Spolupra ce ortodontisty a pedostomatologa. Interceptivnõ leâ cï ba. Cooperation of orthodontist and pedodontist. Interceptive orthodontic treatment. *MDDr. Hana RÏ ehaâcï kovaâ, *Doc. MUDr. PavlõÂna CÏ ernochovaâ, Ph.D., **Mgr. KaterÏina LangovaÂ, Ph.D. * Ortodonticke oddeï lenõâ, Stomatologicka klinikafn u sv. Anny alf MU v BrneÏ * Department of Orthodontics, Clinic of Stomatology, University Hospital of St.Anne, Masaryk University Brno ** U stav leâkarïskeâ biofyziky, LF UP Olomouc ** Department of Medical Biophysics, Medical Faculty, Palacky University Olomouc Souhrn CõÂlem studie bylo formou dotaznõâkoveâ ho sï etrïenõâ zmapovat indikace, celkovyâ zaâ jem a zkusï enosti s jednotlivyâ mi ortodontickyâ mi anomaâ liemi vhodnyâ mi k interceptivnõâ leâ cï beï z pohledu praktickeâ ho zubnõâho leâ karïe. Do studie bylo zahrnuto 448 dotaznõâkuê, ktereâ se tyâ kaly konkreâ tnõâch ortodontickyâ ch anomaâ liõâ, vhodneâ doby jejich odeslaâ nõâ na konzultaci k ortodontistovi, leâ cï ebnyâ ch postupuê a mozïnyâ ch duê sledkuê v prïõâpadeï zanedbaâ nõâ.na zaâ kladeï nasï eho sï etrïenõâ bylo v prevenci a profylaxi ortodontickyâ ch anomaâ liõâ ze strany osï etrïujõâcõâch zubnõâch leâ karïuê zjisï teï no mnoho poteï sï u- jõâcõâch vyâ stupuê, ale zaâ rovenï irïada nedostatkuê (Ortodoncie 2014, 23, cï. 4, s. 228-234). Abstract The purpose of the questionnaire survey was to map the indications, overall demand, and experience with individual orthodontic anomalies suitable for interceptive treatment from the viewpoint of a general dentist. The survey included 448 questionnaires focused on specific orthodontic anomalies, appropriate time of the first consultation with an orthodontist, therapeutic approaches, and possible consequences due to neglect. Our study brought about a number of satisfying outcomes regarding prevention and prophylaxis of orthodontic anomalies provided by general dentists, however, we also found some deficiencies (Ortodoncie 2014, 23, No. 4, p. 228-234). KlõÂcÏ ovaâ slova: Interceptivnõ leâ cï ba, ortodontickeâ anomaâ lie, spolupraâ ce ortodontisty a pedostomatologa Key-words: Interceptive treatment, orthodontic anomalies, cooperation of orthodontist and pedodontist U vod InterceptivnõÂle cï ba, tedy leâ cï bazahaâ jenaâ v docï asneâ m cï i smõâsï eneâ m chrupu, je staâ le velmi kontroverznõâ teâma av odborneâ literaturïe se muê zï eme setkat se dveï maodlisï nyâmi naâ zory natuto problematiku. CÏ aâ st leâkarïuê za - staâ vaâ naâ zor, zï e jsou ortodontickeâ anomaâ lie, u nichzï je vhodneâ zapocïõât leâcï bu jizï v docï asneâm cï i smõâsï eneâm chrupu. CõÂlem takoveâ leâcï by je uâ prava existujõâcõâ nebo vyvõâjejõâcõâ se odchylky acelkoveâ zlepsï enõâ funkce orofaciaâ lnõâho komplexu jesï teï prïed prorïezaâ nõâm staâ leâ dentice [1]. NeÏ ktereâ brzkeâ intervence zabranï ujõâ rozvoji anomaâ- Introduction Interceptive treatment, i.e. treatment commenced in deciduous or mixed dentition, has been a rather controversial issue. There exist two contrary views in the literature. One view believes that there are orthodontic anomalies which should be solved as early as in deciduous or mixed dentition. The purpose of such treatment is to solve already existing or developing anomalies, and to improve the function of orofacial complex before permanent teeth erupt [1]. Some early interventions prevent an anomaly development. However, we 228
