preventive orthodontics ppt for UG lecture

1. Preventive Orthodontics
1

2. Introduction
“Prevention is better than cure”
Dental neglect in the primary and mixed
dentition is the principal cause of malocclusion
in the permanent dentition.
2

3. An Orthodontist has 3 options
– Prevent anything abnormal from happening
– Intercept any abnormal situation that is
developing
– Correct an abnormality which has already
developed.
3

4. Definitions
• Graber (1966) defines preventive orthodontics as
the name implies, action taken to preserve the
integrity of what appears to be normal at specific
time. He further states that, the definition is normal
to start with, and it is the goal of the dentist to see
that it stays that way.
4

5. • J.D.Freeman(1977) states that preventive
orthodontics applies to the elimination of factors
which may lead to malocclusion in an otherwise
normally developing dentition.
• Profitt and Ackermann(1980)---has defined it as
prevention of potential interference with occlusal
development.
5

6. INTERCEPTIVE ORTHODONTICS
It includes procedures that are undertaken at
early stage of malocclusion to eliminate or reduce the
severity of the same.
Ex: extraction of supernumerary teeth before they
cause displacement of other teeth is a preventive
procedure, while their extraction after the signs of
malocclusion have appeared is an interceptive
procedure.
CORRECTIVE ORTHODONTICS
It includes procedures that are undertaken to
correct a fully established malocclusion.
6

7. An ideal orthodontic service should devote.
• 10% - Observation and prevention
• 20% - Interceptive procedures
• 25% - Partial corrective mechanotherapy
• 45% - Full corrective, mechanotherapy cases.
7

8. PREVENTIVE ORTHODONTICS
It includes procedures undertaken prior to
the onset of a malocclusion in anticipation of
a developing malocclusion.
8

9. Preventive Orthodontics means a dynamic, ever
constant vigilance -a routine, a discipline for both
dentist and patient
Early assessment of child followed by regular
review and treatment at appropriate time if
necessary will go in a long way to reduce
malocclusion.
9

10. Preventive group includes
• Parent and Patient Education
• Caries control
• Care of deciduous dentition
• Extraction of supernumerary teeth
• Eliminating occlusal interference
• Management of Quadrant wise Tooth Shedding
timetable.
• Management of ankylosed tooth
• Management of abnormal frenal attachment
• Oral habit checkup
• Prevention of Milwaukee brace damage
• Space maintenance
10

11. Education of parents and patient
– Ideally should begin before the birth of the
child.
– The parents should be educated on matters
such as nutrition (to provide an ideal
environment for the developing foetus), mode
of feeding and maintenance of oral hygiene
apart from normal and problem in developing
occlusion.
11

12. – Should also be educated on proper nursing,
importance of mothers milk and drawbacks of
bottle-feeding and care of the child.
– Mother should be educated on the difference
between the physiological nipple and the
conventional nipple.
12

13. 13
• Conventional nipples are non
physiological and do not permit suckling by
movement of the tongue and the lower jaw
Rather they cause sucking of the milk which
later on lead to various orthodontic problems.
• Physiological nipples on the other hand are
designed to permit suckling of the milk which
more or less resembles the normal functional
activity as in breast feeding.

14. 14

15. They should also be educated on the need for
maintaining good oral hygiene and the correct
method of brushing.
Recommended oral hygiene measure for different
age
Infant (0-1 yr): Parent should do cleaning act.
Moistened gauge or wash cloth can be used to
gently massage the gum and clean teeth.
15

16. Toddlers (1-3 yrs): Tooth brush should be introduced.
Nonfluridated tooth paste are advised. Parents should
brush for child.
Preschooler (3-6 yrs): Children should brush under
parentral care. Fluridated toothpaste is introduced.
School age (6-12 yrs): Proper brushing technique and
regular brushing by child
16

17. 17
Caries control
•Caries on the proximal surfaces of teeth if
not restored in time can lead to loss of arch
length by movement of adjacent teeth into
that space.
•Should be detected by clinical and
radiographic examination eg: bitewing
radiographs are used to detect proximal
caries.

18. 18
•Proper restoration of
affected teeth should be
done immediately to
prevent loss of arch
length.

