Diastema

Definition
Aspacebetweenadjacentteeth
Etiology
Normaldevelopment
Geneticfactors
Toothsizediscrepancies
Racialfactors/characteristics
Inferiorlydisplacedlabialfrenum
Pathologicconditions
Orthodontictreatment
Otherfactors
NormalDevelopment
Primarydentition
o Generalizedanteriorspacing
Maxillaryprimaryteethare23mmsmallerthantheirpermanentsuccessors
o PrimateSpaces
Spacesnormallypresentintheprimarydentition
70%prevalence
NDBquestion:Wherearetheprimatespaces?
Mesialtoprimarymaxillarycanines
Distaltoprimarymandibularcanines
Mixeddentition
o UglyDucklingStage
Frequentparentalconcern
Commoninchildren913y/o
EruptionofLItipsCIcrownsawayfromeachother
Thisspaceusuallyselfcorrectsasthecanineserupt
GeneticFactors
Localized
o SmallPeglaterals
LIthatareundersizedand/orabnormallyshaped
o Congenitallymissing/impactedteeth
LIthataremissing
2ndmostcommonlymissingteeth(after3M)
Spacesappearbetweenanteriorteeth,oftenwithamidlineshift
Mandibular2PM
3rdmostcommonmissing
Impactedpermanentcanine
Posteriorand/oranteriorteethmaydrift diastema
Trytoteelthepermcanineinbuccalvestibuleby9y/o cantfind
getpano ifoverlapping1 canine EXT
Generalized
o Microdontia
Syndromes
o Normalsizedteethinalargearch
o Boltontoothsizediscrepancies
Affectsapprox5%ofpopulation
o Iatrogenicdiscrepancy

Resultsfromvariousorthoextractionpatterns
Todeterminifdescrapancyexists
o DoBoltonanalysis
o Diagnosticwaxup

RacialFactors/Characteristics
IncisorDiastemaprevalence
o AA>Asian>White
o Relatestoraciallynormativeskeletalpatterns(NHANES)data
InferiorlyDisplacedLabialFrenu
Labialfrenumisattachedtoincisivepapillaatbirth migratesapically
Ifmigrationdoesnotoccur
o Thickfibersremainthroughtoincisivepapilla
o NotchingmaybeseenonPA
o Blanchtest(notdiagnostic)
EmbryologicFactors
Clefts
o Imperfectfusionofpremaxillaatmidline
o Mayresultinfailureofdevelopmentof1ormoreincisors
o Adiastemaiscommonamongthesepatients
PathologicConditions
Severecaries
Periodx
o Reducedalveolarbonesupport
Cysts
DiastemasAssociatedw/OrthoTreatment
Teetharetippedintoanextractionspace
o Rootswilleventuallyneedtobeuprighted
Ifnot,spacewillopenupafterbracesareremoved
RapidPalatalExpanders
o Separationofthemidpalatalsuturewillcreateatemporarydiastema
o Spacewillspontaneouslyclose
Distalizingappliances
o DistalizingmaxMcreatesspace PMdriftdistally Anteriordiastemataappear
OtherFactors
Rotatedteeth
o Causespacinginadjacentsites
Supernumeraryteeth
o Mesiodensmaycausespacingand/orimpededCIeruption
Habits
o Disruptequilibriumoftheteeth
o Mayproduceananterioropenbitew/generalizedspacinginmaxillaryanteriorteeth
TongueSize/Posture
o Pushesagainstlingualsurfacesofteeth
o Shiftsequilibriumofteethbuccally
o Generalizedspacingoccurs
Diagnosis
FormationofProblemList

o
o
o
o
o
o

Isspacinglocalizedorgeneralized
Counttheteeth(eruptedandunerupted)
Isdentaldevelopmentnormalorabnormal
Boltonsanalysis:measuretoothsizes/archperimeterandcomparew/Boltnsratios
Checkforlowfrenumattachment
Ispatientundergoingorthotreatment?

