09 Malocclusion

UPDATING OF THE BASIC ORAL CARE NOTEBOOK 2012 FOUSP - MINISTRY OF HEALTH, BRAZIL

Malocclusion

Malocclusion is the dental facial problem that does not derive from a single specific pathologic process most of the time, but from a significant clinical variation of the normal growth resulting from the interaction of several factors during development, such as the interaction between environmental and congenital influences.

Chapters 1. Concepts and Risks a. Conceptual and Epidemiological Aspects b. Main Risk Factors Page 1

2. Abordagem Coletiva a. Ações de Vigilância sobre Risco e de Necessidades em Saúde Bucal b. Ações de Promoção à Saúde c. Ações Educativas e Preventivas d. Universalização do acesso à escova e ao dentifrício fluoretado Page 2

3. Abordagem Individual a. Diagnóstico b. Tratamento c. Restauração/ Reabilitação d. Manutenção Page 2

4. Tratamento a. Instrução de higiene bucal b. Remoção profissional de placa c. Adequação do meio bucal d. Controle da atividade da doença e. Restauração/ Reabilitação Page 3

Updating and Illustrating 5. Tratamento 6. Referências e Restaurador Créditos Atraumático a. Abordagem coletiva Page 4 b. Materiais Indicados c. Passos Operatórios d. Selamento de 1os Molares Permanentes e. Longevidade f. Exemplos e Experiências Page 3

1. Concepts and Risks

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Malocclusions constitute the object of many

a. Conceptual and Epidemiological Aspects

frequency and distribution of these problems. In Brazil, due to the high prevalence of caries and periodontal

international epidemiological trials, especially as to the

If we consider that malocclusion results from a disease, research has been directed to know the morphological functional diversion of the masticatory characteristics of these problems. !

system that is biophysical by nature, it is possible to say that all and any factor interfering in the formation of the cranial facial skeleton will result in alterations of shape

Lesões primárias

and function. The failure in the joint functioning mechanism may produce, according to the individual’s adaptation, a change of the harmonious situation causing a first sign of phasic growth, that is, a primary injury.

Apinhamento dentário na dentição decídua

ROULET, P.C.

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The primary lesion, according to the age and constitution, may cause distinct secondary lesions. The longer a primary lesion lasts, the more severe and greater will be the secondary and greater problems will

Mordida cruzada anterior

Mordida aberta anterior e mordida cruzada posterior

result from this process of inharmonious growth. !

The early diagnosis of these injuries, if followed !

Moreover, there is a wide variation between by adequate treatment, favors the rupture of the methods and indexes adopted in the epidemiological pathological circuit or chain lesion. trials, making it difficult to compare between them.

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UPDATING OF THE BASIC ORAL CARE NOTEBOOK 2012 FOUSP - MINISTRY OF HEALTH, BRAZIL

Epidemiologically, it is fundamental to

facial musculature force or evidence of severe

identify the individuals or communities

craniofacial syndromes.

where malocclusions or dental facial anomalies are 2. Local and systemic illnesses: causing difficulty or psychosocial impairment due to Systemic illnesses: endocrine the severity of such anomaly that significantly diverts ! from the esthetic patterns accepted by society.

syndromes Dentinogênese imperfeita hereditária + osteogênese imperfeita

Lesões secundárias

Mordida aberta Apinhamento anterior

!

ROULET, P.C.

disorders,

Após o diagnóstico de DI devese avisar a família do fator de transmissão hereditária.

Para cada portador, metade de sua prole será afetada, uma vez que é uma desordem autossômica dominante.

O aconselhamento genético é um direito do indivíduo.

Mordida cruzada posterior

According to several authors, around 20% to

30% people are expected to present severe anomalies that require mandatory treatment as they affect the quality of life, regardless where they are or the index

The endocrine dysfunctions can be:

used. !

Results from SB Brasil (2003) indicate that at 5

years, the vast majority of the population presents normal occlusion or light anomalies in all searched regions (North – 92%, Northeast – 80%, Southeast – 81%, South – 77%, Central-West – 90%), being the national average around 84%. !

In the same study, when we observed the dental

facial abnormalities distributed in the 12- year-old group and the age group from 15 to 19 years, according to the macro region, the most severe occlusal condition prevalence was around 21% in 12-year-old children and

•

Prenatal: can be expressed in dental hypoplasia.

•

Postnatal: can retard or accelerate the facial growth direction, affect the bone mineralization speed, sutures closing time, dental eruption period and the speed of deciduous teeth reabsorption.

