Treatment of basal anomalies of the transverse sense
Introduction :
Transverse dysmorphias represent anomalies frequently encountered in daily practice. They are manifested by a decrease or an increase in the transverse dimension of the bony bases, the dental arches or both simultaneously.
Furthermore, the transverse direction takes a predominant place in any orthodontic treatment because associated with other vertical or sagittal dysmorphoses, it is considered the first to be taken into account.
1. Maxillary endognathism:
The treatment of this clinical form is closely related to sutural development, since the latter will affect the midpalatine suture; real consideration must be given to it.
Melsen’s work highlighted different stages of evolution of the intermaxillary suture. Although the bony fusion of the suture is relatively late (16 years), the intertwining of the edges of the suture into a very tight and convoluted lace prevents very early, from 12 years, a fibrous expansion of the suture.
a. Processing purposes:
- Increase in the transverse diameter of the maxilla.
- Correction of linguoclusion.
- Improved nasal ventilation.
- Relief of DDM by increasing the arch perimeter.
b. Therapeutic conduct:
- In temporary dentition:
The particularity of this period is that the intermaxillary suture is still more or less straight with slight convolutions, therefore, a simple treatment with removable devices can give good results especially at the skeletal level with tensioning or even separation of the midpalatine suture and new bone formation at this location.
Treatment should first be etiological by correction of orofacial dysfunctions such as mouth breathing, as well as suppression of parafunctions.
Grinding of the canine tips should be considered before any other active treatment to remove transverse locks.
A removable plate with a medial cylinder can be used, which is activated 1 to 2 times per week with a retention period of 7 months.
A Quad’helix sealed on the second temporary molars, with a retention period of 4 to 5 months.
- In mixed dentition:
In this period, the path of the intermaxillary suture became sinuous, so it would be necessary to move on to rapid expansion of the maxilla developing greater forces.
Rapid intermaxillary disjunction is an orthopedic procedure that allows disjunction of the intermaxillary suture.
The devices used for disconnection are: the Hyrax type circuit breaker or the circuit breaker with thermoformed gutters according to McNamara.
The activation procedure according to McNamara is ¼ turn per day, according to Chateau the first activation is 3 ¼ turns to put the suture under tension followed by 2 ¼ turns per day, one activation in the morning and another in the evening, While Langlade intensifies the
The treatment lasts about 4 weeks, but what is essential is the duration of retention which must be respected, it is 6 months, the first 3 months with the same device, the other months with a palatal plate containing a median jack or a Hawley plate.
- In permanent teeth:
Knowing that the age limit for rapid maxillary expansion is 12 years, two possibilities are available to us:
- Before the age of 12, treatment will be done by rapid disjunction of the maxilla.
- After 12 years, there are several risks associated with rapid expansion of the maxilla: pulp mortification, root resorption as well as lateral fenestrations resulting from excessive expansion force, risks of relapse with alveolo-dental effects more significant than skeletal effects.
In this case, the treatment is either surgical from the outset or surgically assisted maxillary expansion; this is bone distraction.
Bone distraction is a surgical-orthopedic procedure consisting of placing a bone distraction device associated with surgical techniques facilitating the disjunction of the midpalatal suture.
The bone distraction device is implanted at the level of the external cortex of the palate opposite the first permanent molars.
The associated osteotomy consists of a separation of the midpalatal suture by a surgical approach.
The activation of the distraction device is 4 ¼ turns per day for 8 days, the restraint with the same device will be done between 3 months and 6 months.
After any orthopedic treatment of maxillary expansion, orthodontic treatment is almost necessary to reestablish correct intra and inter-arch relationships.
c. Mode of action and effects of rapid maxillary disjunction:
Intermaxillary disjunction provides orthopedic, orthodontic and functional effects:
Orthopedic effects:
- Disjunction of the midpalatine suture.
- A slight posterior rotation of the mandible.
Treatment of basal anomalies of the transverse sense
Orthodontic effects:
- A widening of the upper arch with an increase in the perimeter of the arch thus making it possible to relieve the DDM.
- A vestibuloversion of the lateral sectors.
- Spontaneous widening of the mandibular arch following widening of the maxillary arch.
Functional effects:
- Improving nasal ventilation by widening the nasal cavities combined with nasal ventilation rehabilitation.
- Improving masticatory function by restoring correct inter-arch relationships in the transverse direction.
