Refers to treatment that precedes the
conventional treatment protocol in which
brackets and bands are placed on teeth.
Begins during primary or transitional dentition
period so as to intercept malocclusion in a
manner that will lead to a better, more stable
result than that which would be achieved by
starting treatment later.
Goal is to reduce time and complexity of fixed
1) Posterior and anterior crossbites - Not only for the
functional improvement brought about by therapy but
also for the improved esthetics that occurs with the
anterior crossbite correction .
2) Ankylosed teeth seldom self-corrects , best not to treat
this condition too early because space maintenance will
usually be needed for several months or even years.
By the time the companion permanent tooth on the
opposite side of the mouth is ready to erupt, the
ankylosed tooth should be extracted and the underlying
permanent tooth uncovered if necessary.
3) Excessive protrusions and diastemas that
invite injury or avulsions need treatment at an
early age to avoid permanent damage to the
4) Severe anterior and lateral open bites are
often found accompanied by digit or tongue
Failure to completely eradicate these anomalies
often leads to a lifetime of malocclusion that
eventually becomes impossible to treat without
the benefit of orthognathic surgery.
5) Ectopic molars are best treated when discovered.
Failure to address this problem early enough greatly
reduces the arch length for the permanent dentition.
6) Severe arch length discrepancies – Serial extraction
procedure can be initiated.
7) Patients with cleft palates
8) Pseudo Class III patients, Class III malocclusions that
are true maxillary retrusions are probably best handled
during the mixed dentition stage because osseous
tissues are best modified during the times when rapid
growth is occurring.
As suggested by Gianelly, (AJO 1995) the
late mixed dentition offers the best time for
intervention for several reasons:
a) The E space still exists.
b) Approximately 80% of the patients are
still treatable by nonextraction.
c) The treatment can be completed in one
d) The orthodontist can still capitalize on
Graber (1966) defined it as the action
taken to preserve the integrity of what
appears to be a normal occlusion at a
Proffit & Ackerman (1980) has defined it
as prevention of potential interference with
Maintaining the integrity of deciduous
teeth and occlusion forms one of the most
important steps in preventive orthodontics.
Some procedures and concept of
preventive and interceptive orthodontics
are common but the time of application
pertaining to the stage of dental
development are different.
Council on Orthodontic Education of the
American Association of Orthodontists has
defined it as that phase of science & art of
orthodontics employed to recognize & eliminate
potential irregularities & malpositions in
Corrective measures may be necessary to
prevent a potential irregularity from progressing
into a more severe malocclusion.
1) Caries control.
2) Parent counselling.
3) Space maintenance.
4) Abnormal frenal attachments.
5) Treatment of locked first molars.
6) Abnormal oral musculature & related habits.
7) Others – Care of deciduous teeth, timing of
Extraction of supernumerary
1) Serial extraction.
2) Space regaining.
3) Correction of anterior & posterior crossbites.
4) Oral habits elimination.
5) Muscle exercises.
6) Removal of soft or hard tissue impediments to
path of eruption.
7) Resolution of crowding
8) Interception of developing skeletal
CARIES CONTROL - Proximal caries if
not restored is main cause of
malocclusion. Leads to loss of arch length,
thereby resulting in lesser space for
succedaneous teeth to erupt in right
position. Fluoride mouth rinses can be
PARENTAL COUNSELLING – Most
neglected but most effective method to
practice preventive orthodontics.
Divided into – A) Prenatal Counselling –
Importance of oral hygiene conveyed to
B) Postnatal Counselling – Can be
associated with clinical examination of
child at 1) 6 months to 1yr of age.
2) 2 yrs of age.
3) 3 yrs of age.
4) 5 – 6 yrs of age.
The process of maintaining the space in a
given arch, previously occupied by a tooth
or a group of teeth.
It is appropriate only when adequate
space is available & all unerupted teeth
are present and at proper stage of
development. If there is not enough space
or if succedaneous teeth are missing,
space maintenance alone is inadequate.
