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CHAPTER 7
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Self‐Study Answers
1. Patients with habits of minimal frequency, dura-
tion, or intensity have no or milder deleterious effects
2. The patient must be old enough to understand
the need and must want to discontinue the habit
3. The bluegrass or bead‐type appliances and pala-
tal spur or loop appliances
Bibliography
Dean JA. 2016. Management of the developing occlusion. In:
Dentistry for the Child and Adolescent, 10th edition. Dean
JA (ed). St Louis: Elsevier. pp. 415–87.
4. Commercially available foul‐tasting liquids
painted on the digits, methods to isolate the digit
from being inserted into the mouth such as a sock
taped over the hand, or a commercial strap wrapped
around the thumb
5. Before age 6; that is, before eruption of the
permanent teeth
Kozlowski JT. 2007. A non‐invasive method for ending thumb‐
and fingersucking habits. J Clin Orthod 41(10):636.
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GROWTH ANDDEVELOPMENT
BA
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Case 5
Interceptive Orthodontics: Anterior Crossbite inaChild
intheMixed Dentition
F.
Dental History
• The patient is seen for regular dental care and preventive measures. He has had minor restorative care
Optimal water fluoridation levels (city water), with
•
healthy diet, unsupervised brushing with fluoridated
toothpaste, but has poor oral hygiene practices
Figure 7.5.1 Facial photograph, smiling.
A. Presenting Patient
• Eight‐year‐, one‐month‐old Caucasian male
(Figure7.5.1)
B. Chief Complaint
• Mother states, “His teeth are very crooked”
C. Social History
• Patient is in third grade
• Lives with parents
• Middle socioeconomic status
• One older brother
G. Extraoral Exam
• Mesofacial pattern with normal facial symmetry and
slightly convex facial profile (Figure7.5.2)
H. Intraoral Exam
• Dental class I relationship in the mixed dentition
(Figure7.5.3)
• Overbite: 4 mm deep overbite, with –5 mm overjet
• Anterior crossbite with no mandibular protrusive shift
into maximum intercuspation
• Soft tissue normal, other than mild localized gingivitis
• Moderate plaque accumulation
I. Diagnostic Tools
•
Panoramic and cephalometric radiographs showed no
significant skeletal discrepancies
D. Medical History
• Noncontributory
E. Medical Consult
• Not necessary at this time
Figure 7.5.2 (A, B) Frontal and profile photographs.
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A
D
Figure 7.5.3
(A–E) Preoperative photographs showing anterior crossbite.
J. Differential Diagnosis
• Not applicable
B
E
C
A
K. Diagnosis andProblem List
Diagnosis
• Dental and skeletal class I mixed dentition
malocclusion
Problem List
• Anterior crossbite without anterior functional shift
• Moderate anterior crowding
• Poor oral hygiene
L. Comprehensive Treatment Plan
• Some single tooth anterior crossbites can be
corrected with straightforward techniques such as
finger springs. However, because of the amount of
crowding and the fact that multiple teeth were
involved in the crossbite, it was decided to treat this
problem with maxillary orthodontic bands and
brackets, as well as a lower lingual arch. The parents
were cautioned that a second phase of orthodontic
treatment would be needed in the permanent
dentition
M.
Perioperative Intraoral Photographs
Intraoperatively (Figure 7.5.4)
• This patient’s sequence of treatment included:
Banding of second primary molars (since treatment
alignment of first permanent molars was not
B
C
Figure 7.5.4 (A–C) Intraoperative intraoral photographs.
problematic) and bracketing of remaining anterior
teeth. Asmall amount of resin was added to the
lower second primary molars to temporarily open the
bite to prevent shearing off of the anterior brackets
After initial leveling and aligning, an open coil spring
was placed to develop room for the lingually displaced
maxillary left permanent lateral incisor. Once space
was made, the tooth was brought into position
In an attempt to improve the lower alignment
without bracketing and to maintain the class I
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GROWTH ANDDEVELOPMENT
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FUNDAMENTAL POINT 1
Diagnosis andRationale forTreatment
• When considering treatment for crossbites, either
anterior or posterior, it is important to evaluate the
shifts of the mandible during closure, from the point
of initial contact to maximum intercuspation. In
either case, the clinician is evaluating the extent to
which the crossbite etiology is dental inclination,
skeletal positioning problems, or some combination
of the two. As a general rule, dental inclinations are
more easily managed than skeletal discrepancies.
