PREVENTIVE ORTHODONTICSPREVENTIVE ORTHODONTICS

ByK. Venu gopal reddy1 st year MDSDepartment of orthodonticsS.R.M. Dental college

Graber (1966) defined preventive Graber (1966) defined preventive orthodontics asorthodontics as” the action taken to ” the action taken to preserve the integrity of what preserve the integrity of what appears to be normal occlusion at a appears to be normal occlusion at a specific time”specific time”

Profit and Ackerman (1980)defined asProfit and Ackerman (1980)defined as

“ “ prevention of potential interference prevention of potential interference with occlusal development”with occlusal development”

Preventive orthodontics means a Preventive orthodontics means a dynamic, ever constant vigilance, a dynamic, ever constant vigilance, a routine, a discipline for both dentist and routine, a discipline for both dentist and patients.patients.

It requires a continuing long-term It requires a continuing long-term approach and is not a one shot service. approach and is not a one shot service. Without this, the complex timetable of Without this, the complex timetable of growth, development, tissue growth, development, tissue differentiation, resorption, eruption which differentiation, resorption, eruption which are all under the influence of continuous are all under the influence of continuous functional forces, cannot be assured.functional forces, cannot be assured.

Dental neglect in the primary dentition Dental neglect in the primary dentition is the principal cause of malocclusion in the is the principal cause of malocclusion in the permanent dentition.permanent dentition.

Early, regular and satisfactory dental Early, regular and satisfactory dental care will help in maintaining the primary teeth care will help in maintaining the primary teeth in healthy condition until the time for their in healthy condition until the time for their normal exfoliation.normal exfoliation.

Preventive procedures

Parental counseling prenatal postnatal

Caries control Space maintenance Extraction of deciduous teeth Treatment of abnormal frenal attachments Treatment of locked permanent first molars Abnormal oral musculature related habits

Education of parentsEducation of parents

Parents should be educated regardingParents should be educated regarding Increase in food intake to meet the Increase in food intake to meet the

special physiological changes in the special physiological changes in the body to support the growth of the foetus body to support the growth of the foetus and facilitate normal labour.and facilitate normal labour.

Dental development of their childDental development of their child Dental disease processDental disease process Oral hygiene measures appropriate for Oral hygiene measures appropriate for

infantsinfants

Expecting mother should be Expecting mother should be educated on proper nursing educated on proper nursing and care of the child.and care of the child.

In case the child is being In case the child is being bottle-fed, the mother is bottle-fed, the mother is advised to use physiologic advised to use physiologic nipple and not the nipple and not the conventional nipple. conventional nipple.

conventional

phys

As the child grows, parents should be educated As the child grows, parents should be educated regarding the need for maintaining good oralregarding the need for maintaining good oral

hygiene.hygiene.

In infants small gauze is used over the ridge of In infants small gauze is used over the ridge of top and bottom jaws for cleaningtop and bottom jaws for cleaning

Proper brushing techniques and brushing Proper brushing techniques and brushing

habits to be explained and evaluated habits to be explained and evaluated periodically.periodically.

Fone’s method of brushing is preferred in Fone’s method of brushing is preferred in children.children.

Fluoride application and dental checkup every Fluoride application and dental checkup every 6 months 6 months

Caries control procedures:Caries control procedures:

Diet and oral hygiene MaintenanceDiet and oral hygiene Maintenance Regular CheckupRegular Checkup Fluoride applicationsFluoride applications Prophylactic odontomy Prophylactic odontomy Pit and fissure sealants.Pit and fissure sealants. Restorative procedures like silver Restorative procedures like silver

amalgam, Glass Ionomers, Cermets, amalgam, Glass Ionomers, Cermets, Stainless steel crown. Stainless steel crown.

Immunization Immunization

Diet and Oral hygiene maintenance

Balanced diet

which contains varieties of food, in such quantity and proportion that the need for energy ,amino acids, vitamins, fats,carbohydrates and other nutrients is adequately met for maintaining health.

The cariogenic potential of food depends on many variables such as presence of fermentable sugar –sucrose

• ability to be retained by teeth.• ability to form acids.• ability to dissolve enamel.

The solid foods containing sucrose are more cariogenic than liquid foods.

The frequency in time of ingestion of foods are also important. The sucrose containing food becomes more dangerous if it is eaten more frequent.

The patient should be aided in identification of those foods which are likely to cause oral diseases.

The 3 to 6 yrs olds require parental assistance to achieve effective plaque removal.

Parents should be instructed to brush for the child at least once a day.

Bedtime is the ideal time to establish this routine because the salivary flow rate slows during sleep

Additional brushings may be performed by the child.

Parents need to remain active in supervising the home care practices of 6-12 yrs old

Regular check-up:

The parents should bring their child for his/her first dental visit early at least by the time the baby is 6 months of age.

Frequency of recall visits have to be decided according to the individual needs. Usually a 3 monthly recall checkup is advised to monitor oral hygiene status.

Half yearly visit to the dentist should be routine.

Care of Deciduous dentitionCare of Deciduous dentition

Deciduous teeth act as natural space maintainers Deciduous teeth act as natural space maintainers until the developing permanent teeth are ready to until the developing permanent teeth are ready to erupt into oral cavity.erupt into oral cavity.

All efforts are taken to prevent early loss of All efforts are taken to prevent early loss of deciduous teeth.deciduous teeth.

