Prevention perspective in orthodontics and dento facial orthopedics

1. Prevention perspective in
orthodontics and dento-facial
orthopedics
Supervised by Dr/Hale Guner
Presented by: Ahlam Abdulkareem

2. Introduction
oThe public health directions, considering WHO main objective that
„all people of the world could reach the highest possible health
level”, in medicine, the accent is put on prevention. In spite of the
important progresses achieved in orthodontics field, the treatment
still remains a symptomatic one.
oSo we must ask ourselves: what are the prevention theoretical and
practical coordinates in orthodontics??which measures are available
or could be elaborated for preventing the malocclusions
development??
oFrom the clinical point of view, the most important element of the
new perspective is that most of the cases of anomalies which in
the present are cured by orthodontics are induced by functional
and environmental factors and they can theoretically be prevented.

3. oThe greatest challenge of the future will be to turn
knowledge and expertise acquired in preventing diseases
into active programs.
oThe opportunities are represented by the extension of
prevention and promotion of oral health to the public, by
means of community programs aiming at informing the
community and benefiting from the disease prevention
measures.
oThus, the identification, control and guidance of the
environmental factors which adjust the growing of the
maxillaries and of the other cranio-facial structures would
be the main target of a prevention program in
orthodontics

4. oIn 2004, WHO published the Global Program for Oral
Health Promotion in view of improving oral health during
the XXII century, that emphasizes the fact that despite
the great oral health improvement of the entire world
population, the problems still persist, particularly for the
disadvantaged groups.
In this respect, FDI and OMS drafted
the objectives for 2020:
o Mitigating the impact of oral contamination,
malocclusions and craniofacial anomalies on psycho-
social health and development. –
oMitigating the impact of oral and craniofacial
manifestations of the systemic diseases and the use of
these manifestations for the precocious diagnosis, the
prevention and the efficient management of the systemic
diseases

5. oWe ask ourselves what are the theoretic and practical
coordinates in prevention in orthodontics??
owhat are the available measures or what could be
elaborated in order to prevent the development of
malocclusions??

6. Objectives of Prevention
oTo avert initiation of disease
process
oTo intercept their progress
oTo control their spread
oTo limit their complications and
after effects
oTo provide rehabilitation

7. Successful prevention
oKnowledge of causation
oDynamics of transmission
oIdentification of risk factors
oAvailability of prophylactic or
early detection
oTreatment measures
oOrganization for applying these
measures
oContinuous evaluation of
procedures applied

8. “ If you would understand anything, observe its
beginnings and its development.” —Aristotle

9. Considerations on malocclusions ethiopatogeny
oTo evaluate the perspective and the potential of prevention
in orthodontics.
oFor a long period of time, genetics has been primarily
involved in the development of the occlusion and
malocclusions and has been considered as following a
coded genetic program.
oThe anomaly has been perceived as result of a non-
balanced growth of the craniofacial structures due to an
unfortunate genes combination.
oClassical genital methods fail to separate the
environmental effects or the environment-genes
interaction of the proper genetic influences.

10. oA reasonable separation of the genetic and environment
effects was made possible after 1970, when new genetic
methods had been developed. Ever since, craniofacial
studies revealed that the role of the genetic factors in
controlling the development of the occlusion and the
anomalies is less important than it was believed.
oSignificant genetic variations in several occlusion
characteristics are hereditary transmit in a percentage
of 25-30%.
oMoreover, a longitudinal analysis on blood relatives
(brothers), concluded that „most of the occlusal
modifications are more likely acquired than inherited.

11. oBy Proffit, the main types of dento-maxillary anomalies are
related to the abnormal growth of the alveolar processes, of
basal parts of the jaws or a combination thereof.
oWithout omitting or minimizing the role of the genetic factor,
the observations of this study show that a large part of the
malocclusions are determined by environmental factors. That
is why this part of the modifications may be influenced by
the preventive procedures.

12. oIn order to explain the modifications which appear under
the influence of environmental factors, three main
hypotheses/directions have been promoted, known as
functional hypotheses.
 First of these theories incriminates the
modifications of the diet and the alteration of
masticatory activity
 the second incriminates the factors which concur to
the disturbance of the other functions which involve
the dento-maxillary apparatus (breathing, deglutition,
speaking)
and the third which incriminates
the vicious habits.

