j,c early vs late

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The best timing for treatment of Class II

malocclusion has been controversial. Thequestion is whether early treatment, which is

initiated during the mixed dentition, is more

effective and efficient than treatment started in

the permanent dentition. Can early treatmentprovide superior skeletal, dental, or esthetic

results?


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Reviews of Class II treatment studies before 1989

concluded that, because of their inadequate

designs, it was not yet known whether earlytreatment provided enough benefits to justify it.

Recent data have become available from 2randomized clinical trials that addressed this

question.


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Irrespective of which appliance was used, both

reduced the severity of the Class II skeletaldiscrepancy at the end of phase 1.


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Results from the end of phase 2 treatment in these

studies are beginning to be reported. It appearsthat many differences between treatment groups

that are evident at the end of phase 1 are no longer

present by the end of phase 2.


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Subjects who receive treatment in 2 phases, with

the first aimed at orthopedic correction in themixed dentition and the second detailing the

permanent dentition, do not have significant

skeletal or dental differences from those who

receive 1 phase of treatment in the permanentdentition.


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In this study, we report on the skeletal changes

from phases 1 and 2, using the complete

cephalometric data set from 1 clinical trial.


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The study was a prospective, randomized clinical

trial with 2 treatment groups and an observation

group. During phase 1, the subjects were treatedwith either a bionator or headgear/biteplane.

An equal number of subjects were followed in the

observation group.

Assignment into a group was based on molar class

severity, mandibular plane angle, need for

preparatory treatment, race, and sex

MATERIAL AND

METHODS


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After phase 1 treatment and a 12-month

observation period, all subjects received the most

appropriate phase 2 finishing orthodontic

treatment, usually involving full fixed orthodontic

appliances.


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The exclusion criteria included

periodontal problems or

dental decay,

unwillingness to be randomly assigned to a

treatment group, and

failure to sign informed consent


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Each subject for phase 1 treatment was

randomized into 1 of 3 groups: bionator, headgear/biteplane, and observation.

Phase 1 treatment lasted until 2 project

orthodontists independently agreed that a bilateral

Class I molar relationship was achieved or 2 yearshad elapsed from the start of treatment.


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After phase 1 treatment, half of the subjects in the

bionator and headgear/biteplane groups were

randomly assigned to 6 months of retention.

This consisted of wearing the bionator only at

night or wearing the headgear/biteplane every

other night. This was followed by 6 months of no

retention;


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Phase 2 treatment was determined as follows::

In general, each patient was reviewed by an

average of 4 orthodontists, selected from theAmerican Association of Orthodontists directory.

Based on their responses, a consensus treatment

plan was formulated for phase 2 treatment. Of the

261 subjects, 20% of the observation, 12% of the

headgear/biteplane, and 8% of the bionator groups

had some premolars extracted


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During phase 2 treatment, headgear was used

more often (42%) in the observation group.

All lateral cephalograms were traced and

digitized; 60 points were identified.

Only the following points were used for analysis:nasion (N), sella (S), A-point, B-point, orbitale,

porion, anterior nasal spine posterior nasal spine,

gonion, and gnathion


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Statistical analysis

Descriptive statistics were used to examine the

data. Treatment group were assessed by using chi-

square tests for categorical variables and analysisof variance (ANOVA) for continuous variables.

Linear regression models were used to examine

the impact of a standard set of covariates (age at

baseline, treatment group, sex, initial

cephalometric values, and initial molar class

severity) on cephalometric measures at the end of

phase 1 and the end of treatment


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All analyses were made with software (SAS, Cary,

NC; Insightful Corporation, Seattle, Wash).

A P value less than 0.05 was considered

statistically significant.


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Greatest increase in SNB anglewas in the bionator group .The

observation group had greater

changes in SNB angle than theheadgear/biteplane group

Between the end of phase 1 and

the beginning of phase 2, SNB

angle increased significantly in the

headgear/biteplane group, so that it

became similar to the observation

group.During phase 2 treatment, there

were few changes in SNB angle in

all treatment groups.


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ANB angle decreased in both

the bionator and theheadgear/biteplane groups

The observation group

changed little until phase 2

treatment.

At the end of phase 2, there

was little difference in ANB

angle between the 3 groups.

I h b i d


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In the observation and

bionator groups, SN-MP

angle decreased until phase 2

treatment.

Phase 1 treatment resulted in

an increase in SN-MP angle

in the headgear/biteplane

group it relapsed before

phase 2 treatment.

Phase 2 treatment resulted in

a slight increase in SN-MP

angle in all 3groups.


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DISCUSSION The following possibilities have been suggested as

possible effects of functional appliances onmandibular growth:

(1) increased beyond its genetic potential;

(2) accelerated when there is an increase in the

growth rate during treatment, followed by a periodof slow growth, thereby achieving the expected

growth; or

(3) anterior mandibular positioning withadaptation as further growth occurs.

Our data suggest that there is no growth beyond

the genetic potential, thus eliminating the first

possibility.


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Proffit WR, Tulloch JF.

Pre adolescent ClassII problems: treat now or wait?

Am J Orthod Dento facial Orthop 2002;121:560-2.

The purpose of this study was to determine the

effects of early treatment on the maxillary dental

arches in children with mixed dentition Results: The data revealed that the growth pattern

did not change with the treatment

The early treatment with occipital headgear was

effective in moving maxillary teeth distally and

retracting incisors, improving the jaw relationship

and favoring the second phase of the orthodontic

treatment when necessary.


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Influences on the out come of early treatment

for Class2 malocclusion

1. There is great variation in response to early Class II growth

modification treatment.

2. Approximately 75% of children undergoing early

treatment with either headgear or a modified bionator,

experience a favorable or highly favorable reduction in

skeletal discrepancy.

3. This response to early treatment is significantly differentfrom the growth experienced by similar but untreated

children with Class II malocclusion.

American Journal of Orthodontics and Dentofacial Orthopedics1997;111:533-42


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Comparison of arch dimension changes in

1-phase vs 2-phase treatment of Class II

malocclusion

This study showed that, although early phase 1

treatment was useful in gaining space in the

maxillary arch or minimizing space loss in the

mandibular arch ,over those who had no early

treatment, there were no differences after phase 2therapy when full orthodontic appliances were

removed. In the end, all subjects had similar

changes in arch dimensions.

American Journal of Orthodontics and Dentofacial Orthopedic

July 2009;136:65-74

A J O h d D f i l O h
http://www.ncbi.nlm.nih.gov/pubmed/11786869http://www.ncbi.nlm.nih.gov/pubmed/11786869


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Am J Orthod Dentofacial Orthop.

2002 Jan;121(1):31-7.

Efficiency of early and late Class II Division 1

treatment.

The aim of this study was to assess the efficiency

of early and late Class II Division 1 treatment in the

mixed and permanent dentition. Based on the results of this investigation, we

concluded that treatment of Class II Division 1

malocclusions is more efficient in the permanent

dentition (late treatment) than it is in the mixed

dentition (early treatment).
http://www.ncbi.nlm.nih.gov/pubmed/11786869http://www.ncbi.nlm.nih.gov/pubmed/11786869


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PREVENTIVE ORTHODONTICS

By

Md.Mazhar Ahmed

1st year MDS

Department of orthodontics


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Graber (1966) defined preventive orthodontics as

the action taken to preserve the integrity of what

appears to be normal occlusion at a specific time

Profit and Ackerman (1980)defined as

prevention of potential interference with

occlusal development


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Preventive orthodontics means a dynamic, ever

constant vigilance, a routine, a discipline for both

dentist and patients.

