Interceptive orthodontics / for orthodontists by Almuzian

UNIVERSITY OF GLASGOW
Interceptive orthodontics
Personal notes
Mohammed Almuzian
1/1/2013
.

Mohammed Almuzian, University of Glasgow, 2013 Page 1
Contents
Definition................................................................................................................................ 4
Need for IO............................................................................................................................. 4
General Aims of Interceptive Orthodontics................................................................................ 4
Timing ....................................................................................................................................5
Interceptive orthodontics targets the following orthodontic problems ..........................................5
Spacing and Crowding ............................................................................................................. 6
Definition................................................................................................................................ 6
Type of Crowding.................................................................................................................... 6
1. Primary crowding ..........................................................................................................6
2. Secondary crowding.......................................................................................................7
3. Tertiary or ‘late lower incisor crowding’ .........................................................................7
Management of crowding in developing dentition ......................................................................7
Elective extraction ................................................................................................................... 7
Elective extraction of deciduous canines.................................................................................... 7
Elective extraction of all 6's......................................................................................................8
Wilkinson criteria (Wilkinson, 1940) ........................................................................................ 8
Elective extraction of the second molars.................................................................................... 8
Disadvantages ......................................................................................................................... 8
Elective extraction of the premolars .......................................................................................... 9
Serial extraction....................................................................................................................... 9
Steps of serial extraction...........................................................................................................9
Indications:............................................................................................................................ 10
Advantages of Serial Extractions ............................................................................................ 10
Disadvantages of Serial Extractions ........................................................................................ 10
Modified serial extraction....................................................................................................... 12
Space maintainer................................................................................................................... 12
Advantages............................................................................................................................ 12
Disadvantages ....................................................................................................................... 12
Indications............................................................................................................................. 12
Contraindication .................................................................................................................... 13
Techniques ............................................................................................................................ 13
Space regaining ..................................................................................................................... 14
Technique ............................................................................................................................. 14

Management of Lee way space............................................................................................... 14
Balance and compensatory extraction...................................................................................... 15
Early loss of primary teeth...................................................................................................... 15
RCSEng guidelines and Recommendations.............................................................................. 15
Forced extraction in poor prognosis 6s .................................................................................... 15
Guidelines for forced first molar extraction (RCSEng. By Cobourne 2009)................................ 16
Class I cases with minimal crowding (3mm) ............................................................................ 16
Class I cases with crowding.................................................................................................... 16
Class II case with crowding. ................................................................................................... 18
Abnormality in tooth position ................................................................................................. 19
Infra-occlusion ...................................................................................................................... 19
Management.......................................................................................................................... 19
Impacted incisors ................................................................................................................... 20
SIGN recommendations (Yaqoob et al 2010):.......................................................................... 20
Ectopic canine ....................................................................................................................... 21
Methods ............................................................................................................................... 21
Impacted 6s........................................................................................................................... 24
Treatment options, Kennedy 1987........................................................................................... 24
IO treatment.......................................................................................................................... 25
Treatment to disimpact the molars........................................................................................... 25
Treatment to regain space following early loss of E: Kurol and Bjerklin 1987 ............................ 26
Asymmetric Dental Development ........................................................................................... 26
Prolong retention of primary teeth or Overretained Primary Teeth............................................. 27
Local factors.......................................................................................................................... 28
Enamel defects ...................................................................................................................... 28
Maxillary midline diastema .................................................................................................... 28
Abnormality in teeth shape, form & size.................................................................................. 28
Treatment.............................................................................................................................. 28
Abnormality in teeth number .................................................................................................. 29
Supernumerary teeth.............................................................................................................. 29
Treatment.............................................................................................................................. 29
Indications for Monitoring...................................................................................................... 29
Indications for removal .......................................................................................................... 29
Hypodontia............................................................................................................................ 30

Treatment options .................................................................................................................. 30
Traumatic loss of incisors ....................................................................................................... 31
Management.......................................................................................................................... 31
Displacements & crossbites.................................................................................................... 32
Anterior crossbites ................................................................................................................. 32
Crossbite with Displacement .................................................................................................. 32
Habits ................................................................................................................................... 33
Management of digit-sucking habits........................................................................................ 33
Prevention of digit-sucking habits, BOS guidelines 2000.......................................................... 33
Treatment of digit-sucking habits, BOS guidelines 2000........................................................... 34
Increased and decreased Overjet............................................................................................. 35
Indications for IO treatment of increased OJ (early treatment of CLII problems) ........................ 35
1. Class II females with a significant skeletal discrepancy...................................................... 35
2. An increased overjet, which is a source of teasing and bullying........................................... 35
3. An increased overjet, which is at risk of trauma (often associated with gross lip incompetence
and marked maxillary protrusion)............................................................................................ 35
Advantages of early treatment................................................................................................. 35
Disadvantages of early treatment ............................................................................................ 36
Evidences of poor outcome of early treatment versus late treatment .......................................... 36
Advantages of late IO for increase OJ ..................................................................................... 38
Early treatment of Class III..................................................................................................... 39
Time ..................................................................................................................................... 39
Method ................................................................................................................................. 39
Indication .............................................................................................................................. 39
Problems ............................................................................................................................... 39
Richardson, 1999, screening for IO ........................................................................................ 40
Age....................................................................................................................................... 40
Do ........................................................................................................................................ 40
Don’t .................................................................................................................................... 40

Interceptive orthodontics
Definition
• Profit and Ackerman (1980) defined it as the treatment carried out to reduce
the need for further treatment.
• Any treatment which eliminates or reduces the severity of a developing
malocclusion in order to eliminate or simplify the need for future treatment
(Chung 1987)
Needfor IO
1. 15% of developing malocclusions can be fully corrected in primary / mixed
dentitions with relatively simple means. Ackermann & Proffit, 1980
2. 1 in 3 community patients assessed as in need of IO, Only 20% of these
underwent IO, Al Nimri & Richardson, 2000
3. IO Particularly useful in following patient groups:
 Medically compromised
 Physically or mentally retarded.
 Children with cleft of lip/palate.
 Poorco-operators patients.
GeneralAims of Interceptive Orthodontics
1. Minimize psychological implications like teasing.
2. Prevent trauma.
3. Prevent the occurrence of dental pathology
4. Eliminate crossbites associated with displacement.
5. Minimize crowding.
6. Maintain Class I incisor relationship.
7. Maintain centrelines.

