
material (not the tightness) straightens the child’s arm as he falls
asleep and removes the thumb from the mouth, preventing him
from engaging in the habit while sleeping. Success over several
weeks should be rewarded. e total program may take 6 to 8
weeks (anecdotally noted by success in children who have stopped
habits while arms were casted for broken bones).

CHAPTER 27 Oral Habits 389
is doing with the habit and to encourage the patient if indicated.
e palatal crib usually stops the child from sucking immediately
but requires at least another 6 months of wear to extinguish the
habit completely.
11
e quad helix also requires a minimum of 6
months of treatment. ree months is needed to correct the
crossbite, and 3 months is required to stabilize the movement. A
retrospective study of the Bluegrass appliance determined three of
four patients stopped their habit at 36 weeks.
11
Pacier Habits
Dental changes created by pacier habits are largely similar to
changes created by thumb habits (Fig. 27.9). Anterior open bite
and maxillary constriction (with posterior crossbite) occur consis-
tently in children who suck paciers. Labial movement of the
maxillary incisors may not be as pronounced as that accompanying
a digit habit. Manufacturers have developed paciers that they
claim are more like a mothers nipple and not as deleterious to
the dentition as a thumb or conventional pacier. Research results
have not substantiated this statement.
8,12,13
Increased duration of
pacier habits is related to an increased prevalence of anterior open
bite and reduced overbite and posterior crossbite.
6
It appears the
e palatal crib is designed to interrupt a digit habit by interfer-
ing with nger placement and sucking satisfaction. e palatal
crib is generally used in children in whom no posterior crossbite
exists. However, it may also be used as a retainer after maxillary
expansion with a quad helix in a child who has not stopped sucking
with the quad helix. For a palatal crib, bands are tted on the
permanent rst molars or primary second molars. A heavy lingual
arch wire (0.038 inches minimum) is bent to t passively in the
palate and is soldered to the molar bands. Additional wire is soldered
onto this base wire to form a crib or mechanical obstruction for
the digit. It is advisable to make a lower cast at the time the
appliance is constructed so that the occlusion can be checked for
interferences (Fig. 27.7). e parent and child should be informed
that certain side eects appear temporarily after the palatal crib is
cemented. Eating, speaking, and sleeping patterns may be altered
during the rst few days after appliance delivery. ese diculties
usually subside within 3 days to 2 weeks. If the child is informed
that the appliance is strictly a helpful reminder and not punishment,
psychological implications of ending the habit are not an issue.
9
An imprint of the appliance usually appears on the tongue as an
indentation. is imprint may persist for up to 1 year after the
appliance is removed. e major problem with the palatal crib
and, to a lesser degree, the quad helix is the diculty of maintaining
good oral hygiene. e appliance traps food and is dicult to
clean thoroughly. Oral malodor and tissue inammation can result.
Other appliances have been suggested to accomplish results
similar to the quad helix and the palatal crib. e Bluegrass appliance
places a Teon roller in the most superior area of the palate and
in the same general area as a Nance arch. e appliance is easier
to clean, is less disruptive to eating and speech, and is reported to
be as eective as a crib in discontinuing a habit.
10
e patient is
encouraged to use the tongue to turn the roller, with the idea that
the act of turning will act as a competing habit and decrease the
need to suck a thumb or nger for oral gratication. e other
advantage of the Bluegrass appliance is that it can be combined
with a W arch to correct a transverse constriction if it is present
(Fig. 27.8).
Adjunctive habit discouragement appliances should be left in
the mouth for 6 to 12 months. e clinician should have the
patient return at 1- or 2-month intervals to monitor how the child
Figure 27.7 A palatal crib is a xed appliance designed to stop a digit
habit by mechanically interfering with digit placement and sucking satis-
faction. The parent of the child should expect temporary disturbances in
eating, speaking, and sleeping patterns during the rst few days after use
of the appliance.
Figure 27.8 This Bluegrass appliance has been combined with a W
arch to create an appliance that will help to stop a digit habit and at the
same time correct the posterior constriction that has resulted from the
habit. The Teon roller is placed in the anterior portion of the palate to
disrupt the habit and allow the tongue to turn the roller.
Figure 27.9 A pacier can create dental changes that are nearly identi-
cal to those of a digit habit. The labiolingual movement of the incisors is
usually not as pronounced as that associated with a digit habit.

390 Part 3 The Primary Dentition Years: Three to Six Years
infected. Treatment in the dental setting is palliative; with referral
for cognitive behavioral therapy as an appropriate intervention for
more severe cases.
Milder forms of lip biting and the related habit of lip sucking
generally do not cause dental problems but certainly can maintain
an existing malocclusion if the child engages in them with adequate
intensity, frequency, and duration. Whether these habits can create
a malocclusion is a question that is not easily answered. e most
common presentation of lip sucking is the lower lip tucked behind
the maxillary incisors (Fig. 27.11). is places a lingually directed
force on the mandibular teeth and a facial force on the maxillary
teeth. e result is a proclination of the maxillary incisors, a
retroclination of the mandibular incisors, and increased overjet.
is problem is most common in the mixed and permanent
dentitions. Treatment depends on the skeletal relationship of the
child and on the presence or absence of space in the arch. If the
child has a class I skeletal relationship and an increased overjet
that is solely the result of tipped teeth, the clinician can tip the
teeth to their original or a more normal position with either a
xed or a removable appliance. If a class II skeletal relationship
exists, a more involved growth modication procedure is needed
to manage the malocclusion.
Tongue Thrust
Tongue thrust has been dicult to dene as a habit. Review of
the literature reveals dierent meanings, with some using the term
tongue thrust” to describe a passive anterior posture of the tongue
and others describing an active thrust of the tongue forward on
swallowing. e latter is often specically described as an atypical
swallow,
3
which can be further categorized as primary, with psy-
chological origins for persistence, or secondary, with associated
physical features.
16
e atypical swallow pattern is considered to be normal during
the early period of development. e tongue thrust characteristic
of the infantile swallow decreases between 12 and 15 months as
the primary molars erupt.
17
Between ages 3 and 5, prevalence can
decrease from 55% to 35%, with prevalence between 5% and
15% reported for older children and adults.
18
When the atypical
longer the habit persists, the greater the odds for open bite and
posterior crossbite become. ere are minimal changes after 18
months of use, but changes become more pronounced after 36
months of use. Pediatricians and pediatric dentists should counsel
parents about discontinuing the pacier habit between 18 and 36
months.
14
Pacier habits appear to end earlier than digit habits. More
than 90% were reported to end before 5 years of age and 100%
by age 8.
9
Pacier habits theoretically are easier to stop than digit
habits because the pacifier can be discontinued gradually or
completely withdrawn with discussion and explanation to the child.
is type of control is obviously not possible with digit habits,
which makes a notable dierence in the degree of patient compliance
required to eliminate the two types of habits. In a few cases the
child may stop the pacier habit and then start sucking a digit.
Elimination of the subsequent nger habit may be necessary.
Several reports have demonstrated a relationship between early
use of paciers and a reduced risk of sudden infant death syndrome
(SIDS) in infants. A meta-analysis study supported the use of
paciers during sleep.
15
e clinician should be prepared to discuss
the role of the pacier with parents in reducing SIDS. Early pacier
use may be benecial, but the infant should be weaned from the
pacier around 18 to 36 months to prevent dental changes.
Lip Habits
Habits that involve manipulation of the lips and perioral structures
are called lip habits. ose that might come to the attention of
the dental professional are lip licking, lip biting, and lip sucking.
e inuence of each on the oral structures is varied, with eects
on either soft tissues or malocclusion.
Lip licking is a relatively benign habit as far as dental eects
are concerned. Red, inamed, and chapped lips and perioral tissues
are the most apparent signs associated with lip licking (Fig. 27.10).
e condition increases in frequency during the dry winter season
and is known as lip licking dermatitis. Little can be done to stop
this habit eectively. Treatment is usually palliative and limited to
moisturizing the lips, although some clinicians have used appliances
to interrupt the habits.
Lip biting is included in the group of habits known as body-
focused repetitive behaviors.
4
ese habits have unknown causes,
with possible genetic or neurobiologic origins, and are estimated
to occur in 3% of adults in the United States. e most common
outcome of lip biting, and the related behavior of cheek biting,
is hyperkeratosis or ulcerations and sores, which can become
Figure 27.10 Red, inamed, chapped lips and perioral tissues are
often indicative of a lip sucking or licking habit. These problems are more
common and severe during the winter months.
Figure 27.11 The most common habit involving the lips is tucking the
lower lip behind the maxillary incisors. The lower lip forces the maxillary
teeth facially and the mandibular teeth lingually, resulting in an increased
overjet. In addition, the lower lip and other perioral tissues can become
chapped and inamed as a result of constant wetting.

CHAPTER 27 Oral Habits 391
transitional developmental nding. In children younger than age
8, the percentage of mouth breathers is approximately equivalent
to the percentage of nasal breathers. After age 8, 35% of those
without obvious allergic rhinitis or nasal congestion can continue
to be mouth breathers.
24
Other studies suggest that the prevalence
of habitual mouth breathing without clear signs of airway obstruc-
tion is between 9% and 10%.
24,25
However, many children are
mouth breathers because of a suspected nasal airway obstruction,
with one study indicating a 72% prevalence of mouth breathing
due to tonsil or adenoid obstruction and 19% due to allergic
rhinitis.
25
In terms of the impact of mouth breathing on oral health, an
association with gingival inammation has been well established.
22
However, the association between mouth breathing and malocclusion
is more complex. ere is certainly a stereotype of “adenoid facies
associated with individuals with nasal obstruction, consisting of
anterior open bite, constricted maxilla, and a class II malocclusion.
And although there is a higher prevalence of these occlusal ndings
in children with nasal obstruction, the majority of children with
airway issues do not t the stereotype, suggesting that mouth
breathing may have an environmental inuence on those genetically
susceptible to the hyperdivergent/dolichofacial, constricted, ret-
rognathic growth pattern.
25
For the dental professional, the most important thing to consider
when encountering a child with a tendency toward mouth breathing
is whether the child may be at risk for obstructive sleep apnea
(OSA) or sleep disordered breathing. Upper airway obstruction
that negatively impacts sleep can also aect growth, academic
performance, and behavior.
26,27
ere are also long-term health
consequences to OSA, so appropriate referral and medical manage-
ment are imperative.
Treatment is also complicated and not well reported in the
literature. Some studies have shown that children treated with
adenoidectomy for obstructed airway have shown improvements
both in vertical patterns of growth
28
and in transverse dimensions.
29
However, this does not imply that turbinectomy or adenoidectomy
is required to clear the nasal airway solely to change the facial
growth pattern.
30,31
Recent advances in cone beam computed
tomography (CBCT) may provide more answers to the relationship
among craniofacial morphology, airway size, and function.
32
Nail Biting
Nail biting (onychophagia), like lip biting, is often included among
the body-focused repetitive behaviors, with a prevalence estimated
between 20% and 30% of the general population.
19
It has been
suggested that the habit is a manifestation of increased stress.
Management may include habit counseling or even referral for
behavior therapy. It is a rare habit in persons younger than 4 years.
e incidence increases in the 4- to 6-year age group and continues
to increase until adolescence.
33
e proportion of males to females
is relatively equal up to age 10 years, but then male nail biters are
predominant.
16,34,35
ere have been suggestions that nail biting may
be related to incisor malocclusion, but bacterial infections, gingivitis,
and minor enamel fractures are more commonly associated.
34,35
ere is no recommended protocol for the dental professional
to address nail biting because dental complications are so mild.
Bruxism
Bruxism involves clenching or grinding of the teeth in repetitive jaw
movements. Although it can occur throughout the day, it is usually
swallow is observed in older children and adults, it is often associated
with prolonged breastfeeding, short frenulum, hypertrophic adenoids
and tonsils, oral breathing, allergic rhinitis, and abnormal head
lower jaw, and tongue posture.
18
Nonnutritive sucking habits beyond
the age of 5 have also been associated with atypical swallowing
patterns for 6- to 9-year-old children.
3,19
In terms of malocclusion, tongue thrust has been correlated
with posterior crossbite, open bite, and excess overjet.
18
ere is
no evidence suggesting that the atypical swallow causes malocclusion,
with the frequency, duration, and force magnitude of the thrust
insucient to result in tooth movement.
20
Furthermore, epide-
miologic data indicate that the percentage of persons with infantile
and transitional swallowing patterns is greater than the percentage
of persons with open bite,
18,19,21
indicating no simple cause-and-eect
relationship between tongue thrusting and open bite. us atypical
swallow is often thought of as an “opportunistic behavior” that
adapts to the malocclusion rather than being the causative factor.
18,22
e passive anterior resting posture of the tongue is thought to
have a greater inuence on malocclusion than the atypical swallow,
with the anterior open bite most commonly observed.
23
Treatment of tongue thrust varies depending on the origin of
the associated problems. If there is a concurrent nonnutritive sucking
habit or history of mouth breathing, these issues should be managed
rst. Limited or interceptive orthodontics should be considered if
the patient exhibits malocclusion. Myofunctional therapy is often
suggested, but the body of evidence has not yet clearly demonstrated
the eectiveness of the exercises.
22
Mouth Breathing
Mouth breathing is dicult to label as a habit. Some persons may
appear to be mouth breathers because of their mandibular posture
or incompetent lips. It is normal for a 3- to 6-year-old to be slightly
lip incompetent (Fig. 27.12). Mouth breathing may also be a
Figure 27.12 The normal relaxed lip posture in the 3- to 6-year-old
child is for the lips to be slightly apart or incompetent. These children are
often labeled mouth breathers because of this posture, but they may, in
fact, be completely nasal breathers.

