Preventive and Interceptive for General Practitioners

1. 1 rthodontics for for eneral practitioners s Prepared by Prepared by Dr. M Dr. Mohammed ohammed Alruby Scope of Scope of O Orthodontics G General practitioner Alruby Scope of Scope of Orthodontics Orthodontics for G.P for G.P Dr. Mohammed Alruby Dr. Mohammed Alruby

2. 2 Orthodontics: is a branch of science and art of dentistry dealing with prevention, interception, and correction of positional and dimensional dentofacial abnormalities. Orthodontic treatment could be divided as follow: 1-Preventive orthodontic treatment. 2-Interceptive orthodontic treatment. 3-Corrective orthodontic treatment. a) Early corrective. b) late corrective. 4-Post. Treatment maintenance or retentive and follow up. Preventive orthodontics: It is defined as that phase of orthodontics employed to recognize and eliminate potential irregularities and malposition in the developing dentofacial complex. It is directed toward improving environmental conditions to permit future normal development N: B: the child as a patient: children will accept orthodontic treatment if the purpose for treatment is explained in a simple term that they can understand. Information concerning treatment aims and procedures should be given to the child without hesitation and under authority; neither gives him a great attention nor neglect him. Be familiar with the child and give him some sympathy. Most children at preadolescent age are ready to accept orthodontic treatment if the orthodontist was able to establish a sympathetic relationship with the child. The child must not force to treatment but it is better to postpone treatment until the child feels the needs for treatment. The adolescent patients: the 15 years old patient frequently consider himself as a man and must has a special management. Adolescent patient may deny that his teeth need correction and warning of the appliances. It is very important to know whether the patient came to the office alone, with friends or forced by his parents. Preventive orthodontics is a long range approach and it is largely a responsibility of the general dentist. Many of the procedures are common in preventive and interceptive orthodontics but the timing is different. Preventive procedures are undertaken in anticipation of development of a problem. Interception procedures are undertaken when the problem has already manifested. For extraction of supernumerary teeth before they cause displacement of other teeth is a preventive procedure, while their extraction after the signs of malocclusion have appeared is an interceptive procedure. Preventive procedures: A-Pre-dental preventive procedure ( parents education): Instruct the mother to feed her baby from breast and if the baby to be feed by a bottle, the nipple should be long enough to rest on the anterior third of the tongue. It also should contain a small side opening instead of single large end hole, this allows the milk to flow on the dorsum of the tongue and prevent it from being squeezed directly into the pharynx, by this method the tongue is allowed to function properly during swallowing which is very important in general growth of the jaws, also less air will be swallowed with milk. The mother is also advised against the prolonged use of pacifier that can have a detrimental effect on the dentition. The young mothers are also advised on matters pertaining to prevention of nursing bottle syndrome. Scope of Scope of Orthodontics Orthodontics for G.P for G.P Dr. Mohammed Alruby Dr. Mohammed Alruby

