Child dentistry

The development of teeth starts at approximately 6 to 7 weeks after conception. Tooth development is a continuous process which takes place in many stages.

Each tooth develops through three successive stages

1. Bud stage
2. Cap stage
3. Bell stage

During the early stages, the tooth germs grow and expand and the cells that are to form the hard tissues of the teeth differentiate. This leads to the formation of enamel and dentine. As the crowns of the tooth begin to form and mineralize, the root formation begins. After the roots calcify, the formation of the supporting tissues begin. These supporting tissues are cementum, periodontium and the alveolar bone. Subsequently the completed tooth crown erupts in the oral cavity. Root formation continues until the supporting tissues are fully developed.

Developmentally, missing permanent teeth is usually a result of genetic abnormality. When fewer than 6 teeth is missing in the oral cavity it is termed as hypodontia. When more than 6 teeth are missing it is known as oligodontia.

The primary dentition is made up of central incisors, lateral incisors, canines, first molars and second molars. There is one of a kind in each quadrant making a total of 5 in each quadrant. Hence totally there are 20 primary teeth. All of these are gradually replaced by a permanent counterpart except the primary first and second molars. They are replaced by the premolars. The replacement of the primary teeth starts at about 6 years of age when the permanent first molar develops. This results in mixed dentition. The process of shedding primary teeth and replacing by permanent teeth is called as exfoliation.

We would never think of a newborn having teeth. However by birth itself the crowns of the 20 milk teeth are almost completely formed but are not visible as they are embedded in the infant’s jawbones. The primary teeth gradually erupt through the gums by the age of 2.5 years.

Sequence of eruption

The four front teeth, the upper and lower central incisors are the first to erupt and they generally erupt by 6 to 8 months of age. The eruption pattern is as follows.

Generally most children have a complete set of primary teeth by the time they are 3 years of age. Their jaws continue to grow to accommodate the permanent teeth which start erupting by 6 years of age. The primary teeth begin to shed anywhere between 6 to 7 years of age and continues until about 12 years of age.

This period starts when the permanent first molar erupts and lasts till the last primary tooth is shed. There are 32 permanent teeth but the maxillary teeth eruption sequence varies from the mandibular eruption sequence. Since there are no premolars in the primary dentition, the primary molars are replaced by the permanent premolars. If any primary teeth is shed or lost before the permanent tooth is ready to take its place then the posterior tooth drift forward and hence there may be loss of space in the mouth. This causes crowding and malalignment once the permanent teeth eventually erupt. This is referred to as malocclusion and is a very common finding in the mixed dentition stage. Orthodontics play a major role in this stage for functional and esthetic corrections of the malocclusion.

It is an ugly arrangement of anterior teeth, which is merely a temporary phase during the process of missed dentition. It usually occurs between ages 7 and 12 years preceding the eruption of the permanent canines, when the upper central and lateral incisors are tipped laterally because of the un-erupted crowded canines thus creating a midline gap between the central incisors. This arrangement looks ugly and hence the name. But this stage does not need any orthodontic intervention and is self-correcting. It usually corrects itself once the permanent canines erupt and the midline gap closes.

1. The exfoliation pattern varies from individual to individual. Hence there is no need to extract the deciduous teeth.
2. If the underlying permanent tooth has already erupted and the un-shedded milk tooth is prohibiting it from securing its correct position then it is mandatory to extract that milk tooth.
3. It is common to find some wobbly deciduous teeth in this stage but oral hygiene needs to be maintained by proper brushing in order to protect the already erupted permanent teeth.
4. Regular dental checkups need to be followed in this stage to be able to correct malocclusions for functional and esthetic purposes.

Usually since the physical deformity is so obvious, a prenatal ultrasound can detect this condition in an unborn child. If this has gone unnoticed in the prenatal ultrasound, then a physical examination confirms this condition after the birth of the child. And at this time certain other diagnostic procedures are also carried out to evaluate if there is any other medical condition in association with cleft lip and palate.

