Children’s Orthodontics

INTERCEPTIVE ORTHODONTICS

them with a correct occlusion.Orthodontics in children is relevant in the developmental or interceptive age. The interception of functional problems or bad position of the dental arches is the basis of the diagnosis in this period of skeletal development. Between 5 and 10 years of age during the growth phase we have the possibility of intercepting and treating, with  predictable results, problems of the maxillary skeleton and / or of the jaw, which are the bases on which the permanent teeth will be positioned, intervening to remedy them lest they present difficult-to-resolve structural conditions in later life. For this reason, in child orthodontics, we focus on the reciprocal positions of the dental arches on the 3 planes of  space, analyzing both the existing skeletal conformation and any anomalous positions of the deciduous teeth that may structure an altered occlusion on which the maxillary and mandibular skeleton  could conform wrongly.

Depending on the seriousness of the problems we encounter, it may be necessary to intervene as early as possible (5 – 6 years), or evaluate the young patient during his growth and, if necessary, intervene around 9 – 10 years.

Dental-skeletal dysfunctions that we encounter in this growth phase may originate from several factors:

• genetic factors
• traumatic factors
• bad habits (protracted sucking of the thumb or pacifier …)
• early loss of milk teeth
• altered positions of the milk teeth
• oral respiration

The diagnosis of these problems is carried out by the specialist clinician, through a rigorous course of examination linked to both the anamnesis and to a direct study of the specific case.

Here, we summarize the problems frequently encountered in children comparing

PALATAL EXPANDER

The palatal expander or separator is a fixed device used in interceptive practices, which permit the enlargement of the palatine bone to solve functional problems at the jaw bone level.

The age range useful for this type of treatment varies from 5 – 6 years up to 9 – 10 years. The age of the patient is not a negligible factor, since up to 11-12 years (approximately) the bones of the palate continue to grow and are therefore easily malleable. After this,  growth stops and the bones of the palate merge together becoming a single element, therefore impossible to modify, if not in a surgical way.

The creation of this device is done in the laboratory. The technician is given the impression of the upper arch taken in the clinic with all the useful information to calibrate the device, which will be cemented into the patient’s mouth and removed at the end of the therapy.

Once a  mouth, the device will undergo “activation”, that is, it will be gradually enlarged until it reaches the appropriate shape of the palate.

MYOFUNCTIONAL DEVICE

The myofunctional device is a removable device that works simultaneously on the bone, muscles and dental elements. This therapy can be in addition to a previous palatal expander therapy or can be inserted individually according to the specific case.

CHILDREN’S ORTHODONTICS AND POSTURE

Adequate cranial mandibular growth is of great importance not only for the development of the oral cavity, but also for the realization of a correct postural construction.

The relationship between the mouth and the postural system is now widely credited and for this reason, the growth phase plays a fundamental role in programming  development.

There are different assessments that are carried out at our centre which are fundamentally linked to the verification, as early as possible, of various types of imbalances that are sought through observation of the craniofacial area. This is to prevent it from becoming structured in such a way to involve a functional alteration of the mouth, as well as triggering off a descending imbalance that may affect the child’s postural development.

A visit as early as possible in children offers the possibility to prevent  or remedy  problems that are more difficult to solve in adulthood, as well as allowing precise and predictable therapies in harmony with the general system of the body

Dr. de Nicolo has structured protocols with his team that permit a careful evaluation of the subject where needed, by means of a multidisciplinary evaluation in various specialized areas (Osteopathy, Massage Therapy, Ophthalmology, Otolaryngology, Speech Therapy, Podiatry …), in order to intercept the cause of the imbalance and mediate it with the appropriate specialist.

PRE- ALIGNMENT

Generally, interceptive orthodontic therapy does not provide for dental alignment, in that it is not necessary.

Dental pre-alignment can be expected in particular cases such as:

• Serious imperfections that could cause socio-psychological inconvenience in the child;
• Severe dental crowding that could interfere with the correct development of the skeleton.

Pre-alignment, which is carried out exclusively on the upper arch, involves the central incisors and the lateral incisors, on which orthodontic brackets are cemented, smaller than those used for fixed orthodontic therapy. Within these brackets an arch is mounted which starts the alignment.

This orthodontic therapy is called pre-alignment as it precedes the definitive alignment of the fixed orthodontic therapy.

WHAT IS MALOCCLUSION

The term malocclusion refers to all those factors that negatively affect the dento-skeletal balance. This can be manifested in several ways:

• Dental misalignment
• Disharmony between jaw bone and jaw growth

They can be caused by multiple factors including:

• Inheritance
• Disorders in the development of the bases of the bone and the teeth (skeletal imbalances)
• Bad habits (such as prolonged sucking on a pacifier and / or thumb; oral breathing; onychophagy; incorrect swallowing)
• Premature loss of deciduous or permanent dental elements (due to caries and / ortrauma)

Many malocclusions can be prevented by controlling environmental factors that can negatively influence the growth of the jaws and the development of the teeth.  Other forms of prevention can be carried out by the dentist, intercepting and removing the problems that can hinder a correct development.

Since malocclusion is, in fact, a break in the balance, the main purpose of orthodontics is to restore the dento-skeletal balance, thereby improving the aesthetics of the smile.

