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ENUMERATE THE COMPLICATION OF DIGIT SUCKING. DISCUSS THE NON-SURGICAL

MANAGEMENT OF ANTERIOR OPEN BITE.

By

Dr Aghimien OsaronseUniversity of Benin School of Dentistry. Nigeria

20th March, 2014

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Outline on digit sucking Introduction to digit sucking Definition Etiology andPrevalence Clinical phases Complications of digit sucking considerations classification hard or soft tissue interarch relationship digit affected others consequence of sucking Conclusion

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Introduction

Habit is define as fixed or constant practice established by frequent repetition(Dorlan 1957). Sucking is an inherent biological drive observed in-utero. This can either be nutritive or non nutritive(O’ Brien, 1996).

According to Larsson the non-nutritive sucking include those earliest sucking habit adopted by infants in response to stress and to satisfy their and need for contact.

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In-utero

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Definition

Digit sucking is defined as the placement of the thumb or one or more fingers in varying depth into the mouth. It is considered a natural early childhood developmental habit. This should be discontinue by age 3-4 years.

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The commonest digit is the thumb.Prevalence;2.1% in 10-15 years old(Isiekwe, 1984)17% in 4-15 years old (Quashie-Williams et al)

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ETIOLOGY

Several theories have been postulated as a possible causes of digit sucking. These include;

Freudy theory,1905;related it to oral phase of psychological development

Benjamin theory 1962;described the rooting reflex Sear and wise 1982; oral drive theory due to prolonged

suckling Davidson 1967 –Learning theory

Others have related it to; stress, family conflict, lack of parental love

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Clinical Phases of digit sucking

This is a clinical classification MOYER 1955PHASE I: Seen within the first 3 years of life Normal and sub-clinically significant Prophylactic intervention if it persist. PHASE 11: Extend to 3-6/7 years This is clinically significant Definitive correction is indicated

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PHASE 111:• an intractable sucking• presence of significant problems of

malocclusion exist.

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Complication of digit sucking

Factors to considered;1. Intensity2. Duration3. Frequency4. Digit sucked5. Number of digits6. Position of digit in the mouth7. Associated behavior

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Classification of the complication

1. Base on tissue: Hard tissue: Skeletal and dental Soft tissue2. Base on Interarch relationship3. Digit affected4. Others.

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Skeletal/dental

Proclination of maxillary incisorRetroclination of mandibular incisors Increase maxillary arch length Decrease maxillary arch width Increase mandibular arch width High palatal vaultMaxillary anterior crowdingAbnormal resorption of the primary central

incisor

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Soft tissue

Lip incompetenceTongue thrustingLispingLow tongue resting position

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Interarch relationship

Increase overjetPosterior(buccal) cross biteAnterior open biteTemporomandibular dysfunctionDecrease inter-incisal angle

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digits

Dishpan Ulceration Paronychia

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others

TrichotillomaniaAlopeciaObstructive sleep apnaeInfectionPsychological behavior

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Consequences

MalocclusionSpeech defect: bi-labial, labio-dental, bi-dentalTMJ dysfunctionFeeding defectDermatological problemsPsychological disorders

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Conclusion

While digit sucking can be part of normal response in the early developmental age attention should be paid to this habit when it persist as it could lead to detrimental effect on occlusion, function and psychology of the individual.

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Discussion on the non-surgical management of anterior open bite[AOB]

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Outline IntroductionDefinition Classification base on hard tissue affected unilateral or bilateral symmetrical or asymmetrical physiological or pathological simple or complex

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Etiology oral habit abnormal skeletal growth abnormal tongue size and positioning physiologic trauma mouth breather and causes of mouth breathing

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Characteristic feature of AOB dental AOB skeletal AOBUnderstanding the pathophysiology of AOB physiologic AOB dental AOB skeletal AOBManagement of AOB history clinical examination investigation clinical records treatment options

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Aims and objectives of treatmentTreatment modalities preventive interceptive non surgical treatment corrective: camouflage orthognatic surgery adjunctive treatment.

