GOOD MORNING

INTERCEPTIVE ORTHODONTICS

Guided by Dr Mehamood mothedath

Dr Aseela ahamed

Submitted bySabira S.T.P

INDEX

Definition Aims Procedures undertaken in interceptive orthodontics

1. Serial extraction2. Correction of developing cross bite3. Control of abnormal habits4. Space regaining5. Muscle exercise6. Interception of skeletalmalrelation7. Removal of soft tissue or bony barrier to enable eruption of

teethCommon problems which can be intercepted

-Crowding-Midline diastema

Introduction

Conclusion Reference

INTRODUCTION

There are number of procedures that undertaken by the orthodontist so as to intercept a malocclusion that is developing.The concept of interceptive orthodontics reveals around the minor problems during development of dentition which if left untreated may increase interms of complexity and be consequently difficult to treat at later date.Thus the procedures are instituted once.The problem is detected at an early stage.

The terms preventive and interceptive orthodontics are sometimes used synonymously.But it should be understood that preventive orthodontic procedures are undertaken when the dentition and occlusion are perfectly normal while interceptive procedures are carried out when the signs and symptoms of malocclusion have appeared.

DEFINITIONS

The interceptive orthodontics may be defined as that phase of science and art of orthodontics employed to recognize and eliminate the potential irregularities and malpositions in the developing dentofacial complex. (The American Association of Orthodontists-1969)

Defined as the elimination of existing interferences with the key factors involved in development of dentition. (Profitt and Ackerman-1980)

AIMS:

Permanent dentition with all teeth in good alignment and contacts anatomically compatible with a healthy periodontium.

Dental arches well related in all three planes of space with an optimal intercuspation that is substantialy identical in both centric relation and occlusion.

Dentition in harmony with esthetic in frontal and profile appearance. Stability between skeletal and muscular components.

The procedures undertaken in interceptiveorthodontics

1. Serial extraction2. Correction of developing cross bite3. Control of abnormal habits4. Space regaining 5. Muscle exercise6. Interception of skeletalmalrelation7. Removal of soft tissue or bony barrier to enable eruption of

teeth.

1-SERIAL EXTRACTION

Serial extraction is an interceptive orthodontic procedure usually initiated in mixed dentition when one can recognize and anticipate potential irregularities in the dentofacial complex and is corrected by a procedure that include the planned extraction of certain deciduous teeth and later specific permanent teeth in an orderly sequence and predetermined pattern to guide the erupting permanent teeth in to more favourable position.

Definition Serial extraction is defined as the correctly timed planned

removal of certain deciduous and permanent teeth in mixed dentition stage with dentoalveolar disproportion.

HISTORY

Kjellgren in 1920 used the term serial extraction to describe a procedure where some deciduous teeth followed by permanent teeth were extracted to guide the rest of the teeth in to normal occlusion.

Nance during the 1940’s popularized this technique in the united state of America and termed it”planned and progressive extraction.”

Hotz in 1970 called such a procedure “active supervision of teeth by extraction.”

Rationale

Serial extraction is based on two basic principles.

1-Arch length-tooth material discrepancy: when ever there is an excess of tooth material as compared to the arch length,it is advisable to reduce the tooth material in order to achieve stable result. This principle is utlized in serial extraction procedure where tooth material is reduced by selective extraction of teeth so that rest of the teeth can be guided to normal occlusion. 2-Physiologic tooth movement: Human dentition shows a physiologic tendency to move towards an extraction space.Thus by selective removal of some teeth the rest of the teeth which are in the process of eruption are guided by the natural force in to the extraction space.

