25
Orthodontic Treatment for the Special
Needs Child
Stella Chaushu, Joseph Shapira, Adrian Becker
Summary Therapeutic access
Individuals with special needs are children or adults who are prevented Children with behavioral issues do not respond to tradi-
by a physical or mental condition from full participation in the normal tional discipline nor do they necessarily wish to be sub-
range of activities of their age groups. They usually exhibit high ortho- jected to the various procedures they may need to undergo.
dontic treatment need, because of an increased prevalence and severity Their intellectual level is also not adequate for them to
of malocclusion. Although parents may be highly motivated to improve a understand the need for compliance in the intricacies of a
child’s quality of life by enhancing appearance and oral function, these standard biomechanical apparatus. They require special-
children are the least likely to receive orthodontic treatment. The present ized and, often, simplified strategies that are tailored to
chapter discusses orthodontic treatment for patients with developmental their specific abilities and disabilities. If these important
disability involving behavioral problems, based on our earlier published steps are not considered by the operator, therapeutic access
studies and clinical experience in the treatment of this compromised may be impossible to obtain. The clinician needs to be
minority group within the community. The chapter will discuss the major understanding, flexible, and creative.
obstacles that may preclude the delivery of orthodontic treatment or are
encountered during treatment and the different management modalities There are several specific areas in which the special needs
that may be employed to overcome the behavioral limitations in children, patient will unintentionally obstruct the delivery of treat-
and will provide guidelines for the orthodontist to gain therapeutic access ment (Becker and Shapira, 1996) and this is because he or
to these patients. she typically has shortcomings not usually seen in the
normal child, such as (Shapira et al., 1999):
Introduction
• Increased apprehension, reduced understanding, limited
‘Special needs’ is an umbrella term under which a stagger- • tolerance and short attention span
ing array of diagnoses may be included: from mild learning
disabilities to profound mental retardation; food allergies Exaggerated gag reflex (which seems to be a consequence
to terminal illness; developmental delays that are transitory
to those that are intractable; occasional panic attacks to • of fear)
serious psychiatric problems. The designation is useful for Inability to remain still for any appreciable time; uncon-
garnering needed professional help and services, setting trolled body movements
appropriate goals, and gaining understanding for a child
and his distressed family. The present chapter will focus on • Reduced level of cooperation
those children with developmental disability involving • Drooling.
behavioral problems.
Under these conditions simple exercises such as the taking
of radiographs or dental impressions become tasks of major
proportions. In order to achieve these normally modest
and simple aims, behavior modification techniques may
need to be employed, with or without specific
Integrated Clinical Orthodontics, First Edition. Edited by Vinod Krishnan, Ze’ev Davidovitch.
© 2012 Blackwell Publishing Ltd. Published 2012 by Blackwell Publishing Ltd.
486 Integrated Clinical Orthodontics
pharmacological aids and/or through conscious and deep et al., 1996), which can adversely affect function (Proffit
sedation or with general anesthesia. et al., 2007). Yet, these patients are those least likely to
receive orthodontic treatment.
Over the past 20 years or so, both the absolute number
and proportion of special needs children in society has Beneficial but not essential
increased (Waldman et al., 2000), in spite of prenatal diag-
nostic techniques and the improvement in prenatal identi- The pediatric dentist must treat a patient to eliminate
fication of congenital anomalies. The main reasons are first, dental disease and to relieve pain, regardless of whether the
sophisticated medical care, both perinatal and adult, that child is cooperative in the dental chair and diligent in his
has increased the survival rate of the newborn and their routine homecare. At the same time, the dentist is duty-
overall life expectancy. Second, given the enlightened atti- bound to encourage behavior alteration in both these areas.
tude of society today, changing social policies and legisla- By contrast, orthodontics performed under these adverse
tion, many more special needs children are seen as an conditions is contraindicated since a successful outcome is
integral part of their family, within adoptive families, or in doubtful and iatrogenic damage, in the form of caries and
sheltered housing and are thus far more visible in general, gingival inflammation, is likely. Thus, while treatment need
while three decades ago they were largely housed in institu- is often high and its object beneficial, orthodontics must
tions. This gradual but palpable process of ‘mainstreaming’ still be considered to be an elective item. The order must
has brought about a greater awareness and appreciation on therefore be reversed, with a sustained level of oral hygiene
the part of the general public. being first achieved, and this is the point where parental
involvement will usually be essential.
With their higher public profile, the present-day affluent
society of the Western world has created a general improve- Motivation and expectation
ment in quality of life for these children that, in turn,
expresses itself in an increased demand for esthetics and The motivation for treatment in most of these cases comes
normal function. The aim is acceptance into society, from the parents of the disabled child, rather than from
including the opportunity for employment towards self- other medical or dental professionals (Becker et al., 2000).
sufficiency. As the direct result, the concern for facial A majority of these children live at home, receiving daily
appearance has become an item for discussion among their one-on-one attention from highly motivated parents and
parents and this has generated a demand for orthodontic siblings, who are often prepared to sacrifice much to
treatment (Becker and Shapira, 1996). improve the child’s wellbeing (Becker et al., 2000). Certainly
many of the children will be sufficiently aware to believe
In general, the main goals of orthodontics are to improve that treatment is desirable, but there is a deep abyss between
the alignment and occlusion of the teeth and thus, to con- their ‘in principal’ agreement and the compliance that will
tribute to one of the more important factors involved in be needed when the first clinical steps need to be taken.
improvement of the facial appearance (Shaw et al., 1980).
However, its efficacy is limited and cannot provide a satis- The wearing of a simple orthodontic appliance, together
factory answer for every situation. Individual benefits that with maintaining adequate oral hygiene either alone or per-
are principally associated with the patient’s own concept of mitting the parents to do it, may represent the first chal-
him/herself might have been gained by the patient and lenge of accepting responsibility on the part of the child.
these are often strongly influenced by those around him The special needs child is usually positively influenced by
(Sticker, 1970). praise and compliments from the practitioner, the parent
and those around him/her, when certain functions and
Studies of the effects that dental appearance has on indi- stages are completed successfully and this all combines to
viduals and their surroundings have found this to be form an environment that encourages compliance. A
extremely important in overall facial esthetics (Lew, 1993). marred facial appearance is the principal factor motivating
In adverse conditions, it is a principal focus for teasing the request for orthodontic treatment among normal chil-
among school children (Shaw et al., 1980), has a significant dren but, in the present context, recognition of poor oral
emotional impact on the individual, and is a factor used in health and function and their improvement are parallel
social acceptability and personality judgment by others aims (Becker et al., 2000).
(Shaw, 1981).
Patient management
In their everyday life, special needs children comprise a
group of individuals who depend heavily on their families Special needs patients need much more time and under-
and others for their needs and welfare. From earlier obser- standing for progress to be made in treatment and this
vations (Oreland et al., 1987), we learn that they have requirement may exceed the patience of many otherwise
malocclusion, which is more frequent, more severe, and highly productive providers, since it is difficult to rise to the
more skeletally based than in the general population. challenge and yet blend it with the smooth running effi-
Several conditions, such as cerebral palsy, Down syndrome, ciency of a regular orthodontic office (Waldman et al., 2000;
and mental retardation, exhibit increased prevalence of
specific dental features (Cohen and Winer, 1965; Franklin
Orthodontic Treatment for the Special Needs Child 487
Becker et al., 2001). Sedation or general anesthesia sessions It has to be recognized that most visits for later ortho-
are sometimes needed and it makes sense to include other dontic treatment will usually require using behavior man-
specialists to perform any required endodontic, oral surgery, agement techniques and that sedation and general anesthesia
and restorative procedures, taking advantage of the poten- will only be used for lengthy and involved procedures –
tial that these modalities provide (Chaushu and Becker, perhaps two or three sessions for the duration of the treat-
2000). An orthodontic environment that can accommodate ment. For this reason, time spent in pretreatment
all these specialists and provide a trained anesthetist close preparation and evaluation is usually well spent (Chaushu
at hand is unlikely outside a hospital-type setting, which and Becker, 2000). If the patient is unable to achieve a
limits the capability of the purely orthodontic practice for healthy mouth, the orthodontist should refuse to treat at
the duration of the only the simplest of cases of this type. that time and suggest follow-up at a later date.
Pretreatment visits and patient assessment Drawing up a tentative treatment plan
Although true for every orthodontic case, there are four Treatment plans are usually the product of the gathering
specific aims which have special relevance here, with the and collation of information contributed from a clinical
exception that in the present context they invariably examination, from photographic and radiographic records,
demand more than a single visit to evaluate them. Morbidity a cephalometric analysis, plaster casts, and other aids to
due to medical conditions that feature hypotony and myop- diagnosis and, under normal conditions, these records are
athy is high among this group, which means that food is simply and routinely acquired. In the present circum-
not cleared from the mouth efficiently in normal function, stances, these same diagnostic aids become a major under-
manual dexterity is poor and most subjects practice no oral taking which can frighten the child for months or years to
hygiene whatsoever. Pre-treatment visits are therefore come, if badly managed.
essential and are used for four specific purposes:
The answer may often be to formulate a general direction
• To allay the patient’s anxiety and raise confidence level of treatment based on a clinical examination only and delay
• in the dental chair the needed diagnostic records for the first sedation session.
This initial and tentative treatment plan may then be con-
To evaluate the existing level of homecare, to point out firmed or adjusted in accordance with the new information.
In this way, the first sedation session may be used for algi-
• to both child and parent where it may be lacking nate impressions (to be rapidly cast), intraoral radiographs
Demonstrate how improvement can and must be and photographs (to be quickly processed and viewed), a
achieved always with parental supervision, often with full treatment plan devised on the spot and, perhaps a
their active participation, as a precondition to acceptance further impression to make an initial simple removable
plate. Other activities that may be usefully brought into this
• for treatment single session include scaling, fissure sealants, and minor
To assess the level of actual compliance and whether this restorations or even root treatments for traumatized central
can be maintained through treatment. incisors, which is a common occurrence in these patients.
