Bell - AAO - Ectopic Molars - Dx
Transcription
Bell - AAO - Ectopic Molars - Dx
Ectopic Eruption: Definition! “Early Treatment for Missing & Impacted Teeth”! ë í ë î í ì “Diagnosis & Interceptive Management! of Ectopic First Permanent Molars” Ronald A. Bell, DDS, MEd Diplomate, ABO Diplomate, ABPD Presentation available as E-handout @ AAO website ç ì Developmental disturbance in the eruption patterns of! any permanent teeth that results in atypical resorption! of an adjacent tooth (either primary or permanent).! Ectopic Eruption of Maxillary First Molars ! Ectopic First Molars = When 1st molars are malpositioned and cause atypical resorption of adjacent 2nd primary molar.! Reported prevalence of 1 to 4 %! ! ! 3 to 4% most likely! Young: J Dent Child 24:153,1957 Ectopic Eruption of Mandibular First Permanent Molars! Incidence: 0.2% Kimmel et al: J Dent Child 49:294,1982 Ectopic Eruption: Maxillary 1st Molars ! ! - occurs 20 times more frequently in maxillary first molars than for mandibular first molars.! ! Reversible Irreversible Treatment approach will generally be the same as maxillary ! Bjerklin & Kurol: Swed Dent J 5:29,1981 è è Jump type Hold type Young: J Dent Child 24:153,1957 Reversible Type >> (“Jump Type”)! Ectopic 6 yr. molars > Reversible 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”). Self-correction ≈ 2/3rds of cases ? Young: J Dent Child 24:153,1957 Occurs by age 7 years Resorption usually stops once cleared! Kurol & Bjerklin: J Dent Child 49:273,1982 Bjerklin & Kurol: AJO 84:147, 1983 Bjerklin & Kurol: Swed Dent J 5:29,1981 Ectopic 6 yr. molars > Irreversible Irreversible type >> “Hold Type”! ü Molar becomes blocked by 2nd primary molar and First molar remains locked under E Resorption usually progresses! remains in a locked position until treatment or premature exfoliation of the primary molar occurs. Bjerklin & Kurol: Swed Dent J 5:29,1981 Age 6y. 1m. Bjerklin & Kurol: Swed Dent J 5:29,1981 >>>>>>>> Age 6y. 8m. Potential sequelae of irreversible ectopic maxillary Potential sequelae of irreversible ectopic ! first molars:! maxillary first molars:! ! > Blocked eruption of 6 s.! ! > Supra-eruption of lower 6 > Resorption and early loss of 2nd primary molar! > Disruption of arch integrity & malalignment! ! > Space Loss / Blockage of 2nd bicuspid! Thurow, Atlas of Orthodontic Principles, C.V. Mosby: 1970 Thurow, Atlas of Orthodontic Principles, C.V. Mosby: 1970 Sequelae of ectopic maxillary 1st molars:! 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 Ectopic Maxillary 1st Molars & “Crowding”:! • Premature loss of primary molars almost always results in malocclusion with compromised arch circumference. 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 TREATMENT OF ECTOPIC MOLARS! Step 1. EARLY RECOGNITION !PANORAMIC, PA S or Adequate BWX 5 - 7 Y.O.! • 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). ì ë > 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) TREATMENT OF ECTOPIC MOLARS! Step 1. EARLY RECOGNITION! PAN, PA S or Adequate BWX Pan BEST Option – Rx’d upon eruption of first permanent tooth TREATMENT OF ECTOPIC MOLARS! Step 1. EARLY RECOGNITION > 5 - 7 Y.O. PAN, PA S or Adequate BWX (#2 size)! 5 - 7 Y.O.! # 1 BWX Too small # 2 BWX More vertical exposure TREATMENT OF ECTOPIC MOLARS! Step 2. Consider Observation! ! ! Patient age! Step 3: Interceptive 7 years of age or more! Tx. èè TIMING! ! Six months later >>> worse than before! Lower 6 eruption! At occlusal plane! ! Upper E resorption! Before extensive loss! ! Upper 6 position! Remember – 2/3rds “self-correct”; but not after age 7 years 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. TREATMENT OF ECTOPIC MOLARS! INTERCEPTIVE Options ! Noted indicators negate watchful waiting Time to intercept ! Mesially inclined! Bjerklin & Kurol: AJO 84:147, 1983 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 ELASTIC SEPARATORS! ! 