TreatmentConsiderations
Small(<2mm)diastemapresentinthemixeddentition)
o DoNOTclose
o Willspontaneouslyclose(usually)whenpermanentcanineserupt
o Ifclosedorthodontically,rootsofLIcanimpedeeruptionpathofCorLIrootswill
resorb
Diastemaassociatedw/supernumeraryteeth,cysts,etc
o DoNOTcloseuntiltooth/pathologyremoved
Inferiorlydisplacedlabialfrunum
o Closediastemabeforeexicisionofthefrenum
Why?
Frenectomyresultsinscartissueformation Inhibitsabilitytoclose
spaceandretain
Imperfectfusionatthemidline
o Dentoalveolargraftusuallyplacedduringearlymixeddentition
o Spacescanthenbeclosed
o Ifspaceclosurenotpossible,teethadjacenttothespacearepreparedasabutments
forrestoration
o Implantsarenotappropriateforcleftareas
MissingLI
o TXoptions
Create/maintainspaceforimplants
Lateralizecanines(aka:caninesubstitution)
Needtoaddressshape,color,andgingivalarchitecture
o Determinetheocclusionyouwantandworkwithorthotoachievethatocclusion
PegLaterals
o Evaluatetheroot
Inadequate
EXT lateralizecaninesorplaceimplants
Adequate
Closediastemaw/compositebuildups,veneers,orfullcoverage
crowns
Microdontia/GeneralizedSpacing
o Spacesdifficulttocloseandretain
o Usuallyrequiresinterdisciplinarycare
o Orthodontisalignsteethanddentistrestoresthemtopropersize
ToothSizeDiscrepancies
o Determinewherediscrepancyexists(ie:archw/excessiveperimeter)
Notsevere selectiveinterproxreduction closespaces
Mayalsoplacerestorationsinopposingarch
DiastemaClosureTreatmentConsiderations
Removable
DiastemaType
Small,localized
MovementType
Tipping
Root
Onlyw/wellalignedroots

Fixed
Generalized/large
Bodily
Aligns/maintainsroots

Considerations
Retention
RemovableorFixedRetainer
o Removable
Complaincedriven
o Fixed
Morepermanent,butdifficulttoclean
OcclusalEquilibration
o Prematurecontactsbetweenupperandlowerincisorsgeneratesocclusalforcesthat
maycausethereopeningofspaces

TreatmentofSkeletalClassIIMalocclusion
FacialFeaturesofClassII
Convexprofileasaresultof
o Mandibularretrognathism(mostcommon)
o Maxillaryprognathism(occasionally)
o Combination
SundayBite
o Definition:posturingmandibleforwardtomasktheskeletalanddentalmalocclusion
o BesuretomanipulatethemandibleintoCRduringevaluationoftheprofileand
skeletalrelationship
LipEntrapment
o Lowerlipiscaughtinupperincisors
MentalisStrain
HabitualMouthBreathing
Dueto
o Chronicallergies
o Chronicairwayinfections
o Enlargedadenoids
Breathingthroughmouth changespostureofhead,jaw,andtongue alteredequilibriumof
pressuresonthejawandteeth affectsjawgrowthandtoothposition
Posturalchangesseen
o Loweredmandible
o Loweredtongue
o Headtiltedback
Skeletal/dentalchangesseen
o Faceheightincreased
o Posteriorteethsupraerupting
o Mandiblerotatesdownandback
o Openanteriorbite
o Increasedoverjet
o Narrowingofmaxilla crossbite
Increasedpressurefromstretchedcheeks
Lowtonguepostures
DentalFeatures
o AlmostallclassIIskeletalptshaveClassIImolarrelationship
ClassIIFurtherDivisions
Div1
Div2
MaxCI
Proclined
Retroclined
MandibularPlane
High/Stee
Low

Angle
p
Faceheight
Long
Short
Other
Deepbitecommon
WhydoSkeletalClassIIneedtobetreated?
Theyworsenovertimeifnottreated
Goodtotreatduringgrowthofchild
BenefitsofOrthoTreatment
Lessdiscriminationduetofacialappearance
Fewerproblemswithoralfunction
o Mastication
o Speech
Lesssusceptibleto
o Trauma
o Periodz
Betterairway
WhendoSkeletalClassIIneedtobetreated?
Phasing
o 1stphase(aka:earlytreatment)
Maybebeneficialforsomepts
Occursinlatemixeddentitionw/eruptionofpermanent1M
o 2ndPhase(aka:fulltreatment)
Eruptionofallpermanentdentition
Orthopedic(ie:nonsurgical)Correction
o Canonlybeattemptedinagrowingpatient(youonlyget1chance) treatbeforethe
majorityofgrowthiscomplete
Priortopeakheightvelocity
Females=12
Males=14
MixedDentitionSignsofClassIISkeleton
DistalStepinPrimary2M
o Relationshipoftheperm1Maredeterminedbyprimary2M
o Withgrowththereisusuallycusptransitioninthemolarrelationshipatthetimethe
primary2Marelost
o Adistalstepwithgoodgrowthandshiftofthemolarswillatbestfinishasendonclass
II,butisunlikelytofinishasClassI
TreatmentOptionsforClassIITreatment(SkeletalCorrection)
Orthopedic
o Goal
Improveskeletalrelationshipbtmaxandmandthroughdifferentialgrowth
MaxgrowthrestrictedAP mandiblecatchesupw/normal
mandibulargrowthduringadolescence
o Types
HeadGear
Restrainsmaxgrowthtoallowmandibletocatchup
Noeffectonmandteeth
o Canbegoodorbad
Distalizesmaxdentition
Unesthetic/somewhatuncomforatable( complianceissues)butstill
widelyused

