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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/117868697/30/2019 j,c early vs late
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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/117868697/30/2019 j,c early vs late
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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
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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.
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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
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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
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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
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Treatment
Psychological therapy
Reminder therapy
Extra oral approaches
Intra oral approaches
Mechanotherapy
Blue glass
Quad helix
Tongue trusting:
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Definition:
Schneider 1982: tongue thrust is forwardplacement of the tongue between the anterior
teeth and against the lower lip during
swallowing
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Tongue trusting:
M ill
- Tipping of the palatal plane-Proclination of maxillary anteriors resulting
i i i j t
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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
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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
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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
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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
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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
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Correction of malocclusion
Treating the primary habit
Appliance therapy
Lip bumper
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C l i
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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
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Interceptive orthodontics
123
C
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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
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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
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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.
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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.
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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
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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
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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
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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
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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
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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
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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
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Indications
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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
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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
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Advantages
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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
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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
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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
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142
Dewels Method:
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CD4
143
Moyer's method
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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
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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
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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
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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
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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
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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
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ACTIVE LINGUAL ARCH
LIP BUMPER
MANDIBULAR PENDEX SPRING APPLIANCE
EXPANSION SCREW APPLIANCE
BONDED LINGUAL ARCH
Mandibular space regainers
150
Gerber space regainer
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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
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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
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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
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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
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Mostly used bilaterally & can also beused unilaterally.
Lip bumper/ plumper
155
Removable appliances
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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.
Removable appliances
156
SLING SHOT REGAINER
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SLIDING YOKE SPACE-
REGAINER
EXPANSION SCREW
157
Crossbites
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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
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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
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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
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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
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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
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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
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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
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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.
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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
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COMPOSITE INCLINES
CAST INCLINED
INCLINED CROWNS
BANDED INCLINE
168
Hawley type appliance with Z-
spring
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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:
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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
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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
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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
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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
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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
Removable appliances
Skeletal crossbite
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Removable appliances
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
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"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
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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)
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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Normal Thumb Sucking.
Abnormal Thumb Sucking
Psychological
Habitual
189
Dentofacial changes associated with
thumb sucking
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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.
190
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.
191
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
192
- 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
193
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.
194
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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.
197
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".
198
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
199
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.
203
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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.
205
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.
206
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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.
208
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.
209
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
210
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
211
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
212
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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
214
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
215
Maxillary midline diastemas
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Most common compliant
Def