PREVENTIVE ORTHODONTICS.pptx

Athira Jithendranath
2nd yr PG
Dept. of Orthodontics
PREVENTIVE
ORTHODONTICS

CONTENTS
• Introduction
• Definition
• Parent education
• Caries control & prevention
• Management of occlusal relationship problems
Posterior crossbite
Anterior crossbite
Anterior openbite

CONTENTS
• Management of eruption problems
Over-retained primary teeth
Supernumerary teeth
Delayed incisor eruption
Ankylosed primary teeth
Ectopic eruption
Transposition
Primary failure of eruption
Roots shortened by radiation therapy

CONTENTS
• Abnormal frenal attachment
• Deeply locked in permanent 1st molar
• Prevention of damage to occlusion due to milwaukee
braces
• Space maintenance
• Conclusion
• References

INTRODUCTION
• Preventive orthodontics is concerned with the
patient’s and parents’ education, supervision of
growth & development of dentition and the
craniofacial structures, the diagnostic procedures
instituted to prevent the onset of malocclusion.
• Preventive procedures are undertaken in
anticipation of development of a problem.

WHAT IS PREVENTIVE
ORTHODONTICS??
• “Actions taken to preserve the integrity of what
appears to be a normal occlusion at specific time”
-Graber(1996)
• “Prevention of potential interference with occlusal
development”
-Proffit and Ackerman(1980)

PARENTAL EDUCATION
a) Ideally much before birth of child
b) Expecting mother-nutrition, ideal environment for
developing fetus.
c) Soon after birth—Proper nursing and care of child.
d) 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.
e) Do not use pacifiers for a long time.

f) Prevention of nursing bottle syndrome(due to bottle
feeding during night-Presence of Caries in upper, no caries
in lower)
g) Need for maintaining good oral hygiene
h) Correct method of brushing teeth

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

 Prevention and timely restoration of carious teeth.
 Efforts --to prevent early loss of deciduous teeth(they are
natural space maintainers)
 Simple preventive procedures like: Application of topical
fluorides, Pit & fissure sealants etc.
CARIES CONTROL & PREVENTION

MANAGEMENT OF
OCCLUSAL RELATIONSHIP
PROBLEMS

OCCLUSAL RELATIONSHIP PROBLEMS
a)Crossbite of Dental Origin
b) Oral Habits and Openbite

POSTERIOR CROSSBITES
1. Equilibration to eliminate mandibular shift:-
 Mostly in the primary or early mixed dentition, a shift into
posterior crossbite occur due to occlusal interference caused
by primary canines or primary molars
 Equilibration of primary teeth-- to eliminate the interference
and the resulting lateral shift into crossbite
William R. Proffit- Contemporary Orthodontics- 6th ed

Minor canine interference leading to mandibular shift
The slight lingual position of the primary canines can lead to occlusal
interferences and an apparent posterior crossbite.
Initial contact
Shift into centric occlusion

According to the Cochrane review by Harrison and
Ashby, 2008
Harrison, J. E., & Ashby, D. (2008). Orthodontic treatment for posterior crossbites.
Cochrane Database of Systematic Reviews.

The evidence from the trials reported by Lindner (1989);
Thilander (1984) suggests that:
 Removal of premature primary tooth contacts is
effective in preventing a posterior crossbite from
being perpetuated to the mixed and permanent
dentition.
 When grinding alone is not effective, using an upper
removable expansion plate to expand the upper arch
Harrison, J. E., & Ashby, D. (2008). Orthodontic treatment for posterior crossbites.
Cochrane Database of Systematic Reviews.

2. Expansion of a constricted maxillary arch:-
 Bilateral constriction of the maxillary arch leads to
premature contacts on closure (typically in the canine area)
and a functional shift to one side, which allows for
maximum interdigitation of the arches.
 One important diagnostic feature of unilateral posterior
crossbites resulting from bilateral maxillary constriction and
a functional shift is that they typically have midline
discrepancy in centric occlusion
Samir E Bishara-Textbook of Orthodontics (2001)

Moderate bilateral maxillary constriction
Initial contact
Shift into centric occlusion

 The preferred appliance for a preadolescent child is an
adjustable lingual arch that requires little patient cooperation
 W-arch and the quad helix are reliable and easy to use.
W-arch
 A fixed appliance
 Constructed of 36-mil steel wire soldered to molar bands.
 The lingual wire should contact the teeth involved in the
crossbite
 Activation-- opening the apices of the W

Activation at point 1 produces posterior expansion and activation at
point 2 produces anterior expansion.