Types
o

CervicalPull
Usedforshortornormalfaceheightsduetolower
MPA
o Combo
Usedforaveragefaceheight
o Highpull
UsedforlongfaceheightduetohighMPA
Functionalappliances(ie:Herbst)
Forcespatientstopositionthemandibleforwardtoenhance
growth
Herbstiscementedintoplace nocomplianceissues
o Activator,frankel,andtwinblockareremovable

Orthodontic
o Involvestheremovalof2maxillarybicuspids ClassIImolarrelationshipatendoftx
o Isdentalmaskingofaskeletalproblem doesNOTcorrectskeleton canonlydo
w/relativelyacceptableprofiles
o Usuallydonewhenlittleornogrowthremains Commonadulttreatment
o Bestindicatedwith
Maxillaryprotrustion
Excessiveoverjet
Excessivemaxillarycrowdingw/minimalmandibularcrowding
Surgical
o Mandibularadvancement
o Slidinggenioplasty
o Maxillarysetback
o Maxillaryimpaction
o Combination
o Extractionosteogenesis

WhichTXoption?
Dependsonlotsofthings
IncidenceofMaloclusion
Normal 30%
ClassI
54%
ClassII 15%
Class
1%
III
Summary
ClassIIptspresenta3Dskeletalproblem(vertical,AP,andtransverse)
Treatmentoptions
o Orthopedic
Headgear
Functional
o Orthodontic
CamouflageviaEXT
o Surgical

DiagnosisandTreatmentofCrossbites
ClassificationsofCrossbites

Alwaysdefinedbytherelationshipofthemaxillaryteethtothemandibularteeth
Types
o Anteriorvsposterior
Posterior
BilateralLingualCrossbite
o Nomandibularshift
o Midlinesgenerallycoincident
o Lookforconstrictedmaxillaorexpandedmandibularteeth
Unilateral
o Muchlessprevalentthanfunctionalcrossbiteduetoshift(ie:
rare)
o Midlinesareon
o Causesusuallyunilateraldentoalveolarconstriction
AnteriorCrossbite
TypicallyanAPproblem
o Skeletalordental
o Unilateralorbilateral
BuccalCrossbite(aka:BrodieBiteorScissorBite)
o Bilateral
Theentirearchtelescopesoutandoverthe
mandibulararch
PtisusuallyclassIIdeepbite
o Unilateral
Unilateralmaxillaryexpansionw/orw/o
mandibularconstriction
Supraeruptionofmaxillaryteeth vertical
maxillaryexcess
o Dentalvsskeletal
Dental=malpositionofteeth(singleormultiple)duetoectopiceruptionor
crowdingoutofarch
Skeletal=transverseand/orsagittaldiscrepancies
o Relativevsreal
Relative:ClassIIptdoesnotnormallyhavecrossbite,butwhenplacing
molarsinClassIposition,acrossbitedevelops
o FunctionalvsPseudo
Functional=alteredpostureofthemandiblefromCRcausedbyocclusal
interferencesormildmaxillaryconstrictionwhichcausesthepatienttoslidein
onedirectiontointercuspateoravoidinterferences
Isthemostcommoncrossbiteinchildren
o #1causeis1 canines
CanalsobecausedviamaxFcuspsduetomildmaxillaryconstriction
InCR midlinescoincidentandOJisnominal
InCO midlinesoffandptdisplayssometypeofcrossbite(aka:
pseudocrossbite)
Considerations
Doesthischildhaveocclusalinterferences?
o ManipulatechildintoCRandwatchforshiftintoMI
o Yes equilibrateocclusion
DoesthischildhaveClassImolarocclusionandnormalskeletal
growthbuttheappearanceofmildmaxillaryconstriction?
o MayneedRPE
Earlytreatmentiswarrantedtoavoiddevelopmentofskeletal
asymmetry
Growthisaffectedbilaterally