Fixed or removable appliances designed to
preserve the space created by the premature
loss of a deciduous tooth
Appliances used to maintain space or regain
minor amounts of space lost, so as to guide the
unerupted tooth into a proper position in the arch
Best space maintainer ??? Natural tooth with
proper mesio distal width
Objectives of Space Maintenance
Preserve space created by premature loss
Preserve integrity of dental arch
Preserve normal occlusion
Aid in phonetics
Prevent abnormal habits
Ideal Requirements of Space
Simple, sturdy, easy construction
Occupy less space
Removable space maintainers
Can be removed by patients
Functional or nonfunctional
Abutments have poor strength and health
Multiple loss of deciduous teeth
Lack of patient cooperation
Fixed space maintainers
Bonded or cemented
Cannot be removed by patient
Non functional or functional.
Ex – Band & loop, Crown & loop, Nance
holding arch, Transpalatal arch, Lingual
Band and Loop Space Maintainer
Unilateral, fixed, non
Indicated in unilateral loss
of single posterior
deciduous tooth with
High caries activity
Risk of decalcification
Nance Palatal Arch
Maxillary lingual arch
palate, not teeth
Bilateral loss of
Extends from one maxillary molar along contour
of palate to molar on opposite side.
Made from .036 inch stainless steel wire.
Main function – To prevent mesial migration of
Prevents molar rotation
Lingual arch space maintainer
[Fixed, Non functional, passive]
Control anteroposterior movements
Prevents arch perimeter distortion
Prevents lingual collapse of anteriors
Bilateral loss of single / multiple posterior teeth
in the lower arch after eruption of permanent
Minor tooth movement
Should not interfere with normal occlusal
development / adjustments
Should not cause stress on adjacent teeth or
interfere with their eruption
Maintain individual functional movement of each
Simple, sturdy, easy to construct and less space
Should not restrict normal growth of arches or
Distal Shoe Space Maintainer
Loss of ‘E; before
eruption of ‘6’
Abnormal frenal attachments
Presence of thick & fleshy maxillary labial
frenum – MIDLINE DIASTEMA.
Blanch test helps in diagnosing a thick
Presence of ankyloglossia or tongue tie
prevents normal functions of tongue –
abnormalities in speech & swallowing.
Should be surgically treated to prevent full
Exfoliation of deciduous teeth
Deciduous teeth should exfoliate in about
3 months of exfoliation of one in
Delay ,than rule out – Over retained teeth,
fibrous gingiva, ankylosed teeth,
Supernumerary teeth should be
immediately removed – can lead to
ectopic eruption of permanent teeth.
l Space created because of extraction of
ankylosed teeth should be maintained till
eruption of succedaneous teeth.
l Locked Permanent first molars -
Permanent first molars may get locked
beneath distal bulge of 2nd deciduous
molars at times, Slight distal stripping of
teeth allows the permanent first molar to
erupt in right place.
Normal in developing dentition, till permanent
maxillary canines have erupt. If persist after that
determine the underlying cause which could beFibrous attachment of labial frenum, Mesiodens,
Midline cysts, Habits, Microdontia.
Removal of causative factor can close the space
on its own or a removable appliance can be
used where autonomous closure of space is not
Abnormal Oral habits
In the orthodontic sense refers to certain actions
involving the teeth & other oral or perioral
structures which are repeated often enough by
some patients to have a profound & deleterious
effect on positions of teeth & occlusion.
Can effect growth of jaws also. Ex – Constriction
of maxilla, downward & backward growth of
Common oral habits include mouth breathing,
tongue thrusting, thumb sucking, lip sucking etc.
Studies have linked the development of
class II malocclusions to these habits.
Lead to an imbalance in forces acting on
teeth, causing development of
Lead to abnormal functioning of tongue,
aberrant lip & perioral musculature,
development of unfavorable V shape &
high palatal arches.
Can be obstructive due to nasal obstruction like
nasal polyps, deviated nasal obstruction,
Can be habitual also.
It affects the orofacial equilibrium due to lowered
mandibular & tongue posture – LONG FACE.
Interceptive procedure – Identification & removal
Habitual mouth breathing – Use of oral screen.
Defined as placement of tongue tip
forward between the incisors during
Clinically presents as open bite & anterior
Should be intercepted using habit
breaking appliances. Patient should be
trained & educated on correct technique of
Tongue exercises – To correct aberrant
tongue swallow patterns.
a) Elastic placed on tip of tongue & patient
is asked to raise it to rugae area &
b) 2 elastics are placed on dorsum of
c) Elastic is placed ,patient is told to hold
tongue on a spot over a definite period of
time with lips closed.