Quadhelix
 The quad helix is a more flexible version of the W-arch
 Made with 38-mil steel wire.
 The combination of a posterior crossbite and a finger-
sucking habit is the best indication for this appliance.

Activation at point 1 produces posterior expansion, whereas activation
at point 2 produces anterior expansion.

3. Unilateral repositioning of teeth:-
 Some children do have a true unilateral crossbite because of
unilateral maxillary constriction of the upper arch
 In these children the ideal treatment is to move selected
teeth on the constricted side.
Treatment options:
 Using different length arms on a W-arch or quad helix
 Mandibular lingual arch to stabilize the lower teeth and
attach cross-elastics to the maxillary teeth that are at fault.

Permanent maxillary left first molar is displaced
lingually and the permanent mandibular left first
molar is displaced facially, which resulted in a
posterior crossbite between these teeth.
A short and relatively heavy cross-elastic is
placed between the buttons welded on the
bands.

NON SKELETAL ANTERIOR CROSSBITES
 The most common etiologic factor--lack of space for
the permanent incisors.
 If the developing crossbite is discovered before
eruption is complete and overbite has not been
established the adjacent primary teeth can be
extracted to provide the necessary space
 Those diagnosed after overbite is established
require appliance therapy for correction.

The first concern is adequate space for tooth
movement, which usually requires:
1: Bilateral disking
2: Extraction of the adjacent primary teeth
3: Or opening space for tooth movement

1. Maxillary incisor directed biomechanics / appliances:
– Tongue blade-- Patient self-guide incline
leverage concept for minimal overlap
– Mandibular acrylic inclined plane- Cautiously
recommended due to potential trauma consequences
Removable Appliance Therapy:

2. Fingersprings for facial movement of the maxillary
incisors
3. Active labial bow for lingual movement of mandibular
incisors

b)Corrected with a removable appliance
a)The permanent maxillary left central incisor
has erupted into crossbite

 One of the simplest fixed appliances for correction of
maxillary incisors with a moderate anterior crossbite
is a maxillary lingual arch with finger springs (whip
springs).
 Indicated for a child with whom compliance problems
are anticipated.
 The springs usually are soldered on the opposite side
of the arch from the tooth to be corrected, in order to
increase their length.
Fixed Appliance Therapy:

Alternative: 2 × 4 fixed appliance (2 molar
bands, 4 bonded incisor brackets)

ORAL HABITS AND OPEN BITES
Open bite in a preadolescent child has several
possible causes:
1: The normal
transition as
primary teeth
are replaced by
the permanent
teeth
2: A habit like
finger
sucking

EFFECTS OF SUCKING HABITS
The effect of such a habit on the hard and soft
tissues depends on its :
1: Frequency(hours per day)
2: Duration (months/years)
 With frequent and prolonged sucking, maxillary
incisors are tipped facially, mandibular incisors are
tipped lingually , and eruption of some incisors is
impeded

As long as the habit stops before the eruption of the
permanent incisor, most of the changes resolve
spontaneously.

Non-dental Intervention:
As the time of eruption of the permanent
incisors approaches, habit therapy:-
1. Discussion between the child and the dentist –explanation about
the problems caused by a prolonged finger habit.
2. Reminder therapy—
 Adhesive bandage with waterproof tape on the finger
that is sucked
 Anterior portion of the quad helix appliance- as a
reminder
 Elastic bandage loosely wrapped around the elbow

Appliance therapy:
Maxillary lingual arch with an anterior crib device

MANAGEMENT OF
ERUPTION PROBLEMS

ERUPTION PROBLEMS
 Over-Retained Primary Teeth
 Supernumerary teeth
 Delayed Incisor eruption
 Ankylosed Primary Teeth
 Ectopic eruptions
 Transposition
 Primary failure of eruption
 Roots shortened by radiation therapy

OVER-RETAINED PRIMARYTEETH
 A permanent tooth should replace its primary predecessor
when approximately three fourths of the root of the
permanent tooth has formed.
 A primary tooth that is retained beyond thispoint should be
removed.
An over-retained primary tooth leads to:-
 Gingival inflammation
 Hyperplasia --that causes pain and bleeding
 Deflected eruptionpaths that can result in:
(a) Irregularity, (b) Crowding, (c) Crossbite

Once the primary tooth is out, if
space is adequate, moderately
abnormal facial or lingual
positioning will usually be
corrected by the equilibrium forces
of the lip, cheeks and tongue

