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CHAPTER 7
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Self‐Study Answers
1. Aggressive pulpectomies of the second primary
molars, although given the clinical signs and symptoms and the periapical radiographic appearance,
particularly the maxillary left second primary molar,
the prognosis was questionable
2. Either no space management at this time, permitting the permanent molars to drift mesially and
impacting the second premolars, or the use of a
removable acrylic pressure appliance that would
guide the first permanent molars via pressure and
without penetrating the alveolar mucosa
Bibliography
Alnahwi HH, Donly KJ, Contreras CI. 2015. Space loss following
premature loss of primary second molars. Gen Dent 3(6):e1–
4. Erratum in: Gen Dent 2016;64(1):79.
Barberia E, Lucayechi T, Cardenas D, Maroto M. 2006. Free‐end
space maintainers: design, utilization and advantages. J Clin
Pediatr Dent 31(1):5–8.
3. Angled mesially to help prevent the first
permanent molar from getting impacted under the
distal shoe blade
4. Adequate primary dentition spacing needed for
the transition into the full permanent dentition
5. Deep overbite, distal step primary molar terminal
plane, and convex facial profile that would most
likely lead to a class II deep overbite relationship in
the permanent dentition
Canadian Agency for Drugs and Technologies in Health (CADTH).
2016. Dental Space Maintainers for the Management of
Premature Loss of Deciduous Molars: A Review of the Clinical
Effectiveness, Cost‐effectiveness and Guidelines. Ottawa:
Canadian Agency for Drugs and Technologies in Health.
Durward CS. 2001. Space maintenance in the primary and
mixed dentition. Ann R Austral Coll Dent Surg 15:203–5.
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Case 3
Bilateral Space Management intheMixed Dentition
F.
BA
Dental History
• Regular dental maintenance visits
• Optimal water fluoridation levels (city water)
Fairly healthy diet with low caries risk
•
• Supervised brushing
G. Extraoral Exam
• Normal facial symmetry with slightly convex facial profile
Figure 7.3.1 (A,B) Facial photographs.
A. Presenting Patient
• Twelve‐year‐old Caucasian female (Figure7.3.1)
B. Chief Complaint
•
Mother states, “My child has crooked and missing
teeth”
C. Social History
• Patient is a happy, well‐developed adolescent
• Lives with mother and father
• Middle class socioeconomic status
• One younger brother
D. Medical History
• Noncontributory
E. Medical Consult
• Not necessary at this time
H. Intraoral Exam
• Healthy mixed dentition with lower lingual arch in
place (Figure7.3.2)
• Overbite: 4 mm, with 1 mm overjet
• Soft tissue within normal limits
• Mild plaque accumulation
• Good oral hygiene
• Caries free with sound pit and fissure sealants on the
first permanent molars
I. Diagnostic Tools
• Panoramic radiograph reveals congenitally missing
and ectopically erupting teeth (Figure7.3.3)
J. Differential Diagnosis
• Not applicable
K. Diagnosis andProblem List
Diagnosis
• Class I mixed dentition malocclusion
Problem List
• Congenitally missing maxillary right permanent second
premolar and maxillary right permanent lateral incisor
• Ectopic maxillary right and left permanent canines
• Peg maxillary left permanent lateral incisor
• Moderate mandibular incisor crowding
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A
C
Figure 7.3.2 (A–C) Intraoral photographs showing bilateral space maintenance appliance.
B
FUNDAMENTAL POINT 1
Space Maintenance
• Posterior space maintenance is indicated when
there is premature loss of primary molars.
Failure to hold the space for the premolars often
leads to signicant ectopic eruption or impaction
of these teeth. Management in the mixed
dentition can include:
For unilateral loss: band and loop spacer
For bilateral loss prior to eruption of the permanent incisors: bilateral band and loop spacers
(concerns about the anterior portion of the lower
lingual arch wire precludes consideration of this
appliance until the incisors erupt)
For bilateral loss after eruption of the permanent incisors: lower lingual arch or acrylic
partial denture
• See American Academy of Pediatric Dentistry
(AAPD) Management of the Developing
Dentition and Occlusion in Pediatric Dentistry
(AAPD 2018–2019)
BACKGROUND INFORMATION 1
Mixed Dentition Space Analysis
• The mixed dentition primary molars and canines
are typically larger in width, mesial to distally, than
the permanent dentition premolars and canines.
This extra space is called the leeway space, and
keeping the permanent molars from shifting
mesially after the second primary molars exfoliate
can be benecial in patients with crowding issues.
Space analysis methods have been developed to
aid in determining how much leeway space might
be available. One simple method is the Tanaka and
Johnston Analysis (Tanaka and Johnston 1974):
1.