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Non-surgical treatment option Considerations Preventive counseling reward therapy habit breakers Interceptive vertical holding appliance vertical chin cup active vertical corrector functional appliance high pull head gear Camouflage fixed orthodontic appliance with extraction elastics; multiloop eadgwise arch wire(MEAW) mini-implant/miniscrew/micro-screw

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Introduction

Anterior open bite is one of the most difficult orthodontic problems also with difficulty maintaining stability after treatment(Yu-Ching, 2005).

The bite is said to be open when there lack of anterior vertical overlap. A reduction in such overlap would amount to an incomplete bite.

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A prevalence of 2.8%1 was reported among 2-5 year old and thumb sucking was said to be the major cause. In 2008 a prevalence of 4.1%2 was also reported among other cases of malocclusion.

(1Ize-Iyamu, Isiekwe 2012; 2Ajayi 2008)

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Definition

Subtelney and sakuba in 1964 defined it as an open vertical dimension between the incisal edges of the maxillary and mandibular teeth.

It has also been defined as a vertical discrepancy where the upper incisor crown fail to overlap the incisal third of the lower incisor crown when the mandible is brought into full occlusion.

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classifications

a. base of hard tissue affected skeletal dentalb. Base on symmetry symmetrical assymetricalc. unilateral/ bilaterald. Could either be physiological or pathological

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Etiology

Oral habitdigit suckingtongue thrustingMouth breathing

abnormal skeletal growth pattern Abnormal size and function of the tongue Traumatic injuries; bilateral condylar fracture, Le-Fort

injuries.

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Causes of mouth breathing

Deviated septum and other naso–pharyngeal deformities.

Allergic rhinitis nasal polyps.Enlarged adenoids or tonsils. Abnormally short upper lip preventing proper lip seal.Obstruction in the bronchial tree or larynx.Genetically predisposed individuals Mouth breathing children are breast fed for a Shorter

period of time (Luciana et al. )

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Characteristic features of AOB

DENTAL AOBProclined incisorsUnder-erupted incisorHistory of oral habitNarrow maxillary arch(especially with intense

digit sucking habit)

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Features of skeletal open biteExtraoral features: Long face due to increased lower anterior face height Incompetent lips An increased mandibular plane angle An increased gonia! angle Marked antegonial notch Maxillary base may be more inferiorly placed (vertical maxillary excess) Ratio of upper facial height : total facial height is reduced short posterior facial height; PFH:AFH (Jarabak ratio ) less than normal

Intraoral features: Mild crowding with upright incisors Maxillary, occlusal and palatal planes tilt upwards anteriorly Mandibular occlusal plane canted downwards

Gurkeerat Singh, 2007 •

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Understanding the pathophysiology

Physiologic AOB this is a natural phenomenon that occur during

the mixed dentition stage. Incomplete eruption of the maxillary anterior create the opening in the anterior segment. It should completely overlap on full eruption

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Dental AOB

Oral habit especially digit(thumb sucking) has been reported to be a major cause of AOB(Ize-yamu, 2012).

Habitual position of the digit between the anterior teeth causes a dis-occlusion of the posterior segment which causes a supra-eruption of the molars and infra-occlusion of the anteriors. The intensity of the habit results in other features; high narrow palate, procline incisor, spacing etc.

Gurkeerat Singh, 2007

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Skeletal AOB1The maxilla grows downward and forward due to

forward growth of the anterior cranial with contribution from sutural growth. Mandibular growth is also downward and forward with backward rotation.

2The growth at the head of the condyle occurs in an upward and backward direction. This compensate for the vertical displacement of the mandible.

1Profitt ; 2Bishara, 2001

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Deficiency in the growth of the condyle would lead to uncompensated mandibular downward and forward growth.

Bjork in 1969 outline seven(7) features to help predict abnormal rotation of the mandible which might lead to an open bite.

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MANAGEMENT OF ANTERIOR OPEN BITE

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History Clinical examination

InvestigationClinical records

Treatment options

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History

Age; it is a transitional when transiting from the

deciduous to the mixed dentition period. habits(frequency, duration, intensity, number of

digit or use of pacifier) have been implicated as a major cause in younger children while abnormal skeletal growth becomes more important as a cause in the adolescent age

Adenotonsilitis common among mouth breathing children

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Chief complaint esthetics; possibility of incompetent lips function; biting, speech defectsr/o any traumatic injury that can cause pathological

fractureMedical condition; obstructive sleep apnae could cause mouth breathing Arthritic degeneration of the TMJ could alter condylar

growth.Others include allergies, rhinitis etc.

