ORTHODONTIC TREATMENT PLANNING Dhaval

 

Good morning

 

DR. SOMANI DHAVALKUMAR BAPUJI DENTAL COLLEGE & HOSPITAL

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CONTENTS: DAY 1  INTRODUCTION  STEPS OF TREATMENT PLANNING  EVOLUTION OF TREATMENT PLANNING  ORTHODONTIC TRIAGE  ENVELOP OF DISCREPANCY  ANCHORAGE PLANNING  TREA TREATMENT TMENT PLANNING IN PRIMARY DENTITION 

TREATMENT PLANNING IN EARLY MIXED DENTITION  FOR MINOR & MODERATE PROBLEMS  FOR SEVERE PROBLEMS

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DAY 2  TREA TREATMENT TMENT PLANNING IN LA L ATE MIXED M IXED & EARLY EARLY

PERMANENT DENTITION  FOR PATIENTS WITH DENTAL PROBLEMS

 TREATMENT PLANNING FOR PATIENTS WITH SKELETAL

PROBLEMS  GROWTH MODULA MODULATION TION  ORTHODONTIC CAMOUFLAGE FOR SKELETAL DISCREPANCIES  ORTHOGNA ORTHOGNATHIC THIC SURGERY

 INTERDISCIPLINARY POTOCOLS  PLANNING TREATMENT FOR MAXIMAL ESTHETIC IMPROVEMENT  MACRO-ESTHETIC CONSIDERATIONS  MINI-ESTHETIC CONSIDERATIONS  MICROESTHETIC CONSIDERATIONS CONSIDERATIONS

 CONCLUSION  REFERENCES

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Treatment plan is simply a series of stepwise procedures designed to correct a malrelationships of teeth & associated structures. The task of treatment planning is to synthesize the possible solutions to those specific problems into a specific treatment strategy that is best for the particular patient.

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It is important to keep in mind that diagnosis and treatment planning, though a part of same process are different procedures with fundamentally different goals.

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History Clinical Examination Analysis of diagnostic records

Database

classification

Problem list ( Diagnosis)

Pathology (caries, perio) treat first

Orthodontic (developmental) problems Patient Priority order Possible parent input Evaluate solutions A -------------------- A Interaction Alternate Informed consent plans B----------------------B Compromise C---------------------C Cost-benefit D---------------------D Effectiveness Treatment Plan Treatment Efficiency details plan concept 7

 

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Orthodontic diagnosis is complete when a comprehensive comprehens ive list of the patient’s problems has been developed and pathologic and developmental problems have been separated

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After separating the pathologic and developmental problems, the objective in treatment planning is to design the strategy that a wise and prudent clinician, using his or her best judgment, would employ to address the problems while maximizing benefit to the patient.

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The goal of treatment planning is planning is not a scientific truth, but Wisdom the plan that a wise and prudent clinician would follow to maximize benefit for the patient.

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The answer has shifted over years. From the perspective of the patients, The appearance of teeth and face has always been important.

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In 1920’s Angle’s concept for each individual the ideal facial  facial  esthetics would esthetics  would result when teeth were placed into ideal occlusion whether the patient liked it or not. Edward Hartley Angle   (1855-1930)

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For over 100 years orthodontic theory and practice has been based on Angle paradigm. This model has been based on a belief that assumes Nature intends for all adults to have a perfectly aligned dental arches each containing 16 teeth ◦

that mesh in teethshould in opposing jawideal articulation with the

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When this natural dentitional state occurs, the face also should be in perfect harmony and balance and the stomatognathic system should function ideally

 

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Angles concepts were based on those of Bonwill  (a 19th century dentist in Philadelphia Bonwill during the time that Angle was a student there.) He theorized that nature nature  ordained the dental arches and articulation of the teeth to be in perfect alignment, harmony and function.

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Non Extraction

Extraction

MARTIN DEWEY

CALVIN CASE

Angles followers won that day but current perspective leaves the impression that Calvin Case  Case  had the better argument.

