Early and Interceptive orthodontic treatment

INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandental...
Indications
Rationale
Preventive orthodontic Procedures
Interceptive orthodontic Procedures
Intervention of Skeletal maloc...
EARLY TREATMENT
Refers to treatment that precedes the
conventional treatment protocol in which
brackets and bands are plac...
Indications
1) Posterior and anterior crossbites - Not only for the
functional improvement brought about by therapy but
al...
3) Excessive protrusions and diastemas that
invite injury or avulsions need treatment at an
early age to avoid permanent d...
5) Ectopic molars are best treated when discovered.
Failure to address this problem early enough greatly
reduces the arch ...
As suggested by Gianelly, (AJO 1995) the
late mixed dentition offers the best time for
intervention for several reasons:
a...
PREVENTIVE
ORTHODONTICS

INTERCEPTIVE
ORTHODONTICS

www.indiandentalacademy.com
PREVENTIVE ORTHODONTICS
Graber (1966) defined it as the action
taken to preserve the integrity of what
appears to be a nor...
Maintaining the integrity of deciduous
teeth and occlusion forms one of the most
important steps in preventive orthodontic...
INTERCEPTIVE ORTHODONTICS
Council on Orthodontic Education of the
American Association of Orthodontists has
defined it as ...
Preventive measures
1) Caries control.
2) Parent counselling.
3) Space maintenance.
4) Abnormal frenal attachments.
5) Tre...
Interceptive measures
1) Serial extraction.
2) Space regaining.
3) Correction of anterior & posterior crossbites.
4) Oral ...
CARIES CONTROL - Proximal caries if
not restored is main cause of
malocclusion. Leads to loss of arch length,
thereby resu...
Divided into – A) Prenatal Counselling –
Importance of oral hygiene conveyed to
parents.
B) Postnatal Counselling – Can be...
SPACE MAINTENANCE
The process of maintaining the space in a
given arch, previously occupied by a tooth
or a group of teeth...
Space Maintainers
Fixed or removable appliances designed to
preserve the space created by the premature
loss of a deciduou...
Objectives of Space Maintenance
Preserve space created by premature loss
Preserve integrity of dental arch
Preserve normal...
Ideal Requirements of Space
Maintainers
Simple, sturdy, easy construction
Occupy less space
Cost effective
Durable
Modifia...
Removable space maintainers
Can be removed by patients
Functional or nonfunctional
Indications –
Esthetic demands
Abutment...
www.indiandentalacademy.com
Fixed space maintainers
Bonded or cemented
Cannot be removed by patient
Non functional or functional.
Ex – Band & loop, Cr...
Band and Loop Space Maintainer
Unilateral, fixed, non
functional, passive
Indicated in unilateral loss
of single posterior...
www.indiandentalacademy.com
Nance Palatal Arch
Maxillary lingual arch
Approximates anterior
palate, not teeth
Indications:
Bilateral loss of
maxillary...
Transpalatal Arch
Extends from one maxillary molar along contour
of palate to molar on opposite side.
Made from .036 inch ...
www.indiandentalacademy.com
Lingual arch space maintainer
[Fixed, Non functional, passive]
Control anteroposterior movements
Prevents arch perimeter d...
www.indiandentalacademy.com
Should not interfere with normal occlusal
development / adjustments
Should not cause stress on adjacent teeth or
interfere...
Distal Shoe Space Maintainer
Intra alveolar
appliance
Molar guidance
appliance
Indication:
Loss of ‘E; before
eruption of ...
Contra indications –
Inadequate abutments
Poor oral hygiene or parent/ patient
cooperation
Medically compromised patients
...
Abnormal frenal attachments
Presence of thick & fleshy maxillary labial
frenum – MIDLINE DIASTEMA.
Blanch test helps in di...
Exfoliation of deciduous teeth
Deciduous teeth should exfoliate in about
3 months of exfoliation of one in
contralateral a...
l Space created because of extraction of

ankylosed teeth should be maintained till
eruption of succedaneous teeth.

