Examination, Diagnosis, and Treatment Planning for General and Orthodontic Problems










510 Part 4 The Transitional Years: Six to Twelve Years
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29. Hoshino E, Kurihara-Ando N, Sato I, et al. In-vitro antibacterial
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38. Cvek M, Andreasen JO, Borum MK. Healing of 208 intra-alveolar
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39. Andreasen JO, Andreasen FM, Mejare I, et al. Healing of 400
intra-alveolar root fractures. 2. Eect of treatment factors such as
treatment delay, repositioning, splinting type and period and antibiot-
ics. Dent Traumatol. 2004;20(4):203–211.
40. Andreasen FM. Pulpal healing after luxation injuries and root fracture
in the permanent dentition. Endod Dent Traumatol. 1989;5(3):
111–131.
41. Oginni AO, Adekoya-Sofowora CA, Kolawole KA. Evaluation of
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obliteration: an aid to treatment decision. Dent Traumatol.
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42. Tronstad L. Root resorption—etiology, terminology and clinical
manifestations. Endod Dent Traumatol. 1988;4(6):241–252.
43. Tsilingaridis G, Malmgren B, Andreasen JO, et al. Intrusive luxation
of 60 permanent incisors: a retrospective study of treatment and
outcome. Dent Traumatol. 2012;28(6):416–422.
44. Andreasen JO, Hjorting-Hansen E. Replantation of teeth. I. Radio-
graphic and clinical study of 110 human teeth replanted after
accidental loss. Acta Odontol Scand. 1966;24(3):263–286.
45. Hiltz J, Trope M. Vitality of human lip broblasts in milk, Hanks
balanced salt solution and Viaspan storage media. Endod Dent
Traumatol. 1991;7(2):69–72.
References
1. Andreasen JO, ed. e Dental Trauma Guide. San Diego: International
Association of Dental Traumatology; 2012.
2. Jarvinen S. Incisal overjet and traumatic injuries to upper permanent
incisors. A retrospective study. Acta Odontol Scand. 1978;36(6):
359–362.
3. Palchak MJ, Holmes JF, Vance CW, et al. A decision rule for identifying
children at low risk for brain injuries after blunt head trauma. Ann
Emerg Med. 2003;42(4):492–506.
4. Tecklenburg FW, Wright MS. Minor head trauma in the pediatric
patient. Pediatr Emerg Care. 1991;7(1):40–47.
5. Pandor A, Goodacre S, Harnan S, et al. Diagnostic management
strategies for adults and children with minor head injury: a systematic
review and an economic evaluation. Health Technol Assess.
2011;15(27):1–202.
6. Trope M. Clinical management of the avulsed tooth: present strategies
and future directions. Dent Traumatol. 2002;18(1):1–11.
7. Andreasen JO, Andreasen FM, Andersson L. Textbook and Color
Atlas of Traumatic Injuries to the Teeth. 4th ed. Copenhagen: Blackwell
Munksgaard; 2007:891.
8. Weisleder R, Yamauchi S, Caplan DJ, et al. e validity of pulp
testing: a clinical study. J Am Dent Assoc. 2009;140(8):1013–1017.
9. Alghaithy RA, Qualtrough AJ. Pulp sensibility and vitality tests for
diagnosing pulpal health in permanent teeth: a critical review. Int
Endod J. 2017;50(2):135–142.
10. Mesaros SV, Trope M. Revascularization of traumatized teeth assessed
by laser Doppler owmetry: case report. Endod Dent Traumatol.
1997;13(1):24–30.
11. Caldeira CL, Barletta FB, Ilha MC, et al. Pulse oximetry: a useful
test for evaluating pulp vitality in traumatized teeth. Dent Traumatol.
2016;32(5):385–389.
12. Pozzobon MH, de Sousa Vieira R, Alves AM, et al. Assessment of
pulp blood ow in primary and permanent teeth using pulse oximetry.
Dent Traumatol. 2011;27(3):184–188.
13. Diangelis AJ, Andreasen JO, Ebeleseder KA, et al. International
Association of Dental Traumatology guidelines for the management
of traumatic dental injuries: 1. Fractures and luxations of permanent
teeth. Dent Traumatol. 2012;28(1):2–12.
14. Palomo L, Palomo JM. Cone beam CT for diagnosis and treatment
planning in trauma cases. Dent Clin North Am. 2009;53(4):717–727,
vi–vii.
15. White KC, Cox CF, Kanka J, et al. Histologic pulpal response of
acid etching vital dentin. J Dent Res. 1992;71(1 suppl):188.
16. Costa CA, Hebling J, Hanks CT. Current status of pulp capping
with dentin adhesive systems: a review. Dent Mater. 2000;16(3):
188–197.
17. Hilton TJ, Ferracane JL, Mancl L. Northwest Practice-based Research
Collaborative in Evidence-based Dentistry. Comparison of CaOH
with MTA for direct pulp capping: a PBRN randomized clinical
trial. J Dent Res. 2013;92(7 suppl):16S–22S.
18. Schwendicke F, Brouwer F, Schwendicke A, et al. Dierent materials
for direct pulp capping: systematic review and meta-analysis and trial
sequential analysis. Clin Oral Investig. 2016;20(6):1121–1132.
19. Felman D, Parashos P. Coronal tooth discoloration and white mineral
trioxide aggregate. J Endod. 2013;39(4):484–487.
20. Cvek M. A clinical report on partial pulpotomy and capping with
calcium hydroxide in permanent incisors with complicated crown
fracture. J Endod. 1978;4(8):232–237.
21. Fuks AB, Gavra S, Chosack A. Long-term followup of traumatized
incisors treated by partial pulpotomy. Pediatr Dent. 1993;15(5):
334–336.
22. Schmitt D, Lee J, Bogen G. Multifacted use of ProRoot MTA root
canal repair material. Pediatr Dent. 2001;23(4):326–330.
23. Salako N, Joseph B, Ritwik P, et al. Comparison of bioactive glass,
mineral trioxide aggregate, ferric sulfate, and formocresol as pulpotomy
agents in rat molar. Dent Traumatol. 2003;19(6):314–320.

CHAPTER 35 Managing Traumatic Injuries in the Young Permanent Dentition 511
52. Andreasen JO, Borum MK, Andreasen FM. Replantation of 400
avulsed permanent incisors. 3. Factors related to root growth. Endod
Dent Traumatol. 1995;11(2):69–75.
53. Hammarstrom L, Pierce A, Blomlof L, et al. Tooth avulsion
and replantation—a review. Endod Dent Traumatol. 1986;2(1):
1–8.
54. Sae-Lim V, Wang CY, Trope M. Eect of systemic tetracycline and
amoxicillin on inammatory root resorption of replanted dogs’ teeth.
Endod Dent Traumatol. 1998;14(5):216–220.
55. Coccia CT. A clinical investigation of root resorption rates in
reimplanted young permanent incisors: a ve-year study. J Endod.
1980;6(1):413–420.
46. Krasner P, Person P. Preserving avulsed teeth for replantation. J Am
Dent Assoc. 1992;123(11):80–88.
47. Blomlof L. Storage of human periodontal ligament cells in a combina-
tion of dierent media. J Dent Res. 1981;60(11):1904–1906.
48. Sigalas E, Regan JD, Kramer PR, et al. Survival of human periodontal
ligament cells in media proposed for transport of avulsed teeth. Dent
Traumatol. 2004;20(1):21–28.
49. Lekic PC, Kenny DJ, Barrett EJ. e inuence of storage conditions
on the clonogenic capacity of periodontal ligament cells: implications
for tooth replantation. Int Endod J. 1998;31(2):137–140.
50. Hinckfuss SE, Messer LB. An evidence-based assessment of the
clinical guidelines for replanted avulsed teeth. Part II: prescription
of systemic antibiotics. Dent Traumatol. 2009;25(2):158–164.
51. Andreasen JO, Borum MK, Jacobsen HL, et al. Replantation of 400
avulsed permanent incisors. 2. Factors related to pulpal healing.
Endod Dent Traumatol. 1995;11(2):59–68.

CHAPTER 35 Managing Traumatic Injuries in the Young Permanent Dentition 511.e1
Case Study: Splinting for an Avulsed Tooth
Janice G. Jackson
An adolescent patient suffers a traumatic event and tooth #8 was avulsed
and recovered. The mother retrieves the tooth and places it in milk. They
arrive at the dental ofce 20 minutes later. The International Association of
Dental Traumatology (IADT) Guidelines for avulsion were followed based on a
dry time of less than 60 minutes.
1
Tooth #8 was replanted and splinted
(Video 35.1).
Splinting is a clinical stabilization technique for avulsed teeth, providing a
exible material to be bonded to teeth using owable composite.
2,3
The
splint material can be varied materials such as 20- to 30-pound test nylon
monolament shing line, extremely light orthodontic wire (.010 or .012), or
twisted orthodontic ligature wire (.010).
2,3
The best splints should: be passive
(causing no trauma); allow functional tooth movement; permit endodontic
access and vitality testing; be easy to clean; and be easily placed and
removed.
2,3
Preparation for Splint Placement
Steps required for all patients such as patient histories, consents, and
extraoral and intraoral examinations should be completed. The following
steps should be taken after the initial patient evaluation:
1. Take initial periapical radiograph (Fig. E35.1).
2. Prepare the patient for replanting the tooth:
a. Obtain profound local anesthesia.
b. Irrigate the socket with saline and evaluate. If there is a fracture of
the socket wall, reposition it with an instrument such as the handle
of a mirror.
c. Obtain isolation with cheek retractors and/or cotton rolls.
3. Determine the length of splint material:
Measure from one to two abutment teeth on each side of the avulsed
tooth.
2
Usually for anterior permanent teeth #8 or #9, this span will be
from maxillary cuspid (#6) to cuspid (#11). If the cuspid is unerupted
proceed to the next erupted permanent tooth on that side of the arch.
4. Replant the tooth and check for correct positioning.
5. Clean the labial of the teeth, apply etchant gel to the middle one-third of
the labial surface for 10 to 20 seconds.
6. Rinse thoroughly and lightly dry.
7. Maintain isolation and apply adhesive and light cure.
8. Position the splint material by stabilizing with an instrument or gloved
ngers.
9. Start at one of the end abutment teeth, applying enough owable
composite over the splint material to secure it and light cure.
3
10. Proceed to attach the splint material to the adjacent teeth, skipping the
replanted tooth, and lastly bond the splint material to the replanted
tooth.
3
11. Take a radiograph of the splinted tooth (Fig. E35.2).
12. Give the patient home care instructions (Box E35.1).
2,3
Questions
1. Why is it important to take a preoperative and postoperative periapical
lm?
Answer: A preoperative radiograph assesses that the socket is intact
without alveolar fractures or other material in the socket. If there is an
alveolar fracture, a blunt instrument may be used to reposition the
socket wall. Other debris may be removed by gentle lavage of the socket
with saline. A postoperative radiograph after splinting veries the normal
position of the replanted tooth in the socket.
2. Replantation is not recommended after what length of dry time? Explain
why.
Answer: The long-term prognosis is poor after more than 60 minutes of
dry time outside the socket. The greater the length of dry time outside
the socket, the less favorable the outcome for the vitality of the
periodontal ligament (PDL) cells. Ankylosis and root resorption are the
eventual outcomes due to the nonviable PDL cells. Both eventually lead
to loss of the tooth.
3. What is the importance of good oral hygiene for replanted teeth?
Answer: Good oral hygiene aids the healing process of the replanted
tooth and the surrounding soft tissues.
4. The length of splint wear is inuenced by what factors?
Figure E35.1 Pretreatment periapical radiograph of tooth #8.
Figure E35.2 Posttreatment periapical radiograph of tooth #8.
1. Soft diet; avoid biting on splinted teeth
2. Continue regular oral hygiene twice a day
3. Use mouthrinse as prescribed
4. Take medications as prescribed
5. Call dentist immediately if splint breaks or becomes loose
6. Seek endodontic treatment as recommended
7. Follow up in 2 weeks
Home Care Instructions for a Splint BOX E35.1
Continued

511.e2 Part 4 The Transitional Years: Six to Twelve Years
Answer: The time required for wearing a splint is inuenced by factors
such as severity of the initial injury and bony fractures, if present;
wearing a passive exible splint; tooth stability for endodontic treatment;
any reinjury during the healing process; and good oral hygiene.
5. Why is the replanted tooth the last tooth to be attached to the splint?
Answer: The replanted tooth should be stabilized in the tooth socket
and to the splint using the least amount of force needed for aligning
it in the most natural position with the adjacent teeth. There should
be no interference with the replanted tooth when the teeth are in
occlusion.
References
1. Andersson L, Andreasen JO, Day P, et al. International Association of Dental
Traumatology guidelines for the management of traumatic dental injuries: 2.
Avulsion of permanent teeth. Dent Traumatol. 2012;28(2):88–96.
2. McTigue DJ. Managing traumatic injuries in the young permanent dentition.
In: Casamassimo PS, Fields HW, McTigue DJ, et al, eds. Pediatric Dentistry
Infancy to Adolescence. 5th ed. St Louis: Elsevier; 2013:514–516.
3. Jones JE, Spolnik KJ, Yassen GH. Management of trauma to the teeth and
supporting tissues. In: Dean JA, ed. McDonald and Avery’s Dentistry for the
Child and Adolescent. 10th ed. St Louis: Elsevier; 2016:591.