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In 1960’s & 70’s   Orthodontic treatment was often recommended to prevent periodontal diseases.

   This rationale was weakened when research revealed that alignment & occlusion were much less important in determining the susceptibility to periodontal problems than the nature of bacterial flora & the competence of patients immune system.

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In 1970’s & 80’s   Orthodontic therapy was frequently recommended to prevent or cure ‘TMD’ but no strong evidence exists that poor occlusion is primary etiologic agent in temporomandibular dysfunction

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Today (21st Century) Therefore the focus has returned to what has probably always been the primary reason, patient seek orthodontic treatment. Easing the psychological problems created problems created by crooked teeth & poor facial proportions & achieving benefits to well being through improved dental & facial esthetics

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A paradigm can be defined as “ a set of shared beliefs and assumptions that represents the conceptual foundation of an area of science or clinical practice” As the clinician increasingly now accept the new paradigm, which states that both the goals and limitation of orthodontic treatment are established more by soft tissue considerations than skeletal/dental relationships, treatment planning is inevitably affected

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The primary goal of the treatment becomes soft tissue relationships and adaptation, not Angle’s ideal occlusion. The thought process that goes into “solving the patient’s problems” is reversed. In the past ,the clinician’s focus was on dental and skeletal relationshi relationships. ps. With the broader focus on facial and oral soft tissues, the thought process is to establish what these soft tissue relationship should be, and then determine how the teeth and jaws would have to be arranged to meet the soft tissue goal

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DISTINGUISHING MODERATE FROM SEVERE PROBLEMS

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This process was used in military and military  and emergency medicine. Triage was used to separate casualities by the severity of their injuries.

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Its purpose was to separate the patients who injury,, from can be treated at the scene of injury transportation  to specialized those who need transportation facilities and to develop a sequence for handling patients. So that those most likely to benefit from immediate treatment will be treated first.

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Triage is important for primary care dentist to distinguish moderate from severe problems so problems so as to determine which patients are appropriately treated within general dental practice and which are most appropriately referred to a specialist in orthodontics.

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3.

Syndromes and developmental abnormalities Facial disproportions and asymmetries Facial profile analysis Antero-posterior and vertical problems Excessive dental Protrusion or Retrusion Problems involving Dental development

4. 5.

Space problemsdiscrepancies Other occlusal

1.

  2.

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STEP 1 UNUSUAL FACIAL APPEARANCE ANALYSIS OF FULL FACE PROPORTIONS

TRUE FACIAL ASYMMETRY

CRANIOFACIAL DEFORMITY OR SYNDROMES

COMPLETE EVALUATION BY SPECIAL TEAM WITH MEDICAL CONSULT

 HISTORY OF TRAUMA •EXCESS OR DEFICIENT GROWTH •

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ANTEROPOSTERIOR AND VERTICAL PROBLEMS  Skeletal class II and class III problems and vertical deformities regardless of their cause

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are considered as severe problems.  Before puberty the treatment for these patients should be aimed at modifying the jaw growth.

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After puberty amount of growth remaining is usually  insufficient to allow correction. usually  Then the treatment plan must distinguish  distinguish   

between the possibility of camouflage camouflage  of jaw discrepancy and surgical surgical  repositioning of the  jaw.

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STEP 2 SYMMETRIC FACE FACIAL PROFILE ANALYSIS

A-P OR VERTICAL JAW DISCREPANCIES

GROWTH MODIFICATION CAMOUFLAGE SURGERY

EXCESSIVE PROTRUSION OR RETRUSION OF INCISORS

 EXTRACTION

•

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GOOD FACIAL PROPORTION Review intra oral radiograph for abnormalities abnormaliti es of dental development

1. ABN ABNORM ORMAL AL SEQ SEQUENC UENCE E OF DENTA DENTAL L DEVELOPMENT 2. MISS MISSING ING PERMA PERMANENT NENT TEETH TEETH 3. SUP SUPERNU ERNUMERA MERARY RY TEETH TEETH 4. ECTOPIC ERUPTION ERUPTION & ANKYLOSED ANKYLOSED TEE TEETH TH

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SEVERE PROBLEMS

MONITOR: SELECTIVE EXTRACTION

ASYMMETRIC SEQUENCE OF PATTERN OF DENTAL DEVELOPMENT

Retained primary ? Prosthetic replacement? Extract, allow permanent teeth to drift? Extact, orthodontic space closure?

