PREVENTIVE & INTERCEPTIVE ORTHODONTICS

Preventive and Interceptive Orthodontics

"An Ounce of Prevention is Worth a Pound of Cure"

This axiom may be applied to many facets of life... your house, your car, your health, and your teeth. A comprehensive oral hygiene program that includes good brushing and flossing, fluorides, and limiting frequent sugary or starchy snacks will help prevent cavities and periodontal disease. Many orthodontic problems can be prevented.

Preventive Orthodontics

Preventive orthodontics is that part of orthodontic practice which is concerned with patients and parents education,supervision of the growth and development of the dentition and the cranio-facial structures,the diagnostic procedures undertaken to predict the appearance of malocclusion and the treatment procedures instituted to prevent the onset of malocclusion. Many of the procedures are common in preventive and interceptive orthodontics but the timings are different. Preventive procedures are undertaken in anticipation of developmentof a problem.whereas interceptive procedures are taken when the problem has already manifested.

The following are some of the procedures undertaken in preventive orthodontics:

Parent education Caries control Care of deciduous dentition Management of ankylosed tooth Maintenance of quadrant wise tooth shedding time table Checkup for oral habits and habit breaking appliance if necessary Occlusal equilibrium if there are any occlusal prematurities Prevention of damage to occlusion.eg:-milwaukee braces Extraction of supernumerary teeth Space maintenance Management of deeply locked first permanent molar Management of abnormal frenal attachments

Parent Education

Ideally much before birth of child Expecting mother-nutrition,ideal environment for developing fetus. Soon after birthProper nursing and care of child. If bottle fed---use physiologic nipple and not conventional nipple which are non physiologic(ie,do not permit suckling by movement of tongue and lower jaw).leading to various orthodontic problems of teeth. Do not use pacifiers for a long time. Prevention of nursing bottle syndrome(due to bottle feeding during night.upper teeth caries..but lower no caries) Need for maintaining good oral hygiene Correct method of brushing teeth

Physiologic nipples,pacifiers , conventional nipples &Nursing bottle caries

Caries control:

Caries in proximal surface of deciduous teeth if not restored leads to loss of arch length by movement of adjacent teeth into the space and thus cause discrepancies between arch length and tooth material when larger permanent teeth erupt into the oral cavity.

Care of deciduous dentition

Prevention and timely restoration of carious teeth. All efforts to prevent early loss of deciduous teeth(they are natural space maintainers) Simple preventive procedures like: Application of topical fluorides,Pit & fissure sealnts etc.

Extraction of supernumerary teeth:

Supernumerary & supplemental teeth can interfere with eruption of nearby normal teeth. They deflect adjacent teeth and erupt in abnormal positions. They should be identified and extracted before they cause displacement of other teeth.

Supernumerary teeth:

Eliminating Occlusal Interferance:

These lead to deviations in mandibular path of closure and also predispose bruxism. Detected by using articulating paper and premature contact removed by selective grinding is carried out.

Maintenance of tooth shedding time table:

Not more than 3 months between shedding of deciduous and eruption of permanent teeth. Delayed eruption due to: Over retained deciduous teeth roots Unresorbed deciduous root fragments Supernumerary tooth Cysts and tumors Over hanging restoration (deciduous teeth) Fibrosis of gingival Ankylosed primary teeth

Management of akylosed teeth:

Absence of PDL membrane in a small area or whole for the root surface. They do not resorb---prevent permanent teeth from erupting.or deflect them to erupt in abnormal positions. Diagnose such tooth and surgical removal removal at an appropriate time for permanent tooth eruption.

Managemnet of abnormal frenal attachments:

Thick and fleshy maxillary labial frenum leads midline diastema. Diagnosis blanch test.Treated at an early stage for prevention. Ankyloglossia or tongue tie -abnormal devpt of tongue. Difficulty in speech and swallowing:surgically treated.

Oral habits ,checkups and educating patients and parents.

Identify and stop habits such as Thumb sucking ,nail biting ,tongue thrusting and lip biting. Prevention starts with proper nursing nipple and pacifiers to enhance normal functional and deglutitional activity.

Preventing MILWAUKEE Brace Damage:

Orthopedic appliance used for correction of scoliosis. It applies tremendous force on the mandible and the developing occlusion leading to retardation of mandibular growth and possible deformities.whenever such appliance used, occlusion should be protected using functional appliance or positioners.made of soft materials.

MILWAUKEE BRACES

Deeply locked permanent first molars:

Ocasionally the deciduous second molar have a prominent distal bulge which prevents the eruption of the first permanent molars.Slicing these distal surface helps in guiding the eruption of first permanent molars.