3. 3 b-Dental preventive procedures: 1-Caries control: dental caries makes possible tipping and crowding of the adjacent teeth, over eruption of the opposing teeth, decrease in arch length and possible loss of the teeth. Caries tooth should be restored to its normal contour. Inter proximal cavities should be prepared and permanently filled in one visit especially in mixed dentition period because rapid loss of space by mesial shifting of the teeth. Teeth lost due to caries or any other reasons should be replaced in children as early as possible if malocclusion to be avoided. Malocclusion can be initiated due to caries or loss of teeth as the child favor on side for mastication to avoid chewing on painful caries tooth or hand capping by lost teeth. 2-Care of deciduous dentition: the deciduous teeth are excellent natural space maintainers until the developing permanent teeth are ready erupt into the oral cavity. Simple preventive procedures such as application of topical fluoride and pit and fissure sealant help in preventing caries. 3-Extraction of supernumerary teeth: presence of supernumerary teeth can cause an abnormal eruptive path, malposition, ectopic eruption or even impaction of permanent teeth. Mesiodense is one cause of median diastma; supernumerary teeth should be removed as early as possible when detected to allow normal eruption of permanent teeth. 4-Treatment of ankylosed tooth: ankylosed deciduous molars should be extracted when permanent successors are present, but when permanent successors are congenitally absent, the decision in such case depend on the condition: a)If the arch length is abundant and can accommodate all permanent teeth in good alignment, the tooth should be kept. b)If the arch length is deficient, the ankylosed tooth should be extracted and the space is utilized for aligning the teeth. 5-Management of deeply locked 1st permanent molar: deeply locked 1st permanent molar may cause resorption of the distal roots and cervical portions of 2nd primary molars. This can treat either by disking the distal surface of the second deciduous molar to free the 1st permanent molar or by extraction of the 2nd deciduous molar and maintain space for 2nd premolar. ** slightly locked 1st permanent molar: may free itself automatically without active treatment or may be treated by separation with brass wire that pass interdentally between the 2nd deciduous molar and the 1st permanent molar then twisted and tightened, when become loose it should be twisted again until complete eruption of the 1st permanent molar takes place 6-Maintenance of tooth shedding time table: there should not be more than 3 month's difference in shedding of deciduous teeth and eruption of permanent teeth in one quadrant as compared to other quadrants. Delay in eruption may be due to one of the following factors: a-Presence of over retained deciduous teeth roots. b-Presence of unresorbed deciduous roots fragments. c-Supernumerary tooth. d-Cysts or tumors. e-Over-hanging restoration. f-Fibrosis of gingival. g-Ankylosis of primary teeth. Scope of Scope of Orthodontics Orthodontics for G.P for G.P Dr. Mohammed Alruby Dr. Mohammed Alruby

4. 4 7-Managements of abnormal labial frenum and tongue tie: the presence of a thick and fleshy maxillary labial frenum that is attached relatively low prevents the maxillary centeral incisors from approximating each other producing a midline diastema, this kind of abnormal frenal attachment in most patient caused due to hereditary factors. They should hence be diagnosed and treated at an early age. A blanch test helps in diagnosing a thick frenum, in addition notching of interdental bone in a periapical radiograph confirms a thick frenal attachment. Presence of tongue tie or ankyloglossia which fix the tongue to the floor of the mouth that causing feeding difficulties in infant, abnormal tongue function and speech defects ((the sound sand)) are often affected and this is due to limitation of tongue movements, this condition must be treated to allow prevention of malocclusion. 8-Prevention of oral habits: habits such as finger biting, mouth breathing nail biting, thumb sucking should be identified and stopped. Prevention starts with proper nursing and use of a physiologically designed nursing nipple and pacifier to enhance normal functional and deglutition activity. 9-Elimination of occlusal interferences: all functional prematurity should be eliminated as they can lead to deviation in the mandibular path of closure and also predispose to bruxism. Using articulating paper, the premature contact area is detected and selective grinding is carried out. Sometimes abnormal anatomical features like enamel pearl, may cause premature contact, they should be eliminated by grinding. Presence of abnormal large cingulum on a maxillary incisor prevents establishment of normal over bite and over jet. Grinding of the incisal tip of primary canines is useful to permit free lateral excursion of the mandible to prevent interference with forward movement of the mandible and to correct the early cross bite. 10-Use of space maintainer: premature loss of deciduous teeth can cause drifting of the adjacent teeth into the space. It can result in an abnormal axial inclination of the teeth, in case of premature loss of deciduous second molars, the first permanent molars migrate mesially thereby leaving insufficient space for the erupting second premolars that can get deflected and erupt in an abnormal location. Space maintainer: is an appliance used to maintain the space for the eruption of permanent teeth after premature loss of the deciduous predecessors. Requirements for the use of space maintainer: 1-It should maintain the entire mesio-distal space created by a lost tooth. 2-It must restore the function as far as possible and prevent over-eruption of opposing teeth. 3-It should be a simple in construction. 4-It should be strong enough to withstand the functional forces. 5-It should not exert excessive stress on the adjoining teeth. 6-It must permit maintenance of oral hygiene. 7-It must not restrict the normal growth and development and natural adjustments that takes place during the transition from deciduous to permanent dentition. 8-The space maintainer should not come in the way of other functions. Indication of space maintainer: As a general rule, whenever the losses of deciduous teeth predispose the patient to malocclusion, space maintainer is indicated. Scope of Scope of Orthodontics Orthodontics for G.P for G.P Dr. Mohammed Alruby Dr. Mohammed Alruby

