3B Flashcards
Moderate generalized space discrepancy (<4 mm per arch)
● General info:
○ True shortage of
space including leeway
Moderate generalized space discrepancy (<4 mm per arch)
○ Tooth movement methods will
create space
Moderate generalized space discrepancy (<4 mm per arch)
○ Prognosis & stability
unknown
Moderate generalized space discrepancy (<4 mm per arch)
■ Once arch dimensions begin to change, no
certainty that it will be stable
Moderate generalized space discrepancy (<4 mm per arch)
■ Prognosis good with
RETENTION
Moderate generalized space discrepancy (<4 mm per arch)
● Arch expansion (NOT palatal expansion) →
creates ~ 4mm of space
Moderate generalized space discrepancy (<4 mm per arch)
○ Ideal profile for arch expansion:
■ AP position of lips/incisors
normal or retrusive (NOT protrusive)
Moderate generalized space discrepancy (<4 mm per arch)
○ Ideal profile for arch expansion:
■ Adequate facial
keratinized tissue (gingiva) ● Allows for facial movement
Moderate generalized space discrepancy (<4 mm per arch)
○ Ideal profile for arch expansion:
■ Adequate
overbite & overjet (to allow facial incisor movement of lower arch)
Moderate generalized space discrepancy (<4 mm per arch)
IDeal profile for arch expansion
■ Skeletal
class I & Dental Class I (or end-to-end) molar
Moderate generalized space discrepancy (<4 mm per arch)
Ideal profile for arch expansion
● All teeth should be
present clinically/radiographically
Moderate generalized space discrepancy (<4 mm per arch)
○ Lip Bumpers
■ Treats
lower anterior &/or buccal segment crowding
Moderate generalized space discrepancy (<4 mm per arch)
lip bumpers
● Best for
facial lingual discrepancies
Moderate generalized space discrepancy (<4 mm per arch)
lip bumpers
○ Facial tipping (& bodily movement) of
incisors (NO rotation)
Moderate generalized space discrepancy (<4 mm per arch)
lip bumpers
○ Distal tip of
molar
Moderate generalized space discrepancy (<4 mm per arch)
lip bumpers
○ Arch width
increase
Moderate generalized space discrepancy (<4 mm per arch)
lip bumpers
● Applies
equilibrium theory
Moderate generalized space discrepancy (<4 mm per arch)
lip bumpers
○ Removes lip force, so
resting tongue force causes facial movement
Moderate generalized space discrepancy (<4 mm per arch)
lip bumpers
● Possible
2nd molar impaction
Moderate generalized space discrepancy (<4 mm per arch)
lip bumpers
■ Clinical management & fabrication same as
lingual arch
Moderate generalized space discrepancy (<4 mm per arch)
○ Banded/bonded fixed appliances
■ Treats
lower anterior &/or buccal segment crowding
Moderate generalized space discrepancy (<4 mm per arch)
○ Banded/bonded fixed appliances
● ——- movements
Tipping & bodily
Moderate generalized space discrepancy (<4 mm per arch)
○ Banded/bonded fixed appliances
● Rotations
possible
Moderate generalized space discrepancy (<4 mm per arch)
○ Banded/bonded fixed appliances
● ——– possible (by activating one side more than the other)
Midline shift
Moderate generalized space discrepancy (<4 mm per arch)
○ Banded/bonded fixed appliances
■ Clinical management →
may need to separate to place bands
Moderate generalized space discrepancy (<4 mm per arch)
○ Banded/bonded fixed appliances
● More flexible the wire, the
re-activations can be done less frequently
Moderate generalized space discrepancy (<4 mm per arch)
○ Headgear
■ Treats
buccal segment crowding (maxillary arch ONLY)
Moderate generalized space discrepancy (<4 mm per arch)
○ Headgear
● Molar movement
distally &/or buccally
Moderate generalized space discrepancy (<4 mm per arch)
○ Headgear
○ Interseptal gingival fibers will pull
premolars distally too
Moderate generalized space discrepancy (<4 mm per arch)
○ Headgear
● Cervical headgear → also does
extrusion
Moderate generalized space discrepancy (<4 mm per arch)
○ Headgear
● Requires
compliance
Moderate generalized space discrepancy (<4 mm per arch)
○ Headgear
■ Clinical management:
● Adjustment every
6-8 weeks
Moderate generalized space discrepancy (<4 mm per arch)
○ Headgear
● Can expect ——— in a year
3-4 mm
Severe space discrepancy >
4-5 mm per arch
Severe space discrepancy
● Extraction
○ Based on
crowding & protrusion
■ Extraction allows incisors to be
retruded
○ Premolars most
commonly extracted (~ 7 mm each) ○ Stability unknown - retention required
Serial extractions ⇒ Severe space discrepancy > 10 mm per arch
● Indications:
○ Class I with good facial form & severe space shortage
Serial extractions ⇒ Severe space discrepancy > 10 mm per arch
