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Ortho Flashcards

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1
Q

What EO assessments are made for ortho?

A

Skeletal

  • anteroposterior
  • vertical
  • transverse

Soft Tissue

  • lip competence
  • incisal display
  • lip protrusion
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2
Q

Discuss AP ortho measurements

A

From side on, pt in natural head position/Frankfort plane parallel, bipalpation of deepest curve of maxilla + mandible

Skeletal

  • 1: normal; chin on/up to 2mm behind zero meridian line
  • 2: retrusive; chin behind line
  • 3: protrusive; chin in front of line
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3
Q

Discuss vertical ortho measurements

A 
Two methods
Linear: Lower Ant. Facial Height
- using ruler for numerical value
- lower 1/3 should = middle 1/3
— glabella-> subnasale -> soft tissue gnathion

Angular: Frankfort Mandibular Plane Angle

  • high/obtuse: lines meet before occiput; inc. LAFH
  • av.: lines meet @ occiput
  • low/acute: lines meet behind occiput; red. LAFH
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4
Q

Discuss transverse ortho measurements

A

Measured above + behind and in front of pt
Facial centreline: mid-eyebrow, tip of nose, U lip philtre, chin point

Facial asymmetry: usually mandibular

  • true: X-bite + mandibular displacement
  • common: molar 3, inc. LAFH
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5
Q

Discuss lip assessment for ortho

A

Morphology: thin, normal, full

Competency:

  • competent: meet @ rest w/o muscular effort
  • potentially: separated only by proclined UIs (Class 2/1)
  • incompetent: don’t meet @ rest; Skeletal 2, inc. LAFH

Coverage: L lip cover 1/3 UIs

Length: alar base to vermillion border; 22-24mm

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6
Q

Discuss intro-arch dental features for ortho assessment

A

Crowding: dento-alveolar discrepancy

  • mild: <4mm
  • mod.: 4-8mm
  • severe: >8mm

Spacing: dento-alveolar discrepancy

  • not usually measured
  • qualify where present
  • maxillary median diastema: gap b/w U1s

Rotations

  • describe direction from side w/ largest contact point displacement
  • i.e. MB, DP

Angulation: mesio-distal tip

Inclination: bucco-lingual
- lat. ceph
— U1s: 109d to maxillary plane
— L1s: 93d to mandibular plane

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7
Q

What inter-arch dental features are in ortho assessment?

A 
Incisor relationship 
Overjet
Overbite 
Centrelines 
Molar relationship 
Crossbites + Displacements
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8
Q

Discuss incisal relationship

A

1: incisal edge LIs occludes on cingulum plateau UIs
2: incisal edge LIs occludes post. cingulum plateau UIs
- 1: inc. overjet; UIs proclined or normal
- 2: retroclined
3: incisal edge LIs occludes ant. cingulum plateau UIs

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9
Q

Discuss overjet + overbite

A

Overjet: horizontal distance b/w incisal edge UIs + labial aspect LIs

  • av.: 2-4mm
  • Class 2/1: >
  • Class 3: <

Overbite: vertical overlap of LIs by UIs

  • av.: 2-4mm (1/3-1/2)
  • complete: contact b/w teeth + teeth/palate
  • incomplete: no contact
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10
Q

Discuss dental midlines

A 
U midline (dental) coincident w/ facial midline 
U+L midlines coincident w/ each other 
L midline coincident w/ chin point
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11
Q

Discuss molar relationship

A

1: MB cusp U6 occludes in midbuccal groove L6
2: U6 occludes M
3: U6 occludes D

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12
Q

Discuss crossbites + displacements

A

Crossbites

  • U teeth should occlude B to L; if occlude P = X-bite
  • ant. or post.
  • unilateral or bilateral

Displacement: mandibular deviation b/w centric relation + centric occlusion

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13
Q

Discuss growth control theories for bone, cartilage and soft tissue matrix

A

Bone

  • no innate growth potential; no growth when transplanted
  • growth @ sutures responds to outside stimuli; pulled apart

Cartilage

  • nasomaxillary: some innate growth
  • mandibular condyle: less growth when transplanted, considered growth site

Soft Tissue Matrix: bone + cartilage react to growth of soft tissue

  • cranial vault: size of brain
  • nasal + oral cavities: functional need
  • mandible: impaired by TMJ ankylosis
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14
Q

Discuss theories of growth modulation

A

Genetic: homeobox control generic blueprint of growth

Epigenetic
- Functional Matrix Theory
— capsular matrix: indirectly by altering vol. of capsule
— periosteal matrix: directly on skeleton
- Updated functional Matrix Theory

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15
Q

General features of craniofacial growth

A

Follows somatic growth pattern

Rate inc. pre-/@ puberty
F earlier
Red. facial convexity (class 2); mandible frowns 18+
Continues throughout life

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16
Q

Discuss structures of cranial vault + growth

A 
Comprises
- flat bones
— frontal
— occipital 
— parietal 
— squamous part of temporal
- sutures + fontanelles

Intramembranous ossification

  • apposition: sutures + exterior
  • resorption: interior
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17
Q

Structures of cranial base + growth

A

Comprises

  • basioccipital
  • ethmoid
  • sphenoid
  • petrous part of temporal

Endochondrial ossification
Spheno-occipital synchondrosis: affects AP
Surface remodelling

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18
Q

5 mechanisms of maxillary growth

A 
Sutural
Surface remodelling
Displacement/Myofibroblasts
Nasal Septum
Functional Matrix
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19
Q

Discuss sutural growth of maxilla

A

Sutures

  • frontomaxillary
  • zygomaticomaxillary
  • pterygomaxillary
  • midline
  • zygomatico-frontal (directly)
  • zygomatico-temporal (indirectly)

Intramembranous ossification; apposition @ sutures grows forwards + downwards

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20
Q

Discuss displacement growth of maxilla

A

From 7-15y up to 1/3 forward movement due to passive displacement
Associated w/ sutural growth
Rotational component masked by periosteal remodelling

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21
Q

Discuss nasal septum growth

A

Cartilaginous growth
1 of 1ry mechanisms of nasomaxillary complex growth
- apposition @ sutures
- surface remodelling: down + forward, widening palatal vault
Considerably affects growth of U face

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22
Q

Discuss growth of mandible

A 
Intramembranous 
Endochondral @ condyle
- elongation 
- ant. + downward 
Surface remodelling (majority)
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23
Q