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384 Part 3 The Primary Dentition Years: Three to Six Yearstooth is extracted. In the former situation the gingiva must be incised when the appliance is placed if the extraction site has healed. In the latter situation the construction cast must be modied to simulate loss of the primary second molar, but placement in the extraction site at the time of surgery is straightforward. e appliance is constructed very much like the band and loop. e primary rst molar is banded and the loop extended to the former distal contact of the primary second molar. A piece of stainless steel is soldered to the distal end of the loop and placed in the extraction site. e stainless steel extension acts as a guide plane for the permanent rst molar to erupt into proper position and should be positioned 1 mm below the mesial marginal ridge of will be a void in the cement. Next, the band is placed on the clean, dry abutment tooth (teeth), and the excess cement is cleaned. ere are several types of cement from which to choose, but glass ionomer cement is recommended. is type of cement releases uoride over time to protect the tooth from demineralization. e appliance should be checked every 6 months to ensure it still ts properly, cement has not washed out, and the abutment teeth are nonmobile. Eruption of the permanent tooth is an easily recognized indication for removal.e distal shoe has some variation in the process. e appliance can be constructed from an impression taken after removal of the primary second molar or from an impression taken before the ABCED• Figure 26.9 (A) The initial step in fabricating a band and loop device is to t a band on the abutment tooth. Band selection is a trial-and-error procedure and continues until a band can be nearly seated on the tooth with nger pressure. (B) A band pusher is used to seat the band to a nearly ideal position. The dentist should maintain a good nger rest because soft and hard tissue injury can occur if the pusher slips without proper support. (C) Final occlusogingival position is achieved with a band biter. In the maxil-lary arch the band biter should be placed on the distolingual portion of the band for nal positioning. In the mandibular arch the band biter should be placed on the distofacial portion of the band. (D) A properly tted band is seated approximately 1 mm below the mesial and distal marginal ridges. (E) If a tight inter-proximal contact prevents the band from seating properly, orthodontic separators are placed to create space for the band material. The separators are removed within 7 to 10 days, and the band is tted. CHAPTER 26 Space Maintenance in the Primary Dentition 385 the unerupted rst permanent molar in the alveolar bone. After the molar has erupted, the extension can be cut o or a new band and loop appliance can be constructed. To ensure that the stainless steel extension is in the proper position and in close proximity to the permanent rst molar, a periapical radiograph is recommended before the appliance is cemented (Fig. 26.10).An alternative to the two-step process is the prefabricated appli-ance, which comes in band and loop and distal shoe variations. ese are fabricated intraorally and save chairside time and laboratory expense. ere is extra chairside time and equipment needed to t and place the appliances. ese are a practical alternative to the traditional unilateral space maintainers but may lack durability.10SummarySpace maintenance in the primary dentition should be considered in terms of anterior and posterior space loss. Space maintenance • Figure 26.10 A periapical radiograph is recommended before cement-ing the distal shoe appliance to ensure that it is properly positioned in relation to the unerupted permanent rst molar. is generally not required for missing primary incisors but can be placed if esthetic concerns are a factor. Posterior space maintenance is a necessity in this age group and should be undertaken when primary molars are lost prematurely and the space is adequate. e band and loop appliance is used most often; other appliances can be used as dierent situations dictate. Judicious space main-tenance benets the child patient and may prevent future alignment and crowding problems.References1. Prot WR, Fields HW, Sarver DM. Treatment of nonskeletal problems in preadolescent children. In: Contemporary Orthodontics. 5th ed. St Louis: Elsevier; 2012.2. Ngan PH, Fields HW. Orthodontic diagnosis and treatment planning in the primary dentition. ASDC J Dent Child. 1995;62(1):25–33.3. National Institutes of Health, National Institute of Dental and Craniofacial Research. Dental caries (tooth decay) in children (age 2 to 11). https://www.nidcr.nih.gov/DataStatistics/FindDataByTopic/DentalCaries/DentalCariesChildren2to11.htm. Accessed August 16, 2017.4. Centers for Disease Control and Prevention, National Center for Health Statistics. Oral and dental health. https://www.cdc.gov/nchs/fastats/dental.htm. Accessed August 16, 2017.5. Holan G, Needleman HL. Premature loss of primary anterior teeth due to trauma—potential short- and long-term sequelae. Dent Traumatol. 2014;30(2):100–106.6. Law CS. Management of premature primary tooth loss in the child patient. J Calif Dent Assoc. 2013;41(8):612–618.7. Tunison W, Flores-Mir C, ElBadrawy H, et al. Dental arch space changes following premature loss of primary rst molars: a systematic review. Pediatr Dent. 2008;30(4):297–302.8. Reggiardo P. Coding and Insurance Manual: A Comprehensive Resource for Reporting Pediatric Dental Services. Chicago: American Academy of Pediatric Dentistry; 2016.9. Mayhew MJ, Dilley GJ, Dilley DCH, et al. Tissue response to intragingival appliances in monkeys. Pediatr Dent. 1984;6(3):148–152.10. Brill WA. e distal shoe space maintainer chairside fabrication and clinical performance. Pediatr Dent. 2002;24(6):561–565. CHAPTER 26 Space Maintenance in the Primary Dentition 385.e1 Case Study: Ankyloglossia ClassicationAudrey Jung-Sun YoonAnkyloglossia is a broad denition encompassing individuals with decreased tongue mobility caused by a shortened lingual frenulum. The commonly referred “tongue-tie” has been reported to cause breastfeeding difculties, oromyofacial dysfunction, speech problems, swallowing impediments, and predisposition to sleep breathing disorders.1 Systematic reviews show an association between treatment rendered for ankyloglossia and mother-reported improvements in breastfeeding and nipple pain.2,3Some have suggested that ankyloglossia may affect jaw skeletal development during childhood growth.4–7 A simple lingual frenectomy performed early can prevent many undesirable consequences.8 Due to continuing controversies over the diagnostic criteria and management, a systematic assessment should be conducted on each patient to determine treatment needs.9,10Clinical Assessment in the InfantA comprehensive intraoral dental exam should include inspection of the tongue and its function. As the infant cries or extends the tongue, the anterior edge of the tongue should be inspected. While lifting the infant’s tongue, the frenulum should be palpated and its elasticity determined. The attachment of the frenulum to the tongue should be approximately 1 cm posterior to the tip of the tongue. The attachment of frenulum to the inferior alveolar ridge should be inserted proximal or into the genioglossus muslcle.9,11 The Hazelbaker score can be calculated after scoring the appearance and function items.12Clinical Assessment in a Child or AdolescentAn assessment of the lingual frenulum should include position of the muscle insertion and tongue mobility. Two classication systems, developed to help the clinician determine treatment options, may also contribute to long-term studies of nonintervention versus intervention.Tongue Range-of-Motion RatioA simple and quick grading scale of measuring tongue mobility has been developed.121. Maximal interincisal mouth opening (MIO) (in mm) (Fig. E26.1A). Patient is instructed to “open your mouth” (but not as wide as possible).2. Interincisal mouth opening with tongue tip to maxillary incisive papilla at roof of mouth (MOTTIP) (in mm) (see Fig. E26.1B). Patients are instructed to “touch the tip of tongue to the back of the upper two front teeth and open mouth.”3. Tongue range-of-motion ratio (TRMR) (%) calculated as the proportional variance of MOTTIP divided by MIO.The functional ankyloglossia was classied into four categories using TRMR, based on ratios derived from clinical measurement. Grade 1 patients exhibit the greatest range of motion, whereas grade 4 patients are the most restricted (Fig. E26.2).Kotlow Classication“Free tongue” is dened as the length from base of tongue insertion of the lingual frenulum to the tip (in mm) (see Fig. E26.1C). The length of the ventral surface of the tongue is measured from the insertion of the lingual frenulum to the tongue tip. In the Kotlow classication scheme based on the “free tongue” measurement, normal is considered to be greater than 16 mm. Four other classications are based on millimeter measures of the tongue length.13SummaryClinicians should continue to follow the development of ankyloglossia classications used to measure treatment indications and treatment effectiveness. Treatment options for ankyloglossia include observation, speech therapy, frenotomy without anesthesia, and frenectomy and frenuloplasty using a laser, scalpel, or surgical scissors with anesthesia often under general anesthesia,14 based on ndings derived from the classications. This online content will be updated as studies are published.AB C• Figure E26.1 Measuring the tongue function and length using a Quick Tongue-Tie Assessment Tool. (A) Maximal interincisal mouth opening (example: 46 mm). (B) Mouth opening with tongue tip to incisive papilla (example: 34 mm). (C) Kotlow free tongue measurement (Kotlow, example: 16 mm). Continued 385.e2 Part 3 The Primary Dentition Years: Three to Six YearsQuestions1. Why is it important to identify ankyloglossia, especially at an earlier age?Answer: Ankyloglossia, or “tongue-tied,” often leads to varying degrees of oromyfacial dysfunction, breastfeeding difculties, speech and swallowing impediments, and even predisposition to sleep breathing disorders.2. What are two classication systems used for lingual frenulum in a child or adolescent?Answer: a. TRMR grading: TRMR (%) has been developed for measuring tongue mobility. TRMR is calculated as the proportion variance of MOTTIP (interincisal mouth opening with tongue tip to maxillary incisive papilla at roof of mouth) divided by MIO. Based on TRMR, functional ankyloglossia was classied into four categories—grade 1 (TRMR >80%) shows the greatest range of motion, whereas grade 4 (TRMR <25%) shows the most restricted mobility. b. Kotlow classication: “Free tongue” is dened as the length from base of tongue insertion of the lingual frenulum to the tip (in mm). In the Kotlow classication, free tongue greater than 16 mm is considered to be normal. Four other classications are based on millimeter measures of the free tongue length.3. What are the treatment options for ankyloglossia?Answer: Treatment options for ankyloglossia include observation, speech therapy, frenotomy without anesthesia, and frenectomy and frenuloplasty using a laser, scalpel, or surgical scissors often under general anesthesia.References1. Guilleminault C, Huseni S, Lo L. A frequent phenotype for paediatric sleep apnoea: short lingual frenulum. ERJ Open Res. 2016;2(3).2. O’Shea JE, Foster JP, O’Donnell CP, et al. Frenotomy for tongue-tie in newborn infants. Cochrane Database Syst Rev. 2017;(3):CD011065.3. Francis DO, Krishnaswami S, McPheeters M. Treatment of ankyloglossia and breastfeeding outcomes: a systematic review. Pediatrics. 2015;135(6):e1458–e1466.4. Meenakshi S, Jagannathan N. Assessment of lingual frenulum lengths in skeletal malocclusion. J Clin Diagn Res. 2014;8(3):202–204.5. Defabianis P. Ankyloglossia and its inuence on maxillary and mandibular development. (A seven year follow-up case report). Funct Orthod. 1999;17(4):25–33.6. Northcutt ME. The lingual frenum. J Clin Orthod. 2009;43(9):557–565, quiz 581.7. Whitman CL, Rankow RM. Diagnosis and management of ankyloglossia. Am J Orthod Dentofacial Orthop. 1961;47(6):423–428.8. Ballard JL, Auer CE, Khoury JC. Ankyloglossia: assessment, incidence, and effect of frenuloplasty on the breastfeeding dyad. Pediatrics. 2002;110(5):e63.9. Messner AH. Lalakea ML. Ankyloglossia: controversies in management. Int J Pediatr Otorhinolaryngol. 2000;54(2–3):123–131.10. Suter VG, Bornstein MM. Ankyloglossia: facts and myths in diagnosis and treatment. J Periodontol. 2009;80(8):1204–1219.11. Hazelbaker AK. The assessment tool for lingual frenulum function (ATLFF): Use in a lactation consultant private practice. 1993.12. Yoon A, Zaghi S, Weitzman R, et al. Toward a functional denition of ankyloglossia: validating current grading scales for lingual frenulum length and tongue mobility in 1052 subjects. Sleep Breath. 2017;21(3):767–775.13. Kotlow LA. Ankyloglossia (tongue-tie): a diagnostic and treatment quandary. Quintessence Int. 1999;30(4):259–262.14. Kupietzky A, Botzer E. Ankyloglossia in the infant and young child: clinical suggestions for diagnosis and management. Pediatr Dent. 2005;27(1):40–46.Grade 1 functioningTRMR >80%Grade 2 functioningTRMR 50%–80%Grade 3 functioningTRMR <50%Grade 4 functioningTRMR <25%• Figure E26.2 Clinical examples of varying degrees of ankyloglossia categorized by tongue range-of-motion ratio grading (ratio of interincisal mouth opening with tongue tip to maxillary incisive papilla at roof of mouth to maximal interincisal mouth opening). Higher grade indicates decreased tongue mobility and increased severity of compromised tongue function. 386 27 Oral HabitsCLARICE S. LAWCHAPTER OUTLINEThumb and Finger HabitsTreatmentPacier HabitsLip HabitsTongue ThrustMouth BreathingNail BitingBruxismSummarymouth. e frequency of digit sucking throughout a routine day will also have an impact on tooth movement. Clinical experience suggests that 4 to 6 hours of force per day is probably the minimum necessary to cause tooth movement.3 erefore a child who sucks intermittently with high force may not produce much tooth movement at all, whereas a child who sucks with less force but continuously (for more than 6 hours) can cause signicant dental change, which is consistent with the equilibrium theory. However, it is the duration of time sucking (in months and years) that probably plays the most critical role in tooth movement caused by a digit habit.1,2,4,5 e most frequently reported dental outcomes of an active digit habit are the following3:1. Posterior crossbite2. Anterior open bite3. Increased overjetSome studies have also reported dierences in canine and molar relationship, but these are not present with the same frequency.e maxillary arch constriction associated with a posterior crossbite is probably due to the change in equilibrium balance between the oral musculature and the tongue.1,2,4,5 When the thumb is placed in the mouth, the tongue is forced down and away from the palate. e orbicularis oris and buccinator muscles continue to exert a force on the buccal surfaces of the maxillary dentition, especially when these muscles are contracted during sucking. Because the tongue no longer exerts a counterbalancing force from the lingual surface, the posterior maxillary arch collapses into crossbite (Fig. 27.1).Anterior open bite, or the lack of vertical overlap of the upper and lower incisors when the posterior teeth are in occlusion, develops because the digit rests between the maxillary and mandibular incisors (Fig. 27.2). is prevents complete or continued eruption of the incisors, whereas the posterior teeth are free to erupt. Anterior open bite may also be caused by intrusion of the incisors. However, inhibition of eruption is easier to accomplish than true intrusion, which would be the result of a habit of greater duration.Faciolingual movement of the incisors depends on how the thumb or nger is placed and how many ngers are placed in the mouth. Some consider this positional variable to be a confounding factor related to force and duration of the habit. Usually, the thumb is placed so that it exerts pressure on the lingual surfaces of the maxillary incisors and on the labial surfaces of the mandibular incisors (Fig. 27.3). A child who actively sucks can create enough force to tip the upper incisors facially and the lower incisors lingually. e result is an increased overjet and, by virtue of the tipping, decreased overbite.Data on the amount of skeletal change are not clear. Some believe the maxilla and its alveolar process are moved anteriorly The presence of an oral habit in a 3- to 6-year-old child is an important nding during the clinical examination. e most common oral habits—digit and pacier sucking—generally cease spontaneously between 3 and 4 years of age at the beginning of the age range.1 By 6 years of age, most children begin the transition into the permanent dentition, making habit cessation more important. us the 3- to 6-year age range is a very important period for facilitating the transition out of an oral habit. In this chapter, we will consider the various oral habits that may be associated with either malocclusion or oral health.Thumb and Finger Habitsumb and nger habits make up the majority of oral habits. Approximately two-thirds of such habits end by 5 years of age, decreasing from a prevalence of approximately 30% at 12 months of age to approximately 10% at 5 years.2 Dentists are often questioned about the kinds of problems these habits may cause if they are prolonged. e malocclusions caused by nonnutritive sucking may be more of an individual response than a highly specic cause-and-eect relationship. e types of dental changes that a digit habit may cause vary with the amount of force applied to the teeth (force magnitude), the manner in which the digit is positioned in the mouth (force direction), how much time the child engages in the habit (frequency in hours per day), and how long the habit persists (duration in months or years).Research and clinical experience have shown that as little as 35 g of force can tip a tooth.3 It is apparent that children vary in the amount of force applied during sucking. Some suck with a great deal of intensity, and others essentially rest the digit in their CHAPTER 27 Oral Habits 387 and superiorly.6 Certainly, if the teeth are moved, some alveolar change occurs. Whether this is translated to the skeletal maxilla is not as well known. In one study a signicantly higher per-centage of distal step molar relationships in 5 year olds was noted among digit suckers compared with children with no sucking habit.7TreatmentTiming of treatment must be gauged carefully. If parents or the child does not want to engage in treatment, it should not be attempted. e child should be given an opportunity to stop the habit spontaneously before the permanent teeth erupt. If treatment is selected as an alternative, it is generally undertaken between the ages of 4 and 6 years. Delay until the early school-age years allows for spontaneous discontinuation of the habit by many children, often through peer pressure at school. As long as the habit is eliminated before full eruption of the permanent incisors, the eruption process will spontaneously reduce the overjet and open bite as the permanent teeth occupy new positions. It is generally agreed that interception of a digit-sucking habit does no harm to the child’s emotional development, nor does it result in habit substitution. However, the dentist should evaluate the child for psychological overtones before embarking on habit elimination. Such procedures might best be postponed for children who have recently undergone stressful changes in their lives, such as a new sibling, separation or divorce of parents, moving to a new com-munity, or changing schools. Four dierent approaches to treatment have been advocated, depending on the willingness of the child to stop the habit. It is important to select the approach that is age appropriate and acceptable to parents to increase the odds of successful treatment.Counselinge simplest yet least widely applicable approach is counseling with the patient. is involves discussion between the dentist and the patient of the problems created by nonnutritive sucking. ese adult-like discussions focus on the changes that have occurred because of the sucking and their impact on esthetics. Usually an appeal is made to the children on the basis of their maturity and responsibility. Clearly, this approach is best aimed at older children who can conceptually grasp the issue and who may be feeling social pressure to stop the habit. Some children are captured by this approach and successfully eliminate their habit.Reminder Therapye second approach, reminder therapy, is appropriate for those who desire to stop the habit but need some help. e purpose of any treatment should be thoroughly explained to the child. An adhesive bandage secured with waterproof tape on the oending nger can serve as a constant reminder not to place the nger in the mouth (Fig. 27.4). e bandage remains in place until the habit is extinguished. ere are some parents who are reluctant to use the bandage as a reminder. ey are concerned that it may come o during sleep and the child may swallow or aspirate the bandage. erefore some clinicians use a mitten or a tube sock to cover the ngers of the hand. is is especially useful during sleeping hours. Other commercial products such as shirts that cover the hand or plastic sleeves that cover the thumb are available. Another approach is to paint a commercially available bitter substance on the ngers that are sucked. However, sometimes this type of therapy is perceived as punishment and may not be as eective as a neutral • Figure 27.1 This patient exhibits a right maxillary posterior crossbite. A posterior crossbite is often the side effect of a thumb or pacier habit because the tongue is displaced inferiorly and the orbicularis oris and buccinator muscles exert a force on the upper teeth. When there is no counterbalancing force from the tongue, the upper arch falls into crossbite. • Figure 27.2 This patient’s anterior open bite is a direct result of an active thumb sucking habit. An open bite results when the thumb impedes eruption of the anterior teeth, moves them facially, and allows the posterior teeth to erupt passively. Actual intrusion of the anterior teeth is possible but unlikely. • Figure 27.3 With most thumb-sucking habits, the thumb exerts pres-sure on the lingual surface of the maxillary incisors and on the facial surface of the mandibular incisors. This causes the maxillary incisors to tip facially and the mandibular incisors to tip lingually, resulting in increased overjet. 