Orthodontic Management in Children With Special Needs

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International Journal of Medical Dentistry 207

ORTHODONTIC MANAGEMENT IN CHILDREN WITH SPECIAL NEEDS

Abstract

Special needs individuals are children or adults prevented by a physical or mental condition permitting theirfull participation to the normal range of activities of theirage groups. They usually exhibit high orthodontic treat

ment needs because of an increased prevalence and severity of malocclusions. These conditions often require acoordinated craniofacial orthodontic and surgical treatment in a team setting, to achieve optimal outcome. Orthodontic treatments for patients born with facialdifferences tend to be more complex than ordinary orthodontics. This multidisciplinary treatment often starts frombirth and extends up to the late teen years. The youngpatient may require treatment by multiple specialists,including a craniofacial surgeon, pediatrician, geneticist,neurosurgeon, ENT, speech and language therapist, pediatric dentist, oral surgeon and prosthodontist. The objective of this paper is to summarize protocols of orthodontictreatment and to present various orthodontic managementprotocols regarding the children with special needs.

Keywords: special needs syndromes, orthodontics, behaviour management, facial deformity

INTRODUCTION

In general, syntagm special needs refers toindividuals suffering from developmental disability (e.g., mental retardation, cerebral palsy,autism / attention decit hyperactivity disorder

[ADHD], Down syndrome), or medically compromised, highrisk patients who may requirespecial attention. Over the past 20 years or so,both the absolute number and proportion of special needs children in society has increased,despite prenatal diagnostic techniques andimprovement in prenatal identication of congenital anomalies. The main reasons are, rst,sophisticated medical care, both prenatal andadult, that has increased the survival rate of newborns, but also their overall life expectancy. Sec

ondly, given the progressive attitude of societytoday, changing social policies and legislation,


Adit ARORA1, Amit PRAKASH2

1. Senior lecturer, Dept. Orthodontics and Dentofacial Orthopedics, Darshan Dental College and Hospital, Loyara, Udaipur2. Senior Lecturer, Dept. Orthodontics and Dentofacial Orthopedics, Rishiraj Dental College and Hospital, BhopalContact person: Amit Prakash [email protected]

many more special needs children are seen asintegral parts of their own families, with adoptive families or in sheltered housing, and thus farmore visible in general, whereas three decadesago they were largely housed in institutions.With their higher public prole, the presentdayafuent society of the Western world has considerably improved the life quality of these children, requiring, in turn, an increased demand foraesthetics and normal function. The aim isacceptance into society, including the chance foremployment toward selfsufciency. Concernfor facial appearance has become an item for discussion among parents and this has generated ademand for orthodontic treatment [1].

The pediatric dentist must treat a patient toeliminate dental disease and to relieve pain,regardless of whether the child is cooperative inthe dental chair and dilligent in routine homecare. At the same time, the dentist is bound toencourage behavior alteration in both theseareas. In contrast, orthodontics performed underthese adverse conditions is not indicated, since asuccessful outcome is doubtful and iatrogenicdamage, in the form of caries and gingival inammation, possible [2]. Thus, while treatment need

is often high and its object benecial, orthodontics is still considered as elective.

BEHAVIOR MANAGEMENT ANDTHE ORTHODONTIST

The orthodontist should approach thesepatients with understanding and compassion, togain their trust. Treating these patients is enormously challenging and is not for everyone!

They require more chair side time, an increasednumber of appointments, their treatment in a

Orthodontics


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Adit Arora, Amit Prakash

regular orthodontic ofce and among healthpatients being problematic, since they disturbthe regular schedule times. Furthermore, combining several procedures into a single sedationor general anesthesia (GA) session requires the

availability of several professionals, for example,pedodontist, endodontist, oral surgeon, andanesthesiologist, which is rarely found in a private clinic, being usually achievable only in ahospitaltype setting [3,4].

GENERAL TREATMENT PRINCIPLES

The aim of the pretreatment visits is:1. To raise patients level of condence in the

dental environment;2. To assess patients and parents compliance in

dental homecare;3. To evaluate the expected degree of coopera

tion that will be nally attained.Clearly, sedation or GA cannot be performed

for each visit of orthodontic appliance adjustment, so that it is important to determine if thepatient can reach a level at which simple tasksmay be performed with behavior management

techniques only. Oral hygiene is perhaps themost crucial factor that dictates whether or notthe orthodontic treatment should be providedfor the particular patient.

DRAWING UP A TENTATIVETREATMENT PLAN

In routine orthodontics with healthy children,our treatment plan is drawn up after clinical

evaluation of the patient, examination of plastercasts, study of the clinical photographs, radiographs, and cephalometric analysis. Therefore, ageneral direction of treatment is sometimesdetermined on the basis of a clinical examinationonly, and full diagnostic records are acquiredsubsequently, as the initial items in the rst sedation session. The tentative treatment plan is conrmed or altered, while the actual treatmentprocedures, such as band placement, extractionsand dental llings, are performed in the same

session. In this way, a single sedation proceduremay be wholly exploited, even if it does demand

a high degree of diagnostic skill and experiencefrom the part of the operator [35].