Simple preventive procedures such as proper and Simple preventive procedures such as proper and timely application of fluoride topically/ pit and fissure timely application of fluoride topically/ pit and fissure sealant application help in preventing caries.sealant application help in preventing caries.

More complex treatment procedures to prevent the More complex treatment procedures to prevent the natural space maintainer includes pulp therapy natural space maintainer includes pulp therapy (pulpotomy, pulpectomy ) and stainless steel crown. (pulpotomy, pulpectomy ) and stainless steel crown.

Caries involving proximal surface Caries involving proximal surface of deciduous teeth if not restored of deciduous teeth if not restored early may lead to loss of arch early may lead to loss of arch length into that space.length into that space.

Caries can be detected by clinical Caries can be detected by clinical and Radiographic examination.and Radiographic examination.

Bitewing Radiograph proves to be Bitewing Radiograph proves to be

of great help in detecting proximal of great help in detecting proximal caries.caries.

Once detected, proper restoration Once detected, proper restoration of affected teeth should be of affected teeth should be undertaken immediately to undertaken immediately to prevent loss of arch length. prevent loss of arch length.

Restoration should restore the mesio-distal Restoration should restore the mesio-distal dimension of tooth, but should not be dimension of tooth, but should not be over/under extended allowing drift of over/under extended allowing drift of contiguous teeth or promote food impaction.contiguous teeth or promote food impaction.

Contact size and position should also be Contact size and position should also be

correct.correct.

Re establishment of proper inclined plane Re establishment of proper inclined plane relationship with proper anatomic carving relationship with proper anatomic carving will be esthetic and results in normal will be esthetic and results in normal function and stability of occlusion.function and stability of occlusion.

PIT AND FISSURE SEALANTPIT AND FISSURE SEALANT

Fissure sealants are defined whereby pits Fissure sealants are defined whereby pits and fissures that occur principally on the and fissures that occur principally on the occlusal surfaces of the molar and premolar occlusal surfaces of the molar and premolar teeth are occluded by application of fluid teeth are occluded by application of fluid materials, which are the then polymerized.materials, which are the then polymerized.

ClassificationClassificationMitchell and Gordon (1990)Mitchell and Gordon (1990)Polymerization methodsPolymerization methods

a.a. Self activation (mixing two components)Self activation (mixing two components)b.b. Light activationLight activation

- First generation: U.V LightFirst generation: U.V Light- Second generation: Self cureSecond generation: Self cure- Third generation: Visible lightThird generation: Visible light- Fourth generation: Fluoride releasingFourth generation: Fluoride releasing

Resin Systems Resin Systems BIS-GMABIS-GMA Urethane acrylateUrethane acrylate

Filled and unfilledFilled and unfilledClear or tinedClear or tined

IndicationsIndications

Newly erupted both primary molars Newly erupted both primary molars and permanent and permanent bicuspids and molars bicuspids and molars with complete recession of pericoronal with complete recession of pericoronal operculum and with open and/or sticky operculum and with open and/or sticky grooves and fissures.grooves and fissures.

Stained pits and fissures with Stained pits and fissures with minimum decalcification.minimum decalcification.

The tooth in question should have The tooth in question should have erupted less than 4 years ago.erupted less than 4 years ago.

ContraindicationsContraindications

Individual with no previous caries Individual with no previous caries experience experience pit and fissures,monitor if pit and fissures,monitor if the individual and the teeth are not at the individual and the teeth are not at risk.risk.

Radiographic or clinical evidence of Radiographic or clinical evidence of caries on caries on the proximal surface of the the proximal surface of the tooth should not tooth should not be sealed.be sealed.

Wide and self-cleansable pit and Wide and self-cleansable pit and fissures.fissures.

Tooth that can not be isolated of Tooth that can not be isolated of partially partially erupted tooth.erupted tooth.

Pit and fissures that have remained Pit and fissures that have remained carious carious free for 4 years or longer.free for 4 years or longer.

Fluoride applicationFluoride application

Knutson’s Technique – Sodium fluoride – 2% Knutson’s Technique – Sodium fluoride – 2% (3,7,11,13)(3,7,11,13)

- Weekly internals – 4 times- Weekly internals – 4 times

- After prophylaxis – 3min- After prophylaxis – 3min

Personal attention of parents towards child with respect to dental Personal attention of parents towards child with respect to dental care is a must.care is a must.

The attitudes of parents and child towards dental health and The attitudes of parents and child towards dental health and dental care are very much influenced by the attitude of the dentist dental care are very much influenced by the attitude of the dentist towards preservation of primary dentition and preventive outlook.towards preservation of primary dentition and preventive outlook.

FLOURIDE VARNISHFLOURIDE VARNISH

Bifluoride 12(2.71% NaF, 2.92% CaF)Bifluoride 12(2.71% NaF, 2.92% CaF)

TechniqueTechnique -- Do the through prophylaxis and Do the through prophylaxis and dry the dry the teeth.teeth.

Drop the varnish onto the brush or Drop the varnish onto the brush or foam foam pellet.pellet.

Paint the varnish thinly first on the Paint the varnish thinly first on the lower arch and then on upper lower arch and then on upper

arch arch starting from the proximal starting from the proximal surfaces.surfaces.

Semiannual ApplicationSemiannual Application

With correct application and proper mouth With correct application and proper mouth hygiene varnish remains in place of several days. hygiene varnish remains in place of several days. During this time fluorides act on the treated During this time fluorides act on the treated surface.surface.