Normal till 2 – 3 yrs.
If persist, malocclusion characterized by
flared & spaced maxillary incisors, anterior
open bite,& narrow upper arch is likely to
Habit breakers could be of removable type
or fixed type.
Vaishali Prasad, A.K.Utreja ( JCO 2005)
have found oral screen to be highly
effective in intercepting lip sucking habits
in young child.
Planned & sequential extraction of certain
teeth is undertaken to intercept a
developing arch length deficiency in order
to avoid the need for extensive orthodontic
Hotz, Kjellgren,Nance, Dewel, Tweed
popularized serial extraction.
Instituted when patient is about 8 yrs of
Indications – 1) Arch length tooth size
discrepancy with one of the following features :
a) Absence of physiologic spacing.
b) Ectopically erupted teeth.
c) Mesial migration of buccal segment.
2) Skeletal class I malocclusion, straight profile.
3) Growth is not enough to overcome
Proffit cited a tooth size / arch length
discrepancy of 10mm or greater as
indication for serial extraction.
Ringenberg – Discrepancy of 7mm or
1) Spaced dentition.
2) Class II or III skeletal malocclusion.
3) Anodontia/ oligodontia.
4) Open bite / deep bite cases.
5) Mild arch length discrepancy.
A) Dewel’s Method –
1st step - extract deciduous canine to
create space for alignment of incisors.
2nd step – extract deciduous first molars.
3rd step – extract 1st premolars to permit
permanent canines to erupt.
B) Tweed’s method –
deciduous 1st molars
followed by extraction
of 1st premolars &
Problems & complications –
a) Ditching between canine & 2nd premolar
in mandibular arch.
b) Increased overbite may develop.
c) Excess space.
d) Congenital absence of 2nd premolar in
e) Impacted canines.
A study published by KINE (1975)
comparing patients who had undergone 1 st
premolar extraction as part of serial
extraction procedure followed by
orthodontic treatment & those who had
undergone first premolar extraction in
permanent dentition showed that serial
extraction group exhibited a substantially
smaller long term crowding.
If a primary molar is lost early & space
maintainers are not used, reduction in arch
length by mesial movement of 1st permanent
molar can be expected.
Space lost can be regained by distal movement
of first molar. Estimation of space lost can be
done by mixed dentition analysis.
Upto 3mm of space can be regained.
Space regaining procedures are preferably
undertaken prior to eruption of 2nd permanent
1 Gerber Space regainer – Consist of U shaped
hollow tubing, in which U shaped rod is inserted.
Tube is soldered on mesial aspect of molar to be
moved distally, base of rod contacting tooth
mesial to edentulous area.
Open coil springs are placed around free ends
of rod & inserted into tubing assembly. Forces
generated by compressed coil spring moves
2 Jack Screw – Helps to distalize molar,
thereby gaining space.
3 Cantilever Spring – By using removable
appliance that incorporate simple finger
4 Lip bumper – Uses muscular force
application to distalize molar & gain space.
5 Headgear – Frequently used to distalize
molars ,can gain space upto 3mm.In case
of unilateral space loss, asymmetric
facebow can be used.
Interception of Skeletal
Class I tooth arch size discrepancy – Early
mixed dentition ideal time, after eruption of
Class II malocclusion – Greater growth
response when treatment is initiated
during late mixed dentition.
Class III malocclusion – Immediately as
soon as detected. Early mixed dentition.
Tooth Arch Size discrepancy
Treatment Strategies – a) Serial extractions.
b) Orthopedic expansion.
c) Mandibular decompensation.
Orthopedic expansion: Cornerstone is RME.
Ideal transpalatal width is 33 – 35mm in mixed
dentition. In case of restricted width RME is
Aimed at overcorrection, so that maxillary arch is
in buccal crossbite with mandibular arch.
Passive expansion – When forces of buccal &
labial musculature are shielded from occlusion,
widening of dental arches occur. Ex- FR-2.
Mandibular dental decompensation – Done in
patients whose lower arches exhibit moderate
crowding, or anterior & posterior teeth are tipped
Appliances used – Schwarz appliance & Lip
By decompensating mandibular dental arch,
greater arch expansion of maxilla can be
Preserving leeway space – In his
experience, Gianelly has found that
management of leeway space alone can
resolve the crowding problems in more
than 80% of orthodontic patients.