Timing
 The most suitable ages for screening the child population for interceptive
orthodontics is 9 years and 11 years(Al Nimri & Richardson, 2000)
 The Interception Gauge is useful in categorizing children in respectof
features of the dentition which are quantifiable.
Interceptive orthodontics targets the following orthodontic problems
1. Crowding management
 Elective extraction of C, 4, 6 or 7s
 Serial extraction
 Modified serial extraction
2. Space management
 Spacemaintainer
 Spaceregaining
 Management of Lee way space (should be called D and E spaceand not
include C because we loss spacewith C)
3. Balance and compensatoryextraction
 in primary teeth due to early loss of primary teeth
 Forced extraction in poorprognosis 6s
4. Abnormality in tooth position and eruption
 Infra-occlusion
 Impacted incisors
 Ectopic canine
 Impacted 6s
 Asymmetric dental development
 Prolong retention of primary teeth

5. Localfactors
 enamel defects
 Maxillary midline diastema and labial frenum
 Abnormality in teeth shape, form & size
 Abnormality in teeth number
I. Supernumerary teeth
II. Hypodontia
III. Traumatic loss of incisors
6. Displacements & crossbites
 Anterior crossbites
 Posterior crossbitewith Displacement
7. Habits
8. Increasedand decreased overjet
Spacing and Crowding
Definition
As faulty relationship bet MD of teeth, jaw size and arch perimeter. Jaw size
determine the available spacefor teeth apices, arch perimeter determine the
available spacefor teeth crown while MD falls in between them. Richardson,
1999
Type of Crowding
Crowding can be categorized into three distinctively different types according
to aetiology.
1. Primary crowding refers to tooth size and arch size discrepancy, with this
ratio being more often increased (causing crowding) than reduced (which
results in spacing), and this is genetically determined.

2. Secondarycrowding is caused by premature loss of primary molars, which
is environmental in origin.
3. Tertiary or ‘late lower incisorcrowding’ is a phenomenon that has both
genetic and environmental contributions, the main determinant being
differential late jaw growth.
Managementof crowding in developing dentition
Elective extraction
Elective extractionof deciduous canines
1. Extraction of lower deciduous canines has been suggested for the correction
of mild lower incisor crowding. Houston and Tulley (1989) state that in
general terms this allows some correction of the incisor crowding. Stephens
(1989), reported that the ideal age group for this would be 9-10 years of age
to allow full development of the intercanine width. Proffit (1993) however
warns that this may result in the lower incisors tipping lingually further
reducing arch length.
2. Provide spacefor palatally lateral incisors.
3. Provide spacefor incisors whose eruption is late due to supernumeries.
4. Extraction of upper deciduous canines is often suggested in order to attempt
to encourage a palatally placed canine to erupt into a normal position.
Research has shown that this indeed is quite successfulwith 70% erupting
into favourable positions (Ericsson and Kurol, 1988).
5. Extraction of lower C`s may help in treatment mandibular displacement.
6. Serial extraction
7. Balance extraction for maintaining ML integrity

Elective extractionof all 6's
Wilkinson criteria (Wilkinson, 1940)
1. All successionalteeth present and third molars present
2. Lower second molar bifurcation beginning to form.
3. Angle between long axis of crypts of 6 and 7 = 15-30 degree and crypt of
lower 7 overlaps the rootof lower 6.
4. CIass I
5. Mild anterior segment crowding
6. Moderate posterior crowding
Elective extractionof the secondmolars
1. Relief of premolar crowding in a vertically impacted premolar in the line of
the arch where early extraction indicated for spontaneous correction.
Richardson 1992
2. Provide spacefor the third molars. Richardson 1983
3. Interceptive treatment of the existing or anticipated arch length deficiency.
Extraction in early permanent dentition may prevent or at least limit late
lower arch crowding. Richardson 1983. Requirements for second molar
prophylactic extraction (Lehman, 1979):
 All third molars are present and of normal size and shape.
 Third molars should be of 15 – 30 degrees with the long axis of the first
molar and its root not developed yet.
Disadvantages
1. 3rd molars may erupt into an unsatisfactory position, rarely with proper
angulation and contact relationship in 4% Richardson and Richardson (1993)

2. Difficult to predict which 3rd molars will erupt unsatisfactory (Thomas and
Sandy, 1995).
3. Second course of treatment to orthodontically upright the 3rd molar may be
required (Orton and Jones, 1987).
Elective extractionof the premolars
1. Early loss of 4`s with mesially inclined 3`s can spontaneously improve
certain malocclusions and can reduce time with active appliances.
2. Extraction of 4`s with spacemaintenance can allow impacted 5`s to erupt.
Serialextraction
Popularised in Europe in the 1930’s and recorded by Kjellgren (1947), the
early philosophy behind serial extractions was to attempt to align severely
crowded teeth without further need for treatment.
Steps of serial extraction
 Relieve of crowding in the lower incisor region by extraction of upper and
lower c’s
 Extraction of D’s when half their roots are resorbed to fasten eruption of the
first permanent premolars. This is in an attempt to encourage early eruption
of particularly 4s that it erupts before 3s. If extracted too early this may delay
eruption and cause excessive space loss.
 There is no guarantee that the lower premolar will erupt before the canine and
as such the latter may be impacted. If this occurs extraction of the second
deciduous molars may be an option with Holtz (1970) advocating the
provision of a lingual arch retainer for space maintenance. The latter author
also recommends disking of the second deciduous molars to provide space
for premolar teeth
 Extraction of 4s on eruption to allow alignment of 3s.

Indications:
Sever crowding in:
1. 8-9 yrs old
2. skeletal Class I
3. normal OJ and OB
4. 4`s developmentally ahead of 3`s
5. First permanent molars of good prognosis
6. all permanent teeth present
Advantages of Serial Extractions
 in theory no appliance treatment needed
 appliance may be simpler and shorter 50% reduction in the treatment time
(Little 1990)
 Better stability and retention since tooth completes its formation in a site
where it will remain when treatment is completed (Graber, 2011)
DisadvantagesofSerialExtractions
1. Exposed to multiple extractions (12 teeth)
2. No guarantee, extractions of D`s can lead to impaction of 4`s if the 3s erupt
ahead of the 4s. Removal of twelve teeth is a traumatic experience and there
is no guarantee that the lower premolar will erupt before the canine and as
such the latter may be impacted. If this occurs extraction of the second
deciduous molars may be an option with Holtz (1970) advocating the
provision of a lingual arch retainer for spacemaintenance. The latter author
also recommends disking of the second deciduous molars to provide space
for premolar teeth.

