Bell - AAO - Ectopic Molars - Dx

Ectopic Eruption: Definition!
“Early Treatment for Missing & Impacted Teeth”!
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“Diagnosis & Interceptive Management!
of Ectopic First Permanent Molars”
Ronald A. Bell, DDS, MEd
Diplomate, ABO
Diplomate, ABPD
Presentation available as E-handout @ AAO website
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Developmental disturbance in the eruption patterns of!
any permanent teeth that results in atypical resorption!
of an adjacent tooth (either primary or permanent).!
Ectopic Eruption of
Maxillary First Molars !
Ectopic First Molars = When 1st molars are malpositioned and cause atypical resorption of adjacent 2nd primary molar.!
Reported prevalence of 1 to 4 %!
!
!
3 to 4% most likely!
Young: J Dent Child 24:153,1957
Ectopic Eruption of Mandibular First Permanent Molars!
Incidence: 0.2%
Kimmel et al: J Dent Child 49:294,1982
Ectopic Eruption: Maxillary 1st Molars !
!
- occurs 20 times more frequently in maxillary
first molars than for mandibular first molars.!
!
Reversible
Irreversible
Treatment approach will generally be the same as maxillary !
Bjerklin & Kurol:
Swed Dent J 5:29,1981
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Jump type
Hold type
Young:
J Dent Child 24:153,1957
Reversible Type >> (“Jump Type”)!
Ectopic 6 yr. molars > Reversible
ü After resorbing the distal root surface of the second
primary molar, the permanent molar becomes free
and erupts into a normal position (“self-corrects”).
Self-correction ≈ 2/3rds of cases
?
Young: J Dent Child 24:153,1957
Occurs by age 7 years
Resorption usually stops once cleared!
Kurol & Bjerklin: J Dent Child 49:273,1982
Bjerklin & Kurol: AJO 84:147, 1983
Bjerklin & Kurol: Swed Dent J 5:29,1981
Ectopic 6 yr. molars > Irreversible Irreversible type >> “Hold Type”!
ü Molar becomes blocked by 2nd primary molar and
First molar remains locked under E
Resorption usually progresses!
remains in a locked position until treatment or
premature exfoliation of the primary molar occurs.
Bjerklin & Kurol: Swed Dent J 5:29,1981
Age 6y. 1m.
Bjerklin & Kurol: Swed Dent J 5:29,1981
>>>>>>>>
Age 6y. 8m.
Potential sequelae of irreversible ectopic maxillary
Potential sequelae of irreversible ectopic !
first molars:!
maxillary first molars:!
!
> Blocked eruption of 6 s.!
!
> Supra-eruption of lower 6
> Resorption and early
loss of 2nd primary molar!
> Disruption of arch integrity
& malalignment!
!
> Space Loss / Blockage of
2nd bicuspid!
Thurow, Atlas of Orthodontic
Principles, C.V. Mosby: 1970
Thurow, Atlas of Orthodontic Principles,
C.V. Mosby: 1970
Sequelae of ectopic maxillary 1st molars:!
ECTOPIC MOLARS:
Etiological Factors!
Ø Larger than normal teeth!
Ø Small maxillary base!
Ø Arch length inadequacy!
Ø Retrusive maxilla!
Ø Abnormal mesial eruption path of first molar!
Ø Delayed calcification of first molar!
Ø Cleft palate (up to ≈ 30% concurrance)!
Ø Familial tendency (up to ≈ 20% in affected siblings)!
Pulver: J Dent Child 35:138,1968
Bjerklin & Kurol (AJO 84:147,1983
Ectopic Maxillary 1st Molars & “Crowding”:!
•  Premature loss of primary molars almost always results
in malocclusion with compromised arch circumference.
About 1 in 5 with lower incisor ectopic eruption patterns
will show ectopic eruption of the upper first permanent
molar. Note resorption of lower canines, ectopic laterals.
O’Meara: J Dent Res 41:607, 1962
TREATMENT OF ECTOPIC MOLARS!
Step 1. EARLY RECOGNITION
!PANORAMIC, PA S or Adequate BWX 5 - 7 Y.O.!
•  Early loss of maxillary second primary molar produces
greatest amount of space loss at the fastest rate when
compared with other primary molars (Up to 8 mm. vs.
4.5 mm. in mandible with early loss of 2nd primary molar.)
•  Major indicator of inherent inadequate arch perimeter.
( i.e. - expect further crowding and malocclusion).
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> About 1 in 5 with ectopic upper 1st molars show lower
incisor ectopic eruption (O’Meara: J Dent Res 41:607, 1962)
> One-fourth of canine impaction patients had ectopic upper
1st molars (Becktor et al: Eur J Orthod 27:186,2005)
TREATMENT OF ECTOPIC MOLARS!
Step 1. EARLY RECOGNITION!
PAN, PA
S or Adequate BWX
Pan BEST Option – Rx’d upon eruption of first permanent tooth
TREATMENT OF ECTOPIC MOLARS!
Step 1. EARLY RECOGNITION > 5 - 7 Y.O.
PAN, PA S or Adequate BWX (#2 size)!
5 - 7 Y.O.!
# 1 BWX
Too small
# 2 BWX
More vertical
exposure
TREATMENT OF ECTOPIC MOLARS!
Step 2. Consider Observation!
!
!
Patient age!
Step 3: Interceptive 7 years of age or more!
Tx. èè TIMING!
!
Six months later >>> worse than before!
Lower 6 eruption!
At occlusal plane!
!
Upper E resorption!
Before extensive loss!
!
Upper 6 position!
Remember – 2/3rds “self-correct”; but not after age 7 years
ECTOPIC MOLARS: Treatment Objectives!
ü Distalize ectopic molar into normal A-P position!
ü Maintain arch integrity of buccal segment!
ü Maintain favorable exfoliation sequence!
ü Ensure vertically stable occlusion!
ü Maintain overall arch dimensions!
Before
&
After
Tx.
TREATMENT OF ECTOPIC MOLARS!
INTERCEPTIVE Options !
Noted indicators negate
watchful waiting Time to intercept !
Mesially inclined!
Bjerklin & Kurol: AJO 84:147, 1983
ECTOPIC MOLARS :
Treatment Variables!
Ø Extent of blockage!
Ø Degree of “E” resorption!
Ø Access to 6 year molar!
Ø Timing factors!
Ø Arch-length status!
Ø Cooperation!
Kennedy D, Turley P:
AJODO 92(10):336,1987
ELASTIC SEPARATORS!
!
Ø  Elastic separators!
Ø  Separating springs!
Ø  Brass wire!
Ø  SSC or band extension on 2nd molar!
Ø  Distalizing springs (Humphrey)!
Ø  Distal pull elastomerics (Halterman)!
First option IF separator can be engaged around contact
overhang - pull floss through under contact & vertically.
Can tie the floss across the occlusal with sep. under area.
Diagnosis & Elastic Separator Tx. @ Age 6y. 10m.!
Separating Elastics!
Advantages:
Replaced @ 3 week intervals (4 times)
* Ease of placement
* Cost of materials
* No anesthesia required (?)
* Do not interfere with eruption
* Do not interfere with occlusion.
!
Disadvantages:
* Limited Application
* Frequent Follow up
One year recall
Age 7y. 9m.
SEPARATING SPRINGS!
!
Start
@ 2 weeks
@ 4 weeks
Separator
@ 4 weeks
@ 5 weeks
BRASS WIRE SEPARATION!
Separating Springs!
Advantages:
Combo
Separating Springs > >
Elastic > > Separators!
!
ü “Ease” of placement.!
ü Prefabricated.!
ü Inexpensive.
!
Disadvantages:!
ü Occlusal interference / occlusal clearance.!
!
ü Anesthesia often required to place.!
ü Limited Access = limited application.!
ü “Somewhat” dangerous è dislodgement ???!
Use of a brass ligature wire looped and tightened around !
the contact area of the ectopic eruption. !
Replaced / tightened every week - progressively larger.
BRASS WIRE SEPARATION
Pre-Tx! !Placement !6 weeks
!
Brass Wire Ligature!
q  Difficult to place
q  Usually requires local anesthesia
q  Often requires multiple replacements
q  Breaks easily when attempting to tighten or it will
pull through the contact.
!
q  Relapses easily
q  Can hinder eruption
In essence is vastly over-rated!!!
TREATMENT OF ECTOPIC MOLARS!
Active Distalization Appliances!
HUMPHREY APPLIANCE
!
!
Pre-Tx.!
Springs > Push !
! Elastomerics > Pull!
HUMPHREY APPLIANCE Correction > 8 weeks!
Placement!
Humphrey WP: J Dent Child 29:176,1962
HUMPHREY APPLIANCE Distalizing Springs!
Corrected
Placement
!
!
Retained w/
band extension
Correction Time = six weeks
HUMPHREY APPLIANCE: Design!
Ø Band E - E, connect
with TPB, .036 S.S.!
Ø Distal oriented helical
loop of .025 S.S.!
Ø Passive extends distal
to ectopic molar!
Ø Activated to engage
composite ledge.!
Humphrey Appliance!
The “original”
Humphrey WP: J Dent Child 29:176,1962
Modifications
Braden: Dent Clin N Am 8:441,1964;
Bayardo et al: J Dent Child 46:214,1979;
Garcia-Godoy: JADA 105:244,1982;
Pulver & Croft: Pediatr Dent 5:140,1983;
Harrison & Michal: Dent Clin N Am 28:57,1984;
Kennedy: Pediatr Dent 7:224,1985;
Groper: J Dent Child 52:374,1985;
Rust & Carr: J Dent Child 52:55,1985;
Kennedy & Turley: AJODO 92:336,1987
Humphrey Appliance!
Advantages:
!
* Stability
!
* Quickness of correction
!
* Can correct severe locks of the first permanent molar!
!
Humphrey Appliance helical springs engaged
against bonded composite ledges provide distal
!
forces to ectopic molars.!
!
Ø  Produce forward forces, need TPB anchor. !
Ø  Interfere with vertical eruption, need second
stage of correction >>> band extensions .!
DISTALIZING
ELASTOMERICS!
Disadvantages:
!
* Placement & activation of spring difficult !
* Fabrication and cementation appointments are long!
and require significant cooperation.!
* Spring can distalize molar; but prevents vertical!
eruption, may produce rotations & displacements of !
both permanent and primary molars.!
HALTERMAN APPLIANCE
Stretching elastomeric chain from wire to occlusal
bonded button produces distalization force.!
!
HALTERMAN
APPLIANCE!
Halterman CW: JADA 105:1031,1982
HALTERMAN APPLIANCE!
HALTERMAN
APPLIANCE
Correction in 6 weeks
with distal & vertical
movement of molar.
2 weeks change with distal & vertical movement. !
Elastics disengaged,
!
components left in
place until molar
erupts & occludes
with bonded button.
!
Re-engaged chain to next loop >> need to clear by 2 mm.
!
HALTERMAN APPLIANCE
Halterman Appliance
@ 3 weeks Tx. Time!
!
Correction
in 4 weeks
Occlusion
in 8 weeks
- removed
ç Same
Patient @
6 months
Post. Tx.
Case from Dr. David Kennedy
HALTERMAN APPLIANCE: DESIGN!
Halterman Appliance
ü Band E - E , connect w / TPB, 036 S.S.!
Six weeks treatment!
ü Distally extend .036 wire from palatal side!
Case from Dr. David Kennedy
ü Bond button on 6 as mesial as possible!
ü Elastic chain (closed) from button to wire!
Response @ three weeks
Follow-up @ six months!
Halterman: !Pre > Tx 3 weeks > Post > 4 yr.!
HALTERMAN PROTOCOL!
Ø Place appilance & molar “button” w!
with elastic chain in place!
Ø Monitor at two week intervals!
Ø Reengage elastic chain until !
!distalized 2 to 3 mm. beyond E !
Ø Once cleared, discontinue elastic !
> leave appliance in > monitor!
Ø Once molar button in occlusion, o.k. to remove!
Ø If relapses, reactivate until cleared, retain with
band extension!
Post. Tx. 7y. 5m. ê!
Halterman !!
Pre-treatment!
Post-treatment!
@ four years
Case from Dr. David Kennedy
Treatment
Post-treatment!
@ six months
Halterman Appliance!
The “original”
Halterman CW: JADA 105:1031,1982
Modifications
Kennedy & Turley: AJODO 96:336, 1987;
Kennedy: J SE Soc Pediatr Dent 3:18, 1997;
Pre-Tx. 6 y. 9m. é!
Bell & Leite: J Clin Pediatr Dent Care, 9:16, 2003;
Kennedy: Pediatr Dent 29:327, 2007
Post. Tx. 12y. 2m.è
Kennedy: Pediatr Dent 30:63, 2008
Case from Dr. David Kennedy
Ectopic Lower Molar > Halterman !!
Halterman Appliance!
Advantages:
!
*Ease of basic appliance placement.
*Ease of fabrication design.
*Ease of activation.
!
Pre-treatment
!
!
*Minimal displacement of 2nd primary molar.
*Rarely requires any anesthesia.!
Treatment @ !
three weeks
!
Disadvantages:
*Bonding of occlusal button of first molar.
*Critical adaptation of distal extension wire.
*Difficulty in replacing power chain.!
!
Treatment!
Appliance
!
!
Same basic tx. objectives, !
timing of intervention, !
and appliance options as !
maxillary ectopic molars.
Lower Halterman!
Treatment!
Appliance
Post-treatment!
@ three years
ECTOPIC MOLARS: Summary Overview!
Incidence 3 to 4 % in maxillary arch, rare in lower arch (0.2%).
Self-correction - 2/3rds of cases, resorption stops once “jumped”.
“Irreversible” - molars remain locked in resorption area of 2nd
primary molar. Treat once lower first molar reaches occlusal
plane height, age 7 years.
Ø  Only modification to Mx. Halterman appliance is to!
place distal extension arms from buccal of second!
primary molars - avoids tongue irritation.!
Ø  Can also incorporate lingual holding arch; but must!
be careful of erupting lower incisors.!
Ronald A. Bell, DDS, MEd
Diplomate!
ABPD & ABO
Department of !
Pediatric Dentistry !
and Orthodontics
Medical University !
of South Carolina!
bellr@musc.edu
Intercept to guide 1st molar into normal position, retain primary
molar & favorable eruption sequence, maintain arch length & a
level occlusal plane.
Preferred Tx. Options
1.  Elastic separators
2.  Halterman Appliance