512
36
Treatment Planning and Management
of Orthodontic Problems
JOHN R. CHRISTENSEN, HENRY FIELDS, AND ROSE D. SHEATS
CHAPTER OUTLINE
Skeletal Problems
Growth Modication Applied to Anteroposterior Problems
Growth Modication Applied to Transverse Problems
Growth Modication Applied to Vertical Problems
Dental Problems
Space Maintenance
Potential Alignment and Space Problems
Missing Permanent Teeth
Tooth Size Discrepancies
Alignment Problems
Crowding Problems
Anteroposterior Dental Problems
Transverse Dental Problems
Vertical Dental Problems
the treatment plan is easily derived. Unfortunately, in most cases
a solution for one problem is not the solution for the others and,
worse, may magnify the second problem. e treatment plan should
reect the goals of treatment established by the clinician. Treatment
planning is not entirely scientic and clinical wisdom is needed
to determine a plan in these cases.
e clinician is trained to identify functional and esthetic
problems, so the problem list does not always match the concerns
of the parent and child. When the clinician presents the problem
list and treatment plan, these concerns should be listened to carefully
because they may dictate treatment direction and treatment satisfac-
tion outcomes. Often the motivation for treatment can be elicited
from these concerns. If the child patient desires to have treatment,
cooperation will usually be good during treatment and little parental
support will be necessary. is is called internal motivation. External
motivation, motivation supplied by the parent for treatment, will
require continuous parental support to successfully complete
treatment. If the chief complaint or reason for seeking treatment
ranks low on the treatment priority list or will be addressed later
in the treatment plan, an explanation should be provided to the
child and parent to justify this situation.
Skeletal Problems
Orthodontic problems in the preadolescent patient are generally
thought of as either dental or skeletal in origin. e complexity
of these problems varies tremendously. Many dental problems are
well within the treatment domain of the general practitioner. Skeletal
problems, as diagnosed from the facial prole analysis and conrmed
by supplemental means, are best managed by a specialist. However,
the general practitioner should understand how skeletal discrepancies
are treated.
ere are three basic alternatives for treating skeletal discrepan-
cies: growth modication, camouage, and orthognathic surgery.
Growth modication is a means to change skeletal relationships
by using the patient’s remaining growth to alter the size or position
of the jaws. Camouage and orthognathic surgery usually are
considered for adolescent patients with minimal or no growth
remaining or nongrowing adult patients. Camouage orthodontic
treatment is aimed at hiding a mild skeletal discrepancy by moving
teeth within the jaws so the teeth t together. e skeletal dis-
crepancy still exists, but it is disguised by a compensated occlusion
and acceptable facial esthetics. Orthognathic surgery places the
jaws and teeth in a normal or near-normal position using surgical
W
hen considering treatment for problems during the
mixed-dentition years, the precise problem and the goals
of treatment must be clearly in mind. Few problems
will receive denitive or complete treatment at this stage of develop-
ment, although some simple and isolated dental problems may be
resolved. As described in previous chapters, information regarding
the patient’s problems is gathered through an interview of the
patient and the parents and a clinical examination. e clinician
reviews the information and develops a list of goals for treatment.
e goals should address functional and esthetic concerns of the
patient and the clinician. After the goals of treatment have been
established, a list of orthodontic problems is generated from the
clinical database and the problems are ranked in order from most
to least severe.
1
After the problem list has been generated and each problem
has been ranked in order of severity, possible solutions to each
problem should be listed. e solution list should be comprehensive;
that is, all reasonable solutions should be considered for each
specic problem without regard for the other problems. After the
solution list has been constructed, the clinician looks for similar
solutions listed for more than one problem. In some cases the best
solution for one problem is the best solution for all problems, and

CHAPTER 36 Treatment Planning and Management of Orthodontic Problems 513
ere are several theories oered to explain how growth modica-
tion works to achieve the desired results. e rst theory suggests
that growth modication appliances change the absolute size of
one or both jaws. For example, a class II skeletal prole may be
treated by making a decient mandible larger to t a normal-sized
maxilla or by limiting the size of an oversized maxilla. Some clinical
data show dramatic size changes, but there appears to be large
variability in patient response to growth-modifying appliances,
with modest changes in various structures being the rule rather
than the exception.
Alternatively, growth modication may work by accelerating
the desired growth but not changing the ultimate size or shape of
the jaw. A decient mandible may not end up larger than it
ultimately would have been, but it may achieve its nal size sooner.
is requires the clinician to make some nal dentoalveolar changes
or compensations to establish an ideal occlusion following growth
modication. is type of growth modication response also shows
large individual variability. ere is support for this interpretation
of growth modication based on recent randomized clinical trials
that demonstrate little dierence between an early- and a late-
treatment group of patients with skeletal class II malocclusion.
8
A third possibility is that growth modication may work by
changing the spatial relationship of the two jaws. e ultimate
size of the jaw and its rate of growth are not changed, but by
modifying the orientation of the jaws to each other a more balanced
prole may result. For example, a convex prole and an increased
lower facial height could be made more proportional to each other
if the vertical growth of the maxilla could be inhibited and the
mandible allowed to rotate upward and forward. e prole would
then become less convex and the vertical relations more ideal. Jaw
reorientation would be successful in a concave class III patient
with a short face if the mandible could be rotated downward and
backward (more vertical) to create a more acceptable prole.
Reorientation does not work well in class II short faces or class
III long faces because correcting one problem (e.g., the vertical)
makes the other problem (e.g., the anteroposterior) worse. A recent
meta-analysis review oered the following conclusions on growth
modication with functional appliances: (1) functional appliances
can accelerate forward growth of the mandible in the prepubertal
and adolescent growth stages, (2) functional appliances restrain
maxillary growth, and (3) functional appliances correct class II
malocclusion with dental and skeletal changes.
9
As you can see, growth modication is at best inexact. From
the best available data, it appears that if a patient is growing, on
average, modest skeletal changes can be accomplished during the
mixed-dentition years. ese are reasonably comparable if attempted
early or late in this period of development. It may be advisable to
attempt these changes during the earlier mixed-dentition years if
patients have esthetic complaints or if they are trauma prone.
A number of studies have demonstrated early orthodontic
treatment has a positive benet on a patients self-esteem and a
reduction in negative social encounters.
10,11
However, there are
some questions about early treatment and patient quality of life.
Although it appears that orthodontic treatment has been found
to enhance some aspects of quality of life (especially esthetics), it
does not necessarily change social acceptance. In addition, treatment
does not seem to improve oral health status or oral function
compared with untreated populations.
12
A Cochrane review on early orthodontic treatment and trauma
prevention indicated there was a reduction in dental trauma,
although there was a great deal of uncertainty regarding this
nding.
13
Other studies question whether early treatment provides
procedures and presurgical and postsurgical orthodontic treatment.
2
For the mixed-dentition patient, only growth modication or no
treatment is a reasonable choice for skeletal intervention.
Growth modication during the early mixed-dentition years
rests on several assumptions that are not as clear as many would
presume. First, a child must be growing for the growth to be
modied. Most normal children in the 6- to 12-year age group
are actively growing, and their faces are also growing. Furthermore,
clinicians have thought that it is easiest to correct skeletal problems
if a child is undergoing maximal facial growth during treatment.
Although the data to support this contention are not voluminous
or clear,
3
clinicians have long sought to predict maximum somatic
growth and maximal facial growth from other indicators. ere
appears to be wide variation in the amount of facial growth occurring
at one time and an equally wide variation in the correlation of
facial growth with overall body growth and other indicators that
have been chosen.
4–6
Because of this state of inaccuracy, the clinician
should use as many indicators as possible (personal growth history,
skeletal growth maturation, secondary sexual characteristics, onset
of menarche) to make an educated decision about whether the
child is growing at an acceptable rate. Girls tend to enter the
adolescent growth spurt as dened by obvious somatic growth at
approximately 10 years and boys at approximately 12 years.
e data are not totally clear that one must treat children when
they are at a certain rate of facial growth to be successful, and
experience has shown most skeletal and dental problems can be
managed in one phase during the transition from the mixed to
permanent dentitions. For these reasons a single stage of orthodontic
treatment is most popular and adequately eective. is enables
practitioners to successfully manage most problems in a more
mature patient who is both reasonably cooperative and compliant.
Asynchrony between dental development and rapid facial growth
may create a situation in which the patient may be ready for
growth modication but not for orthodontic dental treatment, or
vice versa. ese patients must be handled individually by balancing
the dental and skeletal interventions. Similarly, some patients have
compelling problems that demand earlier treatment, as described
later.
e second assumption made when growth modication is
undertaken is that the practitioner can accurately diagnose the
source of the skeletal discrepancy and design treatment that will
apply the appropriate amount and direction of force to correct the
discrepancy. Diagnosis is not an exact science and may be confusing
even with the use of cephalometric measures,
7
and the discrepancy
may be due to several small skeletal problems rather than one easily
identied discrepancy. It is important to remember that not all
class II or class III malocclusions are created equal or have only
one skeletal feature at fault. Force delivery to dental and skeletal
structures also is inexact, and the clinical impression and treatment
response may dictate alteration in the amount and direction of
force applied to modify growth. Certainly orthodontic treatment
for skeletal problems is not just a “see it” and “x it” situation.
ird, growth modication is usually only one portion of a
treatment plan. Most appliances used to modify growth (e.g.,
headgears and functional appliances) are designed to alter skeletal
structures rather than precisely move teeth. Although the appliances
can cause tooth movement, they are not as precise as xed orth-
odontic appliances (braces) and usually are used before or in
conjunction with xed appliances. erefore most growth modica-
tion treatments are followed immediately or later by traditional
fixed orthodontic appliances to move the teeth into a final
position.

514 Part 4 The Transitional Years: Six to Twelve Years
Class II Growth Modication
A class II malocclusion is the result of maxillary protrusion,
mandibular retrusion, or a combination of both. Class II maxillary
protrusion has been managed by headgear therapy to restrict or
redirect maxillary growth on the basis of retrospective studies and
randomized clinical trials.
8,9
Headgear places a distal force on the
maxillary dentition and the maxilla (Fig. 36.1). eoretically, the
relative movement of dental and skeletal structures depends on
the amount and time of force application. In actual practice, it is
probably not possible to move selectively only teeth or bones.
9
In
general, skeletal and tooth movement are greater with higher forces,
but tooth movement can occur with either heavy or light forces.
One approach is to apply forces ranging from 12 to 16 ounces
per side for 12 to 14 hours and monitor the skeletal and dental
changes and adjust accordingly. e skeletal and dental response
varies according to the type of headgear chosen and the resultant
direction of force exerted by the headgear. e most common
varieties, cervical and high pull, provide predominantly distal and
a protective benet to incisal trauma.
14
A prudent approach may
be to consider each individual patient and assess their psychosocial
well-being and their risk factors for trauma. Otherwise, conventional
late mixed-dentition treatment appears to be just as sensible.
Growth Modication Applied to
Anteroposterior Problems
Anteroposterior skeletal problems are class II and class III in nature.
However, these descriptions are not very informative because the
source of the discrepancy may be the maxilla, the mandible, or a
combination of the two. erefore the rst step in patient evaluation
is to identify the source of the problem and then design a treatment
plan to resolve the problem. Although this approach appears to
indicate that these problems are clearly identiable and treatable
with concise approaches, the previous discussion makes it clear
that this is not the case. In many moderately severe cases of
anteroposterior problems, a number of approaches may work that
rely more on patient compliance than clinical expertise.
CB
A
Figure 36.1 The class II maxillary–protrusive patient is best treated by headgear therapy to restrict or
redirect maxillary growth. (A) This patient is being treated with cervical headgear that places a distal and
extrusive force on both maxillary skeletal and dental structures. The force is provided by a neck strap
attached to the outer bows of the headgear. (B) The molar relationship is beginning to approach a class
III dental position. (C) Space is beginning to open up between the second primary molar and the rst
permanent molar. This type of change is not apparent for every patient because the amount of growth
and the amount of cooperation can vary from patient to patient.