13. The diet and the masticatory activity modifications
oThe industrial revolution induced an important
adjustment of the energy content particularly of diet
consistency. This adjustment led to
 the decreasing of the
mastication need
 the alteration of maxillaries
growth and
 the increasing of anomalies
frequency
oThis means that the activity level of masticatory
muscles is an important controller of the jaws
growing.

14. oExperimental studies showed that animals which were
bred with a low consistency food instead of high
consistency natural diet, have a minimum masticatory
function, smaller jaws and they develop the same
anomalies observed to men.
oHistological studies showed that the activity level of the
masticatory muscles adjusts the cranial and facial bones
development, influencing not only the sutures growing but
also the bone apposition and resorption

15. During masticatory activity, the jaws are receiving, beside
the teeth pressures, a direct pressure born from the strong
contractions of the tongue, lips and cheeks. The intense
muscular activity is associated with a higher sanguine
intake, which assure to the maxillary bones better
development conditions.

16. The present study was undertaken to determine the effects of different dietary consistencies and malocclusion induced
by extraction of molar teeth on the masticatory organs of weaning and adult rats, by determining the biochemical
properties of masseter muscle, and also Ca and P levels in mandibular bone . rats, 3 and 20 weeks old, were divided into
3 groups. Group one (G-1) was maintained on a solid diet, and Groups two (G-2) and three (G-3) on a semi-solid diet.
Furthermore, the mandibular molar teeth of G-3 rats were extracted. The experimental period was 120 days.
changes in masticatory function, induced by low functional activity due to variation in the physical consistency of the diet,
caused an alteration in the craniofacial growth pattern. Masticatory organs were smaller in rats maintained on a soft diet
than in those on a solid diet[6,7]. These results suggest that mastication of a hard diet during the weaning period may
facilitate masticatory organ development to a greater extent than a soft diet in ra
These results suggest that mastication of a solid diet (G-1) by weaning rats may facilitate the develop-94 ment of the
masseter muscle to a greater extent than mastication of a semi-solid diet with or without tooth extraction. The mandibular
bone weight in weaning and adult rats showed the order : G-1 > G-2 > G-3. A significant correlation was found between
masseter and mandibular bone weights with r=0.837 (weaning) and 0.797 (adult). Thus, growth of the mandibular bone is
accompanied by development of the masseter muscle.

17. The modifications of the functions which implicate the
dento-facial complex (breathing, deglutition)
oIn general, muscles of the head and neck as masticatory
muscles have great importance in craniofacial growing,
maintaining the head posture, and other functions of
dento-maxillary apparatus, such as breathing, deglutition
and speaking.
oThe perturbation of one of the function of the dento-
facial complex frequently attracts the perturbation of the
others, considering the close relation of interdependence
and interconditioning, existing among them.

18. Breathing:
oThe association of respiratory and dento-maxillary
disturbances was first observed by Robert in 1943. Ever
since, several experimental research and clinical
observations (Robin, Bimler, Gudin, Muller, Schwarz, etc)
proved that there are obvious correlations between the
respiratory and the dento-maxillary anomalies.
oConsidering that, it is accepted that the increasing of the
allergy frequency or higher activity of another factor which
alters the functional dimension of the nasopharyngeal
cavity may be correlated with a higher frequency of the
specific dento-maxillary anomalies.

19. oToday it is known that oral breathing and head
extension could affect the maxillaries growing,
concurring to the dento-maxillary anomalies - maxillary
compression. (Class II/1)
Patient with maxillary compression as a result of oral breathing and gingival retraction at
left lower incisor

20. o Revealing the oral breathing on its debut can prevent
with real results the evolution toward pathologically of
jaws development and implicitly of jaws relations,
therefore the settlement of malocclusions
oThis can be achieved by an ORL
examination(oto/rhino/laryngology) which will establish not
only the possible obstacles existing in the
nasopharyngeal passage but also the muscular behavior,
mostly of the orbicular muscles.

21. A quick hint:
Otorhinolaryngology:
a medical specialty concerned
especially with the ear, nose, and
throat and related parts of the head
and neck

22. oStopping the evolution toward malocclusions can be
achieved by the reeducation of the respiratory function (in
subjective oral breathing), or by a surgical intervention of
removing the possible obstacles existing in the superior
respiratory airways, obligatory followed by functional
reeducation (in objective oral breathing).
oThe breathing reeducation exercises, after the removal of
adenoid processes are considered to be of great
importance even in the case of children who are not
presenting malocclusions.