3. Growth prediction problems: difficult to predict amount of incisor crowding
because ICW  between 8-10yrs i.e. lower incisor crowding may resolve
spontaneously
4. Spaceloss with extractions of C`s and especially D`s, by mesial drift of
buccalsegments, lower incisors tip lingually, both of these reduces arch
length
5. Tipping of teeth into extractions site especially anterior teeth causing OB
increasing. Little 1990
6. There was no difference between the serial extraction sample and a matched
sample extracted and treated after full eruption except shorter time for active
orthodontic treatment (Little 1987, 1990): Little (1987) observed lower labial
segment relapse 10 years posttreatment in patients who had undergone
premolar extraction in the mixed dentition, serial extractions, non-extraction
with expansion, no treatment normals and patients with spaced dentition. He
concluded that serial extractions were still a good idea as it reduced further
treatment time (50% reduction in treatment time compared with the late
premolar extraction group) and allowed teeth to erupt through attached
gingivae. Little continued his research into serial extraction with a paper in
1990 which compared patients undergoing serial extractions with the
provision later of fixed appliances and patients with late premolar extractions
and fixed appliances. Diagnostic records were available for the following
stages: pre-extraction, start of active treatment, end of active treatment, and a
minimum of 10 years postretention. All cases were treated with standard
edgewise mechanics and were judged clinically satisfactory by the end of
active treatment. Twenty-two of the 30 cases (73%) demonstrated clinically
unsatisfactory mandibular anterior alignment postretention. Intercanine width
and arch length decreased in 29 of the 30 cases by the postretention stage.
There was no difference between the serial extraction sample and a matched
sample extracted and treated after full eruption.

Modified serial extraction
1. Serial extraction has no real role in modern orthodontics
2. Modified form, by applying stage 3+4 only  extraction of Ds and 4s and
Space maintainer
Advantages
1. Prevent potential mesial drift of permanent molars and the development of
secondarycrowding.
2. Prevent distal drift of incisors
3. Prevent mid-line deviations
4. Prevent overeruption of the opposing teeth.
5. Use Leeway space for relieving of the crowding.
6. Aesthetic purposes
Disadvantages
1. Need to insert immediately
2. Perceived long treatment
3. No guarantee it will prevent later treatment
4. Compliance,
5. Oral hygiene,
6. Regular inspection
Indications
1. Good OH
2. Low caries rate is essential
3. Compliant patient.
4. Loss of central incisor for aesthetic purposes
5. Unilateral loss of c
6. Early loss of E before eruption of 6
7. Early loss of D
8. Difficult to assess clinically the occlusion at the current stage.

9. In an occlusion with only mild crowding where any further spaceloss would
result in the need for more complex orthodontic treatment
10.In an occlusion with severe crowding where any further spaceloss would
result in more than a single tooth unit of space being required.
Contraindication
1. If a permanent successorwill erupt within 6 months (i.e., if more than one-
half to two-thirds of its root has formed), a spacemaintainer is unnecessary.
2. If there is not enough space for the permanent tooth or if it is missing, space
maintenance alone is inadequate or inappropriate
Techniques
1. Band and loop; used with one tooth missing in the posterior area
2. Bonded rigid wire across the space
3. URA and partial denture; used if more than one tooth is lost and to replace
anterior tooth
4. Lingual arch
5. Transpalatal arches or fixed-removable lingual and palatal arch eg 3D Wilson
lingual arch
6. Distal Shoe Space Maintainers:
 The distal shoe has a unique application and is the appliance of choice when a
primary second molar is lost before eruption of the permanent first molar.
 It consists of a metal or plastic guide plane along which the permanent molar
erupts. The guide plane is attached to a fixed or removable retaining device
 To be effective, the guide plane must extend into the alveolar process so that
it is located approximately 1 mm below the mesial marginal ridge of the
permanent first molar, at or before its emergence from the bone.
 When fixed, the distal shoeis usually retained with a band instead of a
stainless steel crown so that it can be replaced by another type of space
maintainer after the permanent first molar erupts.

 If primary first and second molars are missing, the appliance must be
removable and the guide plane is incorporated into a partial denture because
of the length of the edentulous span.
 It is contraindicated in patients who are at risk for sub-acute bacterial
endocarditis
Space regaining
Procedures can be employed if spacehas been lost due to drifting regained
spaceis limited to 3mm or less of spaceregaining.
Technique
1. Sectional fixed appliance
2. URA
3. Lip bumper
4. HG
5. Molar distalization technique can be used to regain space
Managementof Lee way space
Brennan & Gianelly 2000
1. If a lingual arch is placed during the mixed dentition only an arch length
decrease of 0.44 mm has been reported with gaining of 4.44 mm Leeway
space.
2. Also the stability were good after lingual arch treatment
3. However it was shown that intercanine is increased after using lingual
arch and this bec the 3s migrate distally toward a wider arch.

Balance and compensatoryextraction
Early loss of primary teeth
RCSEng guidelines and Recommendations
Radiographic screening is highly desirable before extracting primary molars
to check for the presence, position and correct formation of the crowns and
roots of successionalteeth. Potential problems indicate the need to seek an
orthodontic opinion before teeth are removed.
1. Loss of primary incisors – Early loss of primary incisors has little effect
upon the permanent dentition although it does detract from appearance. It is
not necessary to balance or compensate the loss of a primary incisor.
2. Loss of primary canines– Early loss of a primary canine in all but
spaced dentitions is likely to have most effect on centre lines. The more
crowded the dentition, the more the need for balance.
3. Loss of primary first molars –With regard to a primary first molar, a
balancing extraction may be needed in a crowded arch but compensation is
not needed.
4. Loss of primary secondmolars – There is no need to balance the loss of
a primary second molar becausethis will have no appreciable effect on
centreline coincidence. However when a primary second molar has to be
extracted consideration should be given to fitting a spacemaintainer
Forcedextractionin poor prognosis 6s
The 6s are the more caries prone teeth because
 They are erupted early and exposed to oral environment
 Also they are more commonly affected by hypoplasia than other teeth.
If the 6s are poorly restored or decayed then the it is better to considerearl
extraction to allow spontaneous spaceclosure or use of the spacefor
orthodontic purposes.