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510 Part 4 The Transitional Years: Six to Twelve Years24. Karabucak B, Li D, Lim J, et al. Vital pulp therapy with mineral trioxide aggregate. Dent Traumatol. 2005;21(4):240–243.25. Rafter M. Apexication: a review. Dent Traumatol. 2005;21(1): 1–8.26. Rosenberg B, Murray PE, Namerow K. e eect of calcium hydroxide root filling on dentin fracture strength. Dent Traumatol. 2007;23(1):26–29.27. Shabahang S, Torabinejad M. Treatment of teeth with open apices using mineral trioxide aggregate. Pract Periodontics Aesthet Dent. 2000;12(3):315–320, quiz 322.28. Iwaya SI, Ikawa M, Kubota M. Revascularization of an immature permanent tooth with apical periodontitis and sinus tract. Dent Traumatol. 2001;17(4):185–187.29. Hoshino E, Kurihara-Ando N, Sato I, et al. In-vitro antibacterial susceptibility of bacteria taken from infected root dentine to a mixture of ciprooxacin, metronidazole and minocycline. Int Endod J. 1996;29(2):125–130.30. Banchs F, Trope M. Revascularization of immature permanent teeth with apical periodontitis: new treatment protocol? J Endod. 2004;30(4):196–200.31. Murray PE, Garcia-Godoy F, Hargreaves KM. Regenerative end-odontics: a review of current status and a call for action. J Endod. 2007;33(4):377–390.32. Trevino EG, Patwardhan AN, Henry MA, et al. Eect of irrigants on the survival of human stem cells of the apical papilla in a platelet-rich plasma scaffold in human root tips. J Endod. 2011;37(8):1109–1115.33. Kim JH, Kim Y, Shin SJ, et al. Tooth discoloration of immature permanent incisor associated with triple antibiotic therapy: a case report. J Endod. 2010;36(6):1086–1091.34. McTigue DJ, Subramanian K, Kumar A. Case series: management of immature permanent teeth with pulpal necrosis: a case series. Pediatr Dent. 2013;35(1):55–60.35. Bose R, Nummikoski P, Hargreaves K. A retrospective evaluation of radiographic outcomes in immature teeth with necrotic root canal systems treated with regenerative endodontic procedures. J Endod. 2009;35(10):1343–1349.36. Bertolami CN, Kaban LB. Chin trauma: a clue to associated man-dibular and cervical spine injury. Oral Surg Oral Med Oral Pathol. 1982;53(2):122–126.37. Bender IB, Freedland JB. Clinical considerations in the diagnosis and treatment of intra-alveolar root fractures. J Am Dent Assoc. 1983;107(4):595–600.38. Cvek M, Andreasen JO, Borum MK. Healing of 208 intra-alveolar root fractures in patients aged 7-17 years. Dent Traumatol. 2001;17(2):53–62.39. Andreasen JO, Andreasen FM, Mejare I, et al. Healing of 400 intra-alveolar root fractures. 2. Eect of treatment factors such as treatment delay, repositioning, splinting type and period and antibiot-ics. Dent Traumatol. 2004;20(4):203–211.40. Andreasen FM. Pulpal healing after luxation injuries and root fracture in the permanent dentition. Endod Dent Traumatol. 1989;5(3): 111–131.41. Oginni AO, Adekoya-Sofowora CA, Kolawole KA. Evaluation of radiographs, clinical signs and symptoms associated with pulp canal obliteration: an aid to treatment decision. Dent Traumatol. 2009;25(6):620–625.42. Tronstad L. Root resorption—etiology, terminology and clinical manifestations. Endod Dent Traumatol. 1988;4(6):241–252.43. Tsilingaridis G, Malmgren B, Andreasen JO, et al. Intrusive luxation of 60 permanent incisors: a retrospective study of treatment and outcome. Dent Traumatol. 2012;28(6):416–422.44. Andreasen JO, Hjorting-Hansen E. Replantation of teeth. I. Radio-graphic and clinical study of 110 human teeth replanted after accidental loss. Acta Odontol Scand. 1966;24(3):263–286.45. Hiltz J, Trope M. Vitality of human lip broblasts in milk, Hanks balanced salt solution and Viaspan storage media. Endod Dent Traumatol. 1991;7(2):69–72.References1. Andreasen JO, ed. e Dental Trauma Guide. San Diego: International Association of Dental Traumatology; 2012.2. Jarvinen S. Incisal overjet and traumatic injuries to upper permanent incisors. A retrospective study. Acta Odontol Scand. 1978;36(6): 359–362.3. Palchak MJ, Holmes JF, Vance CW, et al. A decision rule for identifying children at low risk for brain injuries after blunt head trauma. Ann Emerg Med. 2003;42(4):492–506.4. Tecklenburg FW, Wright MS. Minor head trauma in the pediatric patient. Pediatr Emerg Care. 1991;7(1):40–47.5. Pandor A, Goodacre S, Harnan S, et al. Diagnostic management strategies for adults and children with minor head injury: a systematic review and an economic evaluation. Health Technol Assess. 2011;15(27):1–202.6. Trope M. Clinical management of the avulsed tooth: present strategies and future directions. Dent Traumatol. 2002;18(1):1–11.7. Andreasen JO, Andreasen FM, Andersson L. Textbook and Color Atlas of Traumatic Injuries to the Teeth. 4th ed. Copenhagen: Blackwell Munksgaard; 2007:891.8. Weisleder R, Yamauchi S, Caplan DJ, et al. e validity of pulp testing: a clinical study. J Am Dent Assoc. 2009;140(8):1013–1017.9. Alghaithy RA, Qualtrough AJ. Pulp sensibility and vitality tests for diagnosing pulpal health in permanent teeth: a critical review. Int Endod J. 2017;50(2):135–142.10. Mesaros SV, Trope M. Revascularization of traumatized teeth assessed by laser Doppler owmetry: case report. Endod Dent Traumatol. 1997;13(1):24–30.11. Caldeira CL, Barletta FB, Ilha MC, et al. Pulse oximetry: a useful test for evaluating pulp vitality in traumatized teeth. Dent Traumatol. 2016;32(5):385–389.12. Pozzobon MH, de Sousa Vieira R, Alves AM, et al. Assessment of pulp blood ow in primary and permanent teeth using pulse oximetry. Dent Traumatol. 2011;27(3):184–188.13. Diangelis AJ, Andreasen JO, Ebeleseder KA, et al. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 1. Fractures and luxations of permanent teeth. Dent Traumatol. 2012;28(1):2–12.14. Palomo L, Palomo JM. Cone beam CT for diagnosis and treatment planning in trauma cases. Dent Clin North Am. 2009;53(4):717–727, vi–vii.15. White KC, Cox CF, Kanka J, et al. Histologic pulpal response of acid etching vital dentin. J Dent Res. 1992;71(1 suppl):188.16. Costa CA, Hebling J, Hanks CT. Current status of pulp capping with dentin adhesive systems: a review. Dent Mater. 2000;16(3): 188–197.17. Hilton TJ, Ferracane JL, Mancl L. Northwest Practice-based Research Collaborative in Evidence-based Dentistry. Comparison of CaOH with MTA for direct pulp capping: a PBRN randomized clinical trial. J Dent Res. 2013;92(7 suppl):16S–22S.18. Schwendicke F, Brouwer F, Schwendicke A, et al. Dierent materials for direct pulp capping: systematic review and meta-analysis and trial sequential analysis. Clin Oral Investig. 2016;20(6):1121–1132.19. Felman D, Parashos P. Coronal tooth discoloration and white mineral trioxide aggregate. J Endod. 2013;39(4):484–487.20. Cvek M. A clinical report on partial pulpotomy and capping with calcium hydroxide in permanent incisors with complicated crown fracture. J Endod. 1978;4(8):232–237.21. Fuks AB, Gavra S, Chosack A. Long-term followup of traumatized incisors treated by partial pulpotomy. Pediatr Dent. 1993;15(5): 334–336.22. Schmitt D, Lee J, Bogen G. Multifacted use of ProRoot MTA root canal repair material. Pediatr Dent. 2001;23(4):326–330.23. Salako N, Joseph B, Ritwik P, et al. Comparison of bioactive glass, mineral trioxide aggregate, ferric sulfate, and formocresol as pulpotomy agents in rat molar. Dent Traumatol. 2003;19(6):314–320. CHAPTER 35 Managing Traumatic Injuries in the Young Permanent Dentition 511 52. Andreasen JO, Borum MK, Andreasen FM. Replantation of 400 avulsed permanent incisors. 3. Factors related to root growth. Endod Dent Traumatol. 1995;11(2):69–75.53. Hammarstrom L, Pierce A, Blomlof L, et al. Tooth avulsion and replantation—a review. Endod Dent Traumatol. 1986;2(1): 1–8.54. Sae-Lim V, Wang CY, Trope M. Eect of systemic tetracycline and amoxicillin on inammatory root resorption of replanted dogs’ teeth. Endod Dent Traumatol. 1998;14(5):216–220.55. Coccia CT. A clinical investigation of root resorption rates in reimplanted young permanent incisors: a ve-year study. J Endod. 1980;6(1):413–420.46. Krasner P, Person P. Preserving avulsed teeth for replantation. J Am Dent Assoc. 1992;123(11):80–88.47. Blomlof L. Storage of human periodontal ligament cells in a combina-tion of dierent media. J Dent Res. 1981;60(11):1904–1906.48. Sigalas E, Regan JD, Kramer PR, et al. Survival of human periodontal ligament cells in media proposed for transport of avulsed teeth. Dent Traumatol. 2004;20(1):21–28.49. Lekic PC, Kenny DJ, Barrett EJ. e inuence of storage conditions on the clonogenic capacity of periodontal ligament cells: implications for tooth replantation. Int Endod J. 1998;31(2):137–140.50. Hinckfuss SE, Messer LB. An evidence-based assessment of the clinical guidelines for replanted avulsed teeth. Part II: prescription of systemic antibiotics. Dent Traumatol. 2009;25(2):158–164.51. Andreasen JO, Borum MK, Jacobsen HL, et al. Replantation of 400 avulsed permanent incisors. 2. Factors related to pulpal healing. Endod Dent Traumatol. 1995;11(2):59–68. CHAPTER 35 Managing Traumatic Injuries in the Young Permanent Dentition 511.e1 Case Study: Splinting for an Avulsed ToothJanice G. JacksonAn adolescent patient suffers a traumatic event and tooth #8 was avulsed and recovered. The mother retrieves the tooth and places it in milk. They arrive at the dental ofce 20 minutes later. The International Association of Dental Traumatology (IADT) Guidelines for avulsion were followed based on a dry time of less than 60 minutes.1 Tooth #8 was replanted and splinted (Video 35.1).Splinting is a clinical stabilization technique for avulsed teeth, providing a exible material to be bonded to teeth using owable composite.2,3 The splint material can be varied materials such as 20- to 30-pound test nylon monolament shing line, extremely light orthodontic wire (.010 or .012), or twisted orthodontic ligature wire (.010).2,3 The best splints should: be passive (causing no trauma); allow functional tooth movement; permit endodontic access and vitality testing; be easy to clean; and be easily placed and removed.2,3Preparation for Splint PlacementSteps required for all patients such as patient histories, consents, and extraoral and intraoral examinations should be completed. The following steps should be taken after the initial patient evaluation:1. Take initial periapical radiograph (Fig. E35.1).2. Prepare the patient for replanting the tooth: a. Obtain profound local anesthesia. b. Irrigate the socket with saline and evaluate. If there is a fracture of the socket wall, reposition it with an instrument such as the handle of a mirror. c. Obtain isolation with cheek retractors and/or cotton rolls.3. Determine the length of splint material:Measure from one to two abutment teeth on each side of the avulsed tooth.2 Usually for anterior permanent teeth #8 or #9, this span will be from maxillary cuspid (#6) to cuspid (#11). If the cuspid is unerupted proceed to the next erupted permanent tooth on that side of the arch.4. Replant the tooth and check for correct positioning.5. Clean the labial of the teeth, apply etchant gel to the middle one-third of the labial surface for 10 to 20 seconds.6. Rinse thoroughly and lightly dry.7. Maintain isolation and apply adhesive and light cure.8. Position the splint material by stabilizing with an instrument or gloved ngers.9. Start at one of the end abutment teeth, applying enough owable composite over the splint material to secure it and light cure.310. Proceed to attach the splint material to the adjacent teeth, skipping the replanted tooth, and lastly bond the splint material to the replanted tooth.311. Take a radiograph of the splinted tooth (Fig. E35.2).12. Give the patient home care instructions (Box E35.1).2,3Questions1. Why is it important to take a preoperative and postoperative periapical lm?Answer: A preoperative radiograph assesses that the socket is intact without alveolar fractures or other material in the socket. If there is an alveolar fracture, a blunt instrument may be used to reposition the socket wall. Other debris may be removed by gentle lavage of the socket with saline. A postoperative radiograph after splinting veries the normal position of the replanted tooth in the socket.2. Replantation is not recommended after what length of dry time? Explain why.Answer: The long-term prognosis is poor after more than 60 minutes of dry time outside the socket. The greater the length of dry time outside the socket, the less favorable the outcome for the vitality of the periodontal ligament (PDL) cells. Ankylosis and root resorption are the eventual outcomes due to the nonviable PDL cells. Both eventually lead to loss of the tooth.3. What is the importance of good oral hygiene for replanted teeth?Answer: Good oral hygiene aids the healing process of the replanted tooth and the surrounding soft tissues.4. The length of splint wear is inuenced by what factors?• Figure E35.1 Pretreatment periapical radiograph of tooth #8. • Figure E35.2 Posttreatment periapical radiograph of tooth #8. 1. Soft diet; avoid biting on splinted teeth2. Continue regular oral hygiene twice a day3. Use mouthrinse as prescribed4. Take medications as prescribed5. Call dentist immediately if splint breaks or becomes loose6. Seek endodontic treatment as recommended7. Follow up in 2 weeksHome Care Instructions for a Splint• BOX E35.1 Continued 511.e2 Part 4 The Transitional Years: Six to Twelve YearsAnswer: The time required for wearing a splint is inuenced by factors such as severity of the initial injury and bony fractures, if present; wearing a passive exible splint; tooth stability for endodontic treatment; any reinjury during the healing process; and good oral hygiene.5. Why is the replanted tooth the last tooth to be attached to the splint?Answer: The replanted tooth should be stabilized in the tooth socket and to the splint using the least amount of force needed for aligning it in the most natural position with the adjacent teeth. There should be no interference with the replanted tooth when the teeth are in occlusion.References1. Andersson L, Andreasen JO, Day P, et al. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 2. Avulsion of permanent teeth. Dent Traumatol. 2012;28(2):88–96.2. McTigue DJ. Managing traumatic injuries in the young permanent dentition. In: Casamassimo PS, Fields HW, McTigue DJ, et al, eds. Pediatric Dentistry Infancy to Adolescence. 5th ed. St Louis: Elsevier; 2013:514–516.3. Jones JE, Spolnik KJ, Yassen GH. Management of trauma to the teeth and supporting tissues. In: Dean JA, ed. McDonald and Avery’s Dentistry for the Child and Adolescent. 10th ed. St Louis: Elsevier; 2016:591. 512 36 Treatment Planning and Management of Orthodontic ProblemsJOHN R. CHRISTENSEN, HENRY FIELDS, AND ROSE D. SHEATSCHAPTER OUTLINESkeletal ProblemsGrowth Modication Applied to Anteroposterior ProblemsGrowth Modication Applied to Transverse ProblemsGrowth Modication Applied to Vertical ProblemsDental ProblemsSpace MaintenancePotential Alignment and Space ProblemsMissing Permanent TeethTooth Size DiscrepanciesAlignment ProblemsCrowding ProblemsAnteroposterior Dental ProblemsTransverse Dental ProblemsVertical Dental Problemsthe treatment plan is easily derived. Unfortunately, in most cases a solution for one problem is not the solution for the others and, worse, may magnify the second problem. e treatment plan should reect the goals of treatment established by the clinician. Treatment planning is not entirely scientic and clinical wisdom is needed to determine a plan in these cases.e clinician is trained to identify functional and esthetic problems, so the problem list does not always match the concerns of the parent and child. When the clinician presents the problem list and treatment plan, these concerns should be listened to carefully because they may dictate treatment direction and treatment satisfac-tion outcomes. Often the motivation for treatment can be elicited from these concerns. If the child patient desires to have treatment, cooperation will usually be good during treatment and little parental support will be necessary. is is called internal motivation. External motivation, motivation supplied by the parent for treatment, will require continuous parental support to successfully complete treatment. If the chief complaint or reason for seeking treatment ranks low on the treatment priority list or will be addressed later in the treatment plan, an explanation should be provided to the child and parent to justify this situation.Skeletal ProblemsOrthodontic problems in the preadolescent patient are generally thought of as either dental or skeletal in origin. e complexity of these problems varies tremendously. Many dental problems are well within the treatment domain of the general practitioner. Skeletal problems, as diagnosed from the facial prole analysis and conrmed by supplemental means, are best managed by a specialist. However, the general practitioner should understand how skeletal discrepancies are treated.ere are three basic alternatives for treating skeletal discrepan-cies: growth modication, camouage, and orthognathic surgery. Growth modication is a means to change skeletal relationships by using the patient’s remaining growth to alter the size or position of the jaws. Camouage and orthognathic surgery usually are considered for adolescent patients with minimal or no growth remaining or nongrowing adult patients. Camouage orthodontic treatment is aimed