rocïnõâk23 lie, ale je nutneâ pocï õâtat s tõâm, zïe veïtsï inaprïõâpaduê bude vyzï adovat jesï teï naâ slednou, druhou faâ zi leâ cï by beï hem dospõâvaâ nõâ. VhodneÏ na cï asovanaâ leâ cï batedy muê zï e snõâzï it zaâ va zï nost probleâ mu, ale neeliminuje potrïebu dalsï õâ korekce ve staâ leâ m chrupu [2]. Le ka rïi, kterïõâ interceptivnõâ leâ cï bu nepodporujõâ, varujõâ, zï e dvoufaâ zovaâ leâ cï ba muê zïe zbytecï neï veâ st k vycï erpaâ nõâ spolupraâ ce pacienta i jeho rodicïuê, k prodlouzï enõâ celkoveâ doby leâcï by azvyâsï eneâmu riziku posï kozenõâ tkaânõâ. DuÊ lezï ityâ m aspektem uâ speï sï neâ ortodontickeâ leâ cï by je vzaâ jemnaâ spolupraâ ce ortodontisty apedostomatologa. Prakticky zubnõâ leâkarï cï i pedostomatolog by meï l zajistit nejen pecï livou sanaci chrupu deï tskeâho pacienta, ale i depistaâ zï jednotlivyâ ch ortodontickyâ ch anomaâ liõâ. V prïõâpadeï zjisï teï nõâ jakeâ koliv odchylky od fyziologickeâho vyâvoje, by meï l zubnõâ leâkarïdõâteïvcï as odeslat na konzultaci na specializovaneâ ortodontickeâ pracovisï teï azpeï tneï se o vyâ sledek teâ to konzultace zajõâmat [3, 4]. Prvnõ seznam znakuê, naktereâ bysemeï l zubnõâ leâkarï beï hem preventivnõâ prohlõâdky zameï rïit, byl vytvorïen na celostaâ tnõâm sjezdu vsï ech vedoucõâch ortodontickyâch pracovisït' v roce 1957 ve Svratce. Tato smeï rnice, tzv. Svratecky program, obsahuje 9 zaâ kladnõâch boduê [5, 6]. Mezi anomaâ lie, ktereâ by nemeï ly byât v deï tskeâ m veï ku prïehlõâzï eny, muê zï eme podle odborneâ literatury zarïadit zkrïõâzïenyâ skus s nucenyâm vedenõâm, zaâ kus aobraâ cenyâ skus, prïevislyâ skus, otevrïenyâ skus, zlozvyky, vyâ raznou protruzi hornõâch rïezaâkuê, primaâ rnõâ steï snaâ nõâ, prïedcï asneâ ztraâ ty docï asnyâch zubuê, vyârazneâ diastema a poruchy erupce zubuê (hlavneï retence) [7, 8, 9, 10, 11]. Materia l a metodika DotaznõÂkove sï etrïenõâ bylo zameï rïeno napraktickeâ zubnõâ leâ ka rïe, jejichzï alesponï minimaâ lnõâ procento klientely tvorïõâ deï tsï tõâ pacienti. Osloveni byli zubnõâ leâkarïi ze vsï ech krajuê CÏ eskeâ republiky. PozÏa daâ no o spolupraâci prïi vyplneï nõâ dotaznõâkuê bylo 1150 zubnõâch leâkarïuê, tedy 14,5 % z celkoveâ ho pocïtuleâkarïuê, kteryâch bylo ke konci roku 2013 dle RocÏ enky LKS [12] evidovaâ no 7931. Celkovy soubor spraâ vneï vyplneï nyâ ch astatisticky pouzï i- telnyâch dotaznõâkuê v konecïneâ m soucï tu tvorïil 448 dotaznõâkuê, naâ vratnost dotaznõâkuê cï inõâ 36 %. DotaznõÂk obsahoval 24 otaâ zek, naktereâ zubnõâ leâ ka rïi odpovõâdali zcela anonymneï. U neï kteryâ ch z otaâ zek, bylo mozï neâ zvolit võâce odpoveï dõâ. DotaznõÂk byl vytvorïen v programu Google Chrome anaâ sledneï s pruê vodnõâm dopisem elektronicky rozeslaâ n nanaâ hodneï vybraneâ emailoveâ adresy zubnõâch leâkarïuê ze vsï ech 14 krajuê CÏ eskeâ republiky. SbeÏ r dat probeï hl v obdobõâ od zacïaâ tku cï ervence 2013 do konce listopadu 2013. KromeÏ zaâ kladnõâho zpracovaâ nõâ do tabulek a grafuê, byly z nejzajõâmaveï jsï õâch odpoveï dõâ vybraâny anaâ sledneï statisticky vyhodnoceny neï ktereâ hypoteâ zy. Ke statistickeâ mu zpracovaâ nõâ byl pouzï it statistickyâ software should take into account that in majority of patients there will be required the second phase of treatment during their adolescence. Well timed treatment thus may lower the problem severity, but it does not eliminate the need for intervention in permanent dentition [2]. The other view warns that a two-phased treatment may result in the exhaustion of both patients and their parents, in the prolongation of the treatment time, and in higher risk of tissue damage. The cooperation of orthodontist and pedodontist is an important aspect influencing the success of orthodontic treatment. General dentist or pedodontist should provide not only proper care of a children dentition, but also screening of individual orthodontic anomalies. In case of any deviation from physiological development, the child should be sent to orthodontic surgery in time, and the dentist should be provided the feedback [3,4]. The first list of traits that should