19. • Restoration should restore the mesio-distal
dimension of tooth, but should not be over/under
extended allowing drift of contiguous teeth or
promote food impaction.
• Re-establishment of proper inclined plane
relationship with proper anatomic carving will not
only be esthetic but also result in normal function
and stability of occlusion.
19

20. Care of deciduous dentition
• The deciduous dentition are excellent space
maintainer until the developing permanent tooth
are ready to erupt into the oral cavity.
• Thus all effort should be taken to prevent early
loss of deciduous tooth.
20

21. Extraction of Supernumerary teeth:
Presence of supernumerary and
supplemental teeth interfere with the eruption of
nearby normal teeth and deflect adjacent teeth to
erupt in abnormal positions.
Presence of an unerupted mesiodens
prevents central incisors from approximating each
other.
Should be identified and removed before they
cause displacement of other teeth.
21

22. 22

23. 23
Eliminating occlusal interference
All functional prematurities should be eliminated as
they can lead to deviations in the mandibular path of
closure and also predispose to bruxism.
Using articulating paper to detect the premature
contact area can eliminate these and then selective
grinding is carried out.
Also enamel pearls can cause premature contact and
should be eliminated by grinding.

24. Maintenance of tooth shedding time table
It is appropriate to compare a dentist to a
dispatcher at a busy airport who tries to see that
each plane lands/takes off on time and prevents
accidents. Similarly a dentist must monitor the
patient’s dentition. Teeth must leave and arrive
on time and see that this traffic of teeth is
maintained and everything is on schedule.
24

25. 25
•A gap of not more than three months should
exist in the shedding of deciduous teeth and
the eruption of permanent teeth in one
quandrant
•Delay in eruption can be due to the following
conditions
a. Congenital absence of permanent teeth.
b. Endocrinal disturbances such as hypothyroidism
c. Ankylosed deciduous teeth that fails to resorb
d. Non vital deciduous teeth that do not resorb

26. e. Presence of supernumerary tooth can block the
erupting permanent teeth.
f. Presence of a heavy mucosal barrier.
g. Premature loss of deciduous teeth can result in
formation of bone barrier
h. Prolonged retention of primary tooth
i. Presence of unresorbed root fragments
j. cysts or tumors
k. odontomes
26

27. 27

28. 28

29. 29
Management of ankylosed teeth
•Ankylosis is a condition characterized by absence of the
periodontal membrane in a small or the whole of the root
surface.
•Ankylosed deciduous teeth do not get resorbed and
therefore either prevent the deciduous teeth from
erupting or deflect them to erupt in abnormal location.

30. 30

31. – Appropriate management of an ankylosed primary
tooth consists of maintaining it until an
interference with the eruption or drift of other
teeth begins to occur then extracting it and
placing a space maintainer or other space
management appliance if needed. Should be
diagnosed and surgically removed at an
appropriate time to permit the permanent teeth
to erupt.
31

32. 32
Management of abnormal
frenal attachments
•Presence of thick and fleshy maxillary labial frenum that
is attached relatively low prevents the maxillary central
incisor from approximating each other.
•Abnormal frenal attachments in most patients are caused
due to hereditary factors.
•Should be diagnosed and treated at an early age.

33. • Prior to the eruption of teeth, the maxillary labial frenum
is attached to the alveolar ridge with some fibres crossing
over lingually to the region of the incisive papilla. As the
teeth start erupting, alveolar bone is deposited and the
frenal attachment migrates into a more apical position.
• Interincisal gaping will close in most cases without any
interference is confirmed by Taylor(1939)
Age Incidence of diastema
6 97%
6-7 88%
10-11 48%
12-18 7%
33

34. – Presence of ankyloglossia or tongue-tie prevents
normal functional development due to lowered
position of tongue and abnormalities in speech and
swallowing.
– They should be surgically treated to prevent full-
fledged malocclusions.
34

35. 35
ORAL
HABITS

36. 36
•Although it is possible to deform the alveolus and
dentition during the primary dentition years with an
intense habit much of the change is related to the
anterior teeth.
•The effect of habits on the hard and
soft tissues depends on the TRIAD
duration, intensity and frequency of
the habit.