Condylaranddentoalveolarremodelingmayoccur

AdvantagesofTreatingCrossbites
Improvesocclusion
AllowsfornormalTMJfunction
Esthetciandpsychologicalimprovement
Allowsfornormaleruption
Maypreventdevelopmentofamajorskeletalmalocclusion
TreatmentOptionsforCrossbites
SimpleCrossbite limitedtx
o Needtohave
SufficientspaceMD
Sufficientoverbitetoretaintooth
Rootinnormalposition
Normalcuspid/molarocclusion
o Ifabovearenotmetorpthasskeletalmalocclusion needmorecomprehensivetx
o Options
Full/limitedorthotx
Crossbiteelastics/biteraisers
Hawleyretainerw/fingerspring/biteplate
Usedforcorrectionof12teeth
Maybeusedasaretainer
Anteriorinclinedbiteplate
Idealforinterlockedincisors
Shouldengagetoothat45 angle
Cementedw/temporarycementforeasyremoval
Closemonitoringneedtoevaluatesupraeruptionoftheposterior
dentition
Tonguebladetherapy
Notusedmuchanymore
Requirescompliance,parentalencouragementandguidance
Teethmustbeininitialstageoferuptionw/minimalinterlocing
Place10mins/hour rapidresults(daysweeks)
o NeedtocorrectanteriorsingletoothcrossbitesASAP
PosteriorCrossbite
o Usepalatalexpansion
Mustbedoneearly(beforeage1518)bcbonyinterdigitationsform
o RPE
1 accomplishedw/toothborneappliances
Periodof16weeksofactivation
1turn/day(ormore)
0.25mmperturn
Attemptstominimizedtoothmovementwhilemaximizingskeletal
displacement
Typicallylose2533%oftotalexpansiontorelapse
Importanttoretainfor35monthstoallowsuturetoreorganizeand
formnewbone
Typesofappliances
Hyrax(aka:hygienic)
o Toothborne
Haas
o Providesmorepalatalsupportduringexpansion/retention
o Tissueandtoothborn

o Lesshygienic
Bonded
o Biteplaneeffect
o Mixeddentition
o 1 extracteduponremoval
TemporaryDiastemaformation
Isapositivesignthatsutureformationhasoccurred
Usuallyclosesspontaneouslyin12weeks
Ftippingofteeth
Biteopening
Excessivedentalexpansion(vsskeletal)cancausefenestrationof
PMandMrootsthroughtheFcorticalbone

SkeletalClassIIIMalocclusions
TreatmentoptionforGrowingPt
Attempttotxw/expanderand/orfacemaskinprepubertalyears hopethatcorrectionwill
bemaintained
o Protractionfacemask
Orthopedicappliancewhichexertsdownwardandforwardforcetomaxilla
usingchinandforeheadforanchorage
8oz1lbpressureperside
UsuallypreceededbyRPEtoloosensutures promotemaxillary
protraction
Acceptthatskeletalgrowthpatternispredetermined waitforgrowthtostop txw/
orthodontic/orthognathicsurgicalapproach
AdvantagesofTreatingEarly
Helpalleviatepsychologicaltrauma
Eliminateionofanteriorcrossbitesmaypreventabherrantskeletalgrowthpatterns
Prognosisfororthopediccorrectionworsenspostpuberty,sotreatbeforepuberty(butNOTin
primarydentition)
o Someptswhoaretxearlywilloutgrowtheirtxandwillrequiresurgerylateron
TreatmentoptionforAdultsorNonGrowingPts
Dentaland/ormildskeletalclassIII
o ClassIIIelastics
o Lowerincisorextraction
SkeletalCorrection
o Maxillaryadvancementormandibularsetback
o Maxillarydowngraftandtransversesurgicalexpansion(SurgicalAssistedRPE)
Orthopedicexpansioninnongrowingpt
Indicatedwhenmorethan10mmexpansionisneeded
MidlineosteotomyandLeFortI(minusdownfracture)
o Justuseretainerw/oexpander
o Adultusuallyrequiresurgery