MISSING PERMANENT TEETH

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SEVERE PROBLEMS

Combined surgical – orthodontic treatment

Extract supernumerary Reposition other teeth

ANKYLOSED PERMANENT TEETH

SUPERNUMERARY TEETH (complicated by position or number)

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MODERATE PROBLEMS SINGLE SUPERNUMERARY TEETH (with uncomplicated position)

RETAINED OR ANKYLOSED PRIMARY TEETH

ECTOPIC ERUPTION

EXTACT SUPERNUMERARY TEETH

MONITOR: EXTRACTION AND SPACE MAINTAINANCE

MONITOR: REPOSITION EXTRACTION SPACE REGAINING

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For a child with good facial proportions who have any type of orthodontic problem, regardless of whether crowding is apparent, the result of space analysis is essential for planning treatment.

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it should be kept in mind that if the space to align the teeth is inadequate either of the 2 conditions may develop :

1. one

possibility is that incisor teeth remain upright and upright  and well positioned over the basal bone & then rotate , or tip labially or lingually.

  In such cases potential crowding crowding is  is expressed as actual crowding crowding &  & is often difficult to miss. miss.

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2. The

other possibility, is for the crowded teeth teeth   to align themselves completely or partially on

the expense of the lip, lip, displacing it forwards, interfering with lip closure

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On basis of space analysis results, children results, children in mixed dentition who do not have incisor protrusion can be divided into 3 groups

1.

Those with adequate space Those with space deficiency (not more than 3-4 mm) Those with localized or generalized space deficiency (more than 4mm)

2.

3.

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MODERATE PROBLEMS THOSE WITH ADEQUATE SPACE -MISSING PRIMARY CANINE OR MOLAR

SPACE DEFICIENCY NOT MORE THAN 4mm

SPACE MAINTENANCE MAINTENANCE

- Reduce width of primary teeth - Space regaining or - Arch expansion

 - Loss of primary molar & drift of permanent or primary teeth.  - A generalized tooth size-arch length problem usually manifested as incisor crowding

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SEVERE PROBLEMS

EXPANSION EXTRACTION

- SPACE DEFICIENCY GREATER THAN 4 MM IN EACH ARCH OR - INCISOR PROTRUSION WITH SMALLER SPACE DISCREPANCIES DISCREPANCIES..

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Posterior crossbite Anterior crossbite Anterior openbite and deepbite

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A skeletal posterior crossbite, revealed by a narrow palatal vault is vault is categorized as severe problem,

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dental crossbite crossbite falls  falls infactors moderate no other complicating like problem severe (if crowding are present). Treatment Planning◦

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Skeletal suture crossbite = opening the mid palatal Dental crossbite = tip the teeth outward into proper position

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SEVERE PROBLEM

MODERATE PROBLEM

POSTERIOR CROSSBITE

SKELETAL TREATMENT PLANNING

opening the mid palatal suture

DENTAL TREATMENT PLANNING

TIP THE TEETH INTO PROPER POSITION

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Anterior cross bite usually reflects a jaw discrepancy but can arise by lingual tipping of the incisors as they erupt.  Removable

appliances can be used to correct such problems.

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Anterior open bite in a young child with good treatment,   facial proportions usually needs no treatment, because there is good chance of spontaneous correction . (moderate problems)

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A complex open bite ( one with skeletal involvement) or any open bite inep anbite olderat all patient is severe problem, as de deep ages .

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The treatment modalities that are feasible for patients are determined by the nature and severity of the orthodontic problem.