While many patients with crossbites will receive
some benet from correction, those with mandibular
shifts, either protrusive or excursive, may benet the
most. The longer a patient with a shift retains that
shift, the more long‐term skeletal asymmetries will
develop. Having these crossbites with shifts is like
wearing a full‐time functional appliance; however,
unlike the appliances, the effect is not benecial
Anterior Crossbite Shifts
Typically, an individual with an anterior crossbite will
•
tend to shift the mandible in a protrusive direction. If
there is a signicant amount of protrusive shift and
the maxillary incisors are very upright, the crossbite is
usually more dental in nature and may be managed
by aring the maxillary incisors labially. If there is little
to no protrusive shift and the maxillary incisors are
not necessarily upright, the patient should be evaluated cephalometrically for a class III skeletal problem.
Usually, this can be accomplished by comparing the
anterior portion of the maxilla (point A) with the
anterior portion of the mandible (point B); that is, the
“ANB” angle. It is also benecial to evaluate the
incisal inclination on the cephalometric radiograph.
Class III skeletal problems may benet from protraction headgear or some other skeletal correction,
particularly in growing patients
Posterior Crossbite Shifts
•
A mandibular shift from initial contact into maximum
intercuspation and a crossbite indicates a bilateral
posterior crossbite which can be from a maxillary
skeletal constriction or dental buccal segment
tipping. Bilateral crossbite patients will exhibit a shift
of the dental midlines during closure, too, whereas
those with unilateral crossbites will not.
Interestingly, many appliances (W‐arch, Hyrax, Quad
helix, Expansion Plate, etc.) to varying extents, will
effectively correct bilateral crossbites, both dental
and skeletal. However, true unilateral crossbites
benet from an appliance design that only
addresses the maxillary arch side that is causing the
crossbite
(Ngan etal. 1997; Malandris and Mahoney 2004)
BACKGROUND INFORMATION 1
Advantages andDisadvantages of“Early”
Orthodontic Treatment
Over the last 20 years, much has been written about
•
the advantages and disadvantages of early treatment.
Now that it is clear that treatment of class II malocclusions early does not result in an otherwise unobtainable mandibular skeletal lengthening, to a large extent,
the decision to treat malocclusions early comes down
to a few salient considerations: what will eliminate
pathology, what is most efficient, and what does the
patient/parent want? With that, some of the basic
pros and cons of early treatment are as follows:
Pros
• Correction is done sooner, so patient enjoys
outcome sooner
•
Younger children tend to be more compliant
Often parents want treatment sooner
•
• Less skeletal asymmetry the sooner correction is
done
• Can alleviate traumatic occlusions
Cons
• Less efficient; therefore, more appointments
spread out over longer treatment time with
increased costs
• No improved results for earlier treatment in most
cases
• Need for between phase retention until permanent
dentition treatment commences
(Kluemper etal. 2000; Tulloch etal. 2004)
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Clinical Cases inPediatric Dentistry 281
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permanent molar relationship during the transition
into the full permanent dentition, the mesial surfaces of the mandibular primary canines were
disked and a lower lingual arch was placed
After maxillary debanding, a Hawley retainer was
delivered
Postoperatively (Figure 7.5.5)
• Although there was still crowding in the mandibular
incisors, no additional treatment was planned until
after leeway space utilization and transition into the
permanent dentition had occurred
A
N. Prognosis andDiscussion
• Correction of the crossbite should be retained well
with little chance of relapse
O. Complications andAlternative
TreatmentPlan
• Expected complications are minimal. Due to
mandibular incisor crowding after treatment,
bracketing of the mandibular anterior teeth or
additional disking of the mandibular primary
canines might be necessary
B
C
Figure 7.5.5 (A–D) Postoperative intraoral photographs showing correction of the crossbite and the lower lingual arch.
D
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Self‐Study Questions
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GROWTH ANDDEVELOPMENT
1. When correcting anterior and posterior crossbites, is it important to disclude or “open the bite”
so that the treatment mechanics can move the
affected teeth past the point of the crossbite?
2. An obtuse interincisal angle, “upright incisors,” is
a sign of which type of problem associated with an
anterior crossbite, dental or skeletal?
3. Are coincident dental midlines upon maximum
intercuspation a sign of a unilateral or bilateral posterior crossbite?