Local illnesses: nasal obstruction, tumors, periodontal disease, bone losses and migrations, and dental caries.

RESPIRACAO BUCAL obstrução nasal

about 19% in 15 to 19 years old adolescents. !

We reinforce that for this group treatment is

Palato atrésico

mandatory according to the World Health Organization (WHO) recommendation.

Postura baixa de língua

b. Main Risk Factors ROULET, P.C.

1. Heredity: Family similarities can be frequently observed. However, the transmission mode or even the place of genetic action are not known, except for few defined problems, for example the absence of teeth, size of teeth, dental facial growth patterns, UPDATING OF THE BASIC ORAL CARE NOTEBOOK 2012 - FOUSP - Ministry of Health

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UPDATING OF THE BASIC ORAL CARE NOTEBOOK 2012 FOUSP - MINISTRY OF HEALTH, BRAZIL

Nasal obstruction

PERDA PRECOCE DE DENTE DECÍDUO (75) Conseqüências: • migração do primeiro molar permanente inferior (36) • perda do espaço para o sucessor permanente (35) • extrusão do dente antagonista (65) • diminuição da zona de suporte oclusal do lado esquerdo, o que pode levar a diminuição da eficiência mastigatória deste lado

Nasal breathing is one of the most important factors to the stomatognathic system development. !

Altered oral and nasal breathing may be

considered etiologic factors or causes that predispose to certain malocclusion symptoms. !

Augmented tonsils and adenoids and other

nasopharyngeal illnesses may obstruct the airways originating mouth breathing that causes changes in tongue, lips and mandible posture. !

ROULET, P.C.

This disorder in the soft tissues harmony

induces alterations in the craniofacial morphology and

3. Trauma malocclusion, with the following characteristics: increase in the anterior facial height, narrow and deep a. Prenatal trauma and labor injuries palate, incisors in retroversion and increase in the lower facial height, open bite and cross-bite.

!

Intrauterine pressure or trauma during labor

may cause mandible hypoplasia.

Dental Caries

!

The

TRAUMATISMO DURANTE O PARTO (FORCEPS)

major

isolated

cause

of

localized

malocclusion is dental caries.

The large carious lesions may be responsible for: a. Premature loss of deciduous teeth When a deciduous tooth is lost before eruption of the RAKOSI & JONAS, 1992

permanent tooth (beginning of root formation), the

“FACE DE PÁSSARO”

socket will probably be filled with bone and eruption of

ANQUILOSE MANDIBULAR

the permanent tooth will be delayed. !

Inhibition of mandibular growth due to TMJ b. Disorders in the eruption sequence of permanent ankylosis. It may be a development defect or caused by teeth may result in losing space. trauma. c. Loss of permanent teeth: the rupture of mesial distal contacts allows tilting of teeth, interfering in the physiological function of dentition, that is, in occlusal balance.

!

Knee or leg pressure may press the face in such a

way that it may cause asymmetry in the facial growth or delay in the mandibular development. b. Post-natal trauma !

Fractures in the maxilla and teeth

TMJ trauma causing temporomandibular asymmetry and dysfunction.

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4. Physical agents: early loss of deciduous adaptation response of the associated dentoalveolar teeth due to early carious lesions leading to a tissues may lead to malocclusions. greater eating difficulty and reduction of the Pacifier suction masticatory function usually in the absence of hard, dry The prolonged use of pacifiers (after 3 years of and fibrous food and maintenance of a pasty cariogenic ! age) in children with vertical growth pattern, poor

diet that aggravates the general condition.

transverse or sagittal relationship in the maxilla may contribute to malocclusions, mainly open and cross bites.

Digital suction !

Many children present digital suction for many

reasons; however, if it is not directly involved in the establishment or maintenance of malocclusion, it should not be an important clinical concern to the dentist.

ROULET, P.C.

!

Many children develop the habit of digital

suction but do not have any dental facial deformity, but 5. Noxious oral habits !

the pressure produced by digital suction may be a direct

Breastfeeding is fundamental in order to avoid cause of severe malocclusion.

noxious suction habits at an early stage.

!

Most of digital suction habits start early on and

almost always are abandoned around 3 or 4 years of age.

Sucção de dedo

!

They may bring negative consequences to

occlusion mainly if they persist after 4 years of age. !

In the first weeks, these suction habits usually

are related to problems in feeding. In older children, these habits may be related to emotional problems. !

