Guideline on Management of the Developing Dentition and Occlusion in Pediatric Dentistry.

Resident’s Name: Jessica Wilson Program: Lutheran Medical Center - Providence Article title: Guideline on Management of the Developing Dentition and Occlusion in Pediatric Dentistry. Author(s): Clinical Affairs Committee. Journal: AAPD Reference Manual. Year. Volume (number). Page #’s: 2009. 32(6). 213-225. Major topic: Occlusion Overview of method of research: Clinical Guidelines. Purpose: To set forth objectives for management of the developing dentition and occlusion in pediatric dentistry. Methods: Guideline is based on a review of current literature as well as best clinical practice and expert opinion. Recommendations: Oral habits: Habits may apply forces on dentition and dentoalveolar structures and habits with sufficient frequency, duration, and intensity may be associated with increased OJ, decreased OB, posterior crossbite or long facial height. The pressure from the lips, tongue and cheeks have the most effect on tooth position because of the constant duration of the forces. Tongue thrusting or abnormal swallowing patterns may be associated with anterior open bite, flaring of lower incisors and speech abnormalities however if the resting tongue position is normal, “a tongue thrust swallow has no clinical significance.” Research shows that mouth breathing with impaired nasal respiration may contribute to the increase of facial height, anterior open bite, increased OJ and a narrow palate, but this is not the major cause of these conditions. Obstruction sleep apnea syndrome (OSAS) may also be associated with these factors and a history with this syndrome often includes snoring, observed apnea, restless sleep, daytime sleepiness, and bedwetting as well as enlarged tonsils and adenoid facies. Nonnutritive sucking habits are normal in infants and young children, but prolonged habits should be addressed with anticipatory guidance for parents to help their children stop by the age of 36 months or earlier. Bruxism may occur while awake or asleep and is multifactorial in etiology including both central factors (stress, parasomnias, traumatic brain injury, neurologic disabilities) and morphologic factors (muscle recruitment and malocclusion). Complications such as headache, muscle soreness, TMJ problems, dental attrition may occur, but generally bruxism is suggested to be self-limiting that does not lead to adult bruxism. Treatment modalities include: education, occlusal splints, psychological techniques and medications. Self-mutilating is extremely rare in the normal child, but has been associated with mental retardation; psychiatric disorders, developmental disabilities and some syndromes and treatment may include pharmacological management, behavior modification and physical restraint. Some lip-liking or lip-pulling habits are less severe, but more severe biting habits may be associated with neurodisability due to severe brain damage. Dental treatment modalities such as lip bumper, occlusal bite appliances, odontoplasty, protective padding and extractions are sometimes indicated. Patients and parents should be educated about possible consequences of a habit. It is possible for the parent to have a negative effect on the correction of the habit as their nagging or punishment may produce an increase in the behavior. A change in the home environment may be required before cessation of a habit can occur. Referrals may be made to orthodontists, psychologists, myofunctional therapists, otolaryngologists or other specialists. Disturbances in number: Congenitally missing teeth should be expected in cleft lip and palate patients as well as those with certain syndromes and a familial pattern of missing teeth. In treatment for missing maxillary lateral incisors or mandibular second premolars, a practitioner may choose to extract the primary tooth and close the space orthodontically or open the space for an implant or prosthesis. Influential factors include: patient age, canine shape and position, crowding, occlusion, bite depth and amount and quality of bone present. The goal should be to provide an esthetic occlusion that functions well. Supernumerary teeth are 5 times more common in the permanent dentition with 80-90% in the maxilla. A primary supernumerary tooth is followed by a permanent supernumerary tooth 1/3 of the time. Only 25% of all mesiodens erupt spontaneously. Mesiodens can prevent or cause ectopic incisor eruption as well as cause incisor root dilacerations, cyst formation and possible eruption into the nasal cavity. Supernumerary primary dentition usually erupt in normal arch position and exfoliate normally. Removal of a mesiodens or other permanent supernumerary incisors result in the