Sunday, October 30, 2016

Department of Pediatric Dentistry
Lutheran Medical Center
Resident’s Name: Jonathan Kaczmarski    Mentor:   Dr. Hencler Date: 11-02-16
Article Title: Orthodontics and temporomandibular joint internal derangement
Author(s): Richard Katzberg, Per-Lennart Westesson, Ross H. Tallents, Christiana M. Drake
Journal: American Journal of Orthodontics and Dentofacial Orthopedics
Date: 1996
Major Topic: Internal derangement of the TMJ in asymptomatic and symptomatic subjects
Type of Article: Research Article / Case-Control Study
Main Purpose: To compare the internal derangement of the TMJ in asymptomatic versus symptomatic subjects using MRI
Key Points: (2 lines Max): Main conclusion or the most interesting

Key Points/Summary:

To compare the prevalence of internal derangement of the TMJ in asymptomatic volunteers versus symptomatic subjects using MRI, with a detailed comparison to clinical signs and symptoms and with attention to a prior history of orthodontic treatment.

Bilateral MRI scans were obtained of the TMJs in 76 asymptomatic volunteers and 102 symptomatic patients. A comparison was made based on the clinical signs and symptoms, a history of orthodontic treatment, and MRI findings. The MRI scans were reviewed using established criteria for disk displacement and the reviewers were blinded as to the clinical information. 

Prevalence of disk displacement in 25 of 76 (33%) asymptomatic volunteers and 79 of 102 (77%) patients with a statistically significant difference (p < 0.001). No statistical link was noted between a history of prior orthodontic treatment and internal derangement of the TMJ.

Drace + Enzmann: Suggested a strong correlation among abnormal joints detected in asymptomatic volunteers with a history of Ortho treatment. Of all subjects with a history of Ortho treatment, 6 of 17 (35%) had obvious internal derangements of the TMJ. Two subjects had history of multiple tooth extractions. Thus, of the total number of 30 subjects, 8 (27%) had either Ortho treatment or multiple tooth extractions.
Kaplan: Found no evidence of internal derangement in 31 asymptomatic volunteers with TMJ arthrography.

No association between orthodontic treatment and TMJ internal derangement either in volunteer subjects or in symptomatic patients.
Remarks: Special Guest: Barry Hinderstein- Private practice limited to TMD and Orofacial Pain for 25 years, Houston and Asheville, NC. Worked as an adjunct professor at the UT School of Dentistry, and a member of the Facial Pain Team with Dr. Mark Wong, who is the current chair of Oral and Maxillofacial Surgery
1.     I remember this and other Katzburg articles. He, Pullinger and Westesson are known to me. I communicated with Katzburg in the 90's and questioned whether he could predictably draw clinical conclusions from radiographic and mri imaging. I think I received a huffy reply. The truth is that these imaging studies tell you about structure. Without long term studies following  patients vs  non-patients you cannot determine causality.
2.     Dr. Hencler-  A) In the review of this article no association between orthodox tx and TMJ disc derangement was found.  This finding is important to pedo dentists as many of our patients complete ortho tx while under our care. In private practice setting I encounter TMD in older children who in mixed dentition or teens who report bruxism.  The AAPD reference manual states ["prevalence of signs and symptoms of TMD increases with age"]
            B)    Development of TMD can be multifactorial and is often difficult to diagnose as well as treat.  TMD caused by bruxism can be managed with an occlusal guard by pedo dentists.  According to the AAPD reference manual ["Therapeutic modalities to prevent TMD in the pediatric population are yet to be supported by controlled studies. For children and adolescents with signs and symptoms of TMD, reversible therapies (such as physical therapy, occlusal guard) should be considered. Because of inadequate data regarding their usefulness, irreversible therapies (such as ortho tx, surgery) should be avoided"].  More severe TMD causes and symptoms should include a multi specialty approach to dx an tx. 