At the conclusion of this important visit, the new records
At the first visit, the child and parent are shown the are studied and a reasoned working treatment plan estab-
debris surrounding the teeth, the collections of food in the lished. This level of patient management requires a high
palatal vault, in the cheek area and elsewhere, together with degree of diagnostic and clinical skill on the part of the lead
the accompanying gingival inflammation, and are taught to orthodontist.
recognize this situation. In order for the child to reach a
level of oral hygiene consistent with the pursuit of ortho- Control of adverse behavior during treatment
dontic treatment, it is inevitable that the parent must be the
dominant tooth brusher, with the child ‘finishing off ’ the Orthodontics involves many visits for a variety of different
exercise to include him or her in accepting responsibility treatment activities and functions and it must be clear from
that will take them through later life. The act of tooth the outset that negative behavior cannot be controlled with
brushing carried out by a parent on a daily basis is itself a general anesthesia at every visit. Certainly for the more
potentially helpful exercise, since it familiarizes the child anxious special needs patient, the difficult, the exacting, and
with the insertion of foreign items into the oral cavity in a the protracted visits and those in which more meticulous
non-threatening environment, which helps to overcome biomechanics is needed, pharmacological assistance will be
apprehension and gagging (Becker and Shapira, 1996). needed, but these need to be properly planned and kept to
Perhaps the most reliable sign of a good and potentially a minimum. This means that the use of the ‘tell-show-do’
compliant patient is seen at the visit after oral hygiene behavior modification techniques, with positive and nega-
instruction has been given and its importance stressed. The tive reinforcement, needs to become the modus operandi
patient and parent arrive with an optimistic disposition,
having put into practice what they have learned. However,
the acid test is not merely to see clean teeth, but to check
for the resolution of the gingival inflammation.
488 Integrated Clinical Orthodontics
for the most part of any treatment program, leaving a deci- • Pragmatic treatment aims: Ideal results are not always
sion to be made regarding the supplementary modalities achievable because various adverse factors may be present
needed for those procedures that are poorly tolerated in the particular individual, which dictate aiming for
(Becker and Shapira, 1996).
• more limited goals.
A conscious and highly anxious patient can be brought Record taking: We have already mentioned the problems
to a relaxed state by pharmacological agents through several involved in taking impressions and how these may be
routes, including inhalation (nitrous oxide and oxygen), circumvented. Intraoral radiographs are often just as
transmucosally (midazolam via nasal drops), orally (chloral difficult to take in these cases, when the child is fully
hydrate, valium, midazolam), or intravenously (propofol). conscious, and these may need to be taken under
Through the use of these agents, the patient’s compliance sedation. On the other hand, extraoral films, such
may be assured for the duration of the treatment, increas- as panoramic radiographs and cephalograms are usually
ing the range of procedures that may be performed on the better tolerated. However, holding the head of a
unwilling and apprehensive patient, even permitting the frightened child in a cephalostat, or having him/her sit
orthodontist to provide treatment formerly considered still in a particular posture for several seconds while
impossible. Combinations of these drugs, such as mida- the X-ray tube circles the head, may not be possible
zolam (anxiolytic, sedative and amnestic) with nitrous and sedation may not be an asset in this situation.
oxide (analgesic and relaxing effects) can produce con- Accordingly, diagnosis may have to be made with fewer
scious sedation with virtually no side effects and may be diagnostic aids, placing greater emphasis on the clinical
used inexpensively for relatively short procedures (Malamed,
1995). General anesthetic carries with it the accompanying • examination.
need for short term hospitalization, specialized operating Modular treatment: A problem list should be drawn up
theatre, and preoperative and postoperative care. and its various components prioritized into modules,
Nevertheless, until recently it was considered the only beginning with the simpler tasks and progressing to the
answer for the more involved and lengthy procedures, such next, while being prepared to make adaptive alterations
as the placement of a fully bracketed fixed appliance, pos-
sibly combined with the extraction of teeth in appropriate • that may be needed at each stage.
cases, despite the attendant morbidity and much higher Simplified treatment methods:
cost (Jackson, 1967; Chadwick and Asher-McDade, 1997). – Placement of removable appliances is very simple, is
easily learned, and well tolerated (Becker et al., 2001).
Several years ago, we introduced intravenous deep seda- Adjustment and activation are made outside the
tion as an alternative to general anesthesia and this has mouth, which means that the patient’s mouth is not
permitted us to increase the uptake of greater numbers of disturbed by the operator’s hands and by the insertion
very difficult patients (Chaushu et al., 2002b) without the and manipulation of dental instruments. Oral hygiene
need for an operating room. The orthodontic clinic is the is considerably easier than with fixed appliances, both
ideal environment to carry out orthodontic procedures, but for parent and child. It is recommended to continue
it is required to be properly equipped for sedation with the their use to achieve as much as possible before moving
availability of the services of an anesthetist, if sedation is to on to the fixed appliance stage or, possibly, even to be
be performed. The sedation agent used is intravenous pro- in the position to occasionally eliminate it. Care should
pofol, which induces a safe level of sedation very rapidly be taken in the design and construction of the remov-
and is relatively free of side effects. Risk of aspiration and able appliance to include several retention clasps, so
other emergencies is very low and the patient’s vital reflexes that even the more rebellious child with limited dex-
are maintained for the duration of the sedation. Intubation terity will have difficulty in removing it, until quickly
is not usually necessary and recovery is very fast. This becoming accustomed to its presence.
modality permits medium duration procedures to be – Appliances with a long range of action should be pre-
undertaken, including collaboration with oral surgery and ferred, to increase the time between visits. The use of
endodontic specialists in the comprehensive treatment of a removable plate with a headgear cured into the
the patient. Intravenous sedation has greatly improved our acrylic and worn full time has been found to be very
ability to achieve therapeutic access in these patients and acceptable (Becker and Shapira, 1996; Becker et al.,
has facilitated the smooth pursuit of treatment on an out- 2001) to these patients and the corrective influence of
patient basis (Chaushu et al., 2002b). this en bloc appliance on a severe Class II relationship
may be dramatic (Thurow, 1975). It is simple to use,
Adapting orthodontics to the special requires few visits for adjustments, and, above all, is
needs child extremely safe since, with no detachable parts, it con-
trasts very favorably with a headgear that slots into
Modifications to orthodontic treatment and the manner in molar tubes. With its use, fewer premolar extractions
which it is delivered are needed, if success is to be achieved are needed and, therefore, there are fewer corrective
with these patients. root movements to deal with later.
Orthodontic Treatment for the Special Needs Child 489
– When extractions are nevertheless necessary, the Class a rebond will be much more difficult. The operator should
II relation is more efficiently corrected with this use the method and materials that they are most comfort-
removable integral headgear appliance than with Class able with and have proved to be the most reliable.Aluminum
II elastics, with which both child and parent are often oxide sandblasting is recommended, provided suitable pre-
highly dexterity challenged. This means that space cautions regarding aspiration are in place. Anti-sialogog
closure will need to be completed with intra-arch drugs should be used if needed.
mechanics, which are far more reliable, since they are
placed by the operator. Relapse and retention
– With the Class II corrected to a Class I relationship, Teeth move throughout life, whether or not orthodontic
the remainder of the treatment is best carried out with treatment had been performed. Accordingly, when a beauti-
a fixed appliance which offers minimum frictional ful result has been achieved with any patient, it needs to be
resistance to sliding mechanics, such as the Tip-Edge maintained with a suitable retainer for a long period of
Plus or the self-ligating bracket systems. Breakages time. For some, the degree of change/relapse that will occur
may occasionally occur, although experience has post-retention is hardly noticeable. For others it may be
shown that this is less of a problem than in a healthy very marked, due to an untreated or unaccounted for
patient, possibly due to the hypotonic facial and mas- underlying etiologic factor. Special needs individuals have
ticatory musculature. a very high prevalence of abnormal soft tissue behavior,
including tongue thrusting and abnormal anterior oral seal,
– Mechanics may often be simplified by non-routine which are not often amenable to treatment. Retention,
extractions and this should certainly be considered in therefore, is more important than for the healthy child
this subgroup of the population, if not among healthy population.
individuals.
‘Active’ retention, with high-pull headgear, twin-blocks,
Special considerations with orthodontics and the like is sometimes needed against the recurrence of
under sedation some of the more severe skeletal Class II and open bite
cases. Some of these may be surgical cases from the outset,
Certain precautions are necessary when treating the sedated but because of their poor health or other reasons, a con-
patient and the most important concern relates to aspira- servative approach had been advised.
tion because of partial or total loss of the patient’s protec-
tive reflexes. It is essential to prevent the leakage of water, Failures
saliva, blood, debris, or loose orthodontic brackets into the
airway, to avoid laryngospasm or tracheal or bronchial Most of the failures that we see are due to noncompliance
infection. Children with cerebral palsy and muscular dys- with the retaining devices and, inevitably, re-treatment may
trophy may have an impaired cough reflex due to their be necessary, although not before parent and child accept
condition and thus are at greater risk. The best way to sig- that more disciplined retention will be assured in the end.
nificantly reduce this palpable danger is to use a rubber As noted above, some medical conditions may generate
dam under these circumstances (Chaushu et al., 2000b). the adverse changes. Myopathies and cerebral palsy tend
When this is impossible, as with impression taking, band to cause further vertical growth and only some of this
fitting and the cementation of soldered lingual/palatal can be controlled with ‘active’ retention, even with good
arches, an oropharyngeal pack is mandatory. Indirect cooperation.
bonding has also been used in these situations and has
much to recommend it (Thomas, 1979). Post-treatment parental evaluation
Molar band placement is more difficult when the patient There can be no question that those parents who request
cannot bite on a band-seating instrument or bite stick and treatment for their special needs child are highly motivated
it is difficult to apply manual pressure, particularly in the and most appreciative of the efforts made in the delivery of
mandible, when the anesthetist is trying to hold the jaw treatment in these difficult circumstances. But they are not
forward to increase the size of the airway. However, band a random sample of parents with special needs children.
cementation requires less critical and less stringent condi- Nevertheless, when polled in a survey, they expressed con-
tions of saliva control than bracket bonding and, wherever siderable satisfaction at the results achieved (Becker et al.,
possible, should be performed in a separate visit, before the 2000). From their subjective view of their child, they
sedation session. If the special needs individual has been pointed to improvement in oral function, swallowing and
taken patiently through the stages outlined above, this is drooling, speech and in their chewing movements, in addi-
usually possible to achieve and, if so, is of considerable tion to improvement in their facial and dental appearance.
advantage. Among those children who were sufficiently aware of
improvement, the parents reported greater self-confidence
Bracket bonding must be as accurate and as perfect as and a pride in their appearance (Becker et al., 2001).
possible, to reduce the chances of bond failure later on, as
490 Integrated Clinical Orthodontics
Case descriptions (a) (b)
As noted in the introduction to this chapter, the list of Figure 25.1 Patient 1: 10-year-old girl with ataxic cerebral palsy. Pretreatment
medical and psychological diagnoses that may place a child facial photographs showing the convex profile due to marked retrusion of the
in the realm of ‘special needs’ is inordinately long and it is mandible: (a) profile, (b) frontal.
beyond the scope of this chapter to describe the orthodon-
tic management in all of them. Accordingly, a case descrip- In the case of normal children, some recent evidence is
tion of the two most commonly seen conditions among not supportive of two-phase orthodontic treatment and
special needs children in which orthodontic treatment is demonstrates that in spite of temporary skeletal change that
likely to be highly beneficial, and in which special attention may occur in the younger patient, early treatment does
needs to be given to compliance and management issues, not provide patients with any advantage over those treated
will be presented here. at a later age, in regard to the long-term outcome in
Class II patients (Dolce et al., 2007; Harrison et al., 2007).
