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CATCH THEM YOUNG – WATCH THEM GROW” Management of developing malocclusion in early and late mixed dentition period using versatile 2x4 appliance

K.Sudheer kumar1, B.V.Thimma reddy2, E.Lilly grace1, B.Uday kumar chowdary3, R.Hemanth kumar4, J.Raghavendra kumar4

1Senior lecturer, Department of pedodontics, svs institute of dental sciences, INDIA.
2Professor and Head, Department of pedodontics, panineeya institute of dental sciences, INDIA.
3Professor, Department of pedodontics, panineeya institute of dental sciences, INDIA.
4Reader, Department of pedodontics, svs institute of dental sciences, INDIA.

*Corresponding author

K.Sudheer kumar, Senior  lecturer, Department of pedodontics, svs institute of dental sciences, INDIA.

Abstract

The mixed dentition period is considered one of the most ideal ages for undergoing interceptive orthodontic treatment. Children possess a higher perception of dental esthetics. Dental malocclusions were found to affect the self-esteem of the children during this period. American Association of Orthodontics recommends that a child can undergo orthodontic treatment at the early age of 7 years. Certain malocclusions can be corrected during the mixed dentition period which aids in the normal growth of jaws and surrounding structures. This article describes successful management of two cases with angles class 2 division 2 malocclusion treated using 2 x 4 appliance. The 2 x 4 appliance is a partially fixed orthodontic appliance that is used in children in a mixed dentition period to correct simple malocclusions associated with permanent anterior teeth.

Keywords: 2 x 4 appliance, Interceptive orthodontics, Mixed dentition, Children, Malocclusion, Increased overjet.

Introduction

Children having malocclusion in the mixed dentition period are often delayed for treatment until all permanent teeth erupt or are given removable appliances which only result in limited tooth movement.1 A stage of transition from primary to permanent dentition is the period that mostly presents with malocclusion due to various factors. Among the problems most often seen in the mixed dentition period is the anterior crossbite.2

The transition period from primary to permanent dentition between 6 and 12 years of age is often a worrisome period for parents. Parents expect their children’s permanent teeth to erupt into beautiful dental aesthetics following the shedding of the primary teeth.3 Even children are aware of the dental aesthetic of their teeth and that of others.4 However, nature’s expressions often lead to the imperfection of teeth alignment in some children.

Malocclusion of teeth in dentitions is either a malrelationship of dental arches or malalignment of teeth.5 It refers to a significant deviation from the perfect occlusion of teeth that is aesthetically unsatisfactory.6 These malocclusions are categorized into skeletal or dental malocclusions, which are either hereditary or environmental in nature.7 Malposition of teeth refers to the altered positioning of one or more teeth from a well-aligned jaw.5 These malpositions are often caused by local factors such as the presence of supernumerary tooth or teeth, odontomas, cysts, trauma to the primary tooth that displaces the permanent successor tooth germ, ectopic tooth germ, and bony defect of the alveolus due to cleft lip and palate, or other localized bony pathologies.8

Management of malpositioned teeth in the early stage of mixed dentition possesses a great dilemma for dentists. The type of treatment depends on the severity of the malposition, availability of the occlusal space, availability of alveolar bone architecture, availability of eruption path, and patient’s compliance with treatment. Simple discrepancies in the teeth alignment can be corrected with some simple methods such as the use of a wooden spatula tongue blade, composite, or glass ionomer cement incline plane, Catlan’s appliance and removable appliance with z-spring, and expansion screw or micro screw.1,9,10 However, correction of greatly rotated or malposition teeth away from the arch alignment requires slight improvisation in the alignment methods because the use of simple and removable appliances may not be effective in correcting the malpositioned teeth effectively.

This paper describes the series of two cases of malpositioned permanent teeth in the premaxilla treated with a two-by-four (2 × 4) orthodontic appliance.

