BDS [Orthodontics] course

1. INTERCEPTIVE ORTHODONTICS
PROF (Dr.) SAIBEL FARISHTA

2. UNLIKE PREVENTIVE ORTHODONTIC PROCEDURES THAT
ARE AIMED AT ELIMINATION OF FACTORS THAT MAY
LEAD TO MALOCCLUSION, INTERCEPTIVE
ORTHODONTICS IS UNDERTAKEN AT A TIME WHEN THE
MALOCCLUSION HAS ALREADY DEVELOPED OR IS
DEVELOPING.
BASICALLY, IT REFERS TO THE MEASURES UNDERTAKEN
TO PREVENT A POTENTIAL MALOCCLUSION FROM
PROGRESSING INTO A MORE SEVERE ONE.

3. DEFINITION –
INTERCEPTIVE ORTHODONTICS HAS BEEN DEFINED AS THAT PHASE
OF THE SCIENCE AND ART OF ORTHODONTICS EMPLOYED TO
RECOGNIZE AND ELIMINATE POTENTIAL IRREGULARITIES AND
MALPOSITIONS OF THE DEVELOPING DENTOFACIAL COMPLEX.
PROCEDURES UNDERTAKEN IN INTERCEPTIVE ORTHODONTICS
1. SERIAL EXTRACTION
2. CORRECTION OF DEVELOPING CROSSBITE
3. CONTROL OF ABNORMAL HABITS
4. SPACE REGAINING
5. DIASTEMA CLOSURE
6. MUSCLE EXERCISES
7. INTERCEPTION OF SKELETAL MALRELATION
8. REMOVAL OF SOFT TISSUE OR BONY BARRIER TO
ERUPTION OF TEETH.

4. Serial Extraction

5. 1. SERIAL EXTRACTION
IT IS USUALLY INITIATED IN THE EARLY MIXED DENTITION PERIOD
WHEN ONE CAN RECOGNIZE AND ANTICIPATE POTENTIAL
IRREGULARITIES IN THE DENTOFACIAL COMPLEX AND IS
CORRECTED BY A PROCEDURE THAT INCLUDES THE PLANNED
EXTRACTION OF CERTAIN DECIDUOUS AND LATER PERMANENT
TEETH IN AN ORDERLY MANNER TO GUIDE THE ERUPTING
PERMANENT TEETH INTO A MORE FAVOURABLE POSITION.
HISTORY –
KJELLGREN IN 1929 FIRST TIME USED THE TERM ‘SERIAL
EXTRACTION’.
NANCE IN 1940’s POPULARIZED THIS TECHNIQUE IN USAAND
TERMED IT ‘PLANNED & PROGRESSIVE EXTRACTION’.
HOTZ IN 1970 CALLED SUCH A PROCEDURE ‘ACTIVE SUPERVISION
OF TEETH BY EXTRACTION’.

6. RATIONALE –
1. ARCH LENGTH – TOOTH MATERIAL DISCREPANCY
IN CASE OF EXCESSIVE TOOTH MATERIAL, THE TOOTH
MATERIAL IS REDUCED.
SIMILARLY, IN SERIAL EXTRACTION PROCEDURES, THE
EXCESSIVE TOOTH MATERIAL IS REDUCED BY
SELECTIVE EXTRACTION OF TEETH, SO THAT REST OF
THE TEETH CAN BE GUIDED TO NORMAL OCCLUSION.
2. PHYSIOLOGIC TOOTH MOVEMENT
THE HUMAN DENTITION SHOWS A PHYSIOLOGIC
TENDENCY TO MOVE TOWARDS AN EXTRACTION SPACE.
BY SELECTIVE REMOVAL OF SOME TEETH, WHICH ARE
IN THE PROCESS OF ERUPTION, TEETH ARE GUIDED BY
THE NATURAL FORCES INTO THE EXTRACTION SPACE.

