Class II Camouflage Correction with Maxillary Bicuspid Extraction

Many patients present to an orthodontic office with some degree of Class II malocclusion. The treatment approach for correcting a Class II malocclusion depends on various factors, including the type and degree of skeletal dysplasia, facial profile, remaining growth, anteroposterior molar and canine relationship, degree of crowding, malposition or malformation of teeth, patient compliance, and the patient’s acceptance of the treatment plan. This blog will focus on one particular means of Class II correction: dental camouflaging with maxillary premolar extraction.

Choosing an Appropriate Patient
Dental camouflaging by definition is a compromise. The orthodontist is knowingly retracting and retroclining the maxillary anterior dentition into a less than ideal cephalometric position to achieve acceptable overjet and improved smile aesthetics. An appropriate patient to receive this treatment may present with one or more of the following characteristics: refusal of orthognathic surgery, maxillary hyperplasia, moderate retrognathia with an acceptable facial profile, greater than 50% Class II canine, aversion to a Class II corrector, ectopic maxillary canines or premolars, presence of maxillary third molars, lower incisor proclination, compromised periodontal health, treatment-duration restraints, or a metal allergy (Figure 1).

Among the many diagnostic tools I use during an orthodontic consultation in my office, I pay particular attention to canine relationship when determining treatment modality. After all, canine Class I, not simply molar Class I, is my primary objective. In the absence of a Bolton Discrepancy or missing teeth, canine Class I occlusion ensures appropriate overjet and coinciding dental midlines. Furthermore, if the canines are in proper occlusion, often the posterior teeth follow. If the canines are less than 50% Class II occlusion, I am confident that I can achieve ideal occlusion with orthodontic elastics. If the patient presents with greater than 50% Class II occlusion, I may favor bicuspid extraction or a mandibular advancing appliance.

In my office, I enjoy using a variety of mandibular advancing appliances to provide Class II correction. The one key determinant when presenting maxillary premolar extraction as a more appropriate treatment alternative is lower incisor angulation. Fixed Class II correctors that reduce overjet by mandibular advancement, such as the Herbst appliance, MARA®, Crossbow®, and Forsus Fatigue Resistant Springs®, always provide some degree of mandibular incisor advancement. Therefore, in the absence of severe crowding and periodontal attachment loss, when using such appliances I prefer my patient’s pretreatment incisor inclination to be less than 105º. Mandibular advancing appliances used in the presence of mandibular incisor proclination will result in incisor dumping, attachment loss, and creation of an anterior open bite, regardless of whether there is labial support (Figures 2 and 3).

Choosing Between First and Second Bicuspids
Choosing between extracting the maxillary first or second bicuspids depends on the severity of pretreatment overjet, anchorage requirements, aesthetic demands, tooth position, and presence of restoration or caries. Commonly, the maxillary first premolars are extracted to allow for maximum retraction of the anterior teeth with minimal anchorage loss or correction of an ectopic maxillary canine. For example, I might choose extraction of the maxillary first premolars if the patient presents with a greater than 75% canine and molar Class II malocclusion with severe overjet and healthy second premolars.

However, I might favor extraction of the maxillary second premolars if the presenting overjet is less severe and anchorage requirements are lower, or if these teeth are palatally ectopic, severely malrotated, or have a large restoration or root canal treatment (Figure 4).

Also, extraction of the second premolars may be favorable if the patient is concerned with the visibility of extraction spaces during the consolidation phase. In patients receiving maxillary lingual braces, extraction of the maxillary second premolars rather than the first premolars was traditionally encouraged. The thought was that wire engagement and sliding mechanics might be easier if the extraction spaces were further from the “mushroom” bend of the lingual archwire. However, with the advancement of custom-lingual brackets, this archwire bend has been eliminated altogether.

In my office, maxillary premolar extraction is a valuable, efficient, and stable treatment alternative for correcting a Class II malocclusion in patients who present with greater than 50% canine Class II occlusion, lower incisor proclination, and aversion to orthognathic surgery or a mandibular advancing appliance.