INDICATIONS OF SERIAL EXTRACTION1. Class I malocclusion showing harmony between skeletal and muscular

system.2. Arch length deficiency as compared to the tooth material. Arch length deficiency is indicated by the presence of one or more of the following features:• Absence of physiological spacing.• Unilateral or bilateral premature loss of deciduous canine with midline

shift.• Malpositioned or impacted lateral incisor that erupt partially out of the

arch.• Markedly irregular or crowded upper and lower anteriors.• Localized gingival recession in the lower anterior region is a characteristic

feature of arch length deficiency.• Ectopic eruption of teeth.• Mesial migration of teeth.• Abnormal eruption pattern and sequence.• Lower anterior flaring.• Ankylosis of one or more teeth.

3.Where growth is not enough to overcome the discrepancy between tooth and basal bone.4.Patient with straight profile and pleasing appearance.

CONTRA-INDICATIONS OF SERIAL EXTRACTION

1. ClassII and ClassIII malocclusion with skeletal abnormalities.2. Spaced dentition.3. Anodontia or oligodontia.4. Open bite and deep bite.5. Midline diastema.6. ClassI malocclusion with minimal space deficiency.7. Unerupted malformed teeth eg:-dilaceration.8. Extensive caries or heavy filled first permanent molar.9. Mild disproportion between arch length and tooth material that can be

treated by proximal stripping.

The diagnostic exercise should involve comprehensive assessment of the dental ,skeletal and soft tissues: An arch length deficiency of not less than 5-7mm should exist to under

taken this procedure. Study model analysis should be carried out to determine the arch

length deficiency. Carey’s analysis in the lower arch and arch perimeter analysis in the

upper arch should be carried out. Mixed dentition analysis helps in determining the space required for

erupting buccal teeth Eruption status of the dentition is evaluated from an OPG The skeletal tissue assessment should involve comprehensive

cephalometric examination to study the underlying skeletal relation. The soft tissue assessment by clinical examination and cephalograms.

Serial extraction is generally undertaken in patient exhibiting harmonious soft tissue pattern.

DIAGNOSTIC PROCEDURE

Dewel’s method

Dewel has proposed 3 step serial extraction procedure.

Step1:Decidous canines are extracted to create space for alignment of incisosr.This is carried out at8-9 years.

Step2:Ayear later deciduous first molar are extracted so that eruption of the first premolar is accelerated

Step3:Extraction of the erupting first premolars to permit the permanent canines to erupt

PROCEDURE

A number of methods of sequence of extraction have been discribed.Three popular methods are1. Dewel’s method2. Tweed’s method3. Nance method

-In some cases a modified Dewel’s technique is followed where in the first premolars are enucleated at the time of extraction of the first deciduous molar.This is frequently necessary in the mandibular arch where the canines often erupt before the first premolar.Tweed’s method:-Extracton of deciduous first molar around 8 years.-Extraction of the first premolar and the deciduous canine simultaneously.

Nance method: Similar to tweed’s techniques

Post serialextraction fixed therapy: Most cases of the serial extraction need fixed appliance therapy for the correction of axial inclination and detailing of the occlusion.

ADVANTAGE OF SERIAL EXTRACTION1. Treatment is more physiologic,as it involves guidance of the teeth in

to normal position making use of the physiologic force.2. Psycological trauma associated with malocclusion can be avoided by

treatment of the malocclusion an early stage.3. It eliminates or reduces the duration of multibanded fixed treatment.4. Better oral hygiene is possible there by reducing risk of caries.5. Health of investing tissues is preserved.6. Lesser retention period is indicated at the completion of treatment.7. More stable results obtained as the tooth material and arch length are

in harmony.

DISADVANTAGES OF SERIAL EXTRACTION1. Serial extraction requires clinical judgement.no single approach

universally applied to all patien2. Treatment time is prolonged as the treatment is carried out in stages spread over 2-3 years.3. It requires the patient to visit the dentist often.Thus patients co-operation is needed.4. As extraction spaces are created that close gradually the patient has a tendency of developing tongue thrust.5. Extraction of buccal teeth can result in deepening of bite.6. If procedures are not carried out properly there is a risk of arch length reducing by mesial migration of buccal segment.7. Ditching or space can exist between the canine and second pre molar.8. The axial inclination of the teeth at the termination of serial extraction procedure may require correction.This necessitates short term fixed appliance therapy.