at hiding a mild skeletal discrepancy by moving teeth within the jaws so the teeth t together. e skeletal dis-crepancy still exists, but it is disguised by a compensated occlusion and acceptable facial esthetics. Orthognathic surgery places the jaws and teeth in a normal or near-normal position using surgical When considering treatment for problems during the mixed-dentition years, the precise problem and the goals of treatment must be clearly in mind. Few problems will receive denitive or complete treatment at this stage of develop-ment, although some simple and isolated dental problems may be resolved. As described in previous chapters, information regarding the patient’s problems is gathered through an interview of the patient and the parents and a clinical examination. e clinician reviews the information and develops a list of goals for treatment. e goals should address functional and esthetic concerns of the patient and the clinician. After the goals of treatment have been established, a list of orthodontic problems is generated from the clinical database and the problems are ranked in order from most to least severe.1After the problem list has been generated and each problem has been ranked in order of severity, possible solutions to each problem should be listed. e solution list should be comprehensive; that is, all reasonable solutions should be considered for each specic problem without regard for the other problems. After the solution list has been constructed, the clinician looks for similar solutions listed for more than one problem. In some cases the best solution for one problem is the best solution for all problems, and CHAPTER 36 Treatment Planning and Management of Orthodontic Problems 513 ere are several theories oered to explain how growth modica-tion works to achieve the desired results. e rst theory suggests that growth modication appliances change the absolute size of one or both jaws. For example, a class II skeletal prole may be treated by making a decient mandible larger to t a normal-sized maxilla or by limiting the size of an oversized maxilla. Some clinical data show dramatic size changes, but there appears to be large variability in patient response to growth-modifying appliances, with modest changes in various structures being the rule rather than the exception.Alternatively, growth modication may work by accelerating the desired growth but not changing the ultimate size or shape of the jaw. A decient mandible may not end up larger than it ultimately would have been, but it may achieve its nal size sooner. is requires the clinician to make some nal dentoalveolar changes or compensations to establish an ideal occlusion following growth modication. is type of growth modication response also shows large individual variability. ere is support for this interpretation of growth modication based on recent randomized clinical trials that demonstrate little dierence between an early- and a late-treatment group of patients with skeletal class II malocclusion.8A third possibility is that growth modication may work by changing the spatial relationship of the two jaws. e ultimate size of the jaw and its rate of growth are not changed, but by modifying the orientation of the jaws to each other a more balanced prole may result. For example, a convex prole and an increased lower facial height could be made more proportional to each other if the vertical growth of the maxilla could be inhibited and the mandible allowed to rotate upward and forward. e prole would then become less convex and the vertical relations more ideal. Jaw reorientation would be successful in a concave class III patient with a short face if the mandible could be rotated downward and backward (more vertical) to create a more acceptable prole. Reorientation does not work well in class II short faces or class III long faces because correcting one problem (e.g., the vertical) makes the other problem (e.g., the anteroposterior) worse. A recent meta-analysis review oered the following conclusions on growth modication with functional appliances: (1) functional appliances can accelerate forward growth of the mandible in the prepubertal and adolescent growth stages, (2) functional appliances restrain maxillary growth, and (3) functional appliances correct class II malocclusion with dental and skeletal changes.9As you can see, growth modication is at best inexact. From the best available data, it appears that if a patient is growing, on average, modest skeletal changes can be accomplished during the mixed-dentition years. ese are reasonably comparable if attempted early or late in this period of development. It may be advisable to attempt these changes during the earlier mixed-dentition years if patients have esthetic complaints or if they are trauma prone.A number of studies have demonstrated early orthodontic treatment has a positive benet on a patient’s self-esteem and a reduction in negative social encounters.10,11 However, there are some questions about early treatment and patient quality of life. Although it appears that orthodontic treatment has been found to enhance some aspects of quality of life (especially esthetics), it does not necessarily change social acceptance. In addition, treatment does not seem to improve oral health status or oral function compared with untreated populations.12A Cochrane review on early orthodontic treatment and trauma prevention indicated there was a reduction in dental trauma, although there was a great deal of uncertainty regarding this nding.13 Other studies question whether early treatment provides procedures and presurgical and postsurgical orthodontic treatment.2 For the mixed-dentition patient, only growth modication or no treatment is a reasonable choice for skeletal intervention.Growth modication during the early mixed-dentition years rests on several assumptions that are not as clear as many would presume. First, a child must be growing for the growth to be modied. Most normal children in the 6- to 12-year age group are actively growing, and their faces are also growing. Furthermore, clinicians have thought that it is easiest to correct skeletal problems if a child is undergoing maximal facial growth during treatment. Although the data to support this contention are not voluminous or clear,3 clinicians have long sought to predict maximum somatic growth and maximal facial growth from other indicators. ere appears to be wide variation in the amount of facial growth occurring at one time and an equally wide variation in the correlation of facial growth with overall body growth and other indicators that have been chosen.4–6 Because of this state of inaccuracy, the clinician should use as many indicators as possible (personal growth history, skeletal growth maturation, secondary sexual characteristics, onset of menarche) to make an educated decision about whether the child is growing at an acceptable rate. Girls tend to enter the adolescent growth spurt as dened by obvious somatic growth at approximately 10 years and boys at approximately 12 years.e data are not totally clear that one must treat children when they are at a certain rate of facial growth to be successful, and experience has shown most skeletal and dental problems can be managed in one phase during the transition from the mixed to permanent dentitions. For these reasons a single stage of orthodontic treatment is most popular and adequately eective. is enables practitioners to successfully manage most problems in a more mature patient who is both reasonably cooperative and compliant. Asynchrony between dental development and rapid facial growth may create a situation in which the patient may be ready for growth modication but not for orthodontic dental treatment, or vice versa. ese patients must be handled individually by balancing the dental and skeletal interventions. Similarly, some patients have compelling problems that demand earlier treatment, as described later.e second assumption made when growth modication is undertaken is that the practitioner can accurately diagnose the source of the skeletal discrepancy and design treatment that will apply the appropriate amount and direction of force to correct the discrepancy. Diagnosis is not an exact science and may be confusing even with the use of cephalometric measures,7 and the discrepancy may be due to several small skeletal problems rather than one easily identied discrepancy. It is important to remember that not all class II or class III malocclusions are created equal or have only one skeletal feature at fault. Force delivery to dental and skeletal structures also is inexact, and the clinical impression and treatment response may dictate alteration in the amount and direction of force applied to modify growth. Certainly orthodontic treatment for skeletal problems is not just a “see it” and “x it” situation.ird, growth modication is usually only one portion of a treatment plan. Most appliances used to modify growth (e.g., headgears and functional appliances) are designed to alter skeletal structures rather than precisely move teeth. Although the appliances can cause tooth movement, they are not as precise as xed orth-odontic appliances (braces) and usually are used before or in conjunction with xed appliances. erefore most growth modica-tion treatments are followed immediately or later by traditional fixed orthodontic appliances to move the teeth into a final position. 514 Part 4 The Transitional Years: Six to Twelve YearsClass II Growth ModicationA class II malocclusion is the result of maxillary protrusion, mandibular retrusion, or a combination of both. Class II maxillary protrusion has been managed by headgear therapy to restrict or redirect maxillary growth on the basis of retrospective studies and randomized clinical trials.8,9 Headgear places a distal force on the maxillary dentition and the maxilla (Fig. 36.1). eoretically, the relative movement of dental and skeletal structures depends on the amount and time of force application. In actual practice, it is probably not possible to move selectively only teeth or bones.9 In general, skeletal and tooth movement are greater with higher forces, but tooth movement can occur with either heavy or light forces. One approach is to apply forces ranging from 12 to 16 ounces per side for 12 to 14 hours and monitor the skeletal and dental changes and adjust accordingly. e skeletal and dental response varies according to the type of headgear chosen and the resultant direction of force exerted by the headgear. e most common varieties, cervical and high pull, provide predominantly distal and a protective benet to incisal trauma.14 A prudent approach may be to consider each individual patient and assess their psychosocial well-being and their risk factors for trauma. Otherwise, conventional late mixed-dentition treatment appears to be just as sensible.Growth Modication Applied to Anteroposterior ProblemsAnteroposterior skeletal problems are class II and class III in nature. However, these descriptions are not very informative because the source of the discrepancy may be the maxilla, the mandible, or a combination of the two. erefore the rst step in patient evaluation is to identify the source of the problem and then design a treatment plan to resolve the problem. Although this approach appears to indicate that these problems are clearly identiable and treatable with concise approaches, the previous discussion makes it clear that this is not the case. In many moderately severe cases of anteroposterior problems, a number of approaches may work that rely more on patient compliance than clinical expertise.CBA• Figure 36.1 The class II maxillary–protrusive patient is best treated by headgear therapy to restrict or redirect maxillary growth. (A) This patient is being treated with cervical headgear that places a distal and extrusive force on both maxillary skeletal and dental structures. The force is provided by a neck strap attached to the outer bows of the headgear. (B) The molar relationship is beginning to approach a class III dental position. (C) Space is beginning to open up between the second primary molar and the rst permanent molar. This type of change is not apparent for every patient because the amount of growth and the amount of cooperation can vary from patient to patient. CHAPTER 36 Treatment Planning and Management of Orthodontic Problems 515 designed to stimulate mandibular growth, studies have indicated there are secondary eects of restricting forward maxillary skeletal and dental movement.8,15,16 is happens because the mandible, which is postured forward, tends to return to a more distal position as a result of the distal muscle and soft tissue forces. e distal force is transmitted through the appliance to the maxilla and the maxillary teeth. e maxillary teeth tend to tip lingually rather than to move bodily while the mandibular teeth tip facially.occlusal and distal and apical forces, respectively. Traditionally, one avoids using a headgear that tends to extrude posterior teeth in a person with a long face or a limited overbite. On the other hand, a headgear that extrudes the molars is often useful in a patient with a short face and a deep bite.Class II maxillary protrusion can also be managed with a removable functional appliance of the activator, bionator, or twin block type (Fig. 36.2). Although a functional appliance is primarily BACDE• Figure 36.2 The class II mandibular–decient patient is usually treated with a functional appliance that positions the mandible forward in an attempt to stimulate, accelerate, or redirect mandibular growth. (A) This patient has a class II mandibular–decient prole. (B) The patient’s molar and canine relationships reect the skeletal class II relationship. (C) The prole is immediately improved when the functional appli-ance is in place because the mandible is pushed forward into a class I relationship. (D) Because functional appliances (a twin block in this case) position the mandible forward using the upper and lower dental arches, there may be movement of the upper and lower teeth. Dental aspects of the malocclusion must be considered during treatment planning. (E) In this case the patient wore an appliance similar to that shown in (D) for approximately 1 year. In the overall superimposition the blue lines show there was slightly more change in the anteroposterior position of the mandible than in the maxilla. The maxillary superim-position shows the vertical position of the teeth was well controlled. In the mandibular superimposition, it is evident the patient grew favorably. In addition, the mesial and vertical eruption of the lower molar helped to change the dental relationship to class I. 516 Part 4 The Transitional Years: Six to Twelve Yearspreviously, also has been used with mandibular-decient patients. Some studies also indicate that headgear treatment may cause an increase in mandibular growth.21,22 In general, a review of class II treatments shows headgears and functional appliances are equally eective in treating the class II malocclusion.23 It appears a headgear has a small restrictive inuence on maxillary position, whereas functional appliances move B point forward leading to an ANB improvement of approximately 1 degree with either approach. A large portion of the change is dental in nature; headgears inuence maxillary molar position distal, whereas functional appliances tend to move the lower molar mesial and procline the lower incisors.Class III Growth ModicationSimilar to class II malocclusions, a change in the position of the maxilla, the mandible, or both results in a class III malocclusion. e rst possibility is a small maxilla. True midface deciency can be treated by using a reverse-pull headgear or facemask to exert anteriorly directed force on the maxilla (Fig. 36.4).24 e facemask applies force to the maxilla through an appliance (either a removable splint or xed appliance) attached to the teeth; tooth movement also occurs. Some clinicians use the facemask with maxillary expansion (either rapid or slow) to enhance the transverse coordina-tion of the arches and to facilitate anterior movement of the maxilla due to alteration of the bony interfaces with other skeletal structures. A comparison of clinical studies found that less maxillary incisor movement occurs when expansion accompanies protraction.25 One prospective study found no dierence between the expansion and nonexpansion approaches.26Another approach is to use a facemask with miniplates attached to the maxilla. is method can be used in the late mixed dentition, probably at approximately 10 to 11 years of age, and shows greater skeletal change and movement in the zygomatic area as well.27 Finally, miniplates can be attached to the maxilla and mandible, and intraoral elastics can be used at approximately the same age. is has the eect of substantial change with no need for an extraoral appliance, which means the elastic force can be used continuously.28Timing of this treatment has been controversial. Some authors believe that the ideal time to attempt this treatment is soon after eruption of the permanent incisors, whereas others have waited a bit longer. Clearly, postpubertal treatment is not indicated for growth modication.29 Data indicate that there is little anteropos-terior dierence in treatment eect whether treatment is applied early or late, if