23. Deglutition
oThe problem debating the deglutition influence in the
dento-facial development was raised much later, in 1946,
when the orthodontists realized that „there patients had
also a tongue” (Graber)
oThe deglutition is another function which implicates the
components of the dento- maxillary complex, the most
important being the tongue. The deglutition, in a
physiologically evolution has three stages, dependent and
in correlation with the teeth eruption and the jaws relation
development (infantile deglutition – before the deciduous
teeth eruption, the transition deglutition- after the eruption
of the incisors, the adult deglutition- after the dental
arches are constituted).

24. oMost frequently the alteration of this function is identified
as infantile deglutition after the age of 2 ½ -3 years (the
tongue interposition between the dental arches) which on
dento-facial complex has consequences like the
dysfunctional open byte syndrome (by tongue thrust).
oIn the matter of the patients who are presenting
malocclusions determined by these disturbances, the
therapeutic efforts must be centered on the modification of
deglutition comportment. The reeducation of deglutition can
be achieved by exercises or by tongue habit appliances,
orthodontic appliances which prevent the tongue thrust.
These appliances have a double role, to remove the
abnormal tongue forces and to reeducate the function.

25. This is a case of a 9 years patient,
with dysfunctional anterior open byte
caused by tongue thrust. One year of
wearing orthodontic appliances made
possible a further vertical eruption of
the teeth and a considerable
decreasing of the vertical in occlusion
space

26. In this figure we present by antithesis a 30 years patient with
the same type of open byte (caused by tongue thrust) who didn’t
beneficiate of functional reeducation. There are notable the
malocclusion consequences caused by the hypofunction of the
anterior teeth, respective the periodontal disorder, particularly
noticeable in the lower arch (severe gingival retractions)

27. Vicious habits
oThese are habitual actions, gestures achieved voluntarily
and spontaneous by the child, practiced with a certain
intensity and frequency, on a longer period of time,
actions that during the development of the dento-facial
complex can determine the emergence of malocclusions.

28. Objective: To assess the effects of breast-feeding duration, bottle-feeding duration and
oral habits on the occlusal characteristics of primary dentition in 3-6-year-old children in
Beijing.
Methods: This cross sectional study was conducted via an examination of the occlusal characteristics
of 734 children combined with a questionnaire completed by their parents/guardians. The examination
was performed by a single, previously calibrated examiner and the following variables were evaluated:
presence or absence of deep overbite, open bite, anterior cross bite, posterior cross bite, deep overjet,
terminal plane relationship of the second primary molar, primary canine relationship, crowding and
spacing. Univariate analysis and multiple Logistic regressions were applied to analyze the associations
Results: It was found that a short duration of breast-feeding (never or ≤6 months) was directly associated with
posterior cross bite and no maxillary space. In children breast-fed for ≤6 months, the probability of developing
pacifier-sucking habits was 4 times that for those breast-fed for >6 months. The children who were bottle-fed for
over 18 months had a 1.45-fold higher risk of nonmesial step occlusion and a 1.43-fold higher risk of class II
canine relationship compared with those who were bottle-fed for 6-18 months. Non-nutritive sucking habits were
also found to affect occlusion: a prolonged digit-sucking habit increased the probability of an anterior open bite,
while a pacifier-sucking habit was associated with excessive overjet and absence of lower arch developmental
space. Tongue-thrust habit was associated with anterior open bite and posterior cross bite. Lower lip sucking habit
was associated with deep overjet and had a negative association with class III canine relationship. Unilateral
chewing was associated with spacing in mandibular. Mouth breathing was associated with chronic rhinitis and
adenoidal hypertrophy and had an association with spacing in maxillary. The chi-square test did not indicate a
statistically significant association between upper lip sucking habit and any occlusal characteristics

29. oThe pressures developed by cheeks and lips from
outside and by the tongue from inside, are representing
important factors which are not only guiding the
development of the occlusion but also are influencing the
maxillary growth.
oIf the balance between the cheek and lips muscles on
one part and the tongue muscles by the other part is
disturbed, it will be a high probability for skeletal and
occlusion disorders to occur.
oIn this respect, the vicious habits, particularly those of
sucking and interposition representing a part of the
modern lifestyle which is reflected by the decrease of
breast feeding or other changes of the growing habits of
the child, cause malocclusion, concurring to a higher
frequency thereof.