2-CORRECTION OF DEVELOPING CROSSBITE

ANTERIOR CROSSBITE.

Anterior crossbite is an abnormal labiolingual relationship between one or more maxillary and mandibular anterior teeth. OR Anterior crossbite is a condition charecterised by reverse overjet wherein one or more maxillary teeth are in lingual relation to the mandibular teeth.

Graber has defined crossbite as a condition where one or more teeth may be abnormally malposed buccally or lingually or labially with reference to the opposing tooth or teethTwo type1. Anterior crossbite2. Posterior crossbite

DEVELOPING ANTERIOR CROSSBITE.

Anterior cross bite should be intercepted and treated at an early stage

so as to prevent a minor orthodontic problem from progressing in to a major dentofacial anomaly.

An orthodontic maxim states “The best time to treat a cross bite is the first time it is seen.”

Anterior crossbite should be treated early for the following reasons:1. This type of malocclusion is self perpetuating.2. Simple anterior cross bite that are not treated early have the potential

of growing in to skeletal malocclusion.

Classification

ANTERIOR CROSSBITE

Dento-alveolar Functional

Skeletal

1. Dento-alveolar anterior crossbite

• Anterior crossbite in which one or more maxillary anterior teeth are in lingual relation to the mandibular anteriors is termed dento-alveolar anterior crossbite.

• Often manifested as single tooth crossbite and is usually occurs due to over retained deciduous teeth that deflect the erupting permanent teeth in to palatal position.

Treatment1. Use of tongue blade Can be used in case there is sufficient space for the tooth to be brought out.

2- Use of caltan’s applians or lower anterior inclined plane. -Inclined plane constructed on the lower anterior teeth can be used to treat maxillary teeth in crossbite -Can be designed to treat a single tooth in crossbite or a segment of the upper archin arch-The have a 45degree angulation which forces the maxillary teeth in crossbite to more labial position.

3-Use of double cantilever spring. Anterior crossbite involving one or two maxillary teeth can be treated using a double cantilever spring.

2.Functional anterior crossbite.

- Functional crossbite occur as a result of occlusal prematurities that cause a deflection of the mandible in to a forward position during closure.

-Some anterior crossbite are referred to as functional crossbite is the so called pseudo classIII malocclusion where mandible is compelled to close in position forward of its true centric relation.

Treatment- Eliminate the occclusal prematurities.

3.Skeletal anterior crossbite

-Skeletal anterior crossbite are usually a result of skeletal discripancies in growth of maxilla or the mandible.-Anterior crossbite can be a result of maxillary skeletal retrognathism or mandibular prognathism.

Treatment

-These are best treated during growth by growth modification procedures by use of myofuntional or orthopaedic appliance.

3-CONTROL OF ABNORMAL HABITS

Habits refers to certain actions involving teeth and other oral or perioral structures which are repeated often enough by some patients to have a profound and deleterious effect on the position of teeth and occlusion.

Some of the habits that can effect the oral structuresare: Thumb sucking Tongue thrust Lip biting and sucking Mouth breathing

Thumb sucking

Thumb sucking can be defined as placement of the thumb at various depth in to mouth.

Classification based on clinical observation

-Present during first and second year of life.-Disappear as the child mature-Does not generate any malocclusion.

Normal thumb sucking Abnormal thumb sucking

-Persist beyond the preschool period. -If it is not treated or controlled during this stage it may cause deleterious effect to the dentofacial structures.

Effects of thumb sucking Thumb sucking cause number of changes in the dental arch and the supporting structures.The severity of the malocclusion caused by thumb sucking depends on trident of factors they are1. Duration:Amount of time spent indulging in the habit.2. Frequency:The number of times the habit is activated in a day.3. Intensity:The vigor with which the habit is performed.