Can hormonal changes cause gums to swell?

Gingivitis (gingiva: gums,-itis: inflammation) is a form of periodontal disease in which the gums around the teeth become inflamed and swollen. Gingivitis is commonly due to plaque (sticky bacteria and food) and tartar (hardened plaque) on the teeth. The bacteria and toxins they produce cause the gums to become infected, swollen, tender, and bleed.(Pubmed Health)

While gingivitis is commonly associated with poor-oral hygiene, hormonal changes during puberty, pregnancy, contraceptive use, or menopause can cause severe and rapid gingival swelling even in the absence of plaque and tartar. Specifically, increased levels of the hormone progesterone make it easier for certain gingivitis-causing bacteria to grow. Such a condition is often referred to as hormonal gingivitis or pregnancy gingivitis. As a result of varying hormone levels, between 50-70% of women will develop gingivitis sometime during their pregnancy.

I hope this has provided some useful information on gingivitis. Please feel free to respond with any questions or comments.

Sincerely,

Neal D. Kravitz,
South Riding, Virginia
www.kravitzorthodontics.com

Managing Dental Injuries Part 1: Periodontal Injuries

Dental trauma to adult teeth is often painful and distressing for the injured child. The most accident prone times in a child's life in regards to damaging permanent teeth are between 7-10 years of age. Most injuries result from falls and collisions while playing, running, or bicycling. Research suggests that one in three children have experienced dental injury to permanent teeth, with a statistically greater percentage in boys. The premise of this blog will be to review common periodontal injuries (injuries to the tooth root and surrounding ligaments) in adult teeth teeth and proper emergency care.


2 major types of periodontal injuries and their treatments

1. Luxation: the tooth is out of position, but it is still in the mouth.

A luxated tooth has been moved out of the [tooth] socket. The impact may have displaced the tooth upward (very common), downward (Figure 1 below), backwards, forwards or less commonly to the side.

After a luxation injury, it is important to see your orthodontist as quickly as possible. Every hour counts! Luxation injuries have a favorable prognosis with early treatment. Your orthodontist can reset the tooth with a combination digital manipulation and braces on the anterior teeth. The braces function to move the tooth into the proper position and also work as a non-rigid functional splint. Many orthodontists will choose to keep the braces in place for 3 weeks. A soft-food diet (eggs, milk-proteins, pasta, oatmeal, soups) should be kept for 3 weeks.

Luxation injuries often involve damage to tooth pulp and nerves, as well as the ligaments and bone plates (dentoalveolus) around the tooth root. After the tooth has been splinted for 3 weeks, your orthodontist will refer your child to your pediatric or family dentist to further evaluate the health of the tooth. While younger teeth (children 7-9 years of age) typically retain vitality, more mature teeth (children 10+ years of age) are a high risk for inflammatory injuries that may require root canal treatment or less commonly extraction if the tooth fuses to the bone (known as ankylosis).


2. Avulsion: the tooth is completely out of the mouth.

Avulsion is the most severe periodontal injury in which the tooth has been completely knocked-out of the mouth (Figure 2 below). Avulsion injuries commonly occur after a forceful fall to the ground during play, rather than organized sports. Similar to luxation injuries, avulsion is associated with fractures to the dentoalveolus, as well as damage to the nerves, blood vessels and supporting tissues. However, if you act quickly, there is a good chance that the tooth can be saved.

Home-care instructions for an avulsed tooth:
Pick the tooth up by the crown (this is the part of the tooth that see you in the mouth). Avoid touching the root of the tooth. If the tooth is dirty do not attempt to disinfect or scrape the tooth root. Attached to the root are vital periodontal ligaments cells which are crucial to allowing the tooth to re-adhere to the bone. Simply, wash gently under cold tap water (10 seconds). The tooth has a better chance of surviving if it is kept its natural environment. If you feel comfortable doing so, attempt to replace the tooth into its socket. Alternatively, you may transport the tooth in a zip-lock bag filled with milk or the child's saliva to the orthodontist. It is important to keep the tooth moist.