■ Early loss of 1° canines →
a finding of severe crowding
Serial extractions ⇒ Severe space discrepancy > 10 mm per arch
○ Gingival defects from
abnormal eruption
Serial extractions ⇒ Severe space discrepancy > 10 mm per arch
○ Impactions
imminent (from crowding)
Serial extractions ⇒ Severe space discrepancy > 10 mm per arch
● Advantages:
○ Spontaneous incisor alignment, improved psych, & reduced treatment time
Serial extractions
■ Proven benefits
○ Better canine position; improved gingiva; improved hygiene, ↓ retention time, better stability
Serial extractions
● Disadvantages:
○ Incisor lingual tipping & remaining teeth may not erupt or have poor form
■ Thus requiring future treatments
■ Substantiated by data
○ Deep bite; Reduced vertical growth & alveolar development; Poor facial esthetics
Serial extraction
● Begins with
extraction of 1° teeth → Facilitates alignment of erupted permanent teeth & encourages eruption of the premolars that will be extracted
Serial extraction
● Sequence:
- Primary canine (for anterior crowding & alignment)
- Primary 1rst molar (when > ½ PM root formed to expedite eruption)
■ In mandibular arch → want premolars to erupt before canine
■ In maxillary arch → 1rst premolars usually erupt before canines anyway - 1rst premolar (provides space in permanent dentition)
Serial extractions
■ In mandibular arch →
want premolars to erupt before canine
Serial extractions
■ In maxillary arch →
1rst premolars usually erupt before canines anyway
Space regaining - Localized space shortage
● Localized space shortage is an
opportunity to regain space if < 3 mm per quadrant
Space regaining Localized space shortage
● Adhere to
maximum space loss amount & use reliable appliances
Space regaining Localized space shortage
● Causes ⇒
Interproximal caries, ectopic eruption, tooth loss
Moderate localized space discrepancy
(<3mm per quadrant)
Moderate localized space discrepancy
1. Permanent molar ectopic eruption
○ 1rst permanent molar erupts mesially → may cause 1° molar resorption & loss
Moderate localized space discrepancy
○ 1rst permanent molar erupts mesially → may cause 1° molar resorption & loss
■ ⅔
self-correct; Painless occurrence common in maxillary arch
Moderate localized space discrepancy
1. Permanent molar ectopic eruption■ 1rst permanent molar continues shifting
mesially, taking up space
Moderate localized space discrepancy
1. Permanent molar ectopic eruption
■ Diagnosed with
bitewings
Moderate localized space discrepancy
1. Permanent molar ectopic eruption
○ Space regaining treatment plans:
■ If NO succedaneous premolar →
space regaining NOT necessary
● Mesial shift of 1rst permanent molar will close space
● Brackets bonded on dentition with spring inbetween
Moderate localized space discrepancy
1. Permanent molar ectopic eruption
○ Space regaining treatment plans:
■ BRASS WIRE (or separator) for
minimal interference/resorption (<1mm)
● Placed in between contacts, pushing permanent molar distally
Moderate localized space discrepancy 1. Permanent molar ectopic eruption
○ Space regaining treatment plans:
■ BAND & SPRING
● 1° molar banded and spring pushes 2° molar back
● Uncontrolled distal crown tip
○ Short roots bc still erupting - very easy to tip
● Fabrication → made by lab, so need to band and separate tooth for impression; wire bend & soldered by lab
○ Activated 3-4 mm
○ Treatment completed after 2-3 activations
● No retention required
Moderate localized space discrepancy
1. Permanent molar ectopic eruption
○ Space regaining treatment plans:
■ MODIFIED BAND & SPRING
● Direct
(Intraoral) fabrication with no soldering → tooth banded & bent wire used as spring
Moderate localized space discrepancy
■ BONDED SPRING
● Most modern & efficient way →
No banding; intraoral fabrication
Moderate localized space discrepancy
1. Space regaining for posterior tooth loss (maintains space for erupting teeth)
○ Max. removable appliance -
Hawley finger spring
Moderate localized space discrepancy
Max. removable appliance
■ Biomechanics:
● Resistance/anchorage via adams clasps & anterior palate
● Uncontrolled distal crown tip
Moderate localized space discrepancy
Max. removable appliance
■ Lab fabrication;
2-3 mm activation; 1mm movement per month
Moderate localized space discrepancy
Max. removable appliance
■ Retention & stabilization
required (with band & loop)
Moderate localized space discrepancy
Max. removable appliance
○ Banded & bonded appliance with coil spring
■ ————- biomechanics
Open coil spring
Moderate localized space discrepancy