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These two factors can be visualized by considering an envelop of discrepancy based on degree of disparity in occlusal relationships For any characteristic of malocclusion ,three ranges of correction exist

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1.

2.

3.

An amount that can be accomplished by tooth movement alone A larger amount that can be achieved by tooth movement plus functional or orthopedic treatment A still larger amount that requires surgery

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4

2

7 2

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6

5

12

5

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10

10

15

15 54  

4  3 5

2

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6

5 10

5

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10

12

25

15 57  

10

3 2

Palatal

7

4

3

3 4

10

  4 2 3

Buccal

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10

4 3 Lingual

5 4

  1 2 3

2 2 4

10

Buccal

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These numbers are merely guidelines and may underestimate or overestimate the possibilities for any given patients However they help place the potential of the three major treatment modalities in perspective.

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Anchorage is defined by Webster as Webster as a   “Secure hold sufficient to resist a heavy pull.”  •

T.M. Graber : “The nature and degree of resistance to displacement offered by an anatomic unit when 

used for the purpose of effecting tooth t ooth movement.”

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According to Nanda, based on treatment approach, anchorage is classified in to three t hree types

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Anchorage control should be considered in three planes :   Horizontally, Vertically and Transversely.   Horizontally, anchorage control is used to

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achieve a correct antero-posterior position of the teeth in the profile at the end of the treatment.

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  Vertically, anchorage control involves the need to try to influence vertical skeletal and dental development in the posterior segme segments nts and sometimes to limit vertical eruption of anterior segments or even intrude these segments.

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  Transvers Transversely, ely, anchorage control involves maintenance of expansion procedures, procedures, primarily in the maxillary arches and the avoidance of tipping and extrusion of the posterior teeth during any expansion phase.

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Anchorage control is both more difficult and more critical. With only the first molars available as anchorage in posterior segment of the arch, there are limits to the amount of tooth movement that should be attempted in the mixed dentition. Stabilizing arches are more likely to be necessary as an adjunct to anchorage.

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In adults -  -  The orthodontic mechanics may need to be modified.   

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 In young patients, the choice between intrusion and extrusion to correct a deep bite and level an excessive curve of spee often can be resolved in favour of extrusion, because vertical growth will compensate for it. In adults the choice often must be intrusion ideally obtained by segmented arch mechanics.

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Anchorage is difficult to obtain if the posterior teeth are periodontally compromised and very light forces have to be applied. In periodontally compromised compromised patients, anchorage requirement requirement is more and can be reinforced with the help of lingual arches.  It may be necessary to use two-step space closure with frictionless mechanics to reduce the strain on anchorage and to keep forces light.

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Long face syndrome is among the most difficult problems encountered encountered in the practice of orthodontics.

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Unless orthodontic treatments are carefully monitored and controlled, patients with long face syndrome risk developing even more severe

 

characteristics of the syndrome.

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Long face syndrome can be controlled by Minimising the ex trusion of posterior teeth, particularly maxillary molars.    The Masticatory muscles restrict the posterior mandibular teeth more than their maxillary counterparts.  The thin cortical and trabecular bone of maxilla provide less resistance to movement than the thick cortical, more dense trabeculae of the mandible.

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Anchorage enhancement   

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 Is another way that way that maxillary  maxillary molar extrusion can be prevented. Transp alatal arches  can be used. When a patient talks or swallows ,the

tongue exerts a palatally directed force against the loop.   This in turn, helps to overcome the extrusive force of most orthodontic mechanics. The more a patient exhibits the characteristics of long face syndrome ,the more critical is the need to use a TPA.

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  High-pull headgear prevents maxillary molar

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extrusion even more effectively than a transpalatal arch.  It is also used for class II correction. The restriction of the maxillary molar eruption allows the mandible to rotate into a more forward position as it grows. It maximises the horizontal expression of mandibular growth

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Bonded 

ME

  The posterior occlusal coverage of the acrylic acts as posterior bite block, inhibiting the eruption of the posterior teeth during treatment and making possible the use of this appliance with long facial heights.