It requires a continuing long-term approach and is

not a one shot service. Without this, the complex

timetable of growth, development, tissue

differentiation, resorption, eruption which are all

under the influence of continuous functionalforces, cannot be assured.


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Dental neglect in the primary dentition is theprincipal cause of malocclusion in the permanent

dentition.

Early, regular and satisfactory dental care will help

in maintaining the primary teeth in healthy condition until

the time for their normal exfoliation.


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Preventive procedures

Parental counseling prenatalpostnatal

Caries control

Space maintenance

Extraction of deciduous teeth

Treatment of abnormal frenal attachments Treatment of locked permanent first molars

Abnormal oral musculature related habits


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Education of parents

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

physiological changes in the body to support the

growth of the foetus and facilitate normal labour. Dental development of their child

Dental disease process

Oral hygiene measures appropriate for infants


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Expecting mother should be educatedon proper nursing and care of the

child.

In case the child is being bottle-fed,

the mother is advised to use

physiologic nipple and not the

conventional nipple.

conventional

phys


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

hygiene.

In infants small gauze is used over the ridge of top andbottom jaws for cleaning

Proper brushing techniques and brushing habits to beexplained and evaluated periodically.

Fones method of brushing is preferred in children.

Fluoride application and dental checkup every 6 months


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Caries control procedures:

Diet and oral hygiene Maintenance

Regular Checkup

Fluoride applications Prophylactic odontomy

Pit and fissure sealants.

Restorative procedures like silver amalgam, GlassIonomers, Cermets, Stainless steel crown.

Immunization


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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.


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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 carepractices of 6-12 yrs old


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Regular check-up:

The parents should bring their child for his/her firstdental visit early at least by the time the baby is 6

months of age.

Frequency of recall visits have to be decidedaccording 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.


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Care of Deciduous dentition

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

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

Simple preventive procedures such as proper and timelyapplication of fluoride topically/ pit and fissure sealant applicationhelp in preventing caries.

More complex treatment procedures to prevent the natural spacemaintainer includes pulp therapy (pulpotomy, pulpectomy ) and

stainless steel crown.


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Caries involving proximal surface ofdeciduous teeth if not restored early maylead to loss of arch length into that space.

Caries can be detected by clinical andRadiographic examination.

Bitewing Radiograph proves to be of greathelp in detecting proximal caries.

Once detected, proper restoration ofaffected teeth should be undertakenimmediately to prevent loss of arch length.


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Restoration should restore the mesio-distal dimension of

tooth, but should not be over/under extended allowing

drift of contiguous teeth or promote food impaction.

Contact size and position should also be correct.

Re establishment of proper inclined plane relationship

with proper anatomic carving will be esthetic and results

in normal function and stability of occlusion.


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PIT AND FISSURE SEALANT

Fissure sealants are defined whereby pits and fissures

that occur principally on the occlusal surfaces of the

molar and premolar teeth are occluded by application

of fluid materials, which are the then polymerized.


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Classification

Mitchell and Gordon (1990)

Polymerization methods

a. Self activation (mixing two components)

b. Light activation

- First generation: U.V Light

- Second generation: Self cure

- Third generation: Visible light

- Fourth generation: Fluoride releasing

Resin Systems

BIS-GMA

Urethane acrylate

Filled and unfilled

Clear or tined


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Indications

Newly erupted both primary molars and permanentbicuspids and molars with complete recession of

pericoronal operculum and with open and/or sticky

grooves and fissures.

Stained pits and fissures with minimum

decalcification.

The tooth in question should have erupted less than

4 years ago.


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Contraindications

Individual with no previous caries experience

pit and fissures,monitor if the individual andthe teeth are not at risk.

Radiographic or clinical evidence of caries on

the proximal surface of the tooth should not be

sealed.

Wide and self-cleansable pit and fissures.

Tooth that can not be isolated of partiallyerupted tooth.

Pit and fissures that have remained carious free

for 4 years or longer.


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Fluoride application

Knutsons Technique Sodium fluoride2%

(3,7,11,13)

- Weekly internals4 times

- After prophylaxis3min

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

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


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FLOURIDE VARNISH

Bifluoride 12(2.71% NaF, 2.92% CaF)

Technique - Do the through prophylaxis and dry theteeth.

Drop the varnish onto the brush or

foam pellet.

Paint the varnish thinly first on the

lower arch and then on upper arch

starting from the proximal surfaces.

Semiannual ApplicationWith correct application and proper mouth hygiene

varnish remains in place of several days. During this time

fluorides act on the treated surface.


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Prophylactic odontomy

Caries occurs frequently in the pit and

fissures of posterior teeth.

As a preventive procedure the pit and

fissure may be minimally prepared and

restored before visible attack by caries.


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Immunization

Immunization with Streptococcus mutans should induce an immuneresponse which might prevent the dental caries in following ways :

It will prevent ability of the microorganisms to colonize on to the

tooth surfaces.

It can alter the pattern of polysaccharide metabolism by the bacteria

and thereby reduces adhering capacity on to the tooth surfaces.

Oral administration or subcutaneous injection of killed Streptococcusmutans can induce the formation of specific IgA, IgG, IgM in the

blood.


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Various new approaches have been tried out in order to

overcome the existing disadvantages.

Active immunization

1) Synthetic peptides

2) Coupling with cholera toxin subunits

3) Fusing with salmonella

4) Liposomes

Passive immunization

1) Monoclonal antibodies

2) Egg-yolk antibodies

3) Transgenic plants


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Indicators of future Orthodontic Problems:

Aberrant resorptive pattern

Altered eruption cycle of permanent teeth

Contingency of extraction

A visual examination of the patient will quickly reveal a

gross malocclusion, in which there is an anterior open bite,

excessive overbite and overjet, cross-bite, basal mal-relationship and other problems.


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A large percentage of class I malocclusions exist

because of what happens during the critical

developmental years, with most of the activity below the

surface.

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

and accurate radiographic examination should be made

soon after the first visit.


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

In an ideal sequence, right and left deciduous incisorsshould be lost at about the same time, deciduous lateral

incisors should be lost at about the same time, all

canines should be lost within a short period.


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Contingency of extraction

As a rule of Thumb, the shedding of the deciduous

dentition should be kept on schedule by extracting

the tooth or teeth on one side of the arch, when

they have been lost through natural process on theother side.

Should not wait longer than 3 months for nature to

do the job, particularly when there is radiographic

evidence of abnormal resorption Which would

otherwise lead to Malocclusion.


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Effects of premature loss of primary teeth

Oral health and functions Supra eruption of opposing teeth

Psychological effect on child and parent

Position of permanent teeth.

Primary dentition is essential forgrowth of jaws, for normal function and eventually fornormal position and occlusion of permanent teeth andso premature loss of primary tooth is to be avoided.


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Parents usually accept loss of anterior teeth after6years of age, but when lost at an early age, some

parents are concerned by appearance of remainingdentition.

Attitudes of parents and child towards dental health

and care is largely influenced by attitude of dentisttowards preservation of primary dentition.

Any suggestion that the primary dentition isimportant is reflected is a positive awareness and

motivation towards dental care in minds of parentand child.