Max. removable appliance
○ Banded & bonded appliance with coil spring
● Reciprocal force applied
buccal to C-res
Moderate localized space discrepancy
Max. removable appliance
○ Banded & bonded appliance with coil spring
● Distal force & moment produces
rotation
Moderate localized space discrepancy
Max. removable appliance
○ Banded & bonded appliance with coil spring
○ Mesial rotation of
PM & Distal rotation of molar
Moderate localized space discrepancy
Max. removable appliance
○ Banded & bonded appliance with coil spring
■ Contralateral 1rst permanent molar
banded as well
Moderate localized space discrepancy
Max. removable appliance
○ Banded & bonded appliance with coil spring
● Mandibular arch →
Anchorage via anteriors with LLHA
Moderate localized space discrepancy
Max. removable appliance
○ Banded & bonded appliance with coil spring
● Maxillary arch →
Anchorage via nance button on palate
Moderate localized space discrepancy
- Space regaining for anterior & posterior space discrepancy
(<3mm)
Moderate localized space discrepancy
- Space regaining for anterior & posterior space discrepancy
○ Treatment with
Lower lingual holding appliance (LLHA)
Moderate localized space discrepancy
- Space regaining for anterior & posterior space discrepancy
Lower lingual holding appliance
■ Tips
molars distally & anteriors facially (~roughly equal distance)
Moderate localized space discrepancy
- Space regaining for anterior & posterior space discrepancy
Lower lingual holding appliance
● Inefficient way to
move teeth bc wire is heavy with little range of movement, but good way to gain space
Severe localized space discrepancy
( > 3mm per quadrant)
Severe localized space discrepancy
● Possible treatment options include:
palatal anchorage appliances, headgear, &/or extraction
Severe localized space discrepancy
● Palatal anchorage device (with coil springs)
○ Posteriors ⇒
distal bodily movement
■ Distal force on palatal side near level of Cres → more bodily movement
Severe localized space discrepancy
● Palatal anchorage device (with coil springs)
○ Maxillary incisors move
forward (make sure pt. profile not protrusive)
Severe localized space discrepancy
● Mini screw supported distalizing appliance
○ Provide true anchorage with
TADs - no maxillary anterior movement
Severe localized space discrepancy
● Mini screw supported distalizing appliance
○ No acrylic button →
reduced tissue tissue anchorage; better compliance
Space maintenance
● Used when space is adequate following tooth loss (or marginally adequate with extraction)
● Good prognosis
Factors to consider with space maintenance:
- Normal timing of eruption (when will permanent dentition begin erupting?)
○ Assessed by root development ⇒
active eruption begins when ½ - ⅔ root formation
Factors to consider with space maintenance:
- Effects of early & late primary tooth extraction
○ Early loss/extraction (before ½ root formation) ⇒
slows permanent tooth eruption
Factors to consider with space maintenance:
2. Effects of early & late primary tooth extraction
○ Late loss/extraction (after ½ root formation) ⇒
speeds up eruption
Factors to consider with space maintenance:
- Location of tooth loss in the arch
○ 1° anterior tooth loss ⇒
No space maintenance required
■ NO overall space loss (but some minor space redistribution)
Factors to consider with space maintenance:
3. Location of tooth loss in the arch
○ 1° posterior tooth loss ⇒
Space maintenance required
Factors to consider with space maintenance:
4. Eruption of anterior teeth
○ Anteriors erupt lingually, so
DONT use a lingual arch for space maintenance if primary anteriors are not lost yet. Erupting teeth will get caught in the wire
Factors to consider with space maintenance:
- Presence of succedaneous teeth (& supernumerary teeth)
○ Don’t need to
maintain space if no succedaneous tooth replacement
Factors to consider with space maintenance:
- Cause of
tooth loss (ie. is there an ectopic eruption causing root resorption & tooth loss)
Space Maintenance treatment options:
Band and loop
Distal shoe
Lingual arch type appliances
● Band & loop
○ Simple & 60% successful
Band and loop
○ Clinical management:
■ Separate, band, impression, stabilize, pour, loop form & position
● Loop contacts, but doesn’t encompass 1° canine → allows lateral canine movement when lateral incisor erupts
Band and loop
● Loop wide enough for
premolar eruption
Band and loop
● Poor oral hygiene will cause
decalcification of banded tooth (usually permanent 1rst molar - primary 2nd molar difficult to band bc convergent)