Assessment of Article:  Level of Evidence/Comments:

Friday, October 28, 2016

Resident’s Name: Brian Darling Mentor: Dr. Sapir                                                  Date: 11/2/16
Article Title: Prediction of tooth emergence
Author(s): Anna-Marie Gron
Journal: Journal of Dental Research
Date: 1962
Major Topic: Correlation between tooth emergence and skeletal age and stage of root formation
Type of Article: Cohort study
Main Purpose: This article aimed to investigate relationships between skeletal age and root formation and the emergence of teeth.
Key Points: (2 lines Max):
·      Root development is more closely associated with timing of tooth emergence than chronological or skeletal age.
·      Most teeth emerge with ~¾ of their roots developed.
·      This study reinforced the girls before boys tooth eruption pattern.
·      Good table below shows the ranges and differences in tooth emergence for different teeth in boys and girls.
·      This study to found the most asymmetry between right and left sides in stage of root development in premolars. Lower central incisors, canines, and first molars demonstrated no cases of being a full stage of root development different between right and left sides.
o   Asymmetric premolar development may be associated with differences in eruption due to lack of space or premature loss of deciduous predecessor.
·      No teeth emerged with less than ¼ root or a closing apex in this study.
·      Most teeth emerged when they had ¾ of their root lengths.
o   Mandibular first molars and central incisors tended to emerge with ½ of their roots formed.
o   Mandibular canines and 2nd molars tended to emerge a little after ¾ of their roots formed.
·      Good table below shows variations among stage of root formation and chronological age and males versus females in regards to when individual teeth emerge.

·      Tooth emergence was not closely associated with skeletal age in this study (or at least not as well associated with tooth emergence as either chronological age or root formation).

Per Dr. Sapir (I hope this is an accurate representation of what he thinks J)
1- Methodology has a bias toward overestimating the root length during emergence because the model they used for measuring root length was based on radiographs where a tooth was erupting too early. Because of this, the study may have had a tendency to say the root was longer than it actually was at the time of eruption.

2- Results similar to Fanning study because they used a similar population (Boston children) during about the exact same time period. This is a big reason why their results are so similar.

Wednesday, October 26, 2016

Early treatment of palatally erupting maxillary canines by extraction of the primary canines.

Early treatment of palatally erupting maxillary canines by extraction of the primary canines.
Semantha Charles DDS                 Date: 10/26/2016

Mentor: Dr. Downey

Sune Ericson and Juir Kurol, Jonkoping, Sweden
European Journal of Orthodontics Issue 10: 1998.

Purpose: The maxillary canine is the second most commonly impacted tooth, behind third molars.  It effects approximately 2% of the population. Of these patients, 85% are palatally impacted, 15% are buccally impacted. A thorough search of the previous literature showed “sporatic” case reports where extractions of the primary canine had favorable results upon eruption of the permanent canine.  No systematic longitudinal study to evaluate the effect of primary canine extraction on the palatally deflected path of eruption of maxillary canines has been carried out. Therefore, the goal of this study was evaluate the effect of extraction of the primary canine on palatally erupting max canines.

Method: 46 consecutive ectopic palatally placed maxillary canines were studied. 14 boys and 21 girls between the ages of 10 and 13 were referred for treament. The position of the canines were carefully determined in three planes; the frontal plane, the transverse, and the sagittal. Primary canines were extracted immediately after discovery of the position of the permanent canines. In 4 of the 46 cases the lateral incisors already showed root resorption.  All cases had good dental arches and no space deficiency was registered after measuring with sliding calipers.

- 36 of the 46 ectopic canines showed normalization of the path of eruption and later clinically correct position at the final control.
- 23 of the 36 normal final results showed improved position by 6 months of these 23, 9 had already normalized by 6 months.
- Of the 46 canines, 22 overlapped the adjacent lateral incisor by more than half the root of the lateral, 14 of these normalized. Of the 24 that overlapped the root of the lateral by less than half, 22 normalized.
- Complete normalization occurred in 78% of canines in relation to their previous lingual position.
- 10 of the 46 canines showed no change or an impaired position.
- No new cases of resorption were recorded throughout the study. Of the 4 cases noted at the start of the study, 2 normalized, 1 had no change and the last has an impaired position.
- Dentical follicle exceeded 3mm in 13 cases and varied between 1 and 5 mm for the 46 canines.  No association could be made between the size of the follicle and the cases that did not improve.