Cerebral palsy It is critical to be aware that children with cerebral palsy
often experience falls and, without the ability to protect
Cerebral palsy affects 2/1000 live-born children (Longo and themselves with their hands, traumatic injury to the maxil-
Hankins, 2009). It refers to a group of chronic conditions lary incisors is more frequently seen than in normal chil-
affecting body movements and muscle coordination, caused dren. It is for this reason that prevention of trauma and its
by brain damage occurring during fetal development or consequences is mandatory and a short course of early
infancy. Cerebral palsy patients can be classified by the type treatment to reduce an increased overjet is to be encour-
of movement problem into three subgroups: aged (Patient 1: Figure 25.3). This treatment should be
initiated as early as possible after eruption of the maxillary
• Spastic – inability of a muscle to relax incisors, at 8–10 years of age and it should also be aimed at
• Athetoid – inability to control muscle movement improving a skeletal discrepancy, by restraining the forward
• Ataxic – impaired balance and coordination. and downward growth of the maxilla or by encouraging
forward growth of the mandible. Completion of phase 1
Alternatively, they may be grouped by the body parts should see a reduction of the Class II dental relationship
involved, such as hemiplegia (one arm and one leg), diple- to allow better lip cover and thus protect these teeth
gia (both legs), and quadriplegia (all the limbs, trunk, and from incidental trauma (Patient 1: Figure 25.4). The second
neck). There are several associated neurological features justification for a phase 1 treatment is the orthodontic
including epilepsy, mental retardation, learning disabilities, reduction of displaced anterior teeth following trauma,
and attention deficit-hyperactivity disorder (Blair and especially in cases of accidental intrusion or bucco/lingual
Watson, 2006). displacement.
The skeletal features include Class II jaw relationship, Following traumatic intrusion, the long-term survival of
increased lower facial height, backward mandibular rota- the injured tooth hangs in the balance. In the absence of
tion, broad mandible and anterior open bite. The oral char- timely treatment, pulp necrosis, inflammatory root resorp-
acteristics are uncontrolled head and tongue movements, tion, ankylosis, replacement resorption and loss of mar-
forward tongue posture, hypotonic orofacial musculature, ginal bone support are likely to occur (Andreasen and
grossly incompetent lips, and drooling (Strodel, 1987;
Rodrigues dos Santos et al., 2003). The following dental
features are commonly seen: Class II Division 1 malocclu-
sion, an anterior open bite, a posterior crossbite due to
the wide mandibular dental arch, gingival inflammation
and traumatized upper incisors (Franklin et al., 1996;
Carmagnani et al., 2007).
Treatment need is very high (Oreland et al., 1987; Vittek
et al., 1994) (Patient 1: Figures 25.1, 25.2), but these patients
present a plethora of justifiable reasons why treatment is
likely to be denied. Typically, they exhibit exaggerated
apprehension and reduced understanding. This, together
with their physical impairment and involuntary move-
ments, undermines their ability to cooperate. In addition
they have drooling (Harris and Purdy, 1987), a highly sensi-
tive gag reflex, and poor oral hygiene (Guare Rde and
Ciamponi, 2003), with food accumulation and stagnation
which is largely due to poor muscle function.
Orthodontic Treatment for the Special Needs Child 491
(a) (b)
(c) (d)
Figure 25.2 Patient 1: pretreatment intraoral views showing a Class II Division 1 malocclusion: (a) frontal, (b) right side, (c) left side, (d) overjet.
Andreasen, 1994). It should be clearly understood and root canal therapy may then only be provided after exten-
appreciated that the alternative to extraction and prostho- sive gingivectomy (Tronstad et al., 1986).
dontic replacement in the special needs population sub-
group is not an option to be countenanced lightly. Three Surgical repositioning has been advocated to immedi-
options are available for reduction and realignment of dis- ately relocate moderately or severely intruded teeth and to
lodged teeth (Chaushu et al., 2004): provide early access for root canal treatment in order to
prevent infection pursuant to pulpal necrosis. However, this
• Observation alone, in the optimistic expectation of operation has also been reported as actually increasing the
• spontaneous re-eruption incidence of ankylosis, pulp necrosis, and loss of marginal
bone (Chaushu et al., 2004; Andreasen et al., 2006).
Immediate surgical repositioning into their presumed
Orthodontic repositioning of traumatically displaced
• previous locations teeth has been shown to be superior to the other alterna-
Early orthodontic repositioning, which is largely a valid tives, in terms of tooth loss during the follow-up period
procedure to be initiated during a period of up to 3 (Chaushu et al., 2004; Andreasen et al., 2006). Regardless of
months’ post-trauma. treatment approach, external inflammatory root resorption
and marginal bone loss are frequent complications, and the
Observation in anticipation of spontaneous re-eruption of incidence of root resorption appears to be similar between
a traumatically intruded tooth is highly unreliable, but iso- the three treatment approaches (about 40%). Marginal
lated successes have been reported (Shapira et al., 1986). bone loss was higher in those teeth treated by observation
Nevertheless, in the more severely intruded teeth, access for
492 Integrated Clinical Orthodontics
(a) (b)
(c) (d) (e)
Figure 25.3 Patient 1: phase I treatment was initiated with the aim of preventing trauma by reducing the increased overjet. (a) The simple acrylic ‘trainer’
removable expansion appliance with anterior bite plane. (b) Removable appliance in mouth. (c) Twin-block appliance to encourage mandibular growth.
(d) Twin-block appliance in mouth. (e) Profile view with twin block appliance in situ.
only than in those repositioned either in a one-step surgical tain the treated outcome by restraining maxillary growth,
approach or over time by orthodontic traction (Chaushu with the aid of a high-pull extraoral removable en bloc
et al., 2004). Thus, it seems that if the tooth remains in its appliance (Thurow, 1975), or preventing clockwise man-
embedded position in the bone, there is the strong likeli- dibular rotation using a chincap. Despite these precautions,
hood of bone loss, while if the tooth is relocated in its subsequent changes in late adolescence/early adulthood
original position, and the normal relationship between the may still occur and dictate the need for a phase 3 interven-
tooth and the bone is re-established, marginal bone loss is tion involving orthognathic surgery, although this option
minimized. must only be recommended with due consideration and
careful assessment of the individual patient in this sub-
The aims of phase 2 treatment are to align the teeth, to group of the population.
relieve crowding and to close down open bites, while main-
taining the achieved skeletal sagittal interarch relationship Down syndrome
(Patient 1: Figure 25.5). This goal is usually achieved with
the use of fixed multibracketed appliances, with headgear Down syndrome is an autosomal genetic disorder, caused
or extraction support, in the full permanent dentition by an extra chromosome 21, with an incidence of 1/800–
(Patient 1: Figures 25.6, 25.7). 1000 live births. The patient has a short stature, mental
retardation, and phenotypic abnormalities including oral,
In the presence of an abnormal growth direction, delete- cardiovascular, hematopoietic, musculoskeletal, nervous,
rious hypotonic muscle behavior and poor function, main- and behavioral anomalies (Hawli et al., 2009). Down
tenance of the achieved result becomes the major concern. syndrome individuals are prone to the development of
A regimen of active retention is sometimes needed to main-
Orthodontic Treatment for the Special Needs Child 493
(a) (b)
(c) (d)
Figure 25.4 Patient 1: interim photographs at the end of phase I, showing the improvement in the appearance due to correction of the skeletal Class II skeletal
relationship and the overcorrection of dental relationships. (a) Profile, (b) frontal, (c) right, and (d) left views.
(a) (b) (c)
Figure 25.5 Patient 1: intraoral views before the beginning of phase II treatment with fixed appliances. The upper first left molar has been extracted due to
caries with compensatory extraction of the upper second right premolar. (a) Frontal view, (b) right side, and (c) left side.
494 Integrated Clinical Orthodontics
(a) (b) (c)
Figure 25.6 Patient 1: post-treatment facial photographs showing the marked improvement in the esthetics of the face and profile. (a) Profile, (b) frontal, and
(c) smile.
(a) (b) (c)
Figure 25.7 Patient 1: post-treatment intraoral views showing the corrected dental relationships. (a) Frontal, (b) right side, and (c) left side.
infectious, malignant, and autoimmune diseases (Desai, Down syndrome patients are characterized by many
1997). There is also a high incidence of hypothyroidism dental anomalies, including Class III dental relationship
(Fort et al., 1984; Goday-Arno et al., 2009) and delayed with anterior and posterior crossbites, which have been
motor function (Vicari, 2006). reported in the literature (Oliveira et al., 2008). Dental
abnormalities in the number (fewer), size (smaller) and
Down syndrome patients are characterized by many morphology (peg-shaped and other morphological defi-
skeletal and dental anomalies, which have been widely ciencies) (Cohen and Winer, 1965; Townsend, 1983; Peretz
reported in the literature. A skeletal Class III pattern is et al., 1996), and the timing of their development (late
usually present due to an underdeveloped midface. The dentition) (Garn et al., 1970) are constant features of this
maxilla is deficient in all three planes of space: it is retruded syndrome. There is an increased incidence of canine/pre
in the sagittal plane, narrow in the coronal plane and molar transpositions and of impacted canines (Roger, 1994;
short in the vertical plane. The palate is V-shaped and Shapira et al., 2000). The tongue is large and is postured
high (Limbrock et al., 1991; Desai and Flanagan, 1999). The forward at rest and during function (Glatz-Noll and Berg,
mandible is usually of normal size (Reuland-Bosma and 1991). There is often an open mouth posture and mouth
Dibbets, 1991) but, because of the decreased lower breathing, in part due to the hypotonic musculature (Morris
facial height, there is overclosure of the mandible, resulting et al., 1982; Merrick et al., 2000), and recurrent chronic
in a relative mandibular prognathism (Patient 2: Figures upper respiratory infections (Shott, 2006). Salivary output
25.8–25.10).
Orthodontic Treatment for the Special Needs Child 495
(a) (b)
Figure 25.8 Patient 2: 13-year-old child with Down syndrome. Pretreatment facial photographs: (a) profile, (b) frontal.
(a) (b) (c)
(d) (e)
Figure 25.9 Patient 2: pretreatment intraoral views. (a) Frontal, (b) right side, (c) left side, (d) upper occlusal, and (e) lower occlusal.
Figure 25.10 Patient 2: pretreatment panoramic radiograph showing impacted maxillary canines and a missing lower incisor.
496 Integrated Clinical Orthodontics
is reduced and this is reflected as dry lips and oral mucosa, (a)
with frequent ulceration (Chaushu et al., 2002a,c, 2007).
The salivary immune system is impaired – a characteristic (b)
which itself is a potential etiologic factor of the recurrent Figure 25.11 Patient 2: views at the conclusion of intravenous sedation.
upper respiratory infection (Chaushu et al., 2002a,c). (a) Frontal and (b) right side.
Bruxism is a common finding.
Several previous studies have shown that Down syn-
drome individuals have an increased prevalence of perio-
dontal disease compared with normal, age-matched control
groups and other mentally disabled patients of similar age
distribution (Orner, 1976; Reuland-Bosma and van Dijk,
1986). The prevalence of periodontitis under the age of 30
is close to 100% and is in sharp contrast with the low inci-
dence of caries (Orner, 1976). The progression and severity,
as well as the clinical characteristics of the periodontal
destruction reported in Down syndrome individuals, are
consistent with the early-onset/aggressive periodontitis
disease pattern (Shaw and Saxby, 1986; Cichon et al., 1998).
Because of the high prevalence and severity of skeletal
and dental abnormalities, Down syndrome patients present
high orthodontic treatment need (Oreland et al., 1987;
Desai, 1997). From the skeletal point of view, they com-
monly need maxillary expansion and protraction, to
correct/improve the skeletal Class III jaw relationship and
the profile esthetics (Patient 2: Figures 25.11, 25.12).
Dentally, they generally need alignment of their teeth,
opening/closing spaces of congenitally missing teeth and
resolution of impactions and transpositions. However, the
clinician encounters many obstacles in pursuing successful
orthodontic treatment. Their behavior is often problematic
because of reduced understanding and increased apprehen-
(a) (b)
Figure 25.12 Patient 2: expansion of the upper arch. (a) Clinical view and (b) radiographic occlusal view.
Orthodontic Treatment for the Special Needs Child 497
sion, short attention span and limited tolerance. Although of understanding, tolerance, and compliance. It follows,
our experience shows that most of these patients can be therefore, that in order for the orthodontist to achieve
treated at the chairside using the regular behavior manage- therapeutic access, a structured approach to their treatment
ment techniques, some need sedation or general anesthesia is required. This includes the need for considerably more
for the more extensive procedures and potentially painful chairside time, the exploitation of the full range of behavior
appointments, such as bonding/debonding of brackets management modalities and a breakdown of the treatment
or extractions of deciduous teeth (Chaushu and Becker, into individual self-contained tasks, in a modular approach.
2000; Chaushu et al., 2002b). Other impediments are the Above all, there is the essential requirement for a caring,
increased incidence of macroglossia and open mouth patient, and persevering attitude on the part of the treat-
posture. These, together with the hypotonic musculature ment delivery team, which includes the orthodontist, the
that might impede closing of an anterior open bite, chairside assistant and the parent, together with the occa-
cause relapse of a successfully achieved result. In addition, sional services of several other specialists, chief among
these patients require close monitoring from the perio them being the anesthetist.
dontal aspect because of the highly increased risk for
periodontal disease. Early-onset periodontitis is an aggres- (a) (b)
sive disease which should be diagnosed and treated with Figure 25.13 Patient 2: post-treatment facial photographs. (a) Profile and
due attention and speed. Sometimes, the orthodontic appli- (b) frontal views.
ances have to be removed and treatment halted during the
period of periodontal treatment only to be restarted after
improvement in the periodontal status has been achieved.
Dividing the orthodontic treatment into two phases is
indicated in cases of significant skeletal discrepancy. In
these cases, phase I treatment is performed at an age of 8–10
years and its main aim is to treat the posterior and anterior
crossbite by maxillary expansion and protraction. The best
way to achieve this goal is to use a banded or bonded rapid
palatal expansion appliance with hooks for the simultane-
ous maxillary protraction with a face mask. We usually
recommend the use of a custom-made facemask, which can
be constructed on a plaster impression of the face. This
kind of facemask fits the patient’s face, can be made with
clear acrylic chin and forehead pads, and is less obvious to
those around. This is better accepted by the patient in com-
parison to those seen in an orthodontic catalog.
Phase II treatment is usually initiated at an age of 12–15
years, depending on the delay in dental age. It is aimed at
aligning the teeth, closing or opening spaces of congenitally
missing teeth, treating impactions and tooth transpositions
(Patient 2: Figures 25.13–25.16). This treatment is per-
formed with fixed appliances which can usually be placed
at the chairside, unless multiple procedures are needed, in
which case a sedation session may be planned to accom-
modate all of these at a single session.
In cases of severe jaw discrepancies in patients after ces-
sation of growth, orthognathic surgery may be planned for
maxillary expansion and a down-sliding advancement
(Janson et al., 2009).
Conclusion Figure 25.14 Patient 2: smile line.
Special needs patients suffer to a greater extent and from
more grotesque malocclusions than healthy patients;
anxiety and apprehension levels are far greater than among
their peers and they have a much reduced threshold
498 Integrated Clinical Orthodontics
(a) (b) (c)
(d) (e)
Figure 25.15 Patient 2: post-treatment intraoral views: (a) frontal, (b) right side, (c) left side, (d) upper, and (e) lower views.
Figure 25.16 Patient 2: post-treatment panoramic view.
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Index
Aarskog syndrome 114, 120 alveolar bone modelling 169–70, 171, physical basis 73
abfraction 60 394–6 quantitative analysis 74–5
abrasion of teeth 60 audiological tests 206–7
with stem cell technologies 401–18 autoimmune diseases 6–7, 39–40, 49, 114,
see also enamel demineralization and alveolar cleft closures 162–3
erosion alveolar drift 169–70 254–5
amelo-onchohypohydrotic dysplasia 113 autoimmune polyendocrinopathy 114
acetylsalicylic acid 48 amelogenesis imperfecta 60–2, 109, 112, autotransplantation 300–3
achondroplasia 42, 105–6, 114, 148–9 azotemia 47
acromegaly 43–4, 183, 184 114
actinomycosis 244, 248–9 American Board of Clinical Geneticists bacterial infections 241–8
activator appliance 220 management principles 397–8
acute necrotizing ulcerative gingivitis (ABMG) 110–11 within oral cavity 243–5, 397–400
anemia
(ANUG) 244, 245 basal cell carcinoma (nevoid) 42, 112,
acute suppurative parotitis (ASP) 246–7 hemolytic 47 113–14, 123
Addison’s disease 50, 192 sickle cell 47–8
adenoid cystic carcinomas 327–30 angiomas, facial 39 Binder syndrome see maxillonasal
adenoidectomies 201–3 Angle, Edward Hartley 2, 380 dysplasia
adenoids 196–7 ankylosis of teeth 303–5
anorexia nervosa 60, 89 bio-Oss 389
anomalies 197–201 impact on orthodontic treatment 88 bioglass materials 389
investigations 222–7 antidepressants 87 biological status of patient 5–9
removal 201–3 antipsychotics 87 biomaterials 383–4
adhesives, biomimetic 375–6 antiviral agents 47
adolescence 77 ANUG see acute necrotizing ulcerative design requirements 383
diet and food choices 89 see also tissue engineering
adrenal disorders, general 192 gingivitis (ANUG) biomedical engineering
adrenal insufficiency 183, 192 anxieties over treatment, underlying causes background and past research
aerobic infections, affecting oral cavity
70 366–73
243–5 Apert syndrome 42, 113–14, 143–8 archwire-bracket friction 366–8
agenesis see dental agenesis apexification techniques 293–5 fabrication of nonmetallic archwires
airway imaging 198–9, 222 apnea 214
airway obstruction 368–9
see also obstructive sleep apnea force measurements 372
ENT referrals 197–201 appearance concerns 69–70 mechanical properties of archwires
impact on facial length 199–201 appliances (general considerations)
measurement and evaluation 198–9 369–72
otolaryngology 201–3 cariogenic problems 286 use of finite element analysis
see also obstructive sleep apnea (OSA) pulpal reactions 286–8
alcohol use 6 see also biomedical engineering; 372–3
see also fetal alcohol syndrome current studies and potential applications
allergens 47, 373 individual named appliances;
allergic disorders 47 materials science 373–7
allografts 389, 403–18 application service provider (ASP) solutions biomimetic adhesives 375–6
see also alveolar bone grafts 17 brackets with force measurement
alopecia totalis 9, 11 appointment scheduling, IT software 16
alveolar bone grafts 162–3, 401–2 archwires centres 375
contraindications 415–16 coatings 371–2 self-cleaning materials 376–7
future research needs 418 mechanical properties 369–72 self-healing materials 374–5
harvesting methods 406–8 nonmetallic 368–9 shape memory polymers 373–4
post-surgery evaluations 411–12 surface properties 366–8 see also tissue engineering
surgical protocols 408–11 archwire-bracket friction studies 366–8 biomedical engineers 366
transmucal penetration and cell asthma 46 bisphosphonate treatment, jaw necrosis
attention deficit hyperactivity disorder
rejuvenation 412–15 (ADHD) 77 174
use of stem cell technologies 401–18 attractiveness 72–3 blastomycosis 259
ethno-cultural differences 75–6 bleeding disorders 49, 50
perceptual basis 73–4 bleeding index 398
Bloch-Sulzberger syndrome see
incontinentia pigmenti
blood transfusions 49
Integrated Clinical Orthodontics, First Edition. Edited by Vinod Krishnan, Ze’ev Davidovitch.
© 2012 Blackwell Publishing Ltd. Published 2012 by Blackwell Publishing Ltd.
502 Index
body dysmorphia 79 calcium hydroxide 294 speech pathology 156
bone grafts 389 cAMP see cyclic adenosine monophoshate surgery 155
orthodontic management 156–65
alveolar cleft closures 162–3 (cAMP) birth to 7 years 157–62
contraindications 415–16 cancer from 8 to 15 years 162–4
future research needs 418 from 16 to 20 years 164–5
harvesting 406–8 associated conditions 120–1 prevalence 154
surgical protocols 408–11 childhood conditions 100 relapse risk and retention appliances
post-surgery evaluations 411–12 candida-associated lesions 256, 257–8
transmucosal penetration (TMP) candidiasis 256, 257, 258 165
canine protected occlusion (CPO) 477 cleidocranial dysplasia 113–14, 118–19
412–18 canine tooth, impaction 57 clinical examination
using stem cell technologies 401–18 canker sore 242
bone health, nutrient requirements 88 cardiovascular disease 46 basic procedures 38–9
bone loss caries see dental caries dentition evaluations 53–60
prevention through infection control cariogenecity of foods 86–7 occlusion and TMJ assessments 60–2,
Carney complex 44
397–400 Carpenter syndrome 113 332–5, 471
see also root resorption case documentation software 17 periodontal status 52–3
bone marrow 381–3 casein phosphopeptide 306 soft tissue anomalies 50–2
bone metabolism cellular signaling molecules 5 clinical geneticists 109–11
and orthodontic tooth movement cementum, regeneration 388–9 professional development 110–11
centric occlusion 62, 63 referrals 111–12
173–4 centric shifts 62, 63 clinical genetics
regulation 7–9 cephalometry 222 inheritance 40
bone modelling 168–70, 393–4 assessment of growth 105–7 investigations and referrals 111–15
bone ‘morphing’ 394–7 online analysis 21 see also congenital orofacial deformities
bone morphogenetic proteins (BMPs) 377, software comparisons 22 coagulation disorders 49
3D systems 21 Coffin-Lowry syndrome 113–14, 117
385–8 cerebral palsy patients 490–2 Cola drinks 88
bone remodelling 170–5, 394–6 cervical abrasion 60 collagen
cervical fracture 295–6 synthesis 88
clinical implications 172–5 cervical spine fusion 62, 63 use in tissue engineering 383
definitions 170 Chediak-Higashi syndrome 113, 117 color changes
key stages 170–1 cheese 87 dentition 58, 59–60
mechanic forces 175–7 cherubism 113, 117–18 oral mucosa 50–1
bone strain 175–7 chewing gum 87 communication skills, improvement
bone-anchored maxillary protraction sugar-free 306
child and adolescent development strategies 93–4
systems 161–2 compliance issues see patient compliance
bony lesions 52 76–7 compressive stressors 175
borderline personality disorders 78 importance of nutrition 86 computer malware (software) 28–32
braces see brackets and banding childhood obesity 88–9 computer-aided diagnosis 17–22
brackets and banding chondroectodermal dysplasia 113–14, concrescence 55
conductive hearing loss 204–9
ceramic 372–3 119
impact on oral hygiene 88 Class II malocclusions eustachian tube dysfunction 205–7
mechanical properties of archwires maxillary expansion 207–9
congenital disorders 42 otitis media 204–5, 207
369–72 deficiency states and malnutrition 43 condylar fractures 103
nonmetallic archwires 368–9 Class III malocclusions cone-beam computed tomography (CBCT)
self-ligating 367 causes and associated conditions 42, 53
surface coatings 371–2 prevalence 343 62
surface properties 366–8 cleft lip and palate appliances, infants cone-rod dystrophy 114
use of modelling analysis in design congenital orofacial deformities 132–50
157–62
372–3 clefts of lip and palate (CLP) 40 classification of anomalies 133
with force measurement centres 375 management of conditions
brain abscess 261–2 associated conditions 113–14, 127–8
breathing problems 197–200 etiology 153–4 achondroplasia 148–9
Broadbent Bolton templates 345 healthcare burden 143 craniofacial microsomia 133–40
‘brown tumours’ 47 interdisciplinary team care 154–6 craniosynostoses 143–8
bruxism 60 fetal alcohol syndrome 150
Buckley syndrome 113 ENT disciplines 156, 209 holoprosencephalic disorders 149–50
bulimia nervosa 60, 89 genetics 155–6 Teacher-Collins syndrome 140–3
burning mouth syndrome 45, 242 nursing and social work 155 velocardiofacial syndrome 143
obstetrics 154–5 psychological impact 132–3
calcified deposits, pulpal tissue 287 orthodontics 155 connective tissue dysplasias 125–7
calcitonin 184–5 pediatrics 155 consent issues see patient consent
calcium psychology 156 ‘contact splitting’ 375
routine dental care 156 coronary artery disease 46
and bone mass 88
deficiencies 43, 88, 173–4
homeostasis imbalances 6
Index 503
cortical perforations 173 dental caries 53–5, 56 dietary recommendations 84–6
corticosteroids 173 in adulthood 87 see also deficiency states and
corticotomies 173 cariogenic diets 86–7 malnutrition; nutrition
cosmetic dentistry definitions 86
interdisciplinary approaches 284–6 dietary supplements 86
gingival reshaping 430–1 post-treatment remineralization 306 differential scanning calorimetry (DSC)
see also individual orthodontic protective diets 87
resin infiltration 306–7 369–72
interventions difficult patients
Costen’s syndrome 470 dental casts, infants 157–8
CPAP therapy 228 dental dysplasias, associated conditions and body dysmorphia 79
craniofacial growth and development 4–5, borderline personality 79–80
syndromes 113–14 narcissistic personalities 79–80
40 dental eruption failures 121–2 and patient compliance 78–80
assessment methods and analysis perfectionist personalities 78–9
associated conditions 113, 121–2 search engine information 80
104–6 dental implants 444–68 DiGeorge syndrome see velocardiofacial
timing of orthodontic treatment 103–6
see also tooth morphogenesis anchorage considerations 177–9, 444–5 syndrome
craniofacial growth and development bone responses 177–9 digital photography 17–18, 19–20
case presentations 445–63
anomalies 40–3, 96–107, 209 outsourcing 20
specific growth-related problems 98–100 for forced eruptions 461–3 predicted post-treatment profiles 21–2,
trauma-related issues 100–3 for holding molars vertical 445–6
craniofacial microsomia 122, 133–40 for intrusion of molars 446–8 24
etiology 133–5 and surgical placement of digital radiography 18–21
management 135–7 dilacerations see root dilacerations
orthodontic treatments 137–40 microimplants 463–7 diode lasers 424
craniofacial trauma 100–3 innovations 2 discoloration
emergency orthodontic treatments post-surgery complications 467
success rates 466 oral mucosa 51
292–305 timing considerations 466–7 teeth 58, 59–60
craniosynostoses 114, 123–4, 143–8 dental pulp 286 distraction osteogenesis 305
chamber narrowing 47 Don Quixote (Cervantes) 70
etiology 143–5 exposure risks 293 Down syndrome 40, 52, 113–14,
management 145 necrosis 293–4
orthodontic treatments 145–8 preservation in young patients 293 117
Crohn disease 47 problems associated with orthodontic orthodontic interventions 492–7
Cross syndrome 113 dream interpretations, tooth loss 70
Crouzon syndrome 42, 114, 143–8, 149 treatments 286–8 drug users 46
crowding of teeth 53, 56, 58 regeneration technologies 388–9 dry mouth see xerostomia
crown fractures 292–3 tooth morphogenesis 382–3 DUTCHCLEFT trial 158–9
cryptococcosis 259 dentin dysplasia 113 dwarfism 113
CT data and DICOM 17–18 dentinogenesis imperfecta 60 dynamic mechanical analysis (DMA)
Cvek pulpotomy technique 293 dentition examinations 53–60
cyclic adenosine monophospate (cAMP) chronological age and maturation 53 studies 369–72
dental caries 53–5 dyskeratosis congenita 113
7–9 disorders of eruption 58–60 dysostosis see cleidocranial dysplasia
cysts, jaw 62, 64 numbers of teeth 53 dysphagia, family history 112
cytomegalovirus infections 253–4 pigmentation and discolorations 58, dysplasias see connective tissue dysplasias;
data management, overview 16–17 59–60 dental dysplasias
data recovery 29–32 shape anomalies 55–8
data security 17, 28 size anomalies 55 E-models 18, 20–1
depression, post surgery 361 ear pain 209–10
encryption systems 33–4 dermatitis 47 early-onset periodontitis 113, 115–16
malware problems 28–9 development of craniofacial structures see ear, nose and throat (ENT) specialists
passwords and digital signatures 17
recovery measures and solutions 29–32 craniofacial growth and 195–211
data storage 28 development anatomical associations 195–6
De Lange syndrome 113 development stages (general) see child and common anomalies 196–7
debonding 305 adolescent development joint concerns (ENT-orthodontic)
deficiency states and malnutrition 43 diabetes mellitus 6–7, 44–5, 89, 183,
impact on orthodontic treatment 5–6, 191–2 197–211
diagnosis 37–64 airway obstruction 197–204
87–8 approaches and collaborations 4, 37–8 cleft lip and palate patients 156,
maternal 86 computer-aided systems 17–22
see also nutrition template-guided 345 209
delayed tooth eruption 113 ‘diet’ cf. ‘nutrition’ 83–4 conductive hearing loss 204–9
see also dental eruption failures dietary problems craniofacial anomalies 209–10
dens invaginatus 55 cariogenic foods 86–7 temporomandibular dysfunction
dental agenesis 53, 54 see also eating disorders; obesity
associated conditions 114 210–11
key areas of interaction 196
eating disorders 60, 88–9
ectodermal dysplasias 113, 115
ectomesenchymal progenitor cells 382
504 Index
education see orthodontic education Fabry disease 113–14, 119 GHD see growth hormone deficiency
Ehlers Danlos syndrome 113–14, 116, 125 face masks 164 (GHD)
18-P syndrome 114 facial asymmetry 114, 122–3
Ekman-Westborg-Julin syndrome 113 gigantism 43–4, 183, 184
elastic limit 371 functional 124 gingival enlargement 398–400
elastic modulus 371 see also hemifacial microsomia gingival fibromatosis (hyperplasia) 45, 113,
electronic data management 28–35 facial esthetics 1–4
electronic fund transfer (EFT) 16–17 facial hyperplasia 55 121–2
electronic patient record (EPR) 17 facial orthopedics see surgically-facilitated gingival ‘rebound’ 395, 430–2
Ellis-van Creveld syndrome see gingival reshaping 430–1
orthodontic therapy (SFOT) gingivectomies 399
chondroectodermal dysplasia facial palsies 136
email 25 facial regeneration technologies 385–8 laser use 429–30
facial wrap imaging 17–19 gingivitis, acute necrotizing ulcerative 244,
appointment reminders 16 familial adenomatous polyposis 50, 113,
encryption 33 245
HIPAA compliance 33 119 gingivoplasties, laser use 429–30
embryological defects 40, 41–2 and cancer 120–1 glass ionomer cements (GICs) 286
emergency treatments 292–305 familial intestinal polyposis 50 globodontia 112
emotional well-being fat (dietary) 85 gnathology 470–1
post-surgery changes 360–4 fears, of tooth loss 70 goals of treatment, decision-making
treatment motivation levels 71 fetal alcohol syndrome 113, 150
enamel agenesis 113 fetal face syndrome 114 processes 336
enamel demineralization and erosion 60 fetal hydantoin syndrome 113 Goldenhar syndrome 42, 113–14
gastrointestinal diseases 47 fiber composite archwires 369
post-trauma remineralization techniques fiberotomies 291 see also hemifacial microsomia
fibrous dysplasia 183, 190–1 gonorrhea 244, 249
306–7 file transfer protocol 25 GORD 47, 60
prevention regimes 285–6 financial records, maintenance software Gore-Tex materials 389
treatment-induced 280–2 Gorlin syndrome 42, 112, 113–14, 123
white spot lesions 284–6 16–17 Gorlin, Dr. Robert J. 110
enamel hypoplasia 40, 47 flap surgery 409–11, 467 grafting technologies (overview) 388–9
enamel matrix derivatives (EMDs) 386–8 flossing 397
encryption systems 33–4 fluoride 285–6 see also bone grafts; stem cell science
endocarditis 46 grafts see bone grafts
endocrine anomalies 41, 43–5, 182–93 caries infiltration treatments 306 ‘ground glass’ jaw lesions 47
growth hormone deficiency (GHD) protective role 87 growth charts 12, 104
fluorosis 58, 59 growth delays 41, 43–4
182–4 folic acid 86 growth and development see craniofacial
endocrine system, impact on tooth food choices
during treatment 88 growth and development; physical
movement 6–9, 182 general dietary recommendations 84–6 growth (stature); tooth
endodontic treatments, interdisciplinary see also nutrition morphogenesis
forced eruptions 461–3 growth hormone deficiency (GHD) 182–4
approaches 284 Fordyce granules 51 growth hormone excess 43–4, 184
ENT specialists see ear, nose and throat fragile X syndrome 114, 123 growth hormone therapy 105, 183–4
frenectomies 435–7, 438–9
(ENT) specialists FRESH goal prioritising 336, 338 Hajdu-Cheney syndrome 113–14, 116
enterococci infections 243–4 Friedman grading 224 Hallermann-Streiff syndrome 113, 125
Enterococcus faecalis 243–4 frontonasal dysplasia 114 hand, foot and mouth disease 251, 256
enterovirus 251, 256 functional appliances see functional therapy Hashimoto thyroiditis 6–7
enzyme deficiencies 47 functional occlusion, and TMD 477 healthy eating guidelines 84–5
epidermolysis bullosa 113 functional therapy, in craniofacial heavy metal poisoning 51
epidural nevus syndrome 102 HED 114
epiglottitis 244, 248 microsomia 138–9 Helicobacter pylori infection 262
epilepsy 45 fungal infections 256–62 hemangiomas 50–1, 102
epithelial ovarian cancer, and hypodontia hematological disorders 47–9
GAPO syndrome 113 hematopoietic stem cells (HSCs) 381
121 Gardner syndrome 50, 113, 119 hemifacial hypertrophy 55
Epstein-Barr virus 253–4 hemifacial microsomia 122, 133–40
eruption disorders and cancer 120–1
gastritis 47 etiology 133–5
primary failures 58–60, 121–2 gastrointestinal conditions 46–7 management 135–7
see also delayed tooth eruption; forced Gaucher disease 113 orthodontic treatments 137–40
‘geckel’ adhesives 375 hemihypertrophy 114
eruptions genetic inheritance 40 hemophilia 49
erythematous spots 50 hepatitis virus 46–7, 251, 256
erythroplakia 50–1 see also clinical genetics; congenital Herbst appliance 228
erythropoiesis, extramedullary 48 orofacial deformities herpangina 255–6
eustachian tube dysfunction 205–7 herpesvirus infections 250–2
examination see clinical examination genetic tests 111 herpetic gingivostomatitis 250–2
external fixing devices 106 geneticists see clinical geneticists Hertwig’s epithelial root sheath 382
eye malformations 112
Index 505
HFTC 114 use of Internet 22–8 Kohlschutter-Tonz syndrome 114
HIPAA compliance 33 virtual records 32–4 Koplik spots 50
histiocytosis 101 infraocclusion 58–60
histoplasmosis 259 initial examinations 38–9 Laband syndrome 113
history of orthodontics 2–4 intercuspation 57 labial bows 322, 329–30
history-taking see medical history interdisciplinary approaches 4, 38 Larsen syndrome 113
HIV infection 39–40, 49, 254–5 clinical examples of positive outcomes laser therapies 399, 422–42
hMSCs see human mesenchymal stem cells
283–307 choice of anesthetic 425–7
(hMSC) early assessment and evaluations 284–6 components 422–3
holoprosencephalic disorders 149–50 to common orthodontic problems concepts and definitions 422
hormonal control see endocrine system cf. conventional surgery 423–4
HTTP 25–6 286–92 diode vs. solid-state lasers 424–5
human mesenchymal stem cells (hMSC) to TMD treatments 480 historical perspectives 423
working with emergency and trauma machine set-ups 427–9
401, 403–18 postsurgical management 442
human papillomavirus infections 251, 254 specialists 292–305 safety considerations 440–2
Hurler syndrome 113 working with ENT specialists 195–211 surgical applications and procedures
Hurler-Scheie syndrome 113 working with pediatric dentists 267–82
hydroxyapatite 379 interim obturators 322–3 429–40
hypercementosis 58 internal derangements 477–9 timing of interventions 433
hyperimmunoglobulinemia E 113 Internet tooth and mini-implant exposures 433–5
hyperparathyroidism 47 email 25 latex allergies 47
hyperparathyroidism-jaw tumor syndrome evidence sources 27–8 Lemierre abscess 244
file transfer protocol (FTP) 25 Leopard syndrome 114
183, 185–6 HTTP 25–6 leprosy 249
hypertelorism-hypospadias syndrome 114 patient education 80 leukemia 48–9
hypertension 46 remote frame buffer (RFB) protocol 26 leukoplakia 50–1
hypertrichosis lanuginosa 113 interpersonal relationships, post- lichen planus 51
hypodontia 53, 54, 55 lip taping 159
orthodontic interventions 361 lips, crusting 50
and cancer 120–1 invasive cervical resorption 290–2 liver dysfunction 46
see also syndromic hypodontia long anterior facial height 114
hypophosphatasia 58, 113, 115, 186–7 jaundice 51, 58 ‘long face syndrome’ 198–204, 344
hypothalamic – pituitary – adrenal axis 9 jaw imbalances (multidisciplinary Lowe syndrome 115
hypothyroidism 44, 185 lupus erythematosus 6–7
teamwork) 332–64 lymphangioma, tongue 52
I-cell disease 113 assessment and initial examination
imagery see digital photography; digital McCune-Allbright syndrome 44, 113
checklists 332–5 McNeil-type appliances 158
radiography diagnosis 339–41 macrodontia 55
immunodeficiency 6–7 evaluating interdisciplinary records macroglossia 52
immunosuppressive therapy 46 magnesium deficiency 88
implants see dental implants 341–4 malabsorption 47
incontinentia pigmenti 113, 119 final reviews and evaluations 361–2 malar deficiency see midface (malar)
infant orthodontics, for clefts of lip and general patient assessments 341
goal identification and clarification deficiency
palate 157–62 malnutrition 5–6, 43, 86, 87–8
infection management principles 397–8 336–8 malocclusions
intervention pathways and final plan 347
probing 3998 intervention planning sequences 333 impact on self-esteem 106
infections 240–63 multidisciplinary reviews of presenting overview of causes and associated
bacterial 241–8 problem 344–5 syndromes 42, 44
fungal 256–62 patient consultations to explain options treatment ‘need’ vs. ‘demand’ 70–1
impact on craniofacial development see also specific conditions
345–7 malware infections 28–32
40–3 postsurgery reviews and complications mandibular advancement splints 228
impact on oral and dental health 46–7 mandibular deficiency 113, 343
impact on outcomes of orthodontic management 357–61 causes and associated syndromes 42
presurgery procedures 351–7 prevalence 343
interventions 394–400 risk presentation consultations 347–50 mandibular prognathism 114
oral cavity as source 261–2 treatment conference reports 335–6 mandibular retrognathism 124
parasitic 260–1 treatment milestone charts 348 mandibulofacial dysostosis (MFD) see
viral 250–6 treatment plan acceptance 350–1
infective endocarditis 46, 261 jaw pathologies 62, 63–4, 185–6 Treacher Collins syndrome
inflammation 5 see also bone remodelling; prognathism; marble bone disease see osteopetrosis
inflammatory bowel diseases 47 Marfan syndrome 113, 126–7
information technology temporomandibular dysfunctions Maroteaux-Lamy syndrome 113
for diagnosis and treatment 17–22 jaw radiographs 62, 63–4
for electronic data management 29 Johansson-Blizzard syndrome 114
for practice management 16–17
security and safeguards 30–2 Kallmann syndrome 114
Ketcham, Albert 2
Klinefelter syndrome 42, 112, 114
506 Index
Marshall syndrome 114 monobloc appliances 220, 234 nonerythematous pigmentation 50
Martin-Bell syndrome 114, 123 motivational aspects of orthodontic care nonmetallic archwires 368–9
materials science Noonan syndrome 114
69–80 NRL allergies see natural rubber latex
background and past studies 366–73 communication and education 72
current research areas 373–7 emotional and behavioral influencing (NRL) allergies
innovations and recent advances 2, 374 NSAIDs 5, 172–3
see also biomaterials factors 71 numbers of teeth 53
matrix metalloproteinase (MMP) hydrogels ‘need’ vs. ‘demand’ 70–1 nutrition 83–94
perception aspects 72–6
377 personality variables 76 assessment of dietary habits 6
maxillary expansion treatments 207–9, quality of life issues 69–70 cariogenicity of foods 86–7
and treatment compliance 77–80 and child development 86
220–1 see also goals of treatment deficiency states 41, 43
maxillary hypoplasia 123–4 mouth breathing 197–200 dietary recommendations 84–6
maxillary incisor anomalies MRI scans 62 impact on orthodontic outcomes 5–6,
mucosal ulceration 47
absent 275–9 mucositis 241–2 87–8
single central incisor 114, 120, 184 multidisciplinary teamworking (surgical patient education 90–4
maxillary incisor trauma 292 practitioner resources 94
maxillectomies 324–6 case studies) 332–64 role of orthodontists 83–4
maxillofacial prosthodontics, techniques assessment and initial examination strategies for managing 89–94
‘nutrition’ cf. ‘diet’ 83–4
and appliances 322–3 checklists 332–5
maxillonasal dysplasia 114, 123 diagnosis making 339–41 obesity
measles 251, 254 evaluating interdisciplinary records adult 89
mechanical load 175–7 childhood 88–9
mechanics of bone remodelling 175–7 341–4
median cleft lip, associated conditions 114 final reviews and evaluations 361–2 obstructive sleep apnea (OSA) 214–35
medical history 39–40 general patient assessments 341 definitions 214
goal identification and clarification diagnosis and investigations
patient health and medical status 40–9 216–17
medical referrals 38 336–8 examination charts 232–3
medications patient consultations to explain options forms and spectrum 215–16
in adults 220–30
causing mouth dryness 87 345–7 orthodontic management 227–8
impact on tooth movement 5 postsurgery reviews and complications orthognathic management
memory polymer materials 373–4 229–30
meningitis, chronic 262 management 357–61 in children 218–21
Menke kinky hair syndrome 113 presurgery procedures 351–7 orthodontic management 220–1,
mesenchymal stem cells (MSC) 381–3, 401, risk presentation consultations 235
influencing variables 217–18
403–18 347–50 prevalence 215
metabolic anomalies 43–5 treatment conference reports 335–6 surgical interventions 229–30
metal allergies 47 see also interdisciplinary approaches use of orthodontic appliances 220–1,
metallurgy, innovations 2 multiple endocrine neoplasia (MEN) 44 228
micro-implants, surgical placement 463–7 multiple sclerosis, impact on pain responses
microabrasion 306 occlusion
microcracks (bone) 176 6 centric shifts 62, 63
microdontia 55 mumps 251, 254 clinical assessment 60–2, 63
microleakage complications 286 Murray-Puretic-Drescher syndrome 113 impact of temporomandibular
Microsoft Windows, malware infections mycobacterial infections 249 dysfunctions 477
mycoses 259–60 optimal types 477
30–2 role of canine teeth 477
midface (malar) deficiencies 160–2 Nager acrofacial syndrome 113
Nance-Horan syndrome 113, 119 Oct4 markers 382–3
associated conditions 114 Nanog markers 382–3 ocular hypertelorism, associated conditions
orthopedic interventions 160–2 nanotechnologies 377, 383–4
post-CLP treatments 164–6 narcissistic personalities 79–80 114
missing teeth see dental agenesis; tooth nasal stents 159 oculo-facial-cardio-dental syndrome 55
nasoalveolar molding 159 odontogenic keratocyst 112
loss natural rubber latex (NRL) allergies 47 odontoma 112, 113
mixed dentition period, cleft lip and palate nephrocalcinosis 113 oligodontia see supernumerary teeth
neural crest cells 381–3 oligodontia-colorectal cancer syndrome
orthodontics 159–60 neural crest tube defects 133–4
Mobius syndrome 113 neurofibromatosis 44, 113–14 121
modelling see bone modelling neurological conditions, impact on pain online appointment scheduling 16
Mohr syndrome 115 OPCs see osteoprogenitor cells (OPCs)
molars responses 6 open bite 52
neuromuscular asymmetry 124
enlarged 112 neuromuscular disorders 45 anterior 98
impacted 210–11 nickel allergies 47, 373 posterior 101
intrusion 446–53 nickel-titanium archwires, mechanical
maintaining vertical 445–6
simultaneous intrusions 450–3 properties 369–72
uprighting procedures 453–60
operculectomy 437 partnership working see interdisciplinary Index 507
oral health approaches
Pierre Robin complex 42
bacterial infections 243–5 passive appliances, infant 158–9 pituitary gland 43–4
soft tissue examinations 50–2 patient compliance 77–80
oral hygiene 52–3 anomalies 43–4, 184
oral mucosa assessing psychosocial variables 77 placebo trials, for TMD treatments 479
clinical examination 50–2 dealing with substance abuse 77–8 plagiocephaly 103
discolorations 51 managing difficult patients 78–80 platelet-derived growth factor (PDGF)
lesions 51–2 patient consent
melanomas 51 cognitive and emotional factors 71–2 388
pigmentation patches 50–1 see also patient compliance PLGA see poly-lactic-co-glycolic acid
swellings 51–2 patient education
oro-facial-digital syndrome 113–14, 115 computer-assisted technologies 21–2 (PLGA)
orthodontic appliances see appliances Internet searches 80 pneumonia 262
in nutrition 90–4 poly-lactic-co-glycolic acid (PLGA)
(general considerations); brackets patient records, integration 32–3
and banding patients 383–4
orthodontic education, approaches and facial esthetics 1–4 polyglycolic acid (PGA) 384
focus 2–3 importance of biological status 5–9 polymeric archwires 368–9
orthodontically induced inflammatory root whole person approaches 4–5
resorption (OIRR) 288 payment records 16–17 shape memory materials 373–4
orthodontics peak growth velocity 104–5 polyoxometalates (POMs) 377
broadening scope 4 pediatric dentistry and orthodontics post-surgery complications 357–61
history 2–4 posterior crossbites 272–5
holistic approaches 4–5 267–82 practice management systems (PMS) 16
importance of biological status 5–9 coordinating appointments 268–70
public perceptions 2 early identification of problems benefits 16–17
orthopedic interventions see surgically- software comparisons 16
facilitated orthodontic therapy 270–2 pre-prosthetic treatments 313–30
(SFOT) responsibilities for problems 280–2 benefits and rationale 313–14
OSA see obstructive sleep apnea restoring form and function 272–9 case studies
osteocyte plasticity hypothesis 175–6 retention considerations and reviews
osteodystrophy 47 minor tooth movement prior to
osteogenesis imperfecta 42, 113–14, 125–6 279–80 canine guidance and full mouth
osteoglophonic dysplasia 113 pemphigus 51 rehabilitation 320–4
osteoid 173 periodontal flap surgery 291
osteomyelitis 40, 262, 326 periodontal infection orthodontic intrusion 314, 315
osteonecrosis, jaw 174 restoration after maxillectomy for
osteopathia striata 113 impact on outcomes of orthodontic
osteopenia, transient 174 interventions 394–400 ostomyelitis 324–7
osteopetrosis 113, 188–90 restoration of maxillectomy due to
forms 189 see also infections
osteoporosis 174 periodontal ligament (PDL) adenoid cystic carcinoma 327–30
osteoprogenitor cells (OPCs) 401, 405–6 use of implants for anchorage and
otitis media 201, 204–5 stem cells 383
otodental dysplasia 112, 113 stress studies 373 extrusion for site development
otolaryngology 201–3 periodontal status 52–3 314–20
outcomes of treatment, consequences of periodontally accelerated osteogenic predicted post-treatment imagery 21–2,
inadequate training 2 24
orthodontics (PAOO) premature delivery 262
pacifiers 97–8 case studies 403–18 premature tooth exfoliation 115–18
Paget’s diesease 174 described 401–2 associated conditions 113, 116–18
pain responses, impact of underlying periodontitis 398 premaxillary agenesis syndrome 114
early-onset 113, 115–16 ‘pressure’ responses 175
medical condition 6 peritonsillar abscess 244, 246 primary adrenal insufficiency 183, 192
pancreas 44–5 personality primary failure of eruption (PFE) 58–60,
PAOO see periodontally accelerated and motivation for treatment 76 121, 303
see also difficult patients primary herpetic gingivostomatitis 250–2
osteogenic orthodontics (PAOO) petechiae 50 priming (laser therapies) 424–5
papilla flattening, use of laser 432–3 Pfeiffer syndrome 114 progeria 113
Papillon-Lefevre syndrome 113–14, 116 pharyngitis, acute 245–6 prognathism 184