30. The aim of the present epidemiologic study was to obtain representative basic data on the frequency, extent
and age-dependence of malocclusions in the deciduous and early mixed dentition. They were investigated from
the aspect of orthodontic prevention. The collective comprised 8,864 preschool and schoolage children, of
whom 1,225 were in the deciduous dentition (mean age 4.5 years) and 7,639 in the mixed dentition (mean age
8.9 years). The orthodontic data were clinically assessed as sagittal, transversal, or vertical single-arch and
occlusal findings. In addition, the malocclusions were classified according to their primary symptoms. Early
infantile habits, tongue dysfunctions, speech defects and incompetent lip closure were registered separately.
Results:
57% of the children were found to have malocclusions, with the frequency rising statistically significantly in
dependence on age from the deciduous to the mixed dentition. The mean extent of excessive overjet
increased significantly from the deciduous to the mixed dentition. Crossbite with mandibular midline
discrepancies were observed significantly more frequently in the deciduous dentition. Although the
frequency of anterior open bite underwent a significant decline from the deciduous to the mixed dentition,
open bite was the malocclusion most frequently associated with dysfunction in both groups. The significant
increase in traumatic deep bite in the mixed dentition indicates an unfavorable developmental tendency in
this anomaly until after the eruption of the permanent incisors.
Conclusion:
The need for preventive orthodontic therapy and for the intensified application of interceptive and early
treatment measures is stressed in view of the high number of malalignments and malocclusions in the
deciduous and mixed dentition and the tendency for some forms of malocclusion to deteriorate as the
dentition develops.

32. levels of prevention
1- primordial
prevention
2-primary prevention
3-secondary
prevention
4-tertiary prevention

35. Modes of prevention
1- Health promotion
2-Specific protection
3-Early diagnosis and treatment
4-Disabililty limitations
5-Rehabilitation

36. Health promotion
Health promotion
is the process of
enabling people
to increase
control over, and
to improve, their
health. It moves
beyond a focus
on individual
behaviour towards
a wide range of
social and
environmental

37. It is done by:
oHealth education
oEnvironmental modification
oNutritional intervention
oLifestyle and behavioral changed

38. Health education
oOne of the most coast effective intervention Educate
information about diseases and encourage people to
take necessary precautions on time.
oTarget groups for educational efforts include general
public, patients, high risk groups, community leaders,
decision makers, health providers
oFor example: Parent
Counseling/Education

39. Parent Counseling/Education
oParent counseling is the most effective way to
practice orthodontics and which is included prenatal
counseling and post natal counseling.
oPreventive dentistry should ideally begin
before the birth of the child.
oThe pregnant mother should be educated
regarding the intake of foods containing calcium
and phosphorous specially during third trimester,
as they would allow adequate formation of
deciduous crowns.

40. oDuring post natal counseling
oParents should be educated on the maintenance of good
oral hygiene in their children.
oBrushing with the help of finger brush and cleaning of the
deciduous teeth with clean and soft cotton cloth dipped in
warm saline is recommended in early stages. This is
important to prevent the initiation of rampant caries.
oFurther, bottle feeding should be discouraged by the age
of 18- 24 months to decrease the potential for nursing
caries.

41. oThe child should be encouraged to begin brushing on his
own and should practice it twice a day.
oParents must be advised to bring their children for regular
dental assessment with the completion of the deciduous
dentition in order to assess any anticipant decay and
other dental problems.

42. This study aimed at evaluating the Protocol for the Prevention of Malocclusions (PPM),
established in the preventive educational program developed by the Public Infant Oral Health
Program of the State University of Londrina (PIOHP-UEL). Guardians of three-year-olds or
older, maintaining nutritive (bottle) and/or non-nutritive (pacifier and finger) sucking habits,
attended meetings designed to alert and guide them to eliminating these habits from their
children. PPM patient records (2006–2013) were assessed and the data were described and
evaluated by the Chi-square test
As for the children, the most frequently assessed habits were: bottle (56.1%), bottle and
pacifier (18.4%), finger (11.9%), bottle and finger (7.1%), pacifier (5.7%), pacifier and finger
(0.6%), and bottle/pacifier/finger (0.2%). After parent participation in the meetings, 335
(66.2%) children abandoned their habits. T
However, those with only one habit abandoned it more easily (72.6%) than those
with two or more associated habits (48.1%) (p = 0.042). Presence or absence of
breastfeeding and parents’ level of education
Conclusion: PPM was an important tool for spreading knowledge to guardians, greatly
contributing to the abandonment of deleterious oral habits. Bottle sucking warrants special
attention - mentioned by 81.8% of parents - either alone or associated with other habits.
Thus, educational actions to implement the children’s approach to oral health are
fundamental to making behavioral changes and promoting education of healthy habits,
thereby keeping malocclusions from developing

