INTERCEPTIVE ORTHODONTICS

Definition:

Defined as that phase of the science and art of orthodontics employed to recognize & eliminate potential irregularities & malpositions of the developing dentofacial complexes.
Some of the procedures carried out in preventive

orthodontics can also be carried out in interceptive orthodontics but the timings are different.

TIMING FOR THE FIRST VISIT TO THE ORTHODONTIST

The American Association of Orthodontics

recommends that the child first visits the orthodontist at SEVEN years of age. The permanent incisors and molars have erupted and the child has entered the mixed dentition stage of development. Guidance of eruption by the orthodontist can help correct many malocclusions. Skeletal discrepancies require the orthodontist to have as much control as over the magnitude and direction of facial growth.

PROCEDURES UNDERTAKEN IN INTERCEPTIVE ORTHODONTICS

1. Space regaining 2.Control and correction of crowding 3.Correction of developing crossbites 4.Interception of skeletal malocclusions 5.Maxillary midline diastemas 6.Functional jaw orthopaedics 7.Muscle exercises 8.Control of abnormal habits 9.Removal of soft tissue or bony barrier to enable eruption of teeth

REGAINING THE SPACE

Space Regainers

DIAGNOSIS OF CASES REQUIRING SPACE REGAINING

Attention limited to the segment in which the

tooth is missing ,is a frequent cause of failure in attempting to regain space. Considerations should include the following: 1.Alignment and space needs of the other teeth in the arch. 2.Relationships of the teeth to the denture base. 3.The transverse and sagittal dental relationships 4.The vertical relationships 5.The profile of the soft tissue

DENTAL AND SKELETAL RELATION

Clinical assessment should rule out the presence of

skeletal class II ,class III, open bite or closed bite relationships. Dental alignment considerations affecting regaining of space : a)Estimation of rotation b)Slipped contacts c) Faciolingual displacements of teeth from arch circumference. Identification of cases in which a relative protrusion or retrusion of the central alveolar structures does complicate evaluation of the available space.

RADIOGRAPHS AND STUDY MODELS

Aid in assessing space needs and

consideration of tooth alignment. Recognize whether the teeth have moved bodily into the space or tipped axially. Estimate the potential impact of adjacent erupting teeth on the teeth that have crowded the space. Periapical radiographs are necessary.

MIXED DENTITION ANALYSIS

To confirm the amount of space loss that has taken place and to estimate the amount of space to be regained, MOYERS MIXED DENTITION ANALYSIS and TANAKA AND JOHNSTON ANALYSIS should be done.

MOYERS MIXED DENTITION ANALYSIS

The perimeter of the arch is measured from

the mesial surface of one permanent molar to the mesial surface of the opposite molar. Arch can be measured in 4-6 segments. SIZE OF UNERUPTED TEETH: Done either from radiographs or by ratios based on the correlations between the sizes of permanent teeth.

TANAKA AND JOHNSTON ANALYSIS

Variation of Moyers analysis except that a

prediction table is not needed. Total estimated width of canines and premolars= sum of widths of lower incisors/2 +10.5 mm for LOWER ARCH OR 11 mm for UPPER ARCH.

SPACE REGAINERS
FIXED SPACE REGAINERS 1.Open coil 2.Gerber 3.Hotz lingual arch 4.Sectional arch technique 5.Lip bumper/plumper 6.Anterior space regainer

REMOVABLE SPACE REGAINERS 1.Free end loop 2.Split saddle/split block 3.Sling shot 4.Jack screw

OPEN COIL SPACE REGAINER

A reciprocal active fixed regainer . Used in mandibular arch when the first

premolar has erupted into the oral cavity. The band is cemented with the coil springs compressed.

OPEN COIL SPACE REGAINER

OPEN COIL SPACE REGAINER

OPEN SPACE REGAINER

GERBER SPACE MAINTAINER

May be fabricated directly in the mouth

during one relatively short appointment. A u assembly, which maybe welded or soldered in place with silver solder and fluoride flux ,is fitted in the tube, the appliance placed and wire section extended to contact the tooth mesial to the edentulous area.

GERBER SPACE MAINTAINER

GERBER SPACE REGAINER

HOTZ LINGUAL ARCH

For moving the molar distally. Appropriate where the lower first permanent

molar has drifted mesially, but the premolar or cuspid has not drifted distally. Anchorage is achieved as the arch contacts all the teeth and spurs across the canines. Advantage: Facilitates frequent removal of the arch for the purpose of activation.