388 Part 3 The Primary Dentition Years: Three to Six YearsAn intraoral appliance approach can also be used in the adjunct method. e two appliances used most often to discourage the sucking habit are the quad helix and the palatal crib. e quad helix is a xed appliance commonly used to expand a constricted maxillary arch—a common nding accompanied by posterior crossbite in patients who practice nonnutritive sucking (Fig. 27.6). e helices of the appliance serve to remind the child not to place the nger in the mouth if they are placed in the area where the child places the thumb when sucking. e quad helix is a versatile appliance because it can correct a posterior crossbite and discourage a nger habit at the same time.• Figure 27.4 One or two adhesive bandages can be taped to a child’s nger to serve as a reminder not to place the nger in the mouth. The bandage is worn until the child stops sucking the nger. • Figure 27.5 A personalized calendar can be used to motivate a child to stop a thumb sucking habit. Stick-on stars are applied to the calendar on days when the child has successfully avoided the habit. At the end of a month or a specied period of time, a reward and verbal praise can be provided for discontinuing the habit. • Figure 27.6 The quad helix is a xed appliance used to expand a constricted maxillary arch. The anterior helices also discourage a sucking habit by reminding the child not to place a nger in the mouth. This appli-ance is often used in children in whom there is an active sucking habit and a posterior crossbite. reminder. In conclusion, reminder therapy works by changing the sucking sensation enjoyed by the child.Reward SystemA third treatment for oral habits is a reward system. A contract is drawn up between the child and the parent or between the child and the dentist. e contract simply states that the child will discontinue the habit within a specied period of time and in return will receive a reward. e reward does not need to be extravagant but must be special enough to motivate the child. Praise from the parents and dentist has a large role. e more involvement the child takes in the project, the more likely it is that the project will succeed. Involvement may include placing stickers on a homemade calendar when the child has successfully avoided the habit for a specied period of time, for example, an afternoon or an entire day. At the end of the specied time period, the reward is presented with verbal praise for meeting the conditions of the contract (Fig. 27.5). e reward system is less successful if the child uses the habit to fall asleep. Reward systems and reminder therapy are often combined to improve the likelihood of success.Adjunctive TherapyIf the habit persists after reminder and reward therapy and the child truly wants to eliminate the habit, adjunctive therapy that includes a method to physically interrupt the habit and remind the patient can be used. is type of treatment usually involves restraining the patient’s arm in an elastic bandage or some equivalent so it cannot be exed and the hand brought to the mouth.8 Another treatment is to place an appliance in the mouth that physically discourages the habit by making it dicult to suck a thumb or nger. e dentist should explain to the patient and parent that the appliance is not a punishment but rather a permanent reminder not to place the nger in the mouth.e elastic bandage method is usually applied only at night. e bandage is snugly, but not tightly, wrapped over the arm extending from below the elbow to above it. e elasticity of the material (not the tightness) straightens the child’s arm as he falls asleep and removes the thumb from the mouth, preventing him from engaging in the habit while sleeping. Success over several weeks should be rewarded. e total program may take 6 to 8 weeks (anecdotally noted by success in children who have stopped habits while arms were casted for broken bones). CHAPTER 27 Oral Habits 389 is doing with the habit and to encourage the patient if indicated. e palatal crib usually stops the child from sucking immediately but requires at least another 6 months of wear to extinguish the habit completely.11 e quad helix also requires a minimum of 6 months of treatment. ree months is needed to correct the crossbite, and 3 months is required to stabilize the movement. A retrospective study of the Bluegrass appliance determined three of four patients stopped their habit at 36 weeks.11Pacier HabitsDental changes created by pacier habits are largely similar to changes created by thumb habits (Fig. 27.9). Anterior open bite and maxillary constriction (with posterior crossbite) occur consis-tently in children who suck paciers. Labial movement of the maxillary incisors may not be as pronounced as that accompanying a digit habit. Manufacturers have developed paciers that they claim are more like a mother’s nipple and not as deleterious to the dentition as a thumb or conventional pacier. Research results have not substantiated this statement.8,12,13 Increased duration of pacier habits is related to an increased prevalence of anterior open bite and reduced overbite and posterior crossbite.6 It appears the e palatal crib is designed to interrupt a digit habit by interfer-ing with nger placement and sucking satisfaction. e palatal crib is generally used in children in whom no posterior crossbite exists. However, it may also be used as a retainer after maxillary expansion with a quad helix in a child who has not stopped sucking with the quad helix. For a palatal crib, bands are tted on the permanent rst molars or primary second molars. A heavy lingual arch wire (0.038 inches minimum) is bent to t passively in the palate and is soldered to the molar bands. Additional wire is soldered onto this base wire to form a crib or mechanical obstruction for the digit. It is advisable to make a lower cast at the time the appliance is constructed so that the occlusion can be checked for interferences (Fig. 27.7). e parent and child should be informed that certain side eects appear temporarily after the palatal crib is cemented. Eating, speaking, and sleeping patterns may be altered during the rst few days after appliance delivery. ese diculties usually subside within 3 days to 2 weeks. If the child is informed that the appliance is strictly a helpful reminder and not punishment, psychological implications of ending the habit are not an issue.9 An imprint of the appliance usually appears on the tongue as an indentation. is imprint may persist for up to 1 year after the appliance is removed. e major problem with the palatal crib and, to a lesser degree, the quad helix is the diculty of maintaining good oral hygiene. e appliance traps food and is dicult to clean thoroughly. Oral malodor and tissue inammation can result.Other appliances have been suggested to accomplish results similar to the quad helix and the palatal crib. e Bluegrass appliance places a Teon roller in the most superior area of the palate and in the same general area as a Nance arch. e appliance is easier to clean, is less disruptive to eating and speech, and is reported to be as eective as a crib in discontinuing a habit.10 e patient is encouraged to use the tongue to turn the roller, with the idea that the act of turning will act as a competing habit and decrease the need to suck a thumb or nger for oral gratication. e other advantage of the Bluegrass appliance is that it can be combined with a W arch to correct a transverse constriction if it is present (Fig. 27.8).Adjunctive habit discouragement appliances should be left in the mouth for 6 to 12 months. e clinician should have the patient return at 1- or 2-month intervals to monitor how the child • Figure 27.7 A palatal crib is a xed appliance designed to stop a digit habit by mechanically interfering with digit placement and sucking satis-faction. The parent of the child should expect temporary disturbances in eating, speaking, and sleeping patterns during the rst few days after use of the appliance. • Figure 27.8 This Bluegrass appliance has been combined with a W arch to create an appliance that will help to stop a digit habit and at the same time correct the posterior constriction that has resulted from the habit. The Teon roller is placed in the anterior portion of the palate to disrupt the habit and allow the tongue to turn the roller. • Figure 27.9 A pacier can create dental changes that are nearly identi-cal to those of a digit habit. The labiolingual movement of the incisors is usually not as pronounced as that associated with a digit habit. 390 Part 3 The Primary Dentition Years: Three to Six Yearsinfected. Treatment in the dental setting is palliative; with referral for cognitive behavioral therapy as an appropriate intervention for more severe cases.Milder forms of lip biting and the related habit of lip sucking generally do not cause dental problems but certainly can maintain an existing malocclusion if the child engages in them with adequate intensity, frequency, and duration. Whether these habits can create a malocclusion is a question that is not easily answered. e most common presentation of lip sucking is the lower lip tucked behind the maxillary incisors (Fig. 27.11). is places a lingually directed force on the mandibular teeth and a facial force on the maxillary teeth. e result is a proclination of the maxillary incisors, a retroclination of the mandibular incisors, and increased overjet. is problem is most common in the mixed and permanent dentitions. Treatment depends on the skeletal relationship of the child and on the presence or absence of space in the arch. If the child has a class I skeletal relationship and an increased overjet that is solely the result of tipped teeth, the clinician can tip the teeth to their original or a more normal position with either a xed or a removable appliance. If a class II skeletal relationship exists, a more involved growth modication procedure is needed to manage the malocclusion.Tongue ThrustTongue thrust has been dicult to dene as a habit. Review of the literature reveals dierent meanings, with some using the term “tongue thrust” to describe a passive anterior posture of the tongue and others describing an active thrust of the tongue forward on swallowing. e latter is often specically described as an atypical swallow,3 which can be further categorized as primary, with psy-chological origins for persistence, or secondary, with associated physical features.16e atypical swallow pattern is considered to be normal during the early period of development. e tongue thrust characteristic of the infantile swallow decreases between 12 and 15 months as the primary molars erupt.17 Between ages 3 and 5, prevalence can decrease from 55% to 35%, with prevalence between 5% and 15% reported for older children and adults.18 When the atypical longer the habit persists, the greater the odds for open bite and posterior crossbite become. ere are minimal changes after 18 months of use, but changes become more pronounced after 36 months of use. Pediatricians and pediatric dentists should counsel parents about discontinuing the pacier habit between 18 and 36 months.14Pacier habits appear to end earlier than digit habits. More than 90% were reported to end before 5 years of age and 100% by age 8.9 Pacier habits theoretically are easier to stop than digit habits because the pacifier can be discontinued gradually or completely withdrawn with discussion and explanation to the child. is type of control is obviously not possible with digit habits, which makes a notable dierence in the degree of patient compliance required to eliminate the two types of habits. In a few cases the child may stop the pacier habit and then start sucking a digit. Elimination of the subsequent nger habit may be necessary.Several reports have demonstrated a relationship between early use of paciers and a reduced risk of sudden infant death syndrome (SIDS) in infants. A meta-analysis study supported the use of paciers during sleep.15 e clinician should be prepared to discuss the role of the pacier with parents in reducing SIDS. Early pacier use may be benecial, but the infant should be weaned from the pacier around 18 to 36 months to prevent dental changes.Lip HabitsHabits that involve manipulation of the lips and perioral structures are called lip habits. ose that might come to the attention of the dental professional are lip licking, lip biting, and lip sucking. e inuence of each on the oral structures is varied, with eects on either soft tissues or malocclusion.Lip licking is a relatively benign habit as far as dental eects are concerned. Red, inamed, and chapped lips and perioral tissues are the most apparent signs associated with lip licking (Fig. 27.10). e condition increases in frequency during the dry winter season and is known as lip licking dermatitis. Little can be done to stop this habit eectively. Treatment is usually palliative and limited to moisturizing the lips, although some clinicians have used appliances to interrupt the habits.Lip biting is included in the group of habits known as body-focused repetitive behaviors.4 ese habits have unknown causes, with possible genetic or neurobiologic origins, and are estimated to occur in 3% of adults in the United States. e most common outcome of lip biting, and the related behavior of cheek biting, is hyperkeratosis or ulcerations and sores, which can become • Figure 27.10 Red, inamed, chapped lips and perioral tissues are often indicative of a lip sucking or licking habit. These problems are more common and severe during the winter months. • Figure 27.11 The most common habit involving the lips is tucking the lower lip behind the maxillary incisors. The lower lip forces the maxillary teeth facially and the mandibular teeth lingually, resulting in an increased overjet. In addition, the lower lip and other perioral tissues can become chapped and inamed as a result of constant wetting. CHAPTER 27 Oral Habits 391 transitional developmental nding. In children younger than age 8, the percentage of mouth breathers is approximately equivalent to the percentage of nasal breathers. After age 8, 35% of those without obvious allergic rhinitis or nasal congestion can continue to be mouth breathers.24 Other studies suggest that the prevalence of habitual mouth breathing without clear signs of airway obstruc-tion is between 9% and 10%.24,25 However, many children are mouth breathers because of a suspected nasal airway obstruction, with one study indicating a 72% prevalence of mouth breathing due to tonsil or adenoid obstruction and 19% due to allergic rhinitis.25In terms of the impact of mouth breathing on oral health, an association with gingival inammation has been well established.22 However, the association between mouth breathing and malocclusion is more complex. ere is certainly a stereotype of “adenoid facies” associated with individuals with nasal obstruction, consisting of anterior open bite, constricted maxilla, and a class II malocclusion. And although there is a higher prevalence of these occlusal ndings in children with nasal obstruction, the majority of children with airway issues do not t the stereotype, suggesting that mouth breathing may have an environmental inuence on those genetically susceptible to the hyperdivergent/dolichofacial, constricted, ret-rognathic growth pattern.25For the dental professional, the most important thing to consider when encountering a child with a tendency toward mouth breathing is whether the child may be at risk for obstructive sleep apnea (OSA) or sleep disordered breathing. Upper airway obstruction that negatively impacts sleep can also aect growth, academic performance, and behavior.26,27 ere are also long-term health consequences to OSA, so appropriate referral and medical manage-ment are imperative.Treatment is also complicated and not well reported in the literature. Some studies have shown that children treated with adenoidectomy for obstructed airway have shown improvements both in vertical patterns of growth28 and in transverse dimensions.29 However, this does not imply that turbinectomy or adenoidectomy is required to clear the nasal airway solely to change the facial growth pattern.30,31 Recent advances in cone beam computed tomography (CBCT) may provide more answers to the relationship among craniofacial morphology, airway size, and function.32Nail BitingNail biting (onychophagia), like lip biting, is often included among the body-focused repetitive behaviors, with a prevalence estimated between 20% and 30% of the general population.19 It has been suggested that the habit is a manifestation of increased stress. Management may include habit counseling or even referral for behavior therapy. It is a rare habit in persons younger than 4 years. e incidence increases in the 4- to 6-year age group and continues to increase until adolescence.33 e proportion of males to females is relatively equal up to age 10 years, but then male nail biters are predominant.16,34,35 ere have been suggestions that nail biting may be related to incisor malocclusion, but bacterial infections, gingivitis, and minor enamel fractures are more commonly associated.34,35 ere is no recommended protocol for the dental professional to address nail biting because dental complications are so mild.BruxismBruxism involves clenching or grinding of the teeth in repetitive jaw movements. Although it can occur throughout the day, it is usually swallow is observed in older children and adults, it is often associated with prolonged breastfeeding, short frenulum, hypertrophic adenoids and tonsils, oral breathing, allergic rhinitis, and abnormal head lower jaw, and tongue posture.18 Nonnutritive sucking habits beyond the age of 5 have also been associated with atypical swallowing patterns for 6- to 9-year-old children.3,19In terms of malocclusion, tongue thrust has been correlated with posterior crossbite, open bite, and excess overjet.18 ere is no evidence suggesting that the atypical swallow causes malocclusion, with the frequency, duration, and force magnitude of the thrust insucient to result in tooth movement.20 Furthermore, epide-miologic data indicate that the percentage of persons with infantile and transitional swallowing patterns is greater than the percentage of persons with open bite,18,19,21 indicating no simple cause-and-eect relationship between tongue thrusting and open bite. us atypical swallow is often thought of as an “opportunistic behavior” that adapts to the malocclusion rather than being the causative factor.18,22 e passive anterior resting posture of the tongue is thought to have a greater inuence on malocclusion than the atypical swallow, with the anterior open bite most commonly observed.23Treatment of tongue thrust varies depending on the origin of the associated problems. If there is a concurrent nonnutritive sucking habit or history of mouth breathing, these issues should be managed rst. Limited or interceptive orthodontics should be considered if the patient exhibits malocclusion. Myofunctional therapy is often suggested, but the body of evidence has not yet clearly demonstrated the eectiveness of the exercises.22Mouth BreathingMouth breathing is dicult to label as a habit. Some persons may appear to be mouth breathers because of their mandibular posture or incompetent lips. It is normal for a 3- to 6-year-old to be slightly lip incompetent (Fig. 27.12). Mouth breathing may also be a • Figure 27.12 The normal relaxed lip posture in the 3- to 6-year-old child is for the lips to be slightly apart or incompetent. These children are often labeled mouth breathers because of this posture, but they may, in fact, be completely nasal breathers. 392 Part 3 The Primary Dentition Years: Three to Six Yearsduring the mixed-dentition years, the adverse dental changes will begin to reverse naturally. Appliance therapy may be required, but generally the teeth will move toward a more neutral position with the absence of the forces of the habit. If no dental changes have occurred, no treatment can be advocated on the grounds of dental health, but some patients and parents may want treatment because digit or pacier habits become less socially acceptable as the child becomes older. e most important point to remember about any intervention is that the child must want to discontinue the habit for treatment to be successful.Lip habits are not likely to be as prevalent during the primary dentition stage but may be observed as children transition into the mixed dentition stage. ese habits generally do not have harmful oral eects nor inuence malocclusion but in rare cases may be signs of psychological issues requiring interprofessional consultation.Tongue thrust and mouth breathing may be commonly observed during the primary dentition period as normal developmental ndings, but as children transition into the mixed dentition, these habits may be signs of other issues. Tongue thrust might indicate a myofunctional issue or malocclusion that should be addressed. Mouth breathing may be a sign of airway obstruction that could have negative health and growth eects and should also be addressed through interprofessional consultation.Nail biting and bruxism have variable prevalence rates in the primary dentition. Neither habit is expected to have an impact on occlusion or tooth position, but both may aect the integrity of the teeth. Nail biting should be addressed with habit cessation counseling, and bruxism is generally expected to decrease in most cases.References1. Silva M, Manton D. Oral habits—part 1: the dental eects and management of nutritive and non-nutritive sucking. J Dent Child. 