be the focus of any routine check-up was set up in the national meeting of heads of orthodontic departments in Svratka in 1957. The directive, the so-called Svratka Programme (Svratecky program) included 9 basic points [5, 6]. Among the anomalies that should not be neglected in children there are crossbite with forced bite, anterior crossbite and reversed occlusion, cover bite, open bite, bad habits, strong protrusion of upper incisors, primary crowding, premature loss of temporary teeth, distinctive diastema, and problems in teeth eruption (especially impaction) [7, 8, 9, 10, 11]. Material and methods The questionnaire survey focused on dentists with aproportion of children among their clients. Dentists from all regions of the Czech Republic were addressed. We asked for cooperation 1150 dentists, i.e. 14.5% of all the dentists listed in LKS Statistical Yearbook of 2013 [12]; the total number of dentists was 7931 at that time. The sample of correctly filled in and statistically usable questionnaires included 448 forms, i.e. 36% of questionnaires were returned. There were 24 questions to be replied anonymously. In some questions it was possible to choose more options. The questionnaire was created in Google Chrome, and together with a cover letter it was sent via e-mail to randomly chosen addresses of dentists from the 14 regions of the Czech Republic. The data were collected from the beginning of July 2013 till the end of November 2013. The answers were processed and summed up in form of tables and charts; the most interesting replies were chosen and there were statistically evaluated some hypotheses based on the answers. Statistic software SPSS, version 15, SPSS Inc. Chicago USA was used. Charts were made in Microsoft Excel 2010. 229
Obr. 1. Procentua lnõâ zastoupenõâ deï tskeâ klientely Fig. 1. Proportion of children within dentists' clientele Obr. 2. Zhotovenõ OPG Fig. 2. OPG taking SPSS verze 15, SPSS Inc. Chicago USA. Grafy byly vytvorïeny v programu Microsoft Excel 2010. Vy sledky U 172 leâkarïuê (39,1 %) tvorïõâ deï ti 11-30 % klientely a55 leâkarïuê (12,5 %) odpoveïdeï lo, zïedeï ti v jejich praxõâch zastupujõâ võâce nezï 30 % klientely (Obr. 1). BeÏ hem preventivnõâch prohlõâdek sleduje ortodontickeâ anomaâ lie 96,2 % leâkarïuê, pouhyâch 2,3 % leâkarïuê sleduje ortodontickeâ anomaâ lie neï kdy a1,7 % leâkarïuê tuto problematiku prïehlõâzïõâuâ plneï. Naprosta veïtsï inazubnõâch leâkarïuê (99,5 %) maâ v dostupneâ vzdaâ lenosti (30 km) mozï nost konzultace cï i odeslaâ nõâ dõâteï te naortodontickeâ pracovisï teï. Naota zku, zdazubnõâ leâ karïi u dõâteï te zhotovujõâ z profylaktickyâch duê voduê OPG odpoveïdeï lo 436 leâkarïuê, z toho 100 leâkarïuê (22,3 % ) odpoveïdeï lo, zïe ano a zaâ rovenï uvedli veï k, ve ktereâ m zhotovenõâ rentgenu indikujõâ. DalsÏ õâch 285 leâkarïuê (65,4 %) zhotovuje OPG pouze v prïõâpadeï, kdy je to pro dõâteï prïõânosem a51 leâkarïuê (11,4 %) OPG z profylaktickyâch duê voduê nezhotovuje vuê bec (Obr. 2). MozÏnost uvedenõâ veïkudõâteï te, ve ktereâ m zubnõâ leâkarïi nejcï asteï ji indikujõâ zhotovenõâ OPG, vyuzï ilo celkem 100 leâkarïuê,zcï ehozï 41leÂkarÏuÊ (41 %) zadalo veï k 6 let dõâteï te, 15 leâkarïuê (15 %) odpoveïdeï lo, zï e OPG zhotovujõâv 7 av 8 letech dõâteïtea9leâkarïuê (9 %) OPG indikuje v 10 letech av 9 letech dõâteï te. JizÏ v 5 letech dõâteï te nechaâvaâ OPG zhotovit 5 leâkarïuê (5 %) adalsïõâch 5 leâkarïuê (5 %) poteâ zhotovuje OPG azï ve 12 letech dõâteï te. Pouze 1 leâkarï (1 %) uvedl, zïe OPG zhotovuje azï v 15 letech (Obr. 3). Naota zku, zdazubnõâ leâkarïi vysï etrïujõâ palpacõâ prïõâtomnost hornõâch sï picïaâkuê, odpoveïdeï lo celkem 420 leâkarïuê, z toho 229 leâkarïuê (54,5 % ) povazï uje toto vysï etrïenõâ za soucï