HOTZ LINGUAL ARCH

SECTION ARCH TECHNIQUE

Used to regain the lost arch length. 4mm of space can be effectively regained. Used in cases where 2nd molar is erupted.

LIP BUMPER/PLUMPER
Used for procedures where bilateral

movement is desired. Consists of a heavy labial arch over which an acrylic flange is prepared in the anterior region such that it does not contact the lower anteriors. Used to relieve the lip pressure which can be used to distalize the molars by: 1.Incorporting loops in the arch wire just before it enters the buccal tube. 2.Utilizing a coil spring. Can also be used

LIP BUMPER

ANTERIOR SPACE REGAINER

Direct bonding is used to attach labial tubes

to the lateral incisors. A 0.0014 round wire was then inserted in an open coil spring and activated(Bayardo1986).

ANTERIOR SPACE REGAINER

REMOVABLE SPACE REGAINERS

FREE END LOOP SPACE REGAINER

Utilizes a labial arch for stability and

retention, with a back-action spring constructed of No. 0.025 wire. Movement of the permanent molar is achieved by activating the free end of the wire loop at specific intervals of time.

SPLIT SADDLE/SPLIT BLOCK SPACE REGAINER

Differs from the free end spring type in that

the functional part of the appliance consists of an acrylic block that is split buccolingually and joined by No.0.025 wire in the form of a buccal and a lingual loop. Activated by periodic spreading of the loops.

SPLIT SADDLE SPACE REGAINER

SLING SHOT SPACE REGAINER

Consists of a wire elastic holder with hooks

instead of a wire spring that transmits a force against the molar to be distalized. Named so, since the distalizing force is produced by elastic stretched on the middle of the lingual surface of the molar to be moved. The other is arranged in the same position on the buccal surface of the molar. The elastic can be changed once each day.

JACK SCREW
Incorporates an expansion screw in the

edentulous space. Space is opened by expanding the plates anteroposteriorly.

JACK SCREW

JACK SCREW

CROWDING

CROWDING
INCISAL LIABILITY : Permanent incisors being

larger than their deciduous counterparts, may have an impact on the crowding. a)In maxillary arch, the laterals are more palatally placed. b)In mandibular arch, the teeth may be lingually placed accompanied by some amount of rotation.

WILL CROWDING RESOLVE ON ITS OWN???

Depends on following factors:

1.INTERDENTAL SPACING: If absent, the shift of deciduous canines laterally is not possible when permanent incisors erupt and so may decrease the chances of better alignment. 2.INTERCANINE ARCH WIDTH: Increase in it can help in resolving the incisal crowding. Increases 6mm in maxilla and 4mm in mandible from 2 years of age to maturity. HAGBERG (1994) predicted that intercanine distance of >28mm shows little risk of crowding, <26mm maybe associated with some crowding

3.INCLINATION OF THE PERMANENT INCISORS: The more forward inclination of the permanent incisors may increase the arch circumference. 4.RATIO of the size between permanent and primary teeth will give an indication as to whether adequate space will be available or not.

OPTIONS IN MANAGEMENT OF CROWDING

Various options are:

1.Observe 2.Disk primary teeth 3. Extraction of teeth 4. Referral

OBSERVATION
In the primary dentition if incisor position has an additional space creating effect, crowding (<2mm) in most cases will correct themselves in normal dentition and occlusion establishment. If a space analysis, coupled with the measurement of intercanine width shows a favorable situation , the patient should be kept under observation.

DISKING THE PRIMARY TEETH

If the primary teeth prevent the incisors from

aligning themselves and the space required is not more than 3-4mm ,then grinding/disking the mesial surfaces of the canines will help to align the incisors. Then the tongue pressure helps teeth to align. Disking is done with 169L bur or a disking strip and surface protected with floride application. If the laterals are locked behind the centrals ,modification of the lingual arch is used to align the incisors.