l Loc...
Midline Diastema
Normal in developing dentition, till permanent
maxillary canines have erupt. If persist after that
determ...
Abnormal Oral habits
In the orthodontic sense refers to certain actions
involving the teeth & other oral or perioral
struc...
Studies have linked the development of
class II malocclusions to these habits.
Lead to an imbalance in forces acting on
te...
Mouth Breathing
Can be obstructive due to nasal obstruction like
nasal polyps, deviated nasal obstruction,
enlarged adenoi...
www.indiandentalacademy.com
Tongue thrusting
Defined as placement of tongue tip
forward between the incisors during
swallowing.
Clinically presents as...
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www.indiandentalacademy.com
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Tongue exercises – To correct aberrant
tongue swallow patterns.
a) Elastic placed on tip of tongue & patient
is asked to r...
Thumb Sucking
Normal till 2 – 3 yrs.
If persist, malocclusion characterized by
flared & spaced maxillary incisors, anterio...
Vaishali Prasad, A.K.Utreja ( JCO 2005)
have found oral screen to be highly
effective in intercepting lip sucking habits
i...
SERIAL EXTRACTION
Planned & sequential extraction of certain
teeth is undertaken to intercept a
developing arch length def...
Indications – 1) Arch length tooth size
discrepancy with one of the following features :
a) Absence of physiologic spacing...
Proffit cited a tooth size / arch length
discrepancy of 10mm or greater as
indication for serial extraction.

Ringenberg –...
Contraindications
1) Spaced dentition.
2) Class II or III skeletal malocclusion.
3) Anodontia/ oligodontia.
4) Open bite /...
Procedure
A) Dewel’s Method –
1st step - extract deciduous canine to
create space for alignment of incisors.
2nd step – ex...
www.indiandentalacademy.com
B) Tweed’s method –
Extraction of
deciduous 1st molars
followed by extraction
of 1st premolars &
deciduous canine.

www.in...
Problems & complications –
a) Ditching between canine & 2nd premolar
in mandibular arch.
b) Increased overbite may develop...
A study published by KINE (1975)
comparing patients who had undergone 1 st
premolar extraction as part of serial
extractio...
Space Regaining
If a primary molar is lost early & space
maintainers are not used, reduction in arch
length by mesial move...
Appliances used
1 Gerber Space regainer – Consist of U shaped
hollow tubing, in which U shaped rod is inserted.
Tube is so...
www.indiandentalacademy.com
2 Jack Screw – Helps to distalize molar,
thereby gaining space.
3 Cantilever Spring – By using removable
appliance that in...
www.indiandentalacademy.com
Interception of Skeletal
Malocclusion.

www.indiandentalacademy.com
Class I tooth arch size discrepancy – Early
mixed dentition ideal time, after eruption of
incisors.
Class II malocclusion ...
Tooth Arch Size discrepancy
Treatment Strategies – a) Serial extractions.
b) Orthopedic expansion.
c) Mandibular decompens...
Passive expansion – When forces of buccal &
labial musculature are shielded from occlusion,
widening of dental arches occu...
Preserving leeway space – In his
experience, Gianelly has found that
management of leeway space alone can
resolve the crow...
Class II malocclusion
Primarily a sagittal & vertical problem.
Many cases have a strong transverse
component.
Treatment Av...
Cervical facebow most commonly used.
Numerous clinical studies (Kloehn 1953,
Wieslander 1975, McNamara 1996 ) have
shown t...
All appliances have one thing in common,
they induce a forward mandibular
positioning. This alteration in the postural
act...
Expansion appliances – As most class II
malocclusions have tendency of posterior
crossbite, maxilla is overexpanded .This ...
www.indiandentalacademy.com
The effects of early preorthodontic trainer
treatment on Class II, division 1 patients
Usumez S (2004 )
The aim of this st...
Outcomes in a 2-phase randomized clinical trial of early Class II
treatment.
Tulloch JF, Proffit WR, Phillips C. (Am J Ort...
Early treatment also appears to be less
efficient, in that it produced no reduction in
the average time a child is in fixe...
Effectiveness of early orthodontic treatment with the Twin-block
appliance: a multicenter, randomized, controlled trial. O...
Anteroposterior skeletal and dental changes after early
Class II treatment with bionators and headgear
Stephen D. Keeling ...
Both bionator and head-gear treatments
corrected Class II molar relationships, reduced
overjet and apical base discrepanci...
Headgear versus function regulator in the early
treatment of Class II, Division 1 malocclusion: A
randomized clinical tria...
The results indicate that both the
headgear and function regulator were
effective in correcting the malocclusion.
Treatmen...
Class III malocclusion
Goals include – a) To prevent progressive
irreversible soft tissue or bony changes.
Ex- Anterior cr...
Indications & Contraindications
Turpin (1981) developed positive & negative
factors for deciding when to intercept a
devel...
Chin Cup therapy – In relatively normal
maxilla, with protrusive mandible.
Provides growth inhibition or redirection &
pos...
Protraction facemask therapy – Where
maxillary deficiency is present.
Main objective of early treatment with
facemask ther...
Anterior Cross Bite
Should be intercepted & treated at an early age
so as to prevent a minor orthodontic problem
from prog...
www.indiandentalacademy.com
Catalan’s appliance / Lower anterior
inclined plane – Can treat a single tooth or
a segment of upper arch in cross bite.
I...
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www.indiandentalacademy.com
Posterior Crossbite
Other than correcting functional shifts in primary
dentition by selective occlusal adjustment, it is
r...
Most common is to separate midpalatal suture
with expansion appliance.
Even if transverse discrepancy results from
broad m...
www.indiandentalacademy.com
How much expansion? Mandibular arch
limits the amount of maxillary expansion
that can be achieved.
Expansion of arches bey...
Early Management of Impacted
Canines
Suggested preventive procedure for
canine impaction is early extraction of
correspond...
Lateral incisor root on
OPG is divide into 4
sectors using
modified method of
Ericson & Kurol.