SELECTING THE TREATMENTMODALITY

Communication is vital for the education ofour orthodontic special needs patients, since theorthodontic treatment is a multivisit modality ofextended duration. Little progress can be madetoward achieving a change in negative behavioror improving the quality of outcomes withoutcommunication between all participants to thedental health care process, especially with thepatient himself, when this is possible. For the

patients with difculties in communication anda relative inability to cooperate, we can offer conscious sedation, deep intravenous sedation, orthe use of general anesthesia. The choice of thetechnique used should be the simplest and safestavailable, namely appropriate for the needs ofthe specic task to be performed for each individual patient. It is pertinent to note that themain reason for the need of sedation does notrelate to pain, but rather to achieving a submissive or motionless state in the patient, for an

extended period of time. It is essential to establish that, for most routine visits for applianceadjustment, the use of behavior managementtechniques, such as Tell, Show, and Do, behavior modication and positive and negative reinforcement is adequate to achieve the goals of therespective visits. Subsequently, it remains onlyto make a decision as to which of the availableadditional modalities is suitable for the poorlytolerated procedures [46].

Conscious sedation is a pharmacologicallyinduced state of relaxation in which thepatient remains conscious. It is aimed at changing patients mood and degree of compliancethroughout the dental treatment, facilitatingacceptance of the procedure. The several different available methods of conscious sedation havewidened the scope of procedures that may beundertaken in dentistry for the uncooperative,difcult, or frightened patient, while opening theway for the orthodontist to provide treatment in

some of the most resistant cases previouslyconsidered untreatable. This modality is used as


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an adjunct to the regular behavior modicationtechniques, only when the latter have failed topermit therapeutic access. It may be elicited bythe administration of drugs through inhalation(nitrous oxide and oxygen), transmucosally via

nasal drops.

ADAPTING ORTHODONTICS TOSPECIAL NEEDS CHILDREN

In the unusual circumstances presented by aspecial needs child, standard orthodontic protocols must be adapted to solve the individualproblems seen in the patient [15].

1. Realistic treatment goals

The aim of all orthodontic treatments is toachieve maximum correction for any childpatient. Under favourable conditions, the orthodontist should be able to produce resultsapproaching the idealistic standards of BoardCertication. However, when conditions arecompromised by the existence of adverse factors,the treatment must be reoriented toward morelimited goals, better adapted to the circumstances

dictated by patients condition. Each child hashis or her own achievable optimum, which needsto be assessed by the clinician, who must thenapply treatment procedures appropriate for thechild. It is imperative for the clinician to understand that, for achieving an optimal rather thanan ideal result, in spite of these limitations, heshould not consider it a failure or deny suchtreatments. [6]

2. How to take records

While we must assume that an adequate clinical examination is possible by using behaviormodication techniques alone, problems willoften arise when attempting to take impressionsor radiographs. Impressions in a complianthealthy child who has a developed gag reexmay be difcult, but, usually, it can be elicitedsuccessfully with a simple explanation and goodcommunication. This is often not possible in thespecial needs child. Accordingly, alternative

adjunctive modalities must be used, preferablyin a stepbystep approach, starting from nitrous

oxide conscious sedation alone (the simplest), orcombined with other pharmacological agents, asalready mentioned above. When consideringradiographs, the panoramic view is consideredto be the basic overall scan that may be used for

orthodontic assessment. However, it requiresminimal patient cooperation in sitting still during the rotation of the tube of the panoramicmachine. Restricting a misunderstanding andfrightened child in a cephalostate or in a panoramic machine, will often increase his fear andeven generate panic. In many noncooperatingpatients, with neuromuscular disorders or mental retardations, these views may never beobtained. There are several other alternativeradiographic views, such as multiple intraoral

per apical views or lateral extra oral jaw views,where the lm or cassette may be held by a suitably protected parent during xray exposure. Incertain instances, we may send the patient to acomputed tomographic (CT) scan performedunder sedation in the hospital. However, the latter is rarely warranted. Whenever sedation orGA is needed for taking records, we will generally aim to combine them with other necessarydental (pedodontic, orthodontic, oral surgery)procedures, to limit to a minimum their number[5].

3. Treatment provided in modules

It is wise to establish reasonable goals on amodular basis, and to reassess them after eachstage, being prepared to make the necessarychanges, if needed, based on the treatment experience with the previous stage, for the particulardisabled individual.