Guidelines for forced first molar extraction (RCSEng. ByCobourne
2009)
A number of general guidelines on treatment planning first permanent molar
extraction cases for a number of malocclusions are available
 As a general rule, if in doubt, get the patient out of pain, try and maintain
the teeth and refer for an orthodontic opinion.
ClassI cases
Class I cases withminimal crowding (3mm)
 Aim for extraction at the optimal time for eruption of the second molars
into a good position.
 Do not balance unilateral first molar extraction in either the upper or
lower arches with healthy first molars.
 If the lower first molar is to be lost, compensating extraction of the upper
first molar should be considered to avoid overeruption of this tooth, unless
the lower second molar has already erupted and the upper first molar is in
occlusal contactwith it.
 If the upper first molar is to be lost, do not compensatewith extraction of
the lower first molar if it is healthy.
Class I cases withcrowding
 First molar extractions can be delayed until the second molars have
erupted and then the extraction spaceused for alignment with fixed
appliances.
 Alternatively, first molars can be extracted at the optimum time and the
crowding treated once in the permanent dentition. If premolar extractions are
likely to be required at this stage, the third molars should be present. If the
buccalsegment crowding is bilateral, consider balancing extraction to
provide suitable relief and maintain the centreline. Compensating extraction

of upper first molars should be considered to prevent overeruption or relieve
premolar crowding
ClassII cases
The main complicating factors often involve the upper arch becauseof the
need for space to correctthe incisor relationship.
Class II cases withminimal crowding
Lower first molar extraction
 It should be carried out at the ideal time for successfuleruption of the
second permanent molar and controlof the second premolar. Regarding
compensating and balancing extraction:
a) Compensating and balancing extraction of healthy lower first molars are not
indicated. So that, if the upper first molars are to be left unopposed, asimple
removable appliance may be required to prevent their over-eruption, whilst
waiting for the second molars to erupt. Alternatively, a functional appliance
can be used immediately to correct the incisor relationship prior to extraction
of the first molars and fixed appliances.
b) If the upper first permanent molar is sound, elective extraction may be
indicated if it is at risk of over-erupting; however, the third molars should
ideally be present radiographically.
c) If there is no sign of upper third molar development, an appliance to prevent
the over-eruption of sound upper first molars should be considered.
Upper first molar extraction
 In the upper arch, space will often be required to correctthe incisor
relationship: If the upper first permanent molars require immediate
extraction, orthodontic treatment may be instituted to correct the incisor
relationship. A functional appliance or removable appliance and headgear can
be used to correct the buccal segment relationship, followed by fixed
appliances if required.

 If the upper first permanent molars can be temporised or restored, then
their extraction can be delayed until the second permanent molars have
erupted. The resultant extraction spacecan then be used to correct the
malocclusion with fixed appliances.
 Alternatively, after extraction of the upper first permanent molars, the
second permanent molars can be allowed to erupt and the incisor relationship
corrected then by the loss of two upper premolars teeth. But as a condition,
there should be a radiographic evidence of third molar development.
Class II case with crowding.
Lower first molar extraction
 Spacewill also be required in the lower arch for the relief of crowding. If
the third molars are present radiographically, lower first molars can be
extracted at the optimum time to allow second molar eruption and then
premolars extracted at a later stage for the correction of crowding. In these
cases, fixed appliances will usually be required.
 Alternatively, first molars can be extracted after second molar eruption
and the spaceused directly for the correction of crowding with fixed
appliances.
 Balancing and compensating extraction of lower first molars are not
generally required.
Upper first molar extraction
 Spacerequirements in the upper arch can be significant. The upper first
permanent molars should be temporised or restored and the child referred to a
specialist orthodontist whenever possible.
 If the upper first permanent molar is unopposed, at risk of over-erupting
and third molars are present radiographically, then extraction of the upper
first molar may be indicated. The patient should be counselled that additional

premolar extractions in the upper arch may be required in the future to create
sufficient spacefor crowding relief and incisor correction.
ClassIII cases
Class III cases are often even more difficult to manage and ideally require the
opinion of a specialist orthodontist before any first permanent molars are
extracted. As a general rule, extraction of maxillary molars should be avoided
if at all possible, whilst balancing and compensating extractions are not
recommended in class III cases.
Abnormality in tooth position
Infra-occlusion
Management
1. In the presence ofa permanent successor
A. Minimal infraocclusion, the ankylosed tooth can usually be left under
observation to exfoliate naturally.
B. Significant infraocclusion can lead to adjacent teeth displacement, tipping
and overeruption of adjacent teeth. In these circumstances, consideration
should be given to either restoring the vertical dimension or extracting the
affected tooth with lingual or palatal arch to maintain the space until the
permanent teeth erupt.
2. In the absence ofa permanent successor,
A. Early Extraction to facilitate spontaneous spaceclosure to allow permanent
teeth to drift into the edentulous spaceand bring bone with them, and then
reposition the teeth prior to implant or prosthetic replacement, so that large
periodontal defects do not develop.
B. Premolaizing the E and accepting it in the place permanently.
C. Slicing and spaceclosure

D. Extraction and prosthetic replacement;
E. Retention of the second deciduous molar.
Impacted incisors
SIGN recommendations (Yaqoob et al 2010):
1. Children under nine years with incomplete root development of
permanent incisor:
 Remove obstruction.
 Create space if required.
 Maintain the space
 Do not uncover bone from unerupted incisor maintain integrity of follicle.
 Monitor eruption for 18 months – 80% erupt spontaneously
 If exposure required then exposeminimally to eliminate soft tissue
obstruction and wait for 6 months. If tooth is still high, expose and bond
bracket.
2. Children above nine years with complete or nearly complete apex:
 If permanent incisor high then monitor eruption for 12 months.
 If tooth still unerupted at 12 months, expose and bond bracket as required.
3. Children referred late (over 10 years):
 Expose and bond bracket at first operation.