Divide the width of the lower permanent
incisors in half
2. To this number, add 10.5 mm for the lower
buccal segment; add 11 mm for the upper
buccal segment
3. Subtract the number calculated above from
the combined widths of the primary molars
and canine for the buccal segment in question to get the leeway space for that area
• Once the permanent dentition is fully erupted,
initiate comprehensive orthodontics and prosthetic treatment
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•
Use lower lingual arch to maintain the leeway space
until complete eruption of the second permanent
molars
M. Postoperative Intraoral Photographs
• Note the significant amount of space that has
developed in the mandibular premolar area by
holding the permanent molars in place with the
lower lingual arch. This should allow the canines and
incisors to drift distally somewhat to alleviate the
anterior crowding (Figure7.3.4)
Figure 7.3.3 Panoramic radiograph.
N. Prognosis andDiscussion
• As long as the lingual arch appliance is left in place
L. Comprehensive Treatment Plan
• Maintain current caries prevention program with
routine maintenance appointments and effective
home oral hygiene
A B C
Figure 7.3.4 (A–C) Postoperative intraoral photographs showing space in the mandibular arch.
until the second permanent molars fully erupt, the
prognosis is good. However, the congenitally missing
and ectopic teeth in this patient’s maxillary arch
significantly complicate her care
FUNDAMENTAL POINT 2
Space Analysis
• Mixed dentition space analysis is an important
adjunct in diagnosing and managing developing
dentitions
• Lower anterior crowding can be managed in a number
of different ways, depending on the amount of
crowding, dental development, and type of malocclusion. General options in the mixed dentition based on
the amount of crowding include:
Space redundancy: wait until the permanent
dentition has erupted to close the space, do
bonding, or consider tooth replacement
No crowding: even with no crowding, long‐term
alignment cannot be guaranteed in some
patients. Development of alignment problems
later on in life may benefit from retention
Mild crowding (1–4 mm): use of a lower lingual
arch to hold the leeway space, disking of select
primary teeth
Moderate crowding (5–9 mm): flaring of anterior
teeth, distalization of permanent first molars, or
arch expansion with appliances such as a lip
bumper or limited orthodontic with bands on the
molars, brackets on the incisors (“2 × 4”) and
open coil springs
Severe crowding (10 mm or more): serial extraction,
or wait until the permanent dentition and consider
extraction, followed by full orthodontics
(Brennan and Gianelly 2000)
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O. Complications andAlternative
TreatmentPlan
• Long‐term retention is necessary to maintain the
lower anterior alignment for this type of patient
• An alternative treatment plan would have been to wait
until eruption of the permanent dentition to initiate
orthodontic treatment; however, regaining the space
after mesial movement of the permanent molars
would have made this difficult. The simple use of a
lower lingual arch has significant advantages in this
type of case
• Patients undergoing nonextraction orthodontics via
leeway space preservation using a passive lingual
arch have an increased risk of impaction of mandibular permanent second molars
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Self‐Study Questions
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GROWTH ANDDEVELOPMENT
1. What is the major treatment effect of placing a
lower lingual arch in the case of multiple missing
primary molars or lower anterior crowding?
2. Why should lower lingual arches not be
placedprior to eruption of the permanent lower
incisors?
3. Will lingual arches resolve crowding issues in
cases with more than 5 mm of crowding?
4. What is the name of the extra space available in
the transition from the primary molars and canine
to the permanent premolars and canine?
5. Is measurement of the unerupted permanent
premolars and canines from radiographs the only
way to predict how much arch space is needed for
these teeth?
Answers are located at the end of the case
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CHAPTER 7
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Self‐Study Answers
1. Prevent mesial drifting of the permanent molars
which could cause loss of space
2. The anterior portion of the lingual wire can
interfere with normal eruption of the incisors
3. Although they can contribute to the correction,
lingual arches typically hold only 3 to 5 mm of space
in the transition to the permanent dentition
Bibliography
American Academy of Pediatric Dentistry. 2018–2019. 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
Brennan MM, Gianelly AA. 2000. The use of the lingual arch in
the mixed dentition to resolve incisor crowding. Am J Orthod
Dentofacial Orthop 117(1):81–5.
4. Leeway space
5. No, several mixed dentition arch analyses
use astandardized prediction formula to fairly
accurately predict the size of these teeth by
measuring already erupted permanent teeth,
i.e.thelower incisors
Dean, JA. 2016. Management of the developing occlusion. In:
Dentistry for the Child and Adolescent. Dean JA (ed), 10th
edition. St Louis: Elsevier. pp. 415–78.
Sonis A, Ackerman M. 2011. E‐space preservation. Angle Orthod
81:1045–9.
Tanaka MM, Johnston LE. 1974. The prediction of the size of
unerupted canines and premolars in a contemporary orthodontic population. J Am Dent Assoc 88:798–801.
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Case 4
Interceptive Orthodontics: Habit Appliances
D.
Medical History
• Noncontributory
Medical Consult
E.
• Not necessary at this time
Figure 7.4.1 Intraoral photograph showing anterior open bite
due to habit.