Prophylactic odontomyProphylactic odontomy

Caries occurs frequently in the Caries occurs frequently in the pit and fissures of posterior teeth. pit and fissures of posterior teeth.

As a preventive procedure the As a preventive procedure the pit and fissure may be minimally pit and fissure may be minimally prepared and restored before prepared and restored before visible attack by caries. visible attack by caries.

ImmunizationImmunization

Immunization with Streptococcus mutans should induce Immunization with Streptococcus mutans should induce an immune response which might prevent the dental an immune response which might prevent the dental caries in following ways :caries in following ways :•It will prevent ability of the microorganisms to colonize It will prevent ability of the microorganisms to colonize on to the tooth surfaces.on to the tooth surfaces.

•It can alter the pattern of polysaccharide metabolism It can alter the pattern of polysaccharide metabolism by the bacteria and thereby reduces adhering capacity by the bacteria and thereby reduces adhering capacity on to the tooth surfaces.on to the tooth surfaces.

•Oral administration or subcutaneous injection of killed Oral administration or subcutaneous injection of killed Streptococcus mutans can induce the formation of Streptococcus mutans can induce the formation of specific IgA, IgG, IgM in the blood.specific IgA, IgG, IgM in the blood.

Various new approaches have been tried out Various new approaches have been tried out in order to overcome the existing in order to overcome the existing disadvantages.disadvantages.

Active immunization Active immunization

1)1) Synthetic peptidesSynthetic peptides

2)2) Coupling with cholera toxin subunitsCoupling with cholera toxin subunits

3)3) Fusing with salmonellaFusing with salmonella

4)4) LiposomesLiposomes

Passive immunization Passive immunization

1)1) Monoclonal antibodiesMonoclonal antibodies

2)2) Egg-yolk antibodiesEgg-yolk antibodies

3)3) Transgenic plantsTransgenic plants

Indicators of future Orthodontic Indicators of future Orthodontic Problems:Problems:

Aberrant resorptive patternAberrant resorptive pattern Altered eruption cycle of permanent Altered eruption cycle of permanent

teethteeth Contingency of extractionContingency of extraction

A visual examination of the patient will quickly A visual examination of the patient will quickly reveal a gross malocclusion, in which there is an reveal a gross malocclusion, in which there is an anterior open bite, excessive overbite and anterior open bite, excessive overbite and overjet, cross-bite, basal mal-relationship and overjet, cross-bite, basal mal-relationship and other problems.other problems.

A large percentage of class I malocclusions A large percentage of class I malocclusions exist because of what happens during the exist because of what happens during the critical developmental years, with most of critical developmental years, with most of the activity below the surface.the activity below the surface.

So,not only a visual dental examination, but So,not only a visual dental examination, but

a complete and accurate radiographic a complete and accurate radiographic examination should be made soon after the examination should be made soon after the first visit. first visit.

Deciduous canines and second deciduous Deciduous canines and second deciduous molars are particularly prone to aberrant molars are particularly prone to aberrant resorption patterns.resorption patterns.

In an ideal sequence, right and left deciduous In an ideal sequence, right and left deciduous incisors should be lost at about the same incisors should be lost at about the same time, deciduous lateral incisors should be time, deciduous lateral incisors should be lost at about the same time, all canines lost at about the same time, all canines should be lost within a short period.should be lost within a short period.

Contingency of extractionContingency of extraction

As a rule of Thumb, the shedding of the As a rule of Thumb, the shedding of the deciduous dentition should be kept on deciduous dentition should be kept on schedule by extracting the tooth or teeth on schedule by extracting the tooth or teeth on one side of the arch, when they have been one side of the arch, when they have been lost through natural process on the other lost through natural process on the other side.side.

Should not wait longer than 3 months for Should not wait longer than 3 months for nature to do the job, particularly when there nature to do the job, particularly when there is radiographic evidence of abnormal is radiographic evidence of abnormal resorption – Which would otherwise lead to resorption – Which would otherwise lead to Malocclusion.Malocclusion.

Effects of premature loss of primary teethEffects of premature loss of primary teeth

Oral health and functions Oral health and functions Supra eruption of opposing teethSupra eruption of opposing teeth Psychological effect on child and parentPsychological effect on child and parent Position of permanent teeth.Position of permanent teeth. Primary dentition is Primary dentition is

essential for growth of jaws, for normal essential for growth of jaws, for normal function and eventually for normal position function and eventually for normal position and occlusion of permanent teeth and so and occlusion of permanent teeth and so premature loss of primary tooth is to be premature loss of primary tooth is to be avoided. avoided.

Parents usually accept loss of anterior Parents usually accept loss of anterior teeth after 6years of age, but when lost at teeth after 6years of age, but when lost at an early age, some parents are concerned an early age, some parents are concerned by appearance of remaining dentition.by appearance of remaining dentition.

Attitudes of parents and child towards Attitudes of parents and child towards dental health and care is largely influenced dental health and care is largely influenced by attitude of dentist towards by attitude of dentist towards preservation of primary dentition. preservation of primary dentition.

Any suggestion that the primary dentition Any suggestion that the primary dentition is important is reflected is a positive is important is reflected is a positive awareness and motivation towards dental awareness and motivation towards dental care in minds of parent and child.care in minds of parent and child.

Sequence of eruption and clinicalSequence of eruption and clinical

significance:significance:

According to MOYERS normal sequence of According to MOYERS normal sequence of eruption provides the highest percentage eruption provides the highest percentage of normal occlusion.of normal occlusion.