Class II malocclusion
Primarily a sagittal & vertical problem.
Many cases have a strong transverse
Treatment Available - Extraoral traction,
arch expansion ,functional jaw
Extra oral traction – Most common for true
maxillary skeletal protrusion.
Cervical facebow most commonly used.
Numerous clinical studies (Kloehn 1953,
Wieslander 1975, McNamara 1996 ) have
shown that forward movement of maxilla
can be inhibited with use of headgear.
Functional Jaw Orthopedics – Appliances
most commonly used in case of
mandibular skeletal retrusion. Ex –
Activator, Bionator, FR, Twin block,
Herbst, Jasper Jumper.
All appliances have one thing in common,
they induce a forward mandibular
positioning. This alteration in the postural
activity of the muscles of craniofacial
complex ultimately leading to changes in
both skeletal & dental changes.
FR-2 particularly useful in patients with
significant neuromuscular imbalances
such as hyperactive mentalis, hypertonic
Expansion appliances – As most class II
malocclusions have tendency of posterior
crossbite, maxilla is overexpanded .This disrupts
It appears that patient become more comfortable
by positioning jaw forward, thus eliminating
tendency toward buccal crossbite & at same
time improving overall sagittal occlusal
Teeth themselves act as an endogenous
functional appliance, encouraging a change in
mandibular posture & ultimately change in
maxillomandibular occlusal relationship.
The effects of early preorthodontic trainer
treatment on Class II, division 1 patients
Usumez S (2004 )
The aim of this study was to clarify the
dentoskeletal treatment effects induced by a
preorthodontic trainer appliance treatment on
Class II, division 1 cases . Study demonstrates
that the preorthodontic trainer application
induces basically dentoalveolar changes that
result in significant reduction of overjet and can
be used with appropriate patient selection
Outcomes in a 2-phase randomized clinical trial of early Class II
Tulloch JF, Proffit WR, Phillips C. (Am J Orthod Dentofacial Orthop.
In a 2-phased, parallel, randomized trial of early
(preadolescent) versus later (adolescent) treatment for
children with severe (>7 mm overjet) Class II
Favorable growth changes were observed in about 75%
of those receiving early treatment with either a headgear
or a functional appliance. After a second phase of fixed
appliance treatment for both the previously treated
children and the untreated controls, however, early
treatment had little effect on the subsequent treatment
Early treatment also appears to be less
efficient, in that it produced no reduction in
the average time a child is in fixed
appliances during a second stage of
treatment, and it did not decrease the
proportion of complex treatments involving
extractions or orthognathic surgery
Effectiveness of early orthodontic treatment with the Twin-block
appliance: a multicenter, randomized, controlled trial. O'Brien K
(Am J Orthod Dentofacial Orthop. 2003)
The aims of this project were to evaluate
whether early orthodontic treatment with the
Twin-block appliance for the developing Class II
Division 1 malocclusion resulted in any
Results showed that early treatment with Twinblock appliances resulted in an increase in selfconcept and a reduction of negative social
Anteroposterior skeletal and dental changes after early
Class II treatment with bionators and headgear
Stephen D. Keeling (Am J Orthod Dentofacial Orthop1998)
In this study authors examined anteroposterior
cephalometric changes in children enrolled in a
randomized controlled trial of early treatment for Class II
malocclusion. Children, aged 9.6± 6 0.8 years at the
start of study, were randomly assigned to control (n=
581), bionator (n= 578), and headgear/biteplane (n
Cephalograms were obtained initially, after Class I
molars were obtained or 2 years had elapsed, after an
additional 6 months during which treated subjects were
randomized to retention or no retention and after a final 6
months without appliances.
Both bionator and head-gear treatments
corrected Class II molar relationships, reduced
overjet and apical base discrepancies, and
caused posterior maxillary tooth movement.
The skeletal changes, largely attributable to
enhanced mandibular growth in both headgear
and bionator subjects, were stable a year after
the end of treatment, but dental movements
Headgear versus function regulator in the early
treatment of Class II, Division 1 malocclusion: A
randomized clinical trial
J. Ghafari,F. S. Shofer, U. Jacobsson Hunt, D.
L. Markowitz, and L. L. Lasterb
A prospective randomized clinical trial was
conducted to evaluate the early treatment of
Class II, Division 1 malocclusion in prepubertal
children. Facial and occlusal changes after
treatment with either a headgear or a Frankel
function regulator were reported.