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Clinical examination

General examination: a quick general appraisal should be performed. Examine patient digits if sucking is suspected.

Extra-examination: lip: presence of separated lips due to the

proclined incisors facial profile: long lower anterior faceSkeletal pattern: could be 1,2 or 3.

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Intra-oral examination: inspect the extent of the AOB unilateral or bilateral symmetrical or asymmetrical measure the vertical discrepancy

*A typical thumb-sucker has a malocclusion characterized by an asymmetric anterior open bite due to digit position

and a transverse constriction of the maxillary arch.(Peter N and Henry w,1997; chui shan teresa et al, 2008)

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Investigation and diagnostic records

Clinical photograph(intra- and extra-oral) taken to aid planning and also for medical legal reasons

Impression for study model; to assess arch width and amount of space

present space analysisRadiograph; dental panoramic radiograph and

lateral cephalometry

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Lateral cephalometry and OPG

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Bjork in 1969 identified cephalometric features of significant abnormal growth rotation of open bite.

Kim, 1974 also provided information on behavior of vertical relationships using what he called Overbite Depth Indicator (ODI).

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diagnosis

This could either be a dental or skeletal anterior open or a combination.

Patients with skeletal AOB would present with discrepancies in their cephalometric values.

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Aims of treatment

To achieve a vertical overlapImprove estheticsImprove functionMaintain a stable results

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Treatment modalitiesIn general, four treatment modalities are used

by surgeons and orthodontists in the treatment of anterior open bite:

1.advice on early problems and observation2. interceptive treatment3. camouflage treatment by orthodontics only4. a combined orthodontic and surgical

approach(CHUI SHAN TERESA , 2008).

The first 3 constitute the non-surgical mode of treatment.

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NON-SURGICAL TREATMENT

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Treatment considerations

Age of patientPresence of habitSeverity of the open bitePresence of concomitant medical conditionPatient complianceEsthetic consideration of the appliance

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A. CounselingB. Reward C. Habit breakers; reminder therapy tongue rake blue grass goal post long sleeves acrylic thump cap elbow joint restriction chemical aversion adhesive bandage

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D. ApplianceFunctional Frankel regulator IV Teuscher activator Stockfisch avtivator posterior bite blocks passive active(spring loaded/repelling magnet)Vertical holding appliance

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Vertical chin cupActive vertical corrector( Dellinger)Fixed appliance extraction intrusion posterior teeth( TADS,HIGH PULL HEAD GEAR)MEAWExtrusion archesE. Adjunctive treatment glossectomy adenotonsillectomy management of allergy reduction of fracture

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COUNSELLING:

Explain about habits ill effectsShow photographs, videoDunlop hypothesisCard to scoreDiscuss with parents

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REWARD

this is a kind of positive re-enforcement. the children are encouraged with a gift the day

they do not display the habit

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HABIT BREAKERS-REMINDER THERAPY:

depends on the habit indicated for those who are willing to quit but

the habit has entered a subconscious level; they involve:

Removable habit breakersFixed habit breakerChemical approach

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Bluegrass ApplianceThe Bluegrass Appliance is a fixed tongue retraining

device used forpatients with a mixed or permanent dentition. It is an

alternative to the

Rake or Crib design.

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Tongue crip

The Tongue Crib appliance has a vertical gate inhibiting the access of the tongue to the anterior dentition.

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INTERCEPTIVE

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Vertical holding appliance:

It is a modified transpalatal arch with an acrylic pad. It utilizes the tongue pressure to prevent dentoalveolar development of maxillary permanent first molars

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Vertical chin cup

result in a decrease in mandibular plane angleAnterior rotation due to inhibition of mandibular

posterior dento-alveolar segmentIncrease in total anterior facial and lower

anterior facial height.However there is poor compliance

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Posterior bite blocks

The blocks(acrylic) are usually set at a slightly elevated position vertically, so that, the stretched muscles place an intrusive force on the posterior teeth, which in turn helps control eruption and permits an upward and forward autorotation of the mandible.