Sequence of eruption and clinical


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Sequence of eruption and clinical

significance:

According to MOYERS normal sequence of eruptio

provides the highest percentage of normal occlusio

Eruption in

Maxillary arch - 6124537

Mandibular arch - 6124357


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An asymmetry in rate of eruption on the two sides of

dental arch is a frequent variation.

When this happens, there is lack of space to

accommodate the erupting teeth on one side

compared to the other.

As a general rule, if permanent tooth on one side has

erupted but its counter part has not, within three

months, a radiograph should be taken to investigate

the cause of the problem.


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SPACE MAINTAINANCE

Maintenance of arch length during the primary,mixed and early permanent dentition is of greatsignificance for the normal development of future

occlusion. Loss of arch length has been related mainly with

migration of teeth following early loss of primaryteeth.

18th CenturyFauchard reported it

19th CenturyHunter

20th CenturyWillet, Seward,and Davey


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Causes of space loss

Trauma Interproximal caries in primary molars

Ectopic eruption of first perm molars

Delayed eruption

Ankylosis of primary molars.

Congenital absence of permanent teeth

Macrodontia can cause arch length deficiency


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Space maintaining is utilizing an appliance to

preserve space without necessarily an awareness of

the dynamics of the situation.

The preferable approach for space maintenance is to

evaluate the space available, whether the space is

sufficient for eruption of the succedaneous teeth or

regaining space is necessary.

Classification of space maintainers:


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Classification of space maintainers:

According toHitchcock:

Removable or fixed or semi fixed

With bands or without bands

Functional or non functional

Active or passive

Certain combinations of above.

According to Raymond C.Thurow:

Removable

Complete arch

Lingual arch

Extra oral anchorage

Individual tooth.


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According to Hinrichsen

Fixed space maintainers:Class I

1.Non functional types

- Bar type

- Loop type2. Functional type

- Pontic type

- Lingual arch type

class II

- Cantilever type

- Distal shoe

- B and E loop


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Removable space maintainers

Removable

Non functional acrylic plate

Functional acrylic plate with teeth

Active acrylic plate with clasps, springs

Passive - acrylic plate with clasps.


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Fixed appliances

Band and loop

Crown and loop

Band and bar

Distal shoe Lingual arch

Nance palatal arch

Transpalatal arch.

Semi Fixed

Removable arch wire with molar bands


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Indications of space maintainers

If space after premature loss of deciduous teethshows signs of closing.

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

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


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Even though space maintenance is not

necessary in case of anterior tooth loss, afunctional space maintenance or partial

denture should be given as tooth loss affects

speech, induce abnormal tongue habits whichleads to malocclusion .


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Contra indications of space maintainers

If radiograph of extraction region shows that 1/3rd

of the root of succedaneous tooth is already

calcified.

When the space left by the prematurely lost primary

tooth is less than the space needed for the

permanent successor as indicated radiographically.

If the space shows no signs of closing


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Advantages of Removable type of Space

Maintainers. They are easy to clean and permit maintenance of proper

oral hygiene

It maintains and restores the vertical dimension.

It can be worn part time allowing circulation of the blood

soft tissues.

They serve other important functions like

aesthetic,mastication,phonetics


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Dental checkup for caries detection can be

undertaken easily.

They stimulate eruption of permanent teeth

Band construction is not necessary

Room can be made for permanent teeth to erupt

without changing the appliance


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They prevent development of tongue thrust habit

into the extraction space.

More than one tooth can be replaced.

Being tissue-borne, they impose less stress on

remaining teeth.

Easier to fabricate, less chair time.


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When there is general lack of sufficient arch length

and where space maintainer would further

complicate existing malocclusion.

When succedaneous tooth is absent.

When well developed occlusion and cuspal inter

digitations or over eruption of opposing tooth

prevent space closing.


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Disadvantages:

Patient may not wear it, patient compliance in 3-6year age group and uncooperative children is poor.

It may be lost or broken by the patient.

It may restrict lateral growth of the jaws if clasps are

incorporated

They may cause irritation of the underlying soft tissues.


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Fixed Space Maintainers;

Band and Loop Band and Bar

Crown and Bar

Trans palatal arch

Lingual arch

Pin and tube space maintainers.

Bonded space maintainers.


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Modifications of Band and Loop Space Maintaine

Crown and loop Band and loop

Extended band and loop Bonded band and loop

Nances palatal arch space maintainers


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Advantages of Fixed Space Maintainers:

They do not interrupt with passive eruption of

abutment teeth.

Jaw growth not hampered

Succedaneous permanent teeth are free to erupt in

oral cavity.

Can be used in uncooperative patients.

Disadvantages:


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Disadvantages:

Elaborate instrumentation with expert skill isneeded

It may result in decalcification of tooth material

under the bands Supra eruption of opposing teeth can take place if

pontics are not used.

If pontics are used, it can interfere with Verticaleruption of abutment tooth and may preventeruption of replacing permanent teeth, if patientfails to report.

BAND AND LOOP SPACE


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Indications: Unilateral loss of primary first molarbefore or after the eruption ofpermanent first molars.

Bilateral loss of single primarymolar before eruption of permanentincisors.

When second primary molar is lostafter the eruption of first permanent

molar. Sometimes it is given in cases of

premature loss of primary canines.

BAND AND LOOP SPACE

MAINTAINER


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Usually Band- loop space maintainers is not

indicated to preserve the space created by tw

adjacent primary molars.

The lengthy loop created in these situations is more

susceptible to the forces of mastication.

Advantages:

It is an effective space maintainer for unilateral loss

of single tooth in buccal segments.

Economical

Construction is simple


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Takes little chairside time, especially if preformedbands are used.

It adjusts easily to accommodate the changingdentition.

Disadvantages:

Requires constant supervision. Like any other fixed

maintainers, decalcification under the bands is aproblem.

It will not prevent the continued eruption of theopposing teeth.

LINGUAL ARCH:


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The lingual arch is the most effective

appliance for space maintenance inposterior region and minor toothmovement in the lower arch.

The lingual arch space maintainer consists

of two bands cemented to the 1st permanentmolars or sometimes 2nd deciduous molars,which are joined by a SS wire buttingagainst four incisors.

Usually indicated to preserve the spacescreated by multiple loss of primary molarswhen there is no loss of space in the arch.

Th f li l h i d i i i


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The use of lingual arch is a good preventive measure, since it

helps in maintaining the arch perimeter by preventing both mesi

drifting of the molar teeth and also lingual collapse of the anterior

teeth.

Spurs that is Projections of wire, may be used as stoppers distal to

anterior teeth to prevent their migration distally in the arch.

These help in maintaining symmetry of centre lines, especially i

cases of unilateral tooth loss.


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Advantages:-

Causes little inconvenience to patient

Less bulky them removable acrylic space maintainers.

Less conspicuous than other space maintainers

Serves as a space maintenance for more than onesuccedaneous tooth in the arch.

Prevents arch collapse

Prevents mesial migration of banded tooth.


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Disadvantages Prolonged use of orthodontic bandsdecalcification of the tooth.

Arch wire may become embedded into the soft tissue. This

seems to occur more often in patients with poor oral hygiene.

Wire may become distorted by masticatory forces and move teeth

into undesirable positions.

Appliance should be removed every year and inspected for damage

and further usefulness, recemented after topical fluoride treatment

l l h


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Transpalatal Arch : Recommended for stabilizing the maxillary first permanent molars.

Best Indication for transpalatal arch is when one sideof the arch is intact, and several primary teeth on the oth

side are missing.