DISKING

PROXIMAL STRIPPER

EXTRACTION OF TEETH
Well established procedure for creating

space. Includes : 1.SERIAL EXTRACTIONS 2.TIMELY EXTRACTIONS 3.WILKINSONS EXTRACTION

SERIAL EXTRACTIONS

SERIAL EXTRACTIONS
Concept introduced by BUNON(1940). Term coined by KJELLGREN(1929) and

popularised by NANCE(1940). Father of serial extractions NANCE(1940). Definition: defined as the correctly timed ,planned removal of certain deciduous and permanent teeth in mixed dentition stage with dento- alveolar disproportion ,i.e. teeth to supporting bone imbalance in order to:

a)Alleviate crowding of the incisor teeth, for example, to provide space for spontaneous alignment of incisors ,when the lateral incisors are erupted at 7-8 years, deciduous canines may

be extracted. b) Allow unerupted teeth to guide themselves into improved positions. For example, deciduous first molar is extracted to speed the eruption of the first premolar, when root development of the first premolar is halfway. c)Lessen the period of active appliance therapy or eliminate it.

INDICATIONS FOR SERIAL EXTRACTIONS

1.Class I with anterior crowding (space discrepancy 10mm or more). 2.Lingual eruption of the lateral incisors. 3.Midline arch shift potential due to unilateral canine loss. 4.Crowded arches accompanied with extreme proclination. 5.Abnormal primary canine root resorption . 6.Lack of development spacing. 7. Anomalies such as ankylosis ,ectopic eruption.

CONTRAINDICATIONS
1.Mild to moderate crowding( 8mm or less ). 2.Congenital absence of teeth providing space. 3. Where extensive caries of permanent first molars requires their removal. 4. Accompanying deep or open bites without correction. 5.Severe class II.,III of dental/skeletal origin. 6.Cleft lip and palate cases.

ASSESSMENT
Includes :

Clinical examination Occlusion study(models) X-rays - IOPA, OPG, cephalograms with cephalometric tracings Mixed dentition analysis Facial photographs

RULES TO BE FOLLOWED
1.There must be class I molar relationship bilaterally. 2.The facial- skeletal relation must be balanced antero-posteriorly, vertically and mesiodistally. 3. Discrepancy should be at least 5mm in all quadrants. 4.Dental midline should coincide. 5. There must be neither open bite nor deep bite.

RATIONALE
Based on two basic principles:

1.ARCH LENGTH TOOTH DISCREPANCY Excess tooth material as compared to the arch length -reduce the tooth material to achieve the suitable results. 2.PHYSIOLOGIC TOOTH MOVEMENT By selective removal of some teeth the rest of the teeth which are in process of eruption are guided by the natural forces into the extraction space.

PROCEDURE
Three popular procedures are:

1.DEWELS METHOD 2.TWEEDS METHOD 3. NANCE METHOD

DEWELS METHOD(1978)
Sequence proposed is the extraction of CD4. 1. At 8-9 years, deciduous canines are extracted to create space for alignment of incisors. 2. After 1 year deciduous first molars are extracted to accelerate eruption of first molar. 3. Extraction of erupting first premolars to permit permanent canines to erupt in their place.

A)Extraction of deciduous canines B)Extraction to deciduous molars

C)Extraction of erupting first molars D)Serial extraction completed

TWEEDS METHOD(1966)
Proposed the extraction sequence as D4C. A)At 8 years , all the deciduous first molars are

extracted. The deciduous canines are maintained to hamper the eruption of permanent canines. B)After the premolars(crowns) are through the alveolar bone , they along with the deciduous canines are extracted.

NANCE METHOD
Similar to Tweeds method.

ADVANTAGES OF SERIAL EXTRACTIONS

1.Treatment is more physiologic. 2.Physiological trauma associated with malocclusion can be avoided by treatment at an early age. 3.Eliminates or reduces the duration of multibanded fixed treatment. 4. Reduces risk of caries. 5.Health of investing tissues is preserved . 6.Lesser retention period is indicated at the completion of treatment. 7.More stable results as the tooth material and arch length are in harmony.

DISADVANTAGES
1)No single universal approach can be

applied to all patients. 2)Takes 2-3 years for treatment. 3) The patient may develop tongue thrust. 4)Extraction of buccal teeth can result in deepening of the bite. 5)Has to be followed by fixed appliance therapy especially in class I crowding cases, where procedure is accomplished by:

a) Relatively deep overbite. b) Distoaxial inclination of the canines and mesioaxial inclination of the second premolars. This space existing between canine and premolar is called DITCHING. So mechanotherapy and retention may be unavoidable. 6) Selectively in class II malocclusions. 7) May affect the future dental treatment. 8)Caries may affect the second premolars , necessitating their removal. 9)Impacted canines.

