The second of three lectures about interceptive orthodontic, management of the developing dentition, guiding the development of occlusion

1. Sudan International University
Faculty of Dentistry
Department of Orthodontics
Management of the developing
dentition (preventive and
interceptive procedures)
Mohanad Elsherif
BDS (U of K), MFD RCSI, MFDS RCPS(Glasg), MSc (Orthodontics), M.Orth. RCSEd

2. Orthodontic Triage
1. Infraoccluded primary molars:
 Prevalence: 8-14%
 More common in the lower arch
 Primary first molar is the most
commonly affected tooth.
 Believed to be due to ankylosis
but genetic causes and missing
permanent premolars are also
described as etiological factors

3. Orthodontic Triage
Classification of infraocclusion:
 Mild (slight):
Between occlusal surface and interproximal
contact, (less than 2mm).
 Moderate:
Within occluso-gingival margins of interproximal
contact.
 Sever:
Below interproximal contact point.

4. Orthodontic Triage
Consequences of infraocclsion
 Tipping of adjacent teeth
 Overeruption of opposing teeth
 Caries of infraoccluded teeth or
adjacent teeth.
 Delyed eruption, deflection or
impaction of the successor tooth.

5. Orthodontic Triage
Diagnosis:
 Clinical
 Inspection to assess the severity.
 Percussion  classical, high-pitched, ‘cracked-teacup’ sound of ankylosis
when percussed with a metal instrument
 Radiographic
 To assess the severity of infraocclusion and radiographic signs of ankylosis
(absence of lamina dura)
 To assess the presence/absence of successor tooth.

6. Orthodontic Triage
Treatment
 In the presence of successor tooth
 Wait for normal exfoliation
 Extract if no exfoliation occurred or problems
occurred.
 In the absence of successor tooth:
 Depending on the severity:
 Mild to moderate composite filling or crown
 Sever  extract the tooth followed by orthodontic
space closure or prosthetic replacement.

7. Orthodontic Triage
4. Other Eruption Problems
Ectopic eruption
 Eruption of a tooth in the wrong place, or along
the wrong eruption path.
 Often leads to early loss of a primary tooth
 The most commonly affected tooth is the
maxillary first molar (2 -6 %).

8. Orthodontic Triage
4. Other Eruption Problems
Ectopic eruption
 Eruption of a tooth in the wrong place, or along
the wrong eruption path.
 Often leads to early loss of a primary tooth
 The most commonly affected tooth is the
maxillary first molar (2 -6 %).

9. Ectopic eruption of the first permanent
molar
 Ectopic eruption of first
permanent molar occurs when
its eruption is prevented by
the distal surface of the
second primary molar.
 Spontaneous correction
occurs before the age of 8
years in 66% of cases.

10. Ectopic eruption of the first permanent
molar
 It can be classified into:
 Reversible:
if spontaneous eruption occurs
before 8 years of age and
without premature loss of “E”).
 Irreversible:
if no correction after 8 years or
premature loss of “E” occurred.

11. Ectopic eruption of the first permanent
molar
 Treatment:
1. Brass wire separator.
2. Distalization of the first
permanent molar.
3. Disking of the distal surface of
second primary molar.
4. Extraction of second primary
molar and space regaining
following eruption of first molar.

12. Unerupted maxillary incisors
 Presents in the mixed dentition stage and is often noticed between the ages
of 7–9 years.
 Can be due to:
 Early loss or prolonged retention of primary incisors.
 In adequate space or space loss.
 Physical Obstruction (supernumerary, cyst, tumor).
 Trauma.
 Dilaceration and eruption failure following trauma affecting the primary
incisors.
 Cleft lip and palate.

13. Unerupted maxillary incisors
 Diagnosis:
Delayed eruption of the permanent maxillary incisor teeth can be
considered when:
 Eruption of the contralateral incisor has occurred more than six
months earlier.
 The maxillary incisors remain unerupted more than one year
after eruption of the mandibular incisors.
 There is significant deviation from the normal eruption sequence
(for example, lateral incisors erupting before the central incisor).

14. Management
 The management will depend on:
 Patient age and compliance.
 Medical statutes.
 Space within the arch.
 Location of the incisor.
 Developmental stage of the incisor.
 The presence of associated problem (dilacerations,
resorption,..).