Effects are:1. Labial tipping of the maxillary anterior.2. Ovrjet increases due to proclination of maxillary anteriors.3. Anterior open bite can occur as a result of restriction of incisor eruption

and supraeruption of buccal teeth.4. Narrowing of maxillary arch,which predisposes to posterior crossbite.5. Child may develop tongue thrust habit as a result of open bite.6. The upper lip is generally hypotonic while the lower part of the face

exhibits hyper active mentalis activity.

Management1.Psychological approach:

Usually children lacking parental care love and affection resort to this.Thus parents should be counseled to provide the child with adequate love and affection.Parents should also be advised to divert the child’s attention to other things such as play and toys.

Dunlop put forward Betahypothesis that states the best way to break a habit is its conscious purposeful repetition. Dunlop suggest that the child should be asked to sit in front of a large mirror and asked to suck his thumb observing himself as he indulges in the habit.

2.Reminder therapy• Extraoral approach-Use thumb cap

-Use of long-sleeve gown as reminder therapy

Chemical approach

Use of bitter tasting or foul smelling preparation placed on thumb that is sucked and make the habit distasteful.

Mechanotherapy

Habit breaking appliance

Blue glass appliance Quard helix

Tongue thrusting Tongue thrust is defined as a condition in which the tongue makes contact with any teeth anterior to the molars during swallowing.Effects of tongue thrusting:1. Proclination of anterior teeth.2. Anterior open bite.3. Bimaxillary protrusion.4. Posterior open bite in case of lateral tongue thrust.5. Posterior crossbite.Management of tongue thrust Management of tongue thrust involves interception of the habits followed by treatment to correct the malocclusion.Habit interception:1. Use of habit breakers.Both removable and fixed cribs or rakes2. The child is taught the correct method of swallowing 3. Various muscle exercise of the tongue can help in training it to adapt to

the new swallowing pattern.

-Malocclusion associated with tongue thrust is treated using removable or fixed orthodontic appliance.

MOUTH BREATHING

Mouth breathing has been attributed as a possible etiologic factor for

malocclusion.It can be obstructive or habitual in nature.

Obstructive mouth breathing usually a result of nasal obstruction such as

nasalpolyp,nasaltumours,chronicnasal inflammatory condition and

deviated nose and nasal septum.

Habitual mouth breathing is one where oral breathing as a habit after the

removal of nasal obstruction.

Clinical features of mouth breathing:

The type of malocclusion most often associated with mouth breathing is called long face syndrome or the classic adenoid facies. These patient exhibit the following features:

a. Long and narrow face.

b. Narrow nose and nasal passage.

c. Short and flaccid upper lip.

d. Contracted upper arch with possibility of posterior cross bite

e. An expressionless or blank face.

f. Increased over jet as a result of flaring of incisors.

g. Anterior marginal gingivitis can occur due to drying of the

gingiva

h. The dryness of the mouth predisposes to caries.

i. Anterior open bite can occur.

Management of mouth breathing

• Removal of nasal or pharyngeal obstruction:Any nasal or pharyngeal obstruction should be removed by referring the patient to the ENT surgeon.

• Interception of habits: Intercepted by use of a vestibular screen.Alternatively adhesive tapes can be used to establish lip seal.

• Rapid maxillary expansion: patient with narrow constricted maxillary arches benefit from rapid palatal expansion procedure aimed at widening the arch it increase the nasal air flow and decrease the nasal air resistance.

Lip biting and sucking-Lip biting and lip sucking sometimes appear after forced discontinuation of thumb or finger sucking.-Lip biting most often involves the lower lip that is turned inwards and pressure is exerted on lingual surface of the maxillary anteriors.Effects of lip biting and sucking a. Proclined upper anterior and retroclined lower anteriors.b. Hypertrophic lower lip vermilion border become redundant.c. Cracking of lip.

Management This can be intercepted using lip bumbers.