Discuss growth rotations of mandible

A

Determined by

  • post. face height: condyles, synchondroses
  • ant. face height: tooth eruption, soft tissue growth

Backward (clockwise)

  • IO: red. overbite, ant. openbite
  • EO: inc. FMPA + LAFH

Forward (anti-clockwise): class 2/2

  • IO: inc, overbite
  • EO: red. FMPA + LAFH
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24
Q

Discuss predicting of facial growth

A

Numerous methods

  • 2ry sexual characteristics
  • standing height
  • age
  • skeletal maturity
  • dental age

No strong evidence for any of these; no real way to predict max. growth

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25
Ortho relevance of growth + Tx implications
``` Relevance - Tx quicker in presence of growth - favourable in XLA cases (spontaneous closure) - facilitate — overbite red. — space closure — settling — functional appliance + rapid maxillary expansion ``` Implications - orthognathic: timing + stability - timing implant placement - stability
26
Reasons for early loss of teeth
Local - caries - trauma - ectopic eruptions Systemic - gingival hyperplasia, poor OH - cerebral palsy: red. mobility = poor OH - syndromes/disorders
27
Define balancing and compensating extractions
Balancing - tooth from opposite side of same arch; min. centreline shift Compensating - tooth from opposing quadrant - min. occlusal interference by allowing teeth to maintain occlusal relationship as drift forward - more difficult to justify
28
Reasons for early loss A&Bs + management options
Reasons - retained + effecting eruption UIs - XLA as wider Tx: mesiodens, expose + bond UE U1 - traumatised + poor prognosis + not avulsed - carious Management - balancing/compensating not req. - space maintainer: aesthetic (URA + pontic) or crowding concern
29
Reasons for early loss Cs
``` Aid eruptions 3s - provide space B 3s - improve position ectopic 3s Interceptive: unilateral loss UC causing centreline shift when other C lost Carious Trauma ```
30
Reasons for early loss D&Es
Allow eruption of 4/5s Aid improvement position ectopic 4/5s Utilise leeway space to relieve crowding Carious
31
Management options for early loss of C&Ds
Balancing: may be req. crowded arch Compensating: not req. Unbalanced XLA result - no centreline shift; don’t balance - shift w/ complete space closure; don’t balance until sought ortho exam - shift w/ space remaining M to XLA; monitor to see if movement occurring, if yes seek ortho exam
32
Management options for early loss Es
Balancing not req.: no appreciable effect on midline May allow serious tilting + drifting of adjacent 6 Consider space maintainer
33
General effect of early loss of teeth
Red. arch length = - crowding - ectopic eruption - impaction - rotation - centreline shift - unfavourable molar relationship
34
Functions of space maintainers
``` Maintain: arch length, width of leeway space Prevent OE opposing tooth Improve aesthetic (ant.) Aid breaking habits; digit sucking ```
35
Ideal space maintainer
Simple Durable, strong, stable Passive Cleansable; no inc. risk caries
36
When to use space maintainers + considerations
When - presence of permanent successor - successor covered by alveolar bone Consider - specific tooth - T since tooth lost - occlusion - pt age; cooperation - OH - space; already lost? Overcrowding?
37
Types of space maintainers
Unilateral - crown/band and loop - distal shoe ``` Bilateral - fixed — lingual arch — transpalatal arch — nance palatal arch - removable: URA ```
38
Compare indications for lingual arch and transpalatal arch + nance palatal arch
Lingual arch - lost several post. + L6 erupted - maintain length + arch - prevent loss Leeway Space Transpalatal Arch + Nance Palatal Arch - lost several post. + U6 erupted - maintain length + width - prevent Leeway Space loss by prevent M drift 6 - modify: habit breaker for digit sucking
39
Indications for URA
``` A+Bs lost: can + teeth to URA Habit breaker Maintain U6 + Leeway Space Poor OH Unable to bond enamel ```
40
Why are teeth XLA’d for ortho?
Create space for alignment Orthodontically correct malocclusions Aid dental development through removal 1ry/2ry teeth
41
Why is space making required?
``` Relieve crowding Incisor AP movement to obtain normal OJ Change incisor angulation/proclination Levelling occlusal curves Arch contraction Tooth enlargement or replacement ```
42
How can space be created?
``` Leeway Space: 2.5mm/Q L; 1.5mm/Q U D movement UMs Expansion of U teeth Incisor proclination Enamel stripping XLA ```
43
Discuss ortho XLA of incisors
U - rare: poor aesthetics - poor prognosis due to severe trauma - root resorption: ectopic 3 - development malformation: dens in dente, dilaceration, fusion, macrodont L - easily relieve crowding where M Class 1 + I crowding - adult: class 3 + retract LLS - disadv: crowding reappears; red. intercanine width + inc. OB+J - req. bonded retainer
44
Discuss ortho XLA 4s and 5s
4s - provide 8-9mm space - mod-severe crowding + aid ant./post. crowding - impacted 3s where crowding caused shortage of space — U4 XLA as erupt pre-3 - 40-60% XLA space available if anchorage not reinforced 5s - mild-mod crowding: provide 3-8mm - P/L ectopic: early loss U/LE - fixed appliances req. contact b/w 4+6 - 25-50% XLA space available if anchorage not reinforced
45
Common reasons for poor prognosis 6s
Caries Molar-incisor hypominerlisation Enamel hypoplasia
46
Possible effects of early loss of 6s
Localised spacing OE opposing Tipping of adjacent
47
Factors to consider before XLA 6s
``` Age: dental development Crowding Malocclusion DH: hypoplasia Presence/absence of other teeth: 5s, 8s ```
48
Discuss effect of age on 6 XLA
``` U: spaces close faster spontaneously L - spontaneous closure if T correctly — calcification of bifurcation 7s - early: 5s drift + ectopic - late: 7s erupted + req. ortho for space closure in pt not ideal candidate ```
49
Discuss effect of crowding on XLA 6
``` U: potential for rapid space loss L - spaced: still spaced - aligned: min. spaces - crowded: best results ```
50
Are balancing or compensating XLAs req. for 6s?
