A SINGLE APPLIANCE FOR THE CORRECTION OF DIGIT-SUCKING, TONGUE-THRUST, AND POSTERIOR CROSS BITE

Gajanan V. Kulkarni and D. Lau, PEDIATRIC DENTISTRY, V 32, NO 1 JAN - FEB 10 Presented by: Dr. Alok Avinash1

CONTENTS Introduction Appliance design Placement and clinical management Discussion References with other articles Conclusion Referencers

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INTRODUCTIONHabits Definition Classification

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Active sucking and pacifier habits in children frequently result in changes to the orofacial structures and occlusion. (1) Anterior open bite (2) Anterior displacement of the maxilla (3) Proclination of the upper incisors (4) Unilateral or bilateral posterior crossbite (5) Tongue thrusting during swallowing

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Clinical management of sucking habits and the resulting dentofacial changes, however, often requires multiple appliances to correct. This can lead to increased treatment time and costs. For example, the use of a crib is effective at correcting sucking habits but cannot effectively correct posterior crossbites. Additional appliances, such as the quad-helix, are necessary to correct the posterior cross-bite, but alone they cannot prevent the sucking habit or tongue thrusting.

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Thus, combination or single appliances have been implemented to simultaneously correct multiple dental problems that frequently accompany nonnutritive sucking habits.

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This leads to introduce a single appliance combining a Teflon roller, a slow palatal expander, and a tongue crib appliance that is designed to correct the: (1) Sucking habit (2) Anterior open bite (3) Posterior crossbite (4) Tongue thrust (5) Molar relationships Ideally, this appliance should be introduced to patients with late primary or early mixed dentitions, at the earliest age possible.

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APPLIANCE DESIGNAccurate pretreatment patient records should be made, including radiographic survey, study models, and photographs. A single appliance is made with a 0.036-inch Elgiloy stainless steel wire arch with a Teflon roller, with a crib or rake, and wire.8

The appliance is a fixed-removable type allowing for easy removal of the appliance without removal of the molar bands, which are cemented with glass ionomer cement. The molar bands are located on the primary second molars or the permanent first molars.

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PLACEMENT AND CLINICAL MANAGEMENT.Placing the appliance first involves molar separation (24 hours or longer) with orthodontic separators, followed by a try-in to ensure that the fit is optimal. The whole appliance is then cemented on with glass ionomer cement. Treatment duration is typically 6 to 9 months, up to 1 year. The crib covering the roller should be continuously monitored and removed soon after correcting the tongue thrust habit. It also servers as an additional deter-rent for the digit-sucking habit.

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The appliance should be placed in the patient's mouth for approximately 1 month before expansion to allow the child to acclimatize to it.

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The anterior open bite should correct spontaneously following cessation of the habits. The posterior cross bite is corrected by incremental activa-tion of the appliance. Only the wire portion of the appliance is removed outside the mouth for activation and reinserted. The posterior cross bite is monitored and the appliance reacti-vated until overcorrection is achieved. Typically, this can be achieved in 2 to 3 months.

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After overcorrection, the appliance is maintained for an additional 2 to 3 months to retain the correction in the coronal plane and the patient should be monitored with periodic recall appropriate for the individual.

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DISCUSSIONThe multiple appliances arise due to the fact that no one appliance can correct all the dentoskeletal complications that result from sucking. One method of solving this problem is to use multiple appliances sequentially to correct each of the problems individually. This entails longer treatment times, however, as well as additional expenses.

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Thus, the single appliance introduced in this paper was designed to reduce treatment time and cost and correct the: (1) Sucking habit (2) Anterior open bite (3) Posterior crossbite (4) Tongue thrust without the need for multiple treatment strategies.

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The sucking habit is stopped by the rake/crib. Once the tongue thrust habit is controlled, the rake/crib portion of the appliance should be removed. Cessation of the habit and the alteration of the tongue posture are maintained by the remaining portion of the appliance along with repeated patient instructions.

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Retroclination of the proclined maxillary anteriors usually follows spontaneously after the habit is stopped. This is achieved by alleviating the labial pressure from the digit being sucked and allowing natural lingual pressure from the lip. Thrusting of the tongue primarily during swallowing is checked by the rake/crib. The posterior cross bite is corrected by progressively activating (expanding) the W arch laterally.

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In this appliance uses a Teflon roller instead of a crib, which is argued to be more humane compared to other appliances and has better acceptance from patients and parents.

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Even with the prongs, the crib's effectiveness in stopping the tongue thrusting-habit is questionable due to its close a-daptation to the palate. Although the quad-helix structure may give the clinician more control, it also lengthens the time needed during activation and readjustments and oral hygiene can be difficult. The earlier in dental development that the single appliance is used, the more ideal the results and the shorter the treatment time.

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Furthermore, compared to fixed appliances, the appliance introduced in this paper is a fixed removable design, making adjustments easier for the clinician and patient. Achieving multiple treatment objectives with a single appliance also reduces treatment cost.

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REFERENCE WITH OTHER ARTICLESDentoskeletal changes associated with fixed and removable appliances with a crib in open-bite patients in the mixed dentition Veronica Giuntini et al Am J Orthod Dentofacial Orthop 2008;133:77-80

They compare the effects of the quad-helix/crib (Q-H/C) appliance and a removable plate with a crib (RP/C) in patients with dentoskeletal open bite.21

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METHODS Both samples consisted of 20 subjects. Lateral cephalograms were analyzed before treatment (T1) and after active treatment (T2). The average age at T1 was 8.4 years, and the mean duration of treatment was 1.5 years in both groups. The T2-T1 changes in the 2 groups were compared with a nonparametric test for independent samples.

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RESULT Both the Q-H/C and the RP/C appliances induced favorable dental effects. However, a compliance-free appliance, such as the Q-H/C appliance, produced more favorable vertical skeletal changes.

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Sucking habits in childhood and the effects on the primary dentition Karen duncan et al International Journal of Paediatric Dentistry 2008; 18: 178188

Questionnaire data on non-nutritive sucking habits were collected on the children at 15 months, 24 months, and 36 months of age. Dental examinations were performed on the same children at 31 months, 43 months, and 61 months of age.25

RESULTS At 15 months, 63.2% of children had a sucking habit, 37.6% used just a dummy, and 22.8% used a digit. By 36 months, sucking had reduced to 40%, with similar prevalence of dummy and digit sucking. Both habits had effects on the developing dentition, most notably in upper labial segment alignment and the development of anterior open bites and posterior crossbites.

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CONCLUSION

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REFERENCES Text book of Pedodontics, Shobha Tandon 2nd edition 2008. Orthodontics the art and science, S. I. Bhalajhi, 3rd edition 2006. Karen duncan et al International Journal of Paediatric Dentistry 2008; 18: 178188. Veronica Giuntini et al American Journal of Orthodontics and Dentofacial Orthopedics 2008;133:77-80.

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