4-SPACE REGAINING -If a primary molar is lost early and space maintainers are not used, a reduction in arch length by mesial movement of the first molar can be expected.-Space lost can be regained by distal movement of the first molar.-The space regaining procedures are perfectly undertaken at an early age prior to the eruption of second molar.

Space regainer

Fixed space regainer

Removable space regainer

Fixed space regainer:1-Open coil space regainer: A reciprocal active fixed regainer can be used to good advantage in the mandibular arch when the first premolar has erupted in to the oral cavity.

2-Gerber space regainer: -May be fabricated directly in the mouth.-A stainless steel orthodontic band or crown is selected for tooth to be distalised.-Consist of a ‘U’ shaped hollow tubing and a’U’shapedr od that enters the tubing.The tube is soldered or welded on the mesial aspect of first molar to be moved distally.3-Hotz lingual arch:-Appropriate in situation where first permanent molar has drifted mesially but the premolar or cuspid has not drifted distally.-There must be radiographically sufficient space between first molar and developing second molar.4-Sectional arch technique:-Up to 4mm of space can be regained in an effective and efficient manner by this mthod5-Lip bumber/plumber-Most easily used for space regaining in which bilateral movement is desired.

Removable space regainer1-Free end loop space rgainer:-It utlize a labial arch wire for stability and retention with a back-action loop spring constructed of no.0.025.The base made of acrylic resin.-Activated by activating the free end of the wire loop at specific site.2-Split saddle/split block space regainer-Consist of an acrylic block that is split buccolingually and joined by no.0.025 wire in the form of a buccal and lingual loop.-activated by periodic spreading of the loop.

3-Sling shot space regainer -Consist of a wire elastic holder with hooks instead of a wire spring that transmit a force against the molar to be distalised.

4-Jack srew-This will incoperate an expansion screw in the edentulous space is opened by expanding the plate anterio-posteriorly.

5-Muscle exercise The dental tissues are blanked from all directions by muscle .normal occlusal development depends upon the presence of normal orofacial muscle function.Muscle exercise help in improving aberrant muscle function. Uses of muscle exercise

1. To guide the development of occlusion.2. To give the growth pattern an optimal chance to express itself.3. To create an environment for the best possible retention of mechanically

treated casesExercise for masseter muscle An exercise to strengthens the muscle involves the clenching of teeth by patient while counting to ten.The patient is asked to repeat this for some duration of time.

Exercise for lips(circum oral muscle) A number of exercise have been suggested for the cheek muscle1. Stretching of upper lip to maintain lip seal is an important therapeutic

measure in patient having short hypotonic lip.To aid in stretching the patient is asked to hold a piece of paper between the lip.

2. Patient can be asked to stretch the upper lip in a downward direction.3. Massaging of the lip.4. Hold and pumping of water back and forth behind the lip.5. Butten pull exercise.6. Tug of war exercise.

Exercise for the tongue1-One elastic swallow-Used for correction of improper positioning of the tongue -A 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 rugae area and swallow.2-Tongue hold exercise-A 5/16 inch elastics are placed over the tongue in a designated spot for a priscribed period of time with the lips closed.The patient is then asked to swallow with elastic in place and the lip apart.3-Two elastic swallow-Two 5/16 inch elastics are placed over the tongue one in the midline and other on the tip and the patient is asked to swallow with the elastic in position.4-The hold pull exercise-The tip of the tongue and the midpoint are made to contact the palate and the mandible is gradually opened.This exercise helps in stretching the lingual frenum.

6-INTERCEPTION OFOSKELETALMALRELATIONSSkeletalmalrelations if diagnosed at an early age can be intercepted so as

to reduce the severity of malocclusion that may occur.These growth modulation procedures are aimed at normalizing the skeletal relationship.Interception ofclassII malrelations

Class II skeletal malocclusion usually occurs as a result of excessive maxillary growth or deficiency in mandibular growth or combination of both.

