“Early Treatment for Missing & Impacted Teeth” …€œEarly Treatment for Missing & Impacted...
10
“Early Treatment for Missing & Impacted Teeth” “Diagnosis & Interceptive Management of Ectopic First Permanent Molars” Ronald A. Bell, DDS, MEd Diplomate, ABO Diplomate, ABPD Presentation available as E-handout @ AAO website Ectopic Eruption: Definition Developmental disturbance in the eruption patterns of any permanent teeth that results in atypical resorption of an adjacent tooth (either primary or permanent). Ectopic First Molars = When 1st molars are malpositioned and cause atypical resorption of adjacent 2nd primary molar. Ectopic Eruption of Maxillary First Molars Reported prevalence of 1 to 4 % 3 to 4% most likely Young: J Dent Child 24:153,1957 Kimmel et al: J Dent Child 49:294,1982 Ectopic Eruption of Mandibular First Permanent Molars Incidence: 0.2% - occurs 20 times more frequently in maxillary first molars than for mandibular first molars. Treatment approach will generally be the same as maxillary ! Ectopic Eruption: Maxillary 1 st Molars Reversible “Jump” type Irreversible “Hold” type Bjerklin & Kurol: Swed Dent J 5:29,1981 Young: J Dent Child 24:153,1957
Transcript of “Early Treatment for Missing & Impacted Teeth” …€œEarly Treatment for Missing & Impacted...
“Early Treatment for Missing & Impacted Teeth”!
“Diagnosis & Interceptive Management !of Ectopic First Permanent Molars”
Ronald A. Bell, DDS, MEd Diplomate, ABO Diplomate, ABPD
Presentation available as E-handout @ AAO website
ë
ë
Ectopic Eruption: Definition!
Developmental disturbance in the eruption patterns of!any permanent teeth that results in atypical resorption!of an adjacent tooth (either primary or permanent).!
í
í
ì
î ç ì
Ectopic First Molars = When 1st molars are malpositioned and cause atypical resorption of adjacent 2nd primary molar.!
Ectopic Eruption of Maxillary First Molars !
Reported prevalence of 1 to 4 %!! ! 3 to 4% most likely!
Young: J Dent Child 24:153,1957 Kimmel et al: J Dent Child 49:294,1982
Ectopic Eruption of Mandibular First Permanent Molars!
Incidence: 0.2% ! - occurs 20 times more frequently in maxillary first molars than for mandibular first molars.!
Treatment approach will generally be the same as maxillary !
Ectopic Eruption: Maxillary 1st Molars !
!
Reversible è “Jump” type Irreversible è “Hold” type
Bjerklin & Kurol: Swed Dent J 5:29,1981
Young: J Dent Child 24:153,1957
Reversible Type >> (“Jump Type”)!ü After resorbing the distal root surface of the second
primary molar, the permanent molar becomes free and erupts into a normal position (“self-corrects”).
Bjerklin & Kurol: Swed Dent J 5:29,1981
?
“Self-correction” ≈ 2/3rds of cases Occurs by age 7 yearsResorption usually stops once cleared!
Young: J Dent Child 24:153,1957
Ectopic 6 yr. molars > “Reversible”
Kurol & Bjerklin: J Dent Child 49:273,1982 Bjerklin & Kurol: AJO 84:147, 1983
Irreversible type >> “Hold Type”!ü Molar becomes blocked by 2nd primary molar and
remains in a “locked” position until treatment or premature exfoliation of the primary molar occurs.
Bjerklin & Kurol: Swed Dent J 5:29,1981
Ectopic 6 yr. molars > “Irreversible”
First molar remains locked under EResorption usually progresses!
Age 6y. 1m. Age 6y. 8m. >>>>>>>>
Bjerklin & Kurol: Swed Dent J 5:29,1981
!
> Blocked eruption of 6‘s.!!
> Resorption and early loss of 2nd primary molar!!