Eruption in Eruption in

Maxillary arch Maxillary arch - 6124537- 6124537

Mandibular archMandibular arch - 6124357 - 6124357

Abnormal order of arrival may permit Abnormal order of arrival may permit shifting of the teeth, with resultant shifting of the teeth, with resultant space loss.space loss.

Change in the sequence of eruption is a Change in the sequence of eruption is a much more reliable sign of a disturbance much more reliable sign of a disturbance in normal development than generalized in normal development than generalized decay or acceleration.decay or acceleration.

The more a tooth deviates from its The more a tooth deviates from its expected position in the sequence,the expected position in the sequence,the greater the likelihood of some problem.greater the likelihood of some problem.

An asymmetry in rate of eruption on the An asymmetry in rate of eruption on the two sides of dental arch is a frequent two sides of dental arch is a frequent variation.variation.

When this happens, there is lack of space When this happens, there is lack of space to accommodate the erupting teeth on to accommodate the erupting teeth on one side compared to the other.one side compared to the other.

As a general rule, if permanent tooth on As a general rule, if permanent tooth on one side has erupted but its counter part one side has erupted but its counter part has not, within three months, a has not, within three months, a radiograph should be taken to investigate radiograph should be taken to investigate the cause of the problem.the cause of the problem.

SPACE MAINTAINANCESPACE MAINTAINANCE

Maintenance of arch length during the Maintenance of arch length during the primary, mixed and early permanent primary, mixed and early permanent dentition is of great significance for the dentition is of great significance for the normal development of future occlusion.normal development of future occlusion.

Loss of arch length has been related Loss of arch length has been related mainly with migration of teeth following mainly with migration of teeth following early loss of primary teeth.early loss of primary teeth.

18th Century – Fauchard reported it18th Century – Fauchard reported it 19th Century – Hunter 19th Century – Hunter 20th Century – Willet, Seward,and Davey20th Century – Willet, Seward,and Davey

Causes of space lossCauses of space loss Trauma Trauma Interproximal caries in primary molars Interproximal caries in primary molars Ectopic eruption of first perm molarsEctopic eruption of first perm molars Delayed eruption Delayed eruption Ankylosis of primary molars.Ankylosis of primary molars. Congenital absence of permanent teeth Congenital absence of permanent teeth Macrodontia can cause arch length Macrodontia can cause arch length

deficiencydeficiency

‘‘Space maintaining’ is utilizing an Space maintaining’ is utilizing an appliance to preserve space without appliance to preserve space without necessarily an awareness of the necessarily an awareness of the dynamics of the situation.dynamics of the situation.

The preferable approach for space The preferable approach for space maintenance is to evaluate the space maintenance is to evaluate the space available, whether the space is sufficient available, whether the space is sufficient for eruption of the succedaneous teeth or for eruption of the succedaneous teeth or regaining space is necessary. regaining space is necessary.

Classification of space maintainers:Classification of space maintainers: According to According to Hitchcock:Hitchcock:

Removable or fixed or semi fixedRemovable or fixed or semi fixed

With bands or without bandsWith bands or without bands

Functional or non functionalFunctional or non functional

Active or passiveActive or passive Certain combinations of above.Certain combinations of above.

According to According to Raymond C.ThurowRaymond C.Thurow:: RemovableRemovable Complete archComplete arch

Lingual archLingual arch

Extra oral anchorageExtra oral anchorage Individual toothIndividual tooth..

According to HinrichsenAccording to Hinrichsen

Fixed space maintainersFixed space maintainers:: Class IClass I

1.Non functional types1.Non functional types

- Bar type- Bar type

- Loop type- Loop type

2. Functional type2. Functional type

- Pontic type- Pontic type

- Lingual arch type- Lingual arch type

class IIclass II

- Cantilever type- Cantilever type

- Distal shoe - Distal shoe

- B and E loop- B and E loop

Removable space maintainersRemovable space maintainers

Removable

Non functional – acrylic plate Functional – acrylic plate with teeth

Active –acrylic plate with clasps, springs

Passive - acrylic plate with clasps.

Fixed appliancesFixed appliances Band and loopBand and loop Crown and loopCrown and loop Band and barBand and bar Distal shoe Distal shoe Lingual archLingual arch Nance palatal archNance palatal arch Transpalatal arch.Transpalatal arch.

Semi FixedSemi Fixed Removable arch wire with molar bandsRemovable arch wire with molar bands

Indications of space Indications of space maintainersmaintainers

If space after premature loss of If space after premature loss of deciduous teeth shows signs of closing.deciduous teeth shows signs of closing.

If use of space maintainer will aid in or If use of space maintainer will aid in or make the future orthodontic treatment make the future orthodontic treatment less involved.less involved.

If the need for treatment of malocclusion If the need for treatment of malocclusion at a later date is not indicated.at a later date is not indicated.

Even though space maintenance is Even though space maintenance is not necessary in case of anterior not necessary in case of anterior tooth loss, a functional space tooth loss, a functional space maintenance or partial denture should maintenance or partial denture should be given as tooth loss affects speech, be given as tooth loss affects speech, induce abnormal tongue habits which induce abnormal tongue habits which leads to malocclusion .leads to malocclusion .

Contra indications of space Contra indications of space maintainersmaintainers

If radiograph of extraction region shows If radiograph of extraction region shows that 1/3that 1/3rdrd of the root of succedaneous of the root of succedaneous tooth is already calcified.tooth is already calcified.