Also indicated when primary molars are lost bilaterally.

Appliance is designed to prevent the molars from rotating around thpalatal roots ,which is the first movement resulting in loss of

space in the arch perimeter.

The transpalatal arch runs directly across the palatal vault connectin

the permanent first molars, avoiding contact with the soft tissu

Ad


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Advantages: No food lodgment

Simple design

No inflammatory changes in palate

Disadvantages:

If given in case of bilateral missing deciduous molar,

cannot prevent drifting of abutment teeth.

If not passive ,unexpected vertical and transverse movement of the

permanent molars can occur.

Distal Shoe Appliance


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Eruption guiding appliance Intra alveolar appliance

One of the early designs of distal spacemaintainers was cast Gold or Willet distalshoeNow rarely used because of

increased cost, difficulties in toothpreparation, and more complicatedfabrication procedures.

The distal shoe appliance is used tomaintain the space of a primary secondmolar that has been lost before theeruption of the permanent first molar.

Distal Shoe Appliance:


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Normally,the distal surface of the 2nd primary

molar provides a guide for the unerupted 1st

permanent molars, when the 2nd primary

molar is removed prior to the eruption f the first

permanent molar, the Distal Shoe applianceprovides greater control of the path of eruption

of the unerupted tooth and prevents undesirable

mesial migration.

I di i


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

first permanent molar.

Contraindications:

Poor oral hygiene Medically compromised patients like patients with

congenital heart disease, juvenile diabetics, Rheumatic fever,

immunosupression

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

Lack of patient cooperation

N l l h ldi h


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Nance palatal holding arch

Indicated in premature loss offirst deciduous molar.

Advantages:

Economical

Allows growth transversely inthe inter-canine areas.

Disadvantages:

Requires more clinical skill Palatal button may cause

food accumulation; causesinflammation.


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Abnormal frenal attachments

Abnormalities of the maxillary labial frenum are

associated with a midline diastema .

At birth frenum is attached to the alveolar ridge

with fibers running into the incisive papilla.

The teeth erupts and as alveolar bone is

deposited,the frenum attachment migratessuperiorly with the alveolar ridge.

Fibers may persist between the maxillary central


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Fibers may persist between the maxillary central

incisors and in the V shaped intermaxillary suture ,

attaching to the outer layer of the periosteum andconnective tissue of the suture.


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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 Management


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Oral Habits in Children and their Management

These habits bring about harmful unbalanced

pressures to bear upon the immature, highly malleable

alveolar ridges, the potential changes in position of teeth,

and occlusions, which may become decidedly abnormal if

these habits are continued for a long time.

. Bouchera tendency towards an act or an act that

has become a repeated performance, relatively fixed,

consistent, easy to perform and almost automatic

Prevention starts with proper nursing, proper choice


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of physiologically designed nursing nipple & pacifier to

enhance 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 SUCKING


100/225

THUMB SUCKING

Definition

Repeated and forceful sucking of thumb with associated strongbuccal 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 of three to

four years. But an acute increase in childs level of stress and

anxiety due to some underlying psychological or emotional

disturbances can account for continuation of digit sucking habit,

with conversion of an empty habit into a meaningful stress

reducing response.


101/225

Causative factors:

Parents occupation

Working mother

Number of siblings

Order of birth of the child

Social adjustment and stress

Feeding practice

Age of the child

- proclination of maxillary incisors- increased maxillary arch length


102/225

Effects

onmaxilla

y g

- 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

Effectson

mandible

- proclination or reteroclination of the mandibularincisors

- increased intermolar distance

- distal position of point B

- maxillary and mandibular incisal angle- increased over jet


103/225

Effects on

interarch

relationship

j

- 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

incisorsEffect on

tongue

placement and

function

- tongue thrust

- lip to tongue resting position

- lowered tongue position

Other effects - thumb deformity

- speech defects, lisping


104/225

Treatment

Psychological therapy

Reminder therapy

Extra oral approaches

Intra oral approaches

Mechanotherapy

Blue glass

Quad helix

Tongue trusting:


105/225

Definition:

Schneider 1982: tongue thrust is forwardplacement of the tongue between the anterior

teeth and against the lower lip during

swallowing


106/225

Tongue trusting:

M ill

- Tipping of the palatal plane-Proclination of maxillary anteriors resulting

i i i j t


107/225

Maxilla 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 onthe posture of the tongue- Posterior cross bite

- lack of interdigitation of the posterior teeth

- Or all the parameters may be normal

- Convex profileI d LAFH


108/225

Facial form- Increased LAFH

lips- Short upper lip/normal upper lip

- Hyperactive mentalis/ normal

Tongue

- Enlarged

- Forwardly placed- Normal position

Speech

-Tongue thrust children are more likely to have

various speech disorders, such as sibilant distortions,

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

sounds


109/225


110/225

Sassouni (1971) defined mouth breathing as habitual

respiration through the mouth instead of the nose.

Merle (1980) suggested the term oro-nasal

breathing instead of mouth breathing.

F.M. Chacker defined mouth breathing as theprolonged or continued exposure of the tissues of the

anterior area of the mouth to the drying effects of theinspired air.

PREVENTION MYOFUNCTIONAL APPLIANCES


111/225

Oral myofunctional therapy has been shown to be

effective in correcting oral myofunctional disorderssuch 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.

Lip habit


112/225

It may involve either of the lips , with a higher

predominance of lower lip

Definition

Habits involving manipulation of the lips andperioral structures are termed as lip habits.

Classification

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

(schneider1982)

Treatment


113/225

Correction of malocclusion

Treating the primary habit

Appliance therapy

Lip bumper


114/225


115/225

C l i


116/225

Conclusion

Prevention of malocclusion and the success of minor and/ormajor orthodontic intervention in a developingmalocclusion depend upon the diagnostic skill and aclinical ability to reverse the process of the dentitions

maldevelopment. The concept of prevention is based on the belief that some,

if not many, minor dental developmental problems, in theyounger age group become major orthodontic needs.

Early attention to many, if not all problems in dentaldevelopment of children can be helpful in reducing theseverity of malocclusion


117/225

Interceptive orthodontics

123

C


118/225

INTRODUCTION

DEFINITIONS OF INTERCEPTIVE ORTHODONTICS

VARIOUS INTERCEPTIVE ORTHODONTIC PROCEDURES

SERIAL EXTRACTION

CORRECTION OF DEVELOPING CROSS BITE

CONTROL OF ABNORMAL HABITS

SPACE REGAINING

Contents

124

I d i


119/225

orthodontic treatment is popularly regarded as springs,plates, and

braces.

There is however, much in orthodontic treatment that depends not

much upon appliances

In general practice children can be seen from a very early age.

An inherited malocclusion may not be preventable, but much can be

done to correct a developing malocclusion or atleast to alleviate some

of the sequelae.

Introduction

125

The goals of orthodontic care in the primary dentition should be aimed at


120/225

g p y

either intervention in the conditions that predispose one to develop a

malocclusion in the permanent dentition or monitoring conditions that are

better treated later(Nagan and Fields, 1955).

According to the third National Health and Nutritional Examination

Survey, crowding and irregularity remain a consistent problem for children.

The goal of early treatment is to correct existing or developing skeletal,

dentoalveolar and muscular imbalances to improve the orofacial

environment before the eruption of the permanent dentition is complete.

126

early treatment is often a two phased treatment.