Space Maintenance:

Premature loss ->drifting of adjacent teeth.This cause abnormal axial inclination of teeth,spacing & shift in midline. Premature loss of deciduous anteriors leads to very little orthodontic changes. Premature loss of permanent 1st molars-shift of anteriors takes place. Premature loss of permanent 2nd molar--first permanent molar migrate mesially.results in insufficient space for erupting premolars & hence impaction. Space maintainersmaintains space created by premature loss of deciduous teeth.

Ideal requirements of space maintainers:

Maintain entire mesio-distal space created by loss of teeth. Restore function as far as possible. Prevent over-eruption of opposing tooth. Simple in construction. Strong enough to withstand functional forces. Should not exert excessive stress on opposing teeth. Permit maintenance of oral hygiene. Must not restrict normal growth and development & natural adjustments which takes place during transition from deciduous to permanent dentition. It should not come in the way of other functions

Classification of Space maintainers

According to Hitchcock: Removable or fixed or semifixed. With bands or without bands. Active or passive. combinations of the above.
According to Raymond C. Thurow:

1.Removable 2.Complete arch-LingualArch Extra-oral Anchorage 3.Individual tooth.

According to Hinrichsen: 1.Fixed space maintainers: Class I a)Non-functional types i)Bar type. ii)Loop type. b)Functional types i)Pontic type ii)Lingual arch type. Class II-Cantilever type (distal shoe,band & loop) 2.Removable Space maintainers: Acrylic partial dentures.

Removable space maintainers

Removed & reinserted by patient. It can be functional or non-functional. Functional----teeth provided to aid in mastication, speech and esthetics Non functional----only an acrylic extension.over edentuluous area to prevent space closure.

Indications: When esthetics is of importance. When abutment teeth cannot support fixed appliance Cleft palate patients---for obturarion of palatal defects. If radiographs reveal that the unerupted permanent tooth is not going to erupt in less than 5 months. If permanent teeth is not fully erupted.so a band cannot be adapted. Multiple loss of deciduous teeth requiring functional replacement. Contraindications: Lack of patient co-operation Allergy to acrylic Epileptic patients having uncontrolled seizures.

Some commonly used removable space maintainers:

Acrylic partial dentures Full or complete dentures Removable distal shoe space maintainers

Fixed Space Maintainers:

Space mainainers that are fixed or fitted onto the teeth are called fixed space maintainers.

Advantages: Bands & crowns are used.So ,minimum or no tooth preparation Do not interfere with passive eruption of abutment teeth. Jaw growth is not hampered. The succedaneous permanent teeth are free erupt into the oral cavity Useful in uncooperative patients Masticatory function is restored if pontics are placed. Disadvantages: Elaborate instrumentation Experts skill May result in decalcification of tooth material under bands Supra eruption of opposing tooth if no pontics are placed If pontics used ,it may interfere with vertical eruption of abutment teeth & may prevent eruption of replacing permanent teeth,If the patient fails to report.

Examples of fixed space maintainers

Band and loop space maintainers.

Common,distal tooth bandedstainless steel wire soldered with mesial end touching mesial tooth.maily in posteriors.

Crown & loop appliance

Stainless steel crown on abutment teethother same as band and loop.

Lingual arch space maintainer: Most effective for space maintenance in lower arch. Two band on the 2 mandibular first molars/second deciduous molars,which are joined by a stainless steel wire contacting the lingual surface of 4 mandibular incisors.used to preserve space created by multiple loss of primary molars.Helps in maintaining the arch perimeter by preventing mesial drift & also lingual collapse of anteriors.

Platal arch appliance: (Nance holding arch) Similar to lingual arches. They are designed to prevent mesial migrationof maxillary molars. Transpalatal arch: For stabilizing maxillary first permanent molars.

Distal shoe space maintainer: Intra alveolar appliance.The distal surface of the second primary molar guides the unerupted first permanent molars.when the second primary molar is removed prior to eruption of permanent 1st molar ,the intra-alveolar appliance provides greater control of the path of eruption of the unerupted tooth and provides undesirable mesial migration .The appliance now used in practice is Roches distal shoe or its modifications using crown and band appliance with a distal intragingival extension.

Esthetic anterior space maintainers:

Band & bar type space maintainers. Abutment teeth on both side are banded and connected by a bar.

Planning for space maintainers:

1.Time elapsed since loss of tooth 2.Dental age of patient. 3.Thickness of bone covering the unerupted teeth: 4.Sequence of eruption of teeth. 5.Congenital absence of permanent teeth.

INTERCEPTIVE ORTHODONTICS

Definition: Defined as that phase of the science and art of orthodontics employed to recognize & eliminate potential irregularities & malpositions of the developing dento-facial complexes. Unlike preventive orthodontic procedures,interceptive orthodontics is undertaken at a time when the malocclusion has already developed or is developing .Thus interceptive orthodontics basically refers to measures undertaken to prevent a potential malocclusion from progressing into a more severe one. Some of the procedures carried out in preventive orthodontics can also be carried out in interceptive orthodontics but the timings are different.

