Wednesday, September 30, 2015

A review of the diagnosis and management of impacted maxillary canines

Department of Pediatric Dentistry

Lutheran Medical Center


Resident’s Name: John Diune                                                                                    Date:  9/30/15

Article Title: A review of the diagnosis and management of impacted maxillary canines
Author(s): Marisela Bedoya, Jae Hyun Park
Journal: JADA
Date: December 2009
Major Topic: Growth and Development and Orthodontics
Type of Article: Systematic Review
Main Purpose: Review of literature as regards to prevalence, etiology, and diagnosis of impacted maxillary canines, and surgical and orthodontic techniques for proper management
Key Points/Summary:
  • Maxillary canines 2nd most commonly impacted teeth (2nd to 3rd molars) ~2% population, 2x in females
  • Of all patients w/ impacted canines 8% bilateral; 1/3rd labially and 2/3rd palatally
    • 85% palatally impacted had sufficient space for eruption / 17% labially impacted had space
    • Arch length discrepancy thought to be primary etiology for labially impacted max canines
  • Guidance theory (root of lateral incisor) vs Genetic theory (genetics primary factor) for palatally displaced max canines
    • Baccetti reported palatally impacted are associated w/ anomalies such as enamel hypoplasia, infraooclusion of primary molars, aplasia of second premolars and small max lateral incisors
    • Becker reported 2.4x incidence of palatally impacted canines adjacent to sites missing laterals
  • Impacted canines may:
    • Cause migration of neighboring teeth and loss of arch length
    • Increase risk of developing a cystic lesion and infection
    • Cause root resorption of nearby lateral incisors (~0.7% incidence of resorption)
  • Clinical diagnosis include:
    • Delayed eruption of permanent canines
    • Overretention of primary canines
    • Absence of labial bulge (in 9-10 yo, suspect eruption disturbance)
    • Presence of palatal bulge
    • Distal crown tipping of lateral incisor
  • Radiographic diagnosis:
    • Occlusal
    • Two periapical radiographs using buccal object rule
    • Under 8/9yo can use cephalometric
    • Posteroanterior – canines should be angled medially, crowns below apices of laterals, roots should be located laterally to lateral border of nasal cavity
    • CBCT – also can assess damamge to adjacent teeth and amount of bone around canine
  • Interceptive treatment: (simplest interceptive procedure is timely extraction of primary canines)
    • Ericson and Kurol – extracting primary canines before 11yo may normalize erupting position of permanent canine in 91% of cases where crown is distal to midline of later incisor; decreases to 64% if crown is mesial to midline of lateral
    • Probability decreases as horizontal angulation increases
    • Power and Short found decrease chance of normal eruption when vertical angulation >31o d
    • But most influenced by degree of canine overlap with lateral incisor than angulation
  • Management of Impacted Canines:
    • Kokich reported 3 methods uncovering labially impacted max canine: gingivectomy, creating an apically positioned flap, and using closed eruption techniques
    • Kokich suggested 4 criteria for determining correct technique for exposure of labially or intra-alveolar impaction: labiolingual position of impacted canine crown, vertical position of tooth relative to mucogingival junction, amount of gingiva in area of impacted crown, and mesio-distal position of crown
    • Moving impacted teeth into occlusion:
      • recommend making adequate space
      • moving canines in close proximity to lateral roots in occlusal and posterior direction first
Assessment of Article:  Level of Evidence/Comments: I