When the space left by the prematurely When the space left by the prematurely lost primary tooth is less than the space lost primary tooth is less than the space needed for the permanent successor as needed for the permanent successor as indicated radiographically.indicated radiographically.

If the space shows no signs of closingIf the space shows no signs of closing

Advantages of Removable type Advantages of Removable type of Space Maintainers.of Space Maintainers.

They are easy to clean and permit maintenance They are easy to clean and permit maintenance of proper oral hygieneof proper oral hygiene

It maintains and restores the vertical It maintains and restores the vertical dimension.dimension.

It can be worn part time allowing circulation of It can be worn part time allowing circulation of the blood to soft tissues.the blood to soft tissues.

They serve other important functions like They serve other important functions like aesthetic,mastication,phonetics aesthetic,mastication,phonetics

Dental checkup for caries detection can Dental checkup for caries detection can be undertaken easily.be undertaken easily.

They stimulate eruption of permanent They stimulate eruption of permanent teethteeth

Band construction is not necessaryBand construction is not necessary

Room can be made for permanent teeth Room can be made for permanent teeth to erupt without changing the applianceto erupt without changing the appliance

They prevent development of tongue They prevent development of tongue thrust habit into the extraction space.thrust habit into the extraction space.

More than one tooth can be replaced.More than one tooth can be replaced.

Being tissue-borne, they impose less Being tissue-borne, they impose less stress on remaining teeth.stress on remaining teeth.

Easier to fabricate, less chair time.Easier to fabricate, less chair time.

When there is general lack of sufficient When there is general lack of sufficient arch length and where space maintainer arch length and where space maintainer would further complicate existing would further complicate existing malocclusion.malocclusion.

When succedaneous tooth is absent.When succedaneous tooth is absent.

When well developed occlusion and When well developed occlusion and cuspal inter digitations or over eruption cuspal inter digitations or over eruption of opposing tooth prevent space closing.of opposing tooth prevent space closing.

Disadvantages:Disadvantages: Patient may not wear it, patient compliance in Patient may not wear it, patient compliance in

3-6year age group and uncooperative 3-6year age group and uncooperative children is poor.children is poor.

It may be lost or broken by the patient.It may be lost or broken by the patient.

It may restrict lateral growth of the jaws if It may restrict lateral growth of the jaws if clasps are incorporatedclasps are incorporated

They may cause irritation of the underlying soft They may cause irritation of the underlying soft tissues.tissues.

Fixed Space Maintainers; Fixed Space Maintainers; Band and LoopBand and Loop Band and BarBand and Bar Crown and BarCrown and Bar Trans palatal archTrans palatal arch Lingual archLingual arch Pin and tube space maintainers.Pin and tube space maintainers. Bonded space maintainers.Bonded space maintainers.

Modifications of Band and Loop Space Modifications of Band and Loop Space Maintainers.Maintainers.

Crown and loop Crown and loop Band and loopBand and loop Extended band and loopExtended band and loop Bonded band and loop Bonded band and loop Nance’s palatal arch space maintainersNance’s palatal arch space maintainers

Advantages of Fixed Space Maintainers:Advantages of Fixed Space Maintainers:

They do not interrupt with passive They do not interrupt with passive eruption of abutment teeth.eruption of abutment teeth.

Jaw growth not hamperedJaw growth not hampered Succedaneous permanent teeth are free Succedaneous permanent teeth are free

to erupt in oral cavity.to erupt in oral cavity. Can be used in uncooperative patients.Can be used in uncooperative patients.

Disadvantages:Disadvantages:

Elaborate instrumentation with expert Elaborate instrumentation with expert skill is neededskill is needed

It may result in decalcification of tooth It may result in decalcification of tooth material under the bands material under the bands

Supra eruption of opposing teeth can Supra eruption of opposing teeth can take place if pontics are not used.take place if pontics are not used.

If pontics are used, it can interfere with If pontics are used, it can interfere with Vertical eruption of abutment tooth and Vertical eruption of abutment tooth and may prevent eruption of replacing may prevent eruption of replacing permanent teeth, if patient fails to permanent teeth, if patient fails to report.report.

Indications:Indications: Unilateral loss of primary first Unilateral loss of primary first

molar before or after the molar before or after the eruption of permanent first eruption of permanent first molars.molars.

Bilateral loss of single primary Bilateral loss of single primary molar before eruption of molar before eruption of permanent incisors.permanent incisors.

When second primary molar When second primary molar is lost after the eruption of is lost after the eruption of first permanent molar.first permanent molar.

Sometimes it is given in cases Sometimes it is given in cases of premature loss of primary of premature loss of primary canines.canines.

BAND AND LOOP SPACE BAND AND LOOP SPACE MAINTAINERMAINTAINER

Usually Band- loop space maintainers is not Usually Band- loop space maintainers is not indicated to preserve the space created by indicated to preserve the space created by two adjacent primary molars. two adjacent primary molars.

The lengthy loop created in these situations The lengthy loop created in these situations is more susceptible to the forces of is more susceptible to the forces of mastication.mastication.

Advantages:Advantages: It is an effective space maintainer for It is an effective space maintainer for

unilateral loss of single tooth in buccal unilateral loss of single tooth in buccal segments.segments.

EconomicalEconomical Construction is simpleConstruction is simple

Takes little chairside time, especially if Takes little chairside time, especially if preformed bands are used.preformed bands are used.

It adjusts easily to accommodate the It adjusts easily to accommodate the changing dentition.changing dentition.