Compensating - U6: no - L6: often yes Balancing: only if severely crowded premolars
51
Compare XLA 6s for Class 1 w/ mild crowding to Class 1 w/ mod-severe crowding
Mild - XLA @ optimum T for 7s - don’t balance unilateral 6 w/ healthy 6s - L6: compensate UNLESS L7 erupted + O contact w/ U6 - U6: don’t compensate if L6 healthy Mod-severe - XLA @ optimal T for 7 + relieve premolar crowding - bilateral B crowding: balance; relief + maintain centreline - L6: compensate to prevent OE + relieve premolar crowding - labial crowding: little spontaneous relief w/ XLA 6 — delay until 7s erupt + use space for alignment w/ fixed - OR XLA @ optimal T + Tx once in permanent dentition
52
Discuss XLA 6s for Class 2 and Class 3 malocclusions
Class 2 - req. space to correct incisor relationship - L6: @ ideal T for 7s + control 5 - U6 — immediate XLA req.: functional/headgear to correct B segment + fixed (if pt suitable) — temporise + wait until 7s then reassess — consider XLA if risk OE or complication of malocclusion Class 3 - try avoid loss 6s
53
Discuss ortho XLA 7s and 8s
7s - rare: so post. - aid D movement U buccal segment - relieve mild L premolar crowding - additional space prevent impacting 8s: no guarantee 8s - no evidence for XLA to prevent LI crowding
54
Define class 2/1 malocclusion
Lower incisor edge lies post. to cingulum plateau of UIs Always inc. overjet UIs: proclined or av. inclination
55
Skeletal aetiology of Class 2/1
Usually skeletal 2 - skeletal 1 possible Mainly w/ retrognathic mandible (80%)
56
Dental aetiology of Class 2/1
Crowding; push U1s labially
57
Soft tissue aetiology of class 2/1
Teeth erupt in zone of equilibrium w/ soft tissues thus important L lip: incompetent lips w/ lip trap (push U1s labially) Lip muscular tone - inc. mentalis activity = retrocline L1s (normal resting lower lip line)
58
Habit aetiology of class 2/1
Digit sucking - proclined UIs - retroclined LIs - inc. overjet - ant. open bite; usually asymmetric - narrow U arch w/ or w/o unilateral post. X-bite
59
Dental features of class 2/1
``` Inc. overjet M Class 2 Crowding/spacing Overbite - inc. + deep OR - red./incomplete ``` If Skeletal 1 - UIs proclined - LIs retroclined
60
Rationale for Tx class 2/1
Aesthetics Risk of trauma Psychological well-being
61
Discuss risk of trauma associated w/ Class 2/1
Overjet - 5mm 22% trauma incidence - 9mm 24% - >9mm 44% (IOTN 5a) No lip protection Overbite - pain - gingival stripping -> PD
62
5 management options for class 2/1
``` Accept Growth modification Headgear Camouflage Orthognathic surgery ```
63
Define functional appliances
Ortho devices that utilise forces generated by stretched MoM, facial expression + periodontium to change position of teeth and/or jaw relationships in actively growing pt
64
Discuss accepting class 2/1
Aesthetics acceptable Pt not concerned OH not good enough for appliances Must - explain risk to pt - provide mouth guard; red. trauma risk
65
Classification of functional appliances
Mode - myotonic: passive muscle stretching - myo-dynamic: muscular stretching during function Retention - tooth: passive (bionator), active (twin block) — easy, tolerable, adjustable - soft tissue: Functional Regulator (Frankel) — complex, poorly tolerated — changes zone of equilibrium
66
Contra/indications for growth modifications for class 2/1
Indications - motivated - actively growing - mod-severe AP discrepancy - inc. overjet - inc. overbite - red./av FMPA + LAFH - lip trap - proclined UIs, retroclined LIs ``` Contraindications - poor OH - non-growing - mild AP discrepancy - inc. FMPA w/ red. overbite — overbite red. in Tx - retroclined UIs, proclined LIs ```
67
Dental and skeletal effects of growth modification of class 2/1
Dental: 70% - UIs retrocline - LIs procline - LMs erupt M - UMs drift D Skeletal: 30% - mandibular growth @ condyles (1-2mm) - v little restriction of maxilla (0.7mm) - glenoid fossa remodel ant.
68
Discuss headgear, camouflage + orthognathic surgery in Tx of class 2/1
Headgear - generate force to maxilla restrict AP growth - allow catch up of mandible - can direct force to in/extrude Ms = control VD - compliance: wear 14h/d force 500g/side ``` Camouflage - fixed appliances - mild-mod. Skeletal 2 - non/XLA — U4s: easier move teeth back — L5s: preferable w/o ``` Orthognathic - surgery + fixed - adults; growth complete - severe skeletal AP or VD discrepancy - poor facial appearance
69
Define class 2/2
LIs edge lie post. to cingulum plateau UIs UIs retroclined Overjet usually min./dec. can be inc.
70
Skeletal aetiology of class 2/2
AP - mild-mod skeletal 2 - skeletal 1 + mild 3 (rare) possible Vertical - red. VD - red. FMPA - associated w/ forward growth rotation of mandible - progenia: prominent chin
71
Soft tissue aetiology of class 2/2
Influence of skeletal pattern If LAFH red. - lower lip line effectively higher on crowns UIs - high resting lower lip line = retroclined UIs Muscle activity + tone: inc. mentalis activity = high lower lip line If lower lip line high (not v higher) U2s escape effect = av. inclination whilst U1s retroclined - if lower lip line v higher = all UIs retroclined
72
Dental aetiology of class 2/2
Acute crown-root angle (crowns flatter) Thin labial-palatal thickness Retrusive maxillary + mandibular dento-alveolar process
73
Dental features of class 2/2
Retroclined U1s U2s - crowded - M-L rotated - normal or proclined (depending on lip line) Crowding: exacerbated by retroclination U1s (red. arch length) Inc. overbite - retroclination UIs = inc. inter-incisal angle - red. VD + skeletal 2 = no occlusal stop to LIs = OE — occlude w/ UIs or P mucosa — severe = trauma P mucosa or L gingiva LIs
74
Tx rationale for class 2/2
Aesthetic concerns Dental health - traumatic overbite (IOTN 4f) - crowding
75
Tx options for class 2/2
Accept Growth modification Camouflage Orthognathic surgery
76
Discuss accepting class 2/2
``` Aesthetics acceptable Pt - not concerned - not suitable (OH) Overbite: not significant clinically or aesthetically ```
77
Discuss growth modification Tx for class 2/2
Indications - growing pt - mild-mod skeletal 2 Functional appliance to convert to Class 2/1 - procline UIs - inc. overjet Finish w/ fixed to create class 1