SUPERNUMERARY TEETH
Supernumerary teeth can disrupt both the normal
eruption of other teeth and their alignment and spacing.
The most common location for supernumerary teeth is
the anterior maxilla
Treatment is aimed at:
 Extraction of the supernumeraries before problems
arise
 OR at minimizing the effect if other teeth have
already been displaced

DELAYED INCISOR ERUPTION
Etiology:-
• Retained primary tooth
• Supernumerary tooth
• Pathologic condition
If the delayed incisor is located superficially it can be exposed
with a simple soft tissue excision and usually will erupt rapidly.
When the tooth is more deeply positioned, the overlying and
adjacent tissue can be repositioned apically and the crown
exposed, which usually leads to normal eruption or the tooth can
have an attachment placed and repositioned orthodontically

ANKYLOSED PRIMARY TEETH
 Ankylosed primary teeth with permanent successors--potential
alignment problem for the permanent teeth.
 Occasionally --fail to resorb / retained by a bony attachment
 Delays the erupting permanent tooth / deflect it from the
normal eruption path.

Maintaining
it until an
interference with
eruption or drift of
other teeth begins to
occur
then
extracting it
placing a lingual
arch or other
appropriate
fixed appliance
if needed
MANAGEMENT

 If adjacent teeth have tipped over the ankylosed tooth
They need to be repositioned to regain space.
 When an ankylosed primary tooth has no permanent successor.
To avoid long-term periodontal problems
(2 approaches)
Ankylosed primary molar
extraction before a large vertical
occlusal discrepancy develops
Tooth can be decoronated

Both anterior and posterior teeth tipping over adjacent ankylosed
primary molars.
The ankylosed teeth should be removed if significant tipping and
space loss are occurring

ECTOPIC ERUPTION
Eruption is ectopic when a permanent tooth causes
either:
 Resorption of a primary tooth other than the one it
is supposed to replace
 Resorption of an adjacent permanent tooth.

ECTOPIC ERUPTION OF LATERAL
INCISORS
 Loss of one or both primary canines from ectopic eruption
usually indicates lack of enough space for all the permanent
incisors, but occasionallymay result solely from an aberrant
eruption path of the lateral incisor.
 When one primary canine is lost, treatment is needed to prevent
or correct a shift of the midline.
 Depending on the overall assessment; the dentist can either:
remove the contralateral canine or maintain the position of the
lateral incisor on the side of the canine loss, using a lingual arch
with a spur

If both mandibular primary canines are lost, the
permanent incisors tip lingually, which reduces the
arch circumference and increases the apparent
crowding.
A passive lingual arch to prevent the lingual tipping,
or an active lingual arch for expansion may be
indicated.

ECTOPIC ERUPTION OF
MAXILLARY FIRST MOLARS
 When only small amounts of resorption are observed,
a period of watchful waiting is indicated because self-
correction is possible.
 If the blockage of eruption persists for 6 months or if
resorption continues to increase, treatment is
indicated.
 Lack of timely intervention may cause loss of the
primary molar and space loss as the permanent molar
erupts mesially.

Ectopic eruption of the permanent first molar is usually diagnosed
from routine bitewing radiographs. If the resorption is limited,
immediate treatment is not required.
(A)The distal root of the primary maxillary second molar shows
minor resorption from ectopic eruption.
(B)This radiograph taken approximately 18 months later illustrates
that the permanent molar was able to erupt without treatment.

Intervention
1. Move the ectopically erupting tooth away from the
primary molar it is resorbing
 If a limited amount of movement is needed but little
or none of the permanent first molar is visible
clinically
 A 20mil brass wire looped and tightened around the
contact between the primary second molar and the
permanent molar is suggested.
 The brass wire should be tightened approximately
every 2 weeks

.
(A)This distal root of the primary
maxillary second molar shows enough
resorption that self-correction is highly
unlikely.
(B) A 22-mil dead soft brass wire is guided
under the contact and then looped
around the contact between the teeth
(C)the permanent tooth is dislodged
distally and erupts past the primary
tooth that is retained.

2. A steel spring clip separator, may work if only a small
amount of resorption of the primary molar roots exists.
 A simple fixed appliance can be fabricated to move
the molar distally.

ARKANSASSPRING
Scissors-like spring that extends below the contact point,
can be effective in tipping a permanent first molar distally
so that it can erupt.

This primary maxillary second molar
shows severe resorption
The permanent molar is tipped
distally out of the resorption
defect
If the occlusal surface of the permanent molar
is accessible, the primary molar can be banded
and a 20-mil spring soldered to the band.

