UNIVERSITY OF GLASGOW Interceptive orthodontics Personal notes Mohammed Almuzian W/1/2013Contents Definition. Need for 10... General Aims of Interceptive Orthodontics. ‘Timing... Iniereeptive orthodontics targets the follow ing orthodontic problems... Spacing and Crowding Definition. Type of Crowding, 1, Primary crowding 2 Secondary etowding. 3. Tertiary or “te kewer ine isor crowding” Danwei a Bb Management of crowding in developing dentition Blective extraction . Hiective extraction of deviiduous eanities........ Elective extraction of all 6s. inson., 1940) Elective extraction of the second molars. Wilkinson criteria ( Disadvantages Eletive extraction of the premolars Serial extraction corse Steps of serial extraction. Indivations:..... BB beosesosmeevuwi Autvaitages of Serial Extractions .. Disadvantages of Serial Extractions Modified serial extraction........ Space maintainer... Advantages. Disadvantages Tiiclications. Contraindication ... ‘Fechniques Space regaining Techinkjue Mohammed Aimuzian, University of Glasgow, 2013 Page 1Management of Lee way space. Balance and compensatory extraction. Early boss of primary teeth, RCSEng guidelines and Recommendations... Forced extraction in poor prognosis 65 ...sscsssssesessestiestiesisstessnatssttinsinesiestinssnesssseies 1S Guide lines for forced fist molar extraction (RCSEng, By Cobourne 2009) with minimal erowding (3mm) . with erowdin Class II case with crowding. Abnormality in tooth position . SIGN recommendations (Yaqoob et al 2010):,.. Ectopic canine Methods. Impacted 68 snore Treatment options, KEAROIOS?. 10 treatment Treatment to disimpact the molars, ‘Treatment to regain space following early loss of E: Kurol and Bjerklin 1987... Asymmetric Dental Development... Prolong retention of primary teeth or Overretained Primary Teeth. Local factors... Enamel defects Maxillary midline diastema Abnormality in teeth shape, form & size... Treatment. Abnormality in teeth number Supernumerary teeth Treatment, Indications for Monitoring. Indications for removal... Hypodontia. Mohammed Almuzian, University of Glasgow, 2013, Page 2‘Treditment options ... Traymaticloss of incisors.. Management 31 Displacements & crossbites, ‘Atmetior CTOSSbIRES siutecntnestnitnetsstannnniueennaicnssiatiietnttconanies BD Crossbite with Displacement. Habits... Prevention of digit-sucking habits, BOS guide lines 2000. ‘Trentment of dight-sucking habits, BOS guidelines 2000 Increased and decreased Overjet.... Tixdications for 10 teeatmeit of tereased OF tearly treatment of CLI peablemns) 1. Class Il females witha significa skeletal discrepancy, 2. Aminereased overjet, whieh is a source of tasing and bullying... 35 3. An inofeased overjet, which & at isk of trouima (often associated with gross lip incompetence and marked maxillary protrusion 38 3B Advantages of early treatment... Disadvantages of early treatment Evidences of poor outcome of catly treatment versus late treatment... Aidvatitages of late IO for increase 0) .. Early troatment of Class II Time Method... Tiidication Problems... Richardson, 1999; sereening for 10. A BiG da sssassagavitin DOME 6S Ss SF SRBsE ese Bw Mohammed Almuzian, University of Glasgow, 2013 Page 3Interceptive orthodontics Definition + PRGRQRAGACKEARERTGIDRO VE defined it as the treatment carried out to reduce the need for further treatment. * Any treatment which eliminates orreduces the severity ofa developing malocclusion in order to eliminate or simplify the need for future treatment Need for 10 . 15% of developing malocchisions can be fully corrected in primary / mixed dentitions with relatively simple means. |AGKEAainin) SP FOM§1980 in 3 community patients assessed as in need of IO, Only 20% of these underwent 10, (SU SiTSER ICH 2000 . 10 Particularly useful in following patient group: we © Medically compromised © Physically or mentally retarded, * Children with cleft of lip/palate. © Poorco-operators patients. General Aims of Interceptive Orthodontics 1. Minimize psychological implications like teasing. Prevent trauma. Prevent the occurrence of dental pathology 4. Eliminate crossbites associated with displacement. s Minimize crowding. 6 Maintain Class | incisor relationship. 7. Maintain centrelines. Mohammed Almuzian, University of Glasgow, 2013, Page 4Timing rhe most suitable ages for screening the child population for interceptive orthodomos 9 ear a1 Yeas (ALNinil 8 Richins 2000) © The Interception Gauge is useful in categorizing children in respect of features of the dentition which are quantifiable. Interceptive orthodontics targets the following orthodontic problems 1. Crowding management * Elective extraction of C, 4, 6 or 7s © Serial extraction * Modified serial extraction 2. Space management © Space maintainer * Space regaining * Management of Lee way space (should be called D and E space and not include C because we loss space with C) 3, Balance and compensatory extraction © in primary teeth due to carly loss ofprimary teeth * Forced extraction in poorprognosis 6s 4, Abnormality in tooth position and eruption © Infra-oeclusion Impacted incisors © Ectopic canine © Impacted 6s « Asymmetric dental development © Prolong retention of primary teeth Mohammed Almuzian, University of Glasgow, 2013 Page 5. 