78
Discuss functional appliances used for Tx class 2/2
Procline UIs by - URA: Expansion + Labial Segment Alignment Appliance - Twin block w/ proclining spring - sectional fixed appliance
79
Discuss camouflage + orthognathic Tx of class 2/2
Camouflage - fixed appliances - mild-mod skeletal 2 - non/XLA: U4s, L5s (depends on tooth condition) - none: generate space by proclining all Is ``` Orthognathic - surgery + fixed - suitable — adults: growth complete — severe skeletal AP or VD — poor facial appearance ```
80
What is stability of class 2/2 Tx dependent on?
Red. overbite + inter-incisal angle | If IIA not corrected OB will relapse as no occlusal stop to LIs
81
Define class 3
LIs edge lie ant. to cingulum plateau UIs Skeletal 3 Molar Class 3
82
Skeletal aetiology of class 3
``` Maxillary hypoplasia (retrusion) Mandibular prognathism (protrusion) Combination ```
83
Dental aetiology of class 3
``` Maxillary hypodontia Narrow U arch, broad L arch Pseudo class 3: posturing forward to comfortable bite ```
84
Soft tissue aetiology of class 3
Not important part of class 3
85
Other etiological factors of class 3
Genetics: Hapsburg royal family - narrow U arch Craniofacial anomalies - cleft lip + palate - Binders syndrome
86
Indications for Tx of class 3
X-bite + displacement Predicted pattern of future growth (mandible grows more) Aesthetics Functional problems
87
Management options for class 3
``` Accept: do nothing or wait Interceptive - URA - functional - face mask/reverse head gear Camouflage Orthognathic ```
88
Define early, intermediate and late in terms of ortho Tx
Early - mixed dentition - <10yo Intermediate - permanent dentition - growing - 10-16 Late - permanent dentition - non-growing - >16yo
89
Discuss early interceptive Tx of class 3
If do nothing undesirable changes to malocclusion occur Improvable components @ this stage; not severe - ant. X-bite - post. X-bite + displacement - risk of trauma/dehiscence Problems: compliance, stability, growth
90
Intermediate interceptive Tx options for class 3
Growth modifications | Camouflage
91
Discuss growth modification for class 3
Functional appliance or reverse headgear Indications - cooperative, understand pt - mild-mod — severe; Tx not beneficial at this stage Tx not guaranteed Has to be worn whole T maxilla growing = long Tx T + potentially poor results
92
Discuss camouflage of class 3
Indications - mild-mod skeletal 3 - pt happy w/ facial profile - proclination UIs + retroclining LIs possible - good overbite Method - fixed w/o XLA; procline U, retrocline L - fixed w/ XLA; U5s, L4s (need more space ant.) May req. U arch expansion to correct X-bite - URA - tri/quad helix
93
Problems associated w/ intermediate Tx of class 3
Unfavourable growth (unpredictable) Late presentation of non-growing pt Pt unhappy w/ facial profile
94
Discuss late Tx of class 3
Orthognathic surgery + fixed Pt must have stopped growing before commencing - growth modification not possible If facial profile not a concern = camouflage
95
Why is it important pt chooses camouflage or orthognathic?
As cannot do both | First stage of orthognathic is decompensation which would reverse camouflage = extended Tx time, cost, compliance
96
Reasons for IOTN
``` Uniformity of ‘need’ Prioritise need Risk:benefit for pt Monitor standards of care Audit + research Education + teaching ```
97
Define MOCDO
Missing: 5i/h, 4t/h - congenital absence - traumatic loss - ectopic/impacted Overjet: 5a/m, 4a/b/m - reverse: all Is lingual Crossbite: 4c/l - + displacement contact-point Displacement (crowding): 4d - measure b/w anatomical contact points w/ ruler Overbite: 4e/f - deep/complete/traumatic - Openbite: 4e, 3e
98
IOTN Grade 5
i: impacted h: extensive hypodontia (>1 tooth/Q) w/ restorative complication a: overjet >9mm m: reverse overjet >3.5mm w/ masticatory + speech difficulty p: cleft lip/palate + craniofacial anomalies s: submerged deciduous tooth
99
IOTN Grade 4
h: less extensive hypodontia a: overjet >6<9mm b: reverse overjet >3.5mm w/o masticatory + speech difficulty m: reverse overjet >1<3.5mm w/ masticatory + speech difficulty c: ant./post. X-bite w/ >2mm discrepancy l: post. lingual X-bite w/o functional occlusal contact d: severe crowding >4mm e: ant./lat. open bite >6mm f: inc. + complete overbite w/ gingival/palatal trauma t: PE x: supernumerary
100
IOTN Grade 3
a: overjet >3.5<6mm w/ incompetent lips b: reverse overjet >1<3.5mm c: ant./post. X-bite w/ >1<2mm discrepancy d: crowding >2<4mm e: ant./lat. open bite >2<4mm f: complete overbite w/o gingival/palatal trauma
101
IOTN Grade 2 + 1
Grade 2 - a: overjet >3.5<6mm w/ competent lips - b: reverse overjet >0<1mm - c: ant./post. X-bite w/ <1mm discrepancy - d: crowding >1<2mm - e: ant./post. open bite >1<2mm - f: overbite >3.5mm w/o trauma - g: pre/post-normal occlusion w/o other anomaly Grade 1: no Tx need - d: crowding <1mm
102
Aesthetic component of IOTN
Used when 3d recorded 10 photographs of inc. unpleasant aesthetics Subjective assessment by dentist
103
Limitations of IOTN
``` Lacks skeletal/soft tissue factors - only dental factors No account for growth potential Not index of Tx complexity Doesn’t account for pt demands/concerns Doesn’t account psychosocial effects of malocclusion Generalised spacing not recorded ```
104
What is early ortho?
Any ortho assessment or Tx during mixed dentition stage
105
Why is early assessment important?
Most malocclusions Tx’d in permanent dentition Small min. req. Tx early - red. complexity - may eliminate need for future ortho Tx
106
What triggers further Ix during early ortho assessment?
``` Delayed eruption (i) Crowding (d) Inc. OJ (a) X-bite (c) Submergence (i) Palpation of UE U3s >10y (i) ``` Caries Deep/open bite (e)
107
Aetiology of ectopic 3s
``` Tooth tissue disproportion/crowding (d) Long eruption path 2: absence/abnormality c: prolonged retention Ankylosis Pathology Clefts ```
108
Discuss clinical + radiographic diagnosis of UE 3s