5. 5 1-When disturbance in balance and shifting of the teeth is expected this actually true for the premature loss of one of primary mandibular molars. 2-When abnormal muscle function is expected following premature loss, for example: premature loss of one of mandibular incisors associated with hyperactive mentalis muscle. 3-When premature loss of deciduous teeth can stimulate abnormal habits as tongue thrust, thumb sucking. 4-Poor intercuspation and expected shifting. 5-Presence of potential malocclusion which might become more sever after premature loss, for example: arch length inadequacy and expected crowding. 6-When the arch length is sufficient to accommodate all the permanent teeth anterior to 1st permanent molars in a good alignment and no further treatment will be required at later age. 7-When the space supervision reveals sign of closure. 8-If retention of space will aid in prevention of further complicated treatment at later age. Contraindication of space maintainer: 1-When tooth eruption is expected within few weeks as evidenced by: = formation of more than one 1/3 of the roots. = nor or more little amount of covering alveolar bone. 2-Generalized spacing and large tongue. 3-When the space required for permanent teeth is in excess as evidenced by actual analysis of x-ray and cast. 4-When the permanent successor is congenitally missing and there is arch length in adequacy. 5-Well-developed dental arch and proper intercuspation. Requirements of space maintainer: 1-Should maintain the mesio-distal as well as the vertical dimensions of the lost tooth. 2-If possible it should be functional, at least to prevent over eruption of opposing tooth. 3-Should be simple and easily fabricated. 4-Should not endanger the remaining teeth or soft tissues. 5-Should be strong enough to acts over the required periods. 6-Should not interfere with the normal growth and function. 7-Should be hygienic and easily cleaned. Types of space maintainers: I) A) Functional: maintain the mesiodistal as well as the vertical dimensions of the tooth; in addition, restore normal functions (mastication and speech) and esthetic. B) Nonfunctional: maintain the mesiodistal width only. II) A) Fixed: band and loop, crown and loop maintainers fixed lingual arch and space regainers. B) Semi fixed C) Removable: acrylic partial denture III) A) Active: space regainer. B) Passive: band and loop space maintainers. Scope of Scope of Orthodontics Orthodontics for G.P for G.P Dr. Mohammed Alruby Dr. Mohammed Alruby