CASE 1:

A 10year old boy was referred to the Department of Pedodontics regarding irregularly placed teeth in upper front teeth region leading to unaesthetic appearance and bullying amongst his peer groups due to irregular teeth. He presented with a Class 2 div1 incisor relationship on a skeletal Class I base with an average maxillary mandibular planes angle. (figure -1) He was in the early mixed dentition phase, both the upper and lower arches were well aligned with reduced overjet and overbite. Radiographs revealed congenitally missing lower lateral incisor in relation to 42.(figure-2) Patient also had retained deciduous teeth in relation to 54,64,65 which were extracted.

Pre -operative photographs and impressions were taken and model analysis was done. Mixed dentititon analysis inferred, excess space in the arch which can be utilized  for alignment of 11,12,21,22. A 2x4 appliance was placed with bondable buccal tubes on first permanent molars and brackets on the incisors.(figure-3) Initial aligning has been started with 0.014 nickel titanium wire. The archwire sequence was 0.014 nickel titanium,0.016 nickel titanium. Active treatment time involved five visits over an 6-month period. After achieving minimum overjet debonding of the appliance has been done and removable hawleys retainer has been given. (figure-4) At 6-month review positive overjet and overbite have been maintained by regularly using the removable retainer. (figure-5)

Figure 1: Pre-operative intra oral clinical images

Figure 2: Congenitally missing lower lateral incisor in relation to 42.

Figure 3: Bonding of 2x4 appliance.

Figure 4: Debonding of appliance and insertion of removable hawley’s retainer

Figure 5: Post operative after 6 months.

smile enhancement during after the treatment:

Case 2:

Figure 6:  Pre-operative intra oral clinical images.

Figure 7:  Retained deciduous teeth in relation to 72

Figure 8: Bonding of 2x4 appliance.

Figure 9: Debonding and placement of fixed palatal retainer

Figure 10: alignment of crowded lower anteriors following selective removal of deciduous teeth and inherent tongue forces during growing stages.

CASE 2:

A 12year old boy was referred to the Department of Pedodontics regarding irregularly placed teeth in upper front teeth region leading to unaesthetic appearance. He presented with a Class 2 div1 incisor relationship on a skeletal Class I base with an average maxillary mandibular planes angle. (figure -6) He was in the late mixed dentition phase, both the upper and lower arches were well aligned with reduced overjet and overbite. Patient also had retained deciduous teeth in relation to 72 which was extracted.(figure-7)

Pre-operative photographs and impressions were taken and model analysis was done. Mixed dentititon analysis inferred, excess space in the arch which can be utilized for treating malalignment of 11,12,21,22. A 2x4 appliance was placed with bondable buccal tubes on first permanent molars and brackets on the incisors. (figure-8) Initial aligning has been started with 0.014 nickel titanium wire. The archwire sequence was 0.014 nickel titanium,0.016 nickel titanium. Active treatment time involved five visits over an 10-month period. After achieving minimum overjet debonding of the appliance has been done and fixed palatal retainer has been given. (figure-9)          As the patient was in developing dentition stage, in the lower arch only selective extraction of retained deciduous teeth irt 72 has been done and kept under constant supervision for minimal correction of malpositioned lower anterior teeth due to inherent tongue forces. (figure-10)

Discussion:

The 2X4 is a fixed appliance that is made of bands on the first permanent molars, brackets bonded to the erupted maxillary incisors, and continuous arch wires to provide/maintain good arch form, as well as control of anterior teeth. Some limits of removable appliances in children are often lack of cooperation from the patient, lack of retention, and improper activation. Instead, fixed appliances in mixed dentition do not necessitate much patient cooperation.11 Advantages of fixed appliances to mention a few are-minimal discomforts, reduces the need for patient cooperation, increase control of tooth movements, and movement possible in all three planes of space.