43. Another example of health education is caring of
deciduous dentation
oThere is a gross misconception among lay people
regarding maintenance of deciduous teeth as they are
eventually replaced by permanent teeth, there is no
reason to take care of them. However, deciduous teeth
by themselves act as the best natural space maintainers.
oDeciduous teeth not only maintain the space for their
succeeding permanent teeth, but also guide the
permanent teeth into their proper position preventing
malocclusion. Therefore it is important to maintain full
complement of deciduous dentition in children to establish
a proper occlusion in permanent dentition.

44. Nutritional intervention
oChild feeding program
oDietary counseling

45. Environmental modification:
oare internal and external physical adaptations to the home,
which are necessary to ensure the health, welfare and
safety of the waiver participant. These modifications enable
the waiver participant to function with greater
independence and prevent institutionalization
oEx: community water fluoridation
for caries control

46. o Caries control involving the deciduous teeth,
especially proximal caries is the main cause of
development of malocclusion
oNot treated proximal caries of deciduous teeth
cause mesial migration of adjacent teeth and
increase potential for crowding resulting in
malocclusion with the eruption of succeeding larger
permanent teeth.

47. oInitiation of caries can be prevented by dietary
counseling, topical fluoride application, pit and fissure
sealants and educating parents.
oSometimes it may be indicated to fit stainless steel
crowns for badly decayed teeth to restore the
functional occlusion and arch integrity.

48. What about caries and white spot lesions prevention
during orthodontic treatment?

49. Data sources Medline, PubMed and hand searches were used to source studies.
Study selection Publications were screened independently by two observers. Only randomised controlled trials (RCT)
of orthodontic fixed appliance treatment with bonded brackets that addressed prevention of white spot lesions
which were published in English were included. Studies also had to provide enough data to calculate the preventive
fraction (PF)
Results The overall PF of the fluoride-releasing bonding materials was 20% (standard error, 0.09). This effect,
however, was not statistically significant. It was impossible to calculate an overall PF for the other preventive
measures, but the tendency of their caries-inhibiting effect was described. The use of toothpaste and gel with a high
fluoride concentration of 1500–5000 ppm or of complementary chlorhexidine during orthodontic treatment showed
a demineralisation-inhibiting tendency. The use of a polymeric tooth coating on the tooth surface around the
brackets showed almost no demineralisation-inhibiting effect.
Practice point For orthodontic patients undergoing fixed appliance therapy, oral hygiene measures should include
toothbrushing with fluoridated toothpaste, augmented by daily application of high fluoride concentration gel or
chlorhexidine mouthwash. The efficacy of fluoride release from bonding materials or elastomers in reducing
decalcification is unverified as yet.

50. Life style and behavior changes
o
olife style: No sugar addition to bottle milk, however
mothers' milk is preferred and the best for the TMJ
development as well as for nondevelopment of tongue
thrusting habits.
oAt 2 years of age The child should be on 3
square diverse meals a day.
oBehavior changes: as thumb sucking, nail biting, lip
biting, tongue thrusting and mouth breathing have
deleterious effects on oral health including development
of malocclusion

51. oThe dentofacial changes will vary with the intensity,
duration and frequency of the habit and the position of
the digit in the mouth. The dentofacial changes include
the proclination of the maxillary incisors, retroclination of
the mandibular incisors, maxillary constriction and anterior
open bite. Education of parents about the consequences
of abnormal oral habits, educating and motivating the
child to stop the habits, elimination of oral habits using
habit breaking appliances are important initial measures in
prevention of parafunctional habits.

