interceptive orthodontics by almuzian

university of glasgow

Interceptive orthodontics

Personal notes

Mohammed Almuzian

1/1/2013

.

ContentsDefinition.........................................................................................................................................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..............................................................................................................11

Space maintainer............................................................................................................................12

Advantages.....................................................................................................................................12

Disadvantages.................................................................................................................................12

Indications......................................................................................................................................12

Contraindication.............................................................................................................................13

Techniques.....................................................................................................................................13

Space regaining..............................................................................................................................14

Mohammed Almuzian, University of Glasgow, 2013 Page 1

Technique.......................................................................................................................................14

Management of Lee way space.......................................................................................................14

Balance and compensatory extraction............................................................................................14

Early loss of primary teeth..............................................................................................................14

RCSEng guidelines and Recommendations....................................................................................14

Forced extraction in poor prognosis 6s...........................................................................................15

Guidelines for forced first molar extraction (RCSEng. By Cobourne 2009)..................................15

Class I cases with minimal crowding (3mm)..................................................................................15

Class I cases with crowding............................................................................................................16

Class II case with crowding............................................................................................................17

Abnormality in tooth position.........................................................................................................18

Infra-occlusion...............................................................................................................................18

Management...................................................................................................................................18

Impacted incisors............................................................................................................................19

SIGN recommendations (Yaqoob et al 2010):................................................................................19

Ectopic canine................................................................................................................................20

Methods.........................................................................................................................................20

Impacted 6s....................................................................................................................................24

Treatment options, Kennedy 1987..................................................................................................24

IO treatment...................................................................................................................................24

Treatment to disimpact the molars..................................................................................................25

Treatment to regain space following early loss of E: Kurol and Bjerklin 1987..............................25

Asymmetric Dental Development..................................................................................................26

Prolong retention of primary teeth or Overretained Primary Teeth................................................26

Local factors...................................................................................................................................27

Enamel defects...............................................................................................................................27

Maxillary midline diastema............................................................................................................27

Abnormality in teeth shape, form & size........................................................................................28

Treatment.......................................................................................................................................28

Abnormality in teeth number..........................................................................................................28

Supernumerary teeth.......................................................................................................................28

Treatment.......................................................................................................................................28

Indications for Monitoring..............................................................................................................28

Indications for removal...................................................................................................................28


Hypodontia.....................................................................................................................................29

Treatment options...........................................................................................................................29

Traumatic loss of incisors...............................................................................................................30

Management...................................................................................................................................30

Displacements & crossbites............................................................................................................31

Anterior crossbites..........................................................................................................................31

Crossbite with Displacement..........................................................................................................31

Habits.............................................................................................................................................32

Management of digit-sucking habits...............................................................................................32

Prevention of digit-sucking habits, BOS guidelines 2000...............................................................32

Treatment of digit-sucking habits, BOS guidelines 2000...............................................................33

Increased and decreased Overjet.....................................................................................................34

Indications for IO treatment of increased OJ (early treatment of CLII problems)..........................34

1. Class II females with a significant skeletal discrepancy..........................................................34

2. An increased overjet, which is a source of teasing and bullying..............................................34

3. An increased overjet, which is at risk of trauma (often associated with gross lip incompetence and marked maxillary protrusion)...................................................................................................34

Advantages of early treatment........................................................................................................34

Disadvantages of early treatment....................................................................................................35

Evidences of poor outcome of early treatment versus late treatment..............................................35

Advantages of late IO for increase OJ............................................................................................37

Early treatment of Class III............................................................................................................37

Time...............................................................................................................................................37

Method...........................................................................................................................................37

Indication........................................................................................................................................37

Problems.........................................................................................................................................38

Richardson, 1999, screening for IO...............................................................................................38

Age.................................................................................................................................................38

Do...................................................................................................................................................38

Don’t..............................................................................................................................................38


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)

Need for 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.

Poor co-operators patients.

General Aims 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 respect of

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

Space maintainer

Space regaining

Management of Lee way space (should be called D and E space and not

include C because we loss space with C)

3. Balance and compensatory extraction

in primary teeth due to early loss of primary teeth

Forced extraction in poor prognosis 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. Local factors


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 crossbite with Displacement

7. Habits

8. Increased and decreased overjet

Spacing and Crowding

Definition

As faulty relationship bet MD of teeth, jaw size and arch perimeter. Jaw size

determine the available space for teeth apices, arch perimeter determine the

available space for 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. Secondary crowding is caused by premature loss of primary molars, which

is environmental in origin.

3. Tertiary or ‘late lower incisor crowding’ is a phenomenon that has both

genetic and environmental contributions, the main determinant being

differential late jaw growth.

Management of crowding in developing dentition

Elective extraction

Elective extraction of 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 space for palatally lateral incisors.

3. Provide space for 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 successful with 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 extraction of all 6's

Wilkinson criteria (Wilkinson, 1940)

1. All successional teeth 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 root of lower 6.

4. CIass I

5. Mild anterior segment crowding

6. Moderate posterior crowding

Elective extraction of the second molars

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 space for 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 extraction of 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 space maintenance can allow impacted 5`s to erupt.

Serial extraction

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)

Disadvantages of Serial Extractions

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 space maintenance. 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. Space loss with extractions of C`s and especially D`s, by mesial drift of

buccal segments, 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 post treatment 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 extraction1. 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

secondary crowding.

