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CHAPTER 6
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Self‐Study Answers
1. Children who have no significant medical, mental,
or physical compromise are usually good candidates
for anesthesia on an outpatient basis
2. Prior to scheduling a child for general anesthesia
there should be a preanesthetic assessment of the
medical history, an explanation of the procedure
along with the risks and benefits and options for
alternative treatment, and informed consent should
be obtained from the parent or legal guardian
3.
The advantages of general anesthesia are that all
of the child’s dental needs can be met in one visit,
Bibliography
American Academy of Pediatric Dentistry. 2018–2019.
Monitoring and management of pediatric patients before,
during and after sedation for diagnostic and therapeutic procedures. In: Clinical Practice Guidelines and Best Practices
(Reference Manual). Pediatr Dent 40:287–316. https://www.
aapd.org/research/oral‐health‐policies‐‐recommendations/
monitoring‐and‐management‐of‐pediatric‐patients‐before‐
during‐and‐after‐sedation‐for‐diagnostic‐and‐therapeutic‐
procedures‐update‐2016
American Society of Anesthesiologists Task Force on
Preoperative Fasting and the Use of Pharmacologic Agents
to Reduce the Risk of Pulmonary Aspiration. 2017. Practice
guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration:
application to healthy patients undergoing elective procedures. Anesthesiology 126(3):376–93.
quality care can be provided, and the child’s
developing psyche is protected. The disadvantages
include higher cost, the risk of general anesthetic
complications, and the inability for the opportunity
for the child to learn copingskills
A dentist who treats children under general
4.
anesthesia should be trained in hospital protocol,
operating room procedures, preoperative
assessment, and management of postoperative
complications
Turner EG, Hipp CL. 2018. Hospital dentistry and general anes-
thesia. In: The Handbook of Pediatric Dentistry, 5th Edition.
Nowak AJ, Casamassimo PS (eds). Chicago: American
Academy of Pediatric Dentistry. pp. 283–97.
Weddell JA, Jones JE, Emhardt JD. 2016. Hospital dental
services for children and the use of general anesthesia,
In: McDonald and Avery’s Dentistry for the Child and
Adolescent, 10th edition. Dean J, Jones J, Vinson L (eds). St
Louis: Elsevier.
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7
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Growth andDevelopment
Jeffrey A. Dean
Case 1: Orthodontic Documentation, Evaluation, and Assessment ................................................................... 260
Jeffrey A. Dean
Case 2: Space Management: Premature Loss of Primary Second Molar in Preschool Child ............................. 265
Jeffrey A. Dean
Case 3: Bilateral Space Management in the Mixed Dentition ............................................................................ 269
Jeffrey A. Dean
Case 4: Interceptive Orthodontics: Habit Appliances ......................................................................................... 275
Jeffrey A. Dean
Case 5: Interceptive Orthodontics: Anterior Crossbite in a Child in the Mixed Dentition ................................... 279
Jeffrey A. Dean
Case 6: Infant with Cleft Lip and Palate.............................................................................................................. 285
LaQuia A. Vinson
Case 7: Orthodontics for Patient with Cleft Lip and Palate ................................................................................ 293
Tasha E. Hall
Clinical Cases in Pediatric Dentistry, Second Edition. Edited by Amr M. Moursi.
© 2020 John Wiley & Sons, Inc. Published 2020 by John Wiley & Sons, Inc.
Companion website: www.wiley.com/go/moursi/pediatrics
259
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CHAPTER 7
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Case 1
Orthodontic Documentation, Evaluation, andAssessment
D.
A
C
B
Medical History
• Noncontributory
Medical Consult
E.
• Not necessary at this time
F. Dental History
• Seen for routine dental maintenance visits by her
pediatric dentist after having comprehensive restorative care as a preschooler
• Optimal water fluoridation levels (city water)
• Dietary assessment is satisfactory
• Supervised brushing with fluoridated toothpaste
Figure 7.1.1 (A–C) Frontal, lateral, and frontal smiling extraoral
photographs.