52. Specific protection
oSpace Maintenance:A tooth is maintained in its correct
relationship in the dental arch as a result of the action of
a series of forces. If one of these forces is altered or
removed changes in the relationship of adjacent teeth will
take place and result in drifting of teeth and eventual
crowding. When primary teeth are lost prematurely,
migration of adjacent primary or permanent teeth can
occur leading to crowding in the permanent dentition due
to loss of space and reduction in arch length. Therefore,
it is needed to indicate a space maintainer to maintain
entire mesio-distal space created by the loss of space,
restore the function as far as possible and to prevent
over eruption of opposing tooth.

53. The following factors are important to consider when
planning a space maintainer.
oTime elapsed from loss of tooth: Maximum loss of space
occurs within 2 weeks to 6 months of the premature loss
of deciduous tooth, it is recommended to fabricate the
space maintainer before the extraction and to fit
immediately following extraction.
oDental age of the patient: The dental age is more
important than the chronological age of the patient.
oAmount of bone covering the developing tooth bud Stage
of root formation: The developing tooth buds begin to
erupt actively if the root is three- fourth formed.
oSequence of eruption of teeth: The status of the
developing and erupting tooth buds adjacent to the space

54. oPremature loss of deciduous second molar tooth: If the
level of eruption of second permanent molar is at a level
higher than that of the second premolar, then there is
likelihood of permanent first molar to tip mesially and
impede the eruption of second premolar tooth.
oPremature loss of deciduous first molar tooth: If the
permanent lateral incisor is erupting, which tend to push
the deciduous canine thus affecting the eruption of first
premolar tooth.

55. FIXED SPACE MAINTAINERS

56. REMOVABLE SPACE MAINTAINERS

57. oExtraction of Supernumerary Teeth:
oAs mesiodens, paramolar, distomolar.
oThey cause arch length tooth material discrepancy
resulting crowding in the arch and prevent eruption of
succeeding permanent teeth creating more orthodontic
problems.

58. Management of Ankylosed Deciduous Teeth
oAnkylosis is a condition where in a part or whole of the
root surface is directly fused to the bone. Clinically these
teeth are fails to erupt to the normal level and are called
“submerged teeth”. This usually has a profound effect on
the occlusion. Deciduous teeth become ankylosed far
more frequently than do permanent teeth, with an
approximate ratio of 10:1. Ankylosis of deciduous teeth
prevents the eruption of succeeding permanent teeth.

59. oTreatment depends upon the time of onset, the time of
diagnosis, and the location of the affected tooth.
oIf the tooth is deciduous and without a successor and the
onset is early so that “submergence” is threatened,
treatment involves extraction and space maintenance.
oIf the tooth is deciduous and without a successor and the
onset is late, proximal and occlusal contacts may be built
up at maturity.

60. Management of Ectopic Eruption of Permanent First
Molar
oEctopic eruption of first permanent molar represents a
local disturbance in eruptive behavior. These teeth
become “locked” behind the distal surface of deciduous
second molar. Distal resorption of a second deciduous
molar is common sequelae of this condition.
oEctopic eruption of the permanent maxillary first molar
resulting in premature exfoliation of primary second molar
and loss of arch length. This result is not only crowding
but also a class II molar relationship.
oSlight distal (proximal) stripping of second deciduous
molar allows the permanent first molar to erupt in its
proper place.

61. Prevention of Y Canine Impactions
oMaxillary canines are the most commonly impacted teeth,
second only to third molars. Maxillary canine impaction
occurs in approximately 2% of the population and is twice
as common in females as it is in males. The function of
maxillary canines is not limited to tearing of food, as
commonly thought. They have a more important role in
dynamic occlusion and relatedly, in lateral excursions of
the mandible
oDetects early signs of ectopic eruption of the canines, an
attempt should be made to prevent their impaction to
prevent its potential sequelae.

62. oSelective extraction of the deciduous canines around the
age of 8- 9 years has been suggested by Williams as an
interceptive approach to canine impaction in Class I
uncrowded cases. Ericson & Kurol suggested that
removal of the deciduous canine before the age of 11
years will normalize the position of the ectopically
erupting permanent canines in 91% of the cases if the
canine crown is distal to the midline of the lateral incisor.
However, the success rate is only 64% if the canine
crown is mesial to the midline of the lateral incisor

63. o Labial frenum: Surgical removal of the abnormal labial
frenum is needed to prevent median diastema.
oGrinding of cusp tips/occlusal equilibration: Cuspal
interference should be removed by selective grinding of
the tooth. Abnormal anatomical features like enamel pearl,
may cause premature contact. Problem: Deviation in the
mandibular path of closure Predispose to bruxism Dx:
articulating paper/bite paper