2014;81(3):133–139.2. Bishara SE, Warren JJ, Brott B, et al. Changes in the prevalence of nonnutritive sucking patterns in the rst 8 years of life. Am J Orthod Dentofacial Orthop. 2006;130(1):31–36.3. Prot WR, Fields HW, Sarver DM. Contemporary Orthodontics. 5th ed. St Louis: Elsevier; 2012.4. Dogramaci EJ, Rossi-Fedele G. Establishing the association between nonnutritive sucking behavior and malocclusions: a systematic review and meta-analysis. J Am Dent Assoc. 2016;147(12):926–934.e6.5. Duncan K, McNamara C, Ireland AJ, et al. Sucking habits in childhood and the eects on the primary dentition: ndings of the Avon Longitudinal Study of Pregnancy and Childhood. Int J Paediatr Dent. 2008;18(3):178–188.6. Larsson E. Dummy- and nger-sucking habits with special attention to their signicance for facial growth and occlusion: 4. Eect on facial growth and occlusion. Swed Dent J. 1972;65:605–634.7. Fukata O, Braham RL, Yokoi K, et al. Damage to the primary dentition resulting from thumb and nger (digit) sucking. ASDC J Dent Child. 1996;63:403–408.8. Adair SM. e Ace Bandage approach to digit-sucking habits. Pediatr Dent. 1999;21:451–452.9. Haryett RD, Hansen FC, Davidson PO. Chronic thumb-sucking: a second report on treatment and its psychological eects. Am J Orthod Dentofacial Orthop. 1970;57:164–178.10. Haskell BS, Mink JR. An aid to stop thumb sucking: the “Bluegrass” appliance. Pediatr Dent. 1991;13(2):83–85.11. Greenleaf S, Mink JR. A retrospective study of the use of the Bluegrass appliance in the cessation of thumb habits. Pediatr Dent. 2003;25(6):587–590.reported to occur during sleep in children. Most children engage in some bruxism that can result in moderate wear of the primary canines and molars. Rarely, with the exception of developmentally disabled persons, does the wear endanger the pulp by proceeding faster than secondary dentin is produced (Fig. 27.13). Masticatory muscle soreness and temporomandibular joint pain have also been attributed to bruxism. e exact cause of signicant bruxism is unknown. Inuences are multifactorial, with central nervous system activity, genetics, and psychosocial factors under investigation.35 Traditional explanations center on local, systemic, and psychological factors.34–36 e local theory suggests that bruxism is a reaction to an occlusal interference, high restoration, or some irritating dental condition. Systemic factors implicated in bruxism include intestinal parasites, subclinical nutritional deciencies, allergies, and endocrine disorders. e psychological theory submits that bruxism is the manifestation of a personality disorder or increased stress. However, these attributions have been demonstrated only in children older than 6 years. ere is no evidence that sleep bruxism and psychosocial factors are related in children younger than 5.37 Children with musculoskeletal disorders (cerebral palsy) and severely developmentally disabled children commonly grind their teeth. ese patients’ bruxism is the result of their underlying physical and mental condition and is dicult to manage dentally.Treatment for those with marked abrasion or persistent parents could be attempted with a “boil and bite” mouth guard that is inexpensive to purchase and remoldable as the dentition rapidly changes during the mixed dentition years. If this intervention is not successful, referral to appropriate medical personnel should be considered to rule out any systemic problems. If the habit is thought to be due to psychological factors, referral to a child development expert is warranted. Rarely, occlusal wear is so extensive that stainless steel crowns or other restorative options are needed to prevent pulpal exposure or eliminate tooth sensitivity.Summarye period of time between 3 and 6 years of age is an interesting transitional period for addressing potential oral habits. Digit and pacier habits should be decreasing signicantly by the end of this period. Preferably, a habit that has resulted in movement of the primary incisors or has inhibited their eruption or has resulted in posterior crossbite or maxillary constriction will have been eliminated before the permanent incisors erupt. If a habit that causes dental changes is not eliminated or spontaneously discontinued before the permanent incisors erupt, they too will be aected. On the other hand, these are not irreversible changes. If the habit is stopped • Figure 27.13 This patient’s primary maxillary incisors and canines were worn more rapidly than normal owing to a habit of bruxism. CHAPTER 27 Oral Habits 393 24. Warren DW, Haireld WM, Dalston ET. Eect of age on nasal cross-sectional area and respiratory mode in children. Laryngoscope. 1990;100(1):89–93.25. Souki BQ, Pimenta GB, Souki MQ, et al. Prevalence of malocclusion among mouth breathing children: do expectations meet reality? Int J Pediatr Otorhinolaryngol. 2009;73(5):767–773.26. Ivanhoe JR, Lefebvre CA, Stockstill JW. Sleep disordered breathing in infants and children: a review of the literature. Pediatr Dent. 2007;29(3):193–200.27. Owens JA. Neurocognitive and behavioral impact of sleep disordered breathing in children. Pediatr Pulmonol. 2009;44(5):417–422.28. Peltomäki T. e eect of mode of breathing on craniofacial growth—revisited. Eur J Orthod. 2007;29(5):426–429.29. Caixeta AC, Andrade I, Pereira TB, et al. Dental arch dimensional changes after adenotonsillectomy in prepubertal children. Am J Orthod Dentofacial Orthop. 2014;145(4):461–468.30. Bresolin D, Shapiro CC, Shapiro PA, et al. Facial characteristics of children who breathe through the mouth. Pediatrics. 1984;73:622–625.31. Wenzel A, Hojensgaard E, Henriksen JM. Craniofacial morphology and head posture in children with asthma and perennial rhinitis. Eur J Orthod. 1985;7:83–92.32. Lenza MG, Lenza MM, Dalstra M, et al. An analysis of dierent approaches to the assessment of upper airway morphology: a CBCT study. Orthod Craniofac Res. 2010;13(2):96–105.33. Wagaiyu EG, Ashley FP. Mouthbreathing, lip seal and upper lip coverage and their relationship with gingival inammation in 11–14 year-old schoolchildren. J Clin Periodontol. 1991;18(9):698–702.34. Halteh P, Scher RK, Lipner SR. Onychophagia: a nail-biting conun-drum for physicians. J Dermatolog Treat. 2017;28:166–172.35. Tanaka OM, Vitral RW, Tanaka GY, et al. Nailbiting, or onychophagia: a special habit. Am J Orthod Dentofacial Orthop. 2008;134(2):305–308.36. Kuch EV, Till MJ, Messer LB. Bruxing and non-bruxing children: a comparison of their personality traits. Pediatr Dent. 1979;1:182–187.37. Machado E, Dal-Fabbro C, Cunali PA. Prevalence of sleep bruxism in children: a systematic review. Dental Press J Orthod. 2014;19(6): 54–61.12. Adair SM, Milano M, Dushku JC. Evaluation of the eects of orthodontic paciers on the primary dentitions of 24- to 59-month-old children: preliminary study. Pediatr Dent. 1992;14:13–18.13. Bishara SE, Nowak AJ, Kohout FJ, et al. Inuence of feeding and non-nutritive sucking methods on the development of the dental arches: longitudinal study of the rst 18 months of life. Pediatr Dent. 1987;9:13–21.14. Melink S, Vagner MV, Hocevar-Boltezar I, et al. Posterior crossbite in the deciduous dentition period, its relation with sucking habits, irregular orofacial functions, and otolaryngological ndings. Am J Orthod Dentofacial Orthop. 2010;138(1):32–40.15. Hauck FR, Omojokun OO, Siadaty MS. Do paciers reduce the risk of sudden infant death syndrome? A meta-analysis. Pediatrics. 2005;116(5):e716–e723.16. e TLC Foundation for Body-Focused Repetitive Behaviors. Learn about BFRBs. http://www.bfrb.org/index.php. Accessed August 16, 2017.17. Silva M, Manton D. Oral habits—part 2: beyond nutritive and non-nutritive sucking. J Dent Child. 2014;81(3):140–146.18. Maspero C, Prevedello C, Giannini L, et al. Atypical swallowing: a review. Minerva Stomatol. 2014;63(6):217–227.19. Stahl F, Grabowski R, Gaebel M, et al. Relationship between occlusal ndings and orofacial myofunctional status in primary and mixed dentition. Part II: prevalence of orofacial dysfunctions. J Orofac Orthop. 2007;68(2):74–90.20. Ovsenik M, Farčnik FM, Korpar M, et al. Follow-up study of functional and morphological malocclusion trait changes from 3 to 12 years of age. Eur J Orthod. 2007;29(5):523–529.21. Ovsenik M. Incorrect orofacial functions until 5 years of age and their association with posterior crossbite. Am J Orthod Dentofacial Orthop. 2009;136(3):375–381.22. Mason RM. Myths that persist about orofacial myology. Int J Orofacial Myology. 2011;37:26–38.23. Kelly JE, Sanchez M, Van Kirk LE. An assessment of the occlusion of the teeth of children 6-11 years, United States. Vital Health Stat 11. 1973;130:1–60. CHAPTER 27 Oral Habits 393.e1 Case Study: Diagnosis, Treatment Planning, and Correction of a Thumb HabitSamuel J. ChristensenA 7-year-old male presents in your ofce for an initial examination. After a review of the medical and dental history, you perform an intraoral examination. One of your ndings is the patient has a unilateral posterior crossbite with a mandibular shift. The patient also exhibits an open bite (Fig. E27.1). When questioned, the patient informs you that he sucks his thumb. Digit habits are associated with increased overjet and a narrow maxillary arch.1 After meeting with the patient and the patient’s mother, it is determined that the patient would like to stop his habit but needs some assistance. Your problem list includes a thumb habit, a unilateral posterior crossbite with a mandibular shift, and an anterior open bite. Your treatment plan is constructed to treat each problem, and you decide to use a combination of a W arch and a Bluegrass appliance. The W arch will widen the narrow maxillary arch and eliminate the posterior shift. The Bluegrass appliance will help to discourage or remind the patient not to suck his thumb (Fig. E27.2).TreatmentA well-thought-out plan is necessary to provide predictable and successful treatment to discontinue a habit. The rst appointment is to place separators mesial to the upper rst permanent molars. Separators create a small space in the contact area of the teeth to allow ideal band tting. The open contact will make it easier to t the bands and to cement the appliance. It takes 3 days to 1 week to compress the periodontal ligament and create space for the bands. At the second appointment, bands are t on the maxillary permanent rst molars and an impression of the maxillary arch is obtained. Following the impression, the bands are removed from the teeth and are placed in the impression in the proper orientation. It is equally important to replace the separators to hold the band space during fabrication of the appliance. It is useful to teach the parent how to place separators using oss. Often separators fall out and the space between the teeth closes prior to cementation of the appliance. It is very difcult to properly seat the appliance, and incomplete seating will affect the performance of the appliance and how the teeth will move.The next appointment is the delivery appointment. The appliance is tried in, and you verify it was constructed as directed and it ts passively. The appliance must be activated to move the teeth. In most cases, you will expand the appliance so the wire on one side of the appliance is sitting in the central grooves of the posterior teeth when the appliance is seated on the opposite side. An advantage of using the W arch is that if differential expansion is required, the appliance can be expanded in one of three places. If the patient requires more posterior expansion, the appliance is opened in the anterior curve of the appliance. If more anterior expansion is required, the appliance is opened at one or both posterior curves. The appliance was cemented after the desired activation was achieved. Three important points are given to the parent and patient. The rst is the function of the appliance. The second is how to care for the appliance and keep it clean. Last, the patient is instructed on what to eat and more importantly what not to eat so the bands will not loosen or the appliance distort.The patient returned 1 month after delivery to check expansion and the status of the thumb habit. More expansion was needed so the appliance was removed and cement cleaned from the bands. The appliance was reactivated and recemented. It is important to overexpand the posterior segment because some relapse should be anticipated. The patient was seen back at 2 months and 3 months to check expansion and to reactivate the appliance. Expansion should be complete after 3 months. After the desired expansion was achieved after 3 months, the appliance was left for an additional 3 months to serve as a retainer and prevent relapse. More importantly, 4 to 6 months of habit appliance therapy is necessary to eliminate the habit.2The appliance was removed after 6 months, and the patient was monitored at subsequent visits for relapse and habit resumption. With successful habit elimination, the incisors will continue to erupt and the open bite will spontaneously close (Fig. E27.3). This case demonstrates the successful maxillary expansion and habit elimination of a child in the early mixed dentition.• Figure E27.1 Patient with open bite secondary to a thumb habit. • Figure E27.2 Bluegrass appliance with W arch. • Figure E27.3 With successful habit elimination, the incisors will con-tinue to erupt and the open bite will spontaneously close. Continued 393.e2 Part 3 The Primary Dentition Years: Three to Six YearsQuestions1. If a child has an active thumb habit but it is not creating any dental problems, how should the dentist counsel the parent and patient?Answer: Thumb sucking is an inherent reex that is carried out for self-satisfaction. Breaking the habit will be very difcult. The habit duration has not yet produced dental problems but may when the permanent dentition erupts. It is important to know that other sequelae (blisters, calluses, warts, and infections) can occur on the digit. Therefore it is important to discuss the reasons for stopping the habit prior to the eruption of the permanent incisors.2. What is the difference between a W arch and a quad helix? Would one be better than the other in treating a thumb habit?Answer: A quad helix is similar to a W arch in that it allows for expansion in the anterior and posterior based on the particular activation. A quad helix differs from a W arch in that it has four helical loops, two located in the anterior and two in the posterior. The additional wire in the loops makes the delivered force level less in the quad helix than in the W arch for equal activations. Both appliances produce more dental than skeletal expansion. A Bluegrass roller or soldered spurs are needed with a W arch to serve as a reminder to the patient to discontinue the habit. The loops in the quad helix serve the same function, although the quad may not be as effective without a roller or spurs.3. Discuss how the dentist can determine the effectiveness of a habit appliance. What are key features to anticipate and expect during treatment?Answer: A habit appliance is effective if it serves as a reminder to the patient to discontinue the habit and the habit is stopped. In general, the appliance should be left in place for 4 to 6 months to truly extinguish the habit and in some cases it may need to be left for a longer time. The dentist should see spontaneous closure of the anterior open bite over time once the habit has stopped. Dental arch constriction does not spontaneously correct and will need an appliance to correct.References1. Warren JJ, Bishara SE. Duration of nutritive and nonnutritive sucking behaviors and their effects on the dental arches in the primary dentition. Am J Orthod Dentofacial Orthop. 2002;121:347–356.2. Haryett RD, Hansen FC, Davidson PO. Chronic thumb-sucking: a second report on treatment and its psychological effects. Am J Orthod. 1970;57:164–178. 394 28 Orthodontic Treatment in the Primary DentitionJOHN R. CHRISTENSENCHAPTER OUTLINESkeletal ProblemsDental ProblemsArch Length ProblemsIncisor Protrusion and RetrusionPosterior CrossbiteOpen Bitepatients early is that treatment at a later time may be more dicult and complex if the child continues to grow asymmetrically and dental compensation increases. e goal of early treatment is to prevent the asymmetry from becoming worse or to alter growth so the asymmetry improves. Most progressive asymmetry patients are treated with removable functional appliances designed to alter growth by manipulating skeletal and soft tissue relationships and allowing dierential eruption of teeth. Orthognathic surgery is a second treatment option for progressive asymmetry but is reserved for patients with severe asymmetry or those whose condition does not respond to functional appliance therapy. It may be necessary to operate a second time when the child is older because growth often tends to remain asymmetric even after surgical correction. Because diagnosis and treatment of progressive asymmetry are dicult, it is recommended to refer these cases to a specialist for evaluation and treatment.Early evaluation of patients with dentofacial anomalies is also advocated. Dentofacial anomalies include several environmentally and genetically induced conditions that alter the relationship of the facial structures. Examples include cleft lip and palate, hemifacial microsomia, Crouzon and Apert syndromes, and mandibulofacial dysostosis (Treacher Collins syndrome). A specialist or specialty team works to minimize the facial disgurement through early surgical and orthodontic intervention.Dental ProblemsSelected dental malocclusion in the primary dentition is readily managed by the practitioner who has knowledge of xed and removable appliances. e key to successful orthodontic manage-ment is careful diagnosis and treatment planning. A comprehensive database should be obtained. In this age group, tooth movement usually is restricted to tipping teeth into proper position as in anterior crossbite correction. Rarely are orthodontic appliances indicated to move teeth bodily, but posterior crossbite correction is one of those.Before specic treatment problems are discussed, the biology of tooth movement should be briey reviewed. Two theories of tooth movement have been proposed to describe the mechanism of movement. e rst is the “pressure-tension” theory. A force applied to a tooth causes alterations in the periodontal ligament and surrounding alveolar bone. is pressure creates reduced blood ow within the periodontal ligament, leading to limited cellular activity and disorganization of the ligament. On the tension side The goals of orthodontic care in the primary dentition should be to treat conditions that predispose one to develop a malocclusion in the permanent dentition or to monitor conditions that are best treated later.1 Some primary dentition problems can be eectively managed, and the result provides a long-term benet. With other conditions, treatment should be deferred until intervention can provide a long-term benet.e clinician needs to dierentiate skeletal problems from dental to fulll these goals. Treatment of skeletal malocclusions in this age group is ordinarily deferred until a later age; the delay is generally for practical reasons rather than an inability to alter skeletal structure at this age. ree general reasons are oered for delaying treatment. First, the diagnosis of skeletal malocclusion is dicult in this age group. Subtle gradations of skeletal problems and immature soft tissue development make clinical diagnosis of all but the most obvious cases dicult. Second, although the child is growing at this stage, the amount of facial growth remaining when the child enters the mixed dentition years is sucient to aid in the correction of most skeletal malocclusions. ird, any skeletal treatment at this age requires prolonged retention because the initial growth pattern tends to reestablish itself when treatment is discontinued. In essence, retention is active treatment over a sustained period of years to maintain the correction.On the other hand, several dental problems merit attention during the primary dentition years. is chapter is devoted to these issues.Skeletal ProblemsSkeletal problems are addressed only if there is progressive asymmetry due to a functional disturbance.2 e reason for treating these CHAPTER 28 Orthodontic Treatment in the Primary Dentition 395 the role of gingival bers in relapse.4 is type of procedure is not performed in the primary dentition but may be required in the mixed or permanent dentitions. If surgical treatment is not per-formed, long-term retention is indicated to prevent relapse.5 Other factors also inuence postorthodontic tooth movement. Pressure from the orofacial musculature, postorthodontic facial growth, and the interdigitation of the teeth (or lack of) has been reported to contribute to orthodontic instability.6Arch Length Problemse most common arch length problem in the primary dentition is tooth loss. is is managed as outlined in Chapter 26 with space maintenance if the space is adequate. If space has been lost because of tooth loss, space regaining can be instituted. A notable situation in which to use space regaining is when the primary rst molar is lost