SpaceManagementIntheTreatmentofPreadolescentChildren

FunctionofPrimaryTeeth
Mastication
Esthetics
Spacemaintenance
CausedofPrematureSpaceLoss
Caries
o Mostcommoncause
Trauma
o Maxincisorsmostcommon
Ectopiceruption
o Maxillary1Mmostcommon
Resorbsdistalof1 2M earlyloss
Ankylosis(leadingtoEXT)
o Fusionofbonetotooth
o LackofPDLonradiograph
o Clinicalpresentation
Toothappearstobesubmerging
Metallicsoundtopercussion
o Morecommonwhensuccedaneousteetharemissing
o Tx=EXTofankylosedtooth spacemaintenance
Congenitallymissingteeth
o Mostcommonnotincluding3M
MaxLI>Mand2PM
o TXoptions
Maintain1 teeth
Replacemissingteeth
EXT spaceclosure(viadriftingorothodontics)
RoleofRadiographs
DetermineDentalage
IDsequenceoferuption
Determineamountofbonecoveringuneruptedteeth
IDcongenitalabsenceofpermanentteeth
SpaceMaintenance
Indications
o Preventmesialmovementofposteriorteeth(espperm1M)
o Preventlingualmovementofincisors(espmandincisors)
Contraindications
o Wheneruptionofpermteethareeminentandspacemaintainerwouldimpeded
eruption
o Grosscrowding EXTinstead
o Permteetharecongenitallymissingandspaceclosureisdesired
Attributes
o MaintainMDdimensions
o DoNOTinterferew/eruption
o DoNotinterferew/occlusion
o Simpleindesign
o Easytoclean/maintain
TypesofSpaceMaintainers
Fixed
o Unilateral

BandandLoop
Bandprimary2Morperm1M
Indications
o Maintainsspaceofprematurelost1 molar
o Wireloophaslimitedstrength onlyholds1tooth
Contraindications
o Permanentincisorsareerupted LLAisindicated
o Morethan1toothlostw/opermincisoreruption RPD
CrownandLoop
Sameindications/contraindicationsasbandandloop
IndicatediftoothneedsSSC
DistalShoe
Intraalveolarbladeextends1mmbelowMMRoferuptingtooth
Indications
o Whenprimary2Mislostbeforeeruptionofperm1M
o PlaceverysoonafterEXTofprimary2M
o Onlyforreplacementof1Mperside
TranspalatalArch
Design
o Runsacrossthevault doesNOTtouchthesofttissue
Indications
o When1sideofarchisintactandseveral1 teethare
missingontheotherside
Contraindications
o Notforbilateralspacemaintenance
o Bilateral
LowerLingualArch
Preventsanteriormovementofposteriorteethandviceversa
Design
o 1.5mmoffsofttissue
o ATcingulumofincisors
o SteppedawayfromPMs
Indications
o Bilaterallossofmandibularmolars
Contraindications
o Notfordeepbite useNance
MaxillaryLingualArch
NanceHoldingArch
Design
o Isamaxillarypalatalarchwithacrylicbutton
o DoesNOTcontactanteriorteeth usespalataltissueto
provideresistancetoanteriormovementofposteriorteeth
Removable
o Transpalatalarch
CanberemovedbyDr.notpt
o LowerLingualArch
Adjustmentloopcanbeactivatedtoadvancelowerincisors
o Retainer/PartialDenture(aka:pedopartial)
Usedforanteriortoothreplacement
Estheticreplacement,sometimesnecessaryforspacemaintenance
Indications
Whenyoucantuselingualarch
Mostusefulforbilateralposteriorspacemaintenanceandperm
incisorshavenotyeterupted

Helpsreplaceocclusalfunction
Goodptcomplianceandseveralclaspsareneeded
Acrylicneedstoberemovedperiodicallytoallowforeruptionof
teeth