Several modifications exist: application of spring, use of repelling magnets

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Active vertical corrector(Dellinger)

A modified posterior bite blocks with repelling magnet incorporated into the acrylic. Has embedded in it eight opposing field (four per arch) cobalt samarium magnets

Causes intrusion of the molars, allowing the mandible to rotate upward and forward.

Compliance is a factor due to the challenge and duration(4–7 months) of wear.

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Vertical pull chin cup Posterior bite blocks

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High pull headgear

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Functional appliances

Base on the possibility that faulty postural activity of the oral-facial musculature can also cause AOB hence, functional appliances modifying growth. They iclude;

Functional regulator 1VTeuscher activatorStockfisch activator

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Corrective treatment option

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Camouflage treatment

Some cases of open bite can be corrected by fixed appliances that cause dental movements while the skeletal profile and characteristics are kept unchanged.

This may be accompanied with extractions, use of elastics, or application of mini-implants or miniplates.

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extractions

Extraction of premolars have been advocated due to the draw-bridge effect of reducing the inclination of the maxillary and mandibular incisors.

Pearson (1973) reported that a significant increase in the lower posterior facial height can occur during extraction therapy of moderately steep cases.

Molar extraction have been said to remove the wedge created by the supra0eruption of the molars.

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Here retraction of the incisor results in relative extrusion of the incisor as it rotate around its centre of resistance, increasing the bite.

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Elastics

The multi-loop edgewise arch wire(MEAW) is an example.

Involves use of multi-loop wire and vertical elastics on the canine region.

Aim of technique:Correcting the inclination of the occlusal planealigning the maxillary incisors relative to the lip linemaking the axial inclinations of the posterior teeth

upright.

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Treatment changes occur mainly by a dentoalveolar compensation mechanism that causes retraction and extrusion of the anterior teeth and an upright movement of the

posterior teeth. Thus, the upper and lower occlusal planes move towards each other.

There is only minimal skeletal changes

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Temporary anchorage devices

These includeMiniplatesMinisrews MicroscrewsThey provide absolute anchorage for intrusion of

the molars

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Adjunctive treatment

a. Reduction and fixation of fracture injuries e.g. repair of Le Fort and condylar injuries

b. Alignment of deviated nasal septumc. Adenotonsillectomyd. Glossectomy

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conclusion

Anterior open bite is considered to be one of the most difficult clinical encounter by orthodontists. Proper diagnosis and treatment planning, successful treatment, and retention have been stressed for the long-term stability of open bite treatment.

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Brian Palmer: The Importance of Breastfeeding as it Relates to Total Health, 2002.

Andlaw R.J, Rock W.P. A manual of paediatric Dentistry(4th Edition); Persistent digit sucking21:176-177

Ize-Iyamu I, Isiekwe MC; Prevalence and factors associated with anterior open bite in 2 to 5 year old children in Benin city, Nigeria, African Health Science. Dec 2012; 12(4): 446–451.

Ajayi E. O. Prevalence of Malocclusion Among School Children in Benin City, Nigeria . Journal of Medicine and Biomedical Research, Vol. 7, No. 1 & 2, December 2008, pp. 58-65

Gurkeerat Singh. Texbook of Orthodontics (4th Edition,2007). Management of Open Bite; 54:643-654.

Bishara, Samir E. Textbook Of Orthodontics, 2001. Introduction to growth of the Face. 4:41-53

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Yu-Ching W, Ellen Wen; The Nture of Open Bite; Journal Of Taiwan Association of Orthodontist. 17(2):35-41,2005.

Peter N,Henry W. F. Open bite: a review of etiology and management. Pediatric Dentistry 19:91-98, 1997.

chui shan teresa et al: Orthodontic treatment of anterior open bite. International Journal of Paediatric Dentistry 2008; 18: 78–83

Roberto Silva Meza. Practical Application of Overbite Depth Indicator, Anteroposterior Dysplasia Indicator and Extraction Index. Orthodontic cyber journal, 2004.

Julio Pedra e Cal-Netoa et al: Severe Anterior Open-Bite Malocclusion Orthognathic Surgery or Several Years of Orthodontics? Angle Orthodontist, Vol 76, No 4, 2006

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Basanta K Shrestha . Orthodontic Treatment of Anterior Dental Open Bite with Drawbridge Effect: A Case Report. Orthodontic Journal of Nepal, Vol. 3, No. 1, June 2013