Multidisciplinary management of missing maxillary central incisors in children and adolescents.

Missing maxillary central incisors can impact a patient's psychological wellbeing and smile aesthetics. Comprehensive management of such cases requires a multidisciplinary team approach, often involving orthodontic, paediatric and restorative dental teams. This paper summarises the various management options for these complex patients.

The effect of extraction of the lower first permanent molar on the developing third molar in children.

OBJECTIVE: To find the effect of extraction of the lower first permanent molar in children (aged 8-11 years) on the position and angle of the developing third molar. DESIGN: Retrospective radiographic analysis. PARTICIPANTS: Two cohorts of participants were identified: an extraction group, who had extraction of one or more first permanent molars aged 8-11 years; and a non-extraction group, who retained all mandibular teeth. Both cohorts previously had panoramic radiographs taken at mean ages of 9.7 years (T1), before extraction, and 12.12 years (T2). In total, there were 61 third molars with an associated extracted first permanent molar and 60 third molars with an associated retained first permanent molar. METHODS: A digital radiographic analysis was carried out on the panoramic radiographs to measure the movement of the third molar, vertically and horizontally, and its angle. The magnification of the T1 and T2 radiographs was calibrated. Reliability of the radiographic analysis was confirmed via intra- and inter-rater reliability tests. The extraction and non-extraction groups were compared via independent sample tests. RESULTS: The third molar moved significantly more mesial in the extraction group (P < 0.001) and the angle uprighted significantly more than the non-extraction group (P < 0.001). Vertically, the third molar moved inferiorly in both cohorts with no significant difference. CONCLUSION: In the developing dentition, extraction of the lower first permanent molar encouraged mesial movement and uprighting of the developing third molar. This may improve the likelihood of future eruption of the third molar.

Non-nutritive sucking habits in a child: A clinical protocol to their prevention and management.

Patients presenting with anterior open bites can be challenging to manage. This paper discusses the clinical features and aetiology of anterior open bites caused by non-nutritive sucking habits in a young child. It explores how these should be recognised and how certain interventions can be effective in their management. Whilst further high quality research is needed into the different methods and their effectiveness, the aim of the article is to provide a practical guide for general dental practitioners, orthodontists and paediatric dentists, who are involved in monitoring the developing dentitions of these patients.

'The punch technique' for the soft tissue exposure of superficial, buccally impacted teeth.

The management of impacted teeth can be complex, time-consuming and expensive for the patient and healthcare system. These cases often require referral to a different specialty which increases the overall treatment time and number of appointments. This article introduces a simple, efficient technique using a cylindrical punch biopsy instrument to expose superficial, buccally impacted upper permanent canines and incisor teeth in carefully selected cases. This patient- and operator-friendly technique avoids the need for a referral to a different specialty, gives the orthodontist autonomy of the position of the bond, allows immediate traction, thereby reducing the number of appointments and overall treatment time for the patient.

Preventing white spot lesions with fluoride pastes.

Design Randomised controlled trial.Study population Patients undergoing routine orthodontic treatment, aged 12 years and older, were randomly allocated to use either Clinpro 5000, Clinpro Tooth Crème or MI Paste Plus for 4 months.Data Analysis Three-way analysis of variance (ANOVA) was used to analyse the Enamel Decalcification Index (EDI) scores of the maxillary and mandibular arches from the right first premolar to the left first premolar at 0.05 level of significance. Fisher-protected least significant difference intervals were used to compare mean EDI scores. Two operators scored photographs independently and their scores were compared by using the t-test; no statistically significant difference (P ≥.05) was found between the operators. Results of each product were analysed individually and amongst themselves. A multilevel mixed-effects Poisson regression was used to model factors predictive of EDI scores for individual teeth.Results Of the 120 subjects enrolled, 100 (35 using Clinpro 5000, 32 using Clinpro Tooth Crème, and 33 using MI Paste Plus) completed the study. The data lends support for Clinpro 5000 providing superior protection against enamel decalcification when compared to Clinpro Crème, and mixed support when compared to MI Paste Plus.Conclusions The use of Clinpro 5000, Clinpro Tooth Crème, and MI Paste Plus all have a reduction effect on white spot lesions when compared to studies reported previously. They found Clinpro 5000 to have a marginally better effect than the two other test pastes.

Radiographic prognostic factors determining spontaneous space closure after loss of the permanent first molar.