Clinical - bone contour: B/P bulge - adjacent teeth: position, vitality, mobility, colour - contralateral 3 erupted ``` Radiographic Morphology - apex - root resorption of adjacent tooth - size of follicle of 3 (cystic change) Localisation - B-P position - height of crown in relation to O plane - obliquity of long axis - proximity to midline ```
109
Tx options for UE 3
Interceptive: XLA C - if close to line of arch - normalisation in 78% cases Later Tx - no Tx - XLA 3 - XLA + ortho - exposure of 3 + ortho - autotransplantation
110
Tx for UE 1s
Make space - XLA: As/supernumeraries - move 2 D (not all cases)
111
What is a supernumerary and why are they important?
Excess/extra tooth cf to normal | Most common cause of late/delayed eruption
112
Classification of supernumeraries
``` Supplemental: normal form Conical/peg shaped/early forming Tuberculate/barrel shaped/late forming Odontome - complex - compound ```
113
Compare conical and tuberculate supernumeraries
Conical - most common; mesiodens - root formation early or in time w/ permanent I - often erupt, may be inverted - usually don’t impact eruption - Tx: leave unless causing malposition ``` Tuberculate - root formation delayed cf permanent I - usually P - rarely erupt or inverted - usually impact eruption - Tx — XLA ASAP not before 6y — not causing delayed eruption may req. XLA pre-ortho ```
114
Why should tuberculate supernumeraries not be XLA’d before 6y?
May damage developing permanent I
115
General Tx options for supernumeraries
Conservative - XLA $ + 1ry, await eruption permanent - maintain space - review 3-6/12 ``` Exposure of UE Open - tooth close to surface - place apically positioned flap + bracket Closed - tooth far away - bond bracket + Au chain - pull ```
116
Why should localised I X-bites be Tx’d immediately?
``` Eliminate displacement Prevent - PD trauma - mobility opposing tooth - excessive tooth wear ```
117
Aetiology + pathogenesis of infraoccluded teeth
Aetiology - idiopathic - genetic - trauma - absence of successor Pathogenesis - ankylosis during reparative phase of tooth resorption
118
Tx factors + options of infraoccluded teeth
Factors - permanent successor? - degree - co-existing malocclusion - long term prognosis of 1ry Options - conservative advocated - pt not begun growth spurt + 1-2mm infraocclusion = XLA - if left too late = complete coverage + req. extensive bone removal
119
Discuss bone resorption mechanism
Osteoclasts recruited by external stimuli Attach to bone @ clear zone to form seal H+ ions secreted across ruffled border to demineralise bone Organic matrix removed by lysosomal enzymes, MMP remove osteoid
120
What are lacunae?
Pits of bone resorbed osteoclasts
121
How is bone resorption regulated?
Osteoclast differentiation and function regulated by osteoblast derived factors RANKL stim. OC formation and function Osteoprotegrin inhibits resorption - acts as decoy receptor for RANKL
122
Discuss cellular response to light ortho force
1-2s: PDL fluid expressive 5s: PDL fibres + cells compressed Mins: blood flow altered; prostaglandins + cytokines released Hrs: metabolic changes; OB/OC activity 2-3d: frontal resorption, slight OTM 5-14d: lamina dura removed (no OTM w/o removing) 14-30d: OTM again; resorption + deposition
123
Discuss cellular changes seen with heavy ortho force
``` 1-5s: PDL completely compressed Mins: blood flow ceased Hrs: ischaemia, necrosis, hyalinisation 2-3d: OB+OC recruited; undermining resorption begins 14d: hyalinisation zone removed 15-30d: lamina dura removed, OTM ```
124
What is the ideal force for OTM? What does this result in?
``` Force just > capillary pressure Dec - risk tissue + cell necrosis - pulpal damage - pt discomfort ```
125
What is the centre of resistance?
Point of tooth where single force passed through would result in translation of tooth in direction of force
126
What affects the centre of resistance of a tooth?
No./SA of roots Degree of bone resorption Degree of root resorption
127
How do root and bone resorption affect the centre of resistance?
Greater bone resorption, CoR more apical | Greater root resorption, CoR more coronal
128
What are the general optimal forces for different OTM?
Tipping: 30-60gm Bodily: 100-150gm Intrusion: 15-25gm Extrusion: 30-60gm
129
What is ortho anchorage?
Resistance to unwanted tooth movement
130
Why is anchorage important?
Prevent waste of space gained from XLA not being used to align teeth Prevent movement of Ms through fixed + removable appliances Move teeth with higher anchorage value
131
Discuss headgear
EO anchorage system Use Kloehn bow - attaches to headgear tubes on U6 bands to prevent M movement of Ms (loss of anchorage) - move Ms D by inc. forces to create space (up to 1/2 class 2)
132
Discuss temporary anchorage decides
IO device used for indirect anchorage Titanium implant screwed into alveolus @ level of attached gingiva No osseointegration thus easily removed when not req. Use - moving teeth in severe hypodontia case - red. OJ where U6s lost
133
Relationship b/w anchorage value + root SA
Direct | Anchorage value proportional to SA of root
134
Predisposing factors for root resorption during ortho
``` Long Tx T Class 2 elastics Roots in cortical plate Nail biting Previous trauma Atopic pt Blunt, short pipette roots Previous ortho Previous radiotherapy FH ```
135
Mechanism of root resorption
Cementum adjacent to hyalinised PDL resorbed by cementoclasts Progress to dentine destruction Ortho forces removed - repair by deposition of cementum in areas of destruction - dentine not replaced
136
Types of root resorption
Slight blunting: minor blunting of apices Moderate: <1/4 root Severe: >1/4 root Localised/generalised
137
Discuss moderate generalised root resorption
Most teeth show some resorption Greater in pt w/ linger Tx T Shortening of root length; UIs most severe Clinically insignificant
138
Discuss severe localised and generalised resorption
Localised - aetiology: excessive force + prolonged Tx T - UIs greatest risk - v high risk: roots UIs against lingual cortical plate Generalised - aetiology: unknown - MH: thyroid deficiency (high risk) - atopic pt: inc. levels inflammatory mediations
139
Challenges/limitations of adult orthodontics