37. • Dorland (1957) – “as a fixed or constant practice
established by frequent repetition.”
• Buttesworth (1961) - a frequent or constant
practice or acquired tendency which has been
fixed by frequent repetition.
• Mathewson (1982) particularly highlighted the
muscular involvement in oral habit.
According to him, oral habit can be defined as
learned pattern of muscular contractions.
37

38. Classification of habits
Obsessive habits (deep rooted)
• - Intention habits e.g. digit sucking, nail biting
• - Masochistic/self injurious habits e.g. gingival
stripping habit
Non-obsessive (easy learned and easy to drop)
• -Unintentional e.g. chin propping
• -Functional habit e.g. mouth breathing, Bruxism
Tongue threshing etc
38

39. Various Authors have classified habits e.g.
• James (1923) - useful habits
- harmful habits
• Kingsley (1958) - Functional oral habits
- Muscular habits
- Combined
• Morris and Bohana (1969)
-Pressure/non Pressure habits
-Biting habits
• Klein (1971) - empty habits
- meaningful habits
• Finn (1987)
-Compulsive habit
-Non-compulsive habit
-Primary habit
-Secondary habit
39

40. Thumb and finger sucking
• It is placement of the thumb or one or more
fingers in varying depths into the mouth.
• If this habit discontinued before permanent anterior
teeth erupt no damage to alignment or occlusion.
• If habit persist during mixed dentition period (6-12
years)- disfigurement occurs.
40

41. 41

42. Effects of thumb sucking
42
Effects of thumb sucking habits on developing teeth are
minor in infants or children under age three.
Effects of thumb sucking depends on
Duration (How Long)
Frequency (How Often)
Intensity (How strong)

43. 43

44. 44
Direction of application of force to the dentition
during thumb-sucking.
Maxillary incisors are pushed labially, mandibular
incisors are pushed lingually, while buccal
muscles exert pressure lingually against teeth in
the lateral segments of the dental arch.

45. 45
 Increased overjet due to proclined maxillary
anterior teeth
 Lingual tipping of mandibular anterior teeth
 Posterior crossbite due to overactivity of buccinator
compressing the maxilla
 Narrow & high palatal vault.
 Hypotonic upper lip with the lower part of the face
exhibiting hyper active mentalis activity
EFFECTS OF THUMB SUCKING

46. Diagnosis of Thumb sucking
46
History:
It determine the psychological component
involved- Question regarding the frequency,
intensity and duration of habit.
Enquire the feeding patterns, and parental care of
the child.
Presence of other habits should be evaluated.

47. Extra Oral Examination :
• The Digit:
The digit that are involved in habit will appear
reddened, clean, chapped, short finger nail and with
callus formation on the thumb.
47
Callus formation on the thumb as a result of thumb sucking.

48. 48
Lip:
• Chronic thumb sucker are having short,
hypotonic upper lip.
• Upper lip passive or incompetent during
swallowing and lower lips hyper active and this
leads to a further increase in the proclination of
the upper anteriors due to its thrust on these
teeth(LIP TRAP)
Facial form: Appears long with increased chin height

49. 49
Intra Oral Examination :
Tongue : Examine the oral cavity for correct size and
position of tongue at rest, tongue action during
swallowing.
Dento Alveolar Structure : Individuals with severe
finger or thumb sucking habit, where the digit
applied on the upper dentition and palate will
have flared and proclined maxillary anterior with
diastemas and retroclined mandibular anterior,
constriction of buccal musculature and tendency to
narrow palates.
Gingiva: dry with redness on anterior gingiva

50. 50
Forces acting on the teeth while
thumb sucking.

51. Control of thumb sucking
51
Prevention
I. Motive based approach: Its prevention should be directed
towards the motive behind the habit.
II. Child’s Engagement in various activities : Parents can be
consulted on keeping the child engaged in various
activities.
III. Parent’s involvement in prevention : When the parents
are at home they should be advised to ample time with
the child so as to put away his feelings of insecurity.
IV. Duration of Breast Feeding : Duration of feeding should
be adequate.