www.indiandentalacademy.co...
Psychological influences on the timing of
orthodontic treatment (Asuman Kiyak AJO 98)
Psychologic development during the
p...
Treatment during preadolescence is concerned
with adherence. Girls are more likely to adhere
to treatment recommendations ...
Much misunderstanding of “preventive
orthodontics” and “interceptive orthodontics”
stems from the implication that “early”...
REFERENCES
1 Zahid Lalani, Ashima Valiathan -Interceptive
Orthodontics.JICD 1993 vol 33 (7-15).
2 Vaishali Prasad, A.K. Ut...
5 Peter Ngan, Bryan Weaver - Early timely
Management of ectopically erupting maxillary
canine. Semin.Orthod 2005, 11(152 -...
8 Tulloch JF, Proffit WR, Phillips C.Outcomes in a 2-phase randomized clinical trial of
early Class II treatment. AJO 2004...
11 Larry White - Early orthodontic intervention.
AJO 1998 Volume 113, No. 1
12 Michael G. Arvystas - The rationale for ear...
14 Stephen D. Keeling, Timothy T. Wheeler,
Gregory J. King, Cynthia W. Garvan Anteroposterior skeletal and dental changes
...
17 Thomas P George, Valiathan Ashima,
Arji I George & Denny J Payyappilly:
Oral habits (Part II) Tongue thrusting.
Kerala ...
www.indiandentalacademy.com
Leader in continuing dental education

www.indiandentalacademy.com
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Early and interceptive orthodontic treatment /certified fixed orthodontic courses by Indian dental academy

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The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.

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Transcript of "Early and interceptive orthodontic treatment /certified fixed orthodontic courses by Indian dental academy "