Some of the data and studies are outdated I realize and the article itself is from the mid eighties! But I don't believe much would change for this particular subject? I feel like if there is any question of the max canines having any trouble erupting into the arch than the first thing really is to take out an over retained primary canine and make go from there in terms of any further treatments, uncovering and gold bracketing the permanent. Among other treatment, the deciduous canines never seem to cause problems when they are extracted keeping in mind obviously the patient age and timing of eruption of the permanent. Several studies in this article seem overall supportive of this just idea they just have a lot of different measurements and extra things they talk about in relation to the extractions. 

Effect of Extraction of Deciduous Molars on the Formation and Eruption of Their Successors

Department of Pediatric Dentistry
Lutheran Medical Center
Resident’s Name: Nicholas Paquin                                                               Date: 10/26/2016
Faculty Mentor: Dr. Nobrega

Article Title: Effect of Extraction of Deciduous Molars on the Formation and Eruption of Their Successors
Author(s): Elizabeth Fanning, DDS
Journal: Angle Orthodontics
Date: 1962
Major Topic: Effects of extracting deciduous molars on the formation and eruption of permanent teeth
Type of Article:
Main Purpose: To understand what clinical implications there will be on premolars from extracting their associated primary molar early
Key Points: (2 lines Max): 1. Immediate spurt occurred in the eruption of the premolar regardless of its stage in development and the age where the primary molar was removed. 2. Premolar eruption time (early or delayed) is dependent on how much bone is covering the premolar at time of extraction of primary molar.  
-        Only 4 boys and 4 girls were selected from 134 for this study. The patients all had undersgone early and unilateral extraction of deciduous molars to use contralateral side as a control.

-        2 conclusions applied consistently: 1. Rate of root formation of the premolars did not change after the extraction, 2. An immediate spurt occurred in eruption of the premolar following the extraction regardless of its stage in development.
-        Premolars typically erupt when ½ - ¾ of the root are formed. Deciduous molars should not be removed until ¼ - ½ of the premolar root is formed (for spacing reasons/serial extraction)

-        Extraction of deciduous molar before the premolar crown was completely formed resulted in a brief spurt that leveled off, the tooth remained stationary until further root formation, sometimes at a slower speed than the other side: may be explained by formation of scar tissue that provides mechanical barrier, also there is no resorbing tooth that may provide a pathway.
-        Extraction of a deciduous molar at a later period when premolar is well along in root formation (it should have active erupting forces), results in accelerated eruption.
-        Extraction of deciduous tooth with extensive bone loss can result in early eruption regardless of root development status (likely due to initial spurt of eruption with no bone to fight throught)

-        2 instances – premature loss of deciduous mandibular first molars in girls resulted in impaction of 1st pre-molar because of rapid development and early emergence of the permanent canine. In boys this did not happen because the canine develops at a slower rate and emerges later than in girls.
-        Loss of primary second molar may result in impaction of second premolar due to drifting of 1st molar (need for space maintenance).

-        Serial extraction – deciduous tooth should be removed at a time when permanent successor will not be delayed (too early=delayed eruption). Correct planning of extraction ( ½ – ¼  root) will result in accelerated eruption to allow extraction and alleviate crowding.
Nick: Good information on serial extraction and reasons for delayed vs accelerated eruption of premolars. I don’t understand the reason for impaction of 1st premolars in girls vs boys, unless space loss is an issue as the eruption sequence in the mandible should be canine – first premolar – second premolar. Aside from losing space, early loss of the first primary molars accelerating the eruption of the canine resulting in impaction of the first premolar doesn’t make sense. Impaction of the second premolar would make more sense since we have so much crowding makes sense since the 1st premolar erupts before the 2nd premolar, unless the delay resulted in the first premolar erupting after the second premolar.

Dr. Nobrega
1- The consideration of the canine impacting the premolar could be from distal eruption of the canine since the primary molar is no longer there. This is a good article to understand the effects of extraction of primary molars. It should be considered with ankylosed teeth not to rush to extraction, unless there is a large submergence causing a boney defect.