52. Management
I. Psychological measures(enquiry and counselling)
1. Reminder therapy
It employs bitter flavoured preparations are distasteful agents that
are applied to thumb (cayenne, pepper, quinine).
52

53. 2. Distraction therapy
The parents should be consulted to provide the child
with adequate love and affection. They should be
advised to divert the child’s attention to the other
things such as play and toys.
3. Reward therapy
It involve the use of calendar, on which a star is
placed for ever day in which no thumb sucking
habit is observed. A reward is given to the child
after a certain number of star have been earned.
53

54. 54
Dunlop’s beta hypothesis : This hypothesis is the
best way to break a habit bites conscious,
purpose full repetition.
Child should be asked to sit in front of a mirror
and to suck his thumb, observing himself as he
indulges in the habit.

55. 55
II. Physical preventive measure: Mechanotherapy
Habit Breaking appliance

56. 56
(Haskell 1991)

57. 57
Ernest T. Klein,

58. Tongue thrusting
• TULLY (1969) States tongue thrust as the forward
movement of tongue tip between the teeth to
meet the lower lip during deglutition and in
sound of speech that tongue become interdental.
• May be due to anatomic or neuromuscular
variations in oro-facial region and can be acquired
as a habit e.g presence of macroglossia,
interdental spacing, constricted dental arches and
enlarged adenoids
58

59. 59

60. SIMPLE TONGUE THRUST
• It is defined as a tongue – thrust with a teeth –
together swallow
• The malocclusion usually associated with it is
diagnosed well-circumscribed open bite in the
anterior region.
• Cuspal interferences are not present and there is
perfect fit of posterior teeth in occlusion.
60

61. • It is associated with abnormal functioning of the
lips, mentalis and other circum-oral muscles. As
the patient swallows anterior lip seal is made
partly with the teeth and partly with the lips.
61

62. COMPLEX TONGUE THRUST
• A complex tongue thrust is defined as a tongue
thrust with a teeth-apart swallow. The
malocclusion seen with this type has two
distinguishing features.
• A poor occlusal fit is present which usually
prompts a slide into occlusion
• There is generalised anterior open bite extending
to posterior region
62

63. 63

64. Diagnosis-
History
• Information about the upper respiratory tract infection.
• Sucking habits
• Neuromuscular problems
Examination-
Observe the tongue during various swallowing procedures.
Careful differentiation must be made of
• Simple tongue thrust
• Complex tongue thrust
Tongue posture can also be seen in lateral cephalogram of the
mandibular posture.
64

65. Management of Tongue Thrust
Training correct swallow and posture of Tongue
Acquaint the patient with the abnormal swallow by
placing the index finger on the tip of the tongue and
then on the junction of the hard and soft palate and
saying to the patient, most people swallow with this
part of the tongue on this part of the palate.
65

66. The patient should be instructed to practice
correct swallowing at least 40 times a day and to
record the fact on a card.
When the new swallowing pattern has been
learned on the conscious level, it is necessary to
reinforce it subconsciously.
66

67. 67

68. Mechanotherapy
• Removable appliance
• Fixed appliance
• Oral screen
68

69. 69

70. Complex Tongue Thrust-
• Check carefully by palpation the mandibular
elevators during swallow. In the complex tongue
thrust they do not contract and the mandible is
stabilized by tongue and infra-mandibular muscle
contractions.
• It is advisable to treat the occlusion first.
• The muscle training then begin is similar to simple
tongue thrust with minor modifications.
70

71. Mouth breathing
Classified into 3 categories (Finn 1987)
• Obstruction
• Habitual
• Anatomical
71

72. • Obstructive : It is due to increased resistance on
complete obstruction of normal flow of air through
the nasal passage(adenoids,DNS etc)
• Habitual: A habitual mouth breather continues to
breathe through his mouth although abnormal
obstruction is removed(low posturing of tongue)
• Anatomical : An anatomical mouth breather does not
permit complete closure of the mouth due to short
upper lip.
72

73. Mouth breathers have a typical appearance described
as “Adenoid facies” these have a combination of
clinical signs as follows.
• Long face
• Contracted upper dental arch
• Increased overjet
• Receded lower jaw
• Vacant facial expression
• Short upper lip.
• Anterior marginal gingivitis
73

74. 74

75. Diagnosis-
• History-A history should be recorded from the
patient as well as parents.
• Clinical Examination-Look out for various clinical
features.
Clinical tests--
• Observation
• Mirror Test
• Butterfly Test
• Water Holding Test
• Cephalometric Examination
• Rhinomanometry
75