  1. 1. Early and Interceptive orthodontic treatment INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
  2. 2. Indications Rationale Preventive orthodontic Procedures Interceptive orthodontic Procedures Intervention of Skeletal malocclusion www.indiandentalacademy.com
  3. 3. EARLY TREATMENT 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 appliance therapy. www.indiandentalacademy.com
  4. 4. Indications 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. www.indiandentalacademy.com
  5. 5. 3) Excessive protrusions and diastemas that invite injury or avulsions need treatment at an early age to avoid permanent damage to the dentition. 4) Severe anterior and lateral open bites are often found accompanied by digit or tongue habits. 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. www.indiandentalacademy.com
  6. 6. 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. www.indiandentalacademy.com
  7. 7. 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 phase. d) The orthodontist can still capitalize on growth. www.indiandentalacademy.com
  8. 8. PREVENTIVE ORTHODONTICS INTERCEPTIVE ORTHODONTICS www.indiandentalacademy.com
  9. 9. PREVENTIVE ORTHODONTICS Graber (1966) defined it as the action taken to preserve the integrity of what appears to be a normal occlusion at a specific time. Proffit & Ackerman (1980) has defined it as prevention of potential interference with occlusal development. www.indiandentalacademy.com
  10. 10. 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. www.indiandentalacademy.com
  11. 11. INTERCEPTIVE ORTHODONTICS 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 dentofacial complex. Corrective measures may be necessary to prevent a potential irregularity from progressing into a more severe malocclusion. www.indiandentalacademy.com
  12. 12. Preventive measures 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 exfoliation. Occlusal equilibration Extraction of supernumerary www.indiandentalacademy.com
  13. 13. Interceptive measures 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 malocclusion. www.indiandentalacademy.com
  14. 14. 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 prescribed. PARENTAL COUNSELLING – Most neglected but most effective method to practice preventive orthodontics. www.indiandentalacademy.com
  15. 15. Divided into – A) Prenatal Counselling – Importance of oral hygiene conveyed to parents. 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. www.indiandentalacademy.com
  16. 16. SPACE MAINTENANCE 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. www.indiandentalacademy.com
  17. 17. Space Maintainers 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 www.indiandentalacademy.com
  18. 18. Objectives of Space Maintenance Preserve space created by premature loss Preserve integrity of dental arch Preserve normal occlusion Preserve esthetics Aid in phonetics Prevent abnormal habits www.indiandentalacademy.com
  19. 19. Ideal Requirements of Space Maintainers Simple, sturdy, easy construction Occupy less space Cost effective Durable Modifiable Universal application www.indiandentalacademy.com
  20. 20. Removable space maintainers Can be removed by patients Functional or nonfunctional Indications – Esthetic demands Abutments have poor strength and health Multiple loss of deciduous teeth Contraindications – Lack of patient cooperation Acrylic allergy Epileptic patients www.indiandentalacademy.com
  21. 21. www.indiandentalacademy.com
  22. 22. 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 arch. www.indiandentalacademy.com
  23. 23. Band and Loop Space Maintainer Unilateral, fixed, non functional, passive Indicated in unilateral loss of single posterior deciduous tooth with distal abutment Contraindications Severe crowding High caries activity Risk of decalcification www.indiandentalacademy.com
  24. 24. www.indiandentalacademy.com
  25. 25. Nance Palatal Arch Maxillary lingual arch Approximates anterior palate, not teeth Indications: Bilateral loss of maxillary deciduous molars www.indiandentalacademy.com
  26. 26. Transpalatal Arch 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 molars. Prevents molar rotation Rigid www.indiandentalacademy.com
  27. 27. www.indiandentalacademy.com
  28. 28. Lingual arch space maintainer [Fixed, Non functional, passive] Control anteroposterior movements Prevents arch perimeter distortion Prevents lingual collapse of anteriors Indications – Bilateral loss of single / multiple posterior teeth in the lower arch after eruption of permanent anteriors Minor tooth movement Space regaining www.indiandentalacademy.com
  29. 29. www.indiandentalacademy.com
  30. 30. 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 tooth Simple, sturdy, easy to construct and less space occupying Should not restrict normal growth of arches or functions www.indiandentalacademy.com
  31. 31. Distal Shoe Space Maintainer Intra alveolar appliance Molar guidance appliance Indication: Loss of ‘E; before eruption of ‘6’ www.indiandentalacademy.com
  32. 32. Contra indications – Inadequate abutments Poor oral hygiene or parent/ patient cooperation Medically compromised patients – CHD, RF, DIABETES, HEMOPHILIA, GENERALISED DEBILITATION www.indiandentalacademy.com
  33. 33. Abnormal frenal attachments Presence of thick & fleshy maxillary labial frenum – MIDLINE DIASTEMA. Blanch test helps in diagnosing a thick frenum. Presence of ankyloglossia or tongue tie prevents normal functions of tongue – abnormalities in speech & swallowing. Should be surgically treated to prevent full fledged malocclusions. www.indiandentalacademy.com