121/225

Phase-1 treatment typically begins when the child is about 8 years or

younger and lasts about 6-12 months.

This is followed by intermittent observation of transition from the mixed to

the permanent dentition.

Phase-2 treatment usually with the fixed orthodontic appliances on

permanent teeth, begins 6-9 months before the eruption of the second

molars.

127


122/225

However, the single phased treatments have gained popularity in

which the early treatment is initiated in the late mixed dentition, just

before the loss of the deciduous second molars, and is followed

immediately by banding and bonding of the permanent teeth.

Reduction in the total treatment time and better control of the Leeway

spaces in the transitional dentition are some of the advantages.

128

D fi iti


123/225

The American Association of Orthodontists (1969) defined interceptive

orthodontics as that phase of science and art of orthodontics employed to

recognize and eliminate the potential irregularities and malpositions in the

developing dentofacial complex.

Profitt and Ackermen (1980) defined interceptive orthodontics as the

elimination of the existing interferences with the key factors involved in the

development of the dentition.

Sheety N defines interceptive orthodontics as early intervention in the

developing dentition to minimize the developing malocclusion or eliminate the

potential factors interfering with the normal occlusion.

Definitions

129

V i d


124/225

Serial extraction

Correction of developing crossbite

Control of abnormal habits

Space regaining

Interception of skeletal malrelation

Removal of soft tissue or bony barriers to enable eruption of teeth

Various procedures

130

SERIAL EXTRACTIONS


125/225

The term serial extraction describes an orthodontic treatment

procedure that involves the orderly removal ofselected deciduous and

permanent teeth in a predetermined sequence (Dewel 1969).

Serial extraction can be defined as the correctly timed, planned

removal of certain deciduous and permanent teeth in mixed dentition

cases with dento-alveolar disproportion in order to:

Alleviate crowding of incisor teeth.

Allow unerupted teeth to guide themselves into improved positions

(canines in particular).

Lessen (or eliminate) the eriod of active a liance thera .

S C ONS

131


126/225

It is a sequential plan of premature removal of one or more

deciduous teeth in order to improve alignment of succedeous

permanent teeth and finally removal of permanent teeth to

maintain the proper ratio between tooth size and available

bone.

Thus it is one of the positive interceptive orthodontic procedure

generally applied in most discrepancy cases where supporting

bone is less than the total tooth material.

132

Hi t i l d l t


127/225

Paisson was the first person who pointed the extraction procedure in

order to improve the irregular alignment and crowding of teeth.

Bunon in 1743, in his Essay on the Diseases of the teeth proposed

the removal of deciduous teeth to achieve a better alignment of

permanent teeth.

Nance presented clinics on his technique ofprogressiveextraction in

1940 and has been called as the father ofserialextraction philosophy

in the United States.

Historical development

133


128/225

Kjellgren in 1940 termed this extraction procedure as planned or

progressive extraction procedure of teeth.

Hotz named the same procedure as Guidance oferuption.

When a dentist sees a child 5 or 6 years of age with all the deciduous

teeth present in a slightly crowded state or with no spaces between

them, he can predict, with a fair degree of certainity, that there will not

be enough space in the jaws to accommodate all the permanent teeth in

their proper alignment (Lysell 1960)

134


129/225

Indications


130/225

Premature loss of deciduous teeth.

Arch-length deficiency and tooth size discrepancies.

Lingual eruption of lateral incisors.

Unilateral deciduous canine loss and shift to the same side.

Abnormal eruption direction and eruption sequence.

Flaring of incisors.

Ectopic eruption of mandibular first deciduous molar.

Abnormal resorption of II deciduous molar.

Ankylosis. Labial stripping, or gingival recession, usually of lower incisor.

Indications

136

limitations


131/225

According to Dewel (1967), the most serious side effect is

tendency ofbite to close following loss of posterior teeth.

premolars may fail to reach their normal occlusal level.

Lip fullness is not a reliable criterion for extraction in early

mixed dentition & the early removal of premolars is likely to

cause a concave profile.

limitations

137


132/225

Advantages


133/225

Psychological trauma can be avoided by treatment

Reduces the duration of the multi banded treatment

Physiological treatment as it involves the guidance of teeth intonormal positions making use of physiological forces

Better oral hygiene

More stable results

Advantages

139

Disadvantages


134/225

Patient co-operation is needed

Risk of arch length reduction is present

Requires proper professional and clinical judgment

As extraction spaces are created the patient may develop the tendency of

tongue thrusting.

Spacing may develop between canine and second premolar.

Complication of serial extraction when premature eruption of permanent

canines occur, the first premolars are impacted between the canines and the

second premolars

Disadvantages

140

Tweed s method


135/225

At approximately 8 years all deciduous molars are extracted. It is

preferable to maintain in deciduous canines to retard eruption of

permanent canines.

4-10 months of following extraction of deciduous Ist molars, the Ist

premolar will have erupted upto gingival level. Do not extract till the

crown arc, above the alveolar bone.

Extraction of 1st premolar and deciduous canines should be done 4-6

months prior to eruption of permanent canines when they erupt they

migrate posteriorly into good position.

Tweed,s method

141


136/225

142

Dewels Method:


137/225

CD4

143

Moyer's method


138/225

Stage I (Extraction of all deciduous lateral incisors). It helps in

alignment of central incisors.

Stage II (Extraction of all deciduous canines after 7-8 months). It helps

in alignment of lateral incisors.

Stage III (Extraction of all deciduous first molars). It stimulates

eruption of all first premolars.

Stage IV (Extraction of all first premolars after 7-8 months). It

provides space for canines and stimulates eruption of canines.

Moyer s method

144

Enucleation


139/225

Enucleation has been defined as surgical removal of unerupted teeth

usually premolar to minimize crowding.

Most common disadvantage are loss of buccal or lingual cortical plates

of bone or clefting associated with incomplete closure of extracted site.

Enucleation

145

Advantages


140/225

Fewer visits, therefore decrease in trauma and emotional disturbance.

In severe maxillary anterior crowding and excessive protrusion,

enucleation provides space for retraction of 1 and 2 proper eruption of

3.

In crowded high angle cases, enucleation especially of 5 causes mesial

migration of posterior segment.

Advantages

146

Space regaining


141/225

This is a procedure used for recovering the space which once existed in

the arch.

Space regaining procedures should be limited to reestablishing 3-5mm

or less space in the localized area. Space is easier to regain in the

maxillary arch than in the mandibular arch, because of

Increased anchorage for removable appliance afforded by the palatal

vault.

The possibility for use ofextra-oral force like head gear.

Space regaining

147

Selection Criteria For Space Regainer


142/225

The selection of the space regaining appliance is dependent on whether

Tipping

Translation

Rotation or combination of these movements.

p g

148

PALATAL BAR

MAXILLARY SPACE REGAINING


143/225

PALATAL BAR

REMOVABLE DISTALIZING PLATE

HELICAL FINGER SPRING WITH REMOVABLE APPLIANCE

LINGUAL ARCH WITH SEGMENTAL ARCH WIRE

EXTRA ORAL FORCE VIA FACE BOW

EXTRA ORAL FORCE VIA HEADGEAR

REPELLING MAGNETS

MODULE ORTHODONTIC APPLIANCE

LOOP COMBINATION HOOK APPLIANCE

THE K-LOOP MOLAR DISTALIZING APPLIANCE149

Mandibular space regainers


144/225

ACTIVE LINGUAL ARCH

LIP BUMPER

MANDIBULAR PENDEX SPRING APPLIANCE

EXPANSION SCREW APPLIANCE

BONDED LINGUAL ARCH

Mandibular space regainers

150

Gerber space regainer


145/225

Tube and wire U assembly are not welded.