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Interaction between sagittal and vertical components of anchorage. 

  Most concepts of anchorage focus only on sagittal relationship.

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  Even minor extrusion of posterior teeth results in a posterior rotation of mandible.

Vertical chan ges occu ri ring ng in the m olar region du ri ring ng treatm ent influence influence the sagittal relationship significantly .

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established in   Anchorage requirements m ust be established each clinical situations.   In criti critical cal case s  einforcement -.

  This typically involves including as many teeth as possible in the anchorage unit. For significant differential tooth movements, the ratio of PDL area in the anchorage unit to PDL area in the active unit should be atleast 2:1 without friction, 4:1 with it.

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Reinforcement in the form of Transpalatal arch, Lingual arch and Nance palatal arch.   Implants 

   

tip back bends in arch wire v- bends in arch wire

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Reinforcement may also include forces derived from structures outside the mouth. mouth. The reaction forces are dissipated against the bones of the cranial vault, thus adding the resistance of these structures to the anchorage unit.

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Treatment during primary dentition offers the advantage of rapid change in skeletal and dental structures because of relatively rapid growth and because at that age ,even moderate effective. biomechanical forces are quite

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The primary objective of managing orthodontic problems in the primary dentition is to intercept or correct malocclusions that would otherwise be maintained or become progressively more

complex in the permanent dentition. 80  

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By identifying and treating certain problems at an early age it is often possible either to prevent more serious orthodontic problems from developing or to redirect skeletal occlusal relationship. relationship.

growth

and

improve

the

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In a normal primary dentition especially 5-6 normal  yrs of age spacing  spacing between incisors is normal  and in fact is necessary if permanent incisors are to be properly aligned when they erupt

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If the primary incisors contact each other proximally one can confidently predict that permanent incisors will be crowded & irregular irregular..

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Crowding in primary dentition is rare, when Crowding in observed extremely  extremely severe crowding will this is observed be present later in permanent dentition.

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If a child looses primary teeth prematurely because of caries or trauma, there can be impact on the position of permanent teeth when they erupt, & crowding or mal-alignment may occur. Treatment planning guidelines for very early loss of a primary tooth are as follows:1. Loss of primary incisor 2. Loss of primary canine 3. Loss of primary molar

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In most of the children, spaces are present between the primary incisors, & the early loss of an incisor will cause little if any change in the dentition.

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Therefore space maintenance maintenance is  is not necessary, on the other hand, prosthetic replacement replacement  for esthetics reasons may reasons may need to be considered especially since the eruption of tooth permanent teeth will be delayed if primary is lost at an early age

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When the primary canine is lost, the incisor laterally into  into this space, teeth tend to shift  shift laterally creating a midline deviation and dental asymmetry. This tendency is accelerated at the time the permanent incisors begin to erupt, fortunately these teeth are infrequently lost due to caries or trauma.

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It is usually not necessary to institute space maintenance during primary dentition but it may be desirable to intervene at the time permanent incisors begin to erupt.

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Due to the early loss of primary first molar mandible, a  a lateral and posterior particularly in mandible, shift of the incisors may lead to development of asymmetry asymmetry within  within the arch Space maintenance in primary dentition should be considered for prematurely lost primary first molar.

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The primary 2nd molar not only reserves the space for the permanent 2nd premolar but its distal root also guides the erupting permanent first molar into molar into position. If the primary 2nd molar is lost prematurely, the permanent 1st molar will usually migrate mesially within mesially  within the bone even before it emerges into the oral cavity

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A space maintaining device is needed that will both guide eruption of permanent 1st molar before its emergence & then hold the 1st molar in proper position after occlusion is established.

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A distal shoe usually is indicated in such situation.

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Sucking habits often persists throughout the primary dentition, & may cause displacement of incisors, typically forwards in the upper arch and backwards in the lower arch. This incisor displacement is usually self corrective if the habit stops before the permanent teeth erupts.