prematurely. e only realistic space regaining in the primary dentition is repositioning the primary second molar before the permanent rst molar erupts. A removable appliance is best used for this purpose. A primary second molar can be repositioned approximately 1 mm per month using a removable appliance with multiple clasps and a nger spring (Fig. 28.1). ree millimeters of molar movement is a realistic extent of the treatment. e appliance is similar to the appliance used to reposition a permanent rst molar. If a second primary molar is lost, timely placement of a distal shoe is required, to prevent space loss with the eruption of the permanent rst molar.Although inviting and seemingly intuitive, there is little relation-ship between the arch length (arch perimeter) in the primary and permanent dentitions.7 is means that weak correlations do not support the early interventions advocated by some and described here. Early intervention is expanding the primary arches with either a xed or a removable appliance. is treatment is provided to ensure space for the permanent teeth.8 e expansion provides variable increases in arch width and arch perimeter and is associated with little long-term benet.9 is early approach to potential crowding remains controversial and unsubstantiated. It is also important to remember there is a potential to treat up to 4.5 mm of crowding in the late mixed dentition simply with the use of a passive lower lingual arch.10the stretching of bers creates an increase in cellular activity resulting in elevated ber production.3 e pressure-tension theory is based on histologic studies of the periodontium. During the early stages of compression or pressure, cell-free zones are created (hyalinization). e body reacts to the hyalinization by recruiting macrophages, foreign body giant cells, and osteoclasts from nearby undamaged areas. These cells resorb the bone adjacent to the hyalinized periodontal ligament. e term used to describe this process is undermining resorption. e osteoblast also plays a signicant role in tooth movement. In the area of periodontal ligament tension, osteoblasts begin to enlarge and produce new bone matrix. Other preosteoblasts are recruited to aid in bone deposition. Together, the cells work to break down the necrotic tissue and matrix on the pressure side of the tooth and build new bone and structure on the side of tension.e second theory of tooth movement suggests that a force applied to a tooth is spread equally to all regions of the periodontal ligament. e alveolar bone is deected, and this begins the changes seen in the periodontal ligament. is is called the bone-bending theory. Forces applied to teeth will bend bone, tooth, and solid structures of the periodontal ligament. Bone is far more elastic than the other tissues, so when bone is held in a deformed position bone turnover and production are initiated. e force applied to the tooth is dissipated within the bone by production of stress lines within the area of force application. Continuous force applica-tion like that delivered by an orthodontic appliance becomes a stimulus for cells to alter their normal activities. is altered activity modies the shape and internal organization of the bone to accom-modate these forces.After force application, the tooth will move approximately the width of the periodontal ligament or until the hyalinization begins. After this small movement, the tooth will not move again for some 4 to 20 days. Movement will not occur until removal of the necrotic tissue is complete and bone resorption, both direct (from periodontal ligament) and indirect (adjacent marrow spaces), has occurred.When the tooth has moved a certain distance, the force exerted by the orthodontic appliance diminishes to an amount below that necessary for tooth movement. During this time, remodeling is completed and the periodontal ligament and alveolar bone cells begin to return to their normal state. is reorganization period is necessary to prevent injury to the tooth and supporting structures. e clinical implication of cellular change, tooth movement, and cellular reorganization is that orthodontic appliances should be reactivated only at 4- to 6-week intervals with a light, continuous force to avoid injury to the periodontium. ere is some biological basis for the recommendation of monthly visits during orthodontic treatment.After tooth movement is complete, the patient enters the retention phase of treatment. Retention is the time period the teeth are held in their new position. Retention is necessary because teeth that have been moved orthodontically tend to move back or relapse into their original position after the appliance has been removed. Relapse may be due to many factors; however, gingival changes seem to be the primary factor. e gingival tissue does not regain its pretreatment shape like bone and periodontal ligament. e gingiva contains a network of gingival bers that are compressed or stretched during tooth movement. e genes of both collagen and elastin are activated, and tissue collagenase is inhibited. is causes the extracellular matrix of the gingiva to become more elastic and at greater risk for relapse. Reorganization of the gingival tissues most likely requires a full year. Surgical treatment such as a gingival brotomy has been shown to increase stability, indicating • Figure 28.1 This appliance was designed to move the right molar distal. Note there are two retentive clasps to hold the appliance in place. The appliance would dislodge as the spring was activated without reten-tion. This type of appliance can move a molar approximately 3 mm. 396 Part 3 The Primary Dentition Years: Three to Six Yearsthe tipped incisor in its new position. If there is no overbite, the appliance should be maintained until overbite is established to ensure that relapse does not occur.e decision to correct an anterior crossbite in the primary dentition is a dicult one. e clinician should determine if the crossbite is skeletal or dental in nature. Other factors to consider are the number of teeth involved, the presence of a mandibular shift, and the age of the patient. ere are few evidence-based studies to support or refute correction of a dental anterior crossbite in the primary dentition. In other words, would the crossbite self-correct with the exchange of the permanent incisors? Or, does the early correction maintain itself when the permanent incisors erupt? ere are hints that self-correction is possible in dental causes of anterior crossbite.11–13One further point should be made about anterior crossbite. In some cases of posterior crossbite or occlusal interference, a child positions the jaw forward (known as a mandibular shift) to achieve maximal intercuspation and an anterior crossbite results (usually called a pseudo class III malocclusion because the patient is often class I and shifts into a class III position). In this situation the patient positions the lower jaw forward only to obtain comfortable intercuspation as needed to function. is type of anterior crossbite is due to jaw posturing rather than tooth or jaw malposition. In these cases, treatment is directed to the posterior crossbite or the occlusal interference and not to the anterior crossbite. In some cases the interfering tooth is the one in crossbite.Excessive overjet in the primary dentition is usually due to a nonnutritive sucking habit or to a skeletal mismatch between the upper and lower jaws. Most skeletal problems should not be treated at this time because of the tendency for abnormal growth patterns to recur. However, incisor protrusion as a result of a sucking habit can be addressed. Treatment is usually directed at eliminating the habit rather than correcting the incisor protrusion. Incisor protrusion usually corrects itself or is signicantly reduced if the habit is discontinued and if the equilibrium between the tongue, lips, and perioral musculature is reestablished. e quad helix, palatal crib, and Bluegrass appliance are discussed in Chapter 27 and are the appliances of choice for habit therapy (see Figs. 27.6 to 27.8). Studies designed to determine how long the appliance must remain in place to terminate the habit eectively suggest a 6-month minimum.14 e key to treatment is whether the patient and the parents both want to have the patient stop the habit. If one or neither is interested in discontinuing the habit, it is best to delay treatment until they are ready.Posterior CrossbitePosterior crossbite in the primary dentition is usually a result of constriction of the maxillary arch. Constriction often results from an active digit or pacier habit, although there are many cases in which the origin of the crossbite is undetermined. e rst step in managing a posterior crossbite is to establish whether there is an associated mandibular shift. If a mandibular shift is present, treatment generally should be implemented to correct the crossbite. Some authors have implicated a mandibular shift as the cause of asymmetric growth of the mandible.15 e asymmetry is thought to occur because the condyles are positioned dierently within each fossa. Muscle and soft tissue stretch exert forces on the underlying skeletal and dental structures that may alter normal growth and arch development. If no shift is detected, the mandible should grow symmetrically. It has been suggested to wait on treat-ment until the permanent molar erupts if there is no mandibular Incisor Protrusion and RetrusionIn addressing the anteroposterior plane of space, the clinician is mainly concerned with the position of the incisors, particularly the maxillary incisors. e majority of anteroposterior problems involve anterior crossbite, a condition in which the maxillary incisors occlude lingual to the mandibular incisors. A xed lingual arch or a removable appliance can be used to correct the crossbite, but several things should be kept in mind when moving primary anterior teeth. First, the crowns are extremely short incisogingivally. is means overly aggressive activation of springs will cause them to slip down the lingual surface and not engage the crowns of the teeth. It is best to activate the springs in a facial and gingival direction with gentle activation. Second, the crowns of some primary rst molars converge toward the occlusal surface. is makes banding or clasp retention challenging. ird, there are few or no undercuts on the anterior teeth that will engage a labial bow for retention. For this reason, if a labial bow in the primary dentition is not used for tooth movement, it probably should be discarded from the appliance prescription. Finally, because the primary teeth will be exfoliated near 6 to 7 years of age, it is not wise to consider moving a primary incisor much after 4 years of age. Because compliance can be a problem before age 4 years and because primary root resorption and tooth morphology are problems after age 4, few clinicians attempt treatment for anterior crossbites in the primary dentition.If crossbite correction is indicated, a maxillary lingual arch can be designed to push directly on the incisors with reasonably heavy force (0.036-inch wire) or the lingual arch can have lighter forces delivered with attached nger springs (0.022-inch wire). Either way, the arch can be activated to tip maxillary teeth into proper position. e lingual arch is activated approximately 1 mm per visit because it is a heavy-gauge wire that exerts a heavy force. e auxiliary wires can be activated 2 mm (Fig. 28.2). In general, a tooth moves 1 mm per month during treatment. erefore, if a tooth requires 3 mm of movement to be properly aligned, 3 months of treatment is necessary.With a removable appliance, wire nger springs are incorporated into the palatal acrylic to move the teeth facially. Placing retentive clasps on the posterior teeth stabilizes the appliance. e nger springs are activated 1.5 to 2.0 mm per month. If the patient exhibits a positive overbite and overjet after treatment, retention is probably not necessary because the occlusion generally holds • Figure 28.2 This patient’s anterior crossbite involving the primary maxil-lary central incisors is being treated with a T spring soldered to a lingual arch. The spring is activated 1 to 2 mm per month until the incisors are tipped out of crossbite. CHAPTER 28 Orthodontic Treatment in the Primary Dentition 397 popular appliance is the quad helix (see Fig. 27.6). e W arch is constructed of 0.036-inch wire that rests 1.0 to 1.5 mm o the palate to prevent soft tissue irritation. e W arch is expanded approximately 4 to 6 mm wider than its passive width, or so that one arm of the W is resting over the central grooves of the teeth when the other arm is seated. To move teeth preferentially in the anterior region of the mouth, the appliance is activated by bending the palatal portion of the arm near the solder joint, as demonstrated in Fig. 28.4. If more correction is needed in the molar region, the appliance is activated via bending of the anterior palatal portion. e appliance expands the arch approximately 1 mm per side per month.e patient should return monthly to allow the dentist to check the progress of treatment and to reactivate the W arch if needed. e appliance can be activated intraorally by squeezing the wire with a three-pronged plier, although the force and direction of activation may be dicult to approximate, and unwanted tooth movement can result. Usually it is easier and more accurate to remove, activate, and recement the appliance. Expansion should continue until the crossbite is slightly overcorrected and the lingual cusps of the maxillary teeth occlude on the lingual inclines of the buccal cusps of the mandibular teeth. Most crossbites are corrected in 3 months, and the teeth are retained for an additional 3 months.e quad helix is designed much like the W arch but incorporates more wire into the appliance, making it more exible. It is con-structed of 0.038-inch wire with two helices in the anterior palate and two helices near the solder joint in the posterior palate. e helices are wound away from the palate and can serve to remind the digit-sucking patient to refrain from the habit if they are positioned correctly where the patient places the nger or thumb. erefore this is the preferred appliance for a patient with a nger habit and posterior crossbite. Because the quad helix has more wire than the W arch, it has a greater range of action and can be activated farther than the W arch while delivering an equivalent amount of force. Overcorrection and retention are also required for the quad helix.Despite activation of the W arch or quad helix on one side only, teeth on both sides of the arch react to equivalent force. ese types of xed lingual arch type appliances have been shown to produce both skeletal and dental changes in the primary and mixed dentitions.17shift.12 After the permanent molar erupts, the clinician can treat if it erupts in crossbite or continue to observe if there is no per-manent molar crossbite or mandibular shift.ere are two basic approaches to the management of posterior crossbite in young children: (1) equilibration to eliminate man-dibular shift and (2) expansion of the constricted maxillary arch. In a few cases the mandibular shift is due to interference caused by the primary canines. ese cases can be diagnosed by reposition-ing the mandible and noting the interference. Selective removal of enamel with a diamond bur in both arches eliminates the interference and the lateral shift into crossbite. is type of treatment has evidenced-based support.16In cases of bilateral maxillary constriction, expansion is recom-mended to correct the lateral shift. is situation should be managed as soon as it is diagnosed unless the permanent rst molar is expected to erupt within 6 months. If permanent molar eruption is imminent, it is better to allow the permanent molars to erupt and incorporate these teeth into treatment if necessary. Both xed and removable appliances can be designed to correct maxillary constriction, although xed appliances are reliable and require little patient cooperation. A randomized prospective study of unilateral crossbite correction in the mixed dentition suggested the most successful intervention was with xed appliances.17Fixed appliances are variations of a lingual arch bent into the shape of a W. In fact, one of the most popular appliances used to treat crossbites is named the “W arch” (Fig. 28.3). Another • Figure 28.3 The W arch is a xed appliance used to correct posterior crossbites in the primary dentition. BA• Figure 28.4 (A) The W arch can be activated in two spots. (B) The preferred way to move teeth in the anterior region of the mouth is to activate the W arch by bending the arm of the W in the area marked location 1. Continued 398 Part 3 The Primary Dentition Years: Three to Six YearsOpen BiteVertical problems in the primary dentition usually are due to a nger or pacier habit, and they result in an anterior open bite. Treatment for an anterior open bite that is due to a sucking habit is discussed in Chapter 27. Deep bite in the primary dentition is generally not corrected at this time. e depth of bite usually improves with the eruption of the permanent rst molars if the problem is the result of dental malocclusion.References1. Ngan P, Fields HW. Orthodontic diagnosis and treatment planning in the primary dentition. J Dent Child. 1995;62:25–33.2. Prot WR, Fields HW, Sarver DM. Treatment of skeletal problems in children. In: Contemporary Orthodontics. 5th ed. St Louis: Mosby; 2012.3. Kishnan V, Davidovitch Z. Cellular, molecular, and tissue-level reactions to orthodontic force. Am J Orthod. 2005;129:469.e1–469.e32.4. Redlich M, Shoshan S, Palmon A. Gingival response to orthodontic force. Am J Orthod Dentofacial Orthop. 1999;116:152–157.5. Lang G, Alfter G, Göz G, et al. Retention and stability—taking various treatment parameters into account. J Orofacial Orthop. 2002;63:26–41.6. Melrose C, Millett DT. Toward a perspective on orthodontic retention? Am J Orthod Dentofacial Orthop. 1998;113(5):507–514.7. Bishara SE, Khadivi P, Jakobsen JR. Changes in tooth size–arch length relationships from the deciduous to the permanent dentition: DC(C) If the clinician wants to obtain more movement in the molar region, the appli-ance is activated by bending the anterior portion of the W in the area marked location 2. (D) In general, the appliance is activated 3 to 4 mm beyond its passive width or to a position where one arm of the W extends over the central grooves of the teeth when the other arm is seated in place. • Figure 28.4, cont’da longitudinal study. Am J Orthod Dentofacial Orthop. 1995;108: 607–613.8. McInaney JB, Adams RM, Freeman M. A nonextraction approach to crowded dentitions in young children: early recognition and treatment. J Am Dent Assoc. 1980;101:251–257.9. Lutz HD, Poulton D. Stability of dental arch expansion in the deciduous dentition. Angle Orthod. 1985;55:299–315.10. Gianelly AA. Treatment of crowding in the mixed dentition. Am J Orthod Dentofacial Orthop. 2002;121:569–571.11. Nagahara K, Murata S, Nakamura S, et al. Prediction of the permanent dentition in deciduous anterior crossbite. Angle Orthod. 2001;71(5): 390–395.12. Dimberg L, Lennartsson B, Arnrup K, et al. Prevalence and change of malocclusions from primary to early permanent dentition: a longitudinal study. Angle Orthod. 2015;85:728–734.13. Nagahara K, Suzuki T, Nakamura S. Longitudinal changes in the skeletal pattern of deciduous anterior crossbite. Angle Orthod. 1997;67(6):439–446.14. Haryett RD, Hansen FC, Davidson PO. Chronic thumb-sucking. A second report on treatment and its psychological eects. Am J Orthod. 1970;57:164–178.15. Primozic J, Richmond S, Kau CH, et al. ree-dimensional evaluation of early crossbite correction: a longitudinal study. Eur J Orthod. 2011;35(1):7–13.16. Harrison JE, Ashby D. Orthodontic treatment for posterior crossbites. Cochrane Database Syst Rev. 2001;(1):CD000979.17. Petrén S, Bondemark L. Correction of unilateral posterior crossbite in the mixed dentition: a randomized controlled trial. Am J Orthod Dentofacial Orthop. 