An eyelet may be welded to the flattened part ofthe tube next to the band; weldable tube stops

are soldered on wire portion and open coil

spring sections are cut to fit over wire between

stops and ends ofU tube.

The length of the push coil springs is

established by placing the bond tube wire

assembly in the mouth, extending the wire to

the desire length, in contact with the mesial

tooth, and measuring the distance between the

tube stops on the wire and the end of the U

tube. 151

Open coil spring :

An edge wise twin bracket is aligned and welded to the buccal


146/225

surface of the abutment band adjacent to the space before the

lingual arch portion of the appliance is cemented into place.

A band is also fitted to the first permanent molar to be tipped

distally and a buccal tube is properly aligned and welded to the

band before it is cemented into place.

A 0.016 inch round or a 0.016 x 0.016inch rectangular wire is

selected so that it will slide freely in the buccal tube but it can

also be fixed to the bracket with a ligature wire.

The wire is cut to the desired length and adjusted to the alignment

of teeth by making smooth, gentle bends if necessary.

152


147/225

A section of open coil spring (0.009 x 0.020 inch) approximately 2 mm

longer than the space between the bracket and the tube is placed

around the wire, and the entire assembly is fixed in position.

Bilateral stability and anchorage may be provided with a soldered

lingual arch

As this space opens, the wire and spring are replaced with a longer

section at approximately 4 weeks intervals until the desired position is

attained.

153

Hotz lingual arch


148/225

This is appropriate in a situation where first molar

has shifted mesially, but the premolar or cuspid

has not drifted distally.

It is advantageous to use removable type of space

maintainer since it facilitates removal for frequent

activation.

Hotz lingual arch

154

Lip bumper/ plumper


149/225

Mostly used bilaterally & can also beused unilaterally.

Lip bumper/ plumper

155

Removable appliances


150/225

RECURVED HELICAL SPRING REGAINER

It is an appliance that is similar to Hawleys

appliance consisting of an Adams clasp and a

labial bow for retention and a recurved helical

spring regainer which is used for regaining the

space lost due to mesially tipped molar.

The recurved helical spring is activated by

opening the coil.

The wire components are embedded in the acrylic

plate.


156

SLING SHOT REGAINER


151/225

SLIDING YOKE SPACE-

REGAINER

EXPANSION SCREW

157

Crossbites


152/225

Graber, defined cross bite as a condition where one or more

teeth may be abnormally malposed buccally or lingually or

labially with reference to the opposing tooth or teeth.

SCISSOR BITE: - Total maxillary buccal or mandibular lingual

cross bite with mandibular dentition completely contained with

in the maxillary dentition in habitual occlusion.

Crossbites

158

Classification


153/225

Based on their location

Anterior cross bite

Single tooth

Segmental

Total

Skeletal

Posterior cross bite

Unilateral

Bilateral

Based on Nature of Cross Bite

SkeletalDental

Functional

Classification

159

Anterior crossbite


154/225

Anterior cross bite is defined as a malocclusion resulting from the lingual

position of the maxillary anterior teeth in relationship with the

mandibular anterior teeth.

This is a condition where reverse overjet is seen in mandibular anterior

teeth overlapping the maxillary anterior .

Anterior crossbite

160

Anterior crossbite


155/225

Anterior cross bite of one or more of the permanent incisors should be

treated in the mixed dentition state or as soon as it is discovered.

Etiology: A labially positioned Supernumerary tooth.

Fracture to an anterior primary tooth

An archlength deficiency

Persistence of a primary tooth

Presence of habits like thumb sucking and mouth breathing

Patients who suffer from cleft palate (collapsed arch)

Sagittal discrepancies of the jaws

Anterior crossbite

161

Classification


156/225

Individual: Due to a malposed incisor or canine displaced towards palate.

Total: Caused by an anterior displacement of the mandible.

Skeletal: Due to an over growth of the mandible, retarded maxilla or a

combination of these.

B)Simple anterior dental CROSSBITE

Functional anterior CROSSBITE

True skeletal anterior CROSSBITE

Classification

162

Treatment


157/225

TONGUE BLADETHERAPY

It can be used successfully in a developing

single tooth anterior CROSS BITE where

sufficient space is present for bringing the

tooth out.

This technique is useful when child is co-

operative and have proper encouragement

and guidance at home.

A tongue blade is a flat wooden stick

similar to an ice cream stick

Treatment

163


158/225

Mc Donald stated that tongue blade therapy uses the chin as a fulcrum and

exert pressure on the tooth toward the labial side.

Graber stated that the mandibular incisal margin serving as a fulcrum and

the oral portion of the tongue blade should be rotated upward and forward

to engage the lingual surface of the lingually malposed tooth.

The patient is advised to bite with a constant pressure on the wood incline

and at the same time to exert a slight but constant pressure with his hand on

the blade so as to prevent blade displacement.

The proper use of the tongue blade for a 1 or 2 hr/day for 10 to 14 days is

usually sufficient to deflect the lingually erupting maxillary incisor

ACROSS THE FENCE into a proper relationship.164

catalan's appliance/ lower anterior

inclined plane


159/225

Introduced by CATLAN, 150 yr back.

In no instance appliance should be left longer than

six weeks.

If properly constructed it can correct a CROSS BITE

in a matter of days INDICATION

Normal or excessive overbite and adequate space in

the arch to bring the incisor into correct A P

relationship with the opposing mandibular incisor

used only in cases where CROSS BITE is due to

palatally displaced maxillary incisor.

inclined plane

165

CONTRAINDICATION

When CROSS BITE is due to true mandibular prognathism.


160/225

If there is an end to end over bite or an open bite

ADVANTAGES

Ease of fabrication

Rapidity of correction, using functional and muscles forces.

Lack of soreness or looseness of the teeth during movement.

Rarity of relapse

166


161/225


162/225

COMPOSITE INCLINES

CAST INCLINED

INCLINED CROWNS

BANDED INCLINE

168

Hawley type appliance with Z-

spring


163/225

Used to correct 1 or 2 maxillary teeth.

Indicated only when adequate space is present .

In case of deep bite the spring must be given

along with a posterior bite plane to help in

jumping the bite.

Acrylic Hawley type appliance is made with

spring pressing against lingual aspect of the

incisors.

The spring is activated 1.5 to 2mm to provide 1

mm of tooth movement / month.

p g

169

Functional crossbite:


164/225

OCCLUSAL EQUILIBRATION

Correction of a pseudo class III anterior CROSS BITE may

require only the removal of premature tooth contact by incisal

grinding of the maxillary and mandibular incisors.

170

SKELETAL ANTERIOR CROSS BITE


165/225

DURING GROWTH PERIOD

Retropositioned maxilla must be treated

before termination of growth by using a

protraction face mask (reverse head gear).

These helps in protraction of maxilla and

normalizing CROSS BITE.

Excessive mandibular growth is

intercepted by reverse activator or F.R III

or by use by chin cap with head gear.

171

Posterior crossbite


166/225

Failure of the two dental arches to occlude normally in lateral

relationship, known as lateral or posterior CROSS BITE, may

be due to localized problems of tooth position or alveolargrowth or to gross disharmony between maxilla and mandible

(Moyer)

In this condition instead of the mandibular buccal cusps

occluding in the central fossae of the maxillary posterior teeth,

they occlude buccal to the maxillary buccal cusps .