Cephalometrics and Facial Esthetics: The Key to Complete Treatment Planning

Department of Pediatric Dentistry
Lutheran Medical Center

Resident’s Name:             John Kiang                                                                                                Date: 9/30/15
Article Title: Cephalometrics and Facial Esthetics: The Key to Complete Treatment Planning
Author(s): Krull et al.
Journal: Dentistry for the Child and Adolescent
Date: 9th Edition
Major Topic: Cephalometrics
Type of Article: Chapter 26
Main Purpose:  Assessment of craniofacial dimensions  
Key Points/Summary:
·       Primary aim of cephalometrics analysis is to localize malocclusion within a tracing of facial bone and soft tissue structures.
·      As a general rule the goal in tx planning is to treat in the direction of cephalometric norms. The clinical advantages include the following: 1. More favorable and predictable esthetic result 2. Greater posttreatment stability 3 improved function and periodontal health
Reference Points:
·      Sella turnica- midpoint of the hypophyseal fossa. This is the ovoid area of the spheroid bone that contains the pituitary gland
·      Nasion – the external junction of the nasofrontal suture in the medial plane
·      Orbitale – the most inferior point on the external border of the orbit
·      Conylion – the most superior point on the articular head of the condyle
·      Anterior Nasal Spine – The most anterior projection of the anterior nasal spine of the maxilla in the median plane
·      A Point – the deepest point of the curvature of the anterior maxilla between the ANS and the alveolar crest. Although the A point may change with tx it represents the most forward point of the maxilla
·      B Point – The most posterior point on the outer curve of the mandibular alveolar process between the alveolar crest and the bony chin.
·      Pogonion – The most anterior point on the midsagittal mandibular symphysis
·      Menton – The most inferior point of the mandibular symphysis
·      Gnathion – A constructed point that is formed by the intersection of the facial and mandibular planes
·      Gonion – another constructed point that is represented by the intersection of the lines tangent to the posterior margin of the ascending ramus and the mandibular plane
·      Articulare – The point of intersection of the posterior margin of the ascending ramus and the outer margin of the cranial base.
·      Porion – A point located at the most superior point of the external auditory meatus or the superior aspect of the metal ring that is a component of the left ear rod of the cephalostat
·      Basion – the most inferior posterior point on the occipital bone that corresponds to the anterior margin of the foramen magnum
·      Pterygomaxillary fissure- The teardrop shaped fissure of which the posterior wall is created by the anterior borders of the pterygoid plates of the sphenoid bone and the anterior wall represents the posterior border of the maxilla. The tip of this fissure denotes the posterior extent of the maxilla
·      Posterior Nasal Spine – The tip of the posterior spine of the palatine bone.
·      PT point – the intersection of the inferior border of theo foramen rotundum with the posterior wall of the ptm
·      CF point – Center of face/intersection of the Frankfort horizontal plane and a perpendicular line through PT
Reference Lines, Angles, and Planes
·      Frankfort Horizontal Plane – Porion to Orbitale (horizontal plane of head)
·      Sella-Nasion Plane (SN) – line intersecting Sella and the Nasion  (AP extent of the anterior cranial base)
·      Occlusal Plane – The plane separates the maxillary and mandibular molars
·      Facial Plane – Nasion to the FH
·      Mandibular Plane – Tangent to the inferior border of the mandible
·      Pterygoid Vertical Plane – Line perpendicular to the FH through the PT point (very stable as growth has little effect on this plan; vertical reference plane
·      Basion-Nason plane (BN) – Basion to Nasion plane (represents cranial base)
·      Facial Axis (FX) – Pt thorugh the gnathion
·      Palatal Plane (PP) – plane extends through the ANS and posterior nasal spine PNS.

Orthodontic Treatment in the Primary Dentition

Department of Pediatric Dentistry
Lutheran Medical Center

Resident’s Name: Nicholas Paquin                                                                              Date: 9/30/2015

Article Title: Orthodontic Treatment in the Primary Dentition
Author(s): John R. Christensen, Henry W. Fields, JR.
Journal: Cassamassimo Text
Major Topic: Orthodontic treatment in primary dentition
Type of Article: Literature review – Textbook
Main Purpose: To know when to treat and when to postpone orthodontic treatment in primary dentition
Summary: Arch length problems are usually associated with early posterior primary dentition loss. Space regaining can be instituted if the permanent first molar has not yet erupted using a removable appliance with multiple clasps and a finger spring. The repositioning occurs at approximately 1mm per month, so a timeline can be given to the parent. Anterior cross bites are usually not corrected unless there is a functional shift. Due to age and the fact that the incisors will usually exfoliate by the age of 6. Anterior open bites are usually due to habits, both parents and patients must be motivated to stop the habit, the appliance must remain in place for at least 6 months.
Posterior crossbite is usually a result of constriction of maxillary arch, often times from an active habit (not always). Must establish whether there is an associated mandibular shift, if so treatment should be started to avoid possible asymmetrical growth of the mandible. Where there is no shift, treatment is usually delayed until the permanent first molars erupt, unless severe crowding in present. Correction of crossbite in primary molar region during mixed dentition, increases the chances of proper occlusion once premolars erupt. A W arch is a fixed appliance used to fix posterior crossbite.
There are two basic approaches to the management of posterior crossbite in young children: (1) equilibration to eliminate mandibular shift, and (2) expansion of the constricted maxillary arch. In a few cases, the mandibular shift is due to interference caused by the primary canines. These cases can be diagnosed by repositioning the mandible and noting the interference. Selective removal of enamel with a diamond bur in both arches eliminates the interference and the lateral shift into crossbite. This type of treatment has evidenced-based support.