Disadvantages:Disadvantages:

Requires constant supervision. Like any Requires constant supervision. Like any other fixed maintainers, decalcification other fixed maintainers, decalcification under the bands is a problem.under the bands is a problem.

It will not prevent the continued eruption It will not prevent the continued eruption of the opposing teeth.of the opposing teeth.

LINGUAL ARCH:LINGUAL ARCH:

The lingual arch is the most The lingual arch is the most effective appliance for space effective appliance for space maintenance in posterior region maintenance in posterior region and minor tooth movement in the and minor tooth movement in the lower arch.lower arch.

The lingual arch space maintainer The lingual arch space maintainer consists of two bands cemented to consists of two bands cemented to the 1st permanent molars or the 1st permanent molars or sometimes 2nd deciduous molars, sometimes 2nd deciduous molars, which are joined by a SS wire which are joined by a SS wire butting against four incisors.butting against four incisors.

Usually indicated to preserve the Usually indicated to preserve the spaces created by multiple loss of spaces created by multiple loss of primary molars when there is no primary molars when there is no loss of space in the arch.loss of space in the arch.

The use of lingual arch is a good preventive measure, The use of lingual arch is a good preventive measure, since it helps in maintaining the arch perimeter by since it helps in maintaining the arch perimeter by preventing both mesial drifting of the molar teeth and preventing both mesial drifting of the molar teeth and also lingual collapse of the anterior teeth.also lingual collapse of the anterior teeth.

Spurs that is Projections of wire, may be used as Spurs that is Projections of wire, may be used as stoppers distal to anterior teeth to prevent their stoppers distal to anterior teeth to prevent their migration distally in the arch.migration distally in the arch.

These help in maintaining symmetry of centre lines, These help in maintaining symmetry of centre lines, especially in cases of unilateral tooth loss.especially in cases of unilateral tooth loss.

Advantages:-Advantages:-

Causes little inconvenience to patient Causes little inconvenience to patient Less bulky them removable acrylic space maintainers.Less bulky them removable acrylic space maintainers. Less conspicuous than other space maintainersLess conspicuous than other space maintainers Serves as a space maintenance for more than one Serves as a space maintenance for more than one

succedaneous tooth in the arch.succedaneous tooth in the arch. Prevents arch collapsePrevents arch collapse Prevents mesial migration of banded tooth.Prevents mesial migration of banded tooth.

Disadvantages Disadvantages Prolonged use of orthodontic bands – decalcification of Prolonged use of orthodontic bands – decalcification of

the tooth. the tooth.

Arch wire may become embedded into the soft tissue. Arch wire may become embedded into the soft tissue. This seems to occur more often in patients with This seems to occur more often in patients with poor oral hygiene.poor oral hygiene.

Wire may become distorted by masticatory forces and Wire may become distorted by masticatory forces and move teeth into undesirable positions.move teeth into undesirable positions.

Appliance should be removed every year and inspected Appliance should be removed every year and inspected for damage and further usefulness, recemented after for damage and further usefulness, recemented after

topical fluoride treatmenttopical fluoride treatment

Transpalatal Arch :Transpalatal Arch : Recommended for stabilizing the maxillary first Recommended for stabilizing the maxillary first

permanent molars.permanent molars. Best Indication for transpalatal arch is when one side Best Indication for transpalatal arch is when one side

of the arch is intact, and several of the arch is intact, and several primary teeth on the other side are missing.primary teeth on the other side are missing.

Also indicated when primary molars are lost bilaterally.Also indicated when primary molars are lost bilaterally. Appliance is designed to prevent the molars from Appliance is designed to prevent the molars from

rotating around the palatal roots ,which is the first rotating around the palatal roots ,which is the first movement resulting in loss of space in the arch movement resulting in loss of space in the arch perimeter.perimeter.

The transpalatal arch runs directly across the palatal The transpalatal arch runs directly across the palatal vault connecting the permanent first molars, avoiding vault connecting the permanent first molars, avoiding contact with the soft tissue.contact with the soft tissue.

Advantages:Advantages: No food lodgmentNo food lodgment Simple designSimple design No inflammatory changes in palateNo inflammatory changes in palate

Disadvantages:Disadvantages:

If given in case of bilateral missing deciduous molar, If given in case of bilateral missing deciduous molar, it cannot prevent drifting of abutment it cannot prevent drifting of abutment teeth.teeth.

If not passive ,unexpected vertical and transverse If not passive ,unexpected vertical and transverse movement of the permanent molars can occur.movement of the permanent molars can occur.

Eruption guiding applianceEruption guiding appliance Intra alveolar applianceIntra alveolar appliance One of the early designs of distal One of the early designs of distal

space maintainers was cast Gold space maintainers was cast Gold or Willet distal shoe – Now rarely or Willet distal shoe – Now rarely used because of increased cost, used because of increased cost, difficulties in tooth preparation, difficulties in tooth preparation, and more complicated and more complicated fabrication procedures.fabrication procedures.

The distal shoe appliance is used The distal shoe appliance is used to maintain the space of a to maintain the space of a primary second molar that has primary second molar that has been lost before the eruption of been lost before the eruption of the permanent first molar.the permanent first molar.

Distal Shoe ApplianceDistal Shoe Appliance::

Normally,the distal surface of the 2nd Normally,the distal surface of the 2nd primary molar provides a guide for primary molar provides a guide for the unerupted 1st permanent molars, the unerupted 1st permanent molars, when the 2nd primary molar is when the 2nd primary molar is removed prior to the eruption f the removed prior to the eruption f the first permanent molar, the Distal Shoe first permanent molar, the Distal Shoe appliance provides greater control of appliance provides greater control of the path of eruption of the unerupted the path of eruption of the unerupted tooth and prevents undesirable tooth and prevents undesirable mesial migration.mesial migration.