172

classification


167/225

A)SEGMENTAL

SINGLE TOOTH

B)UNILATERAL

BILATERAL

C) BUCCAL NONOCCLUSION: maxillary posteriors occlude entirely

on the buccal aspect of the mandibular posteriors , this condition is also

called as Scissors Bite

LINGUAL NON OCCLUSION: maxillary posteriors occlude entirely

on the lingual aspect of the mandibular posteriors

f

173

treatment


168/225

FOR SINGLE TOOTH / DENTAL

CROSSBITE Crossbite elastics

DENTO ALVEOLARCONTRACTION and / ORCROSSBITE

Removable plate with jackscrew andAdams clasps

Soldered W-arch (Porter appliance)

Quad helix

Coffin spring

Arch expansion using fixedappliances

174


Skeletal crossbite


169/225


Fixed appliances

Tooth borne: Isaacson type and Hyrax type

Tooth and tissue borne: Derichsweiler type and Hass type

Removable appliances :

The treatment during deciduous and early mixed dentition is considered

more favourable in producing skeletal effects using removable appliances.

A removable type of rapid maxillary expansion device consists of a split

acrylic plate with a midline screw. The appliance is retained using clasps

on the posterior teeth.175

Oral habits


170/225

"Habit is defined as an automatic response to a specific situation acquired

normally as the result of repetition and learning. At each repetition the act

becomes less conscious and if repeated often enough, may enter the realm of

unconscious habit.

Boucher O.C. defined habit as a tendency towards an act or an act that has

become a repeated performance, relatively fixed, consistent, easy to perform

and almost automatic.

When the habit involving the oral cavity becomes fatal, that is when the habit

causes defects in orofacial structures it is termed as pernicious oral habit(

periniciousfatal)

176

classification


171/225

1. By Morris and Bohana (1969)

HABIT

EXAMPLE Non-Pressure Habit Mouth Breathing Pressure habits Sucking Habits

Lip sucking

Thumb AndDigitSucking

Biting Habits Nail Biting

Needle Holding

f

177

Earnest Klein(1971)

a. Intentional habits (meaningful)


172/225

b. Unintentional habits (empty)

By Brash

a. Purely muscular, e.g. tongue thrusting, lip sucking

b. Combined activity of the muscles of jaw, mouth and thumb sucking

c. Muscular action combined with introduction of passive object into themouth, e.g. pencil chewing

d. Habits in which muscles of the mouth and jaw take no active part, the

effect on the position of the teeth are produced by extraneous pressure, e.g.

abnormal pillowing

E.Functional disturbance, e.g. mouth breathing.

178

Sydney Finn( 1987)

Compulsive Habit : Acquired as a fixation in the child to the extent that


173/225

he retreats to the practice whenever his security is threatened.

Non Compulsive Habit : Children appear to undergo continuing behavior

modification, which permit them to release certain undesirable habit

patterns and form new ones which are socially accepted.

Primary habit and Secondary habits

Secondary habit is a habit that is due to a

supplemental problem. Eg. Large tongue

causes ton ue thrustin habit

179

8. Physiologic and Pathologic habits :

Physiologic habits : are those that are required for normal physiologic


174/225

functioning. eg Nasal respiration, sucking during infancy.

Pathological habits : Habits that are pursued due to pathological reasons

such as adenoids and nasal sepal defects that may lead to mouth breathing

9. Retained and cultivated habits :

Retained habits : Those that are carried over from childhood into

adulthood.

Cultivated habits : Those cultivated during the socio-active life of an

individual

180


175/225


176/225

For the habit to have its effect depends on the frequency, intensity

and duration with which the habit is exercised.

Frequency - How often the habit is performed (number of times

per day)

Intensity - How vigorously is it practiced?

Duration - Total number of years/months/weeks/days since the

habit is being performed.

182

Points to Consider before treatment of Oral

H bi


177/225

Habits:

Is the habit normal for that age? e.g. tongue thrusting in an infant is normal

Why has the child acquired the habit? It may be a meaning full or empty

habit

Psychological implication for allowing the child to continue the habit

First the psychological problem should be treated then the habit as such

Is the habit potentially harmful to the mouth or ; the paraoral structures?

Intensity, duration, and frequency are the index of severity of the habit

should also be considered

183


178/225

Is the habit self correcting, damaging or persisting?

e.g. thumb sucking normal in infants and self correcting with the

advancing age.

7. What is the correct time of interception for correction?

8. What is the appropriate means of correction the habit?

9.Parental attitude as an important factor

184

Thumb sucking habit


179/225

According to Gellin "it is the placement of thumb or one or more

fingers in varying depths into the mouth".

Thumb sucking in infants is common and is meant to meet both

psychological and nutritional needs.

It is a spontaneous activity that develops soon after birth.

Between birth and 3 months of age, its intensity increases until the age

of 7 months and then gradually declines.

The habit, if persists beyond may lead to dentofacial changes.

185

Classification


180/225

1) According to Subtelny (1973)

Type A - 50% of the children

whole digit is placed inside the mouth with the pad of the thumb

pressing over the palate, while at the same time maxillary and

mandibular oral contact is present.

Thumb is inserted beyond the first joint, pressing against the palatal

mucosa and alveolar tissue.

Lower incisors press against the thumb.186

Type B -13-24% of the children

thumb is placed in the oral cavity and at the same time maxillary and


181/225

mandibular contact is maintained.

The thumb extends upto the first joint or just anterior to it.

No palatal contact. Contact is present with only the anterior teeth

Type C - 16% of the children

thumb is placed into the mouth just beyond the first joint and contacts hard

palate and the maxillary incisors, but there is no contact with mandibular

anterior incisors.

Thumb is placed fully into the mouth in contact with the palate as in group

I but the lower incisors do not contact the thumb187


182/225

Type D - 6% of the children

only a little portion of the thumb is placed into the mouth. The lower incisors

contacted the thumb at the nails

2. According to Cook

1. group: The thumb pushes the palate in a vertical direction and displayed

only little buccal wall contractions.

2. group: Strong buccal wall contractions are seen and a negative pressure

is created resulting in posterior cross bite.

3. group: Alternate positive and negative pressure is created

188


183/225

Normal Thumb Sucking.

Abnormal Thumb Sucking

Psychological

Habitual

189

Dentofacial changes associated with

thumb sucking


184/225

EFFECTS ON MAXILLA

Proclination of the maxillary

incisors

Increased maxillary arch length

Anterior placement of the apical

base of the maxilla

Increased clinical crown length of

maxillarv incisor

High palatal arch

primary central incisor

Increased trauma to maxillary

incisors.

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Effects On Mandible

Retroclination of mandibular

Effects On Lip Placement


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incisors

Retrusion of mandible

Effects on interarch

relationship

Increased overjet

Decreased overbite

Posterior cross bite

Anterior open bite.

Effects On Lip Placement

And Function

Development of tongue thrust

Lower tongue position

Hypotonic upper lip

Hyperactive lower lip.

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Management


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1)Preventive Treatment :

Firstly, feed the child whenever he is hungry and let him eat as much as he

wants.

Secondly, feed the child the natural way; importance of breast-feeding is

primarily psychological and secondarily nutritive.

Thirdly, never let the habit to be started the practice must be discontinued

at its inception.