15. Management
 The general principles of managing delayed
eruption or impaction of the permanent maxillary
incisor teeth, include:
(1) The provision of adequate space in the dental arch; and
(2) Removal of any obstruction to eruption.

16. Treatment options
 Removal of obstruction ± space creation followed by
spontaneous eruption.
 Removal of obstruction ± space creation followed by
orthodontic traction.
 Extraction of the incisor.
 Extraction and reimplantation.

17. Treatment
 In the younger patient (<9 years of age) with an immature
permanent maxillary incisor, it may be reasonable to allow
up to 9–12 months for spontaneous eruption after the
removal of an obstruction and/or creation of space, before
considering further intervention.
 In the older individual (>9 years of age) with a mature
permanent maxillary incisor, it is reasonable to consider
‘open’ or ‘closed’ surgical exposure with bonding of an
orthodontic attachment at the time of removal of an
obstruction, particularly if the unerupted incisor is high.

18. Management of unerupted
incisor

19. Risks of treatment
 The potential risks of treatment include
 Failure of eruption.
 Ankyloses.
 External root resorption.
 Poor gingival aesthetics.
 Occasionally, damage to adjacent teeth.

20. First permanent molar with poor
prognosis
 Extraction of a first permanent molar is rarely the extraction of choice.
 However, favorable spontaneous development of the dentition and space
closure can be expected in some cases.
 Why the 1s molar:
 Early development, makes them susceptible to chronological enamel defects
leading to hypo-mineralisation and/or hypoplasia
 First permanent tooth to erupt makes them vulnerable to the development
of dental caries.
 Commonly Affected by Molar incisor hypomineralizatoin (MIH) [incidence =
15% in Caucasian]

21. Balancing Vs compensating
extraction
 Balancing extraction
 Refers to removal of the equivalent tooth from the contra-lateral
side of the same dental arch.
 It is usually done to prevent midline shift.
 Compensating extraction
 Refers to removal of the equivalent tooth from the same side of
the opposing dental arch.
 It is usually done to prevent overeruption of the opposing tooth

22. Balancing Vs compensating
extraction
 As a general rule:
 Compensating extraction of an upper first molar is often
recommended when extraction of the lower is required to prevent
over-eruption of an unopposed upper first molar.
 On the other hand, compensating extraction of the lower first
molar is not recommended when extraction of the upper first
molar is required.
 Balancing the extraction of healthy first molars is not generally
recommended in either arch and there is little evidence that
unilateral extraction will adversely effect the dental centerline.

23. Ideal timing for extraction
 Ideally, first permanent molar extractions should be
followed by successful eruption of the second molars to
replace them and ultimately, the third molars to
complete the molar dentition.
 The criterial for this to occur are:
1. Patient age 8-10 years
2. The second molar is developed to the bifurcation area
3. Presence of the third molar
4. The angle between the long axis of the first molar and
the long axis of the third molar is 15-30.

24. Conclusion
“As a general rule, if in doubt, get the patient out of
pain, try and maintain the teeth and refer for an
orthodontic opinion”
 Reference:
A Guideline for the Extraction of First Permanent
Molars in Children (Royal college of Surgeon-UK)

25. Orthodontic Triage
Premature loss of deciduous tooth:
1. Primary Incisors:
 Minimal effect after eruption of deciduous canines.
 No space maintainer is usually needed except for aesthetic or
speech.
2. Primary Canines:
 Can cause midline shift.
 Space maintainer or balanced extraction of the contralateral canine
is indicated.

26. Orthodontic Triage
Treatment options for premature loss of primary
canine:
 If no centerline line shift and no crowding  space
maintainer.
 If there is centerline shift and no crowding  balanced
extraction of the contralateral canine followed by space
maintainer after midline correction.
 If there is crowding  complex problem need specialist
evaluation for space management so refer

27. Orthodontic Triage
3. Primary first molar:
 Can cause midline shift specially if it was lost in young age.
 Space maintainer is indicated.
4. Primary second molar:
 Can space loss by mesial drift of the first molar can occur.
 Space maintainer is indicated.

28. Which type of
space maintainer
should we place?

29. Space maintainers
Factors to be considered before placing a space maintainer
 Time lapse since lost.
 Dental age of patient.
 Amount of bone covering the unerupted tooth.
 Which tooth is lost, in which arch.
 Presence or absence of permanent teeth.
 Cooperation level of child and parents.
 Existing malocclusion.