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 Anterior cross bite occasionally occurs in primary dentition because of incisor interference that cause an anterior shift of the mandible. If it occurs it should be corrected, usually this correction can be made by removing the interference. Either by occlusal grinding or extracting the primary incisor if it is already near

exfoliation 92  

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Transverse problems usually manifests as posterior cross bites from a narrow upper upper  arch arch,, are relatively common in primary dentition.  Sucking habits habits tend  tend to produce some constriction of the upper arch, particularly in the canine region and occlusal interference may then lead to a functional shift of the mandible anteriorly and laterally

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 A unilateral crossbite almost always result, not from a true skeletal or dental asymmetry, but from a symmetricall symmetrically y narrow maxilla with a functional shift. If both molar & canine widths are narrow, arch is indicated expansion of the upper arch is

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Primary molar relationships are classified according to the relationship of the distal surface of upper and lower second primary molars:a) Flush terminal plane – plane – is the normal relationship b) Distal step step –  – here the lower molars are distally positioned relative to upper molar step  - here the lower molar is c) Mesial step mesially positioned relative to upper molar.

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lush terminal

Distal step

Mesial step

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Although the mesial step relationship corresponds to class I molar relationship in permanent dentition, but its presence at an early age indicates the possibility of excessive mandibular development. A distal step corresponds to skeletal class II relationship,, which in most children with relationship mandibular deficiency can be recognized at the age of 3 yrs.

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Both deep bite and open bite malocclusion occur in primary dentition.

– it is usually associated with Deep bite – it skeletal proportions that predispose to this condition ◦

◦

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 A relatively short face  Square gonial angle  Flat mandibular plane

98  

Open bite –is –is often seen in children who have good skeletal proportions but sucking habits. ◦

If the skeletal proportions are good, there is strong tendency for open bite to correct spontaneously spontaneous ly when the sucking habits ends.

◦

Upto 5 yrs. sucking habits are unlikely causeage anyof long term problem in children with to good skeletal proportions.

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It is also possible that an open bite results discrepancy of  of the long from a skeletal jaw discrepancy face type characterized by◦ ◦

Increased lower anterior face height Increased gonial angle

spontaneous correction correction of such open bite is not likely to occur . – not required Treatment –    - Results not stable

 

- Lot of growth is remaining 100

 

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In primary dentition malposed, crowded, and irregular incisors are uncommon.

  But the absence of spaces between the primary incisors often indicates that there will be crowding when permanent incisors erupt.   No treatment is indicated until indicated until the mixed

dentition. 101  

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Posterior cross bites, particularly those with a lateral shift of the mandible upon mandible upon closure, should be treated in primary dentition, either by occlusal adjustment or by maxillary expansion.

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An anterior cross bite caused by forward mandibular shift should shift should also be treated early.

102  

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Although Skeletal anteroposterior anteroposterior & Vertical problems can be detected in primary dentition, indications of treatment at that time are rare.

103  

MASTER ASHNITH. S. 4YRS c/c- Backwardly placed upper front teeth

Pre Treatment  

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Removable appliance T-spring with Bite block post.

 

Post Treatment  

Moderate problems Severe problems

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107  

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 These consists entirely of dental problems  problems  resulting fromproblems misplaced teeth, (with skeletal & permanent severe crowding problems excluded).

108  

Missing primary teeth with adequate space:  space maintenance 

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If the primary 1st or nd molar molar is  is missing & if there will be more than 6 months delay before premolars erupt, & there is adequate space (no space loss) maintenance is  is required -Space maintenance Either fixed or removable appliance can be

used depending on patients co-operation. co-operation . 109  

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Early loss of a single primary canine  canine in mixed maintenance or  or dentition requires space maintenance tooth to  to eliminate extraction of the contra lateral tooth the midline changes & development of arch symmetry.

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 If the contra lateral canine is extracted, a lingual arch space arch  space maintainer may still be needed to prevent lingual movement of incisors.

110  

Localized space loss (3mm or less) Space regaining:-  regaining:-  

Potential space problems can created by drift of permanent incisors or be molars after  after molars premature extraction of primary canines or molars. 