ManagementofArchLengthDeficiencies(aka:Crowding)
Maintainleewayspace
o CDEexceedsthatof3,4,5(orthonumbers)
Maxilla=1.5mm/side
Mandible2.5mm/side
Advance/flareincisors
o Maybeunstable teethhavetobeinequilibriumwithtongue/lips
o Indications
Uprightincisors
Crossbites
Distalizemolars
o Maxillaappliances
Pendulumappliance
Distaljet
Nance+coilspring
o MaxillaHeadgear
Distalizesmolarsw/oprotrusionofanteriorteeth
Orthopediceffect
Compliancedependent
o MandibleAppliances
LipBumper
Removedlippressureandallowsincisorstomovefacially
Alsotipslowermolarsdistally
Expansion
o Maxilla
RPE
Splitsthemidpalatalsuturetowidenarch gainspace
1mmexpansionisneededfor0.7mmarchcircumferencegained
o Mandible
Lipbumper
SchwartzPlate
Canbeunstable
Limitedindicationsbcaccentuatescurveofwilson
Interproximalenamelreduction
o Tools
Airrotorstipping
Diamonddisk
Abrasivestrips(byhand)
o Cangain34mmofspace
Serialextraction
o Indicatedwhenyoucannotgainrequiredspacethroughothermethods(severe
crowding)
ALD<4mm nonEXT
ALD48mm borderline
ALD>6mm EXT
o Necessaryifnonexttxwouldbedamagingtofacialprofile/periodontium
Eg:lipincompetence,bimaxprotrusion,mucogingivaldefects
o Occursinmixeddentition
Allowspermanentteethtoeruptoverthealveolusandthroughkeratinized

tissueratherthanbeingdisplacedForL
Sequence=CD4(orthonumbers)
C=allowsincisoralignment
D=speeds1PMeruption
Needto1PMrootdevelopmentfirst
4=canineseruptinto1PMspace

VerticalComponent
3DimensionsofSpace
Vertical
o Dimensionthathasmostamountofgrowthafterpuberty
Horizontal(aka:Transverse)
AP(aka:Sagittal)
InfluencesonVerticalDevelopment
SpecificCauses
o Disturbancesinembryologicdevelopment
Rare(<1%)
Ex:treachercollinssyndrome
o Fetalmolding
Pressureagainstthedevelopingfaceprenatallycanleadtodistortionof
rapidlygrowingareas
EX:armagainstface
Decamnioticfluid underdevelopedmandibleand/orCLP
o Birthinjuries
UseofforcepsmightdamageTMJ
o Childhoodjawfractures
Condyleissusceptibletofracture
Condyleregenerateswell Lessthan5%areproblematic
o Acromegaly
1in25kinUSA
Cause:anteriorpituitarytumor excessGH excessivemandibulargrowth
inadults skeletalclassIII
Abnormalgrowthstopsonetumoristreated
o Skeletalproblempersists orthognathicsurgeryneeded
Alterationsinceph:canseesellandmandibularfrom
Growthmimicstheadolescentgrowthspurt
o TMJProblems
Idiopathiccondylarresorption(ICR)
Resorptionofoneorbothcondyles assymetry
Etiologyunknown
TeenageFemalesaremostsucceptible
Hemimandibularhypertrophy
Etiologyunknown
Unilateralexcessivegrowthofmandible asymmetry
Excessivegrowthmaystopspontaneouslyorcondylectomyw/
subsequentTMJreplacementmaybenecessary
Occursinteenagefemalesmostfrequently
MuscularFunction

Facialmusclesaffectjawgrowthby
Formationofboneatpointofmuscleattachment
Musclesroleaspartofthesofttissuematrix directsjawgrowthdownand
forward
o Decreasedmusclestrength
Dueto
MD,cerebralpalsy,othermuscleweaknesssyndromes
Mandibledropsdownandback excessiveeruptionofposteriorteethand
narrowingofmaxilla anterioropenbite(usually,butnotalways)
o Alterationindiet/musclesstrengtheningexercisesaresometimesincludedaspartoftx
regimen
RespiratoryPattern
o Respiratoryneedsare1 determinantofjaw,tongue,andheadposture altered
respiratorypattern(ie:mouthbreathing) loweredmandible/tongueposition
changedequilibriumofpressuresonjawandteeth
o ChronicairwayobstructionChanges
Dentofacialchanges
Gingivitis
Drymouth
Protrudingmaxincisors
Lowtongueposture
Posteriorcrossbitew/vshapedmaxillaryarch
Craniofacialchanges
Openmouthpostures
Incompetentlips
o Shortupperlip
o Evertedlowerlip
Verticalexcessinlowerfacial1/3
Cephfindings
o SteepMPA
Linealonginfborderofmandible
Hitsocciput normal
Aboveocciput steep abnormalvertical
growth
Belowocciput flat abnormalforward
growth
o Shortramus
o Obtusegonialangle
AdenoidFacies
o Isthecommontermusedforthefamiliarfacialpatternto
obstructingadenoidtissue
o Inreality,anytissuecausingchronicrespiratoryobstruction
couldleadtomorphology bettertermedthelongface
syndrome
GeneralSymptoms
Restlesssleep tiredness
Vacantfacialexpression
Snoring
Lackofscholarlyprogress
Lackofwellbeing
o Etiology
Adenoidhypertrophy
Deviatedseptum
Hypertrophicturbinates