76. Treatment-
• Elimination of the cause.
• Exercise
1. Physical exercise – Deep breathing
2. Lip exercise
Lip excercise
a)Stretching the upper lip to maintain lip seal is an
important therapeutic measure in patients having
short hypo tonic lips.
To aid in stretching the patient is asked to hold a
piece of paper between the lips
76

77. 77

78. b)Patients are asked to stretch the lip in a
downward direction as far as possible to
covering the vermilion border under and
behind the maxillary incisors.
This exercise should be done 15-30 minutes
a day.
• Mechanothrapy
Can be managed by use of vestibular screen
78

79. 79

80. Lip sucking
– It lead to proclined upper anteriors, redundant
lower lip and cracking of lips.
– Lip bumpers can be used and exercise such as
extending the upper lip over upper incisors and
placing lower lip forcibly over upper.
80

81. 81

82. 82

83. Bruxism
– Bruxism is a nonfunctional grinding or gnashing of
teeth. Reding, Rubright, and Zimmerman report
that 15% of the children and young adults in their
study group showed some degree of bruxism. The
habit usually occurs at night and, if continued over a
prolonged period, can result in abrasion of primary
and permanent teeth.
– Associated with occlusal or incisal attrition,
soreness of masticatory muscles and TMJ
discomfort and pain.
83

84. Management
– Psychotherapy- Appropriate psychological
councelling may be initiated.
– Night guards/occlusal splints which covers occlusal
surfaces helps in eliminating occlusal
interferences.
– Occlusal adjustment
– Restorative treatment
– Pharmacological managment
84

85. 85
Prevention of Milwaukee brace
damage
•Milwaukee brace is an orthopaedic appliance used for
correction of scoliosis
•The appliance exerts tremendous amount of pressure on
the mandible and the developing occlusion leading to
retardation of mandibular growth and possible deformities
•Occlusion should be protected using functional
appliances or positioners made of soft materials

86. SPACE CONTROL IN DECIDUOUS DENTITION:
• An important part of preventive orthodontics
is the correct handling of spaces created by the
untimely loss of deciduous teeth.
• Primary dentition is essential for growth of jaws,
for normal function and eventually for normal
position and occlusion of permanent teeth and so
premature loss of primary tooth is to be avoided
86

87. Effects of premature loss of primary teeth are:-
1. On function and oral health:-
Early loss of primary teeth may affect
-Masticatory function if posteriors are lost
-Speech, if anterior teeth are lost.
• Before speech develops in a child- if there is loss
of anterior teeth – it affects speech development,
which might become permanent later.
2. Supra eruption of opposing teeth:
- Premature primary tooth loss leads to
excessive eruption of opposing tooth:
87

88. 3- Psychological effects on child and parent:
- Undoubtedly the premature loss of anterior
primary teeth alters appearance of child which in
some cases may produce undesirable
psychological effects.
4- Effects on the position of permanent teeth:
-Space closure after premature loss of tooth is
most important sequelae.
Space closure by drifting of adjacent teeth into
the edentulous space may prevent eruption of
succedaneous tooth or deflect or may force it to
take an abnormal eruption path.
88

89. 89
SPACE MAINTENANCE
Early loss of a primary tooth presents a potential
alignment problem because drift of permanent or other
primary teeth is likely unless it is prevented by space
maintenance.
Space maintenance is only possible when adequate
space is available and all unerupted teeth are present and at
proper stage of development. If there is not enough space
or if succedaneous teeth are missing space maintenance is
alone inadequate.