4. Is it true that a distinct advantage of early ortho-
dontic treatment is that mandibular skeletal length
can have clinically significant increases with early
functional type appliances?
5. List three reasons why a practitioner may decide
to provide early orthodontic treatment
Answers are located at the end of the case
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Self‐Study Answers
1. An often misunderstood concept is that occlusal
acrylic pads or another bite opening technique is
needed to correct crossbites. In fact, this is generally
not necessary. The main reasons for doing so would
be if the crossbite itself interferes with the appliance
to be used or if there is pathology associated with
the affected teeth
2. Upright incisors are an indication of a dental etiology
3. Unilateral crossbite, because there is no man-
dibular shift as the teeth occlude straight into the
crossbite
Bibliography andAdditional Reading
Fareen N, Alam MK, Khamis MF, Mokhtar N. 2017. Treatment
effects of reverse twin‐block and reverse pull face mask on
craniofacial morphology in early and late mixed dentition
children. Orthod Craniofac Res 20(3):134–9.
Kluemper GT, Seeman CS, Hicks EP. 2000. Early orthodontic
treatment: what are the imperatives? J Am Dent Assoc
131:613–20.
Malandris M, Mahoney EK. 2004. Aetiology, diagnosis and
treatment of posterior cross‐bites in the primary dentition.
Inter J Paed Dent 14:155–66.
4. No, research has shown that typical initial
significant improvements in mandibular length
do not maintain themselves when patients are re‐
examined at the end of normal growth
5. (i) Pathology exists, such as with traumatic
occlusion; (ii) failure to correct the malocclusion
will result in skeletal asymmetries, such as with a
bilateral posterior crossbite; (iii) the patient/parent
understands some of the inherent inefficiencies, but
requests early correction for esthetic reasons
Ngan P, Hu AM, Fields HW Jr. 1997. Treatment of class III prob-
lems begins with differential diagnosis of anterior crossbites.
Pediat Dent 19:386–95.
Ngan P, Moon W. 2015. Evolution of Class III treatment in ortho-
dontics. Am J Orthod Dentofacial Orthop 148(1):22–36.
Tulloch JF, Proffit WR, Phillips C. 2004. Outcomes in a 2‐phase
randomized clinical trial of early Class II treatment. Am J Orthod
Dentofacial Orthop 125(6):657–67.
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Case 6
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Infant withCleft Lip andPalate
GROWTH ANDDEVELOPMENT
B.
Chief Complaint
• Prenatal diagnosis of cleft lip and palate. Cleft was
identified via 20‐week ultrasound (Figures7.6.1
and7.6.2)
Figure 7.6.1 Facial view of infant with left complete unilateral
cleft lip and palate.
A. Presenting Patient
• Four‐day‐old male Caucasian (Figure7.6.1)
• Delivered at 39 weeks via C‐section after an
uncomplicated pregnancy
Figure 7.6.2 Worm’s eye view of infant with left complete
unilateral cleft lip and palate.
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C. Social History
• Parents are married
• Socioeconomic status is middle class
• Patient has a healthy two-year-old brother
D. Medical History
• Review of systems is noncontributory
• Medications: none
• Allergies: none
• Surgical history: none
FUNDAMENTAL POINT 1
Cleft Lip andPalate
• Incidence of cleft lip and palate varies based on
race and geographic regions, averaging at
1/700– 1/1000 worldwide
Unilateral clefts are more common than bilateral
•
clefts, left side is more common than the right
side, and boys are more affected than girls
• Isolated cleft palate is rarer and can often be
linked to other syndromes and conditions, such
as Pierre Robin sequence
Etiology ofcleft is multifactorial
• Environmental factors can include: nutritional
deficiencies (such as folic acid), vitamin excess,
orprenatal alcohol abuse
• Genetics: if other siblings or parents are affected,
incidence of cleft lip and palate increases
• If lip pits are present, Van der Woude syndrome
can be associated in 50% of the cases
Embryology
• Cleft lip and primary palate: failure of fusion of
median nasal process with maxillary processes
at four to seven weeks’ gestation
•
Cleft secondary palate: failure of fusion of lateral
palatine shelves at six to nine weeks’ gestation
(American Academy of Pediatric Dentistry [AAPD]
2018–2019; American Cleft-Palata Craniofacial
Association [ACPA] 2018a,b)
Medical Consult
E.