30. Space maintainers
Space maintainers may not be needed when:
 Widely spaced primary dentition.
 If succeeding tooth is expected to erupt within 6 months When?
1. More than ½ to 2/3 of the root is present on the succeeding
tooth.
2. Less than 1 mm of alveolar bone is covering succeeding tooth.
3. Destruction of the alveolar bone occurred when the primary
tooth was lost.

31. Space maintainer?
Primary
dentition
Mixed
dentition
Single tooth
or multiple
teeth
Single tooth
or multiple
teeth
Unilateral
or bilateral
loss
Unilateral
or bilateral
loss

32. Primary Dentition
 Single unilateral or Single bilateral loss
Band and
loop

33. Primary Dentition
 Single unilateral or Single bilateral loss
with pulp therapy or structural problem
Crown and
loop

34. Primary Dentition
 Multiple Loss
Partial
denture

35. Primary Dentition
 Loss of second
primary molar before
the eruption of
permanent first molar
Distal Shoe
space
maintainer

36. Mixed Dentition
 Single unilateral or Single bilateral loss
in either upper or lower arch
Band and
loop

37. Mixed Dentition
 Multiple unilateral loss in upper
arch
Trans-palatal
arch space
maintainer

38. Mixed Dentition
 Multiple bilateral loss in upper arch
Nance
appliance

39. Mixed Dentition
 Multiple loss in lower arch
Lingual
arch

40. Orthodontic Triage
1. In primary dentition:
 Unilateral single tooth loss
 Bilateral single tooth loss
 Multiple teeth loss
 Loss of second deciduous
molar before eruption of
permanent first molar .
Unilateral Band and loop space maintainer.
Bilateral Band and loop space maintainers.
Partial denture.
Distal shoe space maintainer.
What type of space maintainer should I use?

41. Orthodontic Triage
2. In Mixed dentition:
 Unilateral single tooth loss
 Bilateral single tooth loss
 Lower arch multiple loss
 Upper arch unilateral
multiple loss.
 Upper arch bilateral
multiple loss.
Unilateral Band and loop space maintainer.
Bilateral Band and loop space maintainers.
Lingual arch.
Transpalatal arch.
What type of space maintainer should I use?
Nance button (appliance).

42. Declaration
 The author wish to declare that; these presentations are his original work, all
materials and pictures collection, typing and slide design has been done by the
author.
 Most of these materials has been done for undergraduate students, although
postgraduate students may find some useful basic and advanced information.
 The universities title at the front page indicate where the lecture was first
presented. The author was working as a lecturer of orthodontics at Ibn Sina
University, Sudan International University, and as a Master student in Orthodontics at
University of Khartoum.
 The author declare that all materials and photos in these presentations has been
collected from different textbooks, papers and online websites. These pictures are
presented here for education and demonstration purposes only. The author are not
attempting to plagiarize or reproduced unauthorized material, and the intellectual
properties of these photos belong to their original authors.

43. Declaration
 As the authors reviews several textbooks, papers and other references during
preparation of these materials, it was impossible to cite every textbook and journal
article, the main textbooks that has been reviewed during preparation of these
presentations were:
Contemporary Orthodontics 5th edition; Proffit, William R, Henry W. Fields, and
David M. Sarver.
Handbook of Orthodontics. 1st edition; Cobourne, Martyn T, and Andrew T. DiBiase.
 Clinical cases in orthodontics. Martyn T. Cobourne, Padhraig S. Fleming, Andrew T.
DiBiase, Sofia Ahmad
Essentials of orthodontics: Diagnosis and Treatment; Robert N. Staley, Neil T. Reske
Orthodontics: Current Principles & Techniques 5th edition; Graber, Lee W, Robert L.
Vanarsdall, and Katherine W. L. Vig
Orthodontics: The Art and Science. 3rd Edition. Bhalajhi, S.I.

44. Declaration
 For the purposes of dissemination and sharing of knowledge, these
lectures were given to several colleagues and students. It were also
uploaded to SlideShare website by the author. Colleagues and students
may download, use, and modify these materials as they see fit for non-
profit purposes. The author retain the copyright of the original work.
 The author wish to thank his family, teachers, colleagues and students
for their love and support throughout his career. I also wish to express
my sincere gratitude to all orthodontic pillars for their tremendous
contribution to our specialty.
 Finally, the author welcome any advices and enquires through his
email address: Mohanad-07@hotmail.com

45. To be continued…..