A. Presenting Patient
• Eight‐year‐, five‐month‐old African‐American female
(Figure7.1.1)
B. Chief Complaint
• Mother’s complaint is that her daughter’s “lower jaw
is too far forward”
C. Social History
• Patient is an active middle school student
• Both parents are teachers in local middle school
G. Extraoral Exam
• Concave and forward sloping facial profile secondary
to apparent mandibular prognathia
• Otherwise, fairly symmetrical facial features
H. Intraoral Exam (Figure 7.1.2)
• Transitional dentition
• Overbite: 2 mm, with –3 mm overjet and anterior crossbite
• Soft tissue within normal limits
•
Mild plaque accumulation
• Caries free, but multiple restorations
I. Diagnostic Tools
• Full mouth radiographs
• Panoramic view (Figure7.1.3)
• Lateral cephalometric radiograph (Figure7.1.4)
• Well‐trimmed orthodontic study models
J. Differential Diagnosis
• Maxillary deficiency or mandibular prognathia
K. Diagnosis and Problem List
Diagnosis
• Class III mixed dentition malocclusion
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GROWTH ANDDEVELOPMENT
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A
C
E
Figure 7.1.2 (A–E) Intraoral photographs showing all views.
Figure 7.1.3 Panoramic radiograph.
B
D
FUNDAMENTAL POINT 1
Orthodontic Records
• Comprehensive orthodontic treatment
requires a proper assessment to be done prior
to initiation of care, including a questionnaire
of the patient (medical/dental history, chief
complaint, etc.), examination (oral health,
function, and facial proportions) and diagnostic
records
• Comprehensive diagnostic records include
dental study models, an 8 series photographic
collage, complete intraoral radiographs, a
cephalometric radiograph including tracing, and
an anterior–posterior radiograph when indicated (for example, when there is a possible
facial or occlusal asymmetry). Some adjustment in this standard will more than likely be
forthcoming, with the use of cone beam
computed tomography (CBCT) becoming
morecommonplace
Although it is generally understood that
•
comprehensive orthodontic treatment requires
this complete record documentation, questions often arise as to how many diagnostic
records are needed for minor or interceptive
treatment. While this can vary from case to
case, the main concept is to ensure a full and
complete diagnosis of the problem being
evaluated so that the treatment addresses this
problem and does not overlook confounding
conditions. Dental versus skeletal crossbite
correction is a good example. In the case of a
simple, one‐tooth anterior crossbite caused by
dental tipping, dental study models or a
photographic collage may be enough for
documentation. However, if the patient
appears to have an anterior crossbite because
of a skeletal alignment problem, comprehensive diagnostic records are essential. When in
doubt, a more thorough evaluation may be the
most prudent approach
• See the American Academy of Pediatric
Dentistry (AAPD) Guidelines on Management of
the Developing Dentition
Figure 7.1.4 Cephalometric radiograph.
(Proft etal. 2013; AAPD 2018–2019a)
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BACKGROUND INFORMATION 1
Orthodontic Informed Consent
• Informed consent is basically a discussion and
documentation of the treatment to be rendered,
as well as the risks, benets, and alternatives to
this treatment
• Common orthodontic treatment risks to be
covered during consent include caries, root
resorption, periodontal disease, necrotic pulp,
discomfort, trauma, temporomandibular joint
disorder considerations, impacted teeth, length
of treatment, prognosis, and relapse
• Many examples of orthodontic informed consent
forms are readily available and should be used
by practitioners prior to treatment. Inherent in
the concept of informed consent, however, is
that these forms must be reviewed with the
patient by the practitioner to ensure an understanding by the patient and parent
See the AAPD Best Practices on Informed
•
Consent (AAPD 2018–2019b)
Problem List
• Class III skeletal and dental classification
• Anterior crossbite with significant negative overjet
• Poor position of maxillary permanent canines
L. Comprehensive Treatment Plan
• Comprehensive orthodontic care to include two‐phase
treatment consisting of protraction headgear in phase
one and comprehensive bracketing in phase two
M. Postoperative Intraoral Photographs
• Not applicable
N. Prognosis andDiscussion
• The prognosis is guarded and the need for orthognathic
surgery cannot be ruled out
O. Complications andAlternative
TreatmentPlan
• Complications to this patient’s care include the
possibility of poor compliance or lack of protraction
headgear treatment response, even with good
compliance
• Alternative treatment could include waiting until
growth is complete and addressing the skeletal
discrepancy surgically
• Impaction of the maxillary permanent canines is possible
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Self‐Study Questions
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GROWTH ANDDEVELOPMENT
1. What are the three basic components of a comprehensive orthodontic assessment for a patient?
2. Is it true that diagnostic records for orthodontic
patients must include a cephalometric evaluation?