aâ st preventivnõâ prohlõâdky a191 leâ karïuê (45,5 %) leâkarïuê uvedlo, zïe prïõâtomnost sï picï aâkuê nevysï etrïujõâ. Naota zku, kdy zubnõâ leâkarïi odesõâlajõâ deï tskeâho pacientase zkrïõâzï enyâ m skusem anucenyâ m vedenõâm na konzultaci k ortodontistovi, naprostaâ veï tsï inaz leâkarïuê (393 leâkarïuê, 87,7 %) uvedla, zï e odesõâlaâ jizï v docï asneâm Obr. 3. Zhotovenõ OPG podle veï ku pacienta Fig. 3. OPG according to patients' age Results In 172 dentists (39.1%) the proportion of childrenclients is between 11-30%; in 55 dentists (12.5%) the proportion of child patients is more than 30% (Fig.1). During routine check-ups 96.2% of dentists monitor orthodontic anomalies regularly, 2.3% sometimes, and 1.7% of dentists do not pay attention to orthodontic problems at all. Most dentists (99.5%) can send a child patient to orthodontic practice that is within reach (30 km). The question whether dentists make OPG in their child clients for prophylactic reasons was answered by 436 respondents. 100 dentists (22.3%) answered in positive and gave the age when they indicate OPG. 285 dentists (65.4%) make OPG only if a child benefits from it. 51 dentists (11.4%) do not make OPG for prophylactic reasons (Fig. 2). 100 respondents gave also the age of a child in which they usually indicate OPG: 41 dentists (41%) stated 6 years, 15 (15%) 7 and 8 years, 9 dentists (9%) indicated OPG at the age of 10 and 9, respectively. 5 (5%) respondents indicated OPG as early as in 5 year olds, and 5 dentists (5%) made the second OPG at the age of 12. Only one respondent (1%) made OPG as late as at the age of 15 (Fig. 3). The question whether dentists make palpation examination of upper canines presence was answered by 230
rocïnõâk23 Obr. 4. VyÂskyt nejcï asteï jsï õâch duê voduê k odeslaâ nõâ pacienta s vyâraznou protruzõâ hornõâch rïezaâkuê na konzultaci. a) fonetickyâ; b) prevence traumatu; c) zveï tsï enyâ inicizaâ lnõâ schuê dek; d) estetickyâ cï i psychologickyâ; e) prïõâtomnost hlubokeâ ho skusu Fig. 4. The most frequent reasons for orthodontic consultation in patients with strong protruded upper incisors; a) fonetic problems; b) trauma prevention; c) increased overjet; d) esthetic and/or psychological reasons; e) deep bite cï i smõâsï eneâ m chrupu apouhyâch41leâkarïuê (9,4 %) tento probleâ m rïesï õâ a zï po prorïezaâ nõâ staâ leâ ho chrupu. Jako nejcï asteï jsï õâ jednotlivyâ duê vod pro odeslaânõâ dõâteï te s vyâ raznou protruznõâ vadou na konzultaci, leâ ka rïi uvaâ deï li prïõâtomnost hlubokeâ ho skusu (275 leâ ka rïuê, 64 %), daâle duê vody estetickeâ cï i psychologickeâ (230 leâkarïuê, 53,5 %), zveï tsï enyâ incizaâ lnõâ schuê dek (137 leâ ka rïuê, 31,9 %), prevence traumatu (112 leâkarïuê, 26 %) cïiduêvod fonetickyâ (79 leâkarïuê, 18,4 %) (Obr. 4). V prïõâpadeï zjisï teï nõâ otevrïeneâ ho skusu, z jednotlivyâch postupuê 333 leâkarïuê (76,2 %) nejcï asteï ji volilo variantu, zï e sledujõâ, zdanenõâ duê vodem prïõâtomnyâ zlozvyk. Ostatnõ mozïneâ postupy jsou uvedeny v Obr. 5. Naota zku, jak zubnõâ leâkarïi postupujõâ u pacienta s prïevislyâ m skusem, naprostaâ veï tsï inaleâ ka rïuê (371 leâkarïuê, 85,9 %) odpoveï deï la, zï e odesõâlaâ nakonzultaci k ortodontistovi jizï ve smõâsï eneâ m chrupu. PouhyÂch 61 leâ ka rïuê (14,1 %) nepovazï uje zanutneâ tuto anomaâ lii odeslat na konzultaci k ortodontistovi. Naota zku, zdazubnõâ leâ ka rïi navsï teï vujõâ odborneâ ortodontickeâ kurzy cïiprïednaâsï ky, 284 z nich (65 %) uvedlo, zïe neï kdy, 98 leâkarïuê (22,4 %) takoveâ kurzy nenavsïteïvuje a55 leâkarïuê (12,6 %) se o odbornou ortodontickou teâ matiku zajõâmaâ aktivneï. Diskuse Vza jemnaâ spolupraâ ce obou stomatologickyâ ch oboruê ortodoncie apedostomatologie je pro uâ speï sï nou