2008;133(6):e790–e797. CHAPTER 28 Orthodontic Treatment in the Primary Dentition 398.e1 Case Study: Orthodontics for the Child With Special NeedsJohn R. ChristensenSimilar to the general population, children with special needs exhibit varying malocclusions. Many of the malocclusions are found in the general population; however, there seems to be a higher prevalence of severe malocclusion in individuals with physical and mental disabilities. The higher prevalence is explained by abnormal orofacial musculature (abnormal tongue position), craniofacial anomalies, genetics (Down syndrome), and brain injuries (cerebral palsy).1 Each has a malocclusion characteristic of the specic developmental problem. Studies of children with autism spectrum disorder (ASD) have reported mixed ndings. One did not nd any difference in the Dental Aesthetic Index, a measure of malocclusion severity.2 Another reported children with ASD had an increased prevalence of posterior crossbite, increased overjet, and maxillary crowding.3Parents inquire about treatment of malocclusion for their child with special needs. Studies have indicated they have a high level of motivation for treatment and are willing to participate in oral hygiene practices.4,5 Parents report the number one reason for orthodontic treatment is to improve facial appearance. Their expectations (and hopes) are that treatment will improve the child’s quality of life, role in society, and his or her social acceptance.The dentist’s role in treating the child with special needs is to discuss orthodontic treatment with the parents and patient. Actually, the clinician should be more of an active listener to determine parent and patient concerns. After discussing the need and motivation for treatment, the clinician should consider whether treatment seems reasonable, is achievable, and promises some stability. Each child needs to be evaluated on an individual basis. Some will be good candidates. Other patients could benet from orthodontics, but because of the disability, care will be difcult and may not be stable.6BehaviorEvery child has some innate ability to cooperate with treatment. The dentist must consider how much ability is within the child to cooperate. Oftentimes, behavior can be guided to examine the teeth only, whereas other times the patient may allow complete dental care. Several questions should be considered. Can the child physically sit for appliance placement? Will the child allow appliances to be placed? Will the appliance cause gagging or difculty eating? Can the child clean the appliances so the teeth are not put at risk during treatment? Oftentimes these questions can be answered prior to the start of treatment, but there are times when the limits of cooperation are not known.In general, the clinician can determine a patient’s ability to cooperate during the records appointment. The clinician can assess whether a patient will follow directions or is cooperative for procedures such as radiographs and photographs. Does the child gag? Can the gag reex be managed? Even something as simple as moving the dental chair can startle a child with special needs. Staff need to be trained and encouraged to deliver care in multiple ways. For example, the chair may not be completely reclined, the dental light may not be used, or the patient may need to sit up to drink water from a cup rather than being rinsed with an air/water syringe and suction. The clinician should note patient behaviors as the records are obtained. If records are difcult or impossible to obtain, orthodontic treatment may be just as difcult.Appointment scheduling should be adapted to the individual child. Often a series of desensitization appointments are necessary to acclimate the child to the orthodontic world. Different chairs, different staff, and different doctors are just some of the challenges for a child with special needs. It is helpful to schedule care in the same chair with the same staff so the child has some ability to anchor his or her care from appointment to appointment. The time for each appointment should be adjusted to accommodate the child. The typical time for an orthodontic procedure may be twice as long for the patient with special needs.Patient’s Ability to Tolerate the ApplianceAfter records, the clinician presents a problem list and treatment plan to the family. The dentist should determine from the records appointment or from discussion with the parent whether the patient can tolerate orthodontic appliances. Often it is prudent to place limited orthodontic appliances on the teeth (in a passive state) to determine if the patient can tolerate the appliances. After it is established the child can tolerate the appliances, additional appliances can be added. For example, in a case requiring upper and lower arch treatment, the clinician may place brackets on the upper front teeth. This is an area that is easy to access for placement and removal if necessary. If the child does well with this treatment, additional brackets can be placed on the lower arch or the upper posterior teeth. Appliance placement is staged so the clinician can terminate treatment without creating a situation in which work must continue to get the teeth into a stable position. The most obvious example of staged treatment is tooth removal. It is wise to start appliances prior to tooth removal even if there is no room to move teeth until extractions have been performed. After it is apparent the patient will tolerate appliances, the teeth can be removed. If teeth are removed rst and the patient is not a good candidate for treatment, the patient can end up with an even worse situation.If a removable appliance is being considered, one can construct a sham appliance or deliver the actual appliance without activation. Children can be overwhelmed by a removable appliance, so it is important to introduce it slowly. The patient can be asked to wear the appliance on day 1 for one-half hour. Each day another increment of wear can be added until the targeted time is achieved. If the appliance is intended for night wear, it can be helpful to start the appliance during waking hours. The patient can develop condence in the appliance before attempting to sleep with it at night.Patient’s Ability to Cooperate With the Treatment PlanCooperation in treatment is as important in a child with special needs as it is in a normal child. The clinician should be prepared to modify the plan or the intended treatment based on the individual’s ability to cooperate. This can mean extended chair time to allow the child time to feel comfortable and receive care. It can mean proposed treatment for the day will be postponed due to the child’s inability to cooperate or receive treatment on that particular day.Staff must be trained to deliver care in a manner different than normal. For example, tooth-brushing instructions will vary if a child has a physical difference that prevents a normal brushing stroke. A different technique, a different toothbrush, or another individual must be used to provide good home care. A child with a sensory disorder may not be able to tolerate the taste of materials used to prepare teeth. It may be necessary to use a different material. The key is exibility for the clinician and staff. The rule is there are no rules to treatment approach.Stability of ResultsAs with children without disabilities, the clinician needs to consider several variables in the retention plan. The orthodontic literature is full of questions about retention and the stability of tooth movement. In a patient with special needs, the clinician should consider several issues. Will the patient be able to tolerate an appliance? Will the patient wear the appliance? Is a xed retainer a better option for retention? Will oral hygiene be more difcult with a xed retainer? Will a patient (with a sensory disorder) tolerate the taste or texture of a retainer? In cases of patients with muscular issues (cerebral palsy), retention appropriate for a normal child may not work due to the difference in muscle activity or may not be tolerated due to swallowing and drooling difculties. There are an unlimited number of issues to consider in retention, and it is nearly impossible to anticipate every one. The clinician must be well versed in orthodontic retention and the literature. Each patient requires an individual retention plan based on the special need of the patient.Continued 398.e2 Part 3 The Primary Dentition Years: Three to Six YearsQuestions1. What barriers to orthodontic care do children with special needs face?Answer: The child with special needs faces several barriers to care. The rst is nding a dentist who is trained and comfortable with treating children with different needs. The second is similar to the rst, and that is nding a dentist who participates in Medicaid and other programs designed to help these children. Reimbursement rates are lower in these programs, and many dentists choose not to participate due to the rates. Children with special needs have mental and physical disabilities that may interfere with the delivery of orthodontic care.2. Describe ways a dentist can measure if a child with special needs will tolerate orthodontic care?Answer: The rst answer to this question is how the child does with general dental care. If the patient is cooperative and maintains good oral health, the child will typically do well for orthodontic care. If the child requires extra guidance during regular care, the clinician should anticipate more guidance will be needed for orthodontic care. A stepwise progression is often appropriate to determine the child’s tolerance for care. Orthodontic appliances can be introduced slowly and placed without activation (teeth will not move) just to determine how the child will do with orthodontic appliances. If the child is doing well, the appliance can be activated to move teeth or more appliances can be added. If the child is not doing well with orthodontic care, the limited appliances can be removed without harm to the patient.3. List ve ways orthodontic care may be different for a child with special needs.Answer:• Appointment lengths may be longer to accommodate the child’s special needs.• Treatment plans may be less comprehensive and more exible due to several unknown factors relating to each child’s special needs.• Treatment is staged so if a child cannot tolerate treatment, discontinuing treatment will not result in leaving the patient in a worse condition than the start.• Materials may need to be varied depending on the sensitivities of the patient. This may be a result of multiple allergies or just a sensitivity disorder to a certain taste or texture.• The clinician and staff may vary from the scheduled treatment for the day depending on the disposition of the patient and the ability of the patient to tolerate treatment that day. There is a much greater range of behaviors to negotiate in the child with special needs.References1. Rada R, Bakhsh HH, Evans C. Orthodontic care for the behavior-challenged special needs patient. Spec Care Dentist. 2015;35(3):138–142.2. Luppanapornlarp S, Leelataweewud P, Putongkam P, et al. Periodontal status and orthodontic treatment need of autistic children. World J Orthod. 2010;11(3):256–261.3. Fontaine-Sylvestre C, Roy A, Rizkallah J, et al. Prevalence of malocclusion in Canadian children with autism spectrum disorder. Am J Orthod Dentofacial Orthop. 2017;152(1):38–41.4. Abeleira MT, Pazos E, Ramos I, et al. Orthodontic treatment for disabled children: a survey of parents’ attitudes and overall satisfaction. BMC Oral Health. 2014;14(1):98.5. Becker A, Shapira J, Chaushu S. Orthodontic treatment for the special needs child. Prog Orthod. 2009;10(1):34–47.6. Becker A, Shapira J, Chaushu S. Orthodontic treatment for disabled children: motivation, expectation, and satisfaction. Eur J Orthod. 2000;22(2):151–158. 39929 Oral Surgery in ChildrenABIMBOLA O. ADEWUMICHAPTER OUTLINEPreoperative EvaluationTooth ExtractionsArmamentariumGeneral ConsiderationsSoft Tissue Surgical ProceduresBiopsiesDentoalveolar Surgery for Impacted CaninesFacial InjuriesFacial FracturesOdontogenic InfectionsAnkyloglossia and FrenectomiesAnkyloglossiaSurgical Treatmenttaking appropriate preoperative radiographs. ese often include two or more periapical radiographs of the same area to determine buccal, lingual, facial, or palatal relationships of impacted teeth. ere are instances in which taking a three-dimensional radiograph is indicated (e.g., for locating supernumerary or impacted teeth, teeth adjacent to a cleft site, or in which conditions where ankyloses is suspected). Another preoperative consideration is the need for future space maintenance as a result of the premature loss of primary teeth (see Chapter 26). Failure to provide immediate space main-tenance may allow for the mesial migration of permanent rst molars after premature primary molar loss.Tooth ExtractionsArmamentariumMany dentists choose to use the same surgical instruments for both child and adult patients. However, most pediatric dentists and oral and maxillofacial surgeons prefer the smaller pediatric extraction forceps, such as the no. 150S and 151S (Fig. 29.1), for the following reasons:1. eir reduced size more easily allows placement in the smaller oral cavity of the child patient.2. e smaller pediatric forceps are more easily concealed by the operator’s hand.3. e smaller working ends (beaks) more closely adapt to the anatomy of the primary teeth.e choice of the proper instrumentation can also depend on special considerations unique to the child and the adolescent. e use of cow horn mandibular forceps is contraindicated for primary teeth, owing to the potential for injury to the developing premolars (Fig. 29.2). Great care must also be given to the routine use of elevators and forceps adjacent to large restorations such as chrome crowns and especially restorations adjacent to erupting single-rooted teeth that may easily become dislodged with the slightest force.General Considerationse manual technique used to perform extractions in the child patient is similar to the manual extraction technique used in the adult. e greatest dierence is in patient management. It is essential that the dentist take the time to describe the ensuing procedure completely and accurately to the child. Many practitioners show the child a curette or other benign instrument and explain: “is spoon will walk around your sick tooth and wiggle and dance with it. If your tooth is really sick, then we will give it a big hug, and it will wiggle or dance right out!” e practitioner may give the In many ways, oral surgical procedures for children are similar to and possibly easier than those performed for adults. ere are some important dierences as well. e purpose of this chapter is to present basic techniques and surgical principles needed to perform oral surgical procedures safely and competently on children and adolescents. is chapter discusses the extraction of teeth, minor soft tissue procedures (e.g., biopsies and frenectomies), odontogenic infections, and the recognition and initial management of facial injuries and fractures. is chapter presents an overview of the principles of successful oral surgical procedures in children.Preoperative Evaluatione dentist treating the child patient must be careful to consider the entire patient and not focus only on the oral cavity. Important considerations in caring for the child patient include the following:1. Obtaining a comprehensive medical history, with special emphasis on medical conditions that might complicate treatment, such as bleeding disorders2. Obtaining appropriate medical and dental consultations3. Anticipating and preventing emergency situations4. Being fully capable of managing emergency situations when they occur (see Chapter 10)In addition to the medical preoperative evaluation, it is important to perform a thorough dental preoperative evaluation, which includes 400 Part 3 The Primary Dentition Years: Three to Six Yearsbefore surgery in order to prepare them for the upcoming procedure. e entire surgical procedure and the expected postoperative recovery course should also be described. is allows the parents to make special postoperative arrangements, such as the need for a soft diet or child care support.Several factors make it possible for the child patient to aspirate or swallow foreign objects during dental treatment. ese factors include (1) the common practice of treating the child patient in a reclining position, (2) poor visibility as a result of the smaller opening into the oral cavity and the proportionately larger tongue of the child, and (3) the increased likelihood of unexpected move-ments by the child patient. To prevent this from happening, the patient should be positioned in the chair so that the upper jaw is at no more than a 45-degree angle with the oor (Fig. 29.3). If an angle greater than 45 degrees is preferred by the operator, the posterior oral airway should be protected by placing a gauze screen or performing the extraction with the use of a rubber dam.e dentist should be placed in the position in which he or she can easily control the instrumentation, have good visual access to the surgical site, and control the child’s head. Fingers of the nondominant hand of the dentist are then placed in the patient’s mouth on either side of the tooth being extracted. e role of the nondominant hand is to help control the patient’s head; to support the jaw being treated; to help retract the cheek, lips, and tongue from the surgical eld; and to palpate the alveolar process and adjacent teeth during the extraction.After the proper operator and nondominant hand positions are established, the actual extraction technique may begin. Variations in technique for individual teeth are discussed later in this chapter, but the following general principles apply to all extractions.1,2 An instrument such as a dental curette or periosteal elevator is used to separate the epithelial attachment of the tooth to be extracted (Fig. 29.4). en appropriate elevators may be used to luxate the tooth to be extracted, but great care must be used not to damage adjacent or underlying teeth. e appropriate forceps is then placed child’s shoulder or hand a squeeze to demonstrate that “big hug” so the child knows he or she may still feel some pressure. Alter-natively, just before the actual extraction, the dentist can place the balls of the index nger and thumb in the area of the extraction and demonstrate to the child the types of pressures and movements that he or she will encounter during the extraction. is digital pressure should be rm enough to rock the child’s head from side to side in the headrest. e dentist should be sure to obtain profound anesthesia because, once the patient has felt pain, it may be dicult to regain the child’s condence to a level in which he or she will behave in a manner that allows completion of the procedure. Advanced behavior guidance techniques and pharmacologic adjuncts such as nitrous oxide or sedation may be required in a more anxious child (see Chapter 8).Several steps of the extraction procedure should be performed with every extraction. e dentist should consult with the parents • Figure 29.1 Extraction forceps: left to right, no. 150, no. 150S, no. 151S, no. 151. BA• Figure 29.2 (A and B) The use of cow horn mandibular forceps is contraindicated for primary teeth, owing to the potential for injury to the developing premolars. ([B] Courtesy Gabriel Dominici.) CHAPTER 29 Oral Surgery in Children 401 expansion. Any bone sharpness should be conservatively removed with either a rongeur or a bone le. Digital pressure should be sucient to return the alveolus to its presurgical conguration if gross expansion has occurred.Initial hemostasis must be obtained and is accomplished by having the child bite on an intraoral gauze pack. In the anesthetized, deeply sedated, or very young child, a pack that extends out of the oral cavity should be used to prevent swallowing of the gauze. e extraction site should also be evaluated for the need for sutures, although they are rarely indicated after extraction of primary teeth. An absorbable gelatin sponge (e.g., Gelfoam, Pzer Inc., NY) is an alternative to sutures to aid hemostasis. Gelfoam is particularly useful when gingival and bony tissues immediately surrounding the extraction site are not grossly torn or damaged, but the sponge should not be inserted into the socket that has frank infection. e sponge is rst folded or rolled between the operator’s ngers and then inserted into the socket and held with mild pressure for a minute. e sponge is absorbed by the body over a 4- to 6-week period. Before the patient is dismissed, a written list of postoperative instructions should be given and explained to both the patient and the parents (Box 29.1). e postoperative instruction list should explain how to contact the dentist after hours in case of an emergency.Maxillary Molar ExtractionsPrimary maxillary molars dier from their permanent counterparts in that the height of contour is closer to the cementoenamel junction and their roots tend to be more divergent and smaller in diameter. Because of the root structure and potential weakening of the roots during the eruption of the permanent tooth, root fracture in primary maxillary molars is not uncommon. Adequate local anesthesia must be obtained and can be accomplished through a maxillary inltration and palatal injection or a greater palatine block (see Chapter 7). Another important consideration is the relationship of the primary molar roots to the succeeding premolar crown. If on the tooth to be extracted, usually seating the lingual or palatal beak rst and then rotating the facial beak into proper position. The extraction is then performed via the proper forceps technique.After the tooth is removed from its socket, the surgical site is evaluated visually and with the use of a curette. e curette should be used as an extension of the dentist’s nger to palpate and evaluate the extraction site. No attempt should be made to scrape the extraction site. If a pathologic lesion such as a cyst or periapical granuloma is present at the apex of a permanent tooth socket, it should be gently enucleated. Aggressive manipulation of a curette in a primary tooth socket is contraindicated due to the potential for damage to the succeeding tooth bud. e operator should palpate both the facial and palatal or buccal and lingual aspects of the surgical site to feel for any bone irregularities or alveolar • Figure 29.3 To help prevent aspiration of extracted teeth, the child is positioned so that the upper jaw is at a 45-degree angle to the oor. • Figure 29.4 A periosteal elevator is used to separate the epithelial attachment of the tooth before extraction. 