90. 90
Classification
Hitchcock
•Removable, fixed or semi fixed
•With bands or without bands
•Functional or non functional
•Active or passive
•Combinations of the above
Raymond C. Thurow
•Removable
•Complete arch
•Lingual arch
•extra oral anchorage
•Individual tooth

91. 91
Hinrichsen
•Fixed space maintainers
Class I a) non functional types
-bar type
-loop type
b) functional types
-pontic type
-lingual arch type
Class II – cantilever type (distal shoe, band and loop)
•Removable space maintainers
Acrylic partial dentures

92. Factors to be considered before giving a
space maintainers:-
1. Information required:
• Complete I/o radiographic examination is
essential
• Dentist should measure the width of the
deciduous teeth and all permanent successors in
all buccal segments.
• Check for Leeway space – combined M-D width of
CDE
92

93. • Observe the relative amount of root resorption on
the deciduous teeth, the state of development
and eruption of the permanent successors,
• character of alveolar bone.
• OPG-Gives overall picture of developing dentition
• Mixed dentition analysis
93

94. 2-Crucial factor of Age:
• Age of patient in particularly important
• Individuals own developmental pattern –
slow/fast/average
• If it appears that permanent successor will erupt
within a year or less after the loss of deciduous
tooth, space maintenance in probably not
necessary, but periodic, frequent, checkup must
be done. that is careful measurement of the
edentulous area with dividers and Periapical
radiograph of erupting tooth at 2 month intervals.
94

95. 3-Interdigitation:
• The qualities of interdigitation of the
dentition is another variable influencing space
control. Cuspal height is believed to contribute to
the stability of the dentition.
• Gould (1965) and Devey (1967) stressed
about importance of cuspal interlocking and
cuspal height respectively.
• Gould states that cuspal interlocking will act
as a physical barrier for the migration of the teeth
after extraction.
• Davey Suggested that high cusps inhibit
drifting. Hence the assessment of the type of
interdigitation and its stability is extremely
important when projecting the need for appliance
therapy.
95

96. 4-Anamolies of the teeth:
• Before going for Space Maintains. therapy, we
should make sure that there are no anamolies like
absence of succedaneous teeth, presence of any
supermemorary teeth or odontomes which may
obstruct the succedaneous teeth from erupting
and ankylosis of primary teeth.
96

97. • Indication of space maintainer:
i) To prevent drifting of teeth so as to maintain
space.
ii) To maintain aesthetic
iii) To restore the function of lost tooth
iv) To prevent sequelae of periodontal and caries
problem.
v) To prevent ectopic eruption of teeth
vi) Psychological reasons
97

98. • Contraindications of space maintainer:
i) When the mesio-distal width of the underlying
permanent tooth is less than the space present.
ii) When the tooth is near the crest of the ridge.
iii) When the underlying permanent tooth is
missing
iv) If radiograph of extraction region shows that
2/3rd of the root of succedaneous tooth is
already calcified.
98

99. Prerequisites for space maintainers
(Graber)
1.They should maintain the mesio-distal dimension of
the lost tooth.
2.They should be functional, at least to the extent of
preventing the overeruption of the opposing tooth or
teeth.
3.They should be as simple and as strong as possible.
99

100. 4.They must not endanger the remaining teeth by
imposing excessive stresses on them.
5.They must be easily cleaned and not serve as traps for
debris which might enhance dental caries and soft
tissue pathology.
6.Their construction should be such that they do not
restrict normal growth and development processes
or interfere with such functions as mastication,
speech or deglutition.
100

101. 101
Factors governing the selection of appliance
•Patient cooperation: with removable appliances greater co
operation is required.
•Appliance integrity: all types of appliance suffer breakage.
But as per Wright and Kennedy the mandibular removable
appliance is the most susceptible to breakage and that the
integrity of fixed appliances is better.
•Maintenance: the length of time and projected maintenance
should be considered.
•Modifiability: anticipation of future modifications is
essential.
•Cost: directly bonded are the best as time is saved. As lab
time increases labour charges increase.

102. 102
Removable space maintainers
•They are space maintainers that can be removed and re
inserted into the oral cavity by the patient.
•Can be classified in functional and non functional.
•Functional space maintainers are those that incorporate
teeth to aid in mastication, speech and aesthetics.
•Non functional have an acrylic extension over the
edentulous area to prevent space closure.

103. 103
Advantages
•Easy to clean and permit maintenance of oral hygiene.
•Maintain or restore vertical dimension.
•Can be worn part time and allows circulation of the
blood to the soft tissues.
•Serve important functions like aesthetics mastication and
phonetics.
•Dental check up for caries detection can be undertaken
easily.