Tonsillarhypertrophy
Prolongednasalmucosainflammation(ie:chronicallergies)
o Research
Airwayobstructioncausesgrowthchangesbutitisnottheonlyfactorandwe
dontknowifitiseventhemostimportantfactor
o Txoptions
RefertoENT/allergist
Havetoresolveairwayissuesbeforeorthotx
Cantreatmedicallyorsurgicallyordonothing
Mostlikelytodoadenoidectomyastx
SkeletalGrowth
o Verticalgrowthisinherited
Anterioropenbites:AA>whites
Deepbite:whites>AA
o VerticalExcess
Ptsgenerallyhaveexcessiveeruptionofposteriorteeth goals
Controlverticalthroughmangementofposterioreruption
Growthreductionthroughmandibularautorotation
TxOptions
HighPullHeadGear
o 14hrday
o ControlMx1M
HPHGtoMaxsplint
o Verticalcontroltoallmaxillaryteeth(notforopenbite)
Functionalappliancesw/biteblocks
Surgery
TADs
o VerticalDeficiency
Ptsgenerallyhavereducedfacialdimensionsanddeepbites
Txoptions
Incisorintrusion
Posteriorextrusion
Surgicalintervention
o Lefort
o Mandibularosteotomies
Habits
o Thumb/digitsucking
o TongueThrusting

OpenBitesandHabitControlinthePreadolescentPatient
Etiology
SpecificCauses
o Disturbancesinembryologicaldevelopment
Ie:cleftpalate
o SkeletalGrowthdisturbances

 Hemimandibularhypertrophy
ChildhoodJawfractures
75%ofchildrenw/earlyfracturehavenormalgrowth
<5%becomeproblematic dontdosurgeryforjawfractures
Frequently,jawfracturesareunknowntoparents
Presentsasasymmetricmandibulardeficiencyw/openbiteonunaffected
side
o MuscleDysfunction
DecreaseinmuscletonecanoccurinMD,someformsofcerebralpalsy,and
variousothermuscleweaknesssyndromes
Resultsin
Increasedanteriorfacialheight
Excessiveeruptionofposteriorteeth
Narrowingofmaxillaryarch
Anterioropenbite
HereditaryInfluence
o Manymoderateskeletalmalocclusionareresultofinheritedpattern
o Openbitestendtohavelongeranteriorandlowerfacialheightandincreasedgonial
angle
EnvironmentalInfluences(aka:habits)
o Intro
Variouspressuresandforcesrelatedtophysiologicactivity
Equilibriumtheorystatesthatobjectssubjectedtounequalforcewillmoveto
adifferentpositioninspace
o Types
Respiratorypattern
Respiratoryneedsare1 determinantofpostureofjawsandtongue
Obstruction changespostureofhead/jaw/tongue affect
growth/toothposition
SuckingHabits
Otherhabits
Liptrap
Fingerbiting
Bottlecapchewing
Tonguethrust
o

SuckingHabits
Manychildrenengageinnonnutritivesuckinghabits
During1 dentitiontherearelittlelongtermeffects
o Ifhabitcontinuesduringpermdevelopment malocclusion
Severityofmalocclusiondependson
o Whichteetharecontacted
o Magnitudeofpressure
o Duration(numberofhoursperday)
Mostimportant
Takes6hoursormoretoproducesignificantmalocclusion
Sequelae
o Increasedbuccinatormusclecontraction
o Tonguelowersawayfrommaxteeth affectsequilibrium Uppermolarsmove
lingual archwidthnarrows MaxillaryarchbecomesVshaped
o Hinderederuptionofincisors
o Displacementofincisors
Flaredandspacedmaxillaryincisors