3. What new imaging technique may influence
substantial changes in the way comprehensive orthodontic assessments have been done in the past?
4. Name the four broad areas that need to be
covered during the process of informed consent
5. What are the most common risks covered
whenreviewing orthodontic informed consent
witha patient?
Answers are located at the end of the case
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CHAPTER 7
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Self‐Study Answers
1. Patient questionnaire, examination (oral health,
function, and facial proportions), and diagnostic
records
2. No, this is not true. Depending on the severity of
the patient’s problem, certain orthodontic records
may not be necessary
3. CBCT may eliminate the need to make separate
dental study models, intraoral radiographs, and
cephalometric radiographs because all three
Bibliography
American Academy of Pediatric Dentistry. 2018–2019a. Manage-
ment of the developing dentition and occlusion in pediatric
dentistry. In: Clinical Practice Guidelines and Best Practices
(Reference Manual). Pediatr Dent 40:352–65. https://www.
aapd.org/research/oral‐health‐policies‐‐recommendations/
management‐of‐the‐developing‐dentition‐occlusion‐in‐
pediatric‐dentistry
American Academy of Pediatric Dentistry. 2018–2019b.
Informed consent. In: Clinical Practice Guidelines and Best
Practices (Reference Manual). Pediatr Dent 40:409–11. https://
www.aapd.org/research/oral‐health‐policies‐‐
recommendations/informed‐consent
of these items can be captured in the three‐
dimensional CBCT image
4. Type of treatment to be rendered, the risks, the
benefits, and the alternatives to this treatment
5. Risk for caries, root resorption, periodontal
disease, necrotic pulp, discomfort, trauma,
temporomandibular joint disorder, impacted teeth,
and relapse
American Association of Orthodontics. 2017. Clinical Practice
Guidelines for Orthodontics and Dentofacial Orthopedics.
https://www.aaoinfo.org/d/apps/get‐file?fid=12939.
Accessed 18 June 2019.
Proffit WR, Sarver DM, Ackerman JL. 2013. Orthodontic diag-
nosis: the problem‐oriented approach. In: Contemporary
Orthodontics, 5th Edition. Proffit WR, Fields HW, Sarver DM
(eds). St Louis: Elsevier. pp. 150–219.
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GROWTH ANDDEVELOPMENT
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Case 2
Space Management: Premature Loss ofPrimary Second
Molar inPreschool Child
E.
BA
Medical Consult
• Not necessary at this time
Dental History
F.
• Optimal water fluoridation levels (city water)
• Highly cariogenic diet
• Unsupervised brushing with fluoridated toothpaste
• No dental home
Figure 7.2.1 (A, B) Facial photographs.
A. Presenting Patient
• Three‐year‐, ten‐month‐old Caucasian male (Figure7.2.1)
B. Chief Complaint
• Mother states, “My son has a bunch of cavities and
pain in an upper left tooth”
C. Social History
• Patient is in preschool
• Parents are divorced, no siblings
• Mother is the primary caregiver and works a
full‐time job
• Socioeconomic status is low
D. Medical History
• Noncontributory
G. Extraoral Exam
• Normal facial symmetry with convex facial profile
H. Intraoral Exam
• Primary dentition with distal step primary molar
terminal plane
• Overbite: 6 mm deep, with 2 mm overjet, adequate
dental spacing and arch circumference
• Soft tissue abscess associated with the maxillary
second primary molars
• Moderate plaque accumulation
• Extensive severe dental decay, including sensitivity to
percussion on several teeth
I.
Diagnostic Tools
• Preoperative radiographs: four periapicals and two
bitewings (Figure7.2.2)
• Severe dental decay noted
• Periapical pathology noted with maxillary second
molars
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A
E
Figure 7.2.2 (A–F) Preoperative radiographs.