``` Bone turnover: slower; tooth movement slower, more difficult, inc. risk resorption Dental + PD condition - more likely to be worse - previous Tx - resorption - XLA spaces - relapse + stability ```
140
Difference in management of overbites in adults cf adolescents
Adolescents - post. not occluding thus extrude post. w/o intruding ant. - acceptable as still growing; use functional appliance - relative intrusion Adults - post. occluding thus intrude ant. w/o movement of post. - true intrusion
141
Challenges faced w/ XLAs for ortho in adults and potential alternatives
Challenges - slow space closure/long Tx T - compliance/acceptance of space - space recurrence Alternatives - interdental enamel reduction - I proclination - if XLA: 5s rather than 4s - move Ms D - expansion
142
Define impacted tooth
Tooth that has failed to erupt due to obstruction/barrier to eruption of normally positioned tooth
143
Incidence of UE teeth
8s: 25% 5s: 20% U3s: 2% 6s: 0.75-6% U1s: 0.13%
144
Aetiology of impaction
``` Delayed loss of 1ry Abnormal position of tooth germ Ectopia Supernumerary Cysts Tumours Odontomes Ankylosis Dilaceration: invulsion of 1ry Trauma Systemic Genetic ```
145
Risks associated w/ impacted teeth
Damage adjacent teeth/structures - cyst formation - root resorption Poor aesthetics
146
Tx need for impacted teeth (IOTN)
IOTN 5i Speech benefits Occlusal function Psychological benefits Min. damage adjacent teeth
147
Req./steps to localisation of UE teeth
``` Eruption pattern Dental anatomy Visual exam Palpation X-ray ```
148
Why is knowledge of eruption pattern and anatomy important for localisation fo UE teeth?
Eruption pattern - timing of crown + root formation; how far down should tooth be - eruption dates; late = further Ix - contralateral tooth erupted Anatomy - differentiate 2ry vs 1ry - erupt into path of least resistance; suggests sites for palpation if ectopic
149
Discuss visual exam + palpation of UE teeth
``` Visual - obvious B/P bulges; crown under mucosa - angulation 2: UE 3 - colour changes of 1ry — previous trauma — resorption from impaction ``` Palpation - carried out all 9-10yo - palpate B/L sulcus for crown UE - check mobility Cs + 2s - palpate P for crown - compare contralateral eps. if erupted
150
When is intervention of UE U1s req.?
Contralateral erupted >6/12 Both UE’d + L1s erupted >12/12 Deviation from normal eruption pattern; 2s before 1s
151
Aetiology of UE 1s
Hereditary - supernumerary - cleft lip + palate - cleidocranial dystosis - odontomes - abnormal tooth:tissue - generalised retarded eruption - gingival fibromatosis Environmental - trauma - early XLA/loss 1ry - retained 1ry - cystic formation - endocrine abnormalities - bone disorders
152
Management of UE U1s
``` Remove obstruction: 1ry, supernumerary Ensure sufficient space - URA - sectional fixed appliance - retained appliance Review 3-6/12; 80% erupt unaided ```
153
Management when eruption of U1 failed at 12/12
Exposure indicated Closed if high, open if superficial Avoid incisions in free gingiva Palatal approach where possible
154
Aetiology of UE 3s
``` Long path of eruption Develop before 2s Small/absent 2s Guided eruption by 2s Cs resistant to resorption Polygenic inheritance ```
155
Management strategies for UE 3
``` No Tx Interceptive Expose + ortho Surgical XLA Transalveolar implant Surgical repositioning ```
156
Discuss no Tx for UE 3
Review 6/12 + occasional X-ray Warn re root resorption 2s + cyst formation Indications - cooperative - age - appearance of C: colour, shape, root length - long term restorative options - 3 position
157
Interceptive Tx for UE 3
XLA both Cs - uncrowded mouth = 78% improvement where space - usually within 12/12 - XLA both to avoid centreline shift
158
Exposure + ortho for UE 3
``` When interceptive Tx failed Req. space for 3s - URA - distalisation or XLA 4s Expose + bone (NICE) ```
159
Surgical XLA of UE 3
Indications - poorly positioned - curved root - XLA req. for ortho In uncrowded mouth req. pros replacement Benefit: eliminate need for X-ray monitoring
160
Risks associated w/ aligning impacted 3s
``` Root resorption adjacent teeth Loss of vitality Poor tissue contour Inc. pocket depths 3 root resorption Ankylosis ```
161
Aetiology + management of impacted 5s
``` Aetiology: early loss Es Management - accept - XLA/incorporate into ortho Tx - expose + bone ```
162
Aetiology + management of UE 6s
Aetiology - bulbous E - crowding - M path of eruption - 1ry failure of eruption ``` Management - observe - persist >8yo: interceptive — XLA E — disimpact 6 ```
163
Types of ortho appliances
Removable - Active: URA, functional - Passive: Hawley retained, vacuum formed retainer Fixed - Active: pre-adjusted edgewise appliance - Passive: fixed/bonded retainer
164
Difference b/w URA and functional appliance
Both active removable ortho appliances URA: simple Functional: postures mandible away from rest position
165
Design features of removable ortho appliances
Active components Retentive complements Anchorage Baseplate
166
Discuss active components of ortho appliances
Site of force delivery Springs: T, Z, palatal finger - 0.5mm austenitic SS - optimal force: 25-40g/root - actives 2-3mm, 1mm movement/mnth Labial Bow: retract Is - 0.7mm SS (Hawley bow) - acrylic must be trimmed behind Is Screws: move 1/+ teeth
167
Discuss retentive components of removable ortho appliances
Maintain appliance in mouth Adams clasps - 0.7mm SS - easy to adjust - versatile; can add auxiliary fittings Southend clasps: UIs Fitted labial bow Ball-ended clasps: 0.6mm SS
168
Discuss anchorage features of removable ortho appliances
Prevent unwanted tooth movement IO - Simplified: anchor teeth > moving teeth - Reciprocal: equal no. teeth moving in opp. directions EO: headgear
169
Features of removable ortho appliances baseplate
Hold components together + provide anchorage Heat/cold cure acrylic Incorporate - split screw - ant. bite plane: red. OB by discluding B segments allowing OE + compensatory development of alveolus (growing pt only) - post. bite plane: disclude occlusion allowing correction of ant. X-bite
170
Uses of removable ortho appliances