Key Points
- Skelatal problems - Skeletal problems are addressed only if there is progressive asymmetry as a result of a functional disturbance. The reason for treating these patients early is that treatment at a later time may be more difficult and complex if the child continues to grow asymmetrically and if dental compensation increases. The goal of early treatment is to prevent the asymmetry from becoming worse or to alter growth so that the asymmetry improves.
-The majority of progressive asymmetry patients are treated first with removable functional appliances that are designed to alter growth by manipulating skeletal and soft tissue relationships and allowing differential eruption of teeth. Orthognathic surgery is a second treatment for progressive asymmetry but is reserved for patients with the most severe asymmetry or those whose condition does not respond to functional appliance therapy. Some syndromes should be referred early to craniofacial orthodontists including cleft lip and palate, hemifacial microsomia, Crouzon and Apert syndromes, and mandibulofacial dysostosis (Treacher Collins syndrome).
- Dental Problems - Selected dental malocclusion in the primary dentition is readily managed by the practitioner who has knowledge of fixed and removable appliances. The clinical implication of cellular change, tooth movement, and cellular reorganization is that orthodontic appliances should be reactivated only at 4- to 6-week intervals with a light, continuous force to avoid injury to the periodontium. Relapse is likely if retention completed.
- Arch length problems - The most common arch length problem in the primary dentition is tooth loss. If space has been lost, which can occur in the posterior sextants because of the tooth loss, space regaining can be instituted. A notable situation in which to use space regaining is when the primary first molar is lost prematurely. Thus the only realistic space regaining in the primary dentition is repositioning of the primary second molar before permanent first molar eruption. A removable appliance is best used for this purpose. A primary second molar can be repositioned approximately 1 mm per month using a removable appliance with multiple clasps and a finger spring. Three millimeters of molar movement is a realistic extent of the treatment. This appliance is similar to the appliance used to reposition a permanent first molar. There is little relationship between the arch length (arch perimeter) in the primary and permanent dentitions. This early approach to potential crowding remains controversial and unsubstantiated. Studies have shown that up to 4.5 mm of crowding can be treated in the late mixed dentition simply with the use of a passive lower lingual arch.
-Intrusion and protrusion - The primary teeth will be exfoliated near 6 to 7 years of age, it is probably not wise to consider moving a primary incisor much after 4 years of age. So, compliance can be a problem before age 4 years, and the resorptive issues as well as those related to tooth morphology are a problem after the age of 4 years. Because of these issues, few clinicians attempt treatment for anterior crossbites in the primary dentition. In some cases of posterior crossbite or occlusal interference, a child positions the jaw forward (known as a mandibular shift) to achieve maximal intercuspation and an anterior crossbite results (usually called a pseudo class III malocclusion because the patient is not really class III but some other type, often class I). In this situation, the patient only positions the lower jaw forward to obtain comfortable intercuspation as needed to function. This type of anterior crossbite is due to jaw posturing rather than tooth or jaw malposition. In these cases, treatment is directed to the posterior crossbite or the occlusal interference and not to the anterior crossbite. In some cases, the interfering tooth is the one in crossbite.
Excessive overjet in the primary dentition is usually due to a nonnutritive sucking habit or to a skeletal mismatch between the upper and lower jaws. This habit needs to be stopped, but both the parent and the child need to be motivated to stop the habit before appliance intervention. Once stopped, retention for 6 months before.
Posterior crossbite - Posterior crossbite in the primary dentition is usually a result of constriction of the maxillary arch. Constriction often results from an active digit or pacifier habit, although there are many cases in which the origin of the crossbite is undetermined. The first step in managing a posterior crossbite is to establish whether there is an associated mandibular shift. If a mandibular shift is present, treatment generally should be implemented to correct the crossbite. Some authors have implicated a mandibular shift as the cause of asymmetric growth of the mandible. The asymmetry is thought to occur because the condyles are positioned differently within each fossa. Muscle and soft tissue stretch exert forces on the underlying skeletal and dental structures that may alter normal growth and arch development. If no shift is detected, the mandible should grow symmetrically.
When there is no shift, treatment is usually delayed until the permanent first molars erupt, unless gross crowding is present. In this situation, expansion of the arch should result in more room for the primary and permanent teeth. If the permanent molars erupt into crossbite, treatment can be initiated if no other malocclusion exists. When the permanent molars erupt normally and there is no mandibular shift, treatment may not be indicated for the crossbite of the primary molars until the premolars erupt. Correction of the crossbite in the primary molar region during the period of mixed dentition increases the chance that the premolars will not erupt in crossbite.
There are two basic approaches to the management of posterior crossbite in young children: (1) equilibration to eliminate mandibular shift, and (2) expansion of the constricted maxillary arch. In a few cases, the mandibular shift is due to interference caused by the primary canines. These cases can be diagnosed by repositioning the mandible and noting the interference. Selective removal of enamel with a diamond bur in both arches eliminates the interference and the lateral shift into crossbite. This type of treatment has evidenced-based support.