Skeletal classII malocclusion Treatment

1- Due to maxillary prognathism - Restrict maxillary growth - using headgears

2-Due to mandibular retrognathism - Myofunctional appliance to promote mandibular growth.

3-Due to mandibular retrognathism - Myofunctional appliance to promote andmaxillary prognathism mandibular growth and head gear to restrict maxillary growth.

Interception of classIII malocclusion Class III malocclusion occurs as a result of mandibular prognathism or maxillary retrognathism or a combination of both.

Skeletal class III malocclusion Treatment

1-Due to mandibular prognathism - Chin cup therapy to restrict mandibular growth.

2-Due to maxillary retrognathism - Myofunctional appliance to promote maxillary growth and face mask therapy.

3-Due to maxillary retrognathism and - Face mask therapy and chin cup Mandibula prognathism therapy

7-REMOVAL OF SOFT TISSUE OR BONY BARRIER TO ENABLE ERUPTION

When ever a permanent tooth fail to fail to erupt the appropriate time its eruption may be stimulated by surgically exposing the crown.

Over retained primary teeth and supernumerary teeth are other possible causes of non eruption of succedaneous teeth which should be ruled out prior to this procedure.

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 such that the greatest diameter of the crown of the tooth is exposed.In other words the surgically created opening in the tissue is slightly larger than the greatest dimension of the tooth.

The surgical wound is given a cement dressing for period of 2 weeks.

COMMON PROBLEMS WHICH CAN BE INTERCEPTEDCrowding

Crowding is a common problem encountered at various stage of development.

WILL CROWDING RESOLVE ITS OWN? Depends on several factors. 1. Interdental spacing.2. Increased intercanine arch width. 3. Inclination of permanent incisor.4. Ratio of size between permanent and primary teeth.

Management:1. Observe2. Disk primary teeth3. Extraction of teeth4. Referal

1-ObservationCrowding in most cases correct themselves with normal dentition and occlusion establishment.Concomitantly if a space analysis coupled with the measurement of intercanine width shows favourable situation the patient should be kept under observation.

2-Disking of primary teeth-Primaryteeth may some times prevent the incisor from aligning themselves if space required is not more than 3-4mm the grinding/disking the mesial surface of the canine will help to align the incisor.-Once space is available teeth may spontaneous correct themselves by tongue pressure.

Extraction of teethInclude –Serial extraction -Timely extraction -Wilkinson’s extraction

Midline Diastema

Midline diastema refers to anterior midline spacing between the two maxillary central incisor

Causes1. Normal developing dentition(Ugly duckling stage)2. Familial incidence3. Parafunctional habits

-Flaccid lip and poor muscle tone -Tongue thrust -Thumb/digit sucking over a prolonged period4. Tooth size discripanciesa) Excessive anterior vertical ovelapb) Excessive vertical maxillary alveolar growth ,retrognathic mandible or

prognathic maxilla5. Abnormal frenum attachment6. Tooth anomalies(super numerary tooth,peglaterals,absence of laterals)7. Pathological(Juvanile periodontitis,cyst ect..)

Treatment:

Done in three phases1. Removal of cause-Use habit breakers-Extraction of unerupted mesiodense-Frenectomy2 . Active treatment Done using -Removable appliance:Incorporation of finger spring or split labial bow-Fixed appliance:Incoperation of elastics or springs3 . Retention-Use retainers such as lingual bondedretainers,bandedretainers,Hawley’sretainer-Use esthetic composite resin

CONCLUSION Normal alignment of tooth not only contributes to the oral health but also goes a long way in the overall well being and personality of an individual.Correct tooth position is an important factor for esthetics, function and for over all preservation or restoration of dental health while most malocclusion may not adversly affect the health of an individual they nevertheless are capable of producing undesirable functional and esthetic imbalance.

Reference

Text book of Pedodontics – SHOBHA TANDON

Orthodontic principles and practice – GRABER

Text book of Orthodontics - BHALAJI

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