Suction habits are related to Distal Occlusion,

Open Bite and Deep Bite.

ROULET, P.C.

The type of malocclusion that may develop will depend on:

Consider: duration, intensity, type and time.

•

The position of the finger

•

The

Baby bottle suction !

The non-physiological design of the nipple, big

hole and incorrect position of the child (usually lying down) may force the tongue and the cheeks to carry out atypical compensatory functions to extract milk, besides altering the breathing pattern. The subsequent UPDATING OF THE BASIC ORAL CARE NOTEBOOK 2012 - FOUSP - Ministry of Health

associated

orofacial

muscular

contractions •

The mandible position during suction

•

The facial skeletal morphology

•

The suction intensity and duration

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UPDATING OF THE BASIC ORAL CARE NOTEBOOK 2012 FOUSP - MINISTRY OF HEALTH, BRAZIL

Lip suction

importance and severity of severe malocclusions, we

Lip suction may be a primary or secondary cause of malocclusion.

perpetuate and agree with the social exclusion scenario of low income individuals who cannot chew, show their smile, long for a better job or simply date someone,

!

Signs of primary cause: horizontal penetration besides all social exclusion that is well known and with buccal tilting of upper incisors and lingual tilting completely identified. of lower incisors with light sagittal skeletal discrepancy.

!

Attention and identification of the main risk

!

Signs of secondary cause: the original horizontal factors. penetration is due to the increased sagittal discrepancy, !

Identification and prioritization of populations usually associated to mandibular underdevelopment. that present higher social risk.

Incisors tilting may be normal. The lip accommodates in the space between upper and lower incisors.

!

Identification of individuals or communities

with severe malocclusions that may be interfering in their lives significantly through regular epidemiological actions.

Onychophagia !

It may be the cause of poor dental position. It !

Adaptation to the peculiarities of the Brazilian may cause wear on the incisal edges at medium term. population as to the malocclusion indexes and This habit may be related to anxious children or may be acquired by imitation.

6. Nutritional deficiencies and malnutrition

intervention

proposals (miscegenation,

social

and

economic unbalances, access to health services and care).

b. Health Promotion Actions (inter-sectors and

!

Malnutrition affects the quality of forming educational) tissues and the indexes of mineralization. A good !

As the other problems addressed previously, nutrition plays an important role in growth and promotion, treatment and protection actions are maintenance of good body health and oral hygiene. proposed to control the risk factors, emphasizing the inter-sectors and educational measures in public health 7. Cultural, social and economic factors

that are

obstacles or prevent access to the preventive and promotional oral health services.

that may allow access to information about the risk factors and malocclusion prevention. The policies related to the improvement of social and economic conditions, quality of life, access to the programs that recognize the importance of treating malocclusion are

2. Collective Approaches

also mandatory.

•

a. Surveillance Actions in Risk Signs of Oral Health !

administration regarding the effective priority of

As other oral pathologies, malocclusions can

promotional actions as to the individual’s health,

also be considered multifactorial in nature and they are

following the principles of universality, integrality

directly affected by the social and economic condition,

and equality.

usually denying individuals the access to health services. Rarely do we find prevention and treatment proposals to the problems. When we ignore the UPDATING OF THE BASIC ORAL CARE NOTEBOOK 2012 - FOUSP - Ministry of Health

Active participation of the health team in planning, organization and technical support to the municipal

•

Frequent and timely actions in epidemiological surveillance.

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UPDATING OF THE BASIC ORAL CARE NOTEBOOK 2012 FOUSP - MINISTRY OF HEALTH, BRAZIL •

Dental caries and periodontal disease !

prevention.

•

Treatment of malocclusion or dental facial

anomalies may be classified as preventive, interceptive

and corrective. Occlusion development follow-up Be part of the Oral Health Team in the counseling should start during pregnancy and continue for the and follow-up programs for pregnant women to whole life. avoid the use of teratogenic drugs, that is, those that may produce undesirable cell mutations, !

Preventive and interceptive treatment in Basic

mainly at the embryonic period of facial and oral Attention refers to an informative level and minimum structures formation.

•

Follow-up and counseling of pregnant women

professional intervention. The oral health team should advise and follow the children, stimulating them to:

about care during labor and puerperal period, stimulating

breastfeeding

exclusively

for

a

minimum period of 6 months and continuing up

(1) Keep a nasal breathing pattern;;

to 2 years of age, according to WHO. However, if this is not possible, clarify the use of orthodontic baby bottles and nipples that minimize the problems of facial structures development.