6. 6 Examples of space maintainers: 1-Acrylic partial dentures: have been used successfully in patients who have undergone multiple extractions. This appliance can be readily adjusted to allow the eruption of the teeth. The inclusion of artificial teeth in the denture restores masticatory function; clasp can be fabricated on deciduous canines and molars for retention. 2-Full or complete denture: sometimes all the primary teeth of a pre-school child may require extraction due to rampant caries of teeth that cannot be restored. This procedure was more common in the pre-fluoridation area, even today some children may require complete extraction of their deciduous teeth, and these cases are managed by the use of complete denture. These dentures not only restore the function and esthetic but also the guide the 1st permanent molars into their correct position. The posterior border of the denture should be placed over the area approximating the mesial surface of the unerupted 1st permanent molar. When the permanent incisors and the 1st permanent molars are erupting, a partial denture space maintainer can be used until the remaining permanent teeth erupt. 3-Band and loop space maintainer: one of the most used space controlling appliances used in dental practice. The tooth distal to the extraction space is banded and loop of thick stainless steel wire is soldered to it with its mesial end touching the tooth mesial to the extraction space. 4-Crown and loop space maintainer: similar to the band and loop appliance except that stainless steel crown is used for the abutment tooth, the crown is used when the abutment tooth is highly carious. 5-Lingual arch space maintainer: the most effective one in the lower arch, the classical mandibular lingual arch consists of two bands cemented on the 1st permanent molars or in the 2nd deciduous molars, which are joined by a stainless steel wire contacting the lingual surface of the four mandibular incisors. The appliance is indicated to preserve the space created by multiple loss of primary molars, it maintains the arch parameter by preventing both mesial drifting of the molars and lingual collapse of the anterior teeth. 6-Nance holding appliances: similar to the lingual arch described above, it designed to prevent mesial migration of the maxillary molars, and they are constructed by using 0.036-inch diameter hard stainless steel wire. It does not contact the anterior teeth, but approximate the anterior area of the palate by an acrylic button. Transpalatal arch: More recently, the transpalatal arch has been recommended for stabilizing the maxillary 1st permanent molars when the primary molars require extraction. It consists of a thick stainless steel wire that spans the palate connecting the 1st permanent Molar of one side to the other side, the best indication is when one side of the arch is intact and several primary teeth on the other side are missing. 7-Distal shoe space maintainer: it is otherwise known as the intra alveolar appliance. The distal surface of the 2nd deciduous molar guides the unerupted 1st permanent molar. When the 2nd primary molar is removed prior to the eruption of the 1st permanent molar, the intra alveolar appliance provides greater control to the path of eruption of the unerupted tooth and prevents undesirable mesial migration. 8-Band and bar type space maintainer: this is a fixed space maintainer in which the abutment teeth on either side of the extraction space are banded and connected to each other by a bar. Alternatively, stainless steel crowns can be used on the abutments. Scope of Scope of Orthodontics Orthodontics for G.P for G.P Dr. Mohammed Alruby Dr. Mohammed Alruby

7. 7 Band and loop space maintainer Distal shoe extension space maintainer Lingual arch space maintainer Scope of Scope of Orthodontics Orthodontics for G.P for G.P Dr. Mohammed Alruby Dr. Mohammed Alruby

8. 8 Nance holding arch Partial denture space maintainer Transpalatal arch space maintainer Crown and bar space maintainer Factors affecting the type of space maintainer: 1-Time elapsed since loss of tooth: it is usually advisable to place a space maintainer as soon as the primary teeth are removed; studies indicate that the maximum loss of space occurs within 6 months of extraction of the teeth. It would be a good idea to fabricate the appliance prior to extraction of the primary tooth and insert the appliance soon after extraction. 2-Dental age of the patient: the dental age of the patient should always be considered rather than the chronological age. This is because too much variation in eruption of teeth is observed. It is usually observed that the permanent teeth erupt once 3/4th of their root development is complete. This criterion can be used to predict the age of eruption of the permanent teeth. Early loss of teeth can cause a delay in eruption of the successor, for example early loss of the deciduous molar before 7 years of age result in a delay in eruption of the premolar. 3-Thickness of bone covering the unerupted teeth: the more the bone covering the unerupted tooth, the more would be the time it would take to erupt and therefore space Scope of Scope of Orthodontics Orthodontics for G.P for G.P Dr. Mohammed Alruby Dr. Mohammed Alruby