7. INDICATIONS FOR SERIAL EXTRACTION -
1. CLASS I MALOCCLUSION SHOWING HARMONY BETWEEN
SKELETALAND MUSCULAR SYSTEM.
2. IF ARCH LENGTH DEFICIENCY IS INDICATED BY THE PRESENCE
OF ONE OR MORE OF THE FOLLOWING FEATURES –
 ABSENCE OF PHYSIOLOGIC SPACING
 UNILATERAL OR BILATERAL PREMATURE LOSS OF DECIDUOUS
CANINES WITH MIDLINE SHIFT
 MALPOSITIONED OR IMPACTED LATERAL INCISORS THAT
ERUPT PALATALLY OUT OF THE ARCH
 IRREGULAR OR CROWDED UPPER AND LOWER ANTERIORS
 LOCALIZED GINGIVAL RECESSION IN LOWER ANTERIORS
 ECTOPIC ERUPTION OF TEETH
 MESIAL MIGRATION OF BUCCAL SEGMENT
 ABNORMAL ERUPTION PATTERN
 LOWER ANTERIOR FLARING
 ANKYLOSIS OF ONE OR MORE TEETH
3. WHERE GROWTH IS NOT ENOUGH TO OVERCOME THE TOOTH
MATERIALAND BASAL BONE DISCREPANCY
4. PATIENTS WITH STRAIGHT PROFILE AND PLEASING
APPEARENCE

8. SERIAL EXTRACTION CASES

9. SERIAL EXTRACTION CASES

10. SERIAL EXTRACTION CASES

11. CONTRAINDICATIONS FOR SERIAL EXTRACTIONS -
1. CLASS II AND CLASS III MALOCCLUSION WITH
SKELETALABNORMALITIES
2. SPACED DENTITION
3. ANODONTIA/OLIGODONTIA
4. OPEN BITE AND DEEP BITE
5. MIDLINE DIASTEMA
6. CLASS I MALOCCLUSIONS WITH MINIMAL SPACE
DEFICIENCY
7. UNERUPTED MALFORMED TEETH. EG.
DILACERATION
8. EXTENSIVE CARIES OR HEAVILY FILLED FIRST
PERMANENT MOLARS
9. MILD DISPROPORTION BETWEEN ARCH LENGTH AND
TOOTH MATERIAL THAT CAN BE TREATED BY
PROXIMAL STRIPPING

12. ADVANTAGES OF SERIAL EXTRACTION -
1. TREATMENT IS MORE PHYSIOLOGIC AS IT INVOLVES
GUIDANCE OF TEETH INTO NORMAL POSITIONS
MAKING USE OF THE PHYSIOLOGIC FORCES
2. PSYCHOLOGICAL TRAUMA ASSOCIATED WITH
MALOCCLUSION CAN BE AVOIDED BY TREATMENT AT
AN EARLY AGE
3. IT REDUCES OR ELIMINATES FIXED ORTHODONTIC
TREATMENT
4. BETTER ORAL HYGIENE IS POSSIBLE THEREBY
REDUCING THE RISK OF CARIES
5. HEALTH OF INVESTING TISSUES IS PRESERVED
6. LESSER RETENTION PERIOD IS INDICATED AT THE
COMPLETION OF TREATMENT
7. MORE STABLE RESULTS ARE ACHIEVED AS THE
TOOTH MATERIAL AND ARCH LENGTH ARE IN
HARMONY

13. DISADVANTAGES OF SERIAL EXTRACTION -
1. EACH PATIENT HAS TO BE ASSESSED SEPARATELY AND AN
EXTRACTION TIME TABLE THEN BE PLANNED
2. THE TREATMENT TIME IS MORE, USUALLY 2-3 YEARS
3. PATIENT HAS TO VISIT DENTIST OFTEN, THUS MORE PATIENT
COOPERATION IS REQUIRED
4. PATIENT HAS A TENDENCY TO DEVELOP TONGUE THRUST, DUE
TO THE EXTRACTION SPACES
5. EXTRACTION OF THE BUCCAL TEETH CAN RESULT IN
DEEPENING OF THE BITE
6. IF THE PROCEDURE IS NOT CARRIED OUT PROPERLY, THERE IS A
RISK OFARCH LENGTH REDUCTION BY MESIAL MIGRATION OF
THE BUCCAL SEGMENT
7. DITCHING OR SPACE CAN EXIST BETWEEN THE CANINE AND
SECOND PREMOLAR
8. THE AXIAL INCLINATION OF THE TEETH AT THE TERMINATION
OF SERIAL EXTRACTION MAY REQUIRE CORRECTION BY FIXED
APPLIANCE