  34. 34. Exfoliation of deciduous teeth Deciduous teeth should exfoliate in about 3 months of exfoliation of one in contralateral arch. Delay ,than rule out – Over retained teeth, fibrous gingiva, ankylosed teeth, supernumerary teeth. Supernumerary teeth should be immediately removed – can lead to ectopic eruption of permanent teeth. www.indiandentalacademy.com
  35. 35. 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. www.indiandentalacademy.com
  36. 36. Midline Diastema 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 expected. www.indiandentalacademy.com
  37. 37. 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 mandible. Common oral habits include mouth breathing, tongue thrusting, thumb sucking, lip sucking etc. www.indiandentalacademy.com
  38. 38. Studies have linked the development of class II malocclusions to these habits. Lead to an imbalance in forces acting on teeth, causing development of malocclusion. Lead to abnormal functioning of tongue, aberrant lip & perioral musculature, development of unfavorable V shape & high palatal arches. www.indiandentalacademy.com
  39. 39. Mouth Breathing Can be obstructive due to nasal obstruction like nasal polyps, deviated nasal obstruction, enlarged adenoids. Can be habitual also. It affects the orofacial equilibrium due to lowered mandibular & tongue posture – LONG FACE. Interceptive procedure – Identification & removal of cause. Habitual mouth breathing – Use of oral screen. www.indiandentalacademy.com
  40. 40. www.indiandentalacademy.com
  41. 41. Tongue thrusting Defined as placement of tongue tip forward between the incisors during swallowing. Clinically presents as open bite & anterior proclination. Should be intercepted using habit breaking appliances. Patient should be trained & educated on correct technique of swallowing. www.indiandentalacademy.com
  42. 42. www.indiandentalacademy.com
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  45. 45. Tongue exercises – To correct aberrant tongue swallow patterns. a) Elastic placed on tip of tongue & patient is asked to raise it to rugae area & swallow. b) 2 elastics are placed on dorsum of tongue. c) Elastic is placed ,patient is told to hold tongue on a spot over a definite period of time with lips closed. www.indiandentalacademy.com
  46. 46. Thumb Sucking Normal till 2 – 3 yrs. If persist, malocclusion characterized by flared & spaced maxillary incisors, anterior open bite,& narrow upper arch is likely to be present. Habit breakers could be of removable type or fixed type. www.indiandentalacademy.com
  47. 47. Vaishali Prasad, A.K.Utreja ( JCO 2005) have found oral screen to be highly effective in intercepting lip sucking habits in young child. www.indiandentalacademy.com
  48. 48. SERIAL EXTRACTION Planned & sequential extraction of certain teeth is undertaken to intercept a developing arch length deficiency in order to avoid the need for extensive orthodontic procedure. Hotz, Kjellgren,Nance, Dewel, Tweed popularized serial extraction. Instituted when patient is about 8 yrs of age. www.indiandentalacademy.com
  49. 49. 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 discrepancy. www.indiandentalacademy.com
  50. 50. Proffit cited a tooth size / arch length discrepancy of 10mm or greater as indication for serial extraction. Ringenberg – Discrepancy of 7mm or more. www.indiandentalacademy.com
  51. 51. Contraindications 1) Spaced dentition. 2) Class II or III skeletal malocclusion. 3) Anodontia/ oligodontia. 4) Open bite / deep bite cases. 5) Mild arch length discrepancy. www.indiandentalacademy.com
  52. 52. Procedure 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. www.indiandentalacademy.com
  53. 53. www.indiandentalacademy.com
  54. 54. B) Tweed’s method – Extraction of deciduous 1st molars followed by extraction of 1st premolars & deciduous canine. www.indiandentalacademy.com
  55. 55. 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 mandibular arch. e) Impacted canines. www.indiandentalacademy.com
  56. 56. 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. www.indiandentalacademy.com
  57. 57. Space Regaining 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 molar. www.indiandentalacademy.com
  58. 58. Appliances used 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 molar distally. www.indiandentalacademy.com
  59. 59. www.indiandentalacademy.com
  60. 60. 2 Jack Screw – Helps to distalize molar, thereby gaining space. 3 Cantilever Spring – By using removable appliance that incorporate simple finger springs. 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. www.indiandentalacademy.com
  61. 61. www.indiandentalacademy.com
  62. 62. Interception of Skeletal Malocclusion. www.indiandentalacademy.com
  63. 63. Class I tooth arch size discrepancy – Early mixed dentition ideal time, after eruption of incisors. 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. www.indiandentalacademy.com
  64. 64. 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 initiated. Aimed at overcorrection, so that maxillary arch is in buccal crossbite with mandibular arch. www.indiandentalacademy.com
  65. 65. 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 lingually. Appliances used – Schwarz appliance & Lip bumper. By decompensating mandibular dental arch, greater arch expansion of maxilla can be achieved. www.indiandentalacademy.com
  66. 66. 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. www.indiandentalacademy.com