Ectopic canine
The principles of interceptive treatment for palatal canines are:
1. Remove any obstruction – this usually means removal of the deciduous
canine
2. Ensure adequate spacefor eruption
Methods
1. Extraction of the
primary canines at the
age between 10 and 13
year.
Ericson and
Kurol, 1988
78% success rate
2. Extraction of the
primary canines in
crowded and
uncrowded cases
Power and
Short, 1993.
In general 62% showed
improvement in eruptive
position. In crowded cases
the success rate was 14% as
opposedto 86% in un-
crowded cases
3. The extraction of the
deciduous canine and
creation of excess
spacefor the impacted
tooth
Olive, 2002 94% success rate.
4. Extraction of C + HG.
RCT
Leonardi et
al., 2004
 HG+exo 80%
 Exo 50%,
 Control 34%
5. Extraction of C + HG.
RCT by
Baccetti et
al., 2008,
 HG+exo 88%
 Exo 65%,
 Control 36%
6. Cochrane review by Parkin, 2009 There is currently no
evidence to supportthe
extraction of the deciduous
maxillary canine to facilitate
the eruption of the palatally
ectopic maxillary permanent
canine.
7. Effect of RME and
headgear treatment on
the eruption of
Armi
& Baccetti,
2011
 RME+HG+EXO 86 %
 HG+EXO 83%,

palatally displaced
canines. RCT
 Control 36%.
8. Effects of RME and
TPA treatment
associated with
deciduous canine
extraction on the
eruption of palatally
displaced canines RCT
by
Bacceti 2011  RME+TPA+EXO 80%,
 TPA+EXO 79%
 EXO 62.5%
 Control 28%
9. A systematic review of
the interceptive
treatment of palatally
displaced maxillary
canines, ,
Kurol 2011 No evidence-based
conclusions could be drawn
due to the few studies
identified, the heterogeneity
in study design, and the
unequivocal results
10. Preventive treatment
of ectopically erupting
maxillary permanent
canines by extraction
of C & Ds: RCT
Bonetti
2011,
50% of canines in the TG
improved position by one
sectorand 13% by two
sectors, while on 32% of the
canines in CG improved by
one sectorand none by two
sectors.
 Extraction of the primary canines at the age between10 and 13 year,
Ericsonand Kurol, 1988. 46 consecutive ectopic palatally placed maxillary
canines were studied. In (78%) the palatal eruption changed to normal after
12 months. It suggest that extraction of the primary canine is the treatment of
choice in young individuals (10-13 years) to correctpalatally ectopically
erupting maxillary canines provided that normal spaceconditions are present
and no incisor root resorption are found.
 Extractionof the primary canines in crowdedand uncrowded cases by
Powerand Short, 1993. 9consecutive patients of mean age 11.2 years. In
general 62% showed improvement in eruptive position. In crowded cases the
success rate was 14% as opposedto 86% in un-crowded cases. Horizontal

overlap of the nearest incisor was found to be the most significant factor. If
this exceeded half the tooth width, success was unlikely. The presence of
crowding was found to affect adversely the favourable eruption of the
canine.
 The extractionof the deciduous canine and creationof excess spacefor
the impacted tooth Olive, 2002. Thespacecreated was 1 cm with the
incisors being proclined and displaced up to 3mm across the midline. The
results were impressive 94% success rate.
 Extraction of C + HG. RCT by Leonardi et al., 2004, groups1)with
extraction of C only, groups2) extraction C + HG (to increase arch length)
groups3 control; results were 50%, 80% an 34% respectively.
 Extraction of C + HG. RCT by Baccettietal., 2008, 1) with Xtn of C only,
2) Xtn C + HG, group 2) control, group 3) successfuleruption of 3. 65%,
88% and 36% successfuleruption of 3 resepectively.
 Cochrane review by Parkin, 2009, Extraction of primary (baby) teeth for
unerupted palatally displaced permanent canine teeth in children. There is
currently no evidence to supportthe extraction of the deciduous maxillary
canine to facilitate the eruption of the palatally ectopic maxillary permanent
canine. Two randomised controlled trials were identified but unfortunately,
due to deficiencies in reporting, they cannot be included in the review at the
present time.
 Effectof RME and headgeartreatmenton the eruption of palatally
displacedcanines. RCT by Armi & Baccetti, 2011, Therandomized
prospective design comprised 64 subjects three groups: cervical pull headgear
(HG); rapid maxillary expansion and cervical pull headgear (RME/HG);
untreated control group (CG). The prevalence of successfuleruption was
83%, 86 % and 36% respectively.

 Effects of RME and TPA treatment associatedwith deciduous canine
extraction on the eruption of palatally displacedcanines RCT by Bacceti
2011, Hundred and twenty subjects were enrolled in an RCT based on PDCs
diagnosed on panoramic radiographs and they were randomly assigned to one
of four study groups. Three treatment groups (TGs) (RME followed by TPA
therapy plus extraction of deciduous canines, TPA therapy plus extraction of
deciduous canines, extraction of deciduous canines, EC group. The
prevalence of canine eruption was 80%, 79%, 62.5% and 28% respectively.
The use of a TPA in absenceof RME can be equally effective than the
RME/TPA combination in PDC cases not requiring maxillary expansion, thus
reducing the burden of treatment for the patient.
 A systematic review of the interceptive treatment of palatally displaced
maxillary canines, Kurol 2011, No evidence-based conclusions could be
drawn due to the few studies identified, the heterogeneity in study design, and
the unequivocal results
 Preventive treatment of ectopicallyerupting maxillary permanent
canines by extraction of C & Ds: RCT by Bonetti 2011, 50% of canines in
the TG improved position by one sectorand 13% by two sectors, while on
32% of the canines in CG improved by one sector and none by two sectors.
The extraction of maxillary first deciduous molars, in addition to the
deciduous canines, appears to create more spaceand allow canines, at risk
from impaction, to improve their position spontaneously.
Impacted 6s
Treatment options, Kennedy 1987
 80% self-correct by age 7yrs while 10% self-correct at age 8 or 9yrs
 The optimal treatment approach depends on a number of factors
including