4. Simplifying the treatment

In an earlier report, it had been pointed outthat the problems encountered with xed appliances were generally more severe than in thecase of removable appliances. From the orthodontists point of view, xed appliances are moredifcult to place, especially in these children,because they require specic conditions, such asthe need for the patient to sit still for long periodsof time, to enable precise positioning of the

brackets, and complete dryness of the teeth.Thus, sedation or general anesthesia is


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Adit Arora, Amit Prakash

sometimes needed to facilitate their placement,which is not the case of removable appliances.Adjustment of removable appliances is madeextraorally and does not disturb the child. Incontrast, adjustment of xed appliances can

involve unpleasant sensations of pressure causedby the introduction and manipulation of instruments within the mouth. From the parents pointof view, maintaining adequate oral hygiene ismore difcult with xed than with removableappliances. Accordingly, it is recommended toextend the use of removable appliances, with orwithout extraoral headgear incorporated, and tolimit the period of xed appliance wear. Orthodontic appliances with a longer range of action,

requiring less frequent visits, are to be preferredin cases of extraction, while correction of theanteroposterior and vertical discrepancies in theearlier part of the treatment with the sameextraoral removable maxillary orthopedic splintare recommended, proceeding to space closurewith the use of intraarch mechanics followingonly after these stages. This protocol is preferredto limit or eliminate the use of intermaxillaryelastics, thereby relieving the parent or homecaregivers of the considerable responsibility and bur

den of placing rubber bands bonds on a dailybasis. The use of a Tip Edge appliance versusother types of straight wire brackets is advantageous because it permits insertion of heavierarch wires, that are less likely to be deformed inthe early stages of treatment. Space closure ismuch more rapid since it is performed by slidingmechanics in a broad slot. If, for any reason, thetreatment must be stopped before its completion,more steps will have been achieved.

5. Adapting the treatment of sedation/GA

Aspiration is one of the most dangeroussequelae of any procedure, involving partial ortotal loss of patients protective reexes. Duecare and application of specic safety measuresare essential to prevent debris, water, saliva,blood, or orthodontic materials entering the airway and producing laryngospasm or possibleinfection of the trachea or bronchi. In specic disability groups (e.g., those with cerebral palsy or

muscular dystrophy), the cough reex is impairedand there is an increased danger of aspiration.

Chaushu and colleagues have recommended theuse of a rubber dam as an useful aid and an effective safeguard in bracket bonding during GA. Anoropharyngeal pack is mandatory when rubberdam placement is impossible (for impression

taking, band tting, or appliance cementationsuch as palatal/lingual arches). Indirect bondingof brackets is faster, reducing sedation time andminimizing the possibility of aspiration. Thisdoes not eliminate the need for an oropharyngealpack, which is needed to block uids and smallparticles (e.g., brackets) from entering the upperrespiratory tract. Since the sedated patient cannot bite down on a bite stick, it is prudent to tmolar bands before the sedation or GA session,

wherever possible. High quality and accuratebonding must be assured to avoid the need forsubsequent rebonding without sedation. Themost reliable and proven bonding materialsshould be employed. Sandblasting is recommended, but only with a wellplaced rubber damand highpower suction, to prevent aspiration ofthe ne aluminum oxide powder. Recentlydeveloped primers, that enhance the strength ofbonding even in wet environments, are particularly useful in patients with excessive salivation.

These, together with the use of antisialogoguedrugs and special devices to maintain dryness,such as the Dry system, are also helpful. [710]

6. Relapse and retention

As with any form of orthodontic treatment,posttreatment retention is essential if the fruitsof the combined labors of orthodontist, parent,and child are not to be lost. However, within thespecial needs population, there are many sub

groups of children in whom the etiology may notbe eliminated during the treatment. Thus, children with skeletal discrepancies, particularlyvertical discrepancies seen in cerebral palsy andvarious congential myopathies, or with largetongues, may never achieve stability. This shouldbe predictable prior to initiating the treatmentand, once completed the treatment, retentionmust occur for an extended period of time.Removable retainers will hold the alignment ofteeth within the maxillary or mandibular arch,

but cooperation must be assured. Bonded lingualsplints are preferred, even though this may


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involve a further sedation session for its reliableplacement. A tendency for relapse in Class II andopen bite cases abounds among these patients.Active retention may be essential and is bestachieved by using the same removable total

acrylic hipull integral headgear appliance,which covers (and thereby intrudes) the posterior teeth, while being trimmed free of the incisors [1112].

CONCLUSIONS

The prevalence and severity of malocclusionis especially high in special needs individuals.Many have medical limitations to the various

procedures often needed in the pursuit of excellent orthodontic treatments, and almost all havemoderate to severe behavioural problems thatmake treatment delivery difcult or even impossible to achieve, with any degree of reliability. Ingeneral, the main goals of orthodontics are toimprove the alignment and occlusion of the teethand thus, indirectly, to improve facial appearance. However, its efciency is limited, and itcannot provide a satisfactory answer for everysituation. Individual benets may be gained by

patients mainly associated with patients ownconcept of himself or herself, and strongly inuenced by those around them.

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Orthodontic Management in Children With Special Needs