5. Local factors * chamel defects * Maxillary midline diastema and labial frenum: Abnormality in teeth shape, form & size © Abnormality in teeth number Supernumerary teeth Hypodontia Traumatic loss of incisors. 6. Displacements & crossbites © Anterior crossbites © Posterior crossbite with Displacement 7. Habits 8. Increased and decreased overjet Spacing and Crowding Definition As faulty relationship bet MD of teeth, jaw size and arch perimeter. Jaw size determine the available space for teeth apices, arch perimeter determine the available space for teeth crown while MD falls in between them. Richardson) Type of Crowding Crowding can be categorized into three distinctively different types according to aetiology. |. Primary crowding refers to tooth size and arch size discrepancy, with this ratio being more often increased (causing crowding) than reduced (which results in spacing), and this is genetically determined. Mohammed Almuzian, University of Glasgow, 2013 Page 62. Secondary crowding is caused by premature loss of primary molars, which is environmental in origin. 3. Tertiary or ‘late lower incisor crowding’ is a phenomenon that has both genetic and environmental contributions, the main determinant being differential late jaw growth. Management of crowding in developing dentition Elective extraction Eleetive extraction of deciduous canines . Extraction of lower deciduous canines has been suggested forthe correction ofmild lower incisor crowding. Houston and Tulley (1989) state that in general terms this allows some correction of the incisor crowding. Stephens (1989), reported that the ideal age group for this would be 9-10 years of age to allow full development of the intercanine width. Proffit (1993) however wams that this may result in the lower incisors tipping lingually further redueing arch length, 2. Provide space for palatalty lateral incisors. 3. Provide space for in ors whose eruption is lite dtie to superriumeries 4. Extraction of upper deciduous canines is ofien suggested in order to attempt to encourage a palatally placed canine to erupt into a normal position, Research has shown that this indeed is quite successful with 70% erupting into favourable positions (Ericsson and Kurol, 1988). 5. Extraction of lower C's may help in treatment mandibular displacement, 6. Serial extraction 7. Balance extraction for maintaining ML integrity Mohammed Almuzian, University of Glasgow, 2013 Page7Elective extraction of all 6's Wilkinson eriteria (Wilkinson, 1940) . All suecessional teeth present and third molars present 2. Lower second molar bifurcation beginning to form. 3. Angle between long axis of crypts of 6 and 7 = 15-30 degree and eryptof lower 7 overlaps the rootof lower 6, 4. Class 1 5. Mild anterior segment crowding 6, Moderate posterior crowding Elective extraction of the second molars |. Relief of premolar crowding in a vertically impacted premolar in the line of the arch where early extraction indicated for spontaneous correction. Richardson 1992 2, Provide space for the third molars, Richardson 1983 3. Interceptive treatment of the existing or anticipated arch length deficiency. Extraction in early permanent dentition may prevent or at least limit late lower arch crowding. Richardson 1983. Requirements for second molar prophylactic extraction (Lehman, 1979): «All third molars are present and of normal size and shape. © Third molars should be of 15 — 30 degrees with the long axis of the first molar and its root not developed yet. Disadvantages 1, 36 molars may erupt into an unsatisfactory position, rarely with proper angulation and contact relationship in 4% Richardson and Richardson (1993) Mohammed Almuzian, University of Glasgow, 2013, Page 82. Difficult to predict which 34 molars will erupt unsatisfactory (Thomas and Sandy, 1995), 3. Second course of treatment to orthodontically upright the 3" molar may be required (Orton and Jones, 1987). Elective extractionof the premolars 1. Early loss of 4's with mesially inclined 3°s can spontaneously improve certain maloechusions and can reduce time with active appliances. 2. Extraction of 4°s with space maintenance can allow impacted 5’s to erupt. Serial extraction Popularised in Europe in the 1930's and recorded by RiSISRERIGST, the carly philosophy behind serial extractions was to attempt to align severely crowded teeth without further need for treatment. Steps of serial extraction * Relieve of crowding. in the lower incisor region by extraction of upper and lower c’s © Extraction of D's when half their roots are resorbed to fasten eruption of the first permanent premolars. This is iran attempt to encourage early eruption of particularly 4s that it erupts before 3s. If extracted too carly this may delay eruption and cause excessive space loss. There is no guarantee that the lower premolar will erupt before the canine and as such the latter may