1. The clinical eruption status of 6
2. The change in position of 6
3. The amount of enamel ledge of 6/El
4. The mobility of /El,
5. The presence of pain or infection.
IO treatment
a. If resorption of E <1.5mm:
• observe 3-6mths (to establish if reversible)
• if no resorption and vertical position improved: monitor eruption
• if no resorption and vertical position not improved: exposeunerupted 6 and
wait for 3 months
• if still <1.5mm resorption: treatment to move the impacted tooth distally (see
below)
b. If resorption of E >1.5mm:
• if E symptomatic or mobility >1mm consider Xtn and management of space
problem once 6 erupts
• If E asymptomatic and mobility <1mm and 6 partially erupted: treatment to
move the impacted tooth distally
• If E asymptomatic and mobility <1mm and 6 unerupted: expose 6 and
commence treatment to move the impacted tooth distally
Treatment to disimpact the molars
A.6 is partially erupted
1. brass wire ligature
2. elastomeric
3. steel spring clip separators

4. orthodontic band on E with attached distal spring +/- transpalatal arch when
maximal anchorage required (Halterman appliance)
5. Humphrey appliance. A bonded button is placed on the first permanent
molar at the same time the appliance is cemented on
the second primary molar. The free arm engages on
the mesial side of the button using reciprocal
anchorage to distalize the permanent molar.
Activation at 3 to 4-week intervals is made with
three-prong pliers until overcorrection occurs.
6. orthodontic band on the E and a bonded bracket on the exposed cusp of 6,
with an open coil spring
b. 6 is unerupted: surgicallyexpose and try above techniques or distal
extensionattached to SS crown
Treatment to regainspace following early loss of E: Kurol and Bjerklin
1987
1. Cervical headgear but not in AOB or Cl3
2. A removable appliance with a spring or expansion screw to distalize
maxillary first molar (When there is extensive space loss, an anterior
biteplate may be needed to free up the occlusion to permit uprighting of
the tilted permanent molar)
3. Combination (he removable appliance acts to tip the crown of the molar
distally while the high-pull headgear, directed above the center of
rotation of the molar, acts to distalize the root. (Nudger appliance)
Asymmetric Dental Development
 Asymmetric eruption (one side ahead of the other by 6 months or more) is
significant. It requires careful monitoring of the situation, and in the absence
of outright pathology, often requires early treatment such as selective
extraction of primary or permanent teeth.

 A few patients with asymmetric dental development have a history of
childhood radiation therapy to the head and neck or traumatic injury.
 Surgical and orthodontic treatment for these patients must be planned and
timed carefully and may require tooth removal or tooth reorientation.
 Some of these teeth have severely dilacerated roots and will not be candidates
for orthodontics these situations definitely fall into the complex category and
usually require early intervention.
Prolong retention of primary teeth or Over retained Primary Teeth
 A permanent tooth should replace its primary predecessorwhen
approximately three-fourths of the root of the permanent tooth has formed,
but a primary tooth that is retained beyond this point should be removed
because it often leads to gingival inflammation and hyperplasia that cause
pain and bleeding and sets the stage for deflected eruption paths of the
permanent teeth that can result in irregularity, crowding, and crossbite.
 If a portion of the permanent tooth crown is visible and the primary tooth is
mobile to the extent that the crown will move 1 mm in the facial and lingual
direction, it is probably advisable to encourage the child to “wiggle” the tooth
out. If that cannot be accomplished in a few days, extraction is indicated.
Most overretained primary maxillary molars have either the buccal roots or
the large lingual root intact; most over-retained primary mandibular molars
have either the mesial or distal root still intact and hindering exfoliation
 Once the primary tooth is out, if spaceis adequate, moderately abnormal
facial or lingual positioning will usually be corrected by the equilibrium
forces of the lip, cheeks, and tongue.

Localfactors
Enamel defects
 Monitor,
 Restore temporary,
 Extract if sever
Maxillary midline diastema
It depends primarily upon the removal of the underlying cause.
A. in the deciduous dentition , no treatment
B. in mixed dentition just reassure
C. in permanent dentition
1. Aesthetic build-up of the centrals
2. Active orthodontic treatment to close a diastema is usually carried out in the
permanent dentition. Using:
• URA
• FA
3. Long-term retention is usually mandatory. Forthis reason, particularly for a
minor diastema, persuading the patient that it is a feature of individuality that
does not require closing can be advantageous.
4. Adjunctive procedurelike
 Frenectomy but this is not recommended anymore according to Jensen et al
1973 but Edward 1977 mentioned the opposite.
 Composite build-up of the small teeth.
Abnormality in teeth shape, form & size
Treatment
1. No treatment
2. Inter-Proximal Stripping
3. Composite

4. or veneer reshaping
5. Intentional RCT, Extraction and prosthetic replacement (implant, bridge,
implant). VERY UNSUAL AND DESTRUCTIVE
Abnormality in teeth number
Supernumerary teeth
Treatment
 leave it and monitor
 extract +ortho
Indications for Monitoring
1. There is no associated pathology;
2. Satisfactory eruption of related teeth has occurred and no active orthodontic
treatment is planned;
3. Removal would prejudice the vitality of the related teeth.
Indications for removal
1. Supernumerary caused aesthetic problem.
2. Supernumerary prevent eruption of permanent teeth.
3. Supernumerary caused diastema or displacement.
4. Supernumerary caused pathology
5. Active orthodontic alignment of an incisor in close proximity to the
supernumerary is envisaged;
6. Its presence would compromise secondary alveolar bone grafting in cleft lip
and palate patients;
7. The tooth is present in bone designated for implant placement;

Hypodontia
Treatment options
A. Treatment for hypodontia in primary dentition
 No treatment is indicated at this stage.
 However removable dentures for psychological and functional reasons might
be used but it will require regular adjustments during growth. Retention and
stability may be problematic in those with poorly developed alveolar ridges.
B. Mixed dentition (involve mainly the interceptive treatment)
1. Extract 1o tooth early  allow space closure. Some recommend
extracting primary tooth, allowing permanent teeth to erupt and close space,
then reopen space at adulthood, so by this way we preserve the bone.
2. Composite build-ups to improve aesthetics of microdont permanent
teeth or worn deciduous teeth
3. Removable dentures
4. Simple orthodontic treatment for space redistribution
5. Retain primary tooth:
As long as possible & replace with prosthesis after cession of the growth, this
will help in preserving alveolar bone
Permanently, retain the primary tooth (if the Es survive until 20yrs then they
appear to have a good prognosis for long term survival Bjerklin &
Bennett,2000)
Missing
Class I Class II Class III
2 If closing space 
xtn E to allow
mesial drift of
buccal segments
Can be used as part of
treatment
Space should be
preserved and
regained to allow
proclination
lower 5 Xtn LE early (9yrs) Keep LE as long as May be used as part