``` Interceptive: correct ant. X-bite; space maintainer Functional Test compliance Red. OB D movement U B segments Post-Tx retainer ```
171
Dis/advantages of removable ortho appliances
Adv - effective for tipping teeth over short distances - easy to clean - self-limiting - cheap - min. chair side T - aesthetic - provide anchorage Disadv - compliance - limited to tipping movement - speech + mastication difficulty
172
Indications for fixed appliances
When req. bodily tooth movement - crown + root movement - in/extrusion - de-rotation - space closure
173
Dis/advantages of fixed appliances
Adv - 3D tooth control - not compliance dependent - act like bite turbos (red. OB) - + headgear Disadv - difficulty cleaning - risks: perio, resorption, decalcification - limited anchorage control; may req. adjunctive appliance
174
Components of fixed appliances
Brackets Bands Archwires Auxiliaries
175
Types of archwires
Round/rectangular | NiTi/SS
176
Discuss difference between initial and late archwires
Initial - flexible + elastic - engaged in multiple displaced teeth - round NiTi Late - rigid + strong - resist distortion as teeth moved w/ auxiliaries - rectangular SS
177
Types of auxiliaries
Close/open coils Intermaxillary elastics Springs Hooks
178
What are the functional limitations of fixed appliances?
Alveolar bone has limited capacity for remodelling therefore skeletal pattern offers greatest limit to tooth movement
179
What is ortho relapse?
Change in - tooth position (intra-arch) - arch relationship (inter-arch) From positions placed @ end of Tx
180
Causes and types of ortho relapse
Orthodontic relapse: predictable + avoidable - physiological relapse: return to original malocclusion - true relapse: poor Tx Maturational changes: unpredictable - unfavourable growth
181
Factors affecting ortho stability post-Tx
``` Soft tissue Occlusal Facial growth Soft tissue maturation Occlusal maturation Supporting tissue Habits ```
182
Discuss soft tissue and occlusal impact on ortho stability
Soft Tissue - pre-Tx: malocclusion stable as in zone of equilibrium w/ soft tissues - post-Tx: unstable unless new stability position found - must assess soft tissues + consider during Dx + Tx planning - Class 2/1: OJ dependent on lower L action on U labial segment Occlusal - ant. X-bite: req. +ve OB - post. X-bite: req. good intercuspation
183
Impact of continuing facial growth on ortho stability
Facial growth continues post-Tx Dentoalveolar adaptation usually maintains O relationships even when skeletal relationship change w/ growth ``` If intercuspation poor/dentoalveolar adaptation @ limit, O change - class 3, skeletal open-bite ```
184
Discuss impact of occlusal maturation + soft tissue maturation on ortho stability
Occlusal - continues throughout life; changes from teens to adulthood — dec.: inter-canine width, arch length — inc.: LI crowding, OB Soft Tissue - lip maturation + tone -> uprighting of labial segments thus crowding
185
Discuss impact of supporting tissues on ortho stability
Incl. supporting bone, PDL, supracrestal fibres Recently deposited bone esp. susceptible to resorption - must retain tooth movements until supporting tissues fully adapted Supporting bone + PDL: 6/12 Supracrestal fibres: >12/12
186
Define ortho retention
Holding teeth following ortho Tx in Tx position for period req. for maintenance of result
187
Rationale for ortho retention
Allow PD + gingival reorganisation Min. changes from growth Permit neuromuscular adaptation to correct tooth position Maintain unstable tooth positions; if req. for compromise or aesthetics
188
Relapse risk factors
Pre-Tx - rotations - median diastema - spacing (esp. adults) - palatal 3s - class 2/2 - grossly incompetent lips - forward tongue posture - ant. open bite - PD During Tx - expansion - I advancement/retraction - XLA spaces (adult)
189
Types of ortho retention
Help by Tx occlusion - Class 2/2 reverse OJ held by +ve OB - lip trap: OJ red. complete, prevent L lip becoming caught Appliances: all are passive - removable: vacuum formed, Hawley - fixed/bonded
190
Discuss duration of retention
Part time - removable: nocturnal wear - no evidence for FT wear removable appliance cf PT Long term - relapse potential ongoing - maturational changes continue until late adulthood
191
Discuss the Updated Functional Matrix theory of growth
Periosteal matrix - mechanical loading influence gene expression - mechano-sensing enables cells to respond to extrinsic loading through mechano-reception and mechano-transduction Periosteum - bone loaded dynamically (muscle contraction) - bone loaded statically (gravity)
192
Explain how updated functional matrix theory may apply to ortho
Ortho appliances/muscles deform bone Mechanoreception: osteoblasts/clasts electrically activated Mechanotransduction: osteoblasts/clasts respond Gene expression altered
193
Discuss cheek and nose assessments for ortho
Cheeks: paranasal hollowing; skeletal 3, maxillary hypoplasia ``` Nose - nasio-labial angle; 90D — M: 90-95; F: 95-10 — av., acute, obtuse - asymmetry - flaring @ base ```
194
Define: ant. + post. X-bite and scissor bite
Ant.: 1/+ UIs in linguo-occlusion cf L Post.: B cusp LP/M occludes B to B cusp UP/M Scissor: B cusp LP/M occlude L to L cusp UP/M
195
What should be incl. in ortho Dx summary?
Short description - Pt: name, age, CO - I relationship - skeletal: AP, vertical, transverse Key dental features - presence/absence teeth - condition: caries, restorations - describe L+U arch - O features Relevant X-ray findings + IOTN
196
What structures are visible on lat. ceph?
``` Skeletal structures - calvarium - cranial base - facial skeleton; Md, Mx - cervical spine Teeth Soft tissues ```
197
Ortho uses for lat. ceph
``` Pre-Tx record Dx + Tx Planning - skeletal assessment - Is: inclination, angulation, position - UE teeth - soft tissue profile assessment Assess/monitor growth During Tx - end of functional appliance Tx - monitoring anchorage req. + I inclination (before space closure) - Tx progress (surgical case) End of Tx/retention Research ```
198
Ideal features of point on ceph for tracing
Valid: represent accurately the structure concerned Reproducible: repeatably, accurately identifiable