•

Counseling

about

the

importance

of

nasal

breathing and the maintenance of a closed mouth at rest position for a better facial development.

Padrão de respiração nasal

Padrão de respiração bucal ROULET, P.C.

3. Individual Approach (2) Reinforce eating and hygiene stimuli that are a. Diagnosis !

adequate to the development of the face and occlusion;

Diagnosis should be made as soon as possible

identifying the risk factors and their reduction.

Preventing is anticipating, preparing and avoiding malocclusion. Preventing is also interfering, because even after malocclusion is installed, it is possible to prevent

a

worse

situation

with

irreversible

consequences.

Estímulo à alimentação e higienização adequadas ao desenvolvimento da face e oclusão

!

After detecting malocclusion, it is necessary to perform clinical evaluation and ask complementary diagnostic examinations, such as panoramic and cephalometric radiographs and also study models.

ROULET, P.C.

b. Treatment

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UPDATING OF THE BASIC ORAL CARE NOTEBOOK 2012 FOUSP - MINISTRY OF HEALTH, BRAZIL

(3)

recognize

the

importance

of

•

maintaining deciduous teeth in perfect health for the development of the face and occlusion;

5 to 6-year-old children, physiological wear in deciduous dentition, mainly canines

•

Presence of diastema in the region of incisors at the end of deciduous dentition and beginning of permanent

Importância de manutenção dos dentes decíduos em perfeito estado para o desenvolvimento da face e oclusão;

•

Symmetrical and harmonious shape in the maxilla and mandible

ROULET, P.C.

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Horizontal movements (chewing functional angle ≈ 0º) at 6 years of age

•

Symmetrical lateral protrusive movements

Signs of a deficient chewing: •

Anatomically sound tooth with no attrition signs long after its eruption demonstrates to be an etiologic factor of chewing deficiency

(4) follow the chewing directions trying to correct small postural shifts.

•

Maxillary

and

mandibular

arches

underdevelopment •

Vicious mastication (unilateral) may cause severe or discrete facial asymmetry

• •

Vicious mastication may cause shifts in dental positions and/or mandibular positions that, in

A mastigação esta mais funcional do lado direito, onde há mais contatos dentários durante o lado de trabalho.

No lado esquerdo, o guia canino não permite a atrição fisiológica dos demais dentes posteriores do lado de trabalho

Conduta clinica: • Ajuste oclusal • Orientação mastigatória: lado esquerdo.

• Alimentos: duros, secos e fibrosos

certain periods, may be followed or not by shape diversion (asymmetrical growth). Mandibular shifts in cross bites.

ROULET, P.C.

(5) Selective grinding.

DIET x CHEWING

Selective grinding must follow the directions and

There is evidence that a soft, pasty and low- philosophy of Neural Occlusal Rehabilitation by Pedro fiber-content diet plays a role in the etiology of some Planas. !

malocclusions. The masticatory musculature has little demand and the lack of adequate function results in:

If occlusopathy is installed, the patient should be dental arches underdevelopment; insufficient occlusal ! wear that impairs the bilateral horizontal movements in referred to specialized care as Orthodontic Treatment and/or Functional Orthopedic Maxillary Treatment. chewing.

•

Signs of an efficient chewing:

UPDATING OF THE BASIC ORAL CARE NOTEBOOK 2012 - FOUSP - Ministry of Health

When there is need of interdisciplinary interventions, 7

UPDATING OF THE BASIC ORAL CARE NOTEBOOK 2012 FOUSP - MINISTRY OF HEALTH, BRAZIL

such as the treatment of respiratory tract problems or when there is need of oral habits correction that favor malocclusion by the interposition of mechanical forces such as pacifiers, thumb sucking, nail biting and tongue thrust, the referral should be made to Laryngology and/or Speech Therapy.

Ajuste oclusal os caninos decíduos do lado esquerdo,

Terapêutica para funcionalizar a mastigação deste lado,

permitindo uma melhor atricao fisiológica dos dentes posteriores, Estimulando o desenvolvimento da hemi maxila esquerda e hemimandibula direita, segundo as leis de Planas ( Reabilitacao Neuro Oclusal).

ROULET, P.C.

Credits UPDATING OF THE BASIC ORAL CARE NOTEBOOK 2012 - Ministry of Health/PAHO, Brazil, and images: Patrícia Camacho Roulet Layout: Mary Caroline Skelton-Macedo - FOUSP Translation: Flavia Egner - Intertrad

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