TIMELY EXTRACTIONS
Term coined by STEMM(1973). Similar to serial extractions except that no

permanent teeth are removed. Only deciduous teeth are removed in a sequence.

INDICATIONS
1)There is gingival recession(labially placed incisors). 2)Inadequate dental arch length. 3)Ectopic eruption of the lateral incisors or the first permanent molars. 4) Locking of the tooth below the counterpart ,space loss may also be present. 5) When crowding is 4-9mm so because the alignment of the incisors after the permanent canines have erupted is a difficult task.

INCISOR EXTRACTION
Done in cases where jaws are narrow and the

teeth are fanned out laterally. Any pathology of the incisors , where it cannot be saved or if it is excluded from the arch.

WILKINSONS EXTRACTIONS
Indicated in cases where the crowding exists

in the anterior region. For relief of crowding in the posterior teeth segments , the first molar extractions can be carried out.

CROSSBITE

CROSSBITE
Can be classified as following:

1. Anterior or Posterior 2. Unilateral or Bilateral 3. True or Functional

ANTERIOR CROSSBITE: Abnormal

labiolingual relationship between on or more maxillary and mandibular anterior teeth . POSTERIOR CROSSBITE: Abnormal buccolingual relationship of a tooth or teeth in the maxilla or mandible , or both, when the two dental arches are brought into centric occlusion.

Anterior Crossbite

POSTERIOR CROSSBITE

TREATMENT FOR ANTERIOR CROSSBITE

Factors that need to be evaluated before

treatment are as follows: 1. Axial inclinations of the upper and lower incisors. 2. The absolute size of the mandible and maxilla and their relationship to each other and to cranial base . 3.The molar and cuspid occlusion. 4. The extent of root formation . 5.Adequate mesiodistal space should be available.

CORRECTIVE MEASURES AND APPLIANCES

1.OCCLUSAL EQUILIBRATION: Correction of a pseudo class III crossbite by removal of premature tooth contacts by incisal grinding of the maxillary and mandibular incisors. 2.TONGUE BLADE THERAPY: Used when a simple one tooth anterior dental crossbite exists, with the teeth in the early stages of eruption.

TONGUE BLADE THERAPY

3. LOWER INCLINED PLANE: Introduced by CATALAN. Cemented lower acrylic inclined plane used to treat anterior crossbite involving one or two teeth. The inclined plane should be cemented and polished at a 45 degree angle to the long axis of the lower incisor teeth prior to cementation. The steeper the angle, greater the force applied. DISADVANTAGES: a) The possibility of opening the bite by wearing it longer than two or three weeks. b) Exact amount of labial movement is

LOWER INCLINED PLANE

4.STAINLESS STEEL CROWN: A reverse stainless steel crown given for single tooth crossbites in which the lower mandibular incisor has been previously displaced labially. 5.COMPOSITE INCLINES: Build up a composite incline on the lower teeth directly in the patients mouth. CROLL(1999) suggested use of bonded compomer having less strength than composite can be easily removed when desired.

STAINLESS STEEL CROWN

COMPOSITE INCLINE

6.REMOVABLE HAWLEYS APPLIANCE: A maxillary Hawleys appliance with Z springs incorporated into the acrylic resin used for correction of anterior crossbite involving single or multiple teeth. Retention obtained by- ball clasps, Adams or C clasps. Movement of the in locked incisors byactivating the springs 1.5 to 2 mm every 1 or 2 weeks.

ANTERIOR CROSSBITE

HAWLEYS APPLIANCE

7.FIXED APPLIANCES: lingual arch may be used for space control. Auxillary springs can be used along with lingual or palatal arches for correcting crossbite.

FIXED APPLIANCES

CORRECTION OF POTERIOR CROSSBITE

Factors to be evaluated before

treatment: 1. Crossbite is unilateral or bilateral. 2. Study models using a wax bite used to detect abnormal inclination of teeth , symmetry of the dental arches and growth pattern. 3.Cephalometric analysis. 4. An occlusal radiograph taken preoperatively to compare with the postoperative x-ray. 5. The midline is checked for unilateral mandibular shift. 6. A face-bow transfer may confirm the

CORRECTIVE MEASURES AND APPLIANCES

1.OCCLUSAL EQUILIBRATION: A bilateral lingual crossbite in the primary or mixed dentition is corrected by removing occlusal interferences,usually in cuspid areas. Appliance may be needed. 2.REMOVABLE W-ARCH APPLIANCE: Limited to only bilateral crossbite conditions because of the reciprocal conditions.