A. Presenting Patient
• Twelve‐year‐, five‐month‐old African‐American female
B. Chief Complaint
• Mother states that her child has been a thumb sucker
and they “don’t like the space between her top and
bottom teeth”
C. Social History
• Patient is an active seventh grader
• Parents are divorced
• Mother is the primary caregiver and works full time
• Middle socioeconomic status
• Two older brothers
F. Dental History
• Maintains routine dental checkups
• Optimal water fluoridation levels (city water)
• Moderate cariogenic diet
• Unsupervised brushing
G. Extraoral Exam
• Normal facial symmetry with convex facial profile
H. Intraoral Exam
• Class I molars and canines
• Open bite: 2 mm, with 2 mm overjet (Figure7.4.1)
• Excessive arch length redundancy
Soft tissue within normal limits
•
• Mild plaque accumulation
• Fair oral hygiene
• No active caries
I. Diagnostic Tools
• A full orthodontic diagnostic work‐up was completed
and evaluated
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FUNDAMENTAL POINT 1
Oral Habits
• Oral habits such as non‐nutritive sucking, bruxing,
and abnormal tongue swallowing and positioning
can apply forces to the teeth and dentoalveolar
structures that may cause deleterious effects
• Whereas mild habits many times are not of
concern and the child may eventually stop on
their own, habits of higher frequency, intensity,
and duration can be associated with signicant
problems such as decreased arch width and
crossbites, as well as an increased overjet and
decreased overbite or open bite
• Correction involves two important concepts:
Often, parental anxiety and scolding about
thehabit increases its intensity, instead of
ameliorating it
The child must be old enough to understand
the need to stop the habit and must want to
stop the habit for interventions to be helpful
• Treatment is directed toward behavior modication techniques and appliance therapy, such as a
palatal crib
(Dean, 2016)
J. Differential Diagnosis
• Not applicable
K. Diagnosis andProblem List
Diagnosis
• Class I permanent dentition malocclusion
Problem List
•
Flaring of maxillary and mandibular incisors
• Anterior open bite secondary to thumb‐sucking habit
• Excessive arch length redundancy
L. Comprehensive Treatment Plan
• The treatment plan included placement of a “bluegrass” type habit appliance. This appliance (see
Figure7.4.2a) is comprised of a palatal wire attached
to banded molars. The palatal wire has an acrylic roller
bead that serves as a reminder to the patient not to
suck her thumb and to encourage normal tongue
positioning and swallowing. This appliance is usually
effective over the course of two to three months,
A
B
Figure 7.4.2 Intraoral photographs showing (A) bluegrass
appliance and (B) orthodontic appliances.
followed with traditional orthodontic appliances to
close the space redundancy and continued use of the
habit appliance
M. Postoperative Intraoral Images
• Not available
N. Prognosis andDiscussion
• Treatment with this type of habit appliance is usually
successful but must be performed in patients willing
to stop the habit. Thumb sucking should be significantly reduced and the patient’s open bite should
close down, giving her some minimal overbite
• Although the success rate of this type of treatment is
high, there are patients of this age who are determined to continue the habit despite an intraoral
appliance. In these cases, the patient may not truly
want to stop the habit and a child therapist should be
consulted to determine if there are other psychosocial
issues involved
O. Complications andAlternative
TreatmentPlan
• Complications for this patient could include relapse of
the open bite once the appliances are removed. This
could happen because of her poor swallowing pattern
or thumb sucking returning
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BACKGROUND INFORMATION 1
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Treatment Alternatives
• Once the practitioner is assured that the patient is
both old enough to understand the need for
cessation of the habit and is ready and willing to
comply, options for treatment can be considered.
Treatment alternatives fall into three main areas. A
staged progression of these options or a combination of them may be best, depending on the
particular needs of the patient involved:
Behavior modification: this technique uses positive
reinforcement to encourage the child’s compliance. One good example is a timed rewards
calendar. A short, written agreement is made
about goals and rewards. Then, over a period of
weeks for a predetermined period of time that
successively increases each week, the child does
GROWTH ANDDEVELOPMENT
not suck her digit. A star is placed on the calendar
each successful day, and at the end of each week
some small reward, such as a toy or book, is given.
If the parents remain dedicated to this, cessation
usually occurs, if it is going to occur, within a
month’s time
Extraoral means: various options are available
including wrapping an Ace bandage around the
elbow at night to keep the child from bending her
arm to place the digit in her mouth (must be
careful not to cut off blood circulation), placement of bitter‐tasting liquids on the digit
(Kozlowski 2007), and use of a glove‐like appliance that covers the thumb and straps around
the wrist
Intraoral appliances: palatal appliances with cribs,
loops, spurs, or beads can all be helpful
• Alternative treatment plans might include treatment
with an appliance that had spurs on it to irritate the
tongue into a more posterior posture. Another option
is to just close the anterior spacing with bracketing
Self‐Study Questions
1. What is the main difference between non‐
nutritive sucking habits that are benign and those
that have deleterious oral effects?
In managing a patient’s sucking habit, what is the
2.
most critical component to consider for success?
3. What intraoral appliance types are available to
aid in habit correction?
and no habit appliance; however, without attempting
to retrain the tongue and decrease the habit there
would be a high risk of relapse
4.
What types of extraoral techniques can be used
to reduce non‐nutritive sucking habits?
Deleterious effects on the teeth and supporting
5.
structures are minimized if children will stop their
digit sucking habits by approximately what age?
Answers are located at the end of the case
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