104. 104
•Room can be made for permanent teeth to erupt without
changing the appliance.
•Stimulate eruption of permanent teeth.
•Band construction is not necessary.
•Help in preventing tongue thrust habit in the extraction
spaces

105. 105
Disadvantages
•May be lost or broken by patient.
•Un co-operative patients may not wear the appliance.
•Lateral jaw growth may be restricted if clasps are in
corporated.
•May cause irritation to the underlying soft tissues.

106. 106
•When aesthetics are of importance.
•If abutment teeth cannot support a fixed appliance.
•Cleft palate patients who require obturation of the palatal
defect.
•When permanent teeth are not fully erupted it is difficult
to adapt the bands.
•Multiple loss of deciduous teeth which may require
functional replacement in the form of either partial or
complete dentures.
Indications

107. 107
Contraindications
•Lack of patient co operation.
•Patients who are allergic to acrylic materials.
•Epileptic patients who have uncontrolled seizures.

108. 108
Acrylic partial dentures
•Useful in bilateral posterior space maintenance when
more than one tooth has been lost per segment and
permanent incisors have not erupted as yet.
•They replace the occlusal function.
•Posterior space maintenance in conjunction with
replacement of anterior teeth for esthetics.

109. – Excellent retention is obtained by placement of
several clasps which brings about patient compliance.
– Acrylic portion can be adjusted such as to allow
eruption of permanent teeth.
– Problems encountered with these appliances is the
failure to wear them thus leading to loss of space or
failure to remove it for cleaning can lead to soft tissue
irritation.
109

110. 110

111. 111
Full or complete dentures
•Useful when all the primary teeth are lost due to rampant
caries and cannot be restores.
•Dentures not only restore masticatory function and
esthetics but also guide the first permanent molar into
occlusion. This is done by approximating the posterior
border to the mesial surface of the unerupted first molar.
•Can be subsequently adjusted to allow eruption of
permanent molars and incisors.

112. 112
•Immediate acrylic partial denture with an acrylic distal
shoe extension has been used successfully to guide the
first permanent molar into position when the deciduous
second molar is lost shortly before the eruption of the
permanent first molar.
•Tooth to be extracted is cut away from the stone model
and a depression is cut into the stone model to allow
fabrication of the acrylic extension.
Removable distal shoe space maintainer

113. 113
•Should not be given in children who are
immunocompromised or who are at a risk for subacute
bacterial endocardititis because complete epithelialization
around the intra alveolar portion has not been demonstrated.
•The acrylic will extend into the alveolus after the removal
of the primary tooth and should extend one mm below the
mesial marginal ridge at and before its emergence from the
bone.

114. 114
Fixed Space Maintainers
Advantages
•Bands and crowns are used which require minimum or
no tooth preparation.
•They do not interfere with passive eruption of abutment
teeth.
•Jaw growth is not hampered.
•Succedaneous permanent teeth are free to erupt into the
oral cavity.
•Can be used in un co operative patients.

115. 115
Disadvantages
•Elaborate instrumentation with expert skill is needed.
•Result in decalcification under the bands.
•Supra eruption of opposing teeth can take place if pontics
are not used.
•If pontics are used it can interfere with vertical eruption of
the abutment tooth and may prevent eruption of replacing
permanent teeth if the patient fails to report.

116. 116
Types
Band and loop space maintainer
•Unilateral fixed appliance indicated for space
maintenance in the posterior segment.
•The tooth distal to the extraction space is banded and a
loop of thick stainless steel wire is soldered to it with
mesial end touching the teeth.

117. 117

118. 118
•Simple cantilever design makes it ideal for unilateral
isolated space maintenance.
•Loop has limited strength therefore should not be
expected to accept functional forces of chewing.
•Should be restricted to build up the space for one tooth.
•Loop provides little if any functional replacement for
the missing teeth and will not prevent supraeruption of
teeth in the opposing arch.

119. 119
Crown and loop appliance
•Similar to band and loop in all respects except that a
stainless steel crown is used for the abutment tooth.
•The crown is used when in preference to a band when the
abutment tooth is highly carious exhibits marked
hypoplasia or is pulpotomized.