CORRECTION OF POSTERIOR CROSSBITE USING APPLIANCE

3.CROSS ELASTIC APPLIANCE: For correction of dental unilateral crossbite involving one or two teeth The two teeth are engaged by means of an elastic . Reciprocal movement of both upper and lower teeth occurs. DISADVANTAGES: patient cooperation and increased armamentarium.

CROSS ELASTIC APPLIANCE

4.REMOVABLE HAWLEYS APPLIANCE: Correction of two teeth unilateral crossbite. Offers good control of the amount and direction of force being applied to the teeth, Activation of jackscrew is done at turn every week . After correction of crossbite, the appliance should be worn in passive retention for an additional 3-6 months as a retentive appliance.

SKELETAL CORRECTION: Carried out in two

forms: A) SLOW PALATAL EXPANSION B) RAPID PALATAL EXPANSION The various appliances used are: 1. Minnesota expander 2. Hydrax jackscrew 3. Fixed split palate acrylic appliance

FIXED SPLIT PALATE APPLIANCE

MANAGING POSTERIOR CROSSBITE IN PRIMARY DENTITION

1.Correction of any habit contributing to crossbite. 2.Remove tooth interferences that prevent patient from biting into functional crossbite. 3. Actively expand constricted maxillary arch using removable or fixed appliance.

MAXILLARY MIDLINE DIASTEMA S

MAXILLARY MIDLINE DIASTEMAS are defined space greater than 0.5mm between the proximal surfaces of adjacent teeth.

APPLIANCE THERAPY FOR THE CORRECTION OF DIASTEMA

Principle applied here is reciprocal anchorage(in

fixed). The types of movements are either bodily or more commonly by tipping. REMOVABLE APPLIANCES 1.An active plate. 2. A split labial bow Disadvantage: Space may be created between the laterals. 3. Hawleys plate+ active labial bow used to retract the incisors and close the space in cases of increased overjet with diastema. DISADVANTAGE: Only tipping movements can be achieved.

SPLIT LABIAL BOW

HAWLEYS PLATE

FIXED APPLIANCES a)A stainless steel band with a bracket or more

commonly a bracket may be banded to the tooth and elastics utilized to bring the centrals towards each other. Tubes maybe welded and an archwire used, so that the teeth may slide. b)For esthetic treatment, a lingual button is bonded and an elastic applied which brings only a tipping movement only. c)For bodily movement of teeth edgewise bracket with a simple looped partial archwire be tied under tension into both brackets.

RETENTION:

To prevent relapse, a long term retention is required in the cases of midline diastema. A multi-stranded wire may be used lingually and held in place by means of composite.

FUNCTIONAL JAW ORTHOPAEDI CS

FUNCTIONAL JAW ORTHOPAEDICS

Generate mechanical forces that are transmitted to

teeth. The neuromuscular activity is tapped to alter stresses on teeth and jaw bones. DEFINITIONS: FRANKEL(1974):As a removable or fixed appliance which favorably changes the soft tissue environment. MILLS(1991): As a removable or fixed appliance which changes the position of the mandible so as to transmit forces generated by the stretching of the muscles , fascia and/or periosteum, through the acrylic and wirework to the dentition and the

CLASSIFICATION
Functional appliances can be removable or

fixed and can be classified as: - tooth borne passive, e.g., BIONATOR - tooth borne active, e.g., CLARKS TWIN BLOCK - tissue borne, e.g., FRANKELS FUNCTIONAL REGULATOR.

COMPONENTS OF A FUNTIONAL APPLIANCE

1. ERUPTION BITEPLANES: Act by encouraging a differential eruption of teeth and by removing intercuspal interferences. 2.LINGUO-FACIAL MUSCLE BALANCESHIELDS OR SCREENS: They hold the lips and cheek away from the teeth, thereby disrupting the equilibrium and permitting an unopposed buccal movement of the teeth. 3. MANDIBULAR REPOSITIONINGCONSTRUCTION OR WORKING BITE: Based on the assumption that, by displacing the mandible from its rest position and stretching the muscles attached to it, reflex

INDICATIONS
1.USE OF FUNCTIONAL APPLIANCES ALONE In cases having mild skeletal discrepancy , proclined upper incisors and no dental crowding. 2.USE OF FUNCTIONAL APPLIANCES IN COMBINATION WITH FIXED APPLIANCE To improve the anteroposterior relationship before starting the treatment. Useful in class II cases and reduce the amount of a comprehensive fixed therapy required. Reduce the risk of orthognathic surgery at a later date. 3.INTERCEPTIVE TREATMENT When growth enhancing effect is needed. Effective at reducing the relative prominence of the proclined upper incisors(dentoalveolar trauma).