1. Bite on gauze for 30 minutes. Do not chew on the gauze.2. Do not use a straw to drink for 24 hours.3. Brush remaining teeth daily, but do not rinse or use a mouthwash on the day of the surgery.4. Take pain medication as directed.5. If pain increases after 48 hours or if abnormal bleeding continues, call our ofce.6. To prevent bleeding and swelling, keep your head elevated on two or three pillows while you rest or sleep.7. Do not spit. Spitting will cause bleeding. Excess saliva and a little bit of blood looks like a lot of bleeding.8. If bleeding starts again, put a gauze pad, a clean wash cloth, or a damp tea bag over the bleeding area and bite on it with rm steady pressure for 1 hour. Do not chew on it.9. Ice packs can be used immediately after surgery and for the next 24 hours to reduce swelling. Keep ice packs on for 10 minutes and off for 10 minutes.10. Black and blue marks are bruises that often occur after surgery. Usually they are barely noticeable. Sometimes the skin is discolored. Do not worry about this.11. Drink lots of liquid and eat anything you can swallow.12. Call our ofce about any complications or if you need to change your appointment.Postoperative Instruction List for Patients• BOX 29.1 402 Part 3 The Primary Dentition Years: Three to Six Yearsthrust, twist, and pull). A no. 1 forceps is useful in the extraction of maxillary anterior teeth (Fig. 29.7).Mandibular Molar ExtractionsWhen extracting mandibular molars, the dentist must pay special attention to the support of the mandible with the nonextraction hand to prevent injury to the temporomandibular joints (Fig. 29.8). Adequate local anesthesia is obtained through an inferior alveolar block. Occasionally, supplemental injections like a long buccal block are necessary. Inltration alone is not sucient to obtain adequate anesthesia for extraction procedures (see Chapter 7). After luxation with a no. 301 straight elevator, a no. 151S forceps is used to extract the tooth with the same alternating buccal and palatal motions used to extract maxillary primary molars.Extraction of Mandibular Anterior Teethe mandibular incisors, canines, and premolars are all single rooted. erefore one must take great care that the forceps does not place any force on adjacent teeth because they can become easily luxated and dislodged. is also enables the dentist to use rotational movements in the extraction process, as described previously.the roots encircle the crown, the premolar can be inadvertently extracted with the primary molar (Fig. 29.5). After the epithelial attachment is released, a no. 301 straight elevator is used to luxate the tooth (Fig. 29.6). e extraction is completed using a maxillary universal forceps (no. 150S). Palatal movement is initiated rst, followed by alternating buccal and palatal motions with slow continuous force applied to the forceps. is allows expansion of the alveolar bone so that the primary molar with its divergent roots can be extracted without fracture. e tooth is delivered in the occlusobuccal direction.Extraction of Maxillary Anterior Teethe maxillary primary and permanent central incisors, lateral incisors, and canines all have single roots that are usually conical. is makes them much less likely to fracture. Adequate local anesthesia must be obtained and can be accomplished through inltration of the maxillary anterior vestibule as well as injecting into the incisive papilla (nasopalatine block) to anesthetize the lingual side of the teeth (see Chapter 7). Apply anterior forceps along the long axis of the tooth apical to the cementoenamel junction, followed by slight rotary and vertical movements. e motion simulates using a screwdriver to remove a nail (i.e., apical • Figure 29.5 Primary molars with roots encircling the developing pre-molar may have to be sectioned to prevent accidental extraction of the premolar. • Figure 29.6 A no. 301 straight elevator is used to luxate the tooth. Extreme care is taken to prevent accidental luxation of adjacent teeth. • Figure 29.7 Rotational movements and buccolingual motions are used to extract primary incisors. The dentist’s nondominant hand helps to control the child’s head, supports the jaw being treated, retracts adjacent soft tissues, and palpates the alveolar process and adjacent teeth during extraction. Also note the gauze screen in the oral cavity to aid in preventing aspiration or swallowing of extracted teeth. • Figure 29.8 The nonextraction hand supports the mandible during extraction of mandibular molars. CHAPTER 29 Oral Surgery in Children 403 BiopsiesBiopsy techniques in children are similar to those in adults. A very small lesion is probably best managed with an excisional biopsy, whereas lesions 0.5 cm or larger should probably have an incisional biopsy, especially if there is any doubt regarding the diagnosis of the lesion. Before performing a biopsy on a lesion, the dentist should consider the possibility that the lesion is vascular. Any such area should be palpated for intravascular turbulence (thrill), aus-cultated with a stethoscope for the presence of a bruit, and checked by needle aspiration for the presence of blood within the lesion. Biopsies should not be performed on vascular lesions until a thorough work-up has been completed.3Some areas of the oral cavity, such as the mucosa and lips, are easily accessible, whereas other areas, such as the tongue, can be dicult and may require sedation or general anesthesia (GA) to accomplish the biopsy. e biopsy area should be carefully evaluated for proximity to important anatomic structures, such as the mental nerve or salivary ducts or their orices. Resorbable sutures are preferred to prevent the necessity of removing sutures in the child patient. e disadvantage of some resorbable sutures is that the knot can be very hard to remove and irritating to the child. Soaking Management of Fractured Primary Tooth RootsAny dentist who extracts deciduous molars occasionally has the opportunity to treat root fractures. After the root has fractured, the dentist must consider the following factors. Aggressive surgical removal of all root tips may damage the succedaneous tooth. On the other hand, leaving the root may increase the chance for postoperative infection and may increase the theoretical potential of delaying permanent tooth eruption, although most primary root tips will resorb. A commonsense approach is best. If the tooth root is clearly visible and can be removed easily with an elevator or root tip pick, the root should be removed. If several attempts fail or if the root tip is very small or is situated deep within the alveolus, the root is best left to be resorbed, most probably by the erupting permanent tooth. As a general rule, root tips greater than or equal to one-third of the root should be removed and tips less than a third may be left to prevent damage to the underlying successor. In some cases the root tips do not resorb but are situated mesially and distally to the succeeding premolar and do not impede its eruption (Fig. 29.9). A note of the root left in situ should be placed in the patient’s records, the patient and parents should be notied that a root fragment has been retained, and they should be assured that the chance of unfavorable sequelae is remote.If the preoperative evaluation indicates that a root fracture is likely or that the developing succedaneous tooth may be dislodged during the extraction, an alternative extraction technique should be used. In these cases the crown should be sectioned with a ssure bur in a buccolingual direction (Fig. 29.10) so that the detached portions of the crown and roots can be elevated separately.1Soft Tissue Surgical ProceduresA number of soft tissue procedures occasionally must be performed for the child patient. Careful presurgical consideration should be given to the following:1. Expected change in the condition with maturation2. Optimal time (or patient age) for the procedure3. Type of anesthetic or sedation required4. Postoperative complications or sequelae5. Expected results• Figure 29.9 In this patient, unresorbed primary root tips (arrows) did not impede eruption of the suc-ceeding premolar. Also note that the congenitally missing primary molar roots are not being resorbed and the occlusal surface of this tooth is well below the occlusal plane. • Figure 29.10 The crown should be sectioned with a ssure bur in a buccolingual direction down the midline of the tooth so that the detached portions of the crown and roots can be elevated separately. 404 Part 3 The Primary Dentition Years: Three to Six Yearsis no loss of consciousness or no other serious injuries before addressing the facial injuries.Soft tissue injuries of the face or oral cavity can usually be managed with primary closure. Great care must be taken to be certain that no foreign objects are left hidden within the wound. Gravel or dirt left embedded in the soft tissue may leave a permanent tattoo, especially in the facial region.Puncture-type wounds often carry glass or debris deep within the wound. When there is doubt about the presence or absence of a foreign body in the soft tissue, a soft tissue radiograph may be helpful in identifying the presence of embedded material (see Fig. 29.11).Small lacerations of the wet portion of the lips, gingivae, alveolar mucosa, or tongue usually heal very well even if left unsutured. A resorbable suture is most commonly used intraorally, especially in children because silk sutures have the disadvantage of the need for removal.Large lacerations should be closed, regardless of their location, and multilayer wound closure may be indicated for very deep lacerations or for lacerations that extend from the face into the oral cavity (through-and-through lacerations). Principles of a layered closure include a watertight mucosal closure, followed by closure of the muscular, facial, subcutaneous, and skin layers as necessary. Facial lacerations are always reapproximated rst at signicant anatomic structures, such as the vermilion border, columella of the nose, or eyebrows. Malalignment of these structures produces a noticeable cosmetic defect. It is generally advisable to refer to an oral surgeon or a plastic surgeon if the laceration crosses the vermilion border of the lip.Facial Fracturese denitive treatment of facial fractures is best handled by an experienced dental practitioner, such as an oral maxillofacial surgeon. A thorough head and neck as well as facial exam is necessary to rule out an unsuspected fracture. Patients with maxillary or midface fractures may present with any or all of the signs and symptoms listed in Box 29.2. Patients with mandibular fractures may present with any or all of the signs or symptoms listed in Box 29.3.Initial management of facial fractures should be directed toward the immobilization of fractured segments, early antibiotic therapy for open fractures, and pain control.5 Denitive treatment should then be performed by a qualied specialist.gut sutures in glycerin before their use softens them considerably.Dentoalveolar Surgery for Impacted CaninesProcedures to uncover impacted canines have been associated with a high rate of success and may require referral to a specialist.4 Preoperative radiographs are taken to accurately locate the canine in the alveolus. It is often necessary to take two or more periapical radiographs, using the buccal object rule to predict the labiopalatal position of an impacted tooth. More advanced diagnostic imaging such a cone beam computerized tomography (CBCT) is now recommended for accurate localization of the impacted canine prior to surgery. Great care must be taken not to disturb the root of the impacted canine because it is thought that the chance of ankylosis increases if the cementum is disturbed. If root development is not complete, the exposed canine may be allowed to erupt passively. If the impacted canine has complete root development or is poorly positioned, an orthodontic bracket or chain may be bonded to the exposed portion of the crown with resin to aid a more active eruption. e exposed canine can then be orthodonti-cally positioned in the arch.Facial Injuriese dentist may be the rst health care professional consulted for injuries to the teeth, lips, jaws, or soft tissues of the face. e dentist should be aware of potential problems with each type of injury and either treat the patient appropriately or make a referral to the appropriate specialist.Initial care should be directed to pain control, hemorrhage control, patient reassurance, wound cleansing if possible, and tetanus prophylaxis when indicated. Care should be taken to account for all teeth. In cases of avulsion or crown fractures, in which teeth cannot be accounted for, chest or abdominal radiographs may be needed to locate swallowed or aspirated teeth, whereas soft tissue radiographs may be indicated to rule out crown fragments embedded through, for instance, a lip laceration (Fig. 29.11). See Chapter 16 for the radiographic technique. Traumatic injuries to the teeth are discussed in Chapters 16 and 35. A signicant number of patients who present with facial trauma may also have acute life-threatening injuries such as chest or abdominal trauma or more signicant head or neck injury. e dentist must ensure that there BA• Figure 29.11 A soft tissue radiograph (A) may be indicated to rule out crown fragments embedded through a lip laceration (B). CHAPTER 29 Oral Surgery in Children 405 accomplished in minor infections by way of a pulpectomy or extraction. Management of more serious odontogenic infections is best accomplished by surgical incision and drainage.1 Research has shown that rapid treatment of the oending tooth along with IV antibiotics is signicantly more cost eective and results in a shorter hospital admission than treating the infection with IV antibiotics alone.6 It is often necessary to identify the causative organism or organisms to prescribe the most appropriate antibiotic (see Chapter 9). For outpatient therapy, oral penicillin remains the empirical choice for odontogenic infections7; however, amoxicil-lin may provide more rapid improvement in pain or swelling and better compliance because of the longer dosage interval.8 For individuals with a penicillin allergy, clindamycin or azithromycin are recommended.8 A 5- to 7-day course of treatment is generally recommended.7 For inpatient therapy, common IV antibiotics used in the management of cellulitis are IV ampicillin/sulbactam, clindamycin, or penicillin with metronidazole.8Ankyloglossia and FrenectomiesAnkyloglossiaEtymologically, “ankyloglossia” originates from the Greek words “agkilos” (curved) and “glossa” (tongue). e English synonym is “tongue-tie.”9 Ankyloglossia (AG) is a congenital anomaly characterized by an abnormally short lingual frenum, which may restrict tongue tip mobility.10 AG can be either a classic anterior Odontogenic InfectionsInfections of odontogenic origin are common in child and adolescent patients. Classic signs and symptoms of infection include redness, pain, swelling, and local and systemic temperature increases (Fig. 29.12). Because of wider marrow spaces in the child, an odontogenic infection can rapidly spread through the bone, possibly resulting in damage to the erupting teeth. Most odontogenic infections in the child are not serious and can be easily managed by removing the source of infection with pulp therapy or removal of the involved tooth. Although uncommon, serious complications can occur when infection spreads beyond the dentition, including cellulitis, cavernous sinus thrombosis, brain abscess, temporary blindness, airway obstruction, and mediastinal spread of infection. Managing cellulitis can be challenging because it has a wide variability of clinical presentation due to the involvement of multiple anatomical structures, polymicrobial etiology, and diering disease progression.6 Signs and symptoms of a more serious spread of infection include an elevated systemic temperature (102°F to 104°F), diculty in swallowing, voice hoarseness, diculty in breathing, nausea, fatigue, and sweating. e child with an odontogenic infection may become dehydrated as a result of his or her refusal to take uids because of oral pain. Children who present with these symptoms often need management with hospitalization, intravenous (IV) uids, and antibiotics.Management of odontogenic infections is directed at providing prompt and adequate drainage of the infection. This can be (Patients may present with any or all of the following.)1. Altered occlusion2. Numbness in the infraorbital nerve distribution3. Double vision4. Periorbital ecchymosis (bruising)5. Facial asymmetry or edema6. Limited mandibular opening7. Subcutaneous emphysema (skin cracking upon palpation)8. Nasal hemorrhage9. Ecchymosis of the palatal or buccal mucosa10. Mobility or crepitus upon manipulation of the maxillaSigns and Symptoms of Maxillary or Midface Fractures• BOX 29.2 (Patients may present with any or all of the following.)1. Mandibular hemorrhage2. Numbness in the mental or inferior alveolar nerve distribution3. Altered occlusion4. Ecchymosis or abrasion of the chin5. Ecchymosis of the oor of the mouth or buccal mucosa6. Periauricular pain7. Mandibular deviation on opening8. Mobility or crepitus upon manipulation of the mandibleSigns and Symptoms of Mandibular Fractures• BOX 29.3 • Figure 29.12 A child with right facial cellulitis and swelling due to an abscessed tooth. 406 Part 3 The Primary Dentition Years: Three to Six YearsClassication of AnkyloglossiaAG can be observed at dierent ages with specic indications for treatment for each group.10,14 e Hazelbaker assessment tool for lingual frenulum function (HATLFF) was developed to evaluate the severity of tongue-ties in newborns. It is based on the tongue’s appearance and its functional aspects, and it uses a scoring system to classify babies’ tongues into one of three categories: functionally impaired, acceptable, or perfect.9 However, it is complex, lengthy, and has not been validated in a controlled manner.12Ghaheri et al. described two simpler classications of upper lip-tie and tongue-tie (Box 29.4).11 Coryllos types 1 and 2, con-sidered as “classical” tongue-tie, are the most common and obvious tongue-ties and probably account for 75%. Types 3 and 4 are less common and, because they are more dicult to visualize, are the most likely to go untreated. Type 4 is most likely to cause symptoms that are more signicant for mother and infant.15 Kotlow described upper lip-tie classication for infants.16Ankyloglossia and BreastfeedingRecognition of potential benets of breastfeeding in recent years has resulted in renewed interest in functional AG sequelae. Of infants with AG, there is a reported 25% to 80% incidence of breastfeeding diculties, including failure to thrive, maternal breast pain, poor milk supply, and refusing the breast. Infants with restrictive AG cannot extend their tongues over the lower gum line to form a proper seal and therefore use their jaws to keep the breast in the mouth. Depending on the audience, enthusiasm for surgical treatment varies.13Typically reported problems related to poor latch include signs of frustration such as head-banging, maternal nipple pain, and signs of an unsatised baby (i.e., frequent or continuous feeds often with “fussing”).17 Francis et al. performed a systematic review of the surgical and nonsurgical treatments for infants with AG and breastfeeding outcomes, although the quality of the majority of the studies was very low. In the randomized controlled trials (RCTs) in which the mother self-reported improved breastfeeding, signicant improvements for frenotomized infants versus nontreated infants were noted (96% vs. 3% and 78% vs. 47%, respectively).13 ree RCTs used an observer to assess breastfeeding eectiveness, and in all of these studies the observer was blinded to the treatment. Among these, one study reported signicant improvement in breastfeeding immediately after frenotomy compared with sham treatment. In contrast, of the remaining two RCTs, the independent blinded observers did not detect a dierence in breastfeeding improvement immediately and 5 days following intervention. Regarding maternal nipple pain, similar results as those for breastfeeding have been found, with one RCT reporting signicant improvement and others nding nonsignicant reductions in maternal discomfort between intervention and sham groups. Overall, a small body of evidence suggests that frenotomy may be associated with mother-reported improvements in breastfeeding and pain, but the strength of evidence on this topic is low. Future research could change our understanding of the eect of frenotomy on breastfeeding.13Ankyloglossia and Nonbreastfeeding IssuesNonbreastfeeding OutcomesWith only two comparative studies reviewed by Chinnadurai et al., both with signicant methodologic limitations, evidence is insuf-cient to draw conclusions about the benets of surgical interven-tions regarding nonbreastfeeding feeding (i.e., bottle) outcomes for infants and children with AG.18tongue-tie, a submucosal restriction, and/or a tethered superior labial frenum (upper lip-tie).11Otolaryngologists (ear, nose, and throat specialists), oral surgeons, pediatricians, speech therapists, and lactation consultants may all voice dierent opinions regarding the various aspects of AG, and its denitions range from vague descriptions of a tongue that functions with a less-than-normal range of activity to a specic description of the frenum being short, thick, muscular, or brotic. e plethora and variety of AG denitions in the literature suggest the lingering controversy regarding this condition and its clinical signicance. Associations between tongue-tie, lactation problems, speech disorders, and other oral motor disorders (e.g., problems with swallowing or licking) have also been inconsistent and are an ongoing source of controversy within the medical community.12 One survey of otolaryngologists, pediatricians, speech pathologists, and lactation consultants reported signicant disparities within and among these groups regarding their approaches to AG and their beliefs regarding its association with feeding, speech, and social problems. Unfortunately, dentists are similarly divided on the topic.12 AG may reduce tongue mobility and has been associated with functional limitations in breastfeeding, swallowing, articulation, orthodontic problems including malocclusion, open bite, separation of upper/lower incisors, mechanical problems related to oral clear-ance, and psychological stress.13Etiology of Ankyloglossiae exact etiopathogenesis of tongue-tie is unknown9; however, one author has described the etiology of AG as follows: the tongue is fused to the oor of the mouth in early development. Cell