be impacted. If this occurs extraction of the second deciduous molars may be an option with Holtz (1970) advocating the provision of a lingual arch retainer for space maintenance. The latter author also recommends disking of the second deciduous molars to provide space for premolar teeth * Extraction of 4s on cruption to allow alignment of 3s. Mohammed Almuzian, University of Glasgow, 2013 Page9y Pp Indications: Sever crowding in: 8-9 yrs old skeletal Class 1 normal OJ and OB 4's developmentally ahead of 3's First permanent molars of good prognosis all permanent teeth present Advantages of Serial Extractions * in theory no appliance treatment needed © appliance may be simpler and shorter 50% reduction in the treatment time Better stability and retention since tooth completes its formation in a site where it will remain when treatment is completed (Graber, 2011) Disadvantages of Serial Extractions . Exposed to multiple extractions (12 teeth) 2. No guarantee, extractions of D's can lead to impaction of 4's if the 3s erupt ahead of the 4s. Removal of twelve teeth is a traumatic experience and there is no guarantee that the lower premolar will erupt before the canine and as such the latter may be impacted. If this occurs extraction of the second deciduous molars may be an option with Holtz (1970) advocating the provision ofa lingual arch retainer for space maintenance. The latter author also recommends disking of the second deciduous molars to provide space for premolar teeth. Mohammed Almuzian, University of Glasgow, 2013 Page 103. Growth prediction problems: difficult to predict amount of incisor crowding because ICW 7 between 8-10yrs ic. lower incisor crowding may resolve spontaneously 4, Space loss with extractions of C's and especially D's, by mesial drift of buccal segments, lower incisors tip lingually, both of these reduces arch length 5. Tipping of teeth into extractions site especially anterior teeth causing OB increasing, Littke 1990 6, There was no difference between the serial extraction sample and a matched sample extracted and treated after full eruption except shorter time for active orthodontic treatment (Little 1987, 1990}: Little (1987) observed lower labial segment relapse 10 years posttreatment in patients who had undergone premolar extraction in the mixed dentition, serial extractions, tion-extraction with expansion, no treatment normals and patients with spaced dentition, He concluded that serial extractions were still a good idea as it reduced further treatment time (50% reduction in treatment time compared with the late premolar extraction group) and allowed teeth to erupt through attached gingivae. Little continued his research into serial extraction with a paper in 1990 which compared patients undergoing, serial extractions. with the provision later of fixed appliances and patients with late premolar extractions and fixed appliances, Diagnostic records were available for the following stages: pre-extraction, start of active treatment, end of active treatment, and a minimum of 10 years postretention. All cases were treated with standard edgewise mechanics and were judged clinically satisfactory by the end of active treatment. Twenty-two of the 30 cases (73%) demonstrated clinically unsatisfactory mandibular anterior alignment postretention. Intercanine width and arch length decreased in 29 of the 30 cases by the postretention stage. There was no difference between the serial extraction sample and a matched sample extracted and treated after full eruption. Mohammed Almuzian, University of Glasgow, 2013 Page 11Modified serial extraction 1. Serial extraction has no real role in moder orthodentics 2. Modified form, by applying stage 3+4 only — extraction of Ds and 4s and Space maintainer Advantages 1. Prevent potential mesial drift of permanent molars and the development of secondary crowding, . Prevent distal drift of incisors . Prevent mid-line deviations | Prevent overeruption of the opposing teeth. . Use Leeway space forrelieving of the crowding. Awe Aesthetic purposes Disadvantages Need to insert immediately Perceived long treatment . No guarantee it will prevent later treatment 1 2 3, 4. Compliance, 5. Oral hygiene, 6. Regular inspection Indications 1. Good OH . Low caries rate is essential . Compliant patient. . Loss of central incisor for aesthetic purposes . Unilateral loss of ¢ . Early loss of E before eruption of 6 . Early loss of D . Difficult to assess clinically the occlusion at the current stage. SAA Awe Mohammed Almuzian, University of Glasgow, 2013, Page 129. Inan occlusion with only mild crowding where any further space loss would result in the need for more complex orthodontic treatment 10.In an occlusion with severe crowding where any further space loss would result in more than a single tooth unit of space being required. Contraindi 1. Ifa permanent successor will crupt within 6 months (ic., if more than one- half to two-thirds of its root has formed), a space maintainer is unnecessary, 2. Ifthere is not enough space for the permanent tooth