The clinician needs to differentiate skeletal problems from dental problems in order to properly treatment plan. Treatment of skeletal malocclusions in this age group is ordinarily deferred until a later age. First, the diagnosis of skeletal malocclusion is difficult in this age group. Subtle gradations of skeletal problems and immature soft tissue development make clinical diagnosis of all but the most obvious cases difficult. Second, the amount of facial growth remaining when the child enters the mixed dentition years is sufficient to aid in the correction of most skeletal malocclusions. Third, any skeletal treatment at this age requires prolonged retention because the initial growth pattern tends to reestablish itself when treatment is discontinued.

Personality Development: Managing Behavior of the Cooperative Preschool Child

Department of Pediatric Dentistry
Lutheran Medical Center

Resident’s Name:                                                                                                        Date:

Article Title: Personality Development: Managing Behavior of the Cooperative Preschool Child
Author(s): Jimmy Pinkham
Journal: Dent Clini N America
Date: 1995
Major Topic: Behavioral Management
Type of Article: Expert Opinion
Main Purpose: Child patient management skills
Key Points/Summary:

Child patient management skills are essential for the dentist who wants to successfully manage preschool children. For practicality, dentistry for the preschool child is best thought of as a complex communication between the dentist and the child. Without good communication, a dentist often needs to resort to other management strategies outside the domain of language. It can be asserted that most children will be competent enough in language by their third birthday or shortly thereafter to be managed through language processes. Communication and coaching skills are important for the dentist of any age of patient, but is essential in dentistry for the preschooler.

Overview of Behavior Management Domains for the Preschool Child

There are five domains of management techniques in which a dentist can manage a child: physical, pharmacologic, aversive, reward-oriented, and linguistic techniques.

Physical Domain

Papoose board, pedi-wrap, mouth props are considered physical. Physical restraint is also a form of management, but if it involves having the child restrained over a long dental appointment, it is tiring for both the patient and the dentist.

Pharmacologic Domain

Includes use of nitrous oxide/oxygen, the delivery of medications by a variety of routes, and general anesthesia.

Aversive Domain

Includes voice control, time out, and hand-over-mouth. According to the author, aversive techniques work, although they have won the title of aversive because they can be noxious to encounter and in the case of some parents, quite impossible to observe. As methods to manage preschool children, aversive technique should be only a small part of the list of abilities that a dentist brings to the preschool children.

Reward-Oriented Domain

Reward-oriented behavior management techniques have been around for a long time. The use of rewards by a parent may be dangerous, however-the child may interpret his or her upcoming appointment as a threat because his dental appointment appears to be anxiety provoking for the mother/father.

Linguistic Domain
Linguistic techniques are the techniques of choice for working with a cooperative preschool child. Two constitutive speech acts (requests and promises) allow for humans to take effective actions together. The child’s dental appointment may be regarded as a series of requests by the dentist to the child. The success of working with cooperative or potentially cooperative preschoolers in the linguistic domain is based on the ability of the clinician to frame effective requests and also to effectively reframe when they are denied. The process of conversation evokes various ways of aiding in the management of a preschool child. If the child is actively engaged in a conversation by asking questions or answering questions or making comments, then the conversation itself serves as a distraction and keeps the child from worrying about future events during the dental experience.