death and resorption free the tongue, with the frenum left as the only remnant of initial attachment. e lingual frenulum typically becomes less prominent with the natural process of the child’s growth: as the alveolar ridge grows in height and teeth begin to erupt. is process occurs during the rst 6 months to 5 years of life.12 ere may be a genetic predisposition to AG, and an associa-tion between AG and some syndromes, such as X-linked cleft palate syndrome, have been observed.12 AG has also been diagnosed in some rare syndromes such as van der Woude, orofaciodigital syndrome, and Beckwith-Wiedemann.10,12 Nevertheless, most AGs are an isolated congenital anomaly that is observed in persons without any other congenital anomalies or diseases.9,12 Prevalence ranges from 0.02% to 10.7%, depending on the denition of the authors, and is seen more often in males.Coryllos Classications of Tongue-Tie(Divided into four types, according to how close to the tip of the tongue the leading edge of the frenulum is attached)Type 1: Attachment of the frenulum to tip of tongueType 2: Attachment is 2–4 mm behind tip of tongue/on or behind alveolar ridgeType 3: Attachment to mid-tongue and the middle of the oor of the mouth, usually tighter and less elasticType 4: Attachment against base of tongue, thick shiny and inelasticKotlow Classications of Upper Lip-TieClass I: No signicant attachmentClass II: Attachment mostly into the gingival tissueClass III: Attachment in front of the anterior papillaClass IV: Attachment into the papilla or extending into hard palateClassications of Ankyloglossia• BOX 29.4 CHAPTER 29 Oral Surgery in Children 407 When this technique’s relative simplicity is weighted against the severity of the consequences of untreated cases or future treat-ment with the frenectomy procedure, pediatric dentists should consider the frenotomy technique.10Frenectomy Techniquee frenectomy procedure20 is dened as the excision or removal of the frenum, which can be accomplished by the conventional technique with a scalpel or by the use of a soft tissue laser. Fre-nectomy is the preferred procedure for patients with a thick and vascular frenum where severe bleeding may be expected, and in some cases, reattachment of the frenum by scar tissue may occur. e procedure in young children is often performed under GA. However, older children or adults may tolerate the procedure with the use of local anesthesia alone. e frenum is released in a similar Speech OutcomesSpeech concerns were the second most prevalent outcome described in the AG literature, specically articulation and intelligibility. Poor-quality cohort studies have reported improved articulation and intelligibility with surgical AG treatment; however, other benets to speech are unclear. Given the lack of good-quality studies, the strength of the evidence for the eect of surgical interventions to improve speech and articulation is insucient. In a separate review, authors concluded that although there are some possible positive indications to treating tongue-ties, especially from the parents’ perception, there is no substantial evidence to support prophylactic frenotomy on the basis of promoting subse-quent speech development.17Social ConcernsPossible social concerns related to reduced tongue mobility may include speech, oral hygiene, excessive salivation, kissing, spitting while talking, and self-esteem. With only one poor-quality compara-tive study, the evidence related to the ability of AG treatment to alleviate social concerns is currently insucient.18Surgical TreatmentTreatment options such as observation, speech therapy, frenotomy without anesthesia, and frenectomy under GA have all been sug-gested in the literature to correct an abnormal frenulum. e following techniques are of particular interest in pediatric dentistry: frenotomy and frenectomy.Frenotomy Techniquee frenotomy procedure is dened as the cutting or division of the frenum. e discomfort associated with the release of thin and membranous frena appears to be brief and minor. us there is a paucity of literature regarding eective analgesia for frenotomy.12 e procedure may be accomplished without local anesthesia; however, some practitioners highly recommend the use of topical lidocaine anesthetic gel and/or local anesthetic for pain control and to alleviate any parental concerns.10 Benzocaine should be used with caution in infants, due to the concern for methemo-globinemia (see Chapter 7).19 Release of the tongue-tie appears to be a minor procedure but may cause complications such as bleeding or infection or injury to Wharton duct. There is a risk that postoperative scarring may limit tongue movement even further, necessitating reoperation. From the limited literature, the incidence of complications appears to be rare.12e infant is placed supine with the elbows held close to the body, and the parent or an assistant stabilizes the head. e tongue is lifted gently with sterile gauze and stabilized by the nondominant hand, exposing the frenum. e frenum is then divided with small sterile scissors at its thinnest portion. e incision begins at the frenum’s free border and proceeds posteriorly, adjacent to the tongue (Fig. 29.13). is is necessary to avoid injury to the more inferiorly placed submandibular ducts in the oor of the mouth. ere should be minimal blood loss (i.e., no more than a drop or two, collected on sterile gauze). If needed, bleeding can be controlled easily with a brief period of pressure applied with gauze. e incision is not sutured. Feeding may be resumed immediately. No specic follow-up care is required, except that breast milk is recom-mended for at least the next few feedings. Parents should be advised that a postoperative white brin clot might form at the incision site during the rst few days. Follow-up in 1 to 2 weeks should show that the incision is completely healed.ABC• Figure 29.13 (A–C) Frenotomy procedure for an infant. (From Junqeira MA, Cunha NN, Costa e Silva LL, et al. Surgical techniques for the treat-ment of ankyloglossia in children: a case series. J Appl Oral Sci. 2014;22:241–248.) 408 Part 3 The Primary Dentition Years: Three to Six Yearsthe procedure, and produces less postoperative discomfort and functional complications (eating and speech).21–24 Although emerging research shows advantages to the use of laser energy, the laser technique requires some precautions. The practitioner must understand the type of laser being used and the appropriate settings and technique for that laser because multiple types of lasers are manner as in the frenotomy technique, although occasionally limited division of the genioglossus may be required for adequate release (Fig. 29.14). e wound is sutured with a Z-plasty ap closure.10 Studies that have compared the conventional technique with the use of various lasers have generally found that use of the laser energy negates the need for sutures, results in less bleeding during ABCDEFGH• Figure 29.14 (A–H) Frenectomy procedure in an older child using a hemostat and a surgical blade. Wound closure is usually performed using a Z-plasty ap procedure. (From Junqeira MA, Cunha NN, Costa e Silva LL, et al. Surgical techniques for the treatment of ankyloglossia in children: a case series. J Appl Oral Sci. 2014; 22:241–248.) CHAPTER 29 Oral Surgery in Children 409 11. Ghaheri BA, Cole M, Fausel SC, et al. Breastfeeding improvement following tongue-tie and lip-tie release: a prospective cohort study. Laryngoscope. 2016;127(5):1217–1223.12. Rowan-Legg A. Ankyloglossia and breastfeeding. Canadian Pediatric Society Position Statement. Paediatr Child Health. 2015;20(4): 209–214.13. Francis DO, Krishnaswami S, McPheeters M. Treatment of ankyloglos-sia and breastfeeding outcomes: a systematic review. Pediatrics. 2015;135(6):e1458–e1466.14. Ferrés-Amat E, Pastor-Vera T, Ferrés-Amat E, et al. Multidisciplinary management of ankyloglossia in childhood. Treatment of 101 cases. A protocol. Med Oral Patol Oral Cir Bucal. 2016;21(1):e39–e47.15. Coryllos E, Genna CA, Salloum AC. American Academy of Pediatrics section on breastfeeding. http://www2.aap.org/breastfeeding/les/pdf/BBM-8-27%20Newsletter.pdf. Accessed February 13, 2017.16. Kotlow LA. Diagnosing and understanding the maxillary lip-tie (superior labial, the maxillary labial frenum) as it relates to breastfeed-ing. J Hum Lact. 2013;29(4):458–464.17. Brookes A, Bowley DM. Tongue tie: the evidence for frenotomy. Early Hum Dev. 2014;90(11):765–768.18. Chinnadurai S, Francis DO, Epstein RA, et al. Treatment of ankyloglos-sia for reasons other than breastfeeding: a systematic review. Pediatrics. 2015;135(6):e1467–e1474.19. US Food and Drug Administration. Benzocaine and babies: not a good mix; 2015. https://www.fda.gov/ForConsumers/Consumer Updates/ucm306062.htm. Accessed September 21, 2017.20. Junqeira MA, Cunha NNO, Costa e Silva LL, et al. Surgical techniques for the treatment of ankyloglossia in children: a case series. J Appl Oral Sci. 2014;22(3):241–248.21. Medeiros Júnior R, Gueiros LA, Silva IH, et al. Labial frenectomy with Nd:YAG laser and conventional surgery: a comparative study. Lasers Med Sci. 2015;30:851–856.22. Haytac MC, Ozcelik O. Evaluation of patient perceptions after frenectomy operations: a comparison of carbon dioxide laser and scalpel techniques. J Periodontol. 2006;77:1815–1819.23. Akpinar A, Toker H, Lektemur Alpan A, et al. Postoperative discomfort after Nd:YAG laser and conventional frenectomy: comparison of both genders. Aust Dent J. 2016;61:71–75.24. Gargari M, Autili N, Petrone A, et al. Using the diode laser in the lower labial frenum removal. Oral Implantol. 2012;5(2–3):54–57.available (carbon dioxide, Nd:YAG, diode, etc.). In addition, the clinician and sta must be properly trained in laser safety for themselves and the patient.Complications of Frenotomy/FrenectomyComplications of the frenotomy/frenectomy procedure20 include infection, excessive bleeding, recurrent AG due to excessive scarring, new speech disorders developing postoperatively, and glossoptosis (tongue “swallowing”) due to excessive tongue mobility.A clinician is encouraged to:1. Examine the frenum attachment2. Diagnose AG if it is present and evaluate its severity3. Be aware of the benets of intervention4. Refer patients to a qualied surgeon if unable to perform a frenotomy or frenectomyReferences1. Sanders B. Pediatric Oral and Maxillofacial Surgery. St Louis: Mosby; 1979.2. Kruger G. Textbook of Oral and Maxillofacial Surgery. 6th ed. St Louis: Mosby; 1984.3. Gibilisco JA. Oral Radiographic Diagnosis. Philadelphia: Saunders; 1985.4. Field CA. Surgery and orthodontic treatment for unerupted teeth. J Am Dent Assoc. 1986;113:590–591.5. Rowe N, Williams J. Maxillofacial Injuries. Edinburgh: Churchill Livingstone; 1985.6. ikkurissy S, Rawlins JT, Kumar A, et al. Rapid treatment reduces hospitalization for pediatric patients with odontogenic-based cellulitis. Am J Emerg Med. 2010;28(6):668–672.7. American Academy of Pediatric Dentistry. Guideline on use of antibiotic therapy for pediatric dental patients. Pediatr Dent. 2016;38(6):325–327.8. Flynn T. What are the antibiotics of choice for odontogenic infections, and how long should the treatment course last? Oral Maxillofac Surg Clin North Am. 2011;23(4):519–536.9. Suter VGA, Bornstein MM. Ankyloglossia: facts and myths in diagnosis and treatment. J Periodontol. 2009;80:1204–1219.10. Kupietzky A, Botzer E. Ankyloglossia in the infant and young child: clinical suggestions for diagnosis and management. Pediatr Dent. 2005;27:40–46. CHAPTER 29 Oral Surgery in Children 409.e1 Case Study: Extraction of Primary MolarJillian WallenA healthy, 3-year-old female required full mouth dental rehabilitation in the operating room under general anesthesia. Consent was obtained for all procedures to be completed during the surgical procedure, including extractions. Fig. E29.1A shows the periapical radiograph, which was exposed as part of the full mouth radiographic series. Treatment options for tooth #T (lower left second primary molar) included vital pulpotomy, pulpectomy, and tooth extraction.Given the importance of maintaining the primary second molar for the developing occlusion, pulpal therapy was attempted. However, the pulp was hemorrhagic, and bleeding could not be controlled after the coronal pulp tissue was amputated. Hence the tooth was diagnosed with irreversible pulpitis, and the treatment plan was modied to include extraction. As such, Video 29.1 shows that the tooth has been previously accessed to attempt pulp treatment.A dental curette was used to separate the epithelial attachment. An elevator was then used to luxate the tooth, taking care not to damage underlying and adjacent teeth. A lower forceps #27 was seated as apically as possible on the buccal and lingual aspects of the tooth. The extraction was then performed using the proper forceps technique. A gure-of-eight movement was used to achieve expansion of the socket and tooth delivery, without fracture of remaining crown or root structure.As with all extractions, the nondominant hand was used to control and support the jaw and help retract the cheek, lips, and tongue from the surgical eld. After tooth removal the extracted tooth was visually inspected for fracture or granuloma (see Fig. E29.1B). The socket was also inspected, and hemostasis was achieved using digital pressure (see Fig. E29.1C). Gelfoam was placed in the socket to assist with hemostasis. Gelfoam is a spongelike, porous material that is made from puried porcine gelatin (Fig. E29.2). It will be resorbed by the patient over a 4- to 6-week period. Other hemostatic agents include CollaPlug, which is also spongelike and made from porcine collagen, and Surgicel, a plant-based material made of an oxidized cellulose polymer, which is like a piece of mesh fabric that can be folded and placed into the socket (see Fig. E29.2). Once Surgicel absorbs blood, it becomes a dark gelatinous mass that aids in clotting. Resorbable sutures could also be used as an adjunct to achieve hemostasis.The patient tolerated the procedure well, and specic postoperative instructions were given to the patient’s parent postoperatively (see Box 29.1). These included the risk of cheek and tongue biting in the ABC• Figure E29.1 (A) Preoperative radiograph of tooth #T. (B) Extracted specimen with roots intact. (C) Extraction socket. AB• Figure E29.2 (A) Gelfoam absorbable gelatin sponges. (B) Surgicel absorbable, exible hemostatic material. Continued 409.e2 Part 3 The Primary Dentition Years: Three to Six Yearspostoperative period, risk of prolonged bleeding from sucking on straws or spitting, and the importance of good oral hygiene measures to decrease the risk of future caries and secondary infection.Questions1. Which of the following forceps can be used in the extraction of a mandibular primary molar without risk of damage to permanent tooth bud? a. 1Fs b. 150S c. 151S d. 23Answer: c2. The purpose of the dental curette in extractions includes all of the following except: a. Palpate and evaluate the extraction site b. Separate the epithelial attachment c. Provide buccal lingual force to assist in elevation d. Evaluate the tooth socket after extractionAnswer: c3. Aggressive manipulation of the curette is contraindicated in a primary tooth socket due to risk of damage to succeeding tooth bud. a. True b. FalseAnswer: a4. Initial hemostasis is best achieved using all of the following except: a. Digital pressure by the operator b. The child biting on gauze c. Encouraging spitting and swishing of the mouth d. Placement of a gelatin sponge such as GelfoamAnswer: c 410PART 4The Transitional Years: Six to Twelve Years30 The Dynamics of Change31 Examination, Diagnosis, and Treatment Planning32 Prevention of Dental Disease33 Pit and Fissure Sealants: Scientic and Clinical Rationale34 Pulp Therapy for the Young Permanent Dentition35 Managing Traumatic Injuries in the Young Permanent Dentition36 Treatment Planning and Management of Orthodontic ProblemsMany changes will occur as a child ages from 6 to 12 years old. e physical changes will be dramatic, and the changes relating to facial form, occlusion, the advent of permanent teeth, and the esthetic appearance of these permanent teeth are the professional responsibility of the dentist. He or she must supervise the exfoliation of the 20 primary teeth present in the 6-year-old and eruption of the 28 permanent teeth that are found in most 12-year-olds. e dentist must establish a relationship with the patient and family to ensure that dental care is delivered within a trusting framework. e dentist must advocate preventive measures such as sealants, meticulous hygiene during orthodontics, additional uoride products as needed, and nutrition counseling as these patients make their own food choices. e dentist must also provide answers to parents concerned about the appearance of their child, intercept those developing malocclusions, and when appropriate, refer those patients with malocclusions that need specialist care. e dentist who can deliver the child from age 6 years to adolescence with little to no amount of hard tissue disease, no remarkable soft tissue diseases, allegiance to prevention and developed home care habits, and harmonious dentofacial relationships has indeed mastered the ultimate obligations in treating this age group. 41130 The Dynamics of ChangeMAN WAI NG AND ZAMEERA FIDACHAPTER OUTLINEPhysical ChangesBodyCraniofacial ChangesDental ChangesCognitive ChangesEmotional ChangesSocial ChangesDental Caries and Dietary FactorsWhy Dietary Factors Are Important to the Transitional DentitionSummaryand increases in muscular tissue. In addition, the lymphatic tissues reach a peak of development during these years, to the point where they exceed the amounts found in adults.Craniofacial Changese period from ages 6 through 12 years represents a continuous progression of the growth in the head and neck. From age 5 to 10 years (approximately the age range of interest here), neural and cranial growth are found to be almost entirely complete (Fig. 30.1). During this same age span, the jaws (maxilla = A = 2 and mandible = B = 3 of Fig. 30.1) grow at a faster rate than the cranium.Using the Bolton standards for illustrative purposes,2 nasal projection and increased mandibular prominence are demon-strated (Fig. 30.2). e nasal cartilage and mandibular condyle continue to grow by endochondral bone formation for some time. e female mandibular growth spurt is most likely completed during this time period, whereas the mandibular growth spurt in males is yet to come. Growth modication can therefore be considered in this age group. Changes in cranial base length caused by endochondral bone formation at the sphenooccipital synchondrosis cease in early adolescence, but some appositional changes continue to occur at the basion and nasion. Vertically, there is a continued lowering of the palatal vault with sutural growth and apposition on the oral side of the palate and resorption on the nasal side as the intramembranous process of bone forma-tion continues. Vertical facial growth is also complemented by dentoalveolar growth as the permanent teeth erupt and the alveolar ridges develop.In the transverse plane, there is continued growth at the midpalatal suture. Most transverse palatal sutural growth is completed for females during this period when the rst bridging of the suture occurs. Transverse appositional widening of the alveolar ridge occurs with eruption of the permanent teeth. Widening of the anterior arch accompanies lateral incisor eruption and is followed by width increases in the canines and premolars (Fig. 30.3).e implications of these changes are that anteroposterior growth modication for class III problems should be attempted during this time. It seems there is more total facial change in this age group than in older patients.3 For class II problems, growth modication can be attempted now or during early adolescence with equivalent results. Transverse changes should be completed using lingual arch–type appliances or rapid palatal expansion if greater forces are necessary to interrupt the stable midpalatal suture late in this age group. Vertical growth will continue in the face through late adolescence.Physical ChangesBodye median (50th percentile) weight and height of 6-year-old boys in the United States are 47.5 pounds and 45.5 inches, respectively, whereas the same medians for girls are 46 pounds and 45 inches. By the time children reach age 12 years, boys will weigh 90 pounds and be 59 inches tall and girls will weigh 90.25 pounds and be 59.5 inches tall. is is a time of substantial continuous growth.1During the period between the ages of 6 and 10 years, boys as a group are generally slightly taller than girls until around age 10 years. From age 10 years to around age 15 years, girls are slightly taller than boys. From a weight standpoint, boys are slightly heavier than girls until around age 11 years, when girls overtake boys in weight for a brief time. Although it is generally assumed that girls are a couple of years ahead of boys in their sexual and general maturation, this may be an overstatement due to the observability of the changes taking place. e real dierence is actually about 1 year. is is because height and breast development are considered the main markers of female development compared with penis, scrotum, and height development in males. Nonetheless, the pregrowth spurt in males is steady and creates a larger platform upon which to launch the more robust, later spurt as compared with the pattern in females. is accounts for the larger terminal size of males, in general, to females.Other growth and developmental changes that are noteworthy during these years are further increases in blood pressure, continuing decreases in the pulse rate, increased mineralization of the skeleton,

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