At the surgical appointment, your orthodontist will administer local anesthetic, digitally reinsert the tooth, and place a non-rigid functional splint. The child will likely be given an antibiotic cover, an antibacterial rinse (chlorhexidine mouthwash), and placed on a soft-diet for 3 weeks. It is critical that the tooth be reinserted within 30-60 minutes after trauma so it may undergo pulp revascularization. The longer an avulsed tooth remains out of the tooth socket, the greater the likelihood of ankylosis.


A Quick Summary of Luxation and Avulsion:
1. Visit your orthodontist immediately.
2. After digital manipulation, the tooth will be splinted for 3 weeks or more.
3. Luxation injury (particularly intrusive luxation) have a high risk for root canal treatment. Avulsion injuries have a high risk for both root canal treatment treatment and future ankylosis.
4. Avulsed teeth should be placed in a zip-lock bag with milk. The tooth should be reinserted within 30-60 minutes for best prognosis.

I hope this has provided some useful information of dental trauma. I encourage all dentists to visit the website: http://www.dentaltraumaguide.org for review of traumatic injuries and instructional videos. Please feel free to respond with any questions or comments.

Respectfully,

Neal Kravitz
South Riding, Virginia
www.KravitzOrthodontics.com
Emergency Cell: 703-638-2467

Do Wisdom Teeth Really Cause Crowding?

“It ain't what you don't know that gets you into trouble. It's what you know for sure that just ain't so.” -Mark Twain

Despite popular belief amongst patients and dentists, wisdom teeth do not contribute to lower incisor crowding in adulthood. Blasphemy!, Copernicus!, Leviticus 24:15!, you say? Amazingly, the belief that wisdom teeth contribute to lower incisor crowding is based on an antecdotal statement from a single research paper more than 50 years-old.

In 1961, orthodontist Leroy Vego, published an article, "A Longitudinal Study of Mandibular Arch Perimeter" which examined the role of wisdom teeth on lower incisor crowding. Vego evaluated plaster stone models of 65 individuals who have never had orthodontic treatment; 40 individuals with lower wisdom teeth present and 25 patients with lower wisdom teeth congenitally absent (never born with wisdom teeth), over six years from ages 13 to 19. He reported that there was a significantly greater degree of crowding in [those individuals] with wisdom teeth. Vego concluded: "that the erupting lower third molar can exert a force on approximating teeth."

From this statement, the theory formulated that lower wisdom teeth "push" the teeth in front of them as they come into the mouth, contributing to incisor crowding. As such, general dentists, orthodontists, and oral surgeons recommended the prophylactic extraction of wisdom teeth to prevent against the relapse of crowding after orthodontic treatment.

Ample research exists (References 1-8) which disprove Vego's theory that wisdom teeth exert enough pressure on teeth to move them forward. In fact, numerous elements play a role in crowding, irrespective of whether the individual has wisdom teeth. Most notably, lower incisors tend to drift forward through the bone in the direction of our main chewing muscles (masseter and temporalis). Additionally, bone is continually remodeling and bone in the lower anterior region happens to resorb throughout life. Other factors such as tooth-size, tooth-shape, and original tooth-position also play a significant role. Therefore, little rationale exists for the extraction of third molars solely to minimize present or future crowding.

Nonetheless, timely removal of wisdom teeth is still encouraged. Wisdom teeth may develop cavities, gum inflammation (pericoronitis), root resorption of the second-molar, cysts or tumors, impede orthodontic tooth movement, or interfere with proper occlusion, and therefore should be extracted in many patients. In our office, we encourage the extraction of wisdom teeth during late adolescence, prior to the child leaving for college. As the patient reaches greater skeletal maturity, jaw bones become increasingly more dense, which may result in higher post-operative pain following wisdom tooth removal. Typically, after the age of 25, asymptomatic wisdom teeth are not extracted and simply monitored with routine periodic x-rays.

I hope this has provided some helpful information on wisdom teeth. Please feel free to respond with any questions or comments or requests for additional information.