14. DIAGNOSTIC PROCEDURE FOR SERIAL EXTRACTION
BEFORE TREATMENT - DENTAL, SKELETALAND SOFT TISSUE ASSESSMENT
SHOULD BE CARRIED OUT
A TOOTH MATERIAL – ARCH LENGTH DISCREPANCY OF ATLEAST 5-7 MM
SHOULD EXIST
CAREY’S ANALYSIS IN THE LOWER ARCH AND ARCH PERIMETER ANALYSIS
IN THE UPPER ARCH SHOULD BE CARRIED OUT
OPG X-RAY SHOULD BE ADVISED
CEPHALOMETRIC EXAMINATION SHOULD BE CARRIED OUT TO CHECK FOR
THE SKELETAL RELATIONSHIPS
BEST RESULTS ARE SEEN IN CLASS I SKELETAL PATTERN, WHEREAS
PRESENCE OF CLASS II AND CLASS III PATTERNS ARE CONTRAINDICATED
A HARMONIOUS SOFT TISSUE PATTERN IS A PRE REQUISITE FOR SERIAL
EXTRACTION

15. PROCEDURES -
1. DEWEL’S METHOD
2. TWEED’S METHOD
3. NANCE METHOD
1. DEWEL’S METHOD (3 STEPS) –
• THE DECIDUOUS CANINES ARE EXTRACTED TO CREATE SPACE
FOR ALIGNMENT OF THE INCISORS AT 8-9 YEARS OF AGE.
• AFTER ONE YEAR, THE DECIDUOUS FIRST MOLARS ARE
EXTRACTED TO HELP FACILITATE FIRST PREMOLAR ERUPTION
• THE ERUPTING FIRST PREMOLARS ARE EXTRACTED TO PERMIT
PERMANENT CANINES TO ERUPT IN THEIR PLACE [C-D-4]
2. TWEED’S METHOD –
• IT INVOLVES THE EXTRACTION OF DECIDUOUS FIRST MOLARS
AROUND 8 YEARS, FOLLOWED BY EXTRACTION OF FIRST
PREMOLARS AND THEN DECIDUOUS CANINES [D-4-C]
2. NANCE METHOD –
• SAME AS TWEED’S METHOD [D-4-C]

16. POST SERIAL EXTRACTION
OF FIRST PREMOLARS
POST SERIAL EXTRACTION
OF DECIDUOUS CANINES

17. 2. DEVELOPING ANTERIOR CROSS BITE
ANTERIOR CROSS BITE IS A CONDITION CHARACTERIZED BY
REVERSE OVERJET WHERE ONE OR MORE MAXILLARYANTERIOR
TEETH ARE IN LINGUAL RELATION TO THE MANDIBULAR TEETH
‘THE BEST TIME TO TREAT A CROSS BITE IS THE FIRST TIME IT IS SEEN.’
ANTERIOR CROSS BITE SHOULD BE TREATED EARLY BECAUSE –
• THIS TYPE OF MALOCCLUSION MAY MANIFEST IN MIXED AND
PERMANENT DENTITION
• IT MAY CAUSE SKELETAL MALOCCLUSION, WHICH MAY REQUIRE
COMPLICATED ORTHODONTIC PROCEDURES, LIKE SURGERY.

18. CLASSIFICATION OF ANTERIOR CROSS BITE -
1. DENTO ALVEOLAR
2. SKELETAL
3. FUNCTIONAL
1. DENTO ALVEOLAR – ONE OR MORE MAXILLARYANTERIOR TEETH
ARE IN LINGUAL RELATION TO THE MANDIBULAR ANTERIORS.
USUALLY SINGLE TOOTH CROSS BITES ARE SEEN DUE TO
OVERRETAINED DECIDUOUS TEETH
THESE CAN BE TREATED USING TONGUE BLADES, CATALAN’S
APPLIANCE AND DOUBLE CANTILEVER SPRINGS WITH POSTERIOR
BITE PLATE

19. 2. SKELETAL –WHEN THE ANT. CROSSBITE IS DUE TO MAXILLARY
AND MANDIBULAR PROTRUSION OR RETROGNATHISM.