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)! 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. Diagnosis & Elastic Separator Tx. @ Age 6y. 10m.! Separating Elastics! Advantages: Replaced @ 3 week intervals (4 times) * 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 One year recall Age 7y. 9m. SEPARATING SPRINGS! ! Start @ 2 weeks @ 4 weeks Separator @ 4 weeks @ 5 weeks BRASS WIRE SEPARATION! Separating Springs! Advantages: Combo Separating Springs > > Elastic > > Separators! ! 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 ???! 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!!! TREATMENT OF ECTOPIC MOLARS! Active Distalization Appliances! HUMPHREY APPLIANCE ! ! Pre-Tx.! Springs > Push ! ! Elastomerics > Pull! HUMPHREY APPLIANCE Correction > 8 weeks! Placement! Humphrey WP: J Dent Child 29:176,1962 HUMPHREY APPLIANCE Distalizing Springs! Corrected Placement ! ! Retained w/ band extension 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! Advantages: ! * Stability ! * Quickness of correction ! * Can correct severe locks of the first permanent molar! ! 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 .! DISTALIZING ELASTOMERICS! 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.! HALTERMAN APPLIANCE Stretching elastomeric chain from wire to occlusal bonded button produces distalization force.! ! HALTERMAN APPLIANCE! Halterman CW: JADA 105:1031,1982 HALTERMAN APPLIANCE! HALTERMAN APPLIANCE Correction in 6 weeks with distal & vertical movement of molar. 2 weeks change with distal & vertical movement. ! Elastics disengaged, ! components left in place until molar erupts & occludes with bonded button. ! Re-engaged chain to next loop >> need to clear by 2 mm. ! HALTERMAN APPLIANCE Halterman Appliance @ 3 weeks Tx. Time! ! Correction in 4 weeks Occlusion in 8 weeks - removed ç Same Patient @ 6 months Post. Tx. Case from Dr. David Kennedy HALTERMAN APPLIANCE: DESIGN! Halterman Appliance ü Band E - E , connect w / TPB, 036 S.S.! Six weeks treatment! ü Distally extend .036 wire from palatal side! Case from Dr. David Kennedy ü Bond button on 6 as mesial as possible! ü Elastic chain (closed) from button to wire! Response @ three weeks Follow-up @ six months! Halterman: !Pre > Tx 3 weeks > Post > 4 yr.! 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! Post. Tx. 7y. 5m. ê! Halterman !! Pre-treatment! Post-treatment! @ four years Case from Dr. David Kennedy Treatment Post-treatment! @ six months 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; Pre-Tx. 6 y. 9m. é! Bell & Leite: J Clin Pediatr Dent Care, 9:16, 2003; Kennedy: Pediatr Dent 29:327, 2007 Post. Tx. 12y. 2m.è Kennedy: Pediatr Dent 30:63, 2008 Case from Dr. David Kennedy Ectopic Lower Molar > Halterman !! Halterman Appliance! Advantages: ! *Ease of basic appliance placement. *Ease of fabrication design. *Ease of activation. ! Pre-treatment ! ! *Minimal displacement of 2nd primary molar. *Rarely requires any anesthesia.! Treatment @ ! three weeks ! Disadvantages: *Bonding of occlusal button of first molar. *Critical adaptation of distal extension wire. *Difficulty in replacing power chain.! ! Treatment! Appliance ! ! Same basic tx. objectives, ! timing of intervention, ! and appliance options as ! maxillary ectopic molars. Lower Halterman! Treatment! Appliance Post-treatment! @ three years 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. 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.! Ronald A. Bell, DDS, MEd Diplomate! ABPD & ABO Department of ! Pediatric Dentistry ! and Orthodontics Medical University ! of South Carolina! [email protected] 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