The results indicate that both the
headgear and function regulator were
effective in correcting the malocclusion.
Treatment in late childhood was as
effective as that in mid childhood. This
finding suggests that timing of treatment in
developing malocclusions may be optimal
in the late mixed dentition, thus avoiding a
retention phase before a later stage of
orthodontic treatment with fixed
Class III malocclusion
Goals include – a) To prevent progressive
irreversible soft tissue or bony changes.
Ex- Anterior crossbite.
b) To improve skeletal discrepancies &
provide a more favorable environment for
c) To improve occlusal function.
d) To simplify phase II comprehensive
treatment. Early treatment may eliminate
necessity for orthognathic surgery.
Indications & Contraindications
Turpin (1981) developed positive & negative
factors for deciding when to intercept a
developing class III malocclusion.
Positive factors – Good facial esthetics, mild
skeletal disharmony, no familial prognathism,
symmetric condylar growth, growing patients
with good cooperation.
Negative factors – Severe skeletal disharmony,
poor facial esthetics, asymmetric condylar
growth, growth complete..
Early treatment is considered for patient with
Chin Cup therapy – In relatively normal
maxilla, with protrusive mandible.
Provides growth inhibition or redirection &
posterior positioning of mandible.
To date there is no agreement in literature
as to whether chin cup therapy may or
may not inhibit the growth of mandible.
Stability of chin cup treatment remains
unclear, several investigators reported a
tendency to return to original growth
pattern after chin cup is discontinued.
Protraction facemask therapy – Where
maxillary deficiency is present.
Main objective of early treatment with
facemask therapy is to enhance forward
displacement of maxilla by sutural growth
Clinically anterior crossbite can be
corrected within 3 – 4 months of maxillary
expansion & protraction depending on
severity of malocclusion.
Effective in primary, mixed & early
permanent dentition. (Baccetti 1998, Ngan
Anterior Cross Bite
Should be intercepted & treated at an early age
so as to prevent a minor orthodontic problem
from progressing into a major dentofacial
“The best time to treat a crossbite is the first
time it is seen”.
Treatment – a) Use of tongue blade: Developing
single tooth crossbite can be successfully
treated. Used only if sufficient space is there for
tooth to be brought out.
Worn for 1- 2 hrs for 2 weeks
Catalan’s appliance / Lower anterior
inclined plane – Can treat a single tooth or
a segment of upper arch in cross bite.
It is designed to have a 45˚angulation
which forces maxillary teeth into a more
Use of double cantilever spring ( Z spring)
– Anterior crossbite involving 1 or 2 teeth.
Other than correcting functional shifts in primary
dentition by selective occlusal adjustment, it is
recommended that treatment be postponed until
early mixed dentition.
Treatment decision is made on case by case
basis & include consideration of following factors
– presence or absence of lateral mandibular
shift, degree of skeletal discrepancy, degree of
posterior tooth compensation in each arch
Most common is to separate midpalatal suture
with expansion appliance.
Even if transverse discrepancy results from
broad mandibular arch, it is better to expand
Other appliances – Quad helix, transpalatal
arch, crossbite elastics.
Unilateral Crossbite – A RME with reverse
crossbite elastics on non crossbite side in
conjunction with a lower lingual holding arch is
How much expansion? Mandibular arch
limits the amount of maxillary expansion
that can be achieved.
Expansion of arches beyond point where
mandibular molar crowns are upright is
inherently unstable & not recommended.
According to Little ( AJO 2002) arch
widening in mixed dentition without lifetime
retention yields unstable results.
Early Management of Impacted
Suggested preventive procedure for
canine impaction is early extraction of
corresponding deciduous canine.
Linduaer (JADA 1992) found a relation
between unerupted canine cusp tip &
lateral incisor as it appeared on mixed
dentition radiograph on basis of which it
can be said that canine will be impacted in
future or not.
Lateral incisor root on
OPG is divide into 4
modified method of
Ericson & Kurol.