profylaxi, zachycenõâ a prïõâpadnou leâcï bu ortodontickyâch anomaâ liõâ naprosto nezbytnaâ. VhodnyÂm prïedpokladem tohoto uâ speï chu je i ochotaobou oboruê zajõâmat se nejen o sveâ primaâ rnõâ zameïrïenõâ, ale i o noveâ metody, postupy aproblematiku jinyâ ch stomatologickyâ ch odveï tvõâ. PoteÏsÏ ujõâcõâ je, zï e 65 % leâkarïuê odpovõâdajõâcõâch na otaâ zku, zda se zajõâmajõâ a navsïteï vujõâ kurzy s ortodontickou teâmatikou, odpoveïdeï lo, zïeneï kdy ano. Podstatnou podmõânkou spolupraâ ce je dostupnost ortodontickeâ peâ cï e v daneâ oblasti. Na otaâ zku, zdamajõâ zubnõâ leâ ka rïi mozï nost odesõâlaâ nõâ akonzultace s ortodontistou maximaâ lneï do vzdaâ lenosti 30 km, 99,5 % leâkarïuê odpoveï deï lo, zï e ano. Stejny vyâ sledek prezentovala Kli- Obr. 5. VyÂskyt postupuê u dõâteï te s otevrïenyâm skusem. a) s odeslaânõâm nakonzultaci k ortodontistovi vycï kaâ vaâ m do obdobõâ staâ leâ ho chrupu; b) povazïuji zanutneâ leâcï it co nejdrïõâve aodesõâlaâ m ihned po zjisïteïnõâ k ortodontistovi; c) sleduji, zdase stejnaâ anomaâ lie nevyskytuje i u rodicï uê ; d) odesõâlaâ m nakonzultaci; e) sleduji, zdanenõâ duê vodem prïõâtomnyâ zlozvyk Fig. 5. Way of management in children with open bite. a) I wait till permanent dentition to send to orthodontist; b) I consider to treat early and I send immediately to orthodontist; c) I follow if the same anomaly is in parents; d) I send to consultation; e) I observe whether a bad habit is the reason 420 dentists. 229 respondents (54.5%) consider the examination an integral part of a routine check-up, 191 respondents (45.5%) said they did not check the canines presence. The question whether dentists send achild patient with crossbite and forced bite to orthodontic practice was answered as follows: majority of them (393, i.e. 87.7%) send children even with deciduous or mixed dentition to an orthodontic department. Only 41 dentists (9.4%) deal with the problem only after permanent dentition erupts. Among the most frequent reasons for orthodontic consultation in case of children with strong protrusion are the following: deep bite (257 dentists, i.e. 64%), esthetic and/or psychological reasons (230 dentists, i.e. 53.5%), increased overjet (137 dentists, i.e. 31.9%), trauma prevention (112 dentists, i.e. 26%), or phonetic problems (79 dentists, i.e. 18.4%) (Fig. 4). In case of open bite, 333 dentists (76.2%) observed whether a bad habit is the reason for the anomaly. Other approaches are given in Fig. 5. Majority of dentists (371, i.e. 85.9%) said that patients with cover bite are sent to orthodontic practice as early as in mixed dentition. Only 61 respondents (14.1%) do not consider the orthodontic consultation necessary. The question whether dentists attend orthodontic workshops or lectures was answered as follows: 284 dentists (65%) sometimes, 98 dentists (22.4%) never, 55 dentists (12.6%) take active part in instructions on orthodontic problems. Discussion Cooperation of orthodontist a pedodontist is necessary for succesful prophylaxis, timely detection and possible treatment of orthodontic anomalies. Both areas - orthodontics as well as pediatric dentistry - should be interested not only in their primary focus, 231