  67. 67. Class II malocclusion Primarily a sagittal & vertical problem. Many cases have a strong transverse component. Treatment Available - Extraoral traction, arch expansion ,functional jaw orthopedics. Extra oral traction – Most common for true maxillary skeletal protrusion. www.indiandentalacademy.com
  68. 68. 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. www.indiandentalacademy.com
  69. 69. 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 buccal musculature. www.indiandentalacademy.com
  70. 70. Expansion appliances – As most class II malocclusions have tendency of posterior crossbite, maxilla is overexpanded .This disrupts the occlusion. It appears that patient become more comfortable by positioning jaw forward, thus eliminating tendency toward buccal crossbite & at same time improving overall sagittal occlusal relationship. Teeth themselves act as an endogenous functional appliance, encouraging a change in mandibular posture & ultimately change in maxillomandibular occlusal relationship. www.indiandentalacademy.com
  71. 71. www.indiandentalacademy.com
  72. 72. 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 www.indiandentalacademy.com
  73. 73. Outcomes in a 2-phase randomized clinical trial of early Class II treatment. Tulloch JF, Proffit WR, Phillips C. (Am J Orthod Dentofacial Orthop. 2004) In a 2-phased, parallel, randomized trial of early (preadolescent) versus later (adolescent) treatment for children with severe (>7 mm overjet) Class II malocclusions. 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 outcomes www.indiandentalacademy.com
  74. 74. 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 www.indiandentalacademy.com
  75. 75. 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 psychosocial benefits. Results showed that early treatment with Twinblock appliances resulted in an increase in selfconcept and a reduction of negative social experiences. www.indiandentalacademy.com
  76. 76. 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 =590) treatments. 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. www.indiandentalacademy.com
  77. 77. 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 relapsed www.indiandentalacademy.com
  78. 78. 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. www.indiandentalacademy.com
  79. 79. 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 appliances. www.indiandentalacademy.com
  80. 80. 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 future growth. c) To improve occlusal function. d) To simplify phase II comprehensive treatment. Early treatment may eliminate necessity for orthognathic surgery. www.indiandentalacademy.com
  81. 81. 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 positive factors. www.indiandentalacademy.com
  82. 82. 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. www.indiandentalacademy.com
  83. 83. 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 P 2001) www.indiandentalacademy.com
  84. 84. 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 anomaly. “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 www.indiandentalacademy.com
  85. 85. www.indiandentalacademy.com
  86. 86. 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 labial position. Use of double cantilever spring ( Z spring) – Anterior crossbite involving 1 or 2 teeth. www.indiandentalacademy.com
  87. 87. www.indiandentalacademy.com
  88. 88. www.indiandentalacademy.com
  89. 89. Posterior Crossbite 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 www.indiandentalacademy.com
  90. 90. Most common is to separate midpalatal suture with expansion appliance. Even if transverse discrepancy results from broad mandibular arch, it is better to expand maxilla. 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 recommended. www.indiandentalacademy.com
  91. 91. www.indiandentalacademy.com
  92. 92. 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. www.indiandentalacademy.com
  93. 93. Early Management of Impacted Canines 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. www.indiandentalacademy.com
  94. 94. Lateral incisor root on OPG is divide into 4 sectors using modified method of Ericson & Kurol. www.indiandentalacademy.com
  95. 95. 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 of teeth. www.indiandentalacademy.com
  96. 96. 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 lives. www.indiandentalacademy.com
  97. 97. 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. www.indiandentalacademy.com
  98. 98. REFERENCES 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 – 145). 4 Steven D Marshall, Thomas Southhard – Early transverse treatment. Semin.Orthod 2005, 11(130 -139). www.indiandentalacademy.com
  99. 99. 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. www.indiandentalacademy.com
  100. 100. 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 www.indiandentalacademy.com
  101. 101. 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, No. 1 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.). www.indiandentalacademy.com
  102. 102. 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 – 468. 16 Thomas Graber, Robert Vanarsdall – Orthodontics : Current Principles & techniques. 3rd edtn, Mosby St.Louis. Pg -521-557 www.indiandentalacademy.com
  103. 103. 17 Thomas P George, Valiathan Ashima, Arji I George & Denny J Payyappilly: Oral habits (Part II) Tongue thrusting. Kerala Dental Association. 1992; 15(3 & 4): 721-724. 18 Gurkeerat Singh : Textbook of orthodontics. 1st edtn, Jaypee, New Delhi. Pg – 511– 532. www.indiandentalacademy.com
  104. 104. www.indiandentalacademy.com Leader in continuing dental education www.indiandentalacademy.com

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