Psychological influences on the timing of
orthodontic treatment (Asuman Kiyak AJO 98)
Psychologic development during the
preadolescent & adolescent stages may
influence the child's motive for, understanding of
& adherence to treatment regimen.
Children have reported that the appearance of
their teeth is a common target of teasing
.Overjet, extreme deep bite & crowding are
associated with most unfavorable self perception
Treatment during preadolescence is concerned
with adherence. Girls are more likely to adhere
to treatment recommendations than boys.
Preadolescents generally seek approval of
significant adult role models
( Parents, orthodontist), as a result more
compliant with removable appliance, adhere to
rules & routine established by adults.
Younger children are good candidates for Phase
I orthodontics, have high self-esteem and bodyimage, and expect orthodontics to improve their
Much misunderstanding of “preventive
orthodontics” and “interceptive orthodontics”
stems from the implication that “early” treatment
of malocclusion in children precludes the need
for later orthodontic treatment.
As facial and dental development continues
throughout childhood and adolescence the longterm impact of early treatment may not be
predicted. Yet early intervention may help
develop a normal occlusion and facial harmony.
1 Zahid Lalani, Ashima Valiathan -Interceptive
Orthodontics.JICD 1993 vol 33 (7-15).
2 Vaishali Prasad, A.K. Utreja – An oral screen
for early intervention in lower lip sucking habits.
JCO Feb 2005 vol 39 (97 -100).
3 Peter Ngan – Early timely treatment of class III
malocclusion. Semin.Orthod 2005, 11(140 –
4 Steven D Marshall, Thomas Southhard – Early
transverse treatment. Semin.Orthod 2005,
5 Peter Ngan, Bryan Weaver - Early timely
Management of ectopically erupting maxillary
canine. Semin.Orthod 2005, 11(152 -163).
6 G.Thomas Kleumper, Cynthia Beeman,
E.Preston Hicks – Early Orthodontic treatment:
What are the imperatives.? JADA 2000,131(613620).
7Usumez S, Uysal T, Sari Z, Basciftci FA,
Karaman AI - . The effects of early
preorthodontic trainer treatment on Class II,
division 1 patients. AJO 2004 Jul;126(1):2332.
8 Tulloch JF, Proffit WR, Phillips C.Outcomes in a 2-phase randomized clinical trial of
early Class II treatment. AJO 2004 Jun;125(6):657-67 .
9 Mantysaari R, Kantomaa T, Pirttiniemi P,
Pykalainen A - The effects of early headgear
treatment on dental arches and craniofacial
morphology: a report of a 2 year randomized
study .EJO 2004 Feb;26(1):59-64.
10 O'Brien K, Wright J, Conboy F, Chadwick S,
Connolly I, Cook P - Effectiveness of early
orthodontic treatment with the Twin-block appliance:
a multicenter, randomized, controlled trial. Part 2:
Psychosocial effects. AJO 2003 Nov;124(5):488-94
11 Larry White - Early orthodontic intervention.
AJO 1998 Volume 113, No. 1
12 Michael G. Arvystas - The rationale for early
orthodontic treatment. AJO 1998 Volume 113,
13 J. Ghafari, F. S. Shofer,b U. JacobssonHunt, D. L. Markowitz, L.Lasterb - Headgear
versus function regulator in the early treatment
of Class II, Division 1 malocclusion:A
randomized clinical trial. AJO 1998;113 (51-61.).
14 Stephen D. Keeling, Timothy T. Wheeler,
Gregory J. King, Cynthia W. Garvan Anteroposterior skeletal and dental changes
after early Class II treatment with bionators and
headgear. AJO 1998;113:(40-50.).
15 William R Proffit: Contemporary
Orthodontics.3 edtn, Mosby, St.Louis. Pg – 451
16 Thomas Graber, Robert Vanarsdall –
Orthodontics : Current Principles & techniques.
3rd edtn, Mosby St.Louis. Pg -521-557
17 Thomas P George, Valiathan Ashima,
Arji I George & Denny J Payyappilly:
Oral habits (Part II) Tongue thrusting.
Kerala Dental Association. 1992; 15(3 &
18 Gurkeerat Singh : Textbook of
orthodontics. 1st edtn, Jaypee, New Delhi.
Pg – 511– 532.
Leader in continuing dental education