mesï ovaâ [4]. Naza kladeï jejõâho dotaznõâku maâ ortodontistu v dostupneâ vzdaâ lenosti (20 km) 94 % dotaâ zanyâchleâkarïuê. V dotaznõâku naâ s zajõâmalo, jakeâ je procentuaâ lnõâ zastoupenõâ deï tskeâ klientely v praxõâch zubnõâch leâkarïuê. ZvyÂsledkuÊ sï etrïenõâ lze konstatovat, zïe u nejveïtsï õâho pocï tu odpovõâdajõâcõâch leâkarïuê (172 leâkarïuê ) tvorïõâ deï ti maximaâ lneï trïetinu klientely. Te meï rï stejnyâ pocï et leâ ka rïuê (147) maâ zastoupenõâ deï tskeâ klientely pouhyâ ch 6-10%. KontroverznõÂm teâ matem je, zda u deï tõâ z profylaktickyâch duê voduê nechaâ vat zhotovit rentgen OPG cï i takto cï init pouze v prïõâpadeï podezrïenõâ naurcï itou odchylku. Natuto otaâ zku v dotaznõâku veïtsï inaleâkarïuê (285) odpoveï deï la, zï e OPG zhotovuje pouze, je-li to pro dõâteï prïõânosem, 100 leâkarïuê, kterïõâ zhotovujõâ OPG z profylaktickyâch duê voduê,zaâ rovenï uvedlo veï k dõâteï te. NejcÏ asteï ji zubnõâ leâkarïi zhotovujõâ OPG z profylaktickyâch duê voduê udeïtõâve veï ku mezi 6-8 lety. Stejnou otaâ zkou se ve sveâ atestacï nõâ praâ ci zabyâvala i KlimesÏ ovaâ [4]. Z vyâsledkuê jejõâho dotaznõâkoveâ ho sï etrïenõâ vyplyâvaâ, zï e 22,8 % leâ ka rïuê zhotovuje OPG v prvnõâ faâzivyâmeï ny chrupu, 17,9 % leâkarïuê takto cï inõâ ve 2. faâ zi smõâsï eneâ ho chrupu acelkem 50 % leâkarïuê zhotovuje OPG pouze v prïõâpadeï,zïe maâ dõâteï neïjakyâ probleâm. DalsÏ õâ anomaâ liõâ, kterou je nutneâ vcï as odhalit a leâcïitje retence staâlyâch rïezaâkuê a sï picï aâkuê. Dle neï kolikastudiõâ, bylo chybeïnõâcï i retence hornõâho rïezaâ ku uvaâdeï no jako vyâ znamnyâ faktor v porusï enõâ zubnõâ aoblicï ejoveâ estetiky ajako prïispõâvajõâcõâ faktor k poruchaâm rïecï i [13]. CõÂlem vcï asneâ leâcï by retinovaneâhorïezaâ ku je eliminace funkcïnõâch aestetickyâ ch probleâ muê, zpuê sobenyâ ch neprorïezanyâm zubem [14]. Ponecha nõâ retinovaneâhosï picïaâ ku bez leâcïby cï i jineâ ho, i kdyby kompromisnõâho rïesï enõâ, muêzïe zpuê sobit rïadu komplikacõâ. Zubnõ leâkarï by meï l sledovat symetrii prorïezaâ vaâ nõâ anaerupci druhostranneâ ho zubu vycïkaâ vat maximaâ lneï 3-6meÏsõÂcuÊ. V 9 letech veïkudõâteï te by meï la byâ t nedõâlnou soucï aâ stõâ preventivnõâ prohlõâdky palpace prïõâtomnosti symetrickeâ ho vyklenutõâ alveolu v hornõâm vestibulu. Z celkoveâ ho pocï tu odpovõâdajõâcõâch leâkarïuê jich 229 (54,5 % ) prïõâtomnost sï picï aâkuê vysï etrïuje a191 leâkarïuê (45,5 %) nikoliv. Mnoho otaâ zek v dotaznõâku bylo zameï rïeno nakonkreâ tnõâ anomaâ lie. ZkrÏõÂzÏ enyâ skus s nucenyâm vedenõâm patrïõâ mezi anomaâ lie, u kteryâ ch se doporucï uje zahaâ jit leâcï bu co nejdrïõâve. Mezi mozïneâduê sledky neleâcï eneâho zkrïõâzï eneâ ho skusu patrïõâ naprïõâklad posturaâ lnõâ probleâ my, trvalyâ posun dolnõâ cï elisti v duê sledku asymetrickeâ svaloveâ aktivity cïi muêzï e mõât trvalyâ dopad na ruêst avyâvoj zubuê a cï elistõâ anaâ sledneâ asymetrie [15, 16]. VeÏ tsï inaleâkarïuê povazïuje (87,7 %) zanutneâ odeslat a rïesï it tuto anomaâ lii jizï v docï asneâmcï i smõâsï eneâ m chrupu. Ostatnõ leâkarïi (41, 9,2 %) sdõâlejõâ naâ zor, zïe tuto anomaâ lii postacïõâ odeslat a leâcïitazï po prorïezaâ nõâ staâleâ ho chrupu. V prïõâpadeï ponechaâ nõâ protruze hornõâch rïezaâ kuê bez zaâ sahu se mohou vyskytnout fonetickeâ, funkcïnõâcï i pabut also in new methods, approaches and problems of other areas of dentistry. The positive outcome is that 65% of dentists are interested and sometimes take part in workshops, etc., focused on orthodontic issues. The important condition of cooperation is the availability of orthodontic care in the given locality. 99.5% of respondents stated that an orthodontic practice is within 30 km from their office. The same result was reported by KlimesÏ ovaâ [4]: 94% of respondents had an orthodontic practice within 20 km from their office. We asked about the proportion of child clients in dentists' offices. In most respondents (172) the proportion was up to one third. Almost the same number of respondents (147) gave 6-10%. There is acontroversy in whether to take OPG for prophylactic reasons or whether to take it only when there is an anomaly suspected. Most respondents (285) opt for OPG only in case a child benefits from it; 100 dentists taking OPG for prophylaxis gave the age of