20. 3. FUNCTIONAL –
THESE ARE ‘PSEUDO CLASS III’ MALOCCLUSIONS, WHERE THE
MANDIBLE IS COMPELLED TO CLOSE IN A FORWARD POSITION OF
IT’S TRUE CENTRIC RELATION.
THESE ARE TO BE TREATED BY ELIMINATING THE OCCLUSAL
PREMATURITIES.
3. INTERCEPTION OF HABITS
1. THUMB SUCKING
2. TONGUE THRUSTING
3. MOUTH BREATHING

21. 4. SPACE REGAINING
IF A DECIDUOUS MOLAR IS LOST EARLY AND SPACE MAINTAINERS
ARE NOT USED, A REDUCTION IN ARCH LENGTH MAY OCCUR DUE TO
MESIAL MOVEMENT OF FIRST MOLAR. THIS SPACE CAN BE
REGAINED BY DISTAL MOVEMENT OF THE FIRST MOLAR.
THIS SHOULD BE UNDERTAKEN AT AN EARLY AGE. PRIOR TO THE
ERUPTION OF THE SECOND MOLAR
SOME COMMONLY USED SPACE REGAINERS
1. GRABER SPACE REGAINER
2. SPACE REGAINERS USING JACK SCREWS
3. ADAM’S SPACE REGAINER
4. SPACE REGAINING USING CANTILEVER SPRING

22. 5. DIASTEMA CLOSURE
DIASTEMA REFERS TO AN ANTERIOR MIDLINE SPACING BETWEEN
TWO MAXILLARY CENTRAL INCISORS
1. TRANSIENT MALOCCLUSION – UGLY DUCKLING STAGE
2. TOOTH MATERIAL – ARCH LENGTH DISCREPANCY – ANODONTIA,
MICRODONTIA, MACROGNATHIA, EXTRACTIONS WITH
RESULTANT DRIFTING OF ADJACENT TEETH
3. ABNORMAL FRENALATTACHMENT – DUE TO FIBROUS
CONNECTIVE TISSUE
4. PRESSURE HABITS – PROCLINATION AND ANTERIOR SPACING
5. MIDLINE PATHOLOGY – MESIODENS, CYSTS, TUMOURS, ETC.
6. IATROGENIC – DURING RAPID MAXILLARY EXPANSION
7. RACIAL PREDISPOSITION – NEGROID RACE
ETIOLOGY -

23. DIAGNOSTIC ASPECTS IN DIASTEMA -
A BLANCH TEST IS PERFORMED TO DIAGNOSE A FLESHY LABIAL
FRENUM. THE UPPER LIP IS PULLED OUTWARDS, BLANCHING OF
TISSUE IN THE INCISIVE PAPILLA REGION PALATAL TO THE TWO
CENTRAL INCISORS CONFIRMS THE PRESENCE OF A THICK AND
FLESHY FRENUM
PRESENCE OF NOTCHING IN THE INTER – DENTALALVEOLAR BONE
AS SEEN IN RADIOGRAPH IS ALSO DIAGNOSTIC OFA THICK AND
FLESHY FRENUM
MIDLINE RADIOGRAPHS ARE HELPFUL IN DIAGNOSING FOR
MIDLINE PATHOLOGY
MODELANALYSIS CAN BE DONE TO DETERMINE THE TOOTH
MATERIALAND ARCH LENGTH DISCREPANCY

24. TREATMENT OF MIDLINE DIASTEMA -
1. REMOVAL OF CAUSE
2. ACTIVE TREATMENT
3. RETENTION
1. REMOVAL OF CAUSE -
THE ETIOLOGY HAS TO BE REMOVED FIRST. HABIT BREAKERS,
REMOVAL OF MESIODENS, FRENECTOMY, MIDLINE PATHOLOGY
REMOVAL HAS TO BE DONE.
2. ACTIVE TREATMENT -
REMOVABLE APPLIANCES INCORPORATING FINGER SPRINGS OR A
SPLIT LABIAL BOW CAN BE USED TO CLOSE MIDLINE SPACE
FIXED APPLIANCES INCORPORATING ELASTICS – ECHAINS, ELASTIC
THREAD, CLOSED COIL SPRINGS OR ‘M’ SHAPED SPRINGS CAN BE
GIVEN.