Band and spring appliance
 A band –on primary second molar.
 Omega-shaped loop and a helical loop -
distal to the primary molar.
 The spring is activated--wire is inserted into
the primary molar tube from the distal
surface and bend anterior to the molar tube.
 The helical loop is compressed during
bonding to the occlusal surface of the
permanent first molar
Opening loop, and compress it to seat from the
distal into the primary 2nd molar tube and from
the mesial into the permanent molar tube

ECTOPIC ERUPTION OF
MAXILLARY CANINES
Ectopic eruption of maxillary canines occurs relatively
frequently and can lead to either or both of two problems:
(1)Impaction of the canine
(2)Resorption of permanent lateral incisor roots
There appears to be a genetic basis for this eruption
phenomenon, and in some cases it is related to small or
missing maxillary lateral incisors

At age 10, if the primary canine is not mobile and
there is no observable or palpable facial canine bulge,
ectopic eruption of canine is considered

Ericson and Kurol found that if the permanent canine
crown was overlapping less than half of the root of the
lateral incisor extract the overlying primary canine
there was an excellent chance(91%) of normalization of
the path of eruption.
When more than half of the lateral incisor root was
overlapped, early extraction of the primary tooth
resulted in a 64% chance of normal eruption and likely
improvement in the position of the canine even if it
was not totally corrected

 If the canine is not redirected by this procedure, it
most likely will remain unerupted in a palatal
position or erupt lingual to the maxillary incisors
OR
 May cause resorption of the permanent incisor roots.
 Then, surgically expose the permanent canine and
use orthodontic force to bring it to its correct
position

TRANSPOSITION
 Transposition is a positional interchange of two adjacent
teeth.
 Most likely to be transposed :
mandibular incisors
maxillary premolars
(as a consequence of ectopic eruption)
 Best approach: move a partially transposed tooth to a total
transposed position, or to leave fully transposed teeth in
that position

PRIMARY FAILURE OF ERUPTION
 Diagnosis of primary failure of eruption often occurs
in the late mixed dentition period when some or all
the permanent first molars still have not erupted there
is a genetic component to this problem.
 The affected teeth are not ankylosed, but do not
erupt and do not respond normally to orthodontic
force.

ROOTS SHORTENED BY
RADIOTHERAPY
 Some of the irradiated teeth fail to develop, others
fail to erupt, and some may erupt even though they
have extremely limited root development.
 Although the roots are short, light forces can be
used to reposition these teeth and achieve better
occlusion.

DEEPLY LOCKED PERMANENT
FIRST MOLAR
 Assess with radiograph.
 If second deciduous molar hinders the eruption due to
distal bulging, slight distal stripping.
 If excess bone hinders the eruption, surgical removal of
bone.

ABNORMAL FRENAL ATTACHMENTS
 Frenectomy of high frenal attachments is done to avoid
diastema on eruption of the succedaneous tooth.
 Surgical correction of ankyloglossia.

HIGH FRENAL ATTACHMENT &
ANKYLOGLOSSIA

PREVENTION OF DAMAGE TO OCCLUSION
DUE TO MILWAUKEE BRACES
 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.

SPACE MAINTENANCE
 Early loss of a primary tooth presents a
potential alignment problem, because drift
of permanent or other primary teeth is
likely unless it is prevented

IDEAL REQUIREMENTS OF SPACE
MAINTAINERS
 Should maintain the desired mesiodistal
dimensions of the space.
 Should not interfere with the eruption of the
permanent teeth.
 Maintenance of functional movement
(physiological) of the teeth.
 Should allow for space regaining, when
required

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

According to
Raymond C.
Throw:
1.Removable
2.Complete
arch
LingualArch
Extra-oral
Anchorage
3.Individual
tooth.

According to
Heinrichsen
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 edentulous
area to prevent space closure.

Indications:
 When esthetics is of importance.
 When abutment teeth cannot support fixed appliance
 Cleft palate patients---for obturation 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.

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

FIXED SPACE MAINTAINERS
Space maintainers 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.

Fixed, Non-functional, Passive.
INDICATIONS: -
1) Premature loss of primary first molar.
2) Where the unerupted premolar is more than 2 years from
clinical eruption and root length < ½.
CONTRAINDICATIONS: -
1) Crowding.
2) Space loss.
3) High caries activity.
4) Cannot be used in space loss > 1 tooth.
I. BAND AND LOOP

ADVANTAGES: -
1) Economical & Less chair time required.
2) Allows transverse growth of jaw.
DISADVANTAGES: -
1) Does not restore masticatory function.
2) Does not prevent supra-eruption.
3) May lead to slight mesial tipping.
4) Migration of loop gingivally.
Crown & loop – Modification.