the child patients - the most frequent being 6-8 years. The same problem was solved by KlimesÏ ovaâ in her postgraduate diploma dissertation [4]. Her findings are the following: 22.8% of dentists take OPG during the first phase of dentition change, 17.9% during the second phase of mixed dentition, and 50% of dentists decide for OPG only in case a child patient has a problem. Another anomaly requiring timely detection and treatment is impaction of permanent incisors and canines. Several studies cite missing upper incisor as the important factor disturbing dental as well as facial esthetics, and as the factor contributing to impaired speech [13]. The aim of timely treatment of impacted incisors is to eliminate emotional involvement of the child due to functional and esthetic problems caused by amissing tooth [14]. To neglect the condition may result in anumber of complications. A dentist should observe symmetry of teeth eruption and wait for the eruption of the opposite counterpart for the maximum of 3-6 months. In nine year olds the palpation of symmetric convexity of upper alveolus should be an integral part of a routine check-up. 229 respondents (54.5%) examine the canines presence, 191 (45.5%) do not make this examination. A number of questions focused on individual anomalies. Lateral crossbite with forced bite belongs to anomalies that should be treated as early as possible. The consequence of neglected crossbite include postural problems, permanent shift of the mandible due to asymmetry of muscles activity, permanent impact on teeth and jaws growth and development, and the resulting asymmetry [15,16]. Majority of dentists 232
rocïnõâk23 rodontologickeâ probleâ my. Da le je nutneâ myslet napsychologickyâ aestetickyâ aspekt teâ to anomaâ lie. Velmi podstatnyâm duê vodem k leâcïbeï poteâ muêzïe byât i nebezpecï õâ uâ razu vykloneï nyâ ch rïezaâ kuê. DõÂteÏ s vyâ raznou protruzõâ rïezaâ kuê je k ortodontistovi praktickyâ m zubnõâm leâkarïem odesõâlaâ no hlavneï z duê vodu hlubokeâ ho skusu a z duê vodu estetickeâ ho apsychickeâ ho dopadu teâ to anomaâ lie nadõâteï (Obr. 4). Ponecha nõâ otevrïeneâ ho skusu bez leâcï by s sebou nese mnohaâ rizikav podobeï mozï nyâ ch budoucõâch zï vyâkacõâch a fonacï nõâch probleâ muê, estetickyâ ch probleâ muê cï i v dopadu na sebeveï domõâ pacienta [17]. Dy chaâ nõâ uâ sty prïi stavu neustaâ le otevrïenyâchuâ st, muêzïedaâ le zpuê sobit onemocneï nõâ krku cï i zaâneï ty hltanu. VeÏ tsï inaleâkarïuê (76,2 %) se shodla, zïe u teâ to anomaâ lie je nutneâ paâ trat po mozïneâ m zlozvyku azaâ rovenï odeslat dõâteï nakonzultaci na ortodoncii (Obr. 5). PrÏevisly skus Angle definoval jako distaâ lnõâ polohu dolnõâ cï elisti, nedostatecï nyâ vertikaâ lnõâ ruê st oblasti pod nosem aexcesivnõâ hloubku skusu. V takoveâmprïõâpadeï stolicï ky nemohou dostatecï neï prorïezat do sveâ normaâ lnõâ deâ lky, dolnõâ rïezaâ ky poteâ mohou prïijõât do styku s gingivou napatrïe ainciznõâ hrany hornõâch rïezaâkuê prïesahujõâ gingivaâ lnõâ hranici rïezaâkuê dolnõâch [18]. U pacientamuê zï e dochaâ zet k patologickeâ mu zranï ovaâ nõâ uâ ponu gingivy u dolnõâch frontaâ lnõâch zubuê a naâ sledneï k ruê znyâ m parodontopatiõâm a chronickyâ m zaâ neï tuê m [19]. VeÏtsÏ inazubnõâch leâkarïuê (83 %) povazïuje zanutneâ leâcï it tuto anomaâ lii jizï ve smõâsï eneâ m chrupu. ZaÂveÏr Naza kladeï na sï eho sï etrïenõâ bylo zjisï teï no neï kolik zajõâmavyâ ch skutecï nostõâ. NaprÏõÂklad rentgenoveâ vysï etrïenõâ ve smyslu OPG mnoho leâkarïuê indikuje pouze v prïõâpadeï, zï e maâ podezrïenõâ namozï nou odchylku cï i problematika vysï etrïovaânõâ prïõâtomnosti sï picï aâkuê v hornõâm vestibulu, ktereâ nebyâvaâ rutinnõâ soucï aâ stõâ preventivnõâ prohlõâdky dõâteïteveveï ku