Band adn loop
■ Recall every
3-6 months
Band and loop
■ Potential problems if
lose abutment tooth or if loop becomes distorted downward into tissue
● Distal shoe
○ Indication ⇒
ONLY when primary 2nd molar lost before eruption of permanent 1rst molar
■ 65% successful
● Distal shoe
○ Clinical management:
■ Tooth banded & blade placed into tissue
1-1.5 mm below marginal ridge of unerupted 1rst permanent molar
● Distal shoe
○ Clinical management:
● Blade placement based on
radiographs (factoring magnification distortions), required distance measured
Distal shoe
● Prevents
mesial shift of erupting 1rst permanent molar & maintains space for succedaneous premolar
Distal shoe
■ Placement of device requires
gingival incision (if tooth extracted at the same time as delivery of device, use extraction space as site of blade insertion)
Distal shoe concerns;
■ Permanent molar may
erupt mesially into blade if position gauged incorrectly
Distal shoe concerns
■ ——— in patient with heart or vascular problems
Infectious endocarditis
● Lingual arch type appliances (55% successful)
○ Types:
■ Lower lingual holding appliance (LLHA)
■ Maxillary transpalatal arch (TPA)
■ Maxillary Lingual arch (MxLHA)
● Not used often
■ Nance appliance● Lingual arch type appliances (55% successful)
■ Maxillary transpalatal arch (TPA)
● Can be used when
one side of arch broken but the other is not?
● Lingual arch type appliances (55% successful)
■ Nance appliance
● Anchorage from
palate, but acrylic can cause palatal irritation
● Lingual arch type appliances (55% successful)
○ Fabrication:
■ Arch always made with
adjustment loops
● Lingual arch type appliances (55% successful)
Fabrication
■ Keyhole design →
allows incisor alignment, but steps away from premolar area to allow for eruption
● Lingual arch type appliances (55% successful)
○ Follow up every
3-6 months
● Lingual arch type appliances (55% successful)
○ Problems:
■ Don’t use lingual arch before
permanent incisors have erupted ⇒ arch will get caught on erupting teeth
Space management
● Used with
adequate space & irregularity
Space management
○ Transitional irregularity & crowding due to
incisor liability
Space management
● Ideal for managing
leeway space (up to 9 mm)
Space management
○ Leeway space (E-space) managed to
resolve crowding
Space management
○ E-space
(extra space of 2nd primary molar compared to succedaneous premolar)
Space management
● Potentially can manage up to
75% of crowded pts with resulting < 1mm crowding
Space management
○ Space management must continue until
transition complete & arch perimeter stable
○ Good prognosis
Space management
■ Very stable procedure bc
arch circumference not being changed
Space management
■ Note: when arches are expanded or changed, prognosis is not
known in the end
Space management treatment options (pt with adequate space with irregularity):
- No treatment
○ Allow for
normal transition to take place
Space management treatment options (pt with adequate space with irregularity):
No treatment
○ Results in
anterior crowding with Class I molar relationship
Space management treatment options (pt with adequate space with irregularity):
■ To treat later would require
expansion or extraction treatment
Space management treatment options (pt with adequate space with irregularity):
- Disking
○ Used with
minor irregularity
Space management treatment options (pt with adequate space with irregularity):
■ Normal dentition (with adequate space) usually has
1-2 mm of crowding during transition, so not worth doing in many cases
Space management treatment options (pt with adequate space with irregularity):
○ Must be
vertical reduction of teeth of primary teeth
Space management treatment options (pt with adequate space with irregularity):
■ Consider disking
mesial or distal of 1° canines & molars
Space management treatment options (pt with adequate space with irregularity):
■ Consider Fluoride varnish to reduce
sensitivity
Space management treatment options (pt with adequate space with irregularity):
○ Do NOT disk
permanent teeth in mixed dentition
Space management treatment options (pt with adequate space with irregularity):
■ Skews analysis if done before all
permanent teeth have erupted
Space management treatment options (pt with adequate space with irregularity):
- Holding arches
○ Construct with
ideal arch form (facilitates tooth alignment)
Space management treatment options (pt with adequate space with irregularity):
■ Soldered arches most reliable;