ORTHODONTICS  AND MALOCCLUSION

F. Grazioli, P. Ranaudo, C. Condorelli, G. de Nicolo: Dall’otoneurologia alla posturologia statica e dinamica – Valutazione della sintomatologia vertiginosa da deficit degli ingressi sensoriali

SAGITTAL PLANE

First dental class

The mesio-vestibular cusp of the 1st upper molaroccludes in the vestibular sulcus of the 1st lower molar, while the cusp of the upper canineoccludes between the distal side of the canineand the mesial side of the 1st lower premolar. It is referred to as correct occlusion or normo-occlusion, since the relationships that are established between the various dental elements in this type of occlusion allow an effective and efficient function with less energy expenditure. Obviously, as mentioned in the introduction, the remaining factors that influence the whole system must also be in balance. Precisely for this reason, the correct occlusion is given by a concert of small and large balances that derive from both contiguous areas and from near or distant areas. The same class 1 molar and canine occlusion can present position defects of some dental elements, creating what are called crowding, that is, partial overlapping of some dental crowns which are caused, for example, by inadequate shape relationship between the reciprocal elements contiguous or antagonistic. In addition, the balance of class 1 involves adequate muscle activity, collaborates in achieving and / or maintaining postural balance.

Second dental class first division and second division

Class 2 has similar molar and canine ratios, with differences related to the pro-inclinations or endo-inclinations of the frontal groups.

These different positions of the front elements are attributable to various factors. In particular, we can mention neuromuscular imbalance both in the tongue and in the lips. Imbalance of the lips can occur through a muscle hypotone (for divisions 1), or a muscle hypertone capable of endoinclining the elements of the frontal group (division 2). The vestibular sulcus of the first lower molaris distal to the mesiovestibular cusp of the first lower molar. The superior canineis advanced compared to the inferior canine. The etiopathogenesis of classes 2 can be due to numerous factors. Genetics, trauma from gestation or childbirth that affect the conformation of the skull, parafunctions, facial skull development in childhood, oral respiration, early loss of dental elements, neuromuscular disorders, postural attitudes, more complex syndromes etc. Class 2 can be the result of a dental mal-position, but also of a skeletal mal-position. From the point of view of the skeleton, we can find ourselves in front of a more advanced maxilla with a correct sized jaw, conversely we could have a correct sized maxilla and a smaller or rear positioned jaw, or we could have the sum of the 2 factors. Therapies in different situations are different and require levels of attention appropriate to the severity of the case. From a functional and postural point of view, class 2 negatively affects the neuro-muscular and articular system. When we have a rear-positioned jaw for example, this has impact on the TMJ causing dysfunctions that over time can lead to imbalances that activate more complex disorders, especially when associated with other levels of imbalances or parafunctions (for example, clenching or bruxism). Even the anterior wall that often occurs in division 2, due to the deep bite between the upper and lower frontal group, causes a really significant functional limitation.

Third dental class

The third dental class sees the vestibular sulcus of the first lower molarin a mesial position with respect to the mesiovestibular cusp of the first upper molar. The cusp of the upper canine is positioned distally with respect to the cusp of the canine at more than 3 mm.

An occlusion is defined as incorrect, the etiopathogenesis of which has a strongly genetic component but it can also be caused by several other factors such as: trauma from gestation or childbirth, parafunctions, (defined as fake third classes), due for example to factors that require the jaw to take a more advanced position to function better, neuromuscular disorders, postural positions, more complex syndromes etc.

FRONT PLANE

Normal bite

The correct closure of the dental arches provides for the coverage of the upper arch with respect to the lower of 2 +/- 2 mm.

This closure allows adequate protrusion and lateral movements during the different functions of the mouth.

Deep bite

When the dental elements close excessively between themselves, leading to an excessive coverage of the upper arch compared to the lower one, we are faced with a deep bite. As already mentioned, it functionally causes a blockage of the normal function of the mouth, often causing muscle and temporo-mandibular dysfunction. The deep bite can be anterior or posterior, unilateral or bilateral.

Open Bite

The open bite is characterized by an opening of the space between the teeth of the two arches, which does not allow adequate support and therefore correct occlusion. It is caused by various factors: neuro-muscular dysfunctions, oral respiration, atypical swallowing, dental mal-position, mandibular mal-position.

TRANSVERSE PLANE

On the transverse plane apart from the shape of the arches ( which must be appropriate to the age, the dental  shape  of the subject, as well as having an ovoid shape) there is the aspect of the relationship of the lateral closure of the two arches. When the upper arch is proportionally smaller than the lower arch, or vice versa, we may find ourselves in front of an incoordination of the two arches, so that  cross-chewing  may occur which can be unilateral or bilateral.

Unilateral cross bite

Unilateral cross-bite occurs with a more or less significant deviation of the lower median from the body median. The etiopathogenesis can be linked to several factors: genetic, skeletal, syndromic, from trauma from gestation or childbirth, from parafunction, from ogival palate, from oral respiration, from dental pre-contact with sliding towards a more comfortable position. Unilateral cross bite, if not intercepted early, can lead to a later functional deviation in developmental age becoming structured in adulthood as a facial asymmetry.  Early treatment is highly necessary.

Bilateral cross bite

Bilateral cross bite has the same genesis and characteristics as the unilateral cross bite, with 2 characteristics that distinguish it:

1. cross bite is present both on the right and on the left;
2. it develops a symmetry that makes it, although more serious than the unilateral cross-bite in terms of proportional discrepancy between the two arches, less serious on the asymmetric front, since being present on both sides, most of the time it does not cause facial asymmetry.

Cross-bites are also defined by functionalists as mouth scoliosis. From a functional point of view, they have a negative impact on almost all the functions of the mouth, as well as on the postural level. They cause conditioning, due to the asymmetric function of the muscles, which affects the descending muscle chains.