Ortho Flashcards
Define extra-oral traction
Extra-oral traction is a means of using forces transmitted via safety release spring pull mechanism from an area of the head or neck to move teeth
What are the 3 basic types of retraction headgear?
- Low (cervical) pull / neckstrap
- Straight (combination) pull / headcap
- High pull / headcap
What are the uses of extra-oral traction in Class II cases (3 things)?
- Anchorage reinforcement
- Distal movement of upper buccal segments (molar distalisation)
- Distal movement of upper arch
What form of extra-oral traction is used in Class III cases?
Reverse headgear (protraction facemask)
What form of extra-oral traction is used in Class II cases?
Retraction headgear
What are the components of an extra-oral appliance?
- Extra-oral unit (provides the anchorage for the extra-oral force on a form of headcap, neckpad/strap or chin cup or a facemask)
- Force delivery system (spring-loaded device or heavy-force extra-oral elastic)
- Intermediate/connecting component (transmits the force to the teeth and underlying skeleton and connects the extra-oral and intra-oral components)
- Intra-oral component (the only headgear appliance that has no intra-oral component is the chin-cup appliance)
How does low-pull traction work?
- Mainly for the correction of low angle Class II malocclusion by restraining the forward growth of the maxilla
- Believed to have a reciprocal effect on the mandible as well as extrusion of maxillary molars
- This latter effect results in a clockwise mandibular rotation, thus cervical headgear is indicated mainly for growing children with a deep OB
How does high-pull traction work?
- Produces forces that pass apically through the centre of resistance of the maxillary teeth producing intrusive forces to the molars, which can therefore help the correction of an AOB
- Orthopaedic effects on the maxilla by restraining its vertical growth
How does facemask therapy work?
- Correction of a Class III malocclusion through forward movement of the maxilla
- In addition to skeletal changes, reverse headgear can result in dental compensation to assist with the correction of a reverse OJ or Class III malocclusion
How to fit a patient with retraction headgear
- Select correct facebow size (inner bow - 1.13 mm, outer bow - 1.45 mm for maximum rigidity)
- Facebow set parallel to the occlusal plane with slight expansion
How to fit a patient with protraction headgear
Cams adjusted using the Allen key until they are 15 degrees below the occlusal plane
How is the patient’s use of the headgear monitored? (4 things)
- Ask the pt/parent about compliance, using compliance charts
- Assess the ability of the pt to insert/remove the appliance
- Check for physical signs of wear and tear
- Identify positive tooth movement in comparison with pre-treatment study models/cephalometry and detecting molar mobility
List the potential iatrogenic effects of headgear (5 things)
- Pain due to heavy force levels
- Increased risk of root resorption
- Trauma to the face and eye
- Nickel allergy (contact dermatitis - type IV delayed hypersensitivity)
- Latex allergy
What safety mechanisms are in place in retraction headgear to reduce the risk of ocular injury? (3 things)
- Safety release mechanisms where the headgear is designed to ‘break away’ when excessive force is applied
- Safety facebows e.g. locking mechanisms and recurved reverse entry inner bows
- Additional safety mechanics e.g. blunt ends, locating elastics
What advice is given to the pt/parent for headgear use? (4 points)
- Avoid wearing whilst playing sports
- Stop the use of the headgear and contact the orthodontist immediately if the headgear becomes detached during sleep
- Any ocular injuries occurring as a result of the headgear should be treated as a medical emergency
- Patients to bring headgear to each appointment and report any problem to their orthodontist
What is a functional appliance?
• A removable or fixed appliance that uses the forces of the muscles of mastication, fascia and the periodontium to alter skeletal and dental relationships
- Designed mainly to correct Class II malocclusion
How does a functional appliance work? (5 points)
- They all work by posturing the lower jaw forward, the stretched musculature and soft tissues creating a force, which is transmitted to the dentition
- Much of the effect is dentoalveolar (tipping maxillary teeth distally, mandibular teeth mesially)
- The soft tissue environment is changed
- A new occlusal relationship is established and the OJ is reduced
- Creation of an inter-maxillary force
List some removable functional appliances (6)
- Andresen activator
- Teuscher appliance
- Bionator
- Bass or Dynamax
- Function regulators
- Twin Block
What is the most well-known and popular fixed functional appliance?
Herbst appliance
What is the advantage of the Bionator over the original Andresen activator?
Reduced bulk of the appliance making it easier to wear
What is special about the design of a function regulator?
- Deliberately designed to have minimal tooth contact
- Buccal shields and anterior lip pads incorporated to relieve cheek and lip pressure and disrupt any abnormal perioral muscular activity
Why is the Twin Block so popular?
- Robust and well-tolerated
- Can be worn all the time (including whilst eating)
Describe the design of the Twin Block appliance
- Upper and lower removable appliances (cribs on 4s and 6s, labial bow - optional)
- Incisor capping (for retention)
- Bite blocks composed of bite ramps set at about 70 degrees
- When occluding, the lower block bites in front of the upper to posture the mandible forwards
Describe the design of the Herbst appliance
Consists of separate superstructures cemented to the mandibular and maxillary dentition, and constructed from either ortho bands or Co-Cr cap splints connected by telescopic pistons that provide the protrusive force to the mandible
What is the effect of functional appliances on the growth of the jaws?
Short-term influence ONLY (favourable growth changes eventually lost)
What is the ideal timing of treatment with a functional appliance?
- When the child is entering their adolescent growth spurt
- Male: 14 yrs (+/- 2)
- Female: 12 yrs (+/- 2)
- This is typically in the late mixed/early permanent dentition
What are the indications for earlier referral for functional appliance therapy and what does the pt/parent need to understand as a consequence of this?
- Bullying (psychosocial impact)
- Increased risk of dentoalveolar trauma
- Extended period of retention will be required to allow the permanent dentition to establish itself before fixed appliance therapy (therefore, overall treatment time is longer)
How is the patient’s use of the functional appliance monitored? (5 things)
- Measure the OJ (reduction over time)
- Monitor the buccal segment relationship (Class II –> Class I or even Class III)
- Speech adapted back to normal
- Evidence of general wear and tear
- Lateral open bite produced within a few weeks full-time wear with a Twin Block
What are the indications that a functional appliance is not being worn by the pt? (3 things)
- No reduction in OJ or correction of buccal segment relationship
- No improvement in speech
- Repeated breakages as the appliance is being removed too frequently
Why is a second phase of treatment with fixed appliances required post functional appliance? (2 things)
- Relieve crowding
- Consolidation and detailing of the corrected occlusion
What are some of the limitations of functional appliances? (4 things)
- Major issue = compliance (removable)
- Fixed functional appliances: more prone to breakage, more expensive
- Increases LFH (not ideal for use in pts with increased LFH - e.g. reduced OB, AOB)
- Dentoalveolar effects (proclining lower incisors is inherently unstable)
Which functional appliances may be used to treat Class III pts?
- Reverse twin block
- Frankel III
What is meant by environmental influences on occlusion?
• Environmental influence is a loose term used to describe a cause of malocclusion which is neither pathological nor genetic in origin
- It encompasses the influence of diet, behaviour and habits
What is meant by the zone of soft tissue balance?
• The soft tissue environment is thought to produce an equilibrium in which the various opposing forces are balanced to produce zero resultant force
What are the 4 forces as classified by Proffit acting on the teeth?
- Intrinsic (from the tongue and lips)
- Extrinsic (e.g. digit sucking habits and ortho appliances)
- Forces from dental occlusion
- Forces from the periodontal membrane
What is tooth movement dependent on?
- Level of force
- Duration of force
- Direction of force
- Crown:root ratio
- Root SA
Which is more influential in the aetiology of malocclusion?
- Force magnitude
- Force duration
Force duration
How much does the lower lip usually cover the upper incisors?
3-6 mm
What can be a potential consequence of a large tongue on the lower incisors?
Proclination
What is the relationship between biting force and vertical face height?
- Individuals with a short vertical face height have greater biting forces than long-faced individuals
- Occlusal force is a RESULT of vertical facial form, not a cause
What abnormal lip activity may Class II div 2 patients present with?
- Thin, strap-like, hypertonic lips
- High lower lip line
What is the primary determinant of the posture of the jaws and tongue?
Respiratory needs
What effect does mouth breathing have on the head, jaws and tongue?
- Head tips back
- Lowering of the mandible
- Lowering of the tongue
Hence, increased LFH
List possible causes of chronic nasal obstruction
- Enlarged adenoids
- Common cold
What abnormal lip activity may be seen in Class II div 1 patients?
- Lower lip trap
- Short upper lip (–> lip incompetence)
What role do soft tissues play in Class III patients?
Forces from the tongue, lips and cheeks promote formation of an anterior oral seal for swallowing and in so doing encourage dentoalveolar compensation by retroclining the LLS (soft tissues improve the malocclusion)
Which ethnic group is bimaxillary proclination commonly seen in?
Afro-Caribbean patients
Describe the lip form in patients with bimaxillary proclination
Full, flaccid, everted, hypotonic
What is the effect of soft tissue scarring post surgical repair of cleft lip/palate?
- Facial growth is inhibited
- Anterior and vertical growth of the maxilla is inhibited –> retrusive maxilla with a reverse OJ, narrow maxillary arch, associated crossbites and compensatory increased vertical mandibular growth
What is the role of the periodontal membrane in maintaining tooth position?
Forces within the periodontal membrane offset the imbalance in forces between the lips, cheek and tongue during function
What is the force duration threshold in humans?
6 hours
How do masticatory forces influence the jaws?
a) Shape/morphology
b) Bone density
c) Both
b) Bone density
Do digit-sucking habits during the primary dentition years have any long-term effect?
No
What are the effects of a prolonged digit-sucking habit persisting into the mixed dentition stage?
- Proclined upper incisors
- Retroclined lower incisors
- Reduced OB (or AOB - usually asymmetric)
- Unilateral posterior crossbite with displacement
- Narrowing of the upper arch (V shape)
How do patients with incompetent lips create an anterior oral seal?
- Increased mentalis activity (dimpling of chin visible)
- Posturing mandible forwards
- Tongue is placed between the anterior teeth (adaptive tongue thrust)
- Lower lip to palate
What is the malocclusion most often associated with mouth breathing called?
“Skeletal open bite” or “long face syndrome”
What are the landmarks for measuring upper lip length?
Subnasale to end of upper lip
What is the typical length of the upper lip?
20-22 mm
During smiling, how much clinical crown height should be visible?
Males - full crown height
Females - full crown height + 1-2 mm attached gingiva
Where should the lips be in relation to Ricketts E line?
On or just ahead of it