> Space Loss / Blockage of 2nd bicuspid!
Potential sequelae of irreversible ectopic maxillary first molars:!
Thurow, Atlas of Orthodontic Principles, C.V. Mosby: 1970
> Supra-eruption of lower 6
> Disruption of arch integrity & malalignment!
Potential sequelae of irreversible ectopic !maxillary first molars:!
Thurow, Atlas of Orthodontic Principles, C.V. Mosby: 1970
ECTOPIC MOLARS:Etiological Factors!
Ø Larger than normal teeth!Ø Small maxillary base!Ø Arch length inadequacy!Ø Retrusive maxilla!Ø Abnormal mesial eruption path of first molar!Ø Delayed calcification of first molar!Ø Cleft palate (up to ≈ 30% concurrance)!Ø Familial tendency (up to ≈ 20% in affected siblings)!Pulver: J Dent Child 35:138,1968 Bjerklin & Kurol (AJO 84:147,1983
Sequelae of ectopic maxillary 1st molars:!
About 1 in 5 with lower incisor ectopic eruption patterns will show ectopic eruption of the upper first permanent molar. Note resorption of lower canines, ectopic laterals.
O’Meara: J Dent Res 41:607, 1962
Ectopic Maxillary 1st Molars & “Crowding”:!• Premature loss of primary molars almost always results
in malocclusion with compromised arch circumference. • Early loss of maxillary second primary molar produces
greatest amount of space loss at the fastest rate when compared with other primary molars (Up to 8 mm. vs.
4.5 mm. in mandible with early loss of 2nd primary molar.) • Major indicator of inherent inadequate arch perimeter.
( i.e. - expect further crowding and malocclusion).
> About 1 in 5 with ectopic upper 1st molars show lower incisor ectopic eruption (O’Meara: J Dent Res 41:607, 1962)
> One-fourth of canine impaction patients had ectopic upper 1st molars (Becktor et al: Eur J Orthod 27:186,2005)
Step 1. EARLY RECOGNITION !PANORAMIC, PA’S or Adequate BWX 5 - 7 Y.O.!
TREATMENT OF ECTOPIC MOLARS!
ì ë
Pan BEST Option – Rx’d upon eruption of first permanent tooth
Step 1. EARLY RECOGNITION! PAN, PA’S or Adequate BWX 5 - 7 Y.O.!
TREATMENT OF ECTOPIC MOLARS!Step 1. EARLY RECOGNITION > 5 - 7 Y.O. PAN, PA’S or Adequate BWX (#2 size)!
TREATMENT OF ECTOPIC MOLARS!
# 1 BWX Too small
# 2 BWX More vertical exposure
Step 2. Consider Observation!! ! Six months later >>> worse than before!
TREATMENT OF ECTOPIC MOLARS!
Remember – 2/3rds “self-correct”; but not after age 7 years
Step 3: Interceptive Tx. èè TIMING!
Patient age!7 years of age or more!
!
Lower 6 eruption!At occlusal plane!
!
Upper E resorption!Before extensive loss!
!
Upper 6 position!Mesially inclined!Noted indicators negate
“watchful waiting” - Time to intercept !
Bjerklin & Kurol: AJO 84:147, 1983
ECTOPIC MOLARS: Treatment Objectives!ü Distalize ectopic molar into normal A-P position!ü Maintain arch integrity of buccal segment!ü Maintain favorable exfoliation sequence!ü Ensure vertically stable occlusion!ü Maintain overall arch dimensions!
Before &
After Tx.
ECTOPIC MOLARS :Treatment Variables!Ø Extent of blockage!Ø Degree of “E” resorption!Ø Access to 6 year molar!Ø Timing factors!Ø Arch-length status!Ø Cooperation!
Kennedy D, Turley P: AJODO 92(10):336,1987
INTERCEPTIVE “Options”!!
