diagnosing early pt 1

7/24/2019 Diagnosing Early Pt 1

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Educational ObjectivesUpon completion o this course, the clinician willbe able to do the ollowing:1. Be knowledgeable about normal growth and

development o the dentition and its phases.2. Be knowledgeable about the early treatment

examination and the records that are required

or this examination.3. Understand the actors and potential prob-

lems to consider during the early treatmentexamination.

4. Be knowledgeable about the fixed and remov-able appliances that can be used as spacemaintainers and habit breakers during themixed dentition phase.

5. Be able to treat certain early treatmentproblems with removable appliances.

AbstractIt is important to have a clear picture o how a childis changing dentally and skeletally throughout hisor her growth period. In act the American As-sociation o Orthodontists recommends that everychild have an orthodontic examination by the ageo seven. The early treatment examination in themixed dentition enables the practitioner to identiyproblems at an early stage, and to determine when

to commence treatment and/or reer patients to anorthodontist. Things to look or during a mixeddentition examination include crowding o perma-nent teeth, excessive overjet or overbite, missingprimary teeth needed or space maintenance, su-pernumerary teeth, skeletal discrepancies, habits,airway problems, and eruption path problems.

IntroductionThis continuing dental education article is being

written to describe the need or early examinationand diagnosis o malocclusions in growing chil-dren. A short review o growth and developmentwill be presented, along with a description o thestages o tooth eruption. Ater completing thiscourse, the reader will have a clearer understand-ing o problems associated with children in themixed dentition stage o development.

The American Association o Orthodontistsrecommends that every child have an orthodontic

examination by the age o seven. By then, the maxil-lary and mandibular first molars, lateral incisors,and central incisors should have erupted. This articlewill describe what practitioners should be lookingor during an early treatment examination in themixed dentition and aid them in determining whatthey should treat and/or when they should reer.

This article has been broken into two parts. Part1 will include a discussion o the mixed dentitionexamination, records, tooth eruption sequence,

growth and development, primary teeth as spacemaintainers, normal eruption o permanent teeth,delayed eruption o permanent teeth, over-retainedprimary teeth, and supernumerary teeth.

Part 2 will cover: excessive deep bites, cross-bites, anterior crossbites, class III skeletal and

dental problems, crowding in the mixed denti-tion, excessive spacing, open bites and class IIskeletal or dental problems.

The Mixed DentitionOrthodontic ExaminationWhen perorming a mixed dentition examination,

the main goal is to determine whether there is needor interceptive orthodontic measures that willallow or the eruption o all the permanent teeth.The earlier in the mixed dentition stage a problemis diagnosed and corrected, the better o patientswill be as they continue to grow. When perormingan interceptive orthodontic examination, the ol-lowing records are needed.

Records

Study ModelsStudy models are necessary because they allow youto evaluate the occlusion outside o the patientsmouth. For example, abnormal wear patterns andcrossbites can easily be seen. Study models also al-low the practitioner to perorm a mixed dentitionanalysis. Many mixed dentition analyses exist,such as the Tanaka and Johnston and Moyers pre-diction values. An accurate bite registration mustalso be taken as part o this record.

RadiographsPanoramic Radiograph

In the mixed dentition phase, the panoramic radio-graph is useul or seeing permanent erupting teeth,crowding o teeth, space or lack o space betweenteeth, eruption paths, third molars, supernumeraryteeth, and root apex ormation (which is used todetermine the patients dental age). Using a pan-oramic radiograph is like seeing the world through

a wide-angle lens, as compared to looking througha small looking glass, which could be consideredanalogous to ull-mouth series o radiographs.

Lateral Head Film (Cephalometric Radiograph)

Lateral head films are necessary when evaluatinggrowing children to evaluate dentoacial propor-tions. As teeth erupt and growth occurs, the teethrelationships (within the jaws and skull) are part oa much bigger picture only visible with a cepha-

lometric film and the appropriate cephalometrictracing. In the mixed dentition, the ollowingguidelines are designed to help in the decision pro-cess on when a cephalometric film is indicated.

Class II Patients:

Patients presenting with Class II dental relation-ships such as a distal step in primary second molars.

Patients with Class II relationships o per-manent molars.

Patients who have a significant positive overjetand/or patients with mandibular retrusive profiles.

Class III Patients:

Patients with Class III relationships o perma-nent molars.


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Patients who have a mesial step o primarysecond molars.

Patients who have a significant negativeoverjet (underbite).

Patients who have a protrusive profile o themandible or retrusive profile o the maxilla.

Airway problems:Airway problems diagnosed in children with openmouth breathing tendencies, such as turned up noses,allergic salute (wiping the nose with the hand in anupward swipe), or other medical history findings.

Vertical relationship problems:

Vertical relationship problems such as open bitesassociated with habits, airway problems, verti-cal skeletal growth problems, or patients with lip

incompetency(lips do not touch or seal at man-dibular rest).

Serial Lateral Head Films

Serial lateral head film radiographs are useul whenmonitoring growth in children with Class II orClass III tendencies, beginning at the first visit youdiagnose them. They are also useul in comparingwhat orthodontically has really occurred aterpatients have been treated, by comparing pre- and

post-treatment films.

PhotographsIt is recommended that a ull series o orthodonticphotographs is taken or all patients. There is aproper way to take photographs, along with a wayto retract sot tissues to capture vital anatomy, suchas molar relationships.

The standard orthodontic photographs consist oeight pictures. Extraoral Photos: profile, rontal acial

smiling, rontal acial at rest. Intraoral Photos (teeth inocclusion): maxillary occlusal, mandibular occlusal,right and let buccal dental, and rontal dental.

There are other useul photos one can takewhen documenting an examination. For example,a patient with a tooth intererence that causes ashit when intercuspation occurs can be docu-mented by photographing the midlines at rest andwith the teeth apart. When the patient occludes,the midlines will change, demonstrating the shit.

Close-up shots o individual teeth are also use-ul when documenting chips or decalcificationsthat you may be blamed or in the uture aterorthodontic treatment has been completed.

Other RecordsOther records may also be needed, depending onthe oral examination, such as anterior-posteriorfilms (AP films) (or transverse analysis), cone-beam 3-D imaging films (the new rontier in radi-

ology), and/or occlusal films.

Growth and DevelopmentEruption of TeethBy definition, the mixed dentition has bothprimary and permanent teeth in unction. The

primary dentition ends with the first eruption oa permanent tooth. It is not age dependent. Themixed dentition phase ends when there are no lon-ger any primary teeth in the mouth. This becomesthe permanent dentition.

Prior to age five, most children will have onlytheir primary teeth. At ages six to seven, the first

permanent molars will erupt. Permanent centralswill usually erupt between the ages o six and seven.Lateral incisors will usually erupt between the ageso seven and eight. This sets the stage or utureeruption o the remaining twelve permanent teeth(permanent maxillary and mandibular cuspids,first and second premolars) between the ages o tenand eleven. At twelve years o age, the our secondpermanent molars erupt. For those who have wis-dom teeth, they erupt by age twenty in most cases.

The ages stated above are just basic guidelines.It is important to know that chronological age doesnot ollow dental age, nor does it correlate withchildrens height, weight, or mental development.This is a common question asked by parents.

Growth of the Maxilla and MandibleGrowth in the cranial base pushes the maxillaorward, as well as active growth in the maxillarysutures that is responsible or the passive displace-

ment o the maxillary process. As the maxilla istranslated downward and orward, bone is addedat the sutures and in the tuberosity area posteriorly,while at the same time surace remodeling removesbone rom the anterior suraces. For this reason, theamount o orward movement o anterior suracesis less than the amount o displacement. In theroo o the mouth, however, surace remodelingadds bone, while bone is resorbed rom the fooro the nose. The total downward movement o the

palatal vault, thereore, is greater than the amounto displacement. Between the ages o seven andfiteen, one-third o the total orward movemento the maxilla can be accounted or by this passivedisplacement. It can be concluded that two-thirdso the growth during that time is via active growthat the sutural level. I cranial or acial bones aremechanically pulled apart at the sutures, new bonewill fill in, and the bones will become larger thanthey would have been otherwise. I a suture is

compressed, growth at that site will be impeded. Itis imperative to understand the growth sequencein order to properly diagnose maxillary excess ordeficiency and to treat orthopedically.

Mandibular growth occurs by both endochon-dral prolieration at the condyle and appositionand resorption o bone at suraces. The mandibleis ormed rom Meckels cartilage. The two halveso the mandible are united at the anterior midlineby a suture at the symphysis. Further growth

continues at this suture until it ossifies during thefirst year o lie. Throughout growth the mandibleis translated downward and orward. It seems thatthe mandible is translated in space by the growtho muscles and other adjacent sot tissues andthat addition o new bone at the condyle occurs


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in response to the sot tissue changes. On averagethe ramus height increases 1 to 2 mm per year andbody length increases 2 to 3 mm per year.

The maxilla and mandible grow in all threeplanes o space, in the ollowing sequence: width,length, and then height. In both sexes, growth invertical height o the ace continues longer than

growth in length, with the late vertical growthprimarily in the mandible. Increase in acialheight and concomitant eruption o teeth continuethroughout lie.

Primary Teeth Act as Space MaintainersThe primary cuspids and first and second primarymolars act as space maintainers or the permanenterupting cuspids and premolars. The permanentpremolars are smaller than the primary molars

they replace. In the maxilla an average o 1.5 mmo space exists and in the mandible 2.5 mm due tothe dierences in size o these teeth. This space iscalled Leeway space. The primary cuspids and firstand second primary molars not only act as spacemaintainers or the permanent cuspids and first andsecond premolars, but also act as a guide or the per-manent teeth to ollow when erupting (Figure 1).

Figure 1. Primary Teeth as Space Maintainers

Space MaintenanceIt is essential that children be evaluated or miss-ing primary teeth in order to determine i anyspace maintenance is necessary. As a general ruleo thumb, it is recommended that all space createdby a missing primary tooth should be maintained.When in doubt, maintain space.

I there is an early loss o a primary molarand the first permanent molar has erupted, spacemaintenance must be employed as soon as pos-sible. Doing so will prevent the first permanentmolar rom driting mesially. I the first molar isallowed to drit mesially, it will not only eat up theLeeway space, but it can potentially interere withthe eruption o the premolars or canines.

Posterior Space Maintenance

Space maintainers are very important to keep thisLeeway space intact until eruption o the perma-nent teeth occurs. There are two basic categories ospace maintainers: fixed and removable. As a rule,fixed appliances are generally used as space main-tainers. The two types are unilateral and bilateral.

The unilateral space maintainer can be used invery young children who have lost a single primaryposterior tooth but only when you are sure thatthe successor tooth will not erupt or many years.Otherwise when using a space maintainer considerusing a bilateral space maintainer because:1. I a permanent tooth is erupting a properly

designed bilateral space maintainer will notcause you to have to remove the new applianceyou just placed.

2. I there is need or other space maintenance onthe other side o the arch, a bilateral appliancewould be a better choice.

Figure 2 demonstrates a unilateral spacemaintainer used in the arch with the opposite sidelet untreated. Perhaps a better appliance choice

would have been one that would have maintainedspace throughout the entire arch.

Figure 2. Unilateral Space Maintainer

Here are some questions that should be askedwhen evaluating whether there is enough space inthe mixed dentition patient:

How much anterior mandibular crowding ispresent (teeth numbers 23, 24, 25, and 26)?

Is there enough Leeway space to accommodatethe lower crowding plus the unerupted permanentteeth (cuspid and premolars)?

How much anterior maxillary space (or crowd-ing) is present (teeth numbers 7, 8, 9, and 10)?

This is where the mixed dentition analysis andthe panoramic radiograph become useul.

Analyses such as the Tanaka and Johnston meth-

od measure one hal o the mesiodistal width o theour lower incisors. Then by adding 10.5 mm to thisnumber the space needed or the mandibular canineand premolars in one quadrant can be estimated.Add 11 mm to estimate the space required or themaxillary canine and premolars in a maxillary quad-rant. This method has good accuracy or children oEuropean descent. This method will overestimatethe required space or Caucasian emales in botharches and underestimate the space required in the

lower arch or Arican-American males.An excellent reerence or the mixed denti-

tion analysis can be ound in The Practice Build-ing Bulletin, Volume IV, Issue XIX, located atwww.appliancetherapy.com, under practicebuilding bulletins.


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The lower lingual holding arch (LLHA) inthe mixed dentition is readily used to maintainthe Leeway space in children with minor tomoderate crowding (Figure 3). Note the Leewayspace maintained on the lower right segmentbetween the first premolar and the cuspid.

Figure 3. Lower Lingual Holding Arch

The transpalatal arch appliance is used in themaxillary arch as a bilateral space maintainer(Figure 4).

Figure 4. Transpalatal Arch Appliance

I maximum anchorage is needed, a Nancebutton can be added to a maxillary appliancewhich touches the palate, preventing mesialmovement o the maxillary molars (Figure 5).

Figure 5. Nance Button Appliance

The ollowing case demonstrates a maxillaryarch with no crowding and with a normal erup-tion pattern (Figure 6). In the mandibular arch

(Figure 7), there is minor crowding that will beresolved by using the Leeway space that is main-tained by using a fixed lingual holding arch.

Figure 6. Maxillary Arch with No Crowding

When a patient receives a fixed lower lingualholding arch, it maintains the space that the pri-mary cuspids and primary molars are occupying.Once exoliation occurs, the anterior crowd-ing can be distalized into the Leeway space.From the mixed dentition analysis, the ollow-ing were labeled:A. Corrected lateral position, which corrects

or excess space or crowding in the ante-riors, demonstrating the space the laterals

will occupy when uncrowded and properlyaligned.

B. True available space, which is measuredrom the mesial o the first molar to the thecorrected later position (Figure 7).

Figure 7. Mandibular Arch with Minor Crowding

In Figure 8, the panoramic radiograph

demonstrates enough Leeway space or thepermanent teeth to erupt. Note, it is diicultto see the crowding in the anterior teeth on apanoramic ilm.

Figure 8. Panoramic Radiograph DemonstratingSufficient Leeway Space


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Anterior Space MaintenanceThere are three categories o anterior spacemaintainers: fixed, removable-unctional, andremovable-static. Anterior space needs to bemaintained or esthetics, normal speech andphonetic development, and to allow normal oralmaxilloacial development.

The best fixed appliance or anterior spacemaintenance in arches that do not need arch de-velopment is the Groper appliance (Figure 9).

Figure 9. Groper Appliance

When arch development is needed, remov-able-unctional appliances like the Schwarz canbe used, delivering esthetics during arch devel-opment (Figure 10).

Figure 10. Maxillary Schwarz Appliance

The next category, removable-static, is rep-resented by Hawley-type appliances that havean artificial tooth placed. As permanent teetherupt, adjust the acrylic to accommodate theneeded space. Its main use is in trauma casesand cases that have congenitally missing teeth

(or example, lateral incisors). A labial bow canbe used to add retention i desired (Figure 11).

Figure 11. Hawley Flipper

Delayed EruptionChildren who have a single tooth that is noterupting comparably to the tooth on the op-posite side (same arch) should be watched andreevaluated in (three- to six-month) incrementsto determine i interceptive treatment is needed.There are many possible causes or the delay

o the eruption. One o the most common isan earlier trauma to the region. It is sometimesnecessary to perorm surgical exposure to gin-gival tissue that may be holding up the eruptionprocess. Today these procedures are quite easy,using laser technology to open a small windowin the tissue that will allow the teeth to erupt.In cases where the bone is holding up the erup-tion, it is best to have an oral surgeon remove thebone, leaving a window or the tooth to erupt

through. It is rare that these teeth are ankylosed,or have lost their eruption potential.

Figures 12 and 13 demonstrate tooth number9 almost erupted, with tooth number 8 delayed.The primary right central incisor is still presentin this patient with a complete root.

Figure 12. Panoramic Radiograph ShowingDelayed Eruption

Figure 13. Delayed Eruption of Tooth Number 8

In many cases, ater teeth have been surgi-cally exposed and still do not erupt on their own,a bonded button and some elastic orce anchoredto either a removable appliance or fixed brackets

may be needed to acilitate the movement.I no movement occurs ater orces have

been applied or a short period, the tooth maybe ankylosed. This will require some orm oluxation, which hopeully will ree up the toothand allow the eruption to occur.


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Retained Primary TeethRetained primary teeth need to be extracted toallow or the eruption o the permanent succes-sors (Figure 14). It is not exactly known whysome primary teeth do not exoliate, but in theevent you see a primary tooth with no mobilityand the successor stuck below it, you should

extract the tooth to allow or normal eruption.

Figure 14. Retained Primary Teeth

Some of the mesial root of the primary first molar did not resorb and canbe clearly seen on the radiograph.

Supernumerary TeethDiagnosis o supernumerary teeth is best made

early, and treatment planning their extractionshould begin as soon as an oral surgeon deems itappropriate. In many instances, the oral surgeonmay elect to wait some time beore removingthem in order to prevent damaging adjacentteeth. Set up a consult as soon as supernumer-ary teeth are discovered. I you are planning onmoving teeth orthodontically, supernumeraryteeth need to be removed prior to starting treat-ment. The most requent place or supernumer-

ary teeth to be present is in the maxilla. Figure15 illustrates three supernumerary teeth.

Figure 15. Super numerary Teeth

Habits/Environment/Speech ProblemsDetection o poor habits and speech problemsneeds to be addressed as early as possible. In someinstances, excessive environmental orces (or

example, playing a musical instrument) can altergrowth i orces are applied over long periods otime. The habits o children, both nocturnal andduring the daytime, can alter tooth positions andskeletal development in some cases. Practitionersshould examine all children or signs o habits

and their associated actions that may change theway an individual child grows.

Children with airway obstruction, present-ing with enlarged adenoids or tonsils, should beevaluated or surgical removal o these tissues.Find an ENT in your area who will help you di-agnose and confirm possible airway obstruction

and will take the measures necessary to perormthe surgeries when needed. In undiagnosedairway obstruction, jaws can grow narrow, dueto the open mouth breathing positions. Themuscles o the ace constrict the jaws and canlead to a condition called Adenoid Facies andNarrow Face Syndrome.

I it is suspected that a child may have anobstructive airway, it is recommended that thepatient see a specialist and have a sleep study.

The dangers o obstructive sleep apnea are welldocumented in both children and adults. Dentalpractitioners may be the first line o deense indiagnosing these problems. Symptoms childrenwho have obstructive sleep apnea exhibit in-clude restlessness, inability to do well in school,irritability, etc. For an excellent article on sleepapnea, go to www.appliancetherapy.com anddownload the Practice Building Bulletin onsleep apnea. Articles on sleep apnea can also be

ound at www.ineedce.com.

Speech Problems, Tongue Position,or Thrust ProblemsTongue position problems can cause dentalanterior open bites, which i not treated earlycan lead to unavorable skeletal growth. Normalspeech development is virtually impossible i thetongue is not able to position properly againstthe palate and teeth.

Students o early treatment oten debatewhether the tongue thrust is truly a thrust or aposition the tongue takes to create a seal neededor swallowing. Some patients have verticalgrowing skeletal patterns that can result in openbites. Some children with airway problems whoare orced to breathe through their mouths canalso exhibit narrowing o arches, resulting intransverse discrepancies with open bites, aect-ing tongue position. Regardless, tongue thrust

or tongue position problems are very importantto diagnose and correct.

First, assess i there are any underlying speechproblems. I so, reer the patient or therapy rightaway. Attempting to correct a speech problemlater in lie results in poorer prognoses.

Then ask the patient to swallow as you gen-tly orce the lips open with a gloved finger to seei the tongue is pushing orward. It instantlybecomes obvious that the tongue is filling the

space, and now a diagnosis needs to be made todetermine i this is a simple tongue thrust or amore complex problem involving the airway orvertical skeletal growth. Figure 16 illustrates thetongue at rest in a patient with a tongue thrusthabit. Even when the patient is not swallowing


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(posing or a picture), the tongue decides to restin this position maintaining the open bite.

Tongue appliances can be both fixed andremovable. Fixed appliances use two bands ce-mented on either the permanent first molars orthe primary second molars.

Some practitioners use removable appliancesor tongue problems, but to work, the applianceneeds to be worn all the time, even when eating.

Children adapt quickly to speaking normally

and are instructed to place their tongues up againstthe anterior hard palate when swallowing.

Ater approximately six to eight months,remove the appliance and evaluate whether theproblem has been resolved. When using a fixedtongue crib, it will usually work within this time

rame. Because habits can be dificult to correct,it is necessary to evaluate the patient withinthree months ater the appliance therapy ceases,in order to make sure that the habit is actuallybroken and the open bite does not return. I theproblem does return, replace the appliance oranother our months, and reevaluate.

Figures 17 shows a bonded tongue crib priorto treatment. Figure 18 demonstrates the openbite closing. Note, in most cases the open bitewill close most o the way, but in this case, ad-ditional intervention such as ixed braces willbe needed.

Another appliance that is used to aid in trainingthe tongue rom moving orward is the transpalatalspinner. The patient is inormed that every timethey swallow, they are to reach back with the tip o

the tongue upon swallowing (Figure 19).

Figure 19. Transpalatal Spinner

Figure 20 illustrates a removable Hawleytongue crib appliance. In order or this appli-ance to work, it needs to be worn all day and

night except when eating.

Figure 20. Removable Hawley Tongue Crib

Digit and Other HabitsDigit (finger) habits can include sucking, nail

biting, and other habits including pen/pencilbiting. They are also best solved by using fixedbonded appliances. Leave the appliance in orapproximately six months, and then remove itand evaluate i the child is continuing to placedigits in his or her mouth.

Figure 16. Tongue Thrust Habit

Figure 17. Bo nded Tongue Crib Prior to Treatment

Figure 18. Bo nded Tongue Crib During Treatment


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With digit habits, the bonded appliancealters the way the digit eels when inserted inthe mouth. The bluegrass roller is an excellentappliance or eliminating digit habits (Figure21). Ater successully wearing a tongue or digithabit appliance and eliminating the tooth mov-ing orces created by the digit, the natural orces

rom the muscles in the cheeks and lips will cor-rect the protrusion in most cases.

Figure 21. Bluegrass Roller Appliance

Summary

In accordance with the recommendations o theAmerican Association o Orthodontists, theearly treatment examination o the mixed denti-tion should be perormed by age seven. Duringthis examination radiographs, models and orth-odontic photographs are required. Additionalrecords may also be necessary depending on thepatient. During the examination, it is importantto consider primary teeth as space maintainersand to identiy any problems that may require

intervention. Potential problems can includeearly loss o primary teeth, retained primaryteeth, delayed eruption o permanent teeth,supernumeraries, and habits. Early assessmentenables the early identification o problems,intervention and optimal timing o reerral and/or treatment or the patient.

References1 Proffit WR. Contemporary Orthodontics, Fourth

Edition, Mosby, 2007.2 Ibid.

3 Ibid.

4 Altherr ER, Koroluk LA, Phillps C. The influence of

gender and ethnic tooth-size differences on mixed

dentition space analysis. Am J Orthod Dentofac

Orthop, in press.

5 Proffit WR. Contemporary Orthodontics, Fourth

Edition, Mosby, 2007.

Authors Profiles

Michael Florman, DDSDr. Florman received his den-tal degree rom the Ohio StateUniversity and completed his

post graduate training in Orthodontics at NewYork University. Dr. Florman is a Diplomateo the American Board o Orthodontics, andhas been practicing dentistry since 1991. Hehas authored over orty scientiic publicationsin the ield o dentistry and medicine, and is anactive clinical advisor to many pharmaceutical

and dental companies. He is a member o theAmerican Dental Association, Caliornia Den-tal Association, and the American Associationo Orthodontists

Rob Veis, DDSDr. Rob Veis began 24 years ago as a generaldentist, and taught or twelve years at the Uni-versity o Southern Caliornia as a Clinical Pro-essor in Restorative Dentistry. Dr. Veis lectures

or the AGD/Caliornia masters program. Healso lectures internationally, on the integrationo orthodontics and appliance therapy into thegeneral practice on behal o Space MaintainersLaboratories where he has been a member o theteaching sta since 1990. He is coauthor o thecomprehensive textbook Principles o ApplianceTherapy or Adults and Children, and author oseveral Practice Building Bulletins. Dr. Veis isa member o the Caliornia Dental Association

and the Academy o General Dentistry.

Mark Alarabi, DDS, CECSMODr. Al-Arabi obtained his dental degree romthe University o Tishreen, Syria in 1996.He received his training in Orthodontics andDento-Facial Orthopedics at the University oAix-Marseille II earning a Certificate o SpecialStudies in Clinical Orthodontics (CECSMO)in 2002, and is a ormer member o the French

Society o Dento-Facial Orthopedists and theFrench Society o Bioprogressive. Dr. Al-Arabijoined the aculty at Jacksonville University inJuly 2003. He is a member o the American As-sociation o Orthodontists.

Mahtab Partovi, DDSDr. Partovi received her dental degree romNew York University College o Dentistry. Dr.Partovi is presently a resident at Jacksonville

University, School o Orthodontics, and is amember o the American Dental Associationand the Caliornia Dental Association.

DisclaimerThe authors o this course have no commercial ties

with the sponsors or the providers o the unrestricted

educational grant or this course, except or Dr. Rob

Veis who is an instructor or the Appliance Therapy

Group and the SMILE Foundation.

Reader FeedbackWe encourage your comments on this or anyPennWell course. For your convenience, anonline eedback orm is available at www.ineedce.com.


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Questions

1. The American Association ofOrthodontists recommends thatevery child have an orthodonticexamination by age seven.a. Trueb. False

2. The main goal of a mixed denti-tion examination is _________.a. to determine whether there is a need for

multiple extractionsb. to determine whether there is a need for

interceptive orthodontic measuresc. to assess the patients caries experienced. none of the above

3. The records needed whenperforming an interceptiveorthodontic examination

are _________.a. panoramic and cephalometric

radiographsb. study modelsc. orthodontic photographsd. all of the above

4. Serial lateral head films areuseful when patients haveClass I tendencies.a. Trueb. False

5. Other records that may alsobe needed for an interceptiveorthodontic examinationinclude _________.a. anterior-posterior filmsb. cone-beam 3-D imagesc. occlusal filmsd. all of the above

6. Chronological age correlateswith a childs dental age, height,weight and mental development.a. Trueb. False

7. Lateral incisors usually eruptbetween the ages of _________.a. four and fiveb. five and sixc. six and sevend. seven and eight

8. During growth, the amountof forward movement ofthe anterior surfaces of themaxilla is less than the amountof displacement.a. Trueb. False

9. Late vertical growth occursprimarily in the _________.a. symphysisb. maxillac. mandibled. tuberosity

10. The space maintained by theprimary cuspids and molars

for the permanent eruptingcuspids and premolars isknown as the _________.a. Leeward spaceb. Leeway spacec. Maintained spaced. none of the above

11. If there is early loss of aprimary molar and the firstpermanent molar has erupted,maintaining the space as soonas possible will _________.a. create extra space for wisdom teeth

b. prevent eruption of permanent premolarsc. prevent the first permanent molar fromdrifting mesially

d. none of the above

12. The unilateral space maintainershould be used in _________.a. very young children who have lost a

single primary posterior toothb. very young children when you are sure

the successor tooth will not erupt formany years

c. children whose permanent bicuspidshave already erupted

d. a plus b13. When evaluating space in the

mixed dentition, the _________should be evaluated.a. sufficiency of Leeway spaceb. amount of mandibular crowdingc. amount of anterior maxillary spacing

or crowdingd. all of the above

14. The Tanaka and Johnston methodwill overestimate the requiredspace for Caucasian females.a. True

b. False

15. The lower lingual holding archis readily used _________.a. in the fully erupted permanent dentition

to maintain the Leeway spaceb. in the mixed dentition to maintain

the Leeward space in children withsevere crowding

c. in the mixed dentition to maintain theLeeway space in children with mild tomoderate crowding

d. none of the above

16. The transpalatal arch isused _________.a. in the maxillary arch as a bilateral

space maintainerb. in the maxillary arch as a unilateral

space maintainerc. in the mandibular arch as a bilateral

space maintainerd. a and c

17. The addition of a Nancebutton to a maxillaryappliance _________.a. prevents distal movement of the

maxillary molarsb. prevents mesial movement of the

maxillary molarsc. prevents tongue thrustd. all of the above

18. The three categories of ante-rior space maintainers are thefixed-functional, fixed-staticand removable.a. Trueb. False

19. According to the authors, theGroper appliance is the best

appliance for _________.a. missing posterior teeth in arches that

need arch developmentb. missing anterior teeth in arches that need

arch developmentc. anterior space maintenance in arches that

do not need arch developmentd. a and b

20. Removable-functional appli-ances are used when _________.a. arch development is neededb. arch development is not neededc. the patient is noncompliantd. none of the above

21. Hawley appliances areexamples of _________.a. fixed appliancesb. removable-static appliancesc. removable-functional appliancesd. none of the above

22. One of the most commoncauses for delayed eruptionof a single tooth when thecontralateral tooth has erupted isearlier trauma to the region.

a. Trueb. False

23. A bonded button and someelastic force can be used tofacilitate movement after surgicalexposure of an erupted tooth.a. Trueb. False

24. Retained primary teeth ______.a. can be left in place until they

eventually exfoliateb. need to be extracted to allow for eruption

of the permanent successorsc. are of no consequenced. none of the above

25. The most commonplace for supernumeraryteeth is _________.a. the mental region of the mandibleb. adjacent to the submandibular

salivary glandsc. the maxillad. all of the above

26. Childrens habits canalter tooth positions andskeletal development.a. Trueb. False

27. In undiagnosed airway obstruc-tion in children, _________.a. the jaws can grow narrowb. the muscles of the face constrict the jawc. the patient may exhibit restlessness

and irritabilityd. all of the above

28. Tongue position problems andtongue thrust can cause anterioropen bites.a. Trueb. False

29. When using a fixed tonguecrib, the problem has usuallybeen resolved after wearing theappliance for _________.a. two to three monthsb. three to six monthsc. six to eight months

d. nine to twelve months

30. Digit habits are best solvedby _________.a. using removable appliancesb. using fixed bonded appliancesc. using bitter aloed. none of the above


11/11

PLEASE PHOTOCOPY ANSWER SHEET FOR ADDITIONAL PARTICIPANTS.

Mail completed answer sheet to

Academy of Dental Therapeutics and Stomatology,A Division of PennWell Corp.

P.O. Box 116, Chesterland, OH 44026or fax to: (440) 845-3447

Educational Objectives1. Be knowledgeable about normal growth and development of the dentition and its phases.

2. Be knowledgeable about the early treatment examination and the records that are required for

this examination.

3. Understand the factors and potential problems to consider during the early treatment examination.

4. Be knowledgeable about the fixed and removable appliances that can be used as spacemaintainers and habit breakers during the mixed dentition phase.

5. Be able to treat certain early treatment problems with removable appliances.

Course EvaluationPlease evaluate this course by responding to the following statements, using a scale of Excellent = 5

to Poor = 0.

1. Were the individual course objectives met?

Objective #1:YesNoObjective #3:YesNoObjective #5:YesNo

Objective #2:YesNoObjective #4:YesNo

2. To what extent were the course objectives accomplished overall?

5 4 3 2 1 03. Please rate your personal mastery of the course objectives.

5 4 3 2 1 0

4. How would you rate the objectives and educational methods?

5 4 3 2 1 0

5. How do you rate the authors grasp of the topic?

5 4 3 2 1 0

6. Please rate the instructors effectiveness.

5 4 3 2 1 0

7. Was the overall administration of the course effective?5 4 3 2 1 0

8. Do you feel that the references were adequate?

Yes No

9. Would you participate in a similar program on a different topic?

Yes No

10. If any of the continuing education questions were unclear or ambiguous, please list them.

___________________________________________________

11. Was there any subject matter you found confusing? Please describe.

___________________________________________________

___________________________________________________

12. What additional continuing dental education topics would you like to see?

___________________________________________________

___________________________________________________

For IMMEDIATE results, go to www.ineedce.comand click on the button Take Tests Online. Answer

sheets can be faxed with credit card payment to(440) 845-3447, (216) 398-7922, or (216) 255-6619.

Payment of $59.00 is enclosed.(Checks and credit cards are accepted.)

If paying by credit card, please complete thefollowing: MC Visa AmEx Discover

Acct. Number: ____________________________

Exp. Date: _____________________Charges on your statement will show up as PennWell

ANSWER SHEET

Diagnosing Early Interceptive Orthodontic Problems Part 1Name: Title: Specialty:

Address: E-mail:

City: State: ZIP:

Telephone: Home () Office ()

Requirements for successful completion of the course and to obtain dental continuing education credits: 1) Read the entire course.2) Complete all information above. 3) Complete answer sheets in either pen or pencil. 4) Mark only one answer for each question.5) A score of 70% on this test will earn you 4 CE credits. 6) Complete the Course Evaluation below. 7) Make check payable toPennWell Corp.

AUTHOR DISCLAIMERThe authors of this course have no commercial ties with the sponsors orthe providers of the unrestricted educational grant for this course, exceptDr. Rob Veis who is an instructor for the Appliance Therapy Group and theSMILE Foundation.

SPONSOR/PROVIDER

This course was made possible through an unrestricted educationalgrant from Appliance Therapy Group. No manufacturer or thirdparty has had any input into the development of course content. Allcontent has been derived from references listed, and or the opinionsof clinicians. Please direct all questions pertaining to PennWell or theadministration of this course to Machele Galloway, 1421 S. SheridanRd., Tulsa, OK 74112 or [email protected].

COURSE EVALUATION and PARTICIPANT FEEDBACKWe encourage participant feedback pertaining to all courses. Please besure to complete the survey included with the course. Please e-mail allquestions to: [email protected].

INSTRUCTIONSAll questions should have only one answer. Grading of thisexamination is done manually. Participants will receive confirmationof passing by receipt of a verification form. Verification forms will bemailed within two weeks after taking an examination.

EDUCATIONAL DISCLAIMER

The opinions of efficacy or perceived value of any products orcompanies mentioned in this course and expressed herein arethose of the author(s) of the course and do not necessarily reflectthose of PennWell.

Completing a single continuing education course does not provideenough information to give the participant the feeling that s/he isan expert in the field related to the course topic. It is a combinationof many educational courses and clinical experience that allows theparticipant to develop skills and expertise.

COURSE CREDITS/COSTAll participants scoring at least 70% (answering 21 or more questionscorrectly) on the examination will receive a verification form verifying4 CE credits. The formal continuing education program of this sponsoris accepted by the AGD for Fellowship/Mastership credit. Pleasecontact PennWell for current term of acceptance. Participants areurged to contact their state dental boards for continuing education

requirements. PennWell is a California Provider. The CaliforniaProvider number is 3274. The cost for courses ranges from $49.00to $110.00.

Many PennWell self-study courses have been approved by the DentalAssisting National Board, Inc. (DANB) and can be used by dentalassistants who are DANB Certified to meet DANBs annual continuingeducation requirements. To find out if this course or any otherPennWell course has been approved by DANB, please contact DANBsRecertification Department at 1-800-FOR-DANB, ext. 445.

RECORD KEEPINGPennWell maintains records of your successful completion of anyexam. Please contact our offices for a copy of your continuingeducation credits report. This report, which will list all credits earnedto date, will be generated and mailed to you within five business daysof receipt.

CANCELLATION/REFUND POLICYAny participant who is not 100% satisfied with this course canrequest a full refund by contacting PennWell in writing.

2008 by the Academy of Dental Therapeutics and Stomatology,a division of PennWell

ORTHO10803CED

AGD Code 373

diagnosing early pt 1

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