Children who have a single tooth that is not erupting comparably to the tooth on the opposite side (same arch) should be watched and reevaluated in (three- to six-month) increments to determine if interceptive treatment is needed.
There are many possible causes for the delay of the eruption. One of the most common is an earlier trauma to the region.
It is sometimes necessary to perform surgical exposure to gingival tissue that may be holding up the eruption process. Today these procedures are quite easy using laser technology to open a small window in the tissue that will allow the teeth to erupt.
In cases where the bone is holding up the eruption, it is best to have an oral surgeon remove the bone, leaving a window for the tooth to erupt through.
It is rare that these teeth are ankylosed, or have lost their eruption potential.
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In many cases, after teeth have been surgically exposed and still do not erupt on their own, a bonded button and some elastic force anchored to either a removable appliance or fixed brackets may be needed to facilitate the movement.
If no movement occurs after forces have been applied for a short period, the tooth may be ankylosed. This will require some form of luxation, which hopefully will free up the tooth and allow the eruption to occur.
Retained Primary Teeth
Retained primary teeth need to be extracted to allow for the eruption of the permanent successors. It is not exactly known why some primary teeth do not exfoliate, but in the event you see a primary tooth with no mobility and the successor stuck below it, you should extract the tooth to allow for normal eruption.
Diagnosis of supernumerary teeth is best made early, and treatment planning their extraction should begin as soon as an oral surgeon deems it appropriate. In many instances, the oral surgeon may elect to wait some time before removing them in order to prevent damaging adjacent teeth.
Set up a consult as soon as supernumerary teeth are discovered. If you are planning on moving teeth orthodontically, supernumerary teeth need to be removed prior to starting treatment. The most frequent place for supernumerary teeth to be present is in the maxilla.
Habits/Environment/ Speech Problems
Detection of poor habits and speech problems needs to be addressed as early as possible. In some instances, excessive environmental forces (for example, playing a musical instrument) can alter growth if forces are applied over long periods of time. The habits of children, both nocturnal and during the daytime, can alter tooth positions and skeletal development in some cases.
Practitioners should examine all children for signs of habits and their associated actions that may change the way an individual child grows. Children with airway obstruction, presenting with enlarged adenoids or tonsils, should be evaluated for surgical removal of these tissues. Find an ENT in your area who will help you diagnose and confirm possible airway obstruction and will take the measures necessary to perform the surgeries when needed.
In undiagnosed airway obstruction, jaws can grow narrow, due to the open mouth breathing positions. The muscles of the face constrict the jaws and can lead to a condition called Adenoid Facies and Narrow Face Syndrome.
If it is suspected that a child may have an obstructive airway, it is recommended that the patient see a specialist and have a sleep study. The dangers of obstructive sleep apnea are well documented in both children and adults. Dental practitioners may be the first line of defense in diagnosing these problems.
Symptoms children who have obstructive sleep apnea exhibit include restlessness, inability to do well in school, irritability, etc. For an excellent article on sleep apnea, go to www.appliancetherapy.com and download the Practice Building Bulletin on sleep apnea.
Speech Problems, Tongue Position, or Thrust Problems
Tongue position problems can cause dental anterior open bites, which if not treated early can lead to unfavorable skeletal growth. Normal speech development is virtually impossible if the tongue is not able to position properly against the palate and teeth.
Students of early treatment often debate whether the tongue thrust is truly a thrust or a position the tongue takes to create a seal needed for swallowing. Some patients have vertical growing skeletal patterns that can result in open bites.
Some children with airway problems who are forced to breathe through their mouths can also exhibit narrowing of arches, resulting in transverse discrepancies with open bites, affecting tongue position. Regardless, tongue thrust or tongue position problems are very important to diagnose and correct.
First, assess if there are any underlying speech problems. If so, refer the patient for therapy right away. Attempting to correct a speech problem later in life results in poorer prognoses.
Then ask the patient to swallow as you gently force the lips open with a gloved finger to see if the tongue is pushing forward. It instantly becomes obvious that the tongue is filling the space, and now a diagnosis needs to be made to determine if this is a simple tongue thrust or a more complex problem involving the airway or vertical skeletal growth.
Even when the patient is not swallowing (posing for a picture), the tongue decides to rest in this position maintaining the open bite. Tongue appliances can be both fixed and removable. Fixed appliances use two bands cemented on either the permanent first molars or the primary second molars.
Some practitioners use removable appliances for tongue problems, but to work, the appliance needs to be worn all the time, even when eating. Children adapt quickly to speaking normally and are instructed to place their tongues up against the anterior hard palate when swallowing.
After approximately six to eight months, remove the appliance and evaluate whether the problem has been resolved. When using a fixed tongue crib, it will usually work within this time frame.
Because habits can be difficult to correct, it is necessary to evaluate the patient within three months after the appliance therapy ceases, in order to make sure that the habit is actually broken and the open bite does not return. If the problem does return, replace the appliance for another four months, and reevaluate.
Another appliance that is used to aid in training the tongue from moving forward is the transpalatal spinner. The patient is informed that every time they swallow, they are to reach back with the tip of the tongue upon swallowing.
In order for this appliance to work, it needs to be worn all day and night except when eating.
Digit and Other Habits
Digit (finger) habits can include sucking, nail biting, and other habits including pen/pencil biting. They are also best solved by using fixed bonded appliances.
Leave the appliance in for approximately six months, and then remove it and evaluate if the child is continuing to place digits in his or her mouth.
With digit habits, the bonded appliance alters the way the digit feels when inserted in the mouth. The bluegrass roller is an excellent appliance for eliminating digit habits. After successfully wearing a tongue or digit habit appliance and eliminating the tooth moving forces created by the digit, the natural forces from the muscles in the cheeks and lips will correct the protrusion in most cases.
Diagnosis Early Interceptive Orthodontic Problems - Part 1
Michael Florman, DDS / Rob Veis, DDS / Mark M. Alarabi, DDS, CECSMO / Mahtab Partovi, DDS
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