or if it is missing, space maintenance: alone is inadequate or inappropriate Techniques 1. Band and loop; used with one tooth missing in the posterior area 2. Bonded rigid wire across the space 3. URA and partial denture; used if more than one tooth is lost and to replace anterior tooth 4, Lingual areh 5. Transpalatal arches or fixed-removable lingual and palatal arch eg 3D Wilson lingual arch 6. Distal Shoe Space Maintainers: © The distal shoe has a unique application and is the appliance of choice when a primary second molar is lost before eruption of the permanent first molar. ® It consists ofa metal or plastic guide plane along which the permanent molar erupts. The guide pline is attached to a fixed or removable retaining device * Tobe effective, the guide plane musi extend into the alveolar process so that it is located approximately | mm below the mesial marginal ridge of the permanent first molar, at or before its emergence from the bone. * When fixed, the distal shoeis usually retained with a band instead of a stainless steel crown so that it can be replaced by another type of space maintainer after the permanent first molar erupts. Mohammed Almuzian, University of Glasgow, 2013 Page 13e If primary first and second molars are missing, the appliance must be removable and the guide plane is incorporated into a partial denture because ofthe length of the edentulous span. © Itis contraindicated in patients who are at risk for sub-acute bacterial endocarditis Space regaining Procedures can be employed if space has been lost due to drifting regained spaceis limited to 3mm or less of space regaining. Technique 1, Sectional fixed appliance URA . Lip bumper HG . Molar distalization technique can be used to regain space wren Management of Lee way space 1. Ifa lingual archis placed during the mixed dentition only an arch length decrease of 0.44 mm has been reported with gaining of 4.44 mm Leeway space. 2. Also the stability were good after lingual arch treatment 3. However it was shown that intercanine is increased after using lingual arch and this bec the 3s migrate distally toward a wider arch, Mohammed Almuzian, University of Glasgow, 2013, Page 14Balance and compensatory extraction Early loss of primary teeth RCSEng guidelines and Recommendations Radiographic screening is highly desirable before extracting primary molars. to check for the presence, position and correct formation of the crowns and roots of successional teeth. Potential problems indicate the need to seek an orthodontic opinion before teeth are removed. 1, Loss of primary incisors — Early loss of primary incisors has litle effect upon the permanent dentition although it does detract from appearance. It is not necessary to balance or compensate the loss of a primary incisor. 2. Loss of primary canines~ Early loss of a primary canine in alll but spaced dentitions is likely to have most effect on centre lines. The more crowded the dentition, the more the need for balance. 3. Loss of primary first molars —With regard to a primary first molar, a balancing extraction may be needed in a crowded atch but compensation is not needed. 4. Loss of primary second molars — There is no need to balance the loss of a primary second molar because this will have no appreciable effect on centreline coincidence. However when a primary second molar has to be extracted consideration should be given to fitting a space maintainer Forced extraction in poor prognosis 6s ‘The 6s are the more caries prone teeth because © They are erupted carly and exposed to oral environment © Also they are more commonly affected by hypoplasia than other teeth. If the 6s are poorly restored or decayed then the it is better to considerearl extraction to allow spontaneous space closure or use of the space for orthodontic purposes. Mohammed Almuzian, University of Glasgow, 2013 Page 15Guidelines for forced first molar extraction (RCSEng. By Cobourne 2009) A number of general guidelines on treatment planning first permanent molar extraction cases for a number of malocelusions are available © Asa general tule, if in doubt, get the patient out of pain, try arid maintain the teeth and refer for.an orthodontic opinion. ClassT cases Class I cases with minimal crowding (3mm) Aim for extraction at the optimal time for eruption of the second molars into a good position. © Do not balance unilateral first molar extraction in either the upper or lower arches with healthy first molars. © Ifthe lower first molar is to be lost, compensating extraction of the upper first molar should be considered to avoid overeruption of this tooth, unless the lower second molar has already erupted and the upper first molar is in occlusal contact with it. * = Ifthe upper first molar is to be lost, do not compensate with extraction of the lower first molar if it is healthy. Class [cases with crowding © First molar extractions ean be delayed until the second molars have erupted and then the extraction space used for alignment with fixed appliances ¢ Alternatively, first molars can be extracted