typically keyhole design used ○ Resolves faciolingual discrepancies ○ Limitations as a tooth mover: ■ No rotation ■ Difficult to move teeth with heavy wire (can be uncomfortable)
Space management treatment options (pt with adequate space with irregularity):
- Disking & holding arches
○ When more crowding needs to be resolved
○ Helps guidance and tooth position
Space management treatment options (pt with adequate space with irregularity):
- Holding arches with tooth movement
○ LLHA controls arch form & coordination
■ Can control arch length and move teeth (primarily via tipping)
Space management treatment options (pt with adequate space with irregularity):
■ NOTE: Flat anterior segment does
NOT resolve around an ideal arch form
Space management treatment options (pt with adequate space with irregularity):
○ LLHA can be used as
retainer
Space management treatment options (pt with adequate space with irregularity):
○ LLHA biomechanics may require
adjustment
Space management treatment options (pt with adequate space with irregularity):
■ Heavy tipping force, so needs to be
placed passively on teeth you want to move
Space management treatment options (pt with adequate space with irregularity):
- Holding arches & selective extraction of primary teeth
○ Necessary for
greater irregularity (but still adequate space)
● Expansion of lower canine
least stable
● Removable denture for missing 1° anteriors indicated for
esthetics (NOT space maintenance or speech)
○ Can be used for posterior space maintenance, but compliance a problem (Nance preferred)
● Class II occlusion with crowding extraction pattern:
○ Extract upper 4s & lower 5’s
● Minimal crowding doesn’t mean you
NEVER do extractions
● TADs cannot be used
< 12 y/o
● Space maintenance is NOT more stable than
space management or space regaining
Majority of crowding issues ass. with
Class I
● Maxillary irregularity/crowding
○ Ideal group (0-1 mm crowding) ⇒
worsens from preadolescence to adolescence
○ Hispanics > white > black
● Mandibular irregularity
○ Ideal group ⇒
worsens from pre-adolescence to adolescence to adult
○ Hispanic > white > black
Classification of Crowding based on:
● Facial form analysis (esp. lip protrusion - protrusive/retrusive/normal)
● Appropriate radiographs
● Space analysis - Tanaka Johnson prediction values
○ ½ M-D distance of mand. Incisors + 10.5 = width of mand. canine/PM in quadrant
○ ½ M-D distance of mand. Incisors + 11 = width of max. canine/PM in quadrant
Excess space
● Good for
transitional dentition, so usually NO treatment
Excess space
● Treated for
esthetic concerns or risk of trauma (with protrusive teeth)
Excess space
○ Intervention also required if
eruption problems or pathology (ie. cyst) exists
Excess space classification:
● Normal transition
(usually closes with canine eruption)
○ Oral habit → treating with oral habit appliance will correct. No other treatment needed
Excess space classification:
● Generalized spacing
○ Caused by
large arches or small teeth
Excess space classification:
● Generalized spacing with protrusion:
○ Fixed appliance
■ Bracket & tube;
2 point contact
■ Bodily movement with anchorage on molars
Excess space classification:
Generalized spacing with protrusion
○ Removable appliance with labial bow
■ One-point contact → tips uppers lingually
■ Anchorage to posterior attachment (& palate)
● Retention via adams clasp
■ < 6 month treatment
● Activated 2 mm for 1 mm movement per month
Midline diastema
● Diastemas reduce considerable from
preadolescence to adolescence (when canine erupt)
Midline diastema
● Occurs significantly more in
african american
Midline diastema
● Causes &/or associated problems:
○ Normal transition ○ Supernumerary teeth between centrals ○ Missing laterals ○ Frenums ■ Space closed first ■ Frenectomy performed after space closure if there will be a problem with retention ● Morphology of frenum poor indicator of problem ■ Idiopathic
Midline diastema
■ Frenectomy performed after
space closure if there will be a problem with retention
Midline diastema
● Morphology of frenum
poor indicator of problem
Midline diastema
● Treatment options:
○ Tipping with finger spring
○ Bodily movement with any archwire (round or rectangular) - reciprocal anchorage
Midline diastema
○ Tipping with finger spring
■ Reciprocal anchorage
■ Removable provides short term retention; long term with lingual bonded retainer
Midline diastema
○ Bodily movement with any archwire (round or rectangular) - reciprocal anchorage
■ Long term retention with lingual bonded retainer