Use of a dummy / Pacifier

Psychological therapy

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- hypothesis or Dunlops hypothesis:

Dunlop believed that if a subject can be forced to concentrate on the

f f h h i h i i h ld l


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performance of the act at the time he practice it, he could learn to stop

performing the act.

Forced purposeful repetition of habit eventually associates with unpleasant

reactions and the habit is abandoned.

The child could be asked to sit in front of the mirror and asked to observehimself as he indulges in the habit. This procedure is very effective if the

child is asked to do the same at a time when he is involved in an enjoyable

activity.

4)Chemical Treatment : Quinine, Asafetida, Pepper, Caster oil etc

Femite, Thumb-up, Anti thumb solutions

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Mechanical Therapy or Reminder therapy:

a)Extra-oral approach : Mechanical restraints applied to the hand


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) pp pp

and digits like splints, adhesive tapes. Thumb guard is the most

effective extra-oral appliance for control of the habit.

b)Intra-oral approach :

the optimal time for appliance placement is between the ages of 3-

4 years preferably during spring or summer, when the child's

health is at its peak and the sucking desires can be sublimated in

outdoor play and social activity.

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195


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Removable or fixed Palatal crib

Oral Screen

Quad helix

Blue grass appliance : Developed by

Bruce S. Haskell (1991). It is a fixed

appliance using a Teflon roller, together

with positive reinforcement.

Used to manage thumb sucking habit in

children between 7-13 years of age.196


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Modified Blue grass appliance : This is a modification of the original

appliance with the difference being that this has two rollers of different colors

and material instead of one. If the patient tries to suck on his thumb the suction

will not be created and his thumb will slip from the rollers thus breaking the

act.

Thumb-Home concept: This is the most recent concept.

In this a small bag is given to the child to tie around his wrist during sleep

and it is explained to the child that just as the child sleeps in his home, the

thumb will also sleep in its house and so the child is restrained.

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Tongue thrusting


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Tulley (1969) defined tongue thrust as the forward movement of the

tongue tip between the teeth to meet the lower lip during deglutition

and in sounds of speech, so that the tongue lies interdentally.

Norton and Gellin defined tongue thrust "as a condition in which the

tongue protrudes between the anterior or posterior teeth during

swallowing with or without affecting tooth position".

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classification


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James S. Brauer and Townssend V. Folt

classification of tongue thrusting

Type Clinical Presentation

Type 1 Non deforming Tongue thrust

Type 2 Deforming Anterior Tongue thrust

Subgroup 1 : Anterior open bite

Sub group 2 : Associated

Procumbency of anterior teeth

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Type 3 Deforming lateral tongue thrust

Subgroup 1 : Posterior open bite


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Subgroup 2 : Posterior cross bite

Subgroup 3 : Deep overbite

Type 4 Deforming Anterior and lateral tongue

thrust

Subgroup1 : Anterior and posterior

open bite

Subgroup 2: Associated

procumbency of anterior teeth

Subgroup 3 : Associated posterior

cross bite 200


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Clinical features


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Simple Tongue Thrusting

Normal tooth contact in posterior region

Anterior open bite

Contraction of the lips, mentalis muscle and mandibular elevators.

Complex Tongue Thrusting

Generalized open bite

The absence of contraction of lip and oral muscles.

Lateral Tongue Thrust202

Other Features

Proclination of anterior teeth


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Anterior open bite

Midline diastema

Posterior cross bite.

Prognosis:

Prognosis of Simple tongue thrust habit is excellent and incase of Complex

tongue thrust is good whereas in Retained infantile swallow the prognosis

is very poor.

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Orthodontic elastics : The tongue tip is held

against the palate using orthodontic elastic of


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g p g

5/16" and

sugarless fruit drop exercise : This includes

identifying the spot, salivating, squeezing

the spot (3S EXERCISE)and swallowing.

Using the tongue the spot is identified, the

tongue tip is pressed against this spot and the

child is asked to swallow keeping the tongue

at the same spot.

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4. Other exercises : The child is asked to perform a series of exercise such

as whistling, reciting the count from 60 to 69, gargling, yawning etc to tone


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the respective muscles.

Sub conscious therapy Once the voluntary swallowing pattern is acquired

the patient proceeds to sub conscious therapy in which the patient is asked

to place a reminder sign or auto suggestion which requires the patient to

give self instructions like repeat 6 times I will swallow correctly all night

long"- for 10 nights.

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Mouth breathing habit


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Sassouni (1971) defined mouth breathing as habitual respiration through the

mouth instead of nose.

Classification

Given by Finn in 1987

Obstructive: Increased resistance to or complete obstruction of normal airflow

through nasal passage.

Habitual : persistence of the habit even after elimination of the obstructive

cause.

Anatomical: Short upper lip leads to incompetence of lips and hence mouth

breathing.

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Appearance:

Adenoid face is the characteristic feature ofmouth breathers.

Lips are held wide apart.


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There is lack of tone of oral musculature.

Upper lip is short and upper teeth seen..

The chin is receded and the face has typical

pigeon face appearance.

The nose is tipped superiorly.

Long narrow face.

The face is expression less.

The bridge of the nose is flat.

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Dental & skeletal


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Low tongue position.

Narrow maxillary arch.

Protrusion of maxillary and mandibular incisors.

The palatal vault is high.

Mandible hangs open in a slack manner.

Anterior open bite

Increased incidence of caries.

Mucus and plaque become more tenacious.

Ch i k ti i d i l i i iti

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The main aspect of management of a mouth breathing patient is to

Management


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The main aspect of management of a mouth-breathing patient is to

treat and eliminate the underlying cause or pathology that has

created the habit.. This should be followed by symptomatic

treatment.

Other procedures and appliances that can be used are

Physical exercise - respiratory exercise

Lip exercise -

Stretching and twisting of upper lip

Mechanical -

Oral Screen/Vestibular Screen

Hotz Modification

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Bruxism


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Poselt and Wolffdescribed bruxism as the "clenching or grinding of teeth

when not masticating or swallowing".

Ramfjord in 1966 defined bruxism as the habitual grinding of teeth when an

individual is not chewing or swallowing. Classification :

Daytime : Diurnal bruxism / Bruxomania. Can be conscious or subconscious

and may occur along with para-functional habits.

Night time bruxism : Nocturnal bruxism. Subconscious grinding of teeth

characterized by rhythmic patterns of masseter

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Occlusal Trauma : This include tooth ache, mobility mainly in morning.

Clinical features


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Tooth Structure : Extreme sensitivity due to loss of enamel, atypical wear

facets, Pulp may be exposed and many fractured teeth can also occur.

Muscular: Tenderness of the jaw muscles on palpation, muscular fatigue on

waking up in the morning, hypertrophy of masseter.

TMJ : Pain, crepitation, clicking in joint, restriction of mandibular

movements.

Associated Features : Headache

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Adjunctive therapy

Management


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Adjunctive therapy

a. Psychotherapy

b. Auto-suggestion and hypnosis

c. Relaxing exercise and

physiotherapy

d. Elimination of oral pain and

discomfort

a. Occlusal adjustments

b. Bite plates and splints -

c. Occlusal reconstruction and

prosthesis

d. Bite guard

Tranquilizers (a dose of 25 mg of

hydroxyzine 1 hr before bed

time).

Occlusal therapy

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Maxillary midline diastemas


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Most common compliant

Def

j,c early vs late

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