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The Benefits of Early Treatment by Daniel Grob, DDS, MS, Editorial Director

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by Daniel Grob, DDS, MS, Editorial Director, Orthotown Magazine

First, get them in!
Often, one of the first opportunities to treat a young child is when the six-year molars impact along the distal surface of the primary second molar tooth.

In the following case, a 6-year-old girl was seen at request of her general dentist for an impacted upper-left first molar. As we know, these situations often are the precursor to four bicuspid extraction cases. However, since the observation was made early, an attempt to erupt the teeth into the mouth was indicated. The parents, as well as the dentist, were both of the non-tooth-removal mindset. The medical history was unremarkable and the dental history indicated regular visits were maintained, as evidenced by the timely referral.

Observations
Clinical examination revealed a young girl whose first 12 teeth were beginning to erupt (Figs. 1 & 1a). The upper left six-year molar was sliding into the distal of the primary second molar and was only partially visible in the oral cavity. Thankfully, quite a bit of root was still present on this same tooth, as evidenced on the panoramic X-ray (Fig. 2). The opposite side looked unremarkable and the remaining teeth were erupting in a symmetrical, age-appropriate fashion. The cephalometric X-ray and analysis indicated a relatively horizontal facial pattern and straight profile (Fig. 3). Photos showed a horizontal facial pattern with a straight profile with no lip strain and partially erupted anterior teeth (Fig. 4).



Treatment and results
Because so many teeth still needed to erupt, and the maxillary centrals were still appearing, it was decided to merely place a spring separator distal to the second primary molar to help the tooth erupt (Fig. 5). Following this placement, a rubber separator was inserted three weeks later (Fig. 6).

In some situations, some flattening of the distal surface of the primary second molar is performed to help the tooth glide into place. This procedure was not necessary in this situation. After three visits of nudging the tooth into place, the six-year molars were both in position in a symmetrical place and able to maintain the stable bite (Fig. 7). Anterior teeth continued to erupt and spacing prevented the cuspids from erupting into an orderly straight position (Figs. 8 & 8a).

Phase II treatment was performed for several months, which resulted in no permanent teeth being removed. Aggressively erupting the six-year molar into place provided a foundation for future care and allowed this patient to maintain all of her permanent teeth short of the third molars, which were removed when she was in high school.





Then, stop the habits!
One of the most important things an orthodontist can do to help a young patient is to not only recognize a malocclusion, but to relate that malocclusion to habits.

In the following case the patient is an 11-year-old boy whose parents brought him to the office because he would not quit sucking his thumb. The boy wanted to stop, which in my experience has been a good indicator of success. Dental and medical evaluations were within normal limits, and the family had a good history of regular dental care.

Observations
The clinical examination revealed an anterior open bite in the early mixed dentition stage with a unilateral cross bite, and a subdivision Class II malocclusion with a lateral shift on closure into centric occlusion. The upper arch was narrow and the mandibular arch was broad (Figs. 9-11). The patient admitted to sucking his thumb and demonstrated poor tongue posture during rest and swallowing. The panoramic X-ray indicated age-appropriate eruption of teeth (Fig. 12).

The cephalometric film showed a Class II dental base on a relatively normal skeletal framework. Poor lip posture was demonstrated and the lower lip became trapped under the upper incisor teeth (Fig. 13). Photos documented the malocclusion and a sagittal view demonstrated the everted upper lip and hyperactive lower lip on closure and rest (Fig. 14). Tongue position and lips were consistent with low posture and abnormal lip positon during rest and swallow.





Treatment and results
A combination quad helix thumb appliance was placed on the upper teeth for a period of three to six months for expansion, to lessen the thumb sucking and hopefully retrain the tongue (Fig. 15). Following cessation of the thumb habit, a 2x4 appliance was placed to align the four front teeth for appearance and space closure. The total active treatment time was approximately one year (Fig. 16).

One can see that the arches have been coordinated and the overjet in the buccal corridor has been made uniform bilaterally. It took a while for the overlap of the teeth to become normalized, but with some time and removal of the thumb from the mouth and face-muscle therapy, the overbite and overjet became balanced (Fig. 17).

Final Phase II treatment was a breeze with aligning and leveling of the arches. Elastics were used to settle the occlusion and develop Class I molars on both sides of the mouth. It should be noted that the subdivision Class II malocclusion on the right side was corrected without orthopedic forces.





Conclusion
As much as we all know that the most profitable and efficient manner to treat malocclusions is during the adolescent growth spurt and in one phase, often our patients' situations dictate otherwise.

Hopefully, these two relatively common situations will highlight the need to occasionally help our young patients through some difficult times and provide them with the opportunity to have simpler orthodontics at a later date.

References
  1. Gianelly, Anthony A, Current Topics and Controversies, PCSO Summer 2007 p. 33
  2. Proffit, William R, The topic of early treatment, A Overview, AJO/DO April 2006 p. 47
  3. Grob, Daniel J, Treatment by Twelve's, Orthotown, Nov 2014 p 50


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