5 Severe crowding
Amy, an almost 11-year-old girl, presents with marked space shortage for both unerupted 3’s (Fig. 5.1). What has caused this problem and how may it be treated?
Amy does not like the appearance of the upper ‘side teeth’ being beside her upper front teeth; the ‘side teeth’ she thinks ‘look like two rows of teeth’. She also does not like the crookedness of her lower front teeth.
Amy’s mother reports that her daughter had a heart murmur as a baby and attended a cardiologist at the local hospital. She fractured her right wrist in a fall from her mountain bike 4 months ago and has been attending for physiotherapy at the local hospital since the cast was removed. Mobility is almost back to normal now but she has difficulty with some procedures such as toothbrushing. Otherwise she is fit and well.
Amy’s cardiologist should be consulted regarding the cardiac status and the possible need for antibiotic prophylaxis for procedures likely to produce bacteraemia because of the potential risk of infective endocarditis. The National Institute for Health and Clinical Excellence (NICE, which governs clinical practice in England and Wales) guidelines (2008) recommend no antibiotic prophylaxis for any cardiac defect whereas the American Heart Association (AHA) recommends antibiotic cover only for those at high risk.
Amy’s cardiologist confirmed that her cardiac murmur had fully resolved and that antibiotic prophylaxis was not required prior to any dental or orthodontic (separator placement, fitting / removal of bands) procedures.
As excellent oral hygiene is essential with any orthodontic treatment, the impact of lack of optimal wrist mobility on oral hygiene should be assessed. Assistance with toothbrushing by a parent may be required until wrist mobility is fully restored; compared with manual brushes, powered brushes with a rotation oscillation action provide protection against gingivitis in the long and short term as well as better plaque removal in the short term.
Amy is a regular attender at her general dental practitioner. She had several of the baby back teeth extracted a few years ago and has some fissure sealants placed in the first permanent molars. She brushes her teeth twice per day but her mother says that she needs reminding about toothbrushing; currently her mother assists with toothbrushing (see above).
Amy has a Class I skeletal pattern with average FMPA, average lower facial height and no facial asymmetry. Her lips are competent with the lower lip resting in the mid-labial third of the upper central incisors.
The intraoral views are shown in Figures 5.1 and 5.2. Describe what you see.
|Age at loss||The younger the age at loss, the greater the potential for space loss|
|Degree of crowding||The more crowded the arch, the more space that will be lost|
|Tooth extracted||Early loss of an e, rather than of a d, is likely to lead to more space loss (see below regarding arch). 5’s may erupt and be excluded palatally/lingually or be impacted; 5 may be in crossbite; centreline shift if asymmetrical extraction and in case of e, if early loss before age 7|
|Arch from which tooth is lost||Greater loss is likely in the upper, rather than in the lower arch, as mesial drift tendency is greater in the former|
|Type of occlusion||Less space loss will occur where good buccal interdigitation exists|