Ø Elastic separators!Ø Separating springs!Ø Brass wire!Ø SSC or band extension on 2nd molar!Ø Distalizing springs (Humphrey)!Ø Distal pull elastomerics (Halterman)!
TREATMENT OF ECTOPIC MOLARS! ELASTIC SEPARATORS!
First option IF separator can be engaged around contact overhang - pull floss through “under” contact & vertically. Can tie the floss across the occlusal with sep. under area.
One year recall Age 7y. 9m.
Diagnosis & Elastic Separator Tx. @ Age 6y. 10m.!
Replaced @ 3 week intervals (4 times)
Separating Elastics!Advantages: * Ease of placement * Cost of materials * No anesthesia required (?) * Do not interfere with eruption * Do not interfere with occlusion. !
Disadvantages: * Limited Application * Frequent Follow up
SEPARATING SPRINGS!
!
Combo
Separating Springs > >
Elastic > > Separators!
Start @ 2 weeks @ 4 weeks
@ 4 weeks Separator
@ 5 weeks
Separating Springs!Advantages: !ü “Ease” of placement.!ü Prefabricated.!ü Inexpensive. !Disadvantages:!ü Occlusal interference / occlusal clearance.!ü Anesthesia often required to place.!ü Limited Access = limited application.!ü “Somewhat” dangerous è dislodgement ???!
BRASS WIRE SEPARATION!
!
Use of a brass ligature wire looped and tightened around !the contact area of the ectopic eruption. !Replaced / tightened every week - progressively larger.
BRASS WIRE SEPARATION Pre-Tx! !Placement !6 weeks!
!
Brass Wire Ligature!q Difficult to place q Usually requires local anesthesia q Often requires multiple replacements q Breaks easily when attempting to tighten or it will
pull through the contact. q Relapses easily q Can hinder eruption
“In essence is vastly over-rated!!!”
Active Distalization Appliances!TREATMENT OF ECTOPIC MOLARS!
Springs > Push ! ! Elastomerics > Pull!
HUMPHREY APPLIANCE !
!
Pre-Tx.! Placement!Humphrey WP: J Dent Child 29:176,1962
HUMPHREY APPLIANCE Correction > 8 weeks!
!Placement
Corrected
Retained w/ band extension
HUMPHREY APPLIANCE Distalizing Springs!
!
Correction Time = six weeks
HUMPHREY APPLIANCE: Design!Ø Band E - E, connect
with TPB, .036 S.S.!Ø Distal oriented helical
loop of .025 S.S.!Ø Passive extends distal
to ectopic molar!Ø Activated to engage
composite ledge.!
Humphrey Appliance!The “original”
Humphrey WP: J Dent Child 29:176,1962 Modifications Braden: Dent Clin N Am 8:441,1964;
Bayardo et al: J Dent Child 46:214,1979; Garcia-Godoy: JADA 105:244,1982; Pulver & Croft: Pediatr Dent 5:140,1983; Harrison & Michal: Dent Clin N Am 28:57,1984; Kennedy: Pediatr Dent 7:224,1985; Groper: J Dent Child 52:374,1985; Rust & Carr: J Dent Child 52:55,1985; Kennedy & Turley: AJODO 92:336,1987
Humphrey Appliance helical springs engaged against bonded composite ledges provide distal forces to ectopic molars.! !
Ø Produce forward forces, need TPB anchor. !Ø Interfere with vertical eruption, need second stage of correction >>> band “extensions”.!
!
Humphrey Appliance!Advantages: !* Stability !* Quickness of correction !* Can correct severe locks of the first permanent molar!!
Disadvantages: !* Placement & activation of spring difficult !* Fabrication and cementation appointments are long! and require significant cooperation.!* Spring can distalize molar; but prevents vertical! eruption, may produce rotations & displacements of ! both permanent and primary molars.!
DISTALIZING ELASTOMERICS!
HALTERMAN APPLIANCE!
HALTERMAN APPLIANCE Stretching elastomeric chain from wire to occlusal
bonded button produces distalization force.!