RATIONALE FOR USE

Theoretical basis is that new pattern of

function within the orofacial system, directed by the appliance ,leads to the development of a new morphologic pattern (i.e., an altered dental or skeletal relationship).

EFFECTS ON THE DENTOSKELETAL COMPLEX

Skeletal, dentoalveolar and soft tissue effects

were reviewed by DARE and NIXON(1999). a.SKELETAL EFFECTS 1.By functional therapy during the growth of the mandible growth takes place at the condyles. 2.Some amount of growth restriction of maxilla takes place.

b.DENTOALVEOLAR EFFECTS 1.Inhibition of the downward and forward eruption of the maxillary teeth. 2. Retroclination of the upper incisors. 3.Proclination of the lower incisors. 4.Lower segment intrusion. 5.Leveling of the curve of spee and tipping of the occlusal plane.

c. EFFECTS ON SOFT TISSUES 1. Removal of the lip trap and improved lip competence. 2.Removal of adaptive tongue activity. 3.Lowering of the rest position of the mandible 4.Removal of soft tissue pressures from the cheeks and lips.

COMMON APPLIANCES IN USE

ACTIVATORS
MONOBLOC designed by ROBIN(1902)- first

reported functional appliance. Modified by ANDERSON (1936) and termed ACTIVATOR in 1957.
INDICATIONS: Total correction of class II div

I, class II div II, class III, open bites in a mixed and early permanent dentition and class II div I with deep bite.
CONTRAINDICATIONS: Cases of crowding or

where individual tooth movements are required.

BITE REGISTRATION: Based on horizontal

and vertical opening. a)SCHWARZ (1956) the optimal is the half of the individuals maximum range. b)WOODSIDE(1977) states that mandible registered in a position protruded 3.0 mm distal to the most protrusive position that the patient can achieve.

Generally, the horizontal advancement is kept edge to edge or 2mm less than the maximum protrusion. Vertical opening is kept 5mm posteriorly. In cases where overjet is more than 10mm , a stage-wise advancement is to be carried out. DURATION OF USE: An overjet of 8mm may require 10-12 months of wear. Time taken for correction may be reduced if the patient compliance is good and the patient can wear for more than 14 hours a day.

BIONATOR
Designed by BALTERS in 1964, termed as

OPEN ACTIVATORS Three basic types of bionators are: 1.The STANDARD APPLIANCE used in cases of deficient mandible. Made of an acrylic flange extended posteriorly. With selective trimming, desired eruption of the teeth can be achieved.

2. The OPEN BITE APPLIANCE, used to inhibit any abnormal posture or function of the tongue. 3. The REVERSED/CLASS III APPLIANCE , used to stimulate the growth of the underdeveloped maxilla. Maximum benefit is obtained by wearing the appliance day and night.

BIONATOR

CLARKS TWIN BLOCK

Introduced by CLARK in 1988. Consists of upper and lower removable plates

with acrylic hooks trimmed at an angle of 70 degrees with a midline expansion screw in the upper plate to allow a simultaneous expansion. Designed for high angle cases and are often constructed with an attachment inserted into the upper block for high-pull headgear.

CLARKS TWIN BLOCK

FRANKELS FUNCTIONAL REGULATOR

Much of the appliance is located in the

vestibule and the appliance is said to work by altering both mandibular posture and contour within the dentition. Used to enhance dental eruption as well as correct anteroposterior and lateral arch discrepancies . Frankel advocates advancing the mandible 2 to 3 mm every 4 to 5 months, and notching the maxillary teeth to aid in retention.

FRANKELS FUNCTIONAL REGULATOR

HORSE SHOE APPLIANCE

Used for correction of class III molar

relationship. Develop by SCHWARZ(1997). ADVANTAGES: 1.Easy to construct . 2.Does not allow for the eruption of the teeth due to the presence of acrylic resin over the upper and lower teeth.