Indications:Indications: When 2nd primary molar is extracted or lost before the When 2nd primary molar is extracted or lost before the

eruption of first permanent molar. eruption of first permanent molar.

Contraindications:Contraindications: Poor oral hygienePoor oral hygiene Medically compromised patients like patients with Medically compromised patients like patients with

congenital heart congenital heart ddisease, juvenile isease, juvenile diabetics, Rheumatic fever, immunosupressiondiabetics, Rheumatic fever, immunosupression

If several teeth are missing in same quadrant as there If several teeth are missing in same quadrant as there lack of abutment.lack of abutment.

Lack of patient cooperationLack of patient cooperation

Nance palatal holding Nance palatal holding archarch

Indicated in premature Indicated in premature loss of first deciduous loss of first deciduous molar.molar.

Advantages:Advantages: EconomicalEconomical Allows growth transversely Allows growth transversely

in the inter-canine areas. in the inter-canine areas.

Disadvantages:Disadvantages: Requires more clinical skillRequires more clinical skill Palatal button may cause Palatal button may cause

food accumulation; food accumulation; causes causes inflammation.inflammation.

Abnormal frenal Abnormal frenal attachments attachments

Abnormalities of the maxillary labial frenum Abnormalities of the maxillary labial frenum are associated with a midline diastema .are associated with a midline diastema .

At birth frenum is attached to the alveolar At birth frenum is attached to the alveolar ridge with fibers running into the incisive ridge with fibers running into the incisive papilla. The teeth erupts and as alveolar papilla. The teeth erupts and as alveolar bone is deposited,the frenum attachment bone is deposited,the frenum attachment migrates superiorly with the alveolar ridge.migrates superiorly with the alveolar ridge.

  

Fibers may persist between the maxillary Fibers may persist between the maxillary central incisors and in the ‘V’ shaped central incisors and in the ‘V’ shaped intermaxillary suture , attaching to the intermaxillary suture , attaching to the outer layer of the periosteum and outer layer of the periosteum and connective tissue of the suture.connective tissue of the suture.

Faustin weber noted that diastema may be due to other factors, the possible causative factors :

Microdontia,Macrognathia,Supernumerary teeth,Peg laterals,Missing lateral incisors.

Habits such as thumb sucking, tongue thrusting & midline pathologies..

Oral Habits in Children and their ManagementOral Habits in Children and their Management

These habits bring about harmful These habits bring about harmful unbalanced pressures to bear upon the unbalanced pressures to bear upon the immature, highly malleable alveolar ridges, the immature, highly malleable alveolar ridges, the potential changes in position of teeth, and potential changes in position of teeth, and occlusions, which may become decidedly occlusions, which may become decidedly abnormal if these habits are continued for a abnormal if these habits are continued for a long time.long time.

. Boucher – a tendency towards an act or . Boucher – a tendency towards an act or an act that has become a repeated an act that has become a repeated performance, relatively fixed, consistent, easy performance, relatively fixed, consistent, easy to perform and almost automaticto perform and almost automatic

Prevention starts with proper nursing, proper choice of physiologically designed nursing nipple & pacifier toenhance the normal function and deglutitional maturation

Proper kinesthetic, neuromuscular gratificational activity at this time may ell prevent abnormal finger, lip and tongue deforming action.

Constant tongue thrust into an edentulous area make cause an open bite that remains in the permanent dentition.

An unfavorable oral condition to frequently stimulates a child to place his fingers in his mouth- this can well lead to finger sucking or nail biting.

THUMB SUCKINGDefinition

Repeated and forceful sucking of thumb with associated strong buccal and lip contractions.(Moyers)

Defines digit sucking as placement of thumb or one or more fingers in varying depths into the mouth(Gellin) Most children would stop digit sucking by the age Most children would stop digit sucking by the age of three to four years. But an acute increase in child’s of three to four years. But an acute increase in child’s level of stress and anxiety due to some underlying level of stress and anxiety due to some underlying psychological or emotional disturbances can account psychological or emotional disturbances can account for continuation of digit sucking habit, with for continuation of digit sucking habit, with conversion of an empty habit into a meaningful stress conversion of an empty habit into a meaningful stress reducing response. reducing response.

Causative Causative factors:factors:

Parent’s occupationParent’s occupation Working motherWorking mother Number of siblingsNumber of siblings Order of birth of the childOrder of birth of the child Social adjustment and stressSocial adjustment and stress Feeding practice Feeding practice Age of the childAge of the child

Effects on maxilla

- proclination of maxillary incisors- increased maxillary arch length- anterior placement of apical base- increased SNA- increase in clinical crown length of anteriors- counter clock wise rotation of occl.plane- decreased SN to ANS-PNS angle- decreased palatal arch width- atypical root resorption in primary central incisors- trauma to maxillary central incisors

Effects on mandible

- proclination or reteroclination of the mandibular incisors- increased intermolar distance- distal position of point B

Effects on interarch relationship

-↓ maxillary and mandibular incisal angle- increased over jet- decreased over bite- posterior cross bite- uni-bilateral class-II occlusion