!
Halterman CW: JADA 105:1031,1982
HALTERMAN APPLIANCE
Correction in 6 weeks with distal & vertical movement of molar.
Elastics disengaged,components left in place until molar
erupts & occludes with bonded button.!
!
HALTERMAN APPLIANCE!
2 weeks change with distal & vertical movement. !
Re-engaged chain to next loop >> need to clear by 2 mm.
HALTERMAN APPLIANCE!
!Correction in 4 weeks
Occlusion in 8 weeks - removed
ç Same Patient @ 6 months Post. Tx.
Halterman Appliance@ 3 weeks Tx. Time!
Case from Dr. David Kennedy
Halterman Appliance
Six weeks treatment!
Follow-up @ six months!Response @ three weeks
Case from Dr. David Kennedy
HALTERMAN APPLIANCE: DESIGN!ü Band E - E , connect w / TPB, 036 S.S.!ü Distally extend .036 wire from palatal side!ü Bond button on 6 as mesial as possible!ü Elastic chain (closed) from button to wire!
HALTERMAN PROTOCOL!Ø Place appilance & molar “button” w! with elastic chain in place!Ø Monitor at two week intervals!Ø Reengage elastic chain until !!distalized 2 to 3 mm. beyond “E“!
Ø Once cleared, discontinue elastic ! > leave appliance in > monitor!Ø Once molar button in occlusion, o.k. to remove!Ø If relapses, reactivate until cleared, retain with
band extension!
Halterman: !Pre > Tx 3 weeks > Post > 4 yr.!
Pre-treatment! Treatment
Post-treatment!@ six months
Post-treatment!@ four years
Case from Dr. David Kennedy
Halterman !!
Pre-Tx. 6 y. 9m. é!
Post. Tx. 7y. 5m. ê!
Post. Tx. 12y. 2m.è
Case from Dr. David Kennedy
Halterman Appliance!The “original”
Halterman CW: JADA 105:1031,1982
Modifications Kennedy & Turley: AJODO 96:336, 1987;
Kennedy: J SE Soc Pediatr Dent 3:18, 1997;
Bell & Leite: J Clin Pediatr Dent Care, 9:16, 2003;
Kennedy: Pediatr Dent 29:327, 2007
Kennedy: Pediatr Dent 30:63, 2008
Halterman Appliance!Advantages: !*Ease of basic appliance placement. !*Ease of fabrication design. !*Ease of activation. !*Minimal displacement of 2nd primary molar. *Rarely requires any anesthesia.!!
Disadvantages: *Bonding of occlusal button of first molar. !*Critical adaptation of distal extension wire. !*Difficulty in replacing power chain.!!
Ectopic Lower Molar > Halterman !!
Same basic tx. objectives, !timing of intervention, !and appliance options as !maxillary ectopic molars.
Pre-treatment
Treatment!Appliance
Treatment @ !three weeks
Lower Halterman!
Ø Only modification to Mx. Halterman appliance is to! place distal extension arms from buccal of second! primary molars - avoids tongue irritation.!Ø Can also incorporate lingual holding arch; but must! be careful of erupting lower incisors.!
Post-treatment!@ three years
Treatment!Appliance
ECTOPIC MOLARS: Summary Overview!Incidence 3 to 4 % in maxillary arch, rare in lower arch (0.2%).
Self-correction - 2/3rds of cases, resorption stops once “jumped”.
“Irreversible” - molars remain locked in resorption area of 2nd primary molar. Treat once lower first molar reaches occlusal plane height, age 7 years.
Intercept to guide 1st molar into normal position, retain primary molar & favorable eruption sequence, maintain arch length & a level occlusal plane.
Preferred Tx. Options
1. Elastic separators 2. Halterman Appliance
Ronald A. Bell, DDS, MEd
Medical University !of South Carolina!
Department of !Pediatric Dentistry !and Orthodontics
Diplomate!ABPD & ABO