25. 3. RETENTION -
MIDLINE DIASTEMA IS OFTEN CONSIDERED EASY TO TREAT, BUT
DIFFICULT TO RETAIN.
LINGUAL BONDED RETAINERS, BANDED RETAINERS, HAWLEY
RETAINERS ETC. CAN BE USED.
ROLE OF COSMETIC RESTORATIONS
ESTHETIC COMPOSITE RESINS CAN BE USED IN ADULTS
PROSTHESIS/CROWNS
TOOTH SIZE, SHAPE ANOMALIES LIKE PEG LATERALS OR MISSING
TEETH SHOULD BE REPLACED WITH FIXED OR REMOVABLE
PROSTHESIS

26. BEFORE AFTER
DIASTEMA CLOSURE IN AN ADULT PATIENT

27. 6. MUSCLE EXERCISES
AS THE DENTAL TISSUES ARE BLANKETED FROM ALL DIRECTIONS
BY MUSCLES, NORMAL OCCLUSAL DEVELOPMENT DEPENDS UPON
THE PRESENCE OF NORMAL ORO–FACIAL MUSCLE FUNCTION.
EXERCISE FOR MASSETER MUSCLE
IT INVOLVES CLENCHING OF THE TEETH BY PATIENT WHILE
COUNTING TO TEN. THE PATIENT IS ASKED TO REPEAT THIS FOR
SOME DURATION
EXERCISE FOR THE LIPS (CIRCUMORAL MUSCLES)
1. IN PATIENTS HAVING SHORT HYPOTONIC LIPS, STRETCHING OF
UPPER LIP IS ADVISED TO MAINTAIN LIP SEAL
2. THE PATIENT CAN ALSO BE ADVISED TO STRETCH THE UPPER
LIP IN A DOWNWARD DIRECTION
3. HOLDING AND PUMPING OF WATER BACK AND FORTH BEHIND
THE LIPS
4. MASSAGING THE LIPS
5. BUTTON PULL EXERCISE
6. TUG OF WAR EXERCISE

28. EXERCISE FOR THE TONGUE
1. ONE ELASTIC SWALLOW
2. TONGUE HOLD EXERCISE
3. TWO ELASTIC SWALLOW
4. THE HOLD PULL EXERCISE
7. INTERCEPTION OF SKELETAL MALRELATIONS
1. INTERCEPTION OF CLASS II MALOCCLUSION –
THE MAXILLARY GROWTH CAN BE RESTRICTED BY USE OF
EXTRAORALAPPLIANCE LIKE FACE BOW WITH HEAD GEAR.
DEFICIENT MANDIBULAR GROWTH CAN BE TREATED BY GIVING
MYO – FUNCTIONALAPPLIANCES
2. INTERCEPTION OF CLASS III MALOCCLUSION –
CHIN CUP WITH HEADGEAR HELPS IN RESTRICTION OF
MANDIBULAR GROWTH
FRANKEL III OR FACE MASK THERAPY IS USED IN CASES OF
MAXILLARY DEFICIENCY.

29. 8. REMOVAL OF SOFT TISSUE AND BONY BARRIERS
OVERRETAINED PRIMARY TEETH, ANKYLOSED PRIMARY TEETH
AND SUPERNUMERARY TEETH ARE OTHER CAUSES OF NON
ERUPTION OF SUCCEDENOUS TEETH, WHICH SHOULD BE RULED
OUT, PRIOR TO THIS PROCEDURE
THE EXTENT OF TISSUE REMOVAL SHOULD BE SUCH THAT THE
GREATEST DIAMETER OF THE CROWN OF THE TOOTH IS EXPOSED.
THE SURGICAL WOUND IS GIVEN A Zn-O2 CEMENT DRESSING FOR A
PERIOD OF 2 WEEKS.

30. OVERRETAINED DECIDUOUS TEETH
PROXIMAL REDUCTION OF
DECIDUOUS TEETH TO
FACILITATE ERUPTION OF
PERMANENT TEETH

31. THE END