The Origin of Misbehavior for seemingly “Normal” children

Knowing why a child may misbehave is a useful assessment for the dentist. This knowledge can help maintain cooperativeness. Top three real fears children have about the dental experience are: previous bad experience, acquired (sibling, playmates, parents), needle (pain). There is also a potential of acquiring fear form the clinician-the emotional state of the dentist or dental assistant certainly can have an impact upon the preschool child. The dentist who treats children is encouraged to be calm and poised. Quick or jerky movements, inattentiveness, and failure to talk to the children in terms the child can understand should be avoided.

Children with Special Life Circumstances

Illness, trauma, and poverty may affect behavior. Pinkham states that children of poverty have a more compromised ability to work well with adults, particularly adults that are authoritative and seeking compliance, than do other children. It has been noted that the abilities of poverty-stricken children to learn and communicate are affected adversely. The dentist may need to go slower and repeat himself or herself more often than usual. It is very important for the dentist who interfaces with the children of poverty to understand that extra patience and explanation will probably be required for all but the simplest dental procedures.

The Dentist as an Ontological Coach

The dentist is encourages to become a coach, an ontological one, of his child patients. The dentist who actively engages patients in instructive coaching behavior, uses information to desensitize a perhaps suspicious patient, gives strong encouragement to a child who is looking for such, and reminds a wary child that the dental appointment made by the parent is all about that parent loving the child will find the behavioral management of the preschool child to be rewarding.

Assessment of Article:  Level of Evidence/Comments:

Level 3-Expert Opinion

The communication of pain in Paediatric Dentistry

Department of Pediatric Dentistry
Lutheran Medical Center

Resident’s Name:             Leslie M Slowikowski                                                        Date: 09/30/2015
Article Title: The communication of pain in Paediatric Dentistry
Author(s): J Versloot, K.D. Craig
Journal: European Archives of Paediatric Dentsitry
Date:  2009
Major Topic: Pain and the paediatric patient
Type of Article: position paper
Main Purpose: review the communication model of pain, apply it to the understanding of acute pain, the purpose is to direct to improving the process of pain assessment
Key Points/Summary:  Acute pain is a highly dynamic and subjective experience.  There are typical expressions but usually ambiguous as to their meaning and source, especially in young children and others who are limited in verbal skills needed to report or describe pain.  Pain is a concrete experience and abstract concept.  Children’s understanding of pain and their ability to describe it change in predictably developmental sequence.  Craig and colleagues have proposed a model for understanding the numerous social factors that affect whether children are successful in communicating painful distress. 

Tissue damage and subjective experience to pain:  reaction to tissue damage is individual, some patient are very stoic and others can be hysterical.  Must be careful attend to tissue damage even when it is less obvious, sensitivity to early carious lesion. 

Pain experience:  Central to understanding the impact of painful events is a child thoughts and feelings experienced in the course of an event.  Specific to dentistry is dental anxiety, previous experience, and child’s ability to cope.  Parents can helpful allowing the patients to express themselves but also hinder if they have dental anxiety themselves. 

Pain expression:  Crying, facial expression and bodily activity all convey information of great importance to observers.  In older patients observation of nonverbal behavior in older children and adults.  This is important because it enables children to engage other who may assist them in pain. 

Pain assessment:  Self-report and observational behavioral measures provide the major tools for understanding children’s unique and variable pain experiences.  4 years and older self-reporting can be useful.  Children 4 years and older can use the faces scale.  Children 8 years and older numerical scales and visual analog scales can be used.  However there is are complexities such as who is asking, dentist or parent, there is increase in pain when reported to the parent or if the child can provide self-reports there is a pervasive and systematic tendency to underestimate the pain experience of others.  “Pain blindness” can result when healthcare professionals who often work with painful procedures under estimate the child’s pain level.  The use of systematic scales to guide judgments can reduce the risk of erroneous judgment. 

Pain management:  When pain is underestimated there is considerable risk of failure to deliver needed care.  Good pain management is important and includes topical analgesia, local analgesia, and behavioral management.  Characteristics of the caregiver are important to recognize, minimize and treat pain.  For example, levels of empathy, training and personal judgment.

Conclusion:  In vulnerable populations like toddler and preschooler who have limited verbal abilities being aware of nonverbal communication of pain is very important.  Also being aware of patient’s characteristics such as dental anxiety, previous experience and coping abilities is important and are factors that influence children’s pain experience and expression.  Use of valid reliable pain assessment methods to accurately assess pain is key to adequate pain management.  Finally, look at dental pain from a social and communication perspective, patient/caregiver viewpoint. 

Assessment of Article:  Level of Evidence/Comments: Ib