1. Eating difficulties: With an opening in the palate, foods and liquids may pass through the nose and enter back into the mouth. But nowadays certain specially designed bottles are available which help in the downward flow of the fluid into the stomach. Until surgical intervention is possible, a cleft palate patient may require using a man-made palate to help eat properly and ensure adequate nutrition.
2. Ear infections: In cleft lip and palate there is always a probability of fluid buildup in the middle ear which causes ear infection and if left untreated can even lead to hearing loss. Hence such kids may need to use special tubes in the ear drum to help in fluid drainage.
3. Speech problems: The voices of such children take a nasal sound and speech may be difficult to understand. Surgery generally can fix this issue entirely.
4. Dental problems: Cleft lip and palate patients are more prone to dental caries and also often have missing, extra or malformed teeth which require dental and orthodontic treatments.

Treatment of cleft lip and cleft palate

Surgeries and bone graft are often necessary to treat both these conditions. Additional surgeries may be required to improve the appearance of the lips and the nose, close opening between the nose and mouth and to realign the jaw.

Dental care for cleft lip and cleft palate patients

1. Early dental care: Such patients need special cleaning and fluoride application for healthy teeth. And healthy teeth are important for chewing and good nutrition. Regular dental checkups are mandatory since the initial eruption of teeth. Routine care at home such as regular brushing is also very important.
2. Orthodontic care: The first orthodontic appointment should be scheduled even before any teeth eruption so that the orthodontist can evaluate the facial growth and jaw development.After teeth eruption to understand the short and long term dental needs. After the permanent teeth erupt orthodontic treatment can be done to align the teeth.
3. An oral surgeon along with a prosthodontist and speech pathologist may be required to manage the associated problems like formation of dental bridges and improvement of speech.

Surgeries and bone graft are often necessary to treat both these conditions. Additional surgeries may be required to improve the appearance of the lips and the nose, close opening between the nose and mouth and to realign the jaw

Lip sucking and lip biting can procline the maxillary incisors, retrocline the mandibular incisors means can push the lower front teeth towards tongue and increase the amount of over jet.

Tongue thrusting and mouth-breathing may also play a part in the creation of a malocclusion. An anterior open bite is the most common dental problem associated with these anomalies. 

If positive reinforcement and encouragement do not work to break these habits, habit breaking appliances are required. Dentist will study the severity of the problem & dispense suitable habit breaking appliances.

If positive reinforcement and encouragement do not work to break these habits, habit breaking appliances are required. Dentist will study the severity of the problem & dispense suitable habit breaking appliances.

•  The American Association for Orthodontists recommends that every child have an orthodontic evaluation by the age of 7.    

• Early detection and treatment may give your child an edge: a much better chance for natural and normal development. By working with the natural growth instead of against it, we can prevent problems from becoming worse, and give your child a lifetime of healthy smiles!
• Every treatment may be initiated for: Habits such as tongue thrusting and thumb sucking. 
• Jaw growth irregularities like underdevelopment or overgrowth.
• Constricted airway problems.
• Bad bite. 
• Early loss of milk teeth leading to space deficiency for permanent teeth to erupt.

Jaw growth is a slow and gradual process. Occasionally, something may go wrong with this process and the upper and lower jaws may grow at different rates.

UNEQUAL JAW GROWTH-A CAUSE FOR CONCERN

One or both jaws may grow too much or too little. The resulting abnormality may interfere with:

• Proper teeth alignment. 
• Speaking and chewing. 
• The tongue and lips may be forced to move awkwardly during speech and swallowing in an attempt to compensate for the jaw mal-relationship. 
• There may be a speech defect or excessive mouth breathing.

An improper bite may threaten 

• The long-term health of the gums and teeth. 
• The jaw joint (TMJ) can also be adversely affected by a jaw malrelationship.
• In addition, jaws of different sizes-that don't match-can affect appearance.

The goal of the second phase of orthodontic treatment is to place the teeth into equilibrium such that they will function together properly, be healthy, and look attractive.

Each tooth has a location within the mouth where it is in harmony with the lips, cheeks, tongue, and other teeth. As was the case in the 1st phase, orthodontic records are necessary to establish the appropriate diagnosis and treatment plan.

This 2nd phase is usually initiated once all the permanent teeth have erupted and usually requires braces on all the teeth for a period of time ranging from 12-18 months. 

Two phase orthodontics involves changing jaw structure and jaw relationship to create a more favorable environment for the eruption of a full permanent dentition.

 Potential advantages to this approach are a reduction of the overbite or under bite, allowing for more normal future jaw development, and the possibility that future treatment may not be needed.