9. 9 maintenance in indicated. Normally premolars take 4 – 5 months to erupt through a bone of 1 mm. 4-Sequence of eruption of teeth: whenever a space maintainer is planned, adequate consideration should be given to the adjacent developing and erupting teeth. The neighboring dentition can greatly influence the closure of the extraction space, for example when the deciduous second molar is lost early, we should study the development of the permanent second molar and the successor second premolar. In case the second molar is a head of the second premolar in its eruption, it is likely to exert a mesial force on the 1st molar which can move mesially. This may result in insufficient space for the second premolar. 5-Congenital absence of permanent tooth: if permanent teeth are congenital absence, the dentist should decide if he is going to retain the space until a replacement can be given or allow the other erupting teeth to drift and close the space. Interceptive orthodontics It is the procedures used to intercept a malocclusion that has already developed or is developing, to restore normal occlusion. Interceptive measures: 1-Occlusal equilibration: to eliminate premature contacts and occlusal disharmony, that can develop traumatic occlusion and tooth guidance problem. The most frequent forms of tooth guidance in the deciduous and mixed dentition is the anterior mandibular displacement. 2-Correction of developing anterior cross bite: anterior cross bite is a condition characterized by reverse over jet in one or more of the maxillary anterior teeth are in lingual relation to the mandibular teeth. The anterior cross bite should be treated for the following reasons: a)This type of malocclusion is self-perpetuating, if the cross bite is present in the deciduous dentition, it may manifest in the mixed and permanent dentition well. b)Simple anterior cross bite that are not treated early have the potential of growing into skeletal malocclusion that later need complicated orthodontic treatment combined sometimes with surgical procedures. 3-Control of abnormal habits, before causing irreparable harm to the developing dentition, by placement of habit braking appliance as oral screen in case of mouth breathing. 4-Muscle exercise: the dental tissues are surrounded from all directions by muscles. Normal occlusal development depends upon the presence of oro-facial musclefunction,muscle exercise help in aberrant muscle function. Exercise for masseter muscle: Exercise to strengthen the masseter muscle involves the clenching of teeth by the patient while counting to ten, the patient asked to repeat this for some duration of time. Exercise for the lips (circum- oral muscles): A number of exercises have been suggested for the lips and cheek muscles. A)Stretching of the upper lip to maintain lip seal is an important therapeutic measure in patient having short hypotonic lips, to aid on the stretching, the patient asked to hold a piece of paper between the lips B)Patients can be asked to stretch the upper lip in a downward direction toward the chin. Scope of Scope of Orthodontics Orthodontics for G.P for G.P Dr. Mohammed Alruby Dr. Mohammed Alruby

10. 10 C)Holding and pumping of water back and forth behind the lips. D)Button pull exercise: a button of 1 1/2-inch diameter is taken and a thread passed through the buttonhole, the patient is asked to place the button behind the lips and pull the thread, while restricting it from being pulled out by using lip pressure. E)Tug of war exercise: this similar to the button pull exercise but this involve use of two buttons, with one placed behind the lips and the other button is held by another person to pull the thread. Exercises for the tongue: a)One elastic swallow: this exercise is used for correction of improper positioning of the tongue. 5/16-inch intraoral elastic is placed on the tip of the tongue and the patient is asked to raise the tongue and hold the elastic against the rugea area and swallow. b)Two elastic swallow: two 5/16-inch elastic are placed over the tongue, one in the midline and the other on the tip and the patient is asked to swallow with elastic in position. 5-Interception of skeletal malrelations: skeletal malocclusion if diagnosed at an early age can be intercepted so as to reduce the severity of the malocclusion that may occur. Class II malocclusion due to mandibular growth deficiency is usually treated by myofunctional appliances. Class III with maxillary deficiency can be treated by using of Frankle III appliance or using of face mask. 6-Removal of soft tissue barriers: whenever a permanent tooth fails to erupt at the appropriate time, its eruption may be stimulated by surgically exposing the crown. The surgical procedure involves excision of the soft tissue and removal of any bone overlying the crown of the unerupted tooth. The extent of tissue removal should be such that the greatest diameter of the crown of the tooth is exposed. Scope of Scope of Orthodontics Orthodontics for G.P for G.P Dr. Mohammed Alruby Dr. Mohammed Alruby

11. 11 Correction of anterior cross bite Scope of Scope of Orthodontics Orthodontics for G.P for G.P Dr. Mohammed Alruby Dr. Mohammed Alruby