In such cases lost space can be regained and maintained

111  

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Space regaining is most likely to be needed when primary maxillary or mandibular 2nd molars have been lost prematurely. The permanent 1st molar usually migrates mesially quite rapidly when primary 2nd molar has been lost & in extreme cases may totally close the primary 2nd molar extraction space.

112  

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According to proffit if the primary molar has been lost prematurely in a single quadrant, up tto o 3mm regained by  by tipping the molar back of space can be regained distally.

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Space within the dental arch can also be lost after premature loss of canine. In such circumstances mesial drift of the posterior teeth is rare but the arch length shortens as incisor teeth drift distally

113  

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Loss of one or both primary canines occur because of root resorption , caused by erupting lateral incisors without sufficient space & space  & thereby indicates a generalized crowding problem

114  

 Generalized Moderate Crowding Space Management:Management:A child with a generalized arch length discrepancy up to 4mm and no prematurely missing teeth can be expected to have moderately crowded incisors.

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These patients usually require - Reduce width of primary teeth   - Selectively extract primary teeth - Arch expansion

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Spaced and flared maxillary incisorsIn a child with spaced & flared or irregular 

maxillary incisors, good molar relationship, relationship , good who facialhas proportions, the space analysis should show that the space available is excessive rather than deficient.

116  

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If the upper incisors are flared & there is no contact with lower incisors the protruding upper incisors can be retracted quite satisfactorily satisfactori ly with a simple removable (The presence or absence of excessive appliance. overbite,, must be evaluated) overbite

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This condition often is found in the mixed dentition after prolonged thumb sucking and frequently occurs in connection with some narrowing of the maxillary arch.

117  

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A thumb orbefore finger attempting sucking habit should the be eliminated to retract incisors Physiologic adaptation to adaptation to the space between the anterior requires that be placed in teeth this area to seal offthe thetongue gap forto successful swallowing & speech. This tongue thrust is not the cause of the protrusion or open bite and should not be the focus of therapy. If the teeth are retracted the tongue thrust will disappear.

118  

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On the other hand , if there is a deep overbite anteriorly, the anteriorly,  the protruding upper incisor teeth cannot be retracted until it is corrected.

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The lower incisors biting the lingual of upper prevents them fromagainst moving lingually. 

 A fixed appliance therapy which controls the vertical position of both the upper & lower teeth is necessary to correct this combination of protrusion & deep overbite

119  

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Small spaces between the maxillary incisors are normal, before eruption of maxillary canines. (ugly duckling stage) If the space is greater than 2mm however 2mm however spontaneous closure is unlikely. Persistent spacing between the incisors is process  correlated with cleft in the alveolar process  between the incisors, to which fibres from maxillary labial frenum insert.

120  

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For larger diastema it may be necessary to surgically remove the frenal attachment to attachment to  . obtain a stable closure of diastema The best approach is to do nothing until the permanent canine erupts, if erupts, if the space does not close spontaneously by that time – an appliance can be used to move the teeth together , & then a frenectomy should be considered.

121  

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Crossbite of all the incisors is rarely found in children who do not have class III relationship. A cross bite relation of 1 or 2 anterior teeth may develop in a child with good facial proportions.

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The maxillary lateral incisor tend to erupt to the lingual & may be trapped in that location specially location  specially in presence of severe crowding.  In this situation, extracting the adjacent primary canines canines usually  usually leads to bite. spontaneous correction of cross Lingually positioned incisors limit lateral jaw movements so early correction of the

crossbite is indicated. 123  

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Posterior cross bite in mixed dentition children usually result from narrowing of the maxillary arch  arch & is often observed in children who have prolonged sucking habits. Both removable & fixed appliances can be used for correction.

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According to proffitarch Whichever method over is used the maxillary should be expanded & then held passively passively   in this position for approximately 3 months before appliance is removed.

before appliance is removed. 124  

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A simple anterior open bite is one that is limited to the anterior region in a child with good Major facial causeproportions. of such an open bite is prolonged thumb sucking & sucking & most important step in obtaining correction is to stop sucking habits if they are present.