Traumatic loss ofincisors
 Traumatic loss of a maxillary central incisor is seen in around of 3% of
children
 usually occurs unilaterally, in the mixed dentition and in a child with an
increased overjet
Management
Short term management
 Short term spacemaintenance can be achieved with a simple upper partial
denture.
 Alternatively, the spacecan be allowed to close and reopened in the
permanent dentition prior to prosthetic replacement. This allows preservation
of alveolar bone, but will require fixed appliance treatment and often space
creation in the upper arch.
Long term management
1. Spaceclosure and build up laterals
2. Spaceopening with
 Resin-retained bridge
 Implant,
 Autotransplantation of premolar and subsequent coronalmodification
3. In cases of bilateral loss, if spaceis required to reduce an overjet or
relieve crowding and the lateral incisors are of a reasonable size and form,
to allow mesial
drift
possible  lower
arch should be as big
as possible
of xnt to treat
malocclusion

consideration can be given to moving them into the position vacated by the
centrals
Displacements & crossbites
Anterior crossbites
1. if dental Xbite then
 selective grinding
 extraction of the opposingprimary
 Bodily movement  use fixed appliance 2*4 appliance
 Simple tipping movement  use URA with posterior capping, Z spring,
double cantilever spring, crossed cantilever spring, screw plate
2. Dentoalveolar or mild skeletal then
 Chincap
 Frankle 3 (Functional)
Crossbite with Displacement
Recommendations
1. Encourage habit to stop
2. Removal of premature contacts of the baby teeth
3. Posterior onlay
4. Extraction if it is associated with severely displaced single tooth
5. expand upper arch with:
 URA with midpalatal screw, success rates is 50%
 Coffin spring + posterior capping,
 Quad. (QH and RME success rates is 100%)
According to the Cochrane review byHarrison and Ashby, 2008
Cochrane

 The evidence from the trials reported by Lindner (1989); Thilander (1984)
suggests that
A. Removal of premature contacts of the baby teeth is effective in preventing a
posterior crossbitefrom being perpetuated to the mixed dentition and adult
teeth.
B. When grinding alone is not effective, using an upper removable expansion
plate to expand the top teeth will decrease the risk of a posterior crossbite
from being perpetuated to the permanent dentition.
 No evidence of a difference in treatment effect (molar and canine expansion)
between the test and controlintervention was found in the trials which
compared
A. Banded versus bonded
B. Banded versus bonded slow maxillary expansion,
C. Two point versus four point rapid maxillary expansion,
D. Transpalatal arch with/without buccalroot torque,
E. Upper removable expansion appliance versus quadhelix.
Habits
Managementof digit-sucking habits
Prevention of digit-sucking habits, BOS guidelines 2000
1. If a dummy is provided, there appear to be fewer problems in the long-term,
because the majority of dummy sucking habits are self-limiting and stop
before eruption of the permanent teeth. Any persistent dummy sucking habit
is easily broken by removal of the dummy.
2. It has been suggested that if a digit-sucking habit is noticed, a dummy should
be given to the child.

3. If a dummy is used it must not be sweetened. After the age of 2, to prevent
problems with speech development, it should be used as little as possible
during the day
Treatment of digit-sucking habits, BOS guidelines 2000
1. The child must want to stop otherwise any approachis likely to be
unsuccessful.
2. A child who is undergoing severe psychological trauma is unlikely to respond
to habit breaking. A psychologist’s input may be required
3. The use of orthodontic pacifiers which is oval shape and has a vent to reduce
the effect of dummies
4. The following methods for breaking the habit are listed in the order in which
they should be used:
A. Non-physicalmethods
 Explanation
 Reward
 Habit reversal
Teach the child to carry out alternative activities when they have the urge to
suck the digit
B. Physical methods
Reminder therapy like finger bandage, finger paint, boxing gloves or
thermoplastic finger post
C. Intra-oral appliances
These deterrent appliances have been shown to be effective within 10
months.
They must be fitted with the full understanding and co-operation of the child
and must not compromise compliance with any future orthodontic treatment.
Intraoral appliance
1. Removable appliance

2. Fixed appliance like palatal appliance with crib or Blue grass appliance
3. Functional appliance can stop habit
Increasedand decreased Overjet
Indications for IO treatment of increasedOJ (early treatment of CLII
problems)
1. Class II females with a significant skeletal discrepancy.
2. An increased overjet, which is a source of teasing and bullying.
3. An increased overjet, which is at risk of trauma (often associated with gross
lip incompetence and marked maxillary protrusion).
Advantages of early treatment
The believed advantages of early treatment, King 1990 are:
1. Better cooperation (True, O’Brien 2003 with regard to TB treatment early
treatment 16% failure but late 33%)
2. Psychosocialadvantages if patient is treated early. Sandler and DiBiase 2001
showed that the increased OJ is the most unattractive feature. However, The
treatment itself may introduce a new sourceof bullying, (true, O’Brien 2003),
latest Cochrane review by Thiuroventrachachari 2013 showed that early
treatment reduce risk of trauma.
3. Craniofacial tissues more malleable. Questionable?
4. Favourable changes in skeletal and dental AP relationship achieved but may
not be clinically significant. (true for short term, Tulloch, 1998, Keeling,
1998, O’Brien 2003)
5. improved prognosis for adolescent treatment but not significant (not true,
O’Brien, 2003)
6. Elimination of gingival/palatal trauma. Questionable?