the treatment is completed before 10 to 11 years of age.30,31 Unfortunately, the long-term success of maxillary protrac-tion is not clear. One fact appears to be emerging: mistaken diagnosis or treatment in patients whose class III malocclusion is the result of mandibular protrusion will usually fail. Even with those who are correctly diagnosed, one in four will require additional treatment to correct the skeletal malocclusion.32Functional appliances designed to stimulate maxillary growth do not seem to be eective. e improvement in facial prole obtained by using these appliances in patients with very minor class III problems is usually the result of a downward and backward rotation of the mandible. e occlusion improves because of facial tipping of the maxillary incisors and lingual tipping of the lower incisors.Class III mandibular protrusion has been historically managed with chin cup therapy (Fig. 36.5). e theory of chin cup therapy is to apply a distal and superior force through the chin that inhibits or redirects growth at the condyle. Again, studies in animals have Another functional appliance is the Herbst appliance, which is a xed appliance used to reposition the mandible forward. It is held in place with bands, stainless steel crowns, bonding, or a cemented cast framework (Fig. 36.3). A pin and tube apparatus forces the mandible forward and places constant force on the maxilla and maxillary and mandibular teeth as the mandible attempts to return to a normal and more distal posture. Maxillary teeth tend to move distally and mandibular anterior teeth move forward. is appliance has shown changes similar to those of functional appliances in randomized clinical trials.17 e use of temporary anchorage devices (TADs) combined with the Herbst appliance may reduce some of the lower incisor tooth movement.18If the class II malocclusion is due to a mandibular deciency, treatment options focus on changing the mandibular position. e mandibular-decient patient is usually treated with a removable or xed functional appliance that positions the mandible forward in an attempt to stimulate or accelerate mandibular growth. Retrospec-tive clinical studies have shown that these appliances can produce a small average increase in mandibular projection (2 to 4 mm/year).19,20 is has been conrmed by randomized clinical trials.8,21 Patient response varies greatly, and in many cases the increased growth does not totally correct the class II skeletal problem for several reasons. First, the amount of growth is not enough to overcome the discrepancy. Second, all the available growth would have to be specically directed to produce anteroposterior change. is is usually not the case because some dental eruption and vertical growth occurs. is interaction between anteroposterior and vertical dimensional changes decreases ultimate mandibular projection and class II correction because the mandible grows downward and forward and not straight forward. e rest of the anteroposterior discrepancy is managed by restricting maxillary growth, tipping the maxillary teeth back, and tipping the man-dibular teeth forward. Dierent appliances can be designed that exaggerate the secondary responses of maxillary restriction and dental movement if desired. e Herbst appliance, mentioned AB• Figure 36.3 The Herbst appliance is a xed appliance that uses a pin and tube apparatus to reposition the mandible into a more forward posi-tion. (A) This class II patient demonstrates correction to a near class I occlusion. (B) Used in conjunction with xed appliances, some of the dental effects can be more readily controlled. CHAPTER 36 Treatment Planning and Management of Orthodontic Problems 517 shown some change in absolute mandibular size, but clinical application in humans routinely has been less successful.33,34 e typical short-term treatment response to chin cup therapy is a distal rotation of the mandible and lingual tipping of the lower incisors. erefore chin cup therapy is well tolerated in patients with mild mandibular protrusion and short to normal vertical proportions. However, it is contraindicated in a person with a long lower face, because the anteroposterior correction would come at the expense of an increased vertical dimension. e long-term results of chin cup therapy indicate that, although a transient positive change can occur, the long-term results are dicult to dierentiate from those in untreated patients.31In summary, treatment of class III malocclusion in the mixed dentition is based on the diagnosis of maxillary deciency or mandibular excess. In cases of mandibular excess the clinician can choose between a chin cup or a class III type functional appliance. Both have been shown to restrict mandibular growth but have little inuence on maxillary position.35 Treatment is recommended before age 10. In maxillary decient patients a reverse pull headgear can move the maxilla forward. If the headgear is attached to the maxillary teeth, there is some proclination of the upper incisors as well as downward and backward rotation of the mandible. is results in an increased lower anterior facial height.35 If treatment is delayed until the late mixed dentition when permanent teeth have erupted to a point where bone miniplates can be placed, a combination of upper and lower miniplates with continuous intermaxillary elastic traction has been shown to stimulate upper jaw growth and restrain lower jaw growth without dental compensa-tions.28 e issue seems to be the variable response from patient to patient. It is very dicult to predict how one individual will react to class III growth modication.BA• Figure 36.4 (A) The class III maxillary–decient patient is treated by using a reverse pull headgear or facemask to exert anteriorly directed force on the maxilla. The force is provided by rubber bands extend-ing from the facemask to intraoral hooks or wires. (B) These superimpositions show a successful case in treating a case of class III maxillary deciency. The overall superimposition shows the maxilla has been moved forward to a greater extent than the mandible. The mandible was rotated down and backward somewhat, which helped with the anteroposterior change in the skeletal relations. There was little change in tooth position in both the maxillary and mandibular superimpositions, which suggests most of the change was skeletal in nature. • Figure 36.5 The class III mandibular–protrusive patient has historically been treated with chin cup therapy. The chin cup was designed to apply a distal and superior force through the chin to inhibit growth at the condyle. In clinical practice, this device has not been proven to be routinely suc-cessful, although chin cup therapy does cause a distal rotation of the mandible. Therefore the chin cup may be useful for managing mild man-dibular protrusion in which the vertical proportions are short to normal. 518 Part 4 The Transitional Years: Six to Twelve Yearsquestion because there are no controlled experimental studies to provide answers.Transverse expansion is accomplished by passive or active move-ment of teeth. Acrylic or wire buccal shields remove lip and cheek pressure to allow movement of both maxillary and mandibular teeth. Active expansion is performed with either a W arch–type appliance or a screw-type appliance. e decision to use one appliance or another is based on the age of the patient (an indirect measure of the interdigitation of the palatal suture) and the amount of expansion required. Studies seem to indicate there is less risk for buccal alveolar bone change if the movement is completed at a younger age rather than the complete permanent dentition.Growth Modication Applied to Vertical ProblemsVertical skeletal problems are manifested as long and short facial heights and usually are located below the palatal plane.41 e short-faced person has a reduced mandibular plane angle and undererupted teeth. In the long-faced patient the mandibular plane angle, lower facial height, and amount of dental eruption are increased in comparison with the patient with a normal face. Vertical skeletal problems can be managed with growth modication techniques, and some can be managed successfully; however, even when the treatment has been successful, maintaining the correction is extremely dicult. e face grows vertically for a long time, Growth Modication Applied to Transverse Problemse most common transverse problem in the preadolescent is maxillary constriction with a posterior crossbite. Management of maxillary constriction can begin as soon as the problem is discovered if the child is mature enough to accept treatment. Treatment has the potential to eliminate crossbites of the permanent teeth, increase arch length, and simplify future diagnostic decisions complicated by functional shifts. Most clinicians agree with the philosophy of early correction if there is a mandibular shift. In general, it is believed that long-term facial asymmetry attributable to soft tissue enlargement and in some cases mandibular asymmetry can result from untreated mandibular shifts.36 Regardless of philosophy, treatment before adolescence and midpalatal suture bridging is recommended.ree appliances can be used to correct the constriction, but the appliances are not interchangeable. In Chapter 28 the quad helix and the W arch for management of maxillary constriction are described. e appliances provide both skeletal and dental movement in the 3- to 6-year-old child.37 As the patient gets older, more dental change and less skeletal change occur. is is true because the midpalatal suture, which was open at an early age, has developed bone interdigitation that makes it dicult to separate. More force is required to separate the suture after initial interdigita-tion of the suture to obtain true skeletal correction than a quad helix or W arch can deliver.In the older preadolescent patient, in whom there is a chance that the midpalatal suture is closed, an appliance that can deliver large amounts of force is necessary to correct the skeletal constriction.38 Rapid palatal expansion is the term given to the procedure in which an appliance cemented or bonded to the teeth is opened 0.5 mm/day to deliver 2000 to 3000 g of force (Fig. 36.6). In the active phase of treatment, there is a change in the inclination of the anchor teeth but little dental movement because the periodontal ligament has been hyalinized, which limits dental movement, and the force is transmitted almost entirely to the skeletal structures. However, during retention, the skeletal structures begin to relapse toward the midline. Because the teeth are held rigidly by the appliance, they move relative to the bones. Depending on the amount of expansion needed, active treatment normally takes 10 to 14 days. Another approach to skeletal expansion is slow rather than rapid palatal expansion.39 Essentially the same appliance is used as in rapid palatal expansion, although force levels are calibrated to provide only 900 to 1300 g of force. Coupled with a slower activation rate, slow palatal expansion widens the palate by dental and skeletal movement. Although the nal position of the teeth and supporting structures is approximately the same in rapid and slow expansion, proponents of slow expansion maintain that slower expansion is more physiologic and stable. ere is some evidence that both rapid and slow maxillary expansion can result in loss of buccal bone (height and thickness).40 ese ndings are from cone beam computed tomography (CBCT) and should be viewed with some caution due to the resolution of the image.Transverse growth modication also can be accomplished by means of acrylic or wire buccal shields attached to functional appliances or lip bumpers. e buccal shields relieve the teeth and alveolar structures from the resting pressure of the cheek muscles and soft tissues. Transverse expansion of 3 to 5 mm can be achieved, although the changes vary considerably. Whether the movement is dental or skeletal and whether it will remain stable are still in BA• Figure 36.6 Rapid palatal expansion is used to treat maxillary constric-tion and posterior crossbite when there is a chance that the midpalatal suture is partially closed. The jackscrew in the appliance provides approxi-mately 2000 to 3000 g of force when it is opened 0.5 mm/day. Depending on the amount of expansion needed, the appliance is normally activated two times each day for 10 days to 2 weeks. The appliance can be either cemented on the teeth with orthodontic bands (A) or bonded to the teeth (B). CHAPTER 36 Treatment Planning and Management of Orthodontic Problems 519 and there is a tendency for the original growth pattern and problem to recur.Vertical ExcessVertical skeletal excess may be managed with extraoral force or intraoral force. Extraoral force is delivered by means of a high-pull headgear through the maxillary rst molars. e force is applied in a superior and distal direction and is designed to inhibit vertical development of the maxilla and eruption of the posterior maxillary teeth (Fig. 36.7).42 Because no force is applied to the mandibular teeth, they are free to erupt and compensate for the reduced vertical development in the maxilla. In some cases, this compensatory eruption can eliminate all the positive eects of the high-pull headgear and lead to downward and backward rotation of the mandible instead of forward mandibular projection.An alternative method for controlling vertical development is to block the eruption of the maxillary and mandibular teeth. A functional appliance can be designed that will force the mandible open to an increased vertical rest position. e force of the mandible attempting to return to its original vertical rest position is transmit-ted to the maxilla and the teeth in both arches. is results in mandibular growth being directed forward because no dental eruption has occurred to increase the vertical dimension with less growth in lower and total face height (Fig. 36.8).43 TADs may prove to be of value in restricting vertical facial development. TADs are small-diameter titanium screws placed into cortical bone. ey do not osseointegrate, so they can be removed after use. TADs provide the clinician with an anchor to apply force to teeth without causing other teeth to move because the screw is in bone. In theory, the screws should not move, although it appears they do move with force application. In cases of vertical excess, TADs are placed to provide an intrusive force to the maxillary posterior teeth.44 However, placing TADs in the mixed dentition patient is more dicult because there are unerupted teeth in the way of insertion and the cortical bone does not hold the implant as well • Figure 36.7 The patient with vertical skeletal excess is often treated with high-pull headgear. The force, generated by the strap resting on the head, is applied in a superior and distal direction and is intended to inhibit vertical development of the maxilla and eruption of the maxillary posterior teeth. • Figure 36.8 Vertical skeletal excess also can be managed with a functional appliance designed to inhibit eruption of the maxillary and mandibular teeth. The appliance is constructed so that the mandible is placed in an open posture at an increased vertical position. The force of the mandible attempting to return to its normal, more closed vertical posi-tion is transmitted to the maxilla and to the teeth in both arches. • Figure 36.9 This functional appliance is designed to allow the posterior teeth to erupt and, in this class II patient, drift anteriorly and aid in correc-tion of the dental relationship. This type of appliance can open the bite and increase the dental and skeletal vertical dimensions. before approximately 12 years of age. An alternative is to place the TADs in the palate, where there is better retention of the TAD. Regardless of the means used to manage vertical excess, excellent patient cooperation is necessary because treatment must be con-tinued or retained as long as the patient is growing.Vertical DeciencyVertical skeletal deciencies can be managed with either headgear or functional appliances, depending on the accompanying antero-posterior relationships. e force vector from the headgear should direct the maxilla distally and extrude the maxillary posterior teeth, which would require cervical pull headgear. Because functional appliances are typically designed to inhibit eruption of upper and lower anterior teeth and promote eruption of the posterior teeth, they can also increase vertical facial height (Fig. 36.9). In addition, because there is a component of forward or mesial movement of teeth as they erupt, an astute clinician will encourage lower molar eruption in class II cases (lower molar moves forward into class I) and upper molar eruption in class III cases. As in vertical skeletal excess, the original growth pattern tends to recur until growth is complete, and retention should be designed to prevent this recurrence. 