Procedures undertaken in interceptive orthodontics:

Serial extraction. Correction of developing crossbite. Control of abnormal habits. Space regaining. Muscle exercises . Interception of skeletal malrelation. Removal of soft tissue or bony barrier to enable eruption of teeth.

SERIAL EXTRACTION:

Planned extraction of certain deciduous teeth and later specific permanent teeth in an orderly sequence and predetermined pattern to guide the erupting permanent teeth into a more favourable position.when one can recognize and anticipate potential irregularities in the dento-facial complex. History:-Kjellgren 1929 first used the term serial extraction.Nance(USA) 1940s popularized the technique

Rationale:
Based on 2 basic principles: Arch-length tooth material discrepancy--Tooth material >arch lengthhence, teeth extracted.so that rest of tooth occlude normally. Physiologic tooth movement---Removal some teeth,lets the rest of the teeth(which are erupting) to be guided by natural forces to extraction spaces.

Indications: Class I malocclusions showing harmony between skeletal and muscular systems Arch length deficiency. Where growth is not enough to overcome the discrepancy between tooth material and basal bone. Patients with straight profile and pleasing appearance Contraindications: Class II & III malocclusion with skeletal abnormalities Spaced dentition Anodontia/Oligodontia Open bite and deep bite Midline diastema Class I malocclusion with minimal space deficiency Unerupted malformed teeth. E.g.dilaceration Extensive caries or heavily filled first permanent molars Mild disproportion between arch length and tooth material that can be treated by proximal stripping.

Procedure: Three popular methods are: Dewels method

3 step-C(8-9yrs);D(9-10yrs);Erupting 4s

Tweeds method
D(8yrs);Erupting 4s & C

Nance method
Similar to tweeds

DEVELOPING ANTERIOR CROSSBITE:

Anterior cross bite is a condition characterized by reverse overjet wherein one or more maxillary anterior teeth are in lingual relation to the mandibular teeth. Should be intercepted and treated at an early stage to prevent a minor orthodontic problem from progressing into a major dento-facial anomaly.as an old maxim states

The best time to treat a crossbite is the first time it is seen

Or else it may grow into skeletal malocclusion Classification: Dento-alveolar anterior crossbite. Skeletal anterior crossbite. Functional anterior crossbite.

Anterior Crossbite

Dento-alveolar anterior crossbite: One or more maxillary anterior teeth are in lingual relation to the mandibular anteriors. Treated using tongue blades ,catalans appliance and double cantilever springs. Functional anterior crossbite: Pseudo class III malocclusion.., where the mandible is compelled to close in a position forward of its true centric relation. Treated by eliminating occlusal prematurities. Skeletal anterior cross-bite: Treated by myofunctinal or orthopaedic appliances

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

SPACE REGAINING:

Early loss of primary molar and failure to use space maintainers may lead to reduction in arch length by mesial movement of 1st molars. Space regained by distal movement of first molar. Which is undertaken at an early age prior to eruption of second molar.

Commonly used space regainers: Gerbers Space Regainer: An U tube and an U rod .Rod inserted into tube with activated spring at free ends of rod. Jack Screws: Split acrylic plate with jack screw in relation to edentulous space.Retained using Adams clasps. Cantilever Spring: Removable appliances that incorporate simple finger springs.

Space Regainers

MUSCLE EXERCISES:

Muscle exercises helps in developing improving aberrant muscle functions. Masseter: Clenching of teeth while counting till ten. Lips: Stretching of upper lipto maintain lip seal(paper may be held b/w lips)--for hypotonic lip patients. Stretch upper lip downwards towards chin. Hold & pump water back & forth behind lips. Massaging of the lips. Button pull exercise:-1/2 inch button,,,,thread passed through buttonholeplace button behind lips& pull thread, By using lip pressure. Tug of war exercise: instead 2 buttons. Tongue: One elastic swallow Tongue hold exercise.

Muscle Exercises

INTERCEPTION OF SKELETAL MALRELATIONS:

Interception of class II malocclusions: Causes: Excess maxillary growth. (Restricted by facebow with headgear) Defficient mandibular growth. (Myofunctional appliances) Combination of both.

Interception of class III malocclusions: Causes: Mandibular prognathism.(Chin cap with head gear) Maxillary retrognathism ( Face mask therapy ) Combination of both

Chin cap,Head gear.Face mask

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 causesof non-eruption of succedaneous teeth . The soft tissue and any bone overlying it are removed.tissue is removed to that extent such that the greatest diameter of the crown of the tooth is exposed.

THANK YOU
Prepared by:

Deebah choudhary Prefinal year