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Preferred method is a maxillary lingual arch with an anterior crib device.

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It should be left in place for 3 – 6 months  months   after the habit has apparently been eliminated.

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The eruption of permanent tooth can be delayed if its predecessor is retained too long.

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This usually happens if the permanent tooth bud is displaced. displaced.    General guideline:  A permanent tooth should erupt when 

approximately ¾ of it’s root formation is completed.

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If a primary tooth is lost prematurely   A layer of relatively dense bone & soft tissue may form over the unerupted permanent tooth this usually delays eruption of permanent tooth.  

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Ectopic Eruption Ectopic eruption can be broadly defined as the emergence of a tooth in a site different from its normal location, in all three planes of space. Maxillary 1st molar:The most common site is the maxillary molar

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region, where the second blocks the first permanent molar andprimary suffers molar root resorption in the process.

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Treatment optionsIf a limited amount of movement is needed but little or none of the permanent first molar is visible clinically, a 20 mil brass wire looped and tightened around the contact between the primary second molar and the permanent molar is suggested If E is symptomatic/mobile symptomatic/mobile consider extraction of E followed by space regaining and then space maintainer 

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Maxillary canineEctopic eruption of maxillary canines occurs relatively frequently and can lead to either or both of two problems   (1) Impaction of the canine and/or   (2) Resorption of permanent lateral incisor roots. 

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Treatment optionsWhen mesial inclination of the erupting permanent canine is detected and no incisor root resorption is noted, the treatment of choice is to extract the

overlying primary canine 131  

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The beginning of resorption of the t he permanent incisor roots indicates a severe problem with canine position. Extraction of the primary canine and surgically expose the permanent canine and use orthodontic force to bring it to t o its correct position.

This comprehensive treatment will extend into the

early permanent dentition period 132  

 

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Severe problems in mixed dentition falls into 3 major categories: Dentofacial

problems related to incisor i ncisor

protrusion.  Space discrepancy of 5mm or more. 

 Skeletal jaw discrepancy.

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Excessive protrusion of incisors (bimaxillary protrusion, not excessive overjet) is usually an indication for premolar extraction and retraction of the protruding incisors.  Because of the profile changes produced by adolescent growth, it is better for most children to defer extraction to correct protrusion until late in the mixed dentition or early in the permanent dentition.

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Larger the space discrepancy, the greater the chance that extraction of some teeth will be necessary to align the remaining ones. As a general guideline:Up to 4 mm – without extraction. 5-9 mm range = best treated without ◦

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extraction, but may require extraction of teeth 10 mm or greater = always require extraction

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 Sequential Sequential removal  removal of deciduous teeth to facilitate the unimpeded eruption of permanent teeth. Selective extraction of deciduous & permanent teeth, reduces the severity of malocclusion .

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In its classical form serial extraction applies to patients who meet following criteria:-

  1) No skeletal disproportions. disproportions.   2) Class I molar relations.   3) Normal overbite.   4) Large arch perimeter deficiency (10mm).

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According to proffit It has 4 steps:Extraction of primary lateral incisor incisor as  as 1. permanent central incisors erupt. (if necessary, since this often happens spontaneously in severely crowded cases) canines as  as the lateral 2. Extraction of primary canines erupts. 3. Extraction of primary 1st molar  molar usually  usually 6 -12 months before their normal exfoliation. 4.  premolars before  before Extraction of permanent 1st premolars

eruption of permanent canines.

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1. 

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Dewel`s method  CD4 2. Tweed`s method

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D4C 

3. Nance`s method

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 D4C 140

 

 Dewel’s method 

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IF THE SPACE DISCREPANCY IS SMALL  SMALL    Simplified treatment. 

 Fixed appliance residual spaces. therapy required to close IF THE SPACE DISCREPANCY IS LARGE Serial extraction causes total space closure. 

Fixed appliance is used just to achieve good alignment, root paralleling.

142