12. 12 7-Serial extraction: That procedure which include the extraction of the deciduous tooth followed by permanent tooth to reduce the arch length problem. It is based on the assumption that it is possible to predict at early age that, there will be lack of space to accommodate all of the permanent teeth. Indications: 1-When carful diagnosis predicts an arch length inadequacy. 2-When the radiograph reveals that, all erupting teeth are in good condition and in correct eruptive path. 3-Some cases of mild crowding in mandibular arch in class III. 4-Largely applied to class I malocclusion and should be limited to those cases that have a good face (straight profile and pleasing appearance). 5-Absence of physiologic spacing. 6-Unilateral or bilateral premature loss of deciduous canines with midline shift. 7-Malposed upper lateral incisors that erupt palatally out of the arch. 8-Marked irregular or crowded upper and lower incisors. 9-Localized gingival recession in the lower anterior region is a characteristic feature of arch length deficiency. 10-Mesial migration of buccal segment. 11-Where growth is not enough to overcome the discrepancy between tooth material and basal bone. 12-Lower anterior flaring. Contraindication: 1-Class I malocclusion when there is slight crowding which can be corrected by anyway line of treatment. 2-Class III and Class II division 2 malocclusion, where the problem need comprehensive treatment at later age. 3-Presence of facial asymmetry and midline deviation that will require complicated treatment at later age. 4-When oligodontia or other deficiencies of the teeth are present. 5-Delayed eruption of the teeth or abnormal eruptive path. 6- When fixed appliance cannot be used to avoid arch collapse. 7- In cases of deep over bite or open bite must be treated firstly. 8- Benefits of serial extraction: 1-To avoid loss of alveolar bone. 2-To ensure eruption of permanent teeth in favorable direction and good alignment. 3-To reduce malposition of individual teeth. 4-To reduce the treatment time when major orthodontic treatment is required at later age, and in some cases to eliminate the need for treatment at later age. 5-Psychological trauma associated with malocclusion can be avoided bt treatment of malocclusion at an early age. 6-Less retention period is indicated at the completion of the treatment. 7-More stable results obtained as the tooth material and arch length are in harmony. Scope of Scope of Orthodontics Orthodontics for G.P for G.P Dr. Mohammed Alruby Dr. Mohammed Alruby

13. 13 Disadvantage of serial extraction: 1-Requires clinical judgment, there is no single approach that can be universally applied to all patients. Each patient has to be assessed and a suitable extraction timetable planned. 2-Treatment time is prolonged as the treatment is carried out in stages spread over 2-3 years. 3-Extraction of buccal teeth can result in deepen the bite. 4-If the procedures are not carried out properly there is a risk of arch length reducing by mesial migration of the buccal segment. 5-Ditching or space can exist between the canine and second premolar. 6-The axial inclination of the teeth at the termination of the serial extraction procedure may require correction; this necessitates short term fixed appliance therapy. Procedures: a)Dewel's method: Dewel has proposed a 3 step serial extraction procedure. In the first step: the deciduous canines are extracted to create space for the alignment of the incisors, this step is carried out at 8-9 years of age. A year later, the deciduous 1st molars are extracted so that the eruption of the 1st premolars is accelerated, this followed by the extraction of the erupting 1st premolars to permit the permanent canines to erupt in their place. . Dowel’s method for serial extraction Scope of Scope of Orthodontics Orthodontics for G.P for G.P Dr. Mohammed Alruby Dr. Mohammed Alruby

14. 14 b- Tweed’s method: this method involves the extraction of the deciduous 1st molars around 8 years of age. This followed by the extraction of the 1st premolars and the deciduous canines simultaneously Tweed’s method for serial extraction Scope of Scope of Orthodontics Orthodontics for G.P for G.P Dr. Mohammed Alruby Dr. Mohammed Alruby

15. 15 9-Space regainer: if the primary molar is lost early and space maintainer is not used, a reduction in arch length by mesial movement of the first molar can be expected. In such patients, the space lost by mesial movement of the molar can be regained by distal movement of the 1st molar. Not all patients that have lost arch length by mesial movement of molar are ideal candidates for space regaining. The space regaining procedure are preferably undertaken at an early age prior to the eruption of the 2nd molar Space regainer using spring space regainer using screw Scope of Scope of Orthodontics Orthodontics for G.P for G.P Dr. Mohammed Alruby Dr. Mohammed Alruby