at the optimum time and the crowding treated once in the permanent dentition. If premolar extractions are likely to be required at this stage, the third molars should be present. If the buccal segment crowding is bilateral, consider balancing extraction to provide suitable relief and maintain the centreline. Compensating extraction Mohammed Almuzian, University of Glasgow, 2013 Page 16of upper first molars should be considered to prevent overeruption or relieve premolar crowding Class IT cases ‘The main complicating fictors often involve the upper arch because of the need for space to correct the incisor relationship. Class [I cases with minimal crowding Lower first molar extraction * It should be carried out at the ideal time for success fuleruption of the second permanent molar and control of the second premolar. Regarding compensating and balancing extraction: al Compensating and balancing extraction of healthy lower first molars are not indicated, So that, if the upper first molars are to be left unopposed, asimple removable appliance may be required to prevent their over-eruption, whilst waiting for the second molars to erupt, Alternatively, a functional appliance can be used immediately to correct the incisor relationship prior to extraction of the first molars and fixed appliances. b) Ifthe upper first permanent molar is sound, elective extraction may be indicated if it is at risk of over-erupting: however, the third molars should ideally be present radiographically. © If there is no sign of upper third molar development, an appliance to prevent the over-eruption of sound upper first molars should be considered. Upper first molar extraction ¢ = Inthe upper arch, space will often be required to correctthe incisor relationship: If the upper first permanent molars require immediate extraction, orthodontic treatment may be instituted to correct the incisor relationship. A functional appliance or removable appliance and headgear can be used to correct the buccal segment relationship, followed by fixed appliances if required, Mohammed Almuzian, University of Glasgow, 2013 Page 17e = Ifthe upper first permanent molars can be temporised or restored, then their extraction can be delayed until the second permanent molars have erupted. The resultant extraction space can then be used to correct the malocclusion with fixed appliances. © Alternatively, after extraction of the upper first permanent molars, the second permanent molars can be allowed to erupt and the incisor relationship corrected then by the loss of two upper premolars teeth, But as a condition, there should be a radiographic evidence of third molar development. Class II case with crowding. Lower first molar extraction Space will also be required in the lower arch for the relief of crowding. If the third molars are present radiographically, lower first molars can be extracted at the optimum time to allow second molar eruption and then premolars extracted at a later stage for the correction of crowding. In these cases, fixed appliances will usually be required. © Alternatively, first molars can be extracted after second molar eruption and the space used directly for the correction of crowding with fixed appliances. * Balancing and compensating extraction of lower first molars are not generally required Upper first molar extraction e Space requirements in the upper arch can be significant. The upper first permanent molars should be temporised or restored and the child referred to a specialist orthodontist whenever possible. © Ifthe upper first permanent molar is unopposed, at risk of over-erupting and third molars are present radiographically, then extraction of the upper first molar may be indicated. The patient should be counselled that additional Mohammed Almuzian, University of Glasgow, 2013, Page 18premolar extractions in the upper arch may be required in the future to create sufficient space for crowding relief and incisor correction. Class IIT cases Class III cases are often even more difficult to manage and ideally require the opinion ofa specialist orthodontist before any first permanent molars are extracted. As a general rule, extraction of maxillary molars should be avoided if at all possible, whilst balancing and compensating extractions are not recommended in class III cases. Abnormality in tooth position Infra-occlusion Management 1, Inthe presence ofa permanent successor A, Minimal infraocelusion, the ankylosed tooth can usually be left under observation to exfoliate naturally, B. Significant infraocclision can lead to adjacent teeth displacement, tipping and overeruption of adjacent teeth. In these circumstances, consideration should be given to either restoring the vertical dimension or extracting the affected tooth with lingual or palatal arch to maintain the space until the permanent teeth erupt. 2. In the absence ofa permanent successor, A. Early Extraction to facilitate spontaneous space closure to allow permanent teeth to drift into the edentulous spaceand bring bone with them, and then reposition the