64. Objectives: This study aimed to outline orthodontists' perspectives at what stage they would
initiate orthodontic treatment and also sought to assess the relationship between orthodontists'
views and their genders, types of practice, and experience levels.
Materials and methods: A questionnaire was sent electronically to 165 practicing orthodontists at different
regions in Saudi Arabia. The orthodontists were asked to consider at what stage they would initiate
orthodontic treatment for a child with one of 29 different types of occlusal deviations, functional problems,
and temporomandibular disorders (TMDs) listed in the questionnaire as their main orthodontic problem.
Frequency distributions of all the variables were derived, and comparisons were made using the Chi-square
tests.
Results: Fifty-two electronically completed questionnaires were returned (31.5% response rate). The majority
of the respondents were males (63.5%). The majority of respondents (90%) reported that they would treat most
of the occlusal deviations in the mixed dentition stage. Anterior cross-bite was the most frequent indication for
treatment during the early mixed dentition stage (73.7%). Conditions rated as best treated during the late
mixed, or the permanent dentition stages were; overjet > 6 mm with interdental spacing, maxillary midline
diastema >2 mm and deep bite >5 mm without palatal impingement. The majority of respondents (86.6%)
preferred to treat most of the functional problems in the deciduous or early mixed dentition stage. Orthodontists
with more than 15 years of experience preferred to treat patients with TMDs, whereas those with <15 years of
experience opted to refer such patients to TMD specialists.
Conclusions: The findings of the present study suggest that orthodontists should consider many
factors, such as the risks, benefits, duration, and costs of early and late intervention, when deciding the
best timing to begin orthodontic treatment.

66. Conclusion
oPrevention could be thus considered the best possible
alternative to the active orthodontic treatment. The
preventive strategies should target the provision of normal
function of oro-facial structures and normal craniofacial
growth targeting the decrease the occurrence of
malocclusion.
oThus, the identification, control, and conduct/guidance of
the environment factors that regulate the maxillaries and
other craniofacial factors growth would represent the main
targets of several approaches to set up a prevention and
interception program in orthodontic

67. oFrom the previous mentioned facts it is obvious that the
adjustment of the cranio-facial growth is under a less
strict genetic control; on the other hand, it seems to
highly depend on the influence of several oro-facial
functions, especially during the post birth period.

68. References
.1
Jang JC, Fields HW, Vig KW, Beck FM. Controversies in the timing of orthodontic treatment.
Semin Orthod. 2005;11:112–18.
.2
Hsieh TJ, Pinskaya Y, Roberts WE. Assessment of orthodontic treatment outcomes: Early
treatment versus late treatment. Angle Orthod. 2005;75:162–70. - PubMed
.3
Pietilä I, Pietilä T, Svedström-Oristo AL, Varrela J, Alanen P. Acceptability of adolescents’
occlusion in Finnish municipal health centres with differing timing of orthodontic treatment. Eur J
Orthod. 2010;32:186–92. - PubMed
.4
Pietilä I, Pietilä T, Pirttiniemi P, Varrela J, Alanen P. Orthodontists’ views on indications for and
timing of orthodontic treatment in Finnish public oral health care. Eur J Orthod. 2008;30:46–51. -
PubMed
.5
Ghafari J, Shofer FS, Jacobsson-Hunt U, Markowitz DL, Laster LL. Headgear versus function
regulator in the early treatment of Class II, division 1 malocclusion: A randomized clinical trial.
Am J Orthod Dentofacial Orthop. 1998;113:51–61. - PubMed
.6
Boboc Gh. – Aparatul dento-maxilar. Formare şi dezvoltare, Ed. Medicală, Buc., 1971. 2.
Ionescu Ecaterina – Anomaliile dentare, Ed. Cartea Universitară, Buc., 2005. 3. Graber T.M. –
Orthodontics Principles and Practice – Mosby C., Saint Louis, Missouri, 2000. 4. Proffit W.R.,
Fields H. – Contemporary Orthodontics, Mosby Year Book, 1993. 5. Varrela J., Alanen P. –
Prevention and early treatment in orthodontics, Journal of Dental Research, 1995, vol. 74, nr. 8
6. WHO, Health for All database, 2007

69. THANK YOU