Effect on lip placement and function

- incompetence lips- lower lip function under the maxillary incisors

Effect on tongue placement and function

- tongue thrust- lip to tongue resting position- lowered tongue position

Other effects - thumb deformity- speech defects, lisping

Treatment Treatment

Psychological therapyPsychological therapy Reminder therapyReminder therapy

Extra oral approachesExtra oral approaches

Intra oral approachesIntra oral approaches Mechanotherapy Mechanotherapy

Blue glassBlue glass

Quad helixQuad helix

Tongue trusting:Tongue trusting:

Definition:Definition:

Schneider 1982: tongue thrust is Schneider 1982: tongue thrust is forward placement of the tongue forward placement of the tongue between the anterior teeth and between the anterior teeth and against the lower lip during against the lower lip during swallowingswallowing

Tongue trusting:Tongue trusting:

Maxilla

- Tipping of the palatal plane-Proclination of maxillary anteriors resulting in increase in over jet- Generalized spacing between the teeth- Teeth may be mesially inclined- or all parameters may be norm

Mandible-Retroclination or Proclination of mandibular teeth depending on the type of growth-Generalized spacing between the teeth-Teeth may be mesially tilted- or all parameters may be normal

Inter arch - Anterior or posterior open bite depending on the posture of the tongue- Posterior cross bite- lack of interdigitation of the posterior teeth- Or all the parameters may be normal

Facial form

- Convex profile - Increased LAFH

lips- Short upper lip/normal upper lip- Hyperactive mentalis/ normal

Tongue

- Enlarged- Forwardly placed- Normal position

SpeechSpeech -Tongue thrust children are more likely to have -Tongue thrust children are more likely to have

various speech disorders, such as sibilant various speech disorders, such as sibilant distortions, distortions,

lisping problems in articulation of s, n, i, d, l, th, lisping problems in articulation of s, n, i, d, l, th, z, v z, v

sounds sounds

Mouth BreathingMouth BreathingDefinition:Definition: Sassouni (1971) defined mouth breathing as Sassouni (1971) defined mouth breathing as

habitual respiration through the mouth habitual respiration through the mouth instead of the nose.instead of the nose.

Merle (1980) suggested the term oro-Merle (1980) suggested the term oro-nasal breathing instead of mouth breathing.nasal breathing instead of mouth breathing.

F.M. Chacker defined mouth breathing F.M. Chacker defined mouth breathing as the prolonged or continued exposure of as the prolonged or continued exposure of the tissues of the anterior area of the mouth the tissues of the anterior area of the mouth to the drying effects of the inspired air.to the drying effects of the inspired air.

Oral myofunctional therapy has been shown to be effective in correcting oral myofunctional disorders such as tongue thrust swallow, improper tongue and mouth resting posture, improper use of muscles of the mouth, tongue, and lips for chewing and swallowing, and late thumb/finger sucking habits.

PREVENTION – MYOFUNCTIONAL APPLIANCES

Lip habitLip habit

It may involve either of the lips , with a It may involve either of the lips , with a higher predominance of lower liphigher predominance of lower lip

Definition Definition Habits involving manipulation of the lips Habits involving manipulation of the lips

and perioral structures are termed as lip and perioral structures are termed as lip habits.habits.

ClassificationClassification Wetting the lips with the tongue Wetting the lips with the tongue Pulling the lips into the mouth between Pulling the lips into the mouth between

the teeth (schneider1982)the teeth (schneider1982)

Treatment Treatment

Correction of malocclusion Correction of malocclusion Treating the primary habitTreating the primary habit

Appliance therapy Appliance therapy Lip bumperLip bumper

Nail biting Nail biting Nail biting is one of the most commonest habit in Nail biting is one of the most commonest habit in

children and adults. It is a sign of internal tensionchildren and adults. It is a sign of internal tension

EtiologyEtiology Emotional problemEmotional problem

EffectsEffects DentalDental Crowding, rotation, attrition of incisal edgesCrowding, rotation, attrition of incisal edges

Effects on the nailsEffects on the nails Inflammation of the nail beds Inflammation of the nail beds

Conclusion Conclusion Prevention of malocclusion and the success of Prevention of malocclusion and the success of

minor and/or major orthodontic intervention in minor and/or major orthodontic intervention in a developing malocclusion depend upon the a developing malocclusion depend upon the diagnostic skill and a clinical ability to reverse diagnostic skill and a clinical ability to reverse the process of the dentition’s maldevelopment.the process of the dentition’s maldevelopment.

The concept of prevention is based on the belief The concept of prevention is based on the belief that some, if not many, minor dental that some, if not many, minor dental developmental problems, in the younger age developmental problems, in the younger age group become major orthodontic needs. group become major orthodontic needs.

Early attention to many, if not all problems in Early attention to many, if not all problems in dental development of children can be helpful dental development of children can be helpful in reducing the severity of malocclusionin reducing the severity of malocclusion

ReferencesReferences

Orthodontics Current Principles and Technique – Orthodontics Current Principles and Technique – T.M.Graber.T.M.Graber.

Hand Book of Orthodontics - Robert E MoyersHand Book of Orthodontics - Robert E Moyers

Contemporary Orthodontics - Proffit WRContemporary Orthodontics - Proffit WR

Text Book of Orthodontics - G.SinghText Book of Orthodontics - G.Singh

Essential of Preventive and CommunityEssential of Preventive and Community Dentistry- Shoban Peter Dentistry- Shoban Peter

Text Book of Pedodontics – Shoba Tandon.Text Book of Pedodontics – Shoba Tandon.

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