Linguallypositionmandibularincisors
o Posteriorteetheruptasjawispositioneddownward
o Anterioropenbitedevelops
Suckinghabitsaresignificantcontributortomalocclusionbutitwillnotcreatesevere
malocclusionunlessitpersistswellintomixeddentitionyears
o Preschoolisagoodtimetostop
Theearlieritisstopped,theeasieritistofix
o Ifstoppedin1 dentition normallipandcheekpressurewillrestoreteethtousually
position
o Constrictedmaxillaryarchistheleastlikelythingtocorrectspontaneously may
needRPE
History
o Importanttofindouthowlongthishasbeeoccurring,duration,frequencyand
intensityofhabit
o Assesschildswillingnesstostop
o Mostchildrenstopbyage34
Behaviormodificationiskey
Kidhastowanttostopforbehaviormodificationtowork
Alsohavetohaveenoughduraction
ExtraOralExam
o FingersandHands
Checkforredness,wrinkling,andcleanlinessofdigitsinvolved
o Facialprofile
Flaredincisorscancauseaprotrusiveprofileinmaxillaryregion
o Lipsandfacialmuscles
Istherelipincompetenceatrest?
Swallowing
IntraOralExam
o FlaringandspacingofMaxillaryanteriorteeth
o Lingualltippedmandibularincisors
o Excessoverjet
o Anterioropenbite
o Assessposterior
Molarrelationship
Crossbite
CephExam
o Importanttodistinguishbetweendentalandskeletalproblems
o Cantcorrectskeletalproblemsw/habitappliance
o Itispossibletohavehabitandskeletalproblems

ManagementofSuckingHabits
Determinematurityofpt
o Ifptdoesntnotwanttostophabit,donotbegintx
o Useexplanation,reason,andreward
Interventionremindertherapy
o Bandaidorthumbguard
o Mittens,AceBandage,SocksorGloves
ApplianceTherapy
o Usepalatalcrib
o Removableapplianceiscontraindicatedduetolackofcompliance
PalatalCrib
Preventsdigitplacementinusualpalatalposition
o Blockssensorygratificationstimuli

Preventsfurtherdistortionoftoothpositionoralveolarprocess
Restrainstonguefromthrustingintoanterioropenbite
Thesearereminderappliances,butifpatientdoesntwanttostop,theywont
TherapeuticConsiderations
o Obtainchildsconsent/cooperation
Itisimportantthatthechildunderstandsthattheapplianceisservingasa
reminder,notpunishment
o Expectsomeshorttermspeech,sleeping,andeatingdifficulty
Appliancesshouldremaininplacefor6monthsafterhabithasceasedtoensureithastruly
stopped
Openbitesassociatedw/suckingoftenresolveafterhabitstopsandtheremainingpermanent
teetherupt
o Furtherorthotxmayberequiredthough
Openbitesthatpersistalmostalwayshaveasignificantskeletalcomponentandrequirea
carefuldiagnosisandtreatmentplan

TongueThrust
Definedasplacementofthetonguetipforwardbetweentheincisorsduringswallowing
Isamisnomersinceitimpliesthatthetongueisforcefullythrustforwardduringswallowing
o Usuallyitisjustadifferentposition
Isaphysiologicaladaptationforandindividualwithanopenbite
o Necessarytosealofffrontofmouthduringswallowingtopreventfood/liquidsfrom
escaping
Occursin2circumstances
o Youngerchildrenduringtransitionalswallowstage
o Inpeopleofanyagewhohavespacebetweentheirteeth
Development
o InfantileSwallow
Jaw(gumpadsareapart)
Lipscontracted
Tonguecontactslowerlip
Usedforsucklingreflexinordertoreceivemilk
o TransitionSwallow
Lipscontracted
Separationofposteriorteeth
Forwardprotrusionoftonguebetweenteeth
o AdultSwallow
Teethtogether
Lipsrelaxed
Tonguepositionedinpalate
Presentinthemajorityofkidsbyage6
1015%ofpopulationisabnormal
Tonguepressuresduringswallowingarenotveryinfluentialontoothposition
o Typicalswallowis<1sandpersonswallows<1ktimesperday onlyafewminutesof
pressure tonguethrustnotenoughtoaffectequilibrium notthecauseofopenbite
o However,forwardrestingtongueposturecanbeveryinfluentialontoothpositiondue
todurationofpressure
Txconsiderations
o Changetoothposition changeswallowingpattern
o Refertomyofunctionaltherapist retraintonguerestingposition
Combinew/orthotx(Cribappliance/lingualcleats)