eruption of the normal incisor 75% of the time in the early mixed dentition, prior to root apex completion. Inverted supernumeraries may become more difficult to remove as they move deeper into the jaw. Radiographic evaluation after supernumerary removal should be performed 6 months later and if eruption of incisor is not evident, surgical exposure and extrusion may be indicated. Localized disturbances in eruption: Ectopic eruption (EE) of permanent 1st molars occurs less that 1% of the time and self-corrects or “jumps” in 66% of those cases. The impacted type presents as partial eruption of the permanent first molar with the mesial below the distal of the second primary molar and requires treatment in order to prevent the premature loss of the primary second molar and space loss. Treatment may include an ortho elastic separator for mild cases and brass wire, fixed appliances with open coil springs, sling shot-type appliances Halterman appliance or surgical uprighting for more severe cases. EE of permanent canines may be present as well as incisors, especially after trauma with pulpal treatment to primary incisors, asymmetric eruption or if supernumerary teeth are diagnosed. Extraction of the primary canine is indicated when no canine buldge is evident and radiographic evaluation presents overlapping canine with the lateral incisor. Ankylosis is most prevalent in primary molars which usually exfoliate normally, but extraction is recommended with prolonged retention. Ankylosis is also common with traumatized permanent incisors and can be verified radiographically or with palpation or percussion. Arch length and crowding are of particular importance with crowding being especially common in the early mixed dentition. Functional contacts are diminished with rotated teeth and TMJ problems and occlusal discrepancies may occur. Treatment considerations: primary canine extraction to aid the straight eruption of incisors, orthodontic alignment of permanent teeth, expansion, holding arches until all permanent canines and bicuspids have erupted, extractions of permanent teeth and possible interproximal reduction. Space maintenance: Space maintenance may be required for early loss of primary incisors when an intense digit habit exists as this may reduce space for the subsequent incisor. Possible adverse effects of space maintainers include: dislodged or broken appliances, plaque accumulation, caries, interference of erupting dentition, undesirable tooth movement, inhibition of alveolar growth, soft tissue impingement and pain. Space regaining: The timing of intervention after early loss of a primary molar is critical. Both fixed and removable appliances may be used and the goal of space regaining is the recovery of lost arch width and perimeter and improved eruption position of permanent teeth. Crossbites: Anterior crossbite correction can reduce dental attrition, improve esthetics, redirect skeletal growth, improve tooth to alveolus relationship and increase arch perimeter. Functional shifts should be corrected as soon as possible to avoid asymmetric growth via equilibration, appliance therapy, extractions or a combination of the above. Class II malocclusion: Class II occlusion can effectively be corrected by single or 2-phase regimen. Some studies found corrected class II skeletal pattern, whereas other studies found no changes. Different growth-modification treatments such as headgear or functional appliances show different results, but no reliable predictors have been found. Although evidence does not support significantly better results with 2-phase treatment, some clinicians choose to provide early treatment to improve self-esteem and eliminate significant overjet. When treating a class II patient, one should consider: facial growth pattern, age, AP discrepancy, projected compliance, space analysis, anchorage (headgear), patient and parental desires, functional appliances, fixed appliances, tooth extraction, interarch elastics, and orthodontics with orthognathic surgery. Class III malocclusion: Etiology was found to be about 56% hereditary in one study. The other 44% due to environmental factors such as trauma, oral/digital habits, caries and early childhood OSAS. Early treatment is recommended for improved function and esthetics and may eliminate future need for orthognathic surgery, however, class III growers are less predictable and surgery may still be necessary. When treating a class III patient, one should consider: facial growth pattern, age, AP discrepancy, projected compliance, space analysis, anchorage (headgear), functional appliances, fixed appliances, tooth extraction, interarch elastics, and orthodontics with orthognathic surgery. Assessment of Article: LONG, but great review.