A Longitudinal Study of Tooth Formation and Root Resorption

Department of Pediatric Dentistry

Lutheran Medical Center
Resident’s Name: John Diune   Mentor’s Name: Dr. Shabtai Sapir   Date: 10/26/2016

Article Title: A Longitudinal Study of Tooth Formation and Root Resorption
Author(s): Elizabeth A. Fanning, D.D.S.
Journal: The New Zealand Dental Journal
Date: Oct 1961
Major Topic: Growth and Development
Type of Article: Longitudinal study
Main Purpose: Longitudinal study investigating norms of tooth formation and root resorption for maxillary incisors and all mandibular teeth except 3rd molars; and includes analysis of effects of extraction of deciduous tooth, agenesis, and fusion in relation to tooth formation.
Key Points: Tooth formation (and root resorption) is preferable to tooth emergence as a means to assess age; as tooth emergence is influenced considerably by exogenous factors
Materials and Methods:
-          48 males and 51 females included in study looking at lateral skull radiographs
Radiographs taken at:
Radiograph intervals:
Total radiographic images:
1 (Lateral skull)
2 weeks after birth
1 (Lateral skull)
3 mth intervals to 1 yr
4 (Lateral skull)
6 mth intervals from 1 yr – 4 yrs
6 (Lateral skull)
6 mth intervals from 4 yrs – 11.5 yrs
15 (Lateral skull)
6 mth intervals from 4 yrs – 11.5 yrs (I/O incisors)
30 (PA’s)
-          Developmental stages was defined for incisor, canine, premolar, and molar teeth by Gleiser and Hunt, but was modified with addition of 3 more apical stages for more precision, as well as evaluating mesial and distal roots of molars separately.
1)      Permanent mandibular 1st molar
a.       Molar crown erupted through alveolar bone when approximately 1/3 of the ultimate root length formed
b.      MB cusp appears first, then DB, ML, DL, and D cusps
c.       After coalescence of inner regions of cusp, whole occlusal surface calcifies
d.      Crown 1st forms along external surfaces, proceeding inward until enamel complete
e.      Mesial root completes formation before distal root
2)      Sex differences in development
a.       Early developmental stages same between male and female
b.      Crown completion earlier in females
c.       Root development even earlier in females (especially canines)
3)      Growth velocity
a.       Deceleration in rate when crown formed and root development begins
b.      Acceleration in root development during active eruption continuing to complete root length formation
c.       2nd deceleration during completion and apical closure of apex
4)      Tooth emergence by root length and sex
 Maxillary central incisors:
Males just before 2/3 of root formed
Females just after 2/3 of root formed
Maxillary lateral incisor:
BOTH just before ¾ of root is formed
Mandibular central incisor:
BOTH just after ¾ root is formed
Mandibular lateral incisor:
BOTH Between ¾ of root formed – complete root formed
Mandibular canine:
Females during early stages of apical root closure
Mandibular 1st molar:
Males between 2/3 – ¾ of distal root formed
Females when distal root ¾ formed
5)      Caries on distal or mesial surfaces of crown of deciduous molars associated with resorption of the corresponding root (possibly due to inflammatory tissue response)
6)      Pulp necrosis lead to disintegration and lysis of the root and surrounding bone
7)      Female more advanced than male in root resorption; difference increases with age
8)      Premolar extractions
a.       Very early extraction resulted in delayed eruption
b.      Eruption speeded up if extraction occurred when premolar already erupting
c.       Long standing abscesses with alveolar bone destruction resulted in early emergence (sometimes with immature root development and migration of premolar)
9)      Root resorption delayed in all cases with agenesis of permanent successor
10)   Fusion of mandibular central and lateral incisors showed root resorption and exfoliation occurred in-between normal resorption and exfoliation of the centrals and laterals
1-      Limited number of patients and limited ethnicity of the patient pool.
2-      P.350 avery and mcdonald – things have changed. More so than the genetic pool, are environmental factors such as diet and exposure of people to diet. Well nourished more now. Example puberty earlier in girls now than in the past. 50-60 years ago, 2-3 generations ago.
Assessment of Article:  Level of Evidence/Comments: