Case History 1 = Diseases of bone and the maxillary sinus

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A 58-year-old woman noticed that her front teeth had become spaced and seeks advice from her dentist. On entering the surgery, the dentist notices that she has difficulty in walking and does not respond to his questions. She has become increasingly deaf and her vision has also deteriorated. On examination, the maxilla and zygoma are enlarged and there is enlargement of the forehead.

1. What diagnosis would you suspect?
Pagetʼs disease of bone results in enlargement of cranial bones and deformation of weight- bearing bones. The cranium is usually expanded in thickness and symptoms may arise from cranial nerve compression.

2. What information might be gained from oral radiographs and blood tests to support this diagnosis?
Radiographs of the jaws may show hypercementosis, cemental masses, abnormal trabeculation and a cotton-wool appearance in the jaws. The alkaline phosphatase level is markedly raised.


3. What are the principal histological features of this disorder?

Disordered bone remodelling is seen; larger osteoclasts are present and the trabeculae show a scalloped outline. Numerous resting and reversal lines, resulting in a mosaic pattern, are seen and the vasculature may be increased. Globular cementum-like masses are seen in the jaws. 

Adenoid Faces

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  1. Head is tilted backwards
  2. Anterior open bite
  3. Increased overjet/ Proclined anterior teeth
  4. Crowding seen in anterior segment 
  5. Supra erupted posterior 
  6. Posterior crossbite
  7. Narrow maxilla and deep palatal vault
  8. Xerostomia = prone to caries
  9. Gingival recession
  10. Bleeding from gums
  11. Narrow nasal passages

Cantilever spring/ Finger spring 2m** = 

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  1. used for mesiodistal tooth movement. 
  2. Active arm is 12 mm and retentive tag is 3-5mm. 
  3. Placed along long axis of the tooth which has to be moved. 
  4. If tooth is to be moved mesially, direction of helix will be distal
  5. The finger spring is activated by moving the active arm towards the teeth intended to be moved. This is done as close to the coil as possible.
  6. Activation of upto 3 mm is considered 

SERIAL EXTRACTION

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Defined as correctly timed, planned removal of certain deciduous and permanent teeth in mixed dentition cases with dentoalveolar disproportion

  1. Introduced by KJELLGREN 
  2. Father of SE = nance 1940
  3. RATIONALE
    1. Arch length deficiency as compared to the tooth material using Model analysis method
    2. Physiological tooth material = eg wilkinson extraction of 1st permanent molar
  4. FACTORS THAT PLAY ROLE IN CORRECTION OF CROWDING IN ANTERIOR SEGMENT
    1. Leeway space of nace 
      1. Max = 1.8 mm
      2. Mand = 3.4 mm
    2. Tongue pressure 
    3. Interdental spacing 
    4. Incisal liability = amount of space available and required by permanent tooth
      1. Max = 7 mm
      2. Mand = 5mm 
  5. INDICATIONS 2m
    1. Tooth material and arch length discrepancy of 10mm
    2. Class I malocclusion 
    3. Absence of Spacing 
    4. Midline shift 
    5. Premature loss of primary canine
  6. CONTRAINDICATIONS 2m
    1. Class II and Class III malocclusion 
    2. Anodontia
    3. Oligodontia
    4. Deep bite 
  7. ADVANTAGES =  Prevents fixed appliances and malocclusions in the pt
  8. DISADV = 
    1. Long follow up = pt compliance
    2. Operator = highly trained 
    3. Delay of permanent tooth 
  9. DWELLS PROCEDURE
    1. Extraction of three teeth 
      1. Primary canine = at age of 8-9 years
      2. Primary 1st molar = at age of 9-10 years
      3. 1st premolar 
    2. Always bilateral extraction in the same arch 
    3. If done unilateral = midline shift happens 
    4. In the 1 st Step, the deciduous canines are extracted to create a space for alignment of the incisors. This step is carried out at 8-9 years of age. 
    5. After 1 years, the deciduous 1st molars are extracted so that the eruption of 1st premolars is accelerated. 
    6. This is followed by the extraction of the erupting 1 st premolar to permit the permanent canines to erupt in their place. 
  1. TWEED METHOD = D4C
  1. NANCE METHOD = D4C 
  • BOTH methods involve the extraction of the deciduous 1 st molars around 8 years of age. This is followed by the extraction of the 1 st premolar & the deciduous canines. 
  • MOYERS METHOD = based on intercanine width = BCD4
    1. Maxillary arch 
      1. Boys = 10 years
      2. Girls = 9 years
    2. Mandibular arch 
      1. Boys = 18 years
      2. Girls = 12 years

ACTIVATOR

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DEFINITION = Functional appliances are defined as ‘loose fitting or passive appliances which harness the natural forces of the orofacial musculature that are transmitted to the teeth and alveolar bone through the medium of appliance’.

ACTIVATOR 4m**

  1. Given by anderson and haul
  2. Also called as norwegian appliance or loose fitting appliance
  3. It doesn’t have any clasp to hold onto dentition normally 
  4. Only one wire component = labial bow

Mechanism of action 2m

  1. Pt has to forcibly hold the appliance in its place aka maxilla as its loose appliance with no clasps
  2. This causes the pt to bring his mandible forward and keep mouth closed so the activator doesn’t fall down. 
  3. When pt swallows = muscles get stretched, continous remodeling at TMJ and mandible stays in forward direction
  4. Mandible is staying forward due to a REFLEX – myotatic reflex = due to continuous stretch of muscles, kinetic energy is generated and transferred to maxillary and mandibular dentition and skeletal base. Leading to: 
    1. Distal force on maxilla
    2. Mesial force in mandible 
    3. Hence, condylar adaptation occurs
  5.  ‘viscoelastic property’ = passive tension caused by stretching of muscles, soft tissue, tendinous tissue, etc. are responsible for the action


Indications 2m

  1. Class II division 1 malocclusion
  2. Class II division 2 malocclusion
  3. Class III malocclusion
  4. Class I open bite malocclusion
  5. Class I deep bite malocclusion
  6. As a preliminary treatment before major fixed appliance therapy to improve skeletal jaw relations
  7. For post­ treatment retention
  8. Children with lack of vertical development in lower facial height.

Contraindications

  1. Crowding 
  2. Adult pt 
  3. Too much proclination of lower anteriors 
  4. Increased lower anterior facial height

Advantage

  • pt can remove it
  • oral hygiene is maintained
  • no food restrictions
  • chair side time is less

Disadvantage = pt compliance

TYPES of activator 

  1. H activator 
    1. Horizontally growing pt
  2. V activator 
    1. Vertically growing pt 

FABRICATION STEPS

  1. Take impression
  2. Bite registration = gives us an idea how much mandible needs to be displaced. U shaped wax is placed on the oral cavity and asked to bring it forward and the bite is also opened posteriorly. 
  3. Articulation
  4. Wire elements  
  5. Acrylization of appliance
  6. Trimming = to bring about certain movements of the dentition

MODIFICATIONS 

BOW ACTIVATOR 

  • WUNDERER MODIFICATION = Given in class 3 
  • CYBERNATOR = similar to bionator = activator with reduced palatal acrylic 
  • PROPULSOR
  • Cutout or palate free activator
  • Karwetzky modification 
  • Herren modification 
  • Elastic open activator
  • Kinetor by Stockfish