520 Part 4 The Transitional Years: Six to Twelve YearsSLEEP DISORDERED BREATHINGRose D. SheatsChildren 6 to 12 years old should sleep 9 to 12 hours per day to promote optimal health.1 One condition to be considered in children who sleep less than this amount is pediatric sleep disordered breathing (SDB). SDB consists of partial or complete obstruction of the upper airway during sleep which manifests itself as increased respiratory effort, fragmented sleep, oxygen desaturation, and hypercapnia. It comprises a spectrum of conditions ranging from snoring, hypoventilation, and obstructive sleep apnea. The diagnosis must be made by a physician, but pediatric dentists can aid in the recognition of and screening for this medical condition. Children suspected of suffering from SDB should be referred to their pediatrician, a pediatric sleep specialist, or an otolaryngologist.Pediatric SDB occurs in 1%–5% of children,2–4 but the increasing prevalence of childhood overweight and obesity is likely to portend an increase in the incidence of pediatric SDB.5 In addition to obesity, other risk factors for pediatric SDB include snoring, preterm birth, African American race, male gender, and the presence of enlarged tonsils and adenoids.6 Specic craniofacial features such as narrow maxillary width and mandibular retrognathia have also been associated with pediatric SDB, although such ndings are not consistently supported by data.Several syndromes with craniofacial components are associated with increased risk for SDB. Children with Down syndrome have an especially high risk, with an estimated prevalence of 50%–80%.7,8 Approximately one-third (34%) of syndromic children with cleft palate have SDB, whereas nonsyndromic cleft palate children have half that prevalence (17%).9 Other conditions associated with increased risk for SDB include Pierre Robin sequence, Prader-Willi syndrome, sickle cell diseases, cerebral palsy, Chiari malformation, and neuromuscular conditions such as Duchenne muscular dystrophy, Guillain-Barré syndrome, and myotonic dystrophy.SDB has been associated with pediatric nocturnal enuresis.10–12 A proposed mechanism postulates that release of brain or atrial natriuretic peptides is increased because of cardiac wall distension secondary to the negative intrathoracic pressure caused by snoring or increased upper airway resistance. Other possible mechanisms include diminished arousal response or changes in bladder pressure as a consequence of SDB.Signs and symptoms of SDB overlap those of attention-decit/hyperactivity disorder (ADHD) and thus often result in misclassication of the disease or inappropriate management of the condition.13 Classic signs and symptoms of SDB include snoring, difculty waking up in the morning, inability to concentrate, irritability, and hyperactivity. Unlike adults, children do not often present with excessive daytime sleepiness.Many cases of pediatric SDB remain undiagnosed or untreated. Risks of untreated pediatric SDB include adverse impacts on the neurocognitive, cardiovascular, and metabolic systems.14,15 Childhood snoring was at one time considered benign, but evidence has been accumulating to suggest that it too is associated with cardiovascular and neurocognitive impairment.16,17Findings from the Childhood Adenotonsillectomy Trial reveal spontaneous remission of SDB at the 7-month follow-up in nearly half of the 203 children aged 5 to 9 years assigned to the Watchful Waiting group (nontreatment).18 However, it is important to note that in this study, children diagnosed with severe SDB were excluded from enrollment. As in other studies, the investigators identied obesity and African American race, as well as severity of baseline SDB, as risk factors for SDB at follow-up.Screening for pediatric SDB should begin in the early mixed dentition years and should start with a careful medical history. Childhood obesity and reports of medication to manage attention-decit disorder (ADD) or ADHD should alert the clinician to the possible risk of undiagnosed SDB. Clinicians should inquire about childhood snoring, nocturnal enuresis, and other behavioral features associated with both ADD/ADHD and SDB. Poor academic performance and disruptive behavior at school or at home may also be clues to the presence of pediatric SDB.Questionnaires have been developed to screen for risk of pediatric SDB.19 The most psychometrically rigorous questionnaire is the Pediatric Sleep Questionnaire which has been validated for children 2 to 18 years.20 It consists of 22 questions that examine three domains: snoring, sleepiness, and behavior. A single global score suggests that the child is at either “low risk” or “high risk” for SDB. A “high-risk” score merits referral to medical colleagues for further evaluation.Clinical examination should include an evaluation of the posterior airway space, especially with respect to tonsillar presence and size. Pediatric dentists are particularly well trained to assess and record tonsillar size using the Brodsky scale.21 The presence of enlarged tonsils associated with signs or symptoms of SDB should initiate a referral to a pediatric sleep specialist or otolaryngologist for evaluation.First line treatment for pediatric SDB is adenotonsillectomy (AT), but this does not lead to cure in all cases.22 In otherwise healthy children, AT normalizes SDB in 74% of children, but success rates decrease in obese children and African American children.18,23 Thus it is important to consider additional treatment options to resolve this condition in children with residual sleep disordered events. Although positive airway pressure is often the second line of treatment, poor adherence plagues this effective therapeutic modality. In addition, data suggest that positive airway pressure may have an adverse impact on craniofacial growth. A recent case-control study of positive airway pressure in syndromic children demonstrated a deleterious effect on maxillary growth.24Pediatric dentists, in collaboration with the child’s sleep physician, may be a valuable adjunct to the medical team managing SDB in the pediatric patient. The pediatric dentist’s knowledge of craniofacial growth and development in this population is critical for examining potential treatment options. The clinician should monitor jaw growth in children undergoing treatment for SDB and discuss future treatment options, including potential need for orthognathic surgery.Rapid maxillary expansion (RME) has been demonstrated to improve signs and symptoms of pediatric SDB,25,26 but this treatment thus far has only been explored in those children with SDB who required expansion to correct maxillary transverse deciency. In addition RME has also been demonstrated to ameliorate nocturnal enuresis.27,28 However, caution should be exercised in recommending RME for children younger than 8 years, because anecdotal reports suggest this procedure may lead to nasal deformity.29 Data are currently lacking to demonstrate the risks and benets of offering maxillary expansion to young children, especially to those whose arch widths are coordinated.Mandibular advancement devices have routinely been used in adults with obstructive sleep apnea to prevent the tongue from collapsing into the posterior airway space during sleep. Such appliances are used in orthodontics to manage skeletal and dental class II malocclusions in growing children but are not commonly used to treat SDB in children. Evidence is too limited and of poor quality to support their use at this time in the management of SDB in children in the mixed dentition.30–33 Concerns include the unknown impact on craniofacial growth in class I and class III children, as well as the difculty in device retention and treatment adherence during the tooth exchange period. Further research is needed to clarify the risks and benets of mandibular advancement devices in the management of pediatric SDB in 6- to 12-year-olds.SDB in the child patient has the potential to not only disrupt optimal sleep but can also to lead adverse neurocognitive, cardiovascular, and metabolic problems. Pediatric dentists are well positioned to screen for SDB in patients 6 to 12 years old, to make appropriate referrals when indicated, and to participate in the management of this condition when feasible.References1. Paruthi S, Brooks L, D’Ambrosio C, et al. Consensus Statement of the American Academy of sleep medicine on the recommended amount of CHAPTER 36 Treatment Planning and Management of Orthodontic Problems 521 Premature loss of a primary molar at a very early age delays the eruption of the permanent tooth. On the other hand, premature loss of a primary molar at an age near the time of normal eruption of the permanent tooth may accelerate the eruption of the permanent tooth and make space maintenance unnecessary. In general, eruption of the permanent premolar will be delayed if the primary molar is lost before age 8 years, whereas the premolar will tend to erupt earlier than normal if the primary molar is lost after age 8 years. A more accurate method of determining delayed or accelerated eruption of permanent teeth is to examine the amount of root development and alveolar bone overlying the unerupted permanent tooth from panoramic or periapical lms. e permanent tooth begins to erupt when root development is approximately one-half Dental ProblemsSpace MaintenanceA philosophy for space maintenance and the appliances recom-mended for the primary dentition are discussed in Chapter 26. e same philosophy and appliances apply to space maintenance in the 6- to 12-year-old age group. However, treatment for early loss of primary teeth in the mixed dentition requires some additional thought and consideration. Loss of posterior teeth in the primary dentition is a nearly universal indication for space maintenance therapy. In the mixed dentition the timing of permanent tooth eruption, timing of tooth loss, presence of permanent teeth, and extent of crowding must also be taken into account.sleep for healthy children: methodology and discussion. J Clin Sleep Med. 2016;12:1549–1561.2. Bixler E, Vgontzas A, Lin H, et al. Sleep disordered breathing in children in a general population sample: prevalence and risk factors. Sleep. 2009;32:731–736.3. Rosen C, Larkin E, Kirchner H, et al. Prevalence and risk factors for sleep-disordered breathing in 8- to 11-year-old children: association with race and prematurity. J Pediatr. 2003;142:383–389.4. Lumeng J, Chervin R. Epidemiology of pediatric obstructive sleep apnea. Proc Am Thorac Soc. 2008;5:242–252.5. Arens R, Muzumdar H. Childhood obesity and obstructive sleep apnea syndrome. J Appl Physiol. 2010;108:436–444.6. Katz E, D’Ambrosio CM. Pediatric obstructive sleep apnea syndrome. Clin Chest Med. 2010;31:221–234.7. Southall D, Stebbens V, Mirza R, et al. Upper airway obstruction with hypoxaemia and sleep disruption in Down syndrome. Dev Med Child Neurol. 1987;29:734–742.8. Maris M, Verhulst S, Wojciechowski M, et al. Sleep problems and obstructive sleep apnea in children with Down syndrome, an overwiew. Int J Pediatr Otorhinolaryngol. 2016;82:12–15.9. Muntz H, Wilson M, Park A, et al. Sleep disordered breathing and obstructive sleep apnea in the cleft population. Laryngoscope. 2008;118:348–353.10. Sans Capdevila O, Crabtree V, Kheirandish-Gozal L, et al. Increased morning brain natriuretic peptide levels in children with nocturnal enuresis and sleep-disordered breathing: a community-based study. Pediatrics. 2008;121:e1208–e1214.11. Jeyakumar A, Rahman S, Armbrecht E, et al. The association between sleep-disordered breathing and enuresis in children. Laryngoscope. 2012;122:1873–1877.12. Umlauf M, Chasens E. Sleep disordered breathing and nocturnal polyuria: nocturia and enuresis. Sleep Med Rev. 2003;7:403–411.13. Owens J. Neurocognitive and behavioral impact of sleep disordered breathing in children. Pediatr Pulmonol. 2009;44:417–422.14. Tan H, Gozal D, Kheirandish-Gozal L. Obstructive sleep apnea in children: a critical update. Nat Sci Sleep. 2013;5:109–123.15. Amin R, Somers V, McConnell K, et al. Activity-adjusted 24-hour ambulatory blood pressure and cardiac remodeling in children with sleep disordered breathing. Hypertension. 2008;51:84–91.16. Kennedy J, Blunden S, Hirte C, et al. Reduced neurocognition in children who snore. Pediatr Pulmonol. 2004;37:330–337.17. Li A, Au C, Ho C, et al. Blood pressure is elevated in children with primary snoring. J Pediatr. 2009;155:362–368.e361.18. Marcus C, Moore R, Rosen C, et al. A randomized trial of adenotonsillectomy for childhood sleep apnea. N Engl J Med. 2013;368:2366–2376.19. De Luca Canto G, Singh V, Major M, et al. Diagnostic capability of questionnaires and clinical examinations to assess sleep-disordered breathing in children: a systematic review and meta-analysis. J Am Dent Assoc. 2014;145:165–178.20. Chervin RD, Hedger K, Dillon JE, et al. Pediatric sleep questionnaire (PSQ): validity and reliability of scales for sleep-disordered breathing, snoring, sleepiness, and behavioral problems. Sleep Med. 2000;1:21–32.21. Brodsky L. Modern assessment of tonsils and adenoids. Pediatr Clin North Am. 1989;36:1551–1569.22. Brietzke S, Gallagher D. The effectiveness of tonsillectomy and adenoidectomy in the treatment of pediatric obstructive sleep apnea/hypopnea syndrome: a meta-analysis. Otolaryngol Head Neck Surg. 2006;134:979–984.23. Friedman M, Wilson M, Lin H, et al. Updated systematic review of tonsillectomy and adenoidectomy for treatment of pediatric obstructive sleep apnea/hypopnea syndrome. Otolaryngol Head Neck Surg. 2009;140:800–808.24. Roberts S, Kapadia H, Greenlee G, et al. Midfacial and dental changes associated with nasal positive airway pressure in children with obstructive sleep apnea and craniofacial conditions. J Clin Sleep Med. 2016;12:469–475.25. Pirelli P, Saponara M, Guilleminault C. Rapid maxillary expansion in children with obstructive sleep apnea syndrome. Sleep. 2004;27:761–766.26. Villa M, Rizzoli A, Miano S, et al. Efcacy of rapid maxillary expansion in children with obstructive sleep apnea syndrome: 36 months of follow-up. Sleep Breath. 2015;15:179–184.27. Bazargani F, Jonson-Ring I, Neveus T. Rapid maxillary expansion in therapy-resistant enuretic children: an orthodontic perspective. Angle Orthod. 2016;86:481–486.28. Schutz-Fransson U, Kurol J. Rapid maxillary expansion effects on nocturnal enuresis in children: a follow-up study. Angle Orthod. 2008;78:201–208.29. Proft WR, Fields HW, Sarver DM. Contemporary Orthodontics. 5th ed. St Louis: Mosby–Year Book; 2012.30. Carvalho FR, Lentini-Oliveira DA, Prado LB, et al. Oral appliances and functional orthopaedic appliances for obstructive sleep apnoea in children. Cochrane Database Syst Rev. 2016;(10):CD005520.31. Nazarali N, Altalibi M, Nazarali S, et al. Mandibular advancement appliances for the treatment of paediatric obstructive sleep apnea: a systematic review. Eur J Orthod. 2015;37:618–626.32. Villa MP, Bernkopf E, Pagani J, et al. Randomized controlled study of an oral jaw-positioning appliance for the treatment of obstructive sleep apnea in children with malocclusion. Am J Respir Crit Care Med. 2002;165:123–127.33. Huynh NT, Desplats E, Almeida FR. Orthodontics treatments for managing obstructive sleep apnea syndrome in children: a systematic review and meta-analysis. Sleep Med Rev. 2016;25:84–94.SLEEP DISORDERED BREATHING—cont’d 522 Part 4 The Transitional Years: Six to Twelve Yearsspace or minor crowding in the arch, space maintenance should be initiated. However, early loss of a primary molar in an arch with substantial crowding must be considered carefully. Space maintainers alone will not solve a problem of this magnitude. Either permanent teeth will be extracted or the arches will have to be expanded. Expansion is possible only if the incisor position is normal or retrusive and the periodontium is healthy enough to allow the incisors to be moved facially. If expansion is contem-plated, space maintainers should be placed. However, in some cases, crowding of this magnitude is managed by extracting two rst premolars and closing the remaining space with orthodontic appliances.If no space maintenance is implemented and tooth movement results from drifting before rst premolar extractions, less space remains to be closed later. Consultation with a specialist is desirable before this type of decision is made. If the crowding approaches 10 mm/arch, space maintainers may be needed even though permanent tooth extraction is inevitably required. e average width of a premolar is approximately 7 mm; therefore the extraction of two premolars would eectively result in a gain of 14 mm of arch length. If more space is lost in an arch that is already severely crowded, a two-premolar extraction may not resolve all the crowding. Space maintainers would ensure that no further decrease in arch length occurs. In some instances, timed extraction (called serial extraction) can alleviate the crowding and relieve the demands of subsequent orthodontic treatment.Probably the most signicant dierence between space main-tenance strategy in the mixed dentition and that in the primary dentition is bilateral loss of teeth in the mandibular arch. In the primary dentition, two band and loop appliances are indicated; in the mixed dentition the lingual arch is preferred if all lower incisors have erupted. Primary second molars or permanent rst molars may be used as abutment teeth. If oral hygiene is a problem, it is recommended that primary second molars be banded. is is done so that if decalcication under bands occurs because of poor oral hygiene, it occurs on teeth that will eventually exfoliate.Space maintenance in the mixed dentition requires close supervi-sion as permanent teeth erupt and primary teeth exfoliate. When primary abutment teeth exfoliate, an appliance may have to be