The appliance described is versatile, easy to use, and well-tolerated by all patients. One of the important aspects while selecting a 2 x 4 appliance is the eruption of permanent molars and incisors. The 2 x 4 appliance can be stated as partial fixed orthodontic treatment during the early stages to correct many malocclusions which are common during the mixed dentition period. Anterior crossbite can be a major esthetic and functional concern during the early stages of dental development. Anterior crossbite is defined as a situation in which one or more primary or permanent mandibular incisors occlude labially to their antagonists.12

McNamara et.al stated that anterior crossbites in the early mixed dentition are believed to be transferred from the primary to the permanent dentition and can have long-term effects on the growth and development of the teeth and jaws. Valentine and Howitt stated that anterior crossbite may lead to abnormal enamel abrasion or proclination of the mandibular incisors, which, in turn, leads to thinning of the labial alveolar plate and/or gingival recession.12

One of the most common modes of treatment during the mixed dentition period is the use of removable appliances. Removable appliances although are easy to wear and patient comfort is more satisfactory, there are a few drawbacks which include 2 or 3 appointments, less control of tooth movements, improper activation that can lead to unwanted tooth movements, and requires immense patient cooperation.2 In contrast to this fixed appliance treatment can be initiated immediately as soon as the permanent molars and incisors have erupted, have minimal patient discomfort except while placing the bands and brackets, produces active and controlled tooth movement and due to the high application of force the treatment duration is comparatively faster compared to the removable appliances.13

Ethical approval: This study was approved by the Institutional ethics committee, SVS institute of dental sciences. (Reference ID: SVSIDS/PEDO/1/2021)

Informed Consent: All participants provided written informed consent prior to enrolment in the study.

Written informed consent was obtained from the patient for the publication of this case report.

Conflicting Interest: :No

REFERENCES

  1. Prakash P, Durgesh BH. Anterior crossbite correction in early mixed dentition period using catlan's appliance: a case report. ISRN Dent. 2011;2011.
  2. Ulusoy AT, Bodrumlu EH. Management of anterior dental crossbite with removable appliances. Contemp Clin Dent. 2013 Apr;4(2):223.
  3. Setty JV, Srinivasan I. Knowledge and awareness of primary teeth and their importance among parents in Bengaluru City, India. Int J Clin Pediatr Dent. 2016 Jan;9(1):56.
  4. Vale T, Santos P, Moreira J, Manzanares MC, Ustrell JM. Perception of dental aesthetics in paediatric dentistry. Eur J Paediatr Dent. 2009 Mar;10(3):110-4.
  5. Proffit WR. On the Aetiology of Malocclusion: The Northcroft Lecture, 1985 Presented to the British Society for the Study of Orthodontics, Oxford, April 18, 1985. Br J Orthod. 1986 Jan 1;13(1):1-1.
  6. Sockalingam SN, Zakaria AS, Khan KA, Azmi FM, Noor NM. Simple orthodontic correction of rotated malpositioned teeth using sectional wire and orthodontic appliances in mixed-dentition: a report of two cases. Case Rep Dent. 2020;2020.
  7. McDonald F., Ireland A. J. Diagnosis of the Orthodontic Patient. New York, NY, USA: Oxford University Press; 1998.
  8. Zou J, Meng M, Law CS, Rao Y, Zhou X. Common dental diseases in children and malocclusion. Int J Oral Sci. 2018 Mar 13;10(1):7.
  9. Borrie F, Bearn D. Early correction of anterior crossbites: a systematic review. J Orthod. 2011 Sep;38(3):175-84.
  10. Wiedel AP, Bondemark L. Stability of anterior crossbite correction: a randomized controlled trial with a 2-year follow-up. Angle Orthod. 2015 Mar;85(2):189-95.
  11. Fiona McKeown H, Sandlerd J. The two by four appliance: a versatile appliance. Dent Update. 2001 Dec 2;28(10):496-500.
  12. Bindayel NA. Simple removable appliances to correct anterior and posterior crossbite in mixed dentition: Case report. Saudi Dent J. 2012 Apr 1;24(2):105-13.
  13. Suresh KS, Uma HL, Nagarathna J, Kumar P. Management of ectopically erupting maxillary incisors: a case series. Int J Clin Pediatr Dent. 2015 Sep;8(3):227.

Journal of Clinical Case Reports, Medical Images and Health Sciences (ISSN 2832-1286) is a peer-reviewed journal dedicated to publishing clinical images from all sectors of medicine. The goal of this magazine is to disseminate information about new discoveries and treatments in science and medicine.

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