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 space loss would

result in the need for more complex orthodontic treatment

10.In an occlusion with severe crowding where any further space loss would

result in more than a single tooth unit of space being required.

Contraindication

1. If a permanent successor will erupt within 6 months (i.e., if more than one-

half to two-thirds of its root has formed), a space maintainer 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 shoe is 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 space has been lost due to drifting regained

space is limited to 3mm or less of space regaining.

Technique

1. Sectional fixed appliance

2. URA

3. Lip bumper

4. HG

5. Molar distalization technique can be used to regain space

Management of 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 compensatory extraction

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 successional teeth. 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 second molars – There is no need to balance the loss of

a primary second molar because this 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 space maintainer

Forced extraction in 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 consider earl

extraction to allow spontaneous space closure or use of the space for

orthodontic purposes.


Guidelines for forced first molar extraction (RCSEng. By Cobourne

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.

Class I cases

Class I cases with minimal 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 contact with it.

If the upper first molar is to be lost, do not compensate with extraction of

the lower first molar if it is healthy.

Class I cases with crowding

First molar extractions can be delayed until the second molars have

erupted and then the extraction space used 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

buccal segment 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

Class II cases

The main complicating factors often involve the upper arch because of the

need for space to correct the incisor relationship.

Class II cases with minimal crowding

Lower first molar extraction

It should be carried out at the ideal time for successful eruption of the

second permanent molar and control of 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, a simple

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 correct the 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 space can 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

Space will 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 space used 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

Space requirements 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 space for crowding relief and incisor correction.

Class III 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 of a 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 of a permanent successor ,

A. Early Extraction to facilitate spontaneous space closure to allow permanent

teeth to drift into the edentulous space and 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 space closure


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 expose minimally 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:

Remove obstruction.


Maintain the space

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):

Remove obstruction.


Maintain the space

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 space for eruption

Methods1. 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 opposed to 86% in un-crowded cases

3. The extraction of the deciduous canine and creation of excess space for 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 support the 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%, Control 36%.


palatally displaced canines. RCT

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 sector and 13% by two sectors, while on 32% of the canines in CG improved by one sector and none by two sectors.

Extraction of the primary canines at the age between 10 and 13 year,

Ericson and 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 correct palatally ectopically

erupting maxillary canines provided that normal space conditions are present

and no incisor root resorption are found.

Extraction of the primary canines in crowded and uncrowded cases by

Power and Short, 1993. 9 consecutive patients of mean age 11.2 years. In

general 62% showed improvement in eruptive position. In crowded cases the

success rate was 14% as opposed to 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 extraction of the deciduous canine and creation of excess space for

the impacted tooth Olive, 2002. The space created 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 Baccetti et al., 2008, 1) with Xtn of C only,

2) Xtn C + HG, group 2) control, group 3) successful eruption of 3. 65%,

88% and 36% successful eruption 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 support the 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.

Effect of RME and headgear treatment on the eruption of palatally

displaced canines. RCT by Armi & Baccetti, 2011, The randomized

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 successful eruption was

83%, 86 % and 36% respectively.

Effects of RME and TPA treatment associated with deciduous canine

extraction on the eruption of palatally displaced canines 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 absence of 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 ectopically erupting maxillary permanent

canines by extraction of C & Ds: RCT by Bonetti 2011, 50% of canines in

the TG improved position by one sector and 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 space and 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: expose unerupted 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: surgically expose and try above techniques or distal

extension attached to SS crown

Treatment to regain space 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 predecessor when

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 space is adequate, moderately abnormal

facial or lingual positioning will usually be corrected by the equilibrium

forces of the lip, cheeks, and tongue.

Local factors

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. For this 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 procedure like

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)

MissingClass 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)

to allow mesial

drift

Keep LE as long as

possible lower

arch should be as big

as possible

May be used as part

of xnt to treat

malocclusion


Traumatic loss of incisors 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 space maintenance can be achieved with a simple upper partial

denture.

Alternatively, the space can 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. Space closure and build up laterals

2. Space opening with

Resin-retained bridge

Implant,

Autotransplantation of premolar and subsequent coronal modification

3. In cases of bilateral loss, if space is required to reduce an overjet or

relieve crowding and the lateral incisors are of a reasonable size and form,

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 opposing primary

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 crossbite from 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 control intervention 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 buccal root torque,

E. Upper removable expansion appliance versus quadhelix.

Habits

Management of 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 approach is 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-physical methods

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


Increased and decreased Overjet

Indications for IO treatment of increased OJ (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. Psychosocial advantages 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 source of 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. Better stability 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).

Disadvantages of early treatment

1. Early start and late finish therefore prolonged course of 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, cost of treatment, 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 course of treatment in adolescence with 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 space can 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 mandibular growth

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’tAt

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

space exist 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: observe crowding by

• Maintain space

• Observing and use Lee way space for

crowded cases

• Consider serial extraction or first molar of

poor prognosis

Do: observe local disturbance by

• Extract primary if the permenant is

missing

• Treating impacted 6s

• Extract Transposed teeth

• Extract retained primary

• Extract supernumeray

Do: discourage habit

Don’t: worry about

sligh post-normality

of molars

Don’t: ugly duckling

space

Don’t: slight AOB


Do: observe cross bite and displacement

age

11-

12

Do: treat pathology

Do: observe crowding 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

space available

between lateral and

6s

Don’t: Rotated

premolar when erupt

Don’t: Minor

submerging


interceptive orthodontics by almuzian

Health & Medicine