remade using permanent teeth as abutments. Space-maintaining appliances should be removed when the permanent tooth erupts into its proper position.Potential Alignment and Space ProblemsEctopic EruptionProblems associated with ectopic eruption of the permanent rst molar have been discussed previously in Chapter 31. A 3- to 6-month observation period usually is the best initial therapy if the resorption is not too severe, because there is a possibility that the molar will self-correct spontaneously or “jump” distally and erupt into its normal position (Fig. 36.10). Intervention is necessary if the molar is still blocked from erupting at the end of the observa-tion period or if the permanent molar is severely impacted.47 e goal of treatment is to move the ectopically erupting tooth away from the tooth it is resorbing, allow it to erupt, and retain the primary second molar.If a small amount of movement is needed and little or none of the permanent molar is clinically visible, a piece of 20- to 22-mm brass wire can be passed around the contact between the permanent molar and the primary second molar. e brass wire to two-thirds completed. In terms of alveolar bone coverage, approximately 6 months should be anticipated for every millimeter of bone that covers the permanent tooth. If it is apparent that the tooth will be delayed in erupting and the space is adequate, space maintenance is absolutely indicated. Because space loss usually occurs within the rst 6 months after the premature loss of a primary molar, space maintenance should be undertaken unless the tooth is expected to erupt within 6 months or unless there is enough space in the arch that a 1- or 2-mm space reduction will not compromise eruption of the permanent tooth.A second factor to consider is the amount of time that has elapsed since the primary tooth was lost. At one extreme is the case of a primary molar scheduled for extraction. At the other extreme is a primary molar already missing for 6 months or longer. In the rst case, space maintenance is certainly indicated to prevent space loss when the tooth is extracted. In the second case the majority of space loss has already occurred, and space maintenance may not be indicated. e clinician should complete space and prole analyses and decide based on those ndings. If there is excess space in the arch or if so much space has been lost that extraction of permanent teeth is inevitable, space maintenance is contraindicated. A space maintainer is indicated to prevent any more space loss if the space remaining is only marginally adequate to allow the permanent tooth to erupt. As always, there is little if any rationale for maintaining inadequate space.Another way to look at space maintenance in the mixed dentition is by what tooth is lost prematurely. In general, after the rst permanent molar erupts, there is more space lost when the primary second molar is lost than the primary rst molar. A systematic review of early loss of the primary rst molar indicated that there is an immediate loss of 1.5 mm of space in the mandibular arch and 1.0 mm of loss in the maxillary arch.45 ereafter there is little space loss. Many use this information to question whether space maintainers should be used in the mixed dentition to replace missing primary rst molars. Second primary molar loss seems to be completely dierent. Northway et al. report there are signicant space loss and continued space loss when the second primary molar is lost prematurely.46 Unless there are unusual circumstances such as missing teeth (see later), space maintenance is indicated when second primary molars are lost.The absence of a permanent successor complicates space maintenance in the mixed dentition. e second premolar is the most commonly missing posterior tooth in the permanent dentition, excluding the third molars. If the primary second molar is lost prematurely, the clinician must decide about the space that would have been occupied by the missing second premolar. Two choices can be made. One alternative is to maintain space in the arch and eventually construct a xed prosthesis or have an implant placed and restored. is is most feasible if the skeletal and dental relation-ships are class I, there is no crowding, and there is good interarch occlusion. is is an even more inviting alternative if only one of the premolars is missing (i.e., a unilateral missing premolar). e advent of resin-bonded bridges and intraosseous implants has made this option more popular. Another alternative is to allow or encour-age the space to close. Factors that favor this solution include crowding in the arch, protrusive incisors and lips, bilateral missing premolars, and possibly other missing teeth. is topic is addressed in more detail later in this chapter.e amount of crowding in the arch is an important factor in the decision about space maintenance, and it is predicted from the space analysis and put in perspective by the facial form analysis. If the incisor position is normal and there is adequate CHAPTER 36 Treatment Planning and Management of Orthodontic Problems 523 resorption of the primary molar. It may be dicult to seat the spring if the contact point between the molars is below the cementoenamel junction of the primary molar. Some authors advocate elastomeric separators, but they must be carefully supervised because they can dislodge in an apical direction and bury in the sulcus causing a periodontal abscess. Some elastomeric separators are not radiopaque and can be dicult to locate.Another method of moving the permanent molar distal is to band the primary second molar and apply a distal force to the permanent molar through a helical spring or elastomer (Fig. 36.12). In fact, a type of band and spring appliance can be constructed at chairside using the orthodontic archwire tube on a molar band; the appliance is easily activated intraorally at subsequent appoint-ments. ese methods require that the occlusal surface of the permanent molar be visible so that force can be applied to move the tooth distally. A small ledge of resin or a metal button can be bonded to the occlusal surface to serve as the point of force applica-tion, or the end of the spring can be bonded directly to the impacted tooth. However, salivary contamination of the occlusal surface sometimes makes bonding a frustrating and dicult procedure. An even more cost-eective technique is to bond a permanent rst molar bracket on the primary second molar and a permanent second molar bracket on the permanent rst molar; then a self-retained helical spring is constructed between the two teeth to move the permanent rst molar distally. is can all be accomplished chairside in a few minutes by a procient wire bender. Such a band and spring appliance should be evaluated every 2 weeks and is tightened every 2 weeks. When the wire is tightened, the periodontal ligament space is compressed and the molar is forced distally until it can slip past the primary molar and erupt (Fig. 36.11). In some cases a steel spring clip separator may be used to dislodge the molar, but only in cases in which there is minimal ACB• Figure 36.11 (A) This radiograph shows an ectopically erupting permanent maxillary left rst molar. (B) Because only a small amount of movement is required to correct the ectopic eruption, a piece of 20-mm brass wire is slipped around the contact point between the permanent molar and the primary second molar and is tightened. (C) After the wire has been tightened 3 times at 2-week intervals, the molar is dislodged and begins to erupt into a normal position. (From Fields HW, Proft WR. Orthodontics in general practice. In: Morris AL, Bohannan HM, Casullo DP, eds. The Dental Specialties in General Practice. Philadelphia: Saunders; 1983.)• Figure 36.10 This radiograph illustrates the ability of an ectopically erupting permanent rst molar to self-correct spontaneously. Note that the distal root of the primary maxillary second molar has been resorbed. Usually this type of resorption is the result of an erupting permanent molar that is caught on the distal aspect of the primary molar. If the resorption does not progress too far, the permanent molar usually “jumps” past the resorptive defect in 3 to 6 months. 524 Part 4 The Transitional Years: Six to Twelve Yearsand decrease arch length. When this happens and the incisors align, it appears that the space problem is corrected because the incisor alignment usually improves, but this is only temporary, and the space shortage will become apparent again when the permanent canines begin to erupt. Whether the loss of primary canines is unilateral or bilateral, the clinician should determine whether there is an arch length inadequacy and assess anteroposterior lip and incisor position. is information helps to determine whether space maintenance, space regaining, or more extensive treatment is needed.e goal of treatment should be to manage the space according to the long-term plan. Past recommendations for treatment of crowding and lateral incisor ectopic eruption have included placing a lingual arch with a soldered spur distal to the lateral incisor to hold the midline. If the midline has already shifted, it has been recommended to remove the contralateral primary canine to promote spontaneous midline correction. If space loss cannot be tolerated because of lingual incisor tipping, a lingual arch should be placed following extraction. However, there is no evidence in the literature that removal of the contralateral primary canine will result in spontaneous midline correction. ere is also no evidence that the midline shift is progressive if the primary canine is not removed. A recent study of growth study data conrmed there is no signicant can work eectively in a short time because of the minimal root development on the permanent molar.Occasionally, the primary second molar must be removed if the permanent molar has caused extensive resorption of the primary root structure. In these cases, loss of arch length is certain, and some plan of treatment for the impending space deciency should be considered in advance (Fig. 36.13). If there is a congenitally missing second premolar or premolar extraction is being considered because of the crowding, then reduction in arch length by mesial movement of the molars is advantageous. To manage the space after extraction of the primary molar, a distal shoe can be placed to guide eruption of the permanent molar. A distal shoe maintains space but does not regain space that was lost before the primary molar extraction. An alternative plan is to allow the permanent molar to erupt and then use the appropriate appliance to regain the space (described subsequently). After the space is regained, a space maintainer should be placed.Ectopic eruption of lateral incisors is usually an early indication of crowding but may only be the result of aberrant tooth positioning. If a primary canine exfoliates prematurely as a result of ectopic eruption, the lower incisors typically drift to that side of the arch, creating a midline discrepancy. If the laterals cause resorption and exfoliation of both primary canines, the incisors usually tip lingually ABC• Figure 36.12 (A and B) A band and helical spring appliance is used to treat an ectopically erupting permanent molar that requires a large amount of movement. The primary second molar is banded, and a helical spring is soldered to the band. A small ledge of composite resin, a metal button bonded to the occlusal surface of the permanent molar, or a small preparation can serve as a point of force application. The spring is reactivated at monthly intervals until the permanent molar is dislodged. (C) Another band and spring design with a metal button bonded to the occlusal surface of the erupting permanent molar. Elastomeric chain or thread is attached from the button to the distal hook on the wire and changed monthly to provide the distal force to dislodge the molar. ([A and B] From Fields HW, Proft WR. Ortho-dontics in general practice. In: Morris AL, Bohannan HM, Casullo DP, eds. The Dental Specialties in General Practice. Philadelphia: Saunders; 1983.) CHAPTER 36 Treatment Planning and Management of Orthodontic Problems 525 DCBA• Figure 36.13 (A) In some cases, ectopic eruption causes extensive resorption of the primary tooth root and the tooth is lost prematurely. In some cases the tooth may abscess due to communication with the oral environment. (B) When the primary second molar is lost, the clinician should anticipate mesial movement of the permanent molar and a reduced arch length. (C) This space loss occurred within the rst 6 months of tooth removal. (D) The space was opened with braces and a coil spring. Space main-tenance was necessary to hold space for the unerupted second premolar. dierence in the position of the lower dental midline after unilateral loss of a primary canine or normal exfoliation of both canines.48 ere are studies to show that removal of the mandibular primary canines will result in an improved irregularity index (a measure akin to crowding) compared with those that do not have primary canine removal. However, this tooth removal comes at the expense of nearly 3 mm in arch perimeter decrease.49 Based on this evidence, the clinician should carefully consider whether to remove the contralateral canine when there is ectopic eruption of the lower lateral incisor. Further discussion on lower anterior crowding and premature canine loss will occur later. If there is sucient crowding so that space maintenance is contraindicated, or if the incisors are considered too protrusive to be maintained in this position, no lingual arch should be placed following the extraction of the contralateral primary canine. In situations in which both canines exfoliate prematurely because of ectopic eruption, similar treatment decisions should be made, although the clinician does not normally have to worry about a midline shift.TranspositionEarly transposition can be addressed during the mixed dentition and provides an opportunity to intercept a developing problem. 526 Part 4 The Transitional Years: Six to Twelve Years(Fig. 36.15).52 If there is more than this amount of overlap, the chance of normal eruption diminishes. Other treatments have been proposed to prevent the maxillary canine from erupting into the palate. Besides removal of the primary canine, others have suggested palatal expansion and primary canine removal,53 headgear treatment, and removal of both the primary canine and primary rst molar.54Missing Permanent Teethe absence of permanent teeth creates many treatment problems for the clinician, and most treatment decisions of this nature are best made by a specialist. e maxillary lateral incisor and the mandibular second premolar are the most common congenitally missing teeth in the permanent dentition, whereas anterior teeth, specically the incisors, are often lost to trauma. Treatment decisions are based not only on which tooth is missing but also on arch length, adjacent tooth morphology and color, incisor position, and lip and prole esthetics.Treatment of congenitally missing maxillary lateral incisors varies depending on whether one or both incisors are absent and on the As mentioned earlier, the type of transposition amenable to early treatment is most commonly encountered in the mandibular arch. e lateral incisors resorb either the primary canine or primary canine and rst molar (Fig. 36.14A). ey rotate as they erupt, so treatment includes repositioning them mesially and derotating them (see Fig. 36.14B). If this is accomplished before canine eruption, transposition can be prevented (see Fig. 36.14C).Impacted Teethe most common site of impacted teeth in the mixed dentition is in the maxillary canine region. ese teeth often erupt in a mesial direction and become impacted in the palate or resorb the permanent lateral incisor roots.50 is problem is often diagnosed because there is no bulge on the facial alveolus in the canine area at approximately 9 or 10 years of age.51 Some type of radiograph is indicated to locate the canine. In most cases this is a panoramic radiograph. is may even merit the use of a small eld of view CBCT image (see Chapter 31 for details). If the permanent canine overlaps less than half of the lateral incisor root on a panoramic radiograph, there is a greater than 90% chance of redirecting the canine distally simply by timely extraction of the primary canines CBA• Figure 36.14 (A) Early transposition can cause loss of the primary canine or primary canine and rst molar. In this patient the lower left rst primary molar was removed to allow the lateral incisor to erupt. (B) Often the lateral incisor will require mesial movement and rotation. (C) Correction with banded and bonded appliances has prevented true transposition. CHAPTER 36 Treatment Planning and Management of Orthodontic Problems 527 for prosthetic replacement of the lateral incisor, the placement of an implant or resin-bonded bridge has to be delayed until the patient has stopped growing. is is often greater than 5 years between the nish of orthodontic treatment and a denitive restora-tion. Retention must be well planned, and the patient must be very compliant with retention so the teeth remain in the ideal position for restorations. Even with good retention, studies have shown there is a 1 in 10 chance the roots of the central incisor and canine will converge and prevent implant placement.56 Another long-term consequence of implant-supported restoration of the lateral incisor is the implant itself. ough the implant has a high success rate, there are implant failures. In addition, resorption of labial bone around the implant, a normal nding over time, causes the gingiva to appear blue. Lastly, the implant may show infraoc-clusion after several years. Because the implant does not erupt like teeth, any vertical growth change will result in a change in the vertical relationship of the implant and adjacent teeth.57If the permanent canine erupts into the lateral incisor position, the primary canine can be extracted. Depending on the situation, position of the permanent canine when it erupts into the arch. e canine either erupts into the normal canine position or resorbs the primary lateral incisor and spontaneously substitutes for the missing lateral incisor. If the canine erupts into its proper position, the primary lateral incisor will eventually have to be removed because it does not make an esthetically pleasing substitute for the permanent lateral incisor and because the root will eventually resorb. e missing lateral incisor can be replaced with a resin-bonded bridge or an implant. In general, prosthetic replacement of the missing lateral incisor is preferred when the occlusion, incisor position, and prole are nearly ideal (Fig. 36.16).55 is approach should always be considered when the contralateral lateral incisor is present and has excellent size and shape. Until recently, this approach was also favored when the occlusion was near ideal because it was dicult to close the space without creating a midline dis-crepancy or retracting the incisors. e use of TADs has made space closure much easier and more predictable.e clinician must also consider the long-term consequences of treatment. If the patient and clinician elect to open the space CBA• Figure 36.15 (A) Even though this patient has considerable mesial migration of the permanent maxillary left canine and it overlaps the entire lateral root, the primary canine was extracted in an attempt to redirect its eruption path. (B) Note the distal and occlusal movement of the permanent left canine with reduced overlap of the lateral incisor. (C) Nearly 1 year later the permanent left canine will erupt into relatively normal position. 