- Increase in the lingual space due to maxillary expansion, the tongue can return to a correct physiological position at rest and during functions, which will allow the correction of possible dysfunctions such as swallowing and disturbed phonation.
- Mandibular recentering with correct repositioning of the condyles in their glenoid cavities, with a reestablishment of the coincidence of the inter-incisal points, this in the case of an associated mandibular laterodeviation.
d. Stability of results:
Functional etiological factors are of crucial importance, their persistence after treatment leads us straight to therapeutic failure. Their elimination is essential as early as possible, such as mouth breathing or persistence of primary swallowing.
The age of maxillary expansion is also an important parameter to take into consideration, since the age limit for RME (Rapid Maxillary Expansion) is 12 years, the closer we get to this age the more the skeletal effects diminish compared to the alveolodental effects.
After 12 years, surgery is required, offering good results that are stable over time.
Overcorrection has been adopted by several authors, it allows to slightly exceed the desired result so that after relapse, we return to the result we wanted to obtain.
2. Mandibular endognathism:
a. Processing purposes:
- Increase in the transverse diameter of the mandible.
- Fixed occlusion in box lid.
- Relief of DDM by increasing the arch perimeter.
b. Therapeutic conduct:
At the mandibular level, sutural growth occurs through the symphyseal synchondrosis, however, the latter synostoses during the first year of life, so the treatment of mandibular endognathia can only be surgical-orthopedic, this is called symphyseal distraction.
The surgical intervention consists of the separation of the symphyseal synchondrosis by surgical approach associated with the activation of the separation device sealed on the teeth of the lateral sectors.
Activation after surgery is 2mm, followed by activation of 1mm per day for 7 days, retention is done with the same device for 3 months.
This surgical-orthopedic treatment must be followed by multi-bracket fixed orthodontic treatment.
c. Mode of action and effects:
Mandibular expansion provides an orthopedic effect represented by the increase in the width of the mandibular bone , an orthodontic effect represented by the vestibuloversion of the lateral sectors, and a functional effect represented by the increase in the lingual lodge allowing the tongue to be repositioned correctly.
b. Stability of results:
The durability of the results over time is ensured by the permanent retention which extends from canine to canine along the cingula of the mandibular incisors.
3. Bimaxillary Endognathism:
This clinical form most often accompanies Obstructive Sleep Apnea Hypopnea Syndrome, or is due to microglossia or aglossia.
The treatment of this clinical form combines maxillary and mandibular treatment, once expansion is obtained, spectacular functional improvements are observed, particularly in the ventilatory function with an increase in nasal permeability, and a switch to nasal ventilation.
4. Maxillary exognathia:
The treatment of this clinical form can only be surgical.
5. Mandibular laterognathia:
Mandibular laterognathia can be either congenital such as unilateral condylar hypertrophy, or acquired such as temporomandibular ankylosis of traumatic origin or mandibular laterodeviation which has anatomized into laterognathia.
5.1. Slight asymmetry, little troubled articulation:
When the deformations are minor, surgical treatment will be purely aesthetic, such as repair of the chin protrusion and correction of unilateral flattening.
5.2. Excessive laterognathia:
In unilateral volume increase, the chin deviation occurs on the healthy side which appears abnormally prominent, so to reduce the deformation it is necessary to section the mandible with or without resection of the most developed side. The choice of the intervention will be made according to the associated deformations in the sagittal and vertical direction.
5.3. Laterognathia due to insufficiency:
Unilateral developmental arrests are much more frequent than excesses, the most common example is unilateral temporomandibular ankylosis, the earlier the lesion, the more marked the consequences.
The surgical procedure aims to lengthen the atrophied side. The osteotomy is followed by a forward slide of the short segment.
Treatment of basal anomalies of the transverse sense
Conclusion :
Transverse sense treatment occupies such an important place today that the number of studies and research concerning it continues to increase, thus allowing the improvement of therapeutic methods, the devices used, as well as the quality of the results.
However, despite having a sufficient therapeutic arsenal, treatment may be difficult due to the long-standing nature of the abnormality, which is why simple early treatment may be better than heavy late treatment .
Treatment of basal anomalies of the transverse sense
Deep cavities may require root canal treatment.
Interdental brushes effectively clean between teeth.
Misaligned teeth can cause chewing problems.
Untreated dental infections can spread to other parts of the body.
Whitening trays are used for gradual results.
Cracked teeth can be repaired with composite resins.
Proper hydration helps maintain a healthy mouth.