INTRODUCTION: Permanent first molars (PFM) with a poor prognosis are routinely extracted in children throughout the United Kingdom. National guidelines suggest that to achieve spontaneous closure for the mandibular arch, the PFM should be extracted at 8 to 10 years of age, during bifurcation formation of the second molar. The literature is of limited quality and has suggested alternative variables that may be associated with successful space closure. Our aim was to investigate the radiographic prognostic factors associated with space closure after extraction of PFM. Two objectives of the research are reported in this article: to determine factors that might predict space closure of the second molar after extraction of the PFM, and to develop a tool kit to aid clinical decision making. METHODS: We assessed 148 maxillary and 153 mandibular PFM extracted from 81 participants retrospectively. Dental age, second molar developmental stage, second premolar and second molar angulations, and presence or absence of the third molar were assessed on the preextraction orthopantomograms. Outcome was assessed via visual examination, study models, or radiographs. RESULTS: Closure occurred in 89.9% of the maxillary and 49.0% of the mandibular quadrants. Dental age was statistically, but not clinically, significant in the maxillary arch (P <0.05). For the mandibular arch, presence or absence of the third molar and second molar angulation were statistically and clinically significant (P <0.01 and P <0.05, respectively). A tool kit was developed in relation to the mandibular arch variables. CONCLUSIONS: These findings are contradictory to the Royal College of Surgeons guidelines and suggest that the presence of the third molar and a mesially angulated second molar are favorable for space closure. The developed tool kit requires further validity testing.

A composite photographic image - could it replace a lateral cephalogram?

INTRODUCTION: Computer software allows a photograph of patient's face and a photograph of their dental casts to be combined into one image, similar to that seen in a lateral cephalogram. The aim of this study was to assess the agreement between the measurements carried out on this novel composite photographic image and those taken from a lateral cephalogram of the same patient. METHODS: The method involved the superimposition of a photograph of a patient's dental casts onto a photograph of their profile thus creating a composite image. The position of teeth in relation to the face was then compared on these images and on lateral cephalograms. The distances between a number of facial reference points to the upper right central incisor and the upper right last molar, were measured on both images. RESULTS: The records of 34 participants showed that there was good or acceptable agreement between measurements carried out on composite images and on lateral cephalograms. This agreement was generally better for measurements carried out from the reference points to the incisor tooth than to the molar. However, standard deviations of the mean differences between measurements were relatively high. CONCLUSIONS: The photographic superimposition method eliminates exposure to ionizing radiation and is relatively inexpensive. However, it is not reliable enough to deliver accurate information on the position of teeth in the face.

Failure of eruption of permanent molars: a diagnostic dilemma.

BACKGROUND: Limited studies have proposed protocols for the management of failure of eruption (FOE) of permanent molars with no clear consensus or guidelines. Accurate diagnosis is challenging but key for successful management. AIMS: Confirm key diagnostic criteria that will aid diagnostic differentiation between primary failure of eruption (PFE) and mechanical failure of eruption (MFE) of permanent molars and identify successful management strategies. DESIGN: Retrospective descriptive study. Patients diagnosed with FOE of permanent molars (excluding impaction) between January 2003 and December 2013 were identified. Patient details and clinical and radiological features of FOE were recorded. Two examiners analysed the data. A diagnosis of PFE or MFE was made based on a combination of current protocols. Management strategies for each were identified and reported as satisfactory/unsatisfactory. RESULTS: Thirty-one patients met the inclusion criteria. Fifteen were classified as PFE and 14 as MFE. One patient was too young to confirm diagnosis, and one patient had delayed eruption. A total of 26% of cases were misdiagnosed which led to unsuccessful orthodontic management. CONCLUSION: We propose a protocol based on the results of this study coupled with existing protocols in the form of a simple flow diagram to aid accurate diagnosis and management of this rare and challenging clinical problem.

The Ethics of Interproximal Reduction.

Interproximal reduction (IPR) has become particularly popular with the use of removable aligners. Clinical and ethical factors concerning the use of interproximal reduction to facilitate orthodontic alignment are discussed. CPD/Clinical Relevance: An understanding of the aetiological factors of a malocclusion is essential to enable full discussion of the risks and benefits, or the alternatives to IPR.

An assessment of the effectiveness of mechanical and chemical cleaning of Essix orthodontic retainer.