paracoccidioidomycosis 260 phosphorus, and bone mass 88 prosthodontic treatments
parasitic infections 260–1 physical activity, daily guidelines 85 following maxillectomy 327–9
parathyroid hormone (PTH) 6 physical appearance for radiation therapy 326
Parry-Romberg syndrome 113–14, and motivation 69–70 protein (dietary) 85
perceptions of attractiveness 73–6 protruding jaw see prognathism
122–3 physical growth (stature) psychiatric disturbances 45–6
delays and short stature 41, 43–4 psychosocial factors 9, 69–80
gigantism 43–4, 183, 184 emotional and behavioral infuencing
in males 12 factors 71–2
physiological status of patients 5–9 function vs. quality of life 69–70
pulp see dental pulp
pyknodysostosis 113
quality of life issues 69–70
508 Index
rachitic disorders see rickets scar tissue, cleft lip and palate patients case studies 490–7
radiographic examinations 163–4 cerebral palsy patients 490–2
Down syndrome patients 492–7
initial evaluations 62 sclerosteosis 113
of genetic anomalies 112–15 screw devices see skeletal anchorage deciding treatment plans 487–9
radiography, digital imaging 18–21 Seckel syndrome 113 particular considerations 489
radiotherapy treatments, use of interim sedation risks, with special needs children relapse and retention 489
sedation risks 489
obturators 327–9 489 speech pathology, for CLP patients 156
Ramon syndrome 113 seizure disorders 45 sporotrichosis 260
rapid maxillary expansion (RME) 207–9, selective alveolar decortication (SAD) SSEA3/4 markers 382–3
Staphylococcus aureus 243, 244
220–1 401–2 statins 5
rapid palatal expansion (RPE) 248, 348 self-cleaning materials 376–7 stature see physical growth (stature)
rebooting computer systems 30–1 self-concept 70–1 stem cell science 381–3, 392–419
recurrent aphthous stomatitis 242 background history 393–400
red blood cell defects 47 and adolescence 77
referral systems 38 post-surgery changes 360–1 bone and attachment levels 393–4
reflux disease 47, 60 self-healing appliance materials 374–5 bone restructuring developments
regeneration technologies 385–8 self-ligating brackets 367
regional acceleratory phenomenon (RAP) sex chromosome aneuplodies 42, 55, 394–6
risks of infection and gingival
173, 176–7 112–15
remineralization shape memory polymers 373–4 enlargement 397–400
short stature 41, 43–4 contraindications 415–16
fluoride applications 306 SHORT syndrome 113 future research needs 418
natural 306 sickle cell anemia 47–8 key principles and processes 401–2
remodelling see bone remodelling signaling molecules 384 new technologies 400–18
remote frame buffer (RFB) protocol 26 Singleton-Merten syndrome 113–14, 116
renal diseases 47 sinus problems, post-surgery 360 for facial regeneration 385–6
replantation techniques 298–9 sinusitis 244, 247–8 see also tissue engineering
resin infiltration techniques 306 skeletal anchorage 444–68 steroids 5, 39
resin modified glass ionomer (RMGI) 286 iatrogenic root resorption 47
respiratory disorders 46 bone responses 177–9 impact on bone remodelling 173
retention frames, cleft patients 163–4 case presentations 445–63 inhaled 46
retroviral infections 251, 254–5 Stickler syndrome 113–14, 127
rheumatoid arthritis 6–7 forced eruption 461–3 Stillman clefts 53
rhinitis 244, 247–8 holding molar vertical 445–6 stomatitis (recurrent aphthous) 242
riboflavin 86 intrusion of molars 446–8 Streptococcus mutans studies 373
rickets 102, 187–8 molar uprighting 453–60 substance misuse 46
1-alpha hydroxylase deficiency 183, 188 surgical placement of microimplants sucking habits 97–8
familial 114–15, 116–17, 183, 188 sugar
nutritional 114, 183, 188 463–7 cariogenicity 86–7
Robin sequence 113, 124 interactive approaches 445 daily intake guidelines 85
root canal treatments 284 post-surgery complications 467 definitions 86–7
following trauma 293–9 root damage 467 supernumerary teeth 53–4, 56
root dilacerations 55, 62 success rates 466 associated conditions 113, 118–20
root fractures 293–6 timing considerations 466–7 and cancer 120–1
root resorption 174 types of device 444–5 suppurative parotitis 244, 246–7
causes 2–3, 174 skull trauma 100–3 surgical interventions see laser therapies;
invasive cervical forms 291–2 sleep-disordered breathing (SDB) 215–16
investigations and diagnosis 289 see also obstructive sleep apnea surgically-facilitated orthodontic
key locations 288–9 smart brackets 374–5, 376 therapy (SFOT)
orthodontically-induced 288–92 smart materials 377 surgical screws 177–9
predisposing factors 289 ‘smile esthetics’, gingival reshaping 430–1 see also dental implants
treatments 289–90 SMMCI see solitary median maxillary surgically-facilitated orthodontic therapy
Rothmund-Thomson syndrome 113 (SFOT)
Rutherford syndrome 113 central incisor (SMMCI) bone graft procedures 405–9
snack foods 85, 86, 89 cleft lip and palate 160–2
SAD see selective alveolar decortication sodium intake 85 midface (malar) deficiencies 160–2
(SAD) soft drinks 88 post-graft/implant flap surgery 409–11,
soft tissue examinations 50–2 467
Saethre-Chotzen syndrome 113–14, 123 soft tissue lesions 51–2 replantation techniques 298–9
saliva skeletal anchorage and dental implants
laser excisions 439–40 177–9, 444–63
artificial 87 software comparisons, practice skeletal jaw imbalance case studies
protective role 87 332–64
see also xerostomia management systems (PMS) 16 swallowing difficulties see dysphagia
scaffold materials 383–4 solid-state lasers 425 symbolism and teeth 70
see also tissue engineering solitary median maxillary central incisor
(SMMCI) 114, 120, 184
special needs children 485–98
access arrangements 485–6
care management principles 486–7
Index 509
syndromic hypodontia, associated tongue thrusting 97–8, 99 van der Waals forces 375
conditions 120 tongue-retainer devices 228 van der Woude syndrome 114,
tonsils 196–7
syphilis 39–40, 244, 249–50 127–8
systemic fluorosis 58, 59 anomalies 197–200 varicella zoster infection 252–3
grading systems 224 vascular compression problems
talon cusp 55–8 investigations 222–7
taurodontism 55, 112–15 removal 201–3 287
telemedicine 27 tooth absence see dental agenesis velocardiofacial syndrome 113–14, 124–5,
temporomandibular dysfunctions 47, 210, tooth avulsion 297–8
tooth eruption delays see delayed tooth 143
470–81 video teleconferencing 26–7
background to studies 470–2 eruption viral hepatitis 46–7
causes 471–2 ‘tooth fairy’ issues 70 viral infections 250–6
characteristics of patients 472 tooth loss
classifications 472 clinical appearances 251
controversies and role of orthodontics complete 297–8 oral cavity 244, 247–8, 250–6
fears and anxieties 70 treatments 251
472–4 replantation and stabilization techniques virtual patient records 32–4
key theories 473 virus infections (software) 28–32
centric relation controversy 474–7 298–301 vitamin A, toxicity 88
functional occlusion 477 trauma-related 297–8 vitamin B(2) 86
internal derangements and ‘need to see also premature tooth exfoliation vitamin C, deficiencies 43, 86, 87–8
tooth morphogenesis 382–3 vitamin D
treat’ 477–9 tooth movement ‘with bone’ see bone deficiencies 43
diagnosis and investigations 471 hydroxylation pathways 6
multidisciplinary treatment options 480 modelling toxicity 86
post-surgery complications 360 tooth regeneration technologies 385–8 vitamin K, deficiency 88
treatment controversies 479–80 tooth shape anomalies 55–8 voice over internet protocol (VoIP)
temporomandibular joint (TMJ), clinical tooth size anomalies 55, 57
toothpastes, abrasive 60 26
examination 60–2, 471 torticollis 103 von Willebrand’s disease 49
template-guided diagnosis 345 training see orthodontic education
tensile stressors 175 transmucal penetration (TMP) Waardenburg syndrome 114
‘tension’ responses 175 Waldeyer’s ring 196
tetracycline 58, 60 412–15 web conferencing 27
thalassemia 47, 62 transplantation technologies 385–6 white sponge nevus 51
3D images 18–21 white spot lesions, interdisciplinary
thumb sucking 98 see also allografts
thyroid disease 183, 184–5 trauma see craniofacial trauma treatment approaches 284–6,
thyroid gland 44 Treacher Collins syndrome 42, 113, 127 306
thyrotoxicosis, juvenile 44 ‘whole bone’ models 403
thyroxine 184–5 etiology 140 Wi-Fi phones 26
tissue engineering 380–9 management 140–2 Wildervanck-Smith syndrome 113
orthodontic treatments 142–3 Wilkie oculo-facio-cardio-dental syndrome
definitions 380 treatment consent see patient consent 114
impact on orthodontics 384–8 trichodentoosseous syndrome (TDO) 112, Williams syndrome 113, 115
key principles and processes 381–3 Wolf-Hirschhorn syndrome 114
role of signaling molecules 384 113
types of scaffolds 383–4 trichorhinophalangeal syndrome 113–14, X-linked hypophosphatemic rickets
use of biomaterials 383–4 114–15, 116–17, 183, 188
tissue rebounding 395, 430–2 119–20
titanium oxide coatings 377 Trisomy-18 113, 115 xerostomia 45, 87
TMJ see temporomandibular joint (TMJ) tuberculosis 249 causes 87
tongue Turner syndrome 55, 112–15, 183, 192–3
clinical examination 52, 222–4 2D facial photo wrap 17–19 yeast infections 256, 257–9
enlargements 184 tympanometry 207
zinc 86
ulcerative colitis 47
ulcers, non-healing 51, 242
unilateral posterior crossbites 272–5
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