7. Less root resorption than one phase (Brin 2003 use the data of UNC and
prove that)
8. Eliminate growth/local disturbances before they have had time to act fully.
Questionable?
9. Betterstability measured using PAR index (Pavlow 2008)
 High trauma with increased overjets >9mm (Todd & Dodd 1983) (45% 10 yr
olds with OJ more than 9mm have traumatised incisors compared to 27% if
the OJ was less than 9mm especially if the lip is incompetent) however RCT
comparing early versus late treatment (Koroluk et al 2003)concluded all
groups experienced trauma. But the latest Cochrane review showed that
early Oj reduction would reduce the chance of trauma (Badri
Thiruvenkatachari, 2013).
Disadvantagesofearly treatment
1. Early start and late finish therefore prolonged courseof treatment
2. Risk of burning patient co-operation. Patient has time expiry approximately
3yrs which can be lost in the first phase leaving no compliance in the second
phase.
3. Limited long term benefits skeletal and dentoalveolar effect compared to one
stag.
4. Choice of Xtn is difficult whilst young
5. Soft tissues do not mature until 12-14yrs with vertical growth of lips this
might affects stability of corrected OJ
6. Arch length not maintained in permanent dentition .
Evidences of poor outcome of early treatment versus late treatment
1. An old review of the literature was unable to establish whether early or late
treatment provided the most benefit overall: 'we lack definitive cost-benefit
information. King et al., 1990

2. O’Brien 2009 RCT study
 The aim of this study was to evaluate the effectiveness of early orthodontic
treatment with the Twin-block appliance for the treatment of Class II
Division 1 malocclusion.
 This was a multi-center, randomized, controlled trial with subjects from 14
orthodontic clinics in the United Kingdom. The study included 174 children
aged 8 to 10 years with Class II Division 1 malocclusion; they were
randomly allocated to receive treatment with a Twin-block appliance or to
an initially untreated control group.
 The subjects in both groups were then followed until all orthodontic
treatment was completed by FA .
 Final skeletal pattern, number of attendances, duration of orthodontic
treatment, extraction rate, costoftreatment, and the child's self-concept
were considered.
 At the end of the 10-year study, 141 patients either completed treatment or
accepted their occlusion. Data analysis showed that there were no
differences between those who received early Twin-block treatment and
those who had 1 courseof treatment in adolescencewith respect to skeletal
pattern, extraction rate, and self-esteem.
 Conclusions: Twin-block treatment when a child is 8 to 9 years old has no
advantages over treatment started at an average age of 12.4 years. Those
who had early treatment had more attendances, received treatment for
longer times, and incurred more costs than the adolescent treatment group.
They also had significantly poorer final dental occlusion.
3. Tulloch et al 2004
RCT where the patient allocated at early stage to functional or HG or
control. The results that all benefit from first stage was lost and that early

treatment or two stage treatment didn’t affect extraction prevalence nor
sending to orthognathic surgery.
4. Dolce et al 2007 (completion of Keeling study 1998): compare two stage
treatment with 1 stage treatment and found no skeletal difference between
both
5. Recent Cochrane review suggests that early treatment is no more effective
than orthodontic treatment in early adolescence Harrison et al., 2007 (this
was involving 185 publications, then only 105 paper used and then 8 trials
included (4 early treatment and 4 late treatment) the result show that there is
no difference between early and late treatment regarding OJ, ANB, PAR,
trauma, incidence of extraction, but the self-esteem has been improved.
6. Koroluk 2003, show that no reduction in incisor trauma
7. But, O’Brien, 2003, show benefit from psychological point of view
Advantages of late IO for increase OJ
1. One phase treatment
2. Growth still present
3. Extraction decision is easy
4. E spacecan be used
5. Better final occlusion (O’Brien, 2009)
6. No difference from early treatment (Tulloch 2004, O’Brien 2009, Dolce
2007, Harrison, 2007)
7. However, comparing the effect of functional appliance with no treatment in
adult is an ethical issue because of the equipoise idea. Harrison 2007 quoted
two studies (Cura & Sarac 1997) who compare Dynamax with control and
Mao and Zaho 1997who compared bionator/Hg to control. These studies
suffered from weakness in their design. In general comparing functional
appliance to no treatment conclude that the former reduce OJ and ANB by
2.27. so it is the clinician philosophy to use it or lose it. Again comparing TB

with other functional like bionator or Dynamax showed that TB reduce ANB
by 0.68 more than others. I should mentioned that comparing HG with
untreated was not taken before.
Early treatment of Class III
Time
Before the age of 8 to achieve skeletal correction.
Method
Chin cups or reverse pull HG.
Indication
1. Growing cooperative patient
2. Skeletal class I, or only mildly class III;
3. An average or reduced lower face height;
4. A large anterior displacement on closing.
5. Incisor inclinations normal
6. Average/increased overbite that will retain the correction
In the mild Class III case in the mixed dentition the patient may benefit from
early correction of the incisor relationship so that further mandibulargrowth
may be counterbalanced by dento-alveolar compensation.
Problems
1. Unfavourable growth.
2. Soft tissue relapse after maturity
3. Long treatment and retention times.
4. Forward movement of the maxillary teeth,

5. Retroclination of the lower labial segment
Richardson, 1999, screening for IO
Age
Do Don’t
At
birth
Do: Encourage caries prevention Don’t: worry about
abnormal gum pad
relationship
age
3
Do: look for early signs of malocclusion
Do: expect crowded permanent if no
spaceexist between primary
Do: Discourage habits
Do: Treat abormal path of closure
Don’t: worry about
lisping
Don’t:About spacing
Don’t:About flush
terminal relationship
age
7-9
Do: treat pathology
Do: observecrowding by
• Maintain space
• Observing and use Lee way spacefor
crowded cases
• Consider serial extraction or first molar of
poorprognosis
Do: observelocal disturbance by
• Extract primary if the permenant is
missing
• Treating impacted 6s
• Extract Transposed teeth
• Extract retained primary
• Extract supernumeray
Don’t: worry about
sligh post-normality
of molars
Don’t: ugly duckling
space
Don’t: slight AOB

Do: discourage habit
Do: observecross bite and displacement
age
11-
12
Do: treat pathology
Do: observecrowding by
• Extraction of FPM or second molar
• Extract retained primary
• Extract Cs in ectopic canine
Do: discourage habit
Do: Treat cross bite
Do: Excise large frenaum
Don’t: about buccal
crowding if 22mm
spaceavailable
between lateral and
6s
Don’t: Rotated
premolar when erupt
Don’t: Minor
submerging

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