HORSE SHOE APPLIANCE

HEAD GEAR
For restricting the growth of the maxilla in

cases of skeletal overgrowth of maxilla by applying extraoral force. Forces having vertical and horizontal component are applied through teeth. Improper forces may extrude the molar and also impede mandibular growth. Anchorage is derived from cervical, occipital and parietal regions. Patients cooperation is important.

HEAD GEAR

PENDULUM APPLIANCE
Also termed as non compliance therapy for

molar distalization. It is a hybrid using a larger NANCE ACRYLIC BUTTON in the palate for anchorage along with 0.032 TMA springs that deliver a light continuous force to upper first molar. Produces a broad swinging arc or pendulum of force from midline of palate to the upper molars. Used in patient with class I skeletal relationship and in class II dental

NANCE BUTTON IN PENDULUM APPLIANCE

CHIN CAP
Used in cases of excessive growth of

mandible . Two philosophies exist to its use , which are concerned with the direction of force applied: 1. When used such that the force is applied through the condyle. 2.When used with forces directed below the condyle. The effect is that chin is rotated downward and backward which is caused by the rotation of the mandible. This type of appliance is ideal in cases of short vertical

Chin cap,Head gear.Face mask

PRE-ORTHODONTIC TRAINER
Single size , ready to use , tooth positioned

appliance designed to incorporate myofunctional and tooth positioning characteristics. ADVANTAGES: Prefabricated. Requires no impressions. Can be applied in minimum chair time. Designed to intercept developing malocclusion while the permanent teeth are erupting and the child is still growing. Has easy implementation, better compliance , tooth guidance and helps in myofunctional training thus being an ideal choice for the child, 6- 10 years

TYPES OF PREORTHODONTIC TRAINERS

1. STARTING/PHASE I- Blue in color and soft

to wear(made of silicone). 2. FINISHING/PHASE II- Pink in color and is harder(made of polyurethane).

PRE ORTHODONTIC TRAINER

PHASE I II

PHASE

PRINCIPLE: The starting (blue) trainer imparts only a light force on the teeth, then after 6-8 months the firmer (pink) trainer, which imparts a much higher force on the malaligned anterior teeth, is implemented.

PARTS OF PRE-ORTHODONTIC TRAINER: 1.It has tooth channels and labial bows which guide the erupting/developing dentition into correct alignment. 2.Has incorporated tongue tag and lip bumpers, which are effective in treating myofunctional habits. 3.Base of the appliance rests on first permanent molars only.

AND PERIOD OF WEAR

The starting trainer (blue) is soft for maximum

compliance and flexibility to adapt to the most severe dental misalignment. Child should be shown tongue tag and instructed to position his tongue there with trainer in place. Child should be trained to put trainer in his mouth and used every day for 1 hour plus overnight while the child sleeps. Once the dental alignment improves , the hard or phase II trainer is used. As the teeth come into place , more force can be used to encourage their alignment. Finishing trainer should be used for a further 6 to 12 months. Use beyond this period is recommended depending on

APPLICATIONS
1. EARLY TREATMENT FOR DEVELOPING MALOCCLUSIONS in mixed dentition. 2.HABIT CORRECTION Actively trains the positioning of the tongue tip as in myofunctional speech therapies. Tongue guard stops tongue thrusting when in place and forces the child to breathe through the nose. Lip bumpers discourage over-active mentalis muscle activity. 3.DENTAL ALIGNMENT- The trainer is premoulded to the parabolic shape of the natural arches and adapted to large and small arches alike guiding the dentition into an edge-to-edge class I jaw position. 4.PREVENTS EXTRACTIONS- The forces widen the arch gaining space for the coming dentition.

5.CLASS II OR III CORRECTION- Mandibular growth is achieved by changes in the mode of breathing. Passive maxillary expansion is achieved by change in tongue position plus bite opening. Changing a child from mouth to nose breather increases the horizontal growth of the mandible and normalizes incisor position. 6.LIMITS BRUXISM- By double mouthguard effect it decreases aberrant myofunctional forces on the dentition. So faster tooth movement by removing the influence of interlocking occlusal forces occurs.