528 Part 4 The Transitional Years: Six to Twelve Yearsgingival display all inuence whether this approach should be considered (Fig. 36.17). ese canines require recontouring by enamel removal, bleaching to lighten the color, and resin addition to improve the esthetic appearance of the teeth. e recommended treatment is to extrude the canine and intrude the rst premolar the permanent canine can be moved back to the correct position, and a prosthetic solution for the missing lateral incisor can be determined as discussed previously. ere are several factors to consider in canine substitution. e existing malocclusion, crowding, patient prole, crown shape and color of the canine, and smiling ACB• Figure 36.16 (A) This patient is missing the maxillary left lateral incisor. Because the patient has class I molars and relatively good alignment, a decision was made to replace the missing lateral incisor pros-thetically. (B) At the end of treatment, a space identical in size to the right lateral incisor was created to replace the left lateral incisor. (C) A dental laboratory created a left lateral incisor pontic with thin abutment wings. The abutment teeth were etched and composite resin was used to bond the abutment wings to each tooth. This type of restoration does not work with a deep bite because of the shearing force of occlusion on the lingual surface. BA• Figure 36.17 (A) This patient was congenitally missing both upper lateral incisors. A decision was made to substitute the canines into the lateral position. (B) The central incisors and canines have been recontoured by adding resin and using a dental bur. If the rst premolar is too small in shape, it is possible to recontour the rst premolar with composite resin to mimic a canine. CHAPTER 36 Treatment Planning and Management of Orthodontic Problems 529 injuries to adjacent teeth further complicate decisions. Not only is the clinician faced with the normal questions of conventional orthodontics, but the clinician is making decisions on teeth with uncertain prognoses and diminished or missing bony support. Traditional management of replacing incisors lost to trauma usually involves prosthetic tooth replacement or natural tooth replacement through substitution of teeth.Another possibility is the use of transplanted posterior teeth, usually a premolar, into the position of the missing maxillary central incisor. With reshaping and either resin or veneer restoration, this option can be quite successful. Although not widely adopted in North America, posterior tooth transplantation is a real option in Scandinavian countries.60Arch length, incisor position, and facial appearance must be thoroughly evaluated before a treatment plan is generated when a premolar is congenitally missing. Unlike primary canines and laterals, a primary molar may be a reasonable substitute for a missing premolar. e size, shape, and restorative status of the primary molar give some indication of the possibility of main-taining the tooth for a period of time (Fig. 36.18). Ankylosis and advanced root resorption indicate that the primary molar should be removed. Most clinicians favor removing the primary to create gingival margins that match normal occlusions. e ideal case for canine substitution is a nice prole, a class II dental relationship, no crowding in the lower arch, and small canines with color that matches the central incisors.57 Canine substitution cases are considered dicult to treat well. A normal pretreatment occlusion favors canine retraction and prosthetic replacement, as does short or wide canine crown morphology and dark canine color. ese elements reduce the chances of providing an esthetic canine substitution for the lateral incisor. Even if the canine must be retracted, this is not without some virtue. e canine brought bone with it during its eruption, and this bone will enhance future esthetics and potential implant placement in the lateral incisor position. e clinician should discuss all treatment options with the patient in missing lateral incisor cases. It is especially important when studies show patients are more satised with natural tooth replacement (canine substitution) than prosthetic replacement.58,59When incisors are lost to trauma, the clinician must study the existing situation in a manner similar to congenitally missing lateral incisors. e age and growth status of the patient, the amount of crowding, and the skeletal relationship must be considered. e number of teeth lost, the status of the periodontium, and the BA• Figure 36.18 In some cases, retaining primary molars as an interim replacement for missing premolars is acceptable. Usually, the primary molars ultimately will require replacement. (A) Patient with missing maxillary left second premolar and both mandibular second premolars. (B) The parents and patient did not want prosthetic replacement of teeth, so the orthodontic treatment was directed to the anterior teeth only. 530 Part 4 The Transitional Years: Six to Twelve YearsABC• Figure 36.19 Closing the spaces that accompany missing teeth and avoiding prosthetic replacements are sometimes advantageous. (A) This patient is missing maxillary lateral incisors and mandibular second premolars. (B) The remaining primary teeth were extracted and allowed to drift. (C) Orthodontics was completed, and the teeth were nally positioned. molar and closing the space orthodontically (Fig. 36.19); but in certain situations a resin-bonded bridge, conventional bridge, or implant may be a more ideal treatment (Fig. 36.20). Prosthetic replacement is more likely in class I skeletal and dental patients with ideal or nearly ideal occlusions or when a tooth is missing unilaterally. Again, the introduction of TADs allows the clini-cian to determine if space closure is appropriate in a case where prosthetic replacement used to be automatic, such as when it would be dicult to move teeth without aecting the occlusion and relationship of the remaining teeth. e TAD can be used to move a posterior segment forward without causing the anterior teeth to shift (creating a midline deviation), because the movement of the teeth is pitted against the stability of the TAD within the bone and not the teeth. As a general guideline, use of TADs is contraindicated in children younger than 12 years because of bone density, the presence of unerupted teeth, and the inability to hold the miniscrew.If the arch is so crowded that teeth must be extracted, or if the incisors are too protrusive or the prole too full, the retained primary molar should be removed and the case treated in a manner similar to that for a four-premolar extraction case. Typically, rst premolars are removed in an extraction case, but the majority of congenitally missing premolars are second premolars. If it can be determined that the second premolar is missing and that extractions are necessary to resolve the arch length inadequacy, the primary molar can be removed early, allowing the space to close by mesial drifting of the permanent rst molar and distal drifting of the anterior teeth. Unfortunately, congenital absence of the second premolar may not be denitively determined at an early age, and this delays the extractions. e longer the extractions are delayed, CHAPTER 36 Treatment Planning and Management of Orthodontic Problems 531 Supernumerary TeethA supernumerary tooth may create space and eruption problems. It can cause permanent teeth to erupt into malalignment or even prevent eruption. Treatment is directed at minimizing the eect of the supernumerary tooth by immediate removal or observation and later removal. Management of the supernumerary varies depending on the size, shape, number of supernumeraries, and the dental development of the patient. Typically, the supernumerary is detected on a panoramic radiograph or an anterior occlusal lm unless there is clinical evidence of an extra tooth at an earlier age. If the supernumerary is conical and is not inverted, there is a reasonable chance that it will erupt, at which time it should be removed (Fig. 36.22). If the supernumerary is inverted, it may migrate superiorly away from the teeth and possibly into the nose. A tubercular-shaped tooth will not migrate but may, as with any supernumerary tooth, signicantly impede eruption of the adjacent teeth. When multiple supernumerary teeth are present or if the supernumerary tooth fails to erupt, there is an increased chance of impeding the eruption of at least one tooth. In these cases, the less drifting and spontaneous space closure will occur. Using the space of the missing second premolars to reduce protrusion is much more complicated and requires the teeth to be retracted into the space of the missing teeth. is precludes dental drifting and should be planned by the specialist.One further word of caution. If the primary molars are ankylosed and the permanent successor missing, then the primary molars should be extracted before the vertical bony discrepancy of the alveolus becomes too great (Fig. 36.21). is may require subsequent space maintenance. Studies show that loss of bony ridge will be minimal, and the maintenance of good bony contours for the adjacent teeth without periodontal defects will be improved. ere is a reduction of alveolar bone width of 25% to 30%, but the authors show that implant placement is still feasible without bone grafting.61 Later, implants or restorations can be placed, and in some cases the space can be closed orthodontically. Some have suggested using decoronation of the ankylosed primary molar to maintain alveolar width, but there are no data to support this claim.AB• Figure 36.20 When permanent teeth are missing, often unilaterally, the best solution is to adjust the space and plan for prosthetic replacement. (A) Because of the short roots and restorative status, the primary mandibular right second molar was extracted. (B) The space was adjusted to accommodate a prosthetic replacement. 532 Part 4 The Transitional Years: Six to Twelve YearsAB• Figure 36.21 (A) This patient has an ankylosed primary maxillary right second molar, as illustrated by the more apical marginal ridges of the tooth. (B) The panoramic radiograph shows that the maxillary right and mandibular second premolars are missing. Because of the developing vertical discrepancy in the bone levels, the primary molars should be removed as atraumatically as possible and the space either maintained or closed. BA• Figure 36.22 (A) A conical supernumerary in the maxillary central incisor region was detected during a radiographic examination. This supernumerary was not interfering with the normal eruption of the per-manent incisors. (B) The supernumerary was allowed to erupt before it was removed. surgical removal makes sense. Ideally, the surgery is timed so that removal of the supernumerary tooth does not interfere with permanent tooth development. However, the earlier the supernumer-ary can be removed, the more likely it is that the permanent teeth will erupt normally. Surgery to remove a supernumerary is often complicated, especially if there are multiple supernumerary teeth or if access to the supernumerary tooth is limited. ese patients are appropriately referred to a specialist.Tooth Size DiscrepanciesIsolated tooth size discrepancies can cause alignment problems. e maxillary lateral incisor commonly creates this type of problem because it is undersized or has a pegged shape. Occasionally the lateral incisor can be restored to its normal size with composite resin and requires no other treatment. As discussed in Chapter 31, sometimes the pegged lateral needs a combination of tooth movement and restorative dentistry to achieve normal occlusion. Depending on the size of the discrepancy, the pegged lateral can be treated in one of three ways.If the lateral incisor is only slightly smaller than normal, the entire space can be closed. An alternative method for a marginally small incisor is to move the lateral incisor orthodontically until it contacts the central incisor and leave space distal to the lateral. is solution is generally not esthetically pleasing unless only a small space is left distal to the lateral. It also requires retention to hold the space. e canine usually is not brought forward to close the space because this would put the canine in an end-to-end relationship and disrupt the previously normal occlusion. An alternative to this approach is to use interproximal tooth reduction in the lower arch to make those anterior teeth narrower, so the upper space can be fully closed. A third solution, usually reserved for incisors that are considerably undersized, is a combination of orthodontic tooth movement and resin bonding to reshape the crown (Fig. 36.23). e lateral incisor should be positioned so that the resin addition will be cosmetically pleasing and will restore near-normal crown anatomy. is type of treatment is best per-formed by a specialist who has completed a diagnostic setup as described in Chapter 38 to plan the tooth movement and restorative requirements. CHAPTER 36 Treatment Planning and Management of Orthodontic Problems 533 ACDB• Figure 36.24 (A and B) The right central incisor was fused to a supernumerary tooth creating a single large incisor. In addition to the unappealing appearance, there was no room for the lateral incisor to erupt. The tooth was sectioned after careful review of the canal anatomy with a cone beam computed tomog-raphy radiograph. After sectioning, the tooth was moved into correct position with orthodontics (C) and restored on the mesial surface (D). BA• Figure 36.23 (A) One possible solution to a small lateral incisor is a combination of orthodontic tooth movement and resin bonding to reshape the crown of the tooth. (B) This patient had bilateral small lateral incisors. The laterals were positioned so resin addition would make the teeth esthetically pleasing, restore near-normal crown anatomy, and provide good functional occlusion. Occasionally a single tooth will be extremely large, which will result in crowding and malpositioning of the teeth. In these cases the tooth often can be reduced to match the contralateral tooth and repositioned.Fusion and gemination in the permanent dentition are even more dicult to treat and should also be referred to a specialist. It is possible in some cases to divide fused permanent teeth, move one or both of the resulting teeth into good position, and then restore the remaining tooth or teeth.62 Often endodontic treatment is required because the division violated the pulpal space (Fig. 36.24).Dens evaginatus and incisor talon cusps provide interesting challenges in securing an ideal occlusion (see Fig. 31.16). In most cases of dens evaginatus a ne, threadlike pulp extends from the main pulp chamber into the evagination, and the location of this pulp tissue extension should be determined radiographically. Most such teeth in the posterior region do not require treatment because the force of mastication slowly wears the evagination down, and

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