• Patient is followed by the Cleft/Craniofacial Team of a
children’s hospital to provide evaluations from nutrition, feeding, speech, growth and development,
pediatrics, audiology, otololaryngology (ear, nose, and
throat), and genetics
BACKGROUND INFORMATION 1
Initial Management ofCleft lip andPalate by
anInterdisciplinary Team
• Prenatal diagnosis can be conrmed from 18 to
20weeks. Prenatal ultrasound will often detect
cleft lip with/without cleft palate. Isolated cleft
palate is more difcult to detect and is rarely
identied on ultrasound. Prenatal diagnosis can
help with psychosocial support for the parents,
provide education, alleviate anxiety, and aid in
preparation for long‐term cleft care. This is
particularly helpful for specialty feeding and if
any presurgical treatment is anticipated soon
after birth. If there is no prenatal diagnosis, the
optimal time for the rst evaluation is within
the rst few weeks of life and, whenever
possible, within the rst few days
Management of patients with craniofacial
anomalies is best provided by an
interdisciplinary team of specialists. Teams are
comprised of professionals from medical,
surgical, dental, and allied health disciplines
working in an interdisciplinary and coordinated
system. An interdisciplinary team may include,
but is not limited to: anesthesiology,
audiology, genetics, nursing, oral and
maxillofacial surgery, orthodontics,
otolaryngology (ear, nose, and throat),
pediatrics, pediatric dentistry, plastic surgery,
prosthodontics, psychology, social work, and
speech–language pathology. The team also
maintains a list of community resources and a
mechanism for referral. The team can also
exchange information with schools, primary
care professionals, outside agencies, and
other professionals involved with the welfare
of the patient. Theprimary goal of an
interdisciplinary team is to ensure that care is
provided in a coordinated manner with proper
sequencing within the framework of the
patient’s overall developmental, medical, and
psychological needs
•
Standards for Approval of Cleft Palate and
Craniofacial Teams
• The Parameters for Evaluation and Treatment of
Patients with Cleft Lip/Palate or Other
Craniofacial Differences
(ACPA 2018a, b; AAPD 2018-2019)
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F. Extraoral Exam
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• Wide complete left cleft lip and nose
G. Intraoral Exam
• Left complete cleft of the alveolus and hard and
softpalate
FUNDAMENTAL POINT 2
Presurgical Appliances andTherapy
• The goal of presurgical maxillary orthopedics is
to improve the position of the maxillary alveolar
segments and/or enhance the nasolabial esthetic
outcomes prior to surgical closure of the cleft lip
• Common types of presurgical appliances/
therapy are listed below, from most passive to
most active:
Lip taping
Obturators
DynaCleft lip tape with nasal elevator
Nasoalveolar molding (NAM)
Latham appliance
• Prosthetic appliances such as an obturator
(apassive static appliance) may be helpful
toassist in feeding, close a stula, or aid in
speech. However, the use of obturators to aid
with feeding for infants has declined with the
advent of modied specialty feeding bottles
(Haberman, Pigeon, etc.) that assist with feeding
• Treatment is dependent on each cleft center’s
surgical and presurgical philosophy and
outcomes. This is combined with patient’s
needs, extent and severity of the cleft, and
consideration of any precluding medical
conditions (risk of aspiration, airway
compromise, etc.) and the ability of the patient
and family to comply with care and return for
follow‐up and treatment visits
•
Depending on the type of presurgical therapy,
treatment is usually initiated within one to
fourweeks after birth, to maximize the exibility
of cartilage. The appliance is in place until the rst
surgery takes place (three to six months of age)
GROWTH ANDDEVELOPMENT
Figure 7.6.3 Maxillary arch preoperative cast prior to presurgical orthopedics.
Diagnostic Tools
H.
• Maxillary arch preoperative cast prior to presurgical
orthopedics. The greater and lesser alveolar segments
can be identified in the cast (Figure7.6.3)
I. Differential Diagnosis
• Not applicable
J. Diagnosis and Problem List
Diagnosis
• Unilateral left complete cleft lip and palate
Problem List
• Immediate attention to assure adequate nutrition,
growth, and development
• Rule out any other medical conditions and/or syndromes that would preclude or modify the use of
apresurgical appliance
• Poor position of maxillary segments and potential for
arch collapse
• Potential for high caries risk when teeth erupt
(Wells2013)
(ACPA 2018b)
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