7.CLOSES OPEN BITES AND OPENS DEEP BITES by removing detrimental effect of the tongue and the perioral musculature on the anterior dentition,prior to regular orthodontic treatment. 8.REMOVES LOWER ANTERIOR CROWDINGArch length is gained by reducing the overactive mentalis muscle. There is facial improvement by changing mode of breathing and a passive arch expansion from change in tongue position.

WHEN TO TREAT WITH FUNCTIONAL APPLIANCE????

1.Best time is late mixed dentition. 2.Advantage can be taken of the pubertal growth spurt so that this active growth phase can be harnessed to optimize the amount of growth restraining effect or growth enhancing effect. 3. In the maxilla, generally the growth needs to be retarded and thus if the growth spurt is not over even after appliance therapy, some amount of growth may lead to a recurrence of the problem. In the mandible the growth needs to be enhanced by taking the help of the growth spurt. 4. YANG(1997) suggested use of horse-shoe appliance for the treatment of class III malocclusion. It has two separate plates for the upper and lower arch and is easily constructed . Also prevents extrusion and individual movements of teeth as it covers the whole

LIMITATIONS AND COMPLICATIONS

1.Discomfort , as both upper and lower teeth are joined together. 2. Depends on the patients compliance. 3.Can be used only if a favorable horizontal growth pattern is present in cases of class II correction. 4. Has to be removed during mastication . 5. May interfere with speech. 6. Treatment is often increased- the two stage treatment may prolong treatment by upto 18 months. 7. Laboratory and technical resources are required for construction and adjustment. 8. High cost.

MUSCLE EXERCISES
Normal occlusal development depends on the normal

oro-facial muscle function. Muscle exercises help in improving the aberrant muscle function. 1.EXERCISE FOR MASSETER- Clench the teeth while counting to ten. Repeat for some time. 2.EXERCISE FOR THE LIPS(CIRCUM-ORAL MUSCLES)a) Stretching of the upper lip to maintain lip seal in patients having short hypotonic lips by holding a paper between the lips. b) Stretching of the upper lip in downward direction towards the chin. c) Holding and pumping of water back and forth behind the lips. d) Button pull exercise. e) Tug of war exercise.

3.EXERCISES FOR THE TONGUE

a) One elastic swallow for improper positioning of the tongue. A 5/16 inch intra-oral elastic is placed on the tip of the tongue and the patient is asked to raise the tongue and hold the elastic against the rugae area and swallow. b) Tongue hold exercise: A 5/16 inch elastic is positioned over the tongue in a designed spot for a prescribed period of time with the lips closed. Then asked to swallow with the elastic in place and lips apart. c) Two elastic swallow: Two 5/16 inch elastics are placed over the tongue , one in the midline and other on tip. d) The hold pull exercise : the tip of the tongue and the midpoint are made to contact the palate and the mandible is gradually opened. Helps in

Muscle Exercises

INTERCEPTION OF HABITS:
Habits refers to certain actions involving the

teeth and other oral or perioral structures which are repeated often enough by some patients to have a profound and deleterious effect on the positions of teeth and occlusion. Some such habits are: Thumb sucking Tongue thrusting Mouth breathing

THUMB SUCKING
Most frequently practiced by children. Causes damaging effect on dento-alveolar

structures. Its presence upto2-1/2 to 3 years age is considered normal. Persistence beyond 3-1/2 to 4 years have damaging effect.& should be intercepted Intercepted by use of HABIT BREAKERS that could be removable or fixed.

TONGUE THRUSTING
Condition in which tongue makes contact

with any teeth anterior to the molars during swallowing. Deleterious habit , can clinically present along with open bite and anterior proclination. Intercepted using HABIT BREAKERS. Trained for correct technique of swallowing.

MOUTH BREATHING
Obstructive-nasal polyps ,tumors

,inflammations ,deviated septum Habitual persistence of habit after removal of the obstruction. It affects the orofacial equilibrium due to lowered mandible & tongue posture. And hence cause malocclusion. Intercepted by identifying and removing the cause.If persists , VESTIBULAR SCREEN can be used.

Habit Breakers

REMOVAL OF SOFT TISSUE & BONY BARRIERS:

Failure of teeth to erupt in appropriate time

should be intercepted by surgically exposing the crown. Over retained primary teeth, ankylosed primary teeth & supernumerary teeth are possible causes of non-eruption of succeedaneous teeth . The soft tissue and any bone overlying on it are removed. Tissue is removed to that extent such that the greatest diameter of the crown of the tooth is exposed.

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