199
What are the sella and naison points on a lat. ceph?
Sella: midpoint sella turcica Naison: most ant. point frontonasal suture
200
What are the orbitale, porion, menton and gonion points on lat. ceph?
Orbitale: most ant., inf. point margin of orbit Porion: uppermost, outermost point EA Menton: most inf. point of mandibular symphysis in midline Gonion: most post., inf. point angle of mandible
201
What are ANS, PNS, A, B points on lat. ceph?
ANS: tip ant. nasal spine PNS: tip post. nasal spine A: most post. point profile maxilla b/w ANS + alveolar crest B: most post. point profile mandible b/w chin point + alveolar crest
202
What are UIA, UIT, LIA, LIT on lat. ceph?
UIA: upper incisor apex UIT: upper incisor tip LIA: lower incisor apex LIT: lower incisor tip
203
Lines drawn on lat. ceph
Frankfort: orbitale->porion Maxillary plane: ANS->PNS Mandibular: menton->gonion McNamara: through naison perp. to Frankfort Functional occlusal plane: through U and L P/Ms
204
Discuss SNA/SNB analysis of lat. ceph and what it means for ortho
SNA: sella-naison-A angle; av: 81+3 SNB: sella-naison-B angle; av 78+3 ANB: SNA-SNB - Skeletal 1: 2-4 - Skeletal 2: >4 - Skeletal 3: <2
205
Discuss dental analysis of lat. ceph
Incisal inclination UI-Mx: angle b/w Mx plane + line through UIA and UIT - av: 109 +6 LI-Md: angle b/w Md plane + line through LIA and LIT - av: 93 +6 Inter-incisal angle: b/w UI-Mx and LI-Md - av: 135 +10
206
Importance of determining aetiology of malocclusion
Tx governed by aetiology | - accept/moody skeletal; age? Severity?
207
Differentiate b/w ortho Tx modalities
Orthopaedic (Growth Modification) - growing pt w/ skeletal discrepancy - usually headgear Ortho Camouflage - non/growing pt w/ mild-mod. skeletal discrepancy - correct I, accept skeletal Orthognathic - non-growing pt w/ mod.-severe skeletal discrepancy - correct I + skeletal
208
Aetiology of Skeletal 2 and 3
2 - Md retrognathia - +/- Mx protrusion 3 - Mx hypoplasia - +/- Md prognathism
209
Soft tissue aetiology of class 2 malocclusion
Class 2/1 - low lip line, fail to control UIs -> OJ - stability: retract UIs - lip trap -> exacerbate OJ Class 2/2 - high lip line; mentalis hyperactive — U1s: retroclined due to lip pulling back — U2s: proclined as shorter so not impacted by high lip line — LIs: retroclined as lack lip support
210
Effect of strap-like lip on arch
L arch has square shape
211
Effect of tongue on malocclusion
Size: large - procline LIs - spacing Position: forward -> procline LIs + spacing
212
What is dentoalveolar disproportion? What is it’s effect?
Discrepancy b/w no and/or size teeth and size of arch/space within arch Leads to spacing/crowding
213
Aetiology of crowding/spacing
``` Size of teeth No. of teeth Position of teeth Red. arch size Insufficient space within arch - early loss 1ry - retained 1ry ```
214
Causes of retained 1ry
Successor developmentally absent Successor ectopic Local abnormality in alveolar development (infra-occlusion) Failure of permanent to resorb 1ry
215
Tooth size aetiology of malocclusions
Microdont: spacing in normal arch Macrodont: crowding in normal arch
216
Indications for ortho space creation
``` Crowding relief OB red. OJ red. Arch constriction Torquing UIs ```
217
Methods and factors affecting space creation for ortho
``` Methods - inc. arch length — Ms D — Is forward - arch expansion - interproximal enamel red. - XLA ``` Factors - dental health - degree of crowding - total space req. - aetiology
218
Mechanism of how habits cause malocclusion
Digit sucking alters intrinsic soft tissue pressures - > equilibrium b/w teeth + soft tissues lost - > teeth move
219
What is the severity of the effect of digit sucking dependent on?
Duration; threshold 6h/d Freq. Intensity
220
Effects of digit sucking
``` UIs: proclined LIs: retroclined Inc. OJ Bi/unilateral X-bite +/- displacement Ant. OB; usually asymmetric - differential eruption Mx constriction - lower tongue position - inc. buccinator activity ```
221
When should digit sucking be stopped by?
5-6y
222
Methods for dissuading digit sucking
Explain cause + effect Conservative: 3-6/12 - reward - reframing - bitter nail varnish - plaster - wearing sock over @ night Persistent: 6-12/12; fixed/removable appliance Hypnosis
223
Discuss management of debonded bracket and loose bands
``` Debonded - not urgent - usually still attached by elastic to wire — moves/spins -> irritation - Tx — wax to stop moving — ortho appt ``` ``` Loose - usually no immediate harm - left 3-4/52 — swallowing — enamel demineralisation - Tx — remove if poss. — ortho appt ```
224
Management of poking ortho wire
Usually handled @ home w/ wax by pt Cut wire flush to terminal band/bracket w/ D end cutters Turn wire in at end Ortho appt
225
Management of lost/loose ortho appliance
Urgent: see ortho Management - adjust URA + refit - encourage commitment
226
Management of swallowed appliance/brace
Infrequent Small + asymptotic; reassure will pass easily Airway compromised + symptomatic - AE chest X-ray - provide description of inhaled object
227
EO risks of ortho + management
Usually headgear/protraction face mask - skin trauma: ill fitting - skin rash: Ni allergy - eye damage -> blindness Tx - allergy: stop, refer to GP - ill fitting: stop, don’t refit - eye injury: AE - urgent ortho appt
228
Importance of Dx UE 3s
``` 3s cornerstone of mouth Canine guidance Last tooth to be lost IOTN5i Multidisciplinary care req. Long Tx T ```
229
What is ‘late’ eruption for U3s?
Normal: 11-12y Late - F: 12.3y - M: >13.1y
230
When should radiographs be used for localisation of UE 3s?
>11y + 3s not palpable or erupted
231
Sequelae following impacted 3
``` Dentingerous cyst formation Internal resorption impacted tooth External resorption impacted + neighbouring teeth Ankylosis Infection Crowding 2/4 contact + red. arch length ```
232
How to determine if correct T for XLA 6? (Ortho)
Calcification of bifurcation 7: body movement to position of 6 UE5 engaged in roots E: prevent drifting + ectopic M angulation 7; 15-30° Follicle 7 contact w/ 6 Additional: presence 5s, 8s?
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