120. 120
Lingual arch space maintainer
•When multiple primary posterior teeth are missing and
the permanent incisors have erupted.
•Helps in maintaining arch perimeter by preventing both
mesial drfting of the molars and the lingual collapse of
anterior teeth.
•A conventional lingual arch attached to bands on primary
second or first permanent molars and contacting the
cingula of the mandibular incisors, prevents anterior
movement of the posterior teeth and posterior movement
of anterior teeth.

121. 121
•Lingual arch should be positioned to rest on the cingula
of the incisors approximately 1 to 1.5 mm off the soft
tissue and should be stepped to the lingual in the canine
region or remain away from the primary molars and
unerupted premolars.
•Common problems are distortion and breakage and loss.

122. 122

123. 123

124. 124
•Similar to the lingual arch.
•Designed to prevent mesial migration of the maxillary
molars.
•Constructed using 0.036 inch diameter hard stainless steel
wire.
•Also call nance holding arch which is a maxillary lingual
arch that does not contact the anterior teeth but
approximates the palate.
•Incorporates an acrylic button in the anterior region that
contacts the palatal tissue.
Palatal arch appliances

125. 125
•Soft tissue irritation can be a problem.
•It can become embedded into the tissue if the tissue
hypertrophies because of poor oral hygiene or if appliance
gets distorted.
•Can`be used when primary molars are lost bilaterally, then
it is attached to both the permanent first molars to prevent
mesial tipping.

126. 126
Transpalatal arch
• Recommended for stabilizing the maxillary first
permanent molars when the primary molars require
extraction.
• Consists of a thick stainless steel wire that spans the
palate connecting the first permanent molar of one side
with the other.
• Best indication is when one side of the arch is intact and
several primary teeth on the other side are missing.

127. 127
•The rigid attachment to the intact side usually provides
adequate stability for the space maintenance.
•Avoids contact with the soft tissue.
•The arch prevent the anterior movement of the molars by
preventing rotation of the tooth around the lingual root.

128. 128
Distal shoe space maintainer
• Also known as intra alveolar appliance.
• Distal surface of the second primary molar guides the
first molar into position therefore when the second
primary molar is removed prior to the eruption of the first
permanent molar the intra alveolar appliance provides
greater control of the path of eruption of the unerupted
tooth and prevents undesirable mesial migration.
• The appliance used in practice now is roches distal shoe
or its modifications using crown and band appliances with
a distal intragingival extension.

129. 129

130. 130
Band and bar type space maintainer
• Fixed space maintainer.
• Abutment teeth on either side of the extraction space are
banded and connected to each other by a bar.
• Alternatively stainless steel crowns can be used and
these are called crown and bar space maintainers.

131. Conclusion
• Guidance of the eruption and development of the
primary and permanent dentitions is an integral
part of the specialty of Orthodontics. Such guidance
should contribute to the development of a
permanent dentition that is in a harmonious,
functional, and esthetically acceptable occlusion.
• Early diagnosis and successful treatment of
developing malocclusions can have both short-term
and longterm benefits while achieving the goal of
occlusal harmony, function, and dental facial
esthetics.
131

132. “An ounce of prevention is worth a
pound of cure”
132

133. References:
– Premkumar S, Graber’s Textbook of Orthodontics, Basic
principles and practice ;3rd ed. Elsevier, 2009
– Klein, E.: Pressure habits, etiological factors in
malocclusion, Am. J. Orthod. 38: 569-587, 1952.
– William,L.W:Some considerations of preventive and
interceptive orthodontics, Am.J.Ortho.53:525-
532,1967.
– Moyers,R.E.:Handbook of orthodontics,4th edition.
1988
– Proffit WR: Contemporary Orthodontics,St Louis, CV
Mosby,4th edition. 2007
133

134. – William,L.W:Some considerations of preventive and
interceptive orthodontics, Am.J.Orthod. 53:525-
532,1967.
– David,G.O:The incidence and nature of space closure
following premature extraction of deciduous
teeth,Am.J.Orthod. 59:37-49,1971
– Ackerman, J.L. and Proffit, W.R.: Preventive and
interceptive orthodontics: A strong theory proves weak
in practice, Angle Orthod., 50: 75-87, 1980
Peter,S:Essentials of preventive and community
dentistry,2nd edition. 2004
– Mcdonald: Dentistry for the child and Adolescent,8th
edition, CV Mosby Company. 2004
134

135. Thank u
135