B
DC
F
Problem List
•
High caries risk due to poor diet and oral hygiene
• Premature loss of the maxillary second primary molars
L. Comprehensive Treatment Plan
• A detailed informed consent should be obtained for
this care. The patient will receive posterior stainless
steel crowns on maxillary first primary molars,
extraction of the maxillary right and left second
primary molars, and placement of two distal shoe
space maintainers to guide the eruption of the
maxillary right and left first permanent molars
• Establish a dental home and aggressive preventive
care to include caries risk assessment, parent education, adequate oral hygiene, fluoride varnish, and
special maintenance intervals tailored to the responsiveness of the parent and child to the preventive
care
Prevent malocclusion with use of distal step primary
•
molar terminal plane
• Maintain distal shoe space maintainer and eventually
follow up with replacement bilateral maxillary lingual
arch (Nance appliance)
FUNDAMENTAL POINT 1
History forSpace Management
• Obtain a thorough medical history to determine if
a patient can tolerate intratissue metal extensions
(distal shoe) in the oral cavity. For example, is
there a history of a congenital heart defect, heart
surgery, or bleeding disorder?
• Obtain a thorough dental history to manage all
oral health problems, including restorative,
preventive, educational, in conjunction with the
space maintenance care
• Consider occlusal relationships and options for
management of the early loss of the second
primary molars. Which treatment will provide
the most benet with the least drawbacks?
(Durward 2001; Canadian Agency for Drugs and
Technologies in Health 2016)
J. Differential Diagnosis
• Not applicable
K. Diagnosis andProblem List
Diagnosis
• Early childhood caries
• Poor diet
• Poor oral hygiene
M. Postoperative Intraoral Photographs
• Postoperative photographs (Figure7.2.3) and panoramic radiograph (Figure7.2.4) were obtained at age
five years, five months, showing stainless steel
crowns and distal shoe space maintainers all in
goodrepair
A
B
Figure 7.2.3 (A, B) Intraoral photographs showing space
maintenance appliances in maxillary arch.
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Figure 7.2.4 Postoperative panoramic radiograph at age five
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years, five months.
N. Prognosis andDiscussion
Prognosis for caries is now good secondary to
•
compliance with the aggressive preventive plan that
was implemented
• Prognosis for preventive occlusion management
(space maintainers) is good secondary to success to
date with the bilateral distal shoes and initial eruption of the first permanent molars. It will be essential that the patient continues regular dental visits to
have the distal shoes removed and a bilateral maxillary lingual arch (Nance appliance) placed, once the
first permanent molars are erupted far enough for
banding
GROWTH ANDDEVELOPMENT
BACKGROUND INFORMATION 1
Distal Shoes andAlternatives
• The second primary molar is essential to the
proper eruption and positioning of the rst permanent molar, which is an essential tooth in establishing a normal permanent dentition occlusion
• Early loss of the second primary molar can lead
to multiple occlusal problems such as space loss
and altered eruption; however, these problems
can be prevented with proper space maintenance
• While there are a few ways to address premature
loss of this primary tooth, maintenance of its
space minimizes orthodontic correction problems
• Distal shoe space maintainers or acrylic pressure
(free‐end) appliances are useful in guiding the
eruption of the first permanent molar, but require
some careful management and close follow‐up
(Barberia etal. 2006; Alnahwi etal. 2015)
O.
Complications andAlternative
TreatmentPlan
• Complications to this patient’s care could include
premature loss of the distal shoes, mismanagement
of the distal shoes (particularly if the first permanent
molars erupted under the most gingival aspect of the
distal shoe blades), and lack of adequate follow‐up
Self‐Study Questions
1. What alternative management plans related to
the maxillary second primary molars were available
for this patient at the initiation of care?
2. What alternatives to bilateral distal shoes could
be considered as this patient matures?
3. What angulation is usually built into the distal
shoe blades from an occlusal to gingival direction
and why?
4. What about this patient’s occlusal relationships
presents a positive prognosis regarding the need for
future orthodontic care?
5. What about this patient’s occlusal relationships
presents a negative prognosis regarding the need
for future orthodontic care?
Answers are located at the end of the case
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