INDICATIONS: -
1) Bilateral loss of primary teeth.
2) Minor Anterior teeth movement.
3) Maintainence of Leeway space.
4) Space Regaining.
CONTRA-INDICATIONS: -
1) Before eruption of mandibular incisors.
II. LINGUAL ARCH

ADVANTAGES: -
1) Economical.
2) Less irritating to the tongue.
DISADVANTAGES: -
1) Loss of cementation and solder.
2) May cause untoward movement.
3) Wire may get disfigured.

Fixed / Removable, Intraalveolar,
Eruption guidance appliance.
INDICATIONS: -
Early loss of 2nd primary molar
prior to eruption of 1st permanent molar.
CONTRAINDICATIONS: -
1) Inadequate abutments due to multiple loss.
2) Poor patient co-operation & oral hygiene.
3) Medically compromised patients.
III. DISTAL SHOE

ADVANTAGES: -
1) Durable, Maintains occlusion.
2) Can be used after removal of extension.
DISADVANTAGES: -
1) Difficulty to construct, Costly, Time consuming.
2) over-extension causes injury to permanent tooth bud.
3) If under-extended, tooth tips mesially.
4) Prevents complete epithelialization of socket.

INDICATIONS: -
1) Unilateral space loss in maxillary arch.
ADVANTAGES: -
1) No inflammatory changes in palate.
2) More effective if there is bilateral premature loss of
deciduous 1st molars.
DISADVANTAGES: -
Food debris entrapment
IV. TRANSPALATAL ARCH

Fixed. Non-functional, Passive.
INDICATIONS: -
1) Bilateral loss of deciduous molars.
2) Combined habit breaking Appliance.
CONTRA-INDICATIONS: -
1) Palatal lesions.
2) One of the molars not erupted.
V. NANCE PALATAL HOLDING ARCH

ADVANTAGES: -
1) Economical.
2) Allows growth transversely in inter-canine area.
3) If deciduous molars are used as Abutments, allows
intermolar transverse growth.
DISADVANTAGES: -
Food accumulation & Inflammatory response of soft tissues
of palate.

Consists of 2 bondable mesh pads connecting teeth on either
sides of the lost teeth
VI. PREFORMED BONDED SPACE
MAINTAINERS

CONCLUSION
• As the word goes, “Prevention is better than
cure”, preventing orthodontic malocclusion at a
very early age can be beneficial for the children
than interceptive and corrective procedures at a
later age.
• Hence it is the need of the age, for children and
parents to be well informed, educated and
motivated to take preventive measures against
development of malocclusion.

REFERENCES
• William R. Proffit- Contemporary Orthodontics- 6th ed
• Graber LW, Vanarsdall RL, Vig KW, Huang GJ.
Orthodontics-Current Principles & techniques-6th ed
• Graber TM, Swain BF: Orthodontics; Current Principles and
Techniques
• Graber TM, Rakosi T. Orthodontic and Dentofacial
Orthopedic treatment. 2010
• Samir E Bishara-Textbook of Orthodontics. 2001
• Declan Millet. Orthodontics in Pediatric Dentistry
• Behremann. Early-age Orthodontics

REFERENCES
• Harrison, J. E., & Ashby, D. Orthodontic treatment for
posterior crossbites. Cochrane Database of Syst Rev 2008.
• Ackerman JL, Proffit WR. Preventive & interceptive
orthodontics: A strong theory proves weak in practice.
AJODO, 1980.
• Spencer PG. Preventive Orthodontics- AJODO,1946
• Wilson WL. Some considerations of preventive and
interceptive orthodontics. AJO, 1967
• Willet RC. Preventive Orthodontics. The Journal of the
American Dental Association, 1936

REFERENCES
• Cardoso MA, et al. Preventive Orthodontic management
of tooth transposition. International Journal of
Orthodontics, 2014
• Agostino P, Ugolini A, Signori A, et al. Orthodontic
treatment for posterior crossbites. Cochrane Database Syst
Rev. 2014
• Ngan P, Hu AM, Fields HW. Treatment of Class III
problems begins with differential diagnosis of anterior
crossbites. Pediatr Dent. 1997
• Kennedy DB, Turley PK. The clinical management of
ectopically erupting first permanent molars. Am J Orthod
Dentofacial Orthop. 1987

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