Respectfully,
Dr. Kravitz
South Riding, Virginia
www.kravitzorthodontics.com


References:
1. Fastlicht (1970) found that in orthodontically treated subjects, only 11% had wisdom teeth present but 86% still had a relapse of lower anterior crowing after treatment.
2. Kaplan (1974) concluded that the presence of third molars does not produce a greater degree anterior crowding after the cessation of retention.
3. Little (1981) observed that 90% of patients treated orthodontically with extractions relapsed with lower anterior crowding.
4. Lifshitz (1982) evaluated lower anterior crowding in patients with lower premolar extraction in the presence or absence of lower third molars, and concluded that a relapse of crowding occurs after treatment regardless of whether lower premolars were extracted or third molars were present.
5. Linqvist and Thilander (1982) reported that patients with prophylactic removal of wisdom teeth had similar relapse of lower anterior alignment than those with wisdom teeth present.
6. Ades et al. (1990) reported no difference in mandibular growth pattern whether wisdom teeth were erupted, impacted, or missing, and concluded that there is no basis for recommending third molar extractions to alleviate or prevent mandibular incisor crowding.
7. Southard et al. (1991) found that the surgical removal of third molars did not have an effect on contact tightness.
8. Pirttiniemi et al. (1994) evaluated the effect of removal of impacted wisdom teeth on subjects in their third decade of life (30-39 years of age) and found that wisdom tooth extraction had no significant change in the lower anterior area.

Phase I Correction of Thumbsucking

As an orthodontist, everyday I work with children, adolescents, and adults to help overcome prolonged thumbsucking habits. A thumbsucking habit (which may manifest in adulthood to a thumbnail biting habit) often results in significant skeletal deformities such as maxillary arch constriction (narrow upper jaw), aperto-gnathia (skeletal openbite or upward sloping palate), anterior dental openbite, and bilateral posterior crossbite.

Etiology:
The behavior has been historically associated as either (1) an innate desire (pyscho-analytical theory) or (2) a learned response (behavioristic theory). However, research has been unable provide consistent support for either theory. After all, we know from research that chronic thumbsuckers suffer no more neurotic or emotional disorders than other children (contradictory to the psychoanalytical position), and furthermore, thumbsucking can be found in a fetus (which contradicts the behavioristic theory).

We do know that habitual thumbsucking appears to be a means of relief from tension (i.e. the child is tired, hungry, or sad) and associated with pleasure and comfort. Research also shows a direct correlation between the probability of thumbsucking with the degree of introversion (shy children may have a greater likelihood of prolonged thumbsucking).

The following is an excerpt from orthodontist Arthur C. Hawkins, on the psychological need for thumbsucking: "Every person has feelings of apprehension and insecurity at times, even though he may not be in touch with them. Grown people have at their disposal a wide variety of ways to vent these feelings. They can eat, drink, smoke or work in excess. They can vent feelings while driving, attending sports events, playing games, socializing or working . . . but what options does the infant or small child have for venting feelings of apprehension or insecurity? There are few available; one of them is [thumb]sucking."

Constructive Correction of a Thumb Habit
*It is critical to remember that a constructive, positive approach in which the patient can gain self confidence and take pride in accomplishment is always better than a destructive approach of nagging or belittling.

In our office, openbite correction and cessation of prolonged thumbsucking is a treatment that I take great pride in performing. The first photo of our patient James with a severe skeletal openbite with bilateral dental crossbite and incisor intrusion). In addition to Phase I orthodontic treatment, I choose to prescribe by Dr. Hawkin's constructive model with a few additions:

1. I always begin the appointment by complimenting the patient about his appearance (which can be the color or shape of his teeth)
2. **I assure the patient that everything will be fine and that we will work together to create a beautiful smile and help control the thumb.
3. It is important to emphasize with the patient. "Sometimes the thumb just goes in the mouth." But also, "they are in control, not the thumb."
4. After emphasizing, also explain that the retained habit is having an adverse effect on his teeth and bite, and if we can control our thumb (I like using the word "our" rather than "your") the bite will turn out perfect.
5. Offer some suggestions that aid correction of the thumb habit. I say something, like: "Johnny, I know sometimes the thumb just goes in the mouth after a tough day at school, or if you get hungry, or tired. We have a few suggestions that may help. We can also help too."
6. In addition to positive reinforcement, suggestions to help with thumbsucking may include:
a) Phase I orthodontic treatment (which may include a maxillary expander, a thumb guard, or simply upper and lower braces on the incisors)
b) Use of band-aids or Mavala (nail biting varnish) on the thumbs
c) Sleeping with an oversized sweater with the sleeves sewn or teaching the child to sleep on their hands
d) For girls, painting of finger nails
e) Development of a reward system (working toward recognition and goals)
f) Lastly, and this is the hardest: often thumbsucking is associated with a secondary habit (i.e use of a security blanket, a teddy bear, twirling the hair, rubbing the tummy) which parents should consider correcting. Often, the moment the child is given the blanket, the thumb goes in the mouth. As such, without the blanket or teddy, the thumb habit quickly corrects.

Early correction of thumbsucking may prevent against the development of a skeletal or dental malocclusion, and the associated speech and masticatory difficulties. I suggest parents attempt to correct a thumb habit no later than 7 years of age, prior to the eruption of the permanent incisors. The second photo below is of an adult patient with a prolonged childhood thumb habit which resulted in developing tongue thrust, causing a challenging openbite with dental asymmetry. Her dramatic improvement was achieved with 18 months of braces (upper braces are behind the teeth, known as Incognito braces).

I hope this has provided some helpful information on thumbsucking. Please feel free to respond with any questions or comments or requests for additional information.

Respectfully,
Dr. Kravitz
South Riding, Virginia
www.kravitzorthodontics.com

Can Orthodontic Appliances Cause a Fever

It is not uncommon for a child to break into a fever a day or two after receiving orthodontic appliances. Typically, this fever is brought on by anxiety (stress of receiving of receiving braces), mild discomfort, and lack of nutrition, rather than from an allergic reaction.

With this said, patients undergoing orthodontic treatment with braces are exposed to various biomaterials including metal alloys, resin cements, latex, and etchants which release potential allergens. According to Kerosuo and Dahl, reactions to biomaterial cause of number of symptoms , including mild skin or mucusal irritation, allergic reactions, generalized dermatoses, throat closure, lip swelling, an even asthmatic reactions.

If a patient develops a high fever (+101 degrees) days after receiving orthodontic appliances, the patient should be seen by the orthodontist to ensure an allergic reaction is not the culprit. The orthodontist should look for signs of gingival inflammation and erythema, blisters, and lip swelling, as well as past history of irritation to jewelry. If no allergic reaction can be determined, consider removing the orthodontic arch wires for improved patient comfort, which reduces stress, allows for improved nutrition, and with the use of Tylenol, can aid in rapid fever reduction.

Please feel free to respond with any questions and comments.

Respectfully,
Dr. Kravitz
South Riding, Virginia
www.kravitzorthodontics.com

The Right Time for an Orthodontic Evaluation: No Later Than Age 7

Even though most people think of pre-teens and teens when they think of orthodontics, there are good reasons your child should have an orthodontic evaluation much sooner. The American Association of Orthodontists (AAO), recommends a checkup with an orthodontist no later than age 7. At our office, we typically tell our parents: Third Grade. At this time, the incisors and molars are erupting and the orthodontist can evaluate your child's occlusion.

Early treatment may give your orthodontist the chance to: 1) guide proper jaw growth, (2) lower the risk of trauma to protruded teeth, (3) correct harmful habits or crossbite, (4) improve appearance, self-esteem, and speech, (5) eliminate crowding and avoid extractions. In essence, Phase I treatment lays down the proper foundation.

If you are considering Phase I treatment for your child, consider looking for an orthodontist in your area who participates with your insurance plan and provides convenient hours. Most orthodontists offer complimentary consultations.

Please feel free to respond with any questions or requests for any future information.

Respectfully yours,
Dr. Kravitz
South Riding, Virginia
www.kravitzorthodontics.com