okolo 9. roku. PozitivnõÂje, zïeveïtsï inaleâkarïuê vzïdybeï hem vysï etrïenõâ sleduje i ortodontickeâ anomaâ lie. Mnoho leâkarïuê si uveï domuje maximaâ lnõâ cï asovyâ odstup pro vycï kaâ vaâ nõâ v prïõâpadeï neprorïezaâ nõâ druhostranneâ ho zubu. PrÏi prïedcï asnyâch ztraâtaâ ch docï asnyâch molaâruêcïi sï picï aâkuê, leâkarïi znajõâ riziko posunu sousednõâch zubuê do mezery cï i mozïnyâprïesun strïedu zubnõâho oblouku. Vza jemnaâ spolupraâ ce nejen stomatologickyâ ch oboruê je pro zdravyâ vyâ voj aplnou funkci zï vyâ kacõâho systeâmu dõâteï te nezastupitelnaâ. DeÏ ti jsou nedõâlnou soucï aâ stõâ populace, je trïebase jejich specifickyâ mi probleâ my zabyâvat v plneâ m rozsahu a vcï asnyâm zaâ chytem ortodontickyâ ch anomaâ liõâ prïedchaâ zet mozï nyâ m komplikacõâm vyplyâvajõâcõâm z jejich pozdnõâ leâcï by. AutorÏi nemajõâ komercï nõâ, vlastnickeâ nebo financï nõâ zaâ jmy na produktech nebo spolecï nostech popsanyâ ch v tomto cïlaâ nku. (87.7%) believe that the anomaly should be solved as early as in deciduous or mixed dentition. The rest (41, i.e.9.2%) conclude that the anomaly may be treated only after eruption of permanent dentition. Untreated upper incisors protrusion may result in phonetic, functional or periodontal problems. We should also bear in mind psychological and esthetic aspects of this anomaly. The risk of injury of protruded incisors is one of the most essential reasons of treatment. Children with distinctive protrusion of incisors are sent to orthodontic practices especially due to deep bite, and for esthetic and psychological impact on achild (Fig. 4). Neglected open bite may lead to masticatory and phonetic problems in the future, as well as to esthetic problems that may affect patient's self-confidence [17]. Mouth breathing, when the mouth is always open, may lead to sore throat and pharyngitis. Most dentists (72.6%) agreed on that in case of this anomaly it is necessary to find out whether a bad habit is not the cause, and to send a child to an orthodontic practice (Fig. 5). Angle defined cover bite as a distal position of the mandible, insufficient vertical growth of the area under the nose, and excessive overbite. Molars cannot erupt to their normal length, lower incisors may touch the gingiva on the palate, and incisal edges of upper incisors exceed gingival level of lower incisors [18]. Gingival ligament of lower anterior teeth may be pathologically damaged, which may lead to various periodontal problems and chronic inflammations [19]. Majority of dentists (83%) believe the anomaly should be solved as early as in mixed dentition. Conclusion Our survey proved several interesting facts. E.g. OPG is indicated by many dentists only in case an anomaly is suspected; examination of upper canine's presence is not an integral part of a routine check-up of children around the age of 9. The good news is that most dentists pay attention to orthodontic anomalies. A lot of them are aware of the maximum time gap between the eruption of atooth and its opposite counterpart. In case of premature loss of deciduous molars or canines, the dentists know about the risk of shift of adjacent teeth into the space, or about possible shift of the dental arch centre. Cooperation of different specialists is indispensable for healthy development and fully functional masticatory system of a child. Children make the integral part of population, therefore it is necessary to focus on their specific problems and through timely identification of orthodontic anomalies prevent their potential complications. The authors have no commercial, proprietary or financial interest in products or companies mentioned in the article. 233
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