OBJECTIVES: To determine the effectiveness of mechanical and chemical cleaning on the removal of microorganisms from Essix orthodontic retainers. DESIGN: In vitro laboratory study. SETTING: Department of Orthodontics and Microbiology, Eastman Dental Institute, University College London, UK. METHODS: Study 1: 120 Essix retainers were divided into four cleaning groups. The effectiveness of each cleaning method to remove a single species biofilm of Streptococcus mutans from the retainer was assessed. Study 2: 140 Essix retainers were divided into four study groups (brushing with fluoride toothpaste, chlorhexidine gel, immersion in chlorhexidine solution only and a control) to investigate the chemical and mechanical cleaning of the multispecies biolfilm of (Streptococcus sanguis, Actinomyces naeslundii, methicillin-resistant Staphylococcus aureus and Candida albicans). RELEVANT RESULTS: In study 1, brushing with toothpaste resulted in 99% reduction of Streptococcus mutans. In study 2, all three cleaning methods recorded similarly statistically significant reductions in colony forming units per millilitre compared to the control. There were no statistically significant differences between any of the cleaning groups for any of the microorganisms except MRSA-16. For MRSA-16, chlorhexidine mouthwash and gel were significantly more potent in eliminating the microorganism than the fluoride toothpaste. CONCLUSIONS: All three cleaning methods effectively removed 99% of microorganisms from the Essix retainers. Brushing with fluoride toothpaste can therefore be confirmed as an effective method for cleaning retainers in most circumstances. The use of chlorhexidine gel or mouthwash is recommended in patients where bacterial infection has to be avoided due to immunosuppression or other reasons.

Cone beam computed tomography--current understanding and evidence for its orthodontic applications?

Cone beam computed tomography (CBCT) is a fast developing technology which provides relatively low-dose, high spatial resolution imaging of the craniofacial complex in three dimensions (3D). During the past decade, the number of CBCT-related publications in the literature has increased significantly, but the crucial question is whether this technology leads to improved outcomes. In this paper, the literature is reviewed and the main applications of CBCT in orthodontics are highlighted, as well as the current evidence and understanding in each area. It is clear that at the present time, despite the popularity of CBCT, there is no clear evidence that the information obtained from these images substantially enhances clinical treatment decisions. Future research on CBCT should focus on interpretation of the images obtained. Visualizing the dentofacial skeleton in ever greater detail may be seductive, but without understanding the implications of findings such as 'minor' external root resorption or having the technical ability to provide treatment at a microscopic level may mean that these images do not have any meaningful impact on clinical practice.

Digital versus plaster study models: how accurate and reproducible are they?

OBJECTIVE: To compare measurements of occlusal relationships and arch dimensions taken from digital study models with those taken from plaster models. DESIGN: Laboratory study SETTING: The Orthodontic Department, Kettering General Hospital, Kettering, UK Methods and materials: One hundred and twelve sets of study models with a range of malocclusions and various degrees of crowding were selected. Occlusal features were measured manually with digital callipers on the plaster models. The same measurements were performed on digital images of the study models. Each method was carried out twice in order to check for intra-operator variability. The repeatability and reproducibility of the methods was assessed. RESULTS: Statistically significant differences between the two methods were found. In 8 of the 16 occlusal features measured, the plaster measurements were more repeatable. However, those differences were not of sufficient magnitude to have clinical relevance. In addition there were statistically significant systematic differences for 12 of the 16 occlusal features, with the plaster measurements being greater for 11 of these, indicating the digital model scans were not a true 11 representation of the plaster models. CONCLUSIONS: The repeatability of digital models compared with plaster models is satisfactory for clinical applications, although this study demonstrated some systematic differences. Digital study models can therefore be considered for use as an adjunct to clinical assessment of the occlusion, but as yet may not supersede current methods for scientific purposes.

Management of 'double teeth' in children and adolescents.

BACKGROUND: Abnormally, large teeth are often referred to as 'double teeth'. These can pose numerous challenges for the clinician. There is no published protocol on the management of double teeth. AIM: To review the published literature and also patients managed at the Eastman Dental Hospital (EDH) and to develop a clinical protocol for the management of double teeth in children and adolescents. DESIGN: Literature was searched (Medline and Embase) and data collated. Patient notes of cases managed at the EDH were reviewed. RESULTS: Eighty-one teeth from 53 papers and 22 patients were included in the review. Success criteria were only reported in 32 papers and were variable. Twenty-three papers had no follow-up period. The main factor in determining the management of a double tooth was root and root canal system morphology. The treatment of choice in teeth with separate roots was hemisection and in those with a single root was crown modification or extraction. CONCLUSION: It was not possible to determine the best management strategies because of the variable reporting in the literature. The authors have proposed a protocol for management and a data collection sheet for essential information needed when reporting on double teeth cases.

Evaluation of the CT scanogram for assessment of craniofacial morphology.

OBJECTIVE: The purpose of this prospective laboratory study was to investigate the suitability of the computed tomography scanogram (CT) as compared with conventional (CC) or storage phosphor digital (SP) lateral cephalograms. MATERIALS AND METHODS: Twenty intact, adult-sized, dry human skulls were used. Each skull was fixed in a custom-made plastic box and imaged in each of the three radiographic machines. All 60 hard copy radiographs were directly digitized using a customized cephalometric program, and all skulls were measured with an external caliper. All measurements were carried out twice, 2 weeks apart. "A priori" ranges were defined in advance for all 18 craniofacial parameters. Linear measurements were corrected for radiographic magnification. Data were analyzed using coefficients of repeatability, limits of agreement, and paired t-tests. RESULTS: Direct skull, anterior face height, sella-nasion, and cephalometric SnMx, SNA, SNB, and ANB (except CT) measurements were repeatable. Sella-basion, basion-nasion, most posterior face height measurements, MxMn, and incisor angulations were either not repeatable or not in agreement. When statistical significance was noted, however, the mean difference was of small magnitude for nearly all parameters. CONCLUSION: Depending on the clinical situation and the degree of precision required, the scanogram is a viable alternative to lateral cephalometry for assessment of sella-nasion, anterior face height, skeletal planes angles (SnMx, MxMn), SNA, SNB, and ANB, but not of sella-basion, basion-nasion, posterior face height measurements, and incisor angulations.

The occlusal effects of digit sucking habits amongst school children in Northamptonshire (UK).

OBJECTIVE: To compare the occlusal characteristics of persistent digit suckers with those of a group of individuals who reported never to have sucked their thumb or finger. SETTING: School children and regular attenders to four general dental practices in Kettering, UK. DESIGN: Cross-sectional, observational. OUTCOME MEASURES: Prevalence of anterior open bite, posterior crossbite, size of overjet, overbite and buccal segment relationship. SUBJECTS AND METHODS: The exposed group consisted of 7-13-year-old children with a persistent digit sucking habit or those who had given up the habit less than 2 years previously, compared with an unexposed group of children who had never reported a history of the habit. Upper and lower alginate impressions were taken and the resultant study models were used to measure occlusal differences between the two groups. RESULTS: Following exclusions, 39 digit suckers were compared to 36 non-suckers. The odds of a reduced overbite being present were significantly higher in the digit sucking group compared to the non-suckers (OR: 5.6, 95% CI: 1.6-20.8). The prevalence of anterior open bites was higher in the digit suckers (P<0.001). Although the overjet was slightly increased in the digit suckers compared with the non-suckers (mean difference: 1 mm, P = 0.036), this result needs to be interpreted with caution. No significant differences were seen in the presence of posterior crossbites or buccal segment relationships between the two groups. CONCLUSIONS: This study has shown that reduced overbite and anterior open bites were significantly more prevalent in digit suckers. The orthodontic management of anterior open bites can involve complex and prolonged treatment. Early intervention to eliminate digit sucking habits is therefore recommended on both oral health and health economic grounds.

An alternative retainer design for cleft patients: the "aesthetic" retainer.

The objective of this report is to describe an original retainer design for retention following orthodontic treatment in cleft lip and palate patients in order to improve the aesthetics of anterior maxillary dentoalveolar cleft defects. The technique incorporates features of both traditional and modern retainer design. The advantages of the technique and fabrication process are described.

Change of incisor inclination effects on points A and B.

OBJECTIVE: To identify and evaluate changes in the cephalometric position of points A and B due to an incisal inclination change caused by orthodontic treatment. MATERIALS AND METHOD: A total of 103 pairs of consecutive pretreatment and posttreatment lateral cephalographs that met the inclusion criteria were systematically collected from the departmental database and digitized using a customized software program (Gela). Repeatability analyses showed good reliability and no evidence of bias. A statistical model was generated using a Generalized Estimating Equation approach to analyze the data accounting for growth and bodily movement because both factors influence the position of points A and B (P < .001, P < .001). Changes in tooth length were also accounted for, as these changes may influence the calculated position of the centroid (P = .002). RESULTS: Each 10 degrees change in the maxillary incisor inclination results in a statistically significant average change in point A of 0.4 mm in the horizontal plane (P = .028). Each 10 degrees change in the mandibular incisor inclination results in a borderline statistically significant average change in point B of 0.3 mm in the horizontal plane (P = .058). There were no significant changes in the vertical position of points A and B. CONCLUSION: The effects of incisal inclination changes, due to orthodontic treatment, are of no clinical relevance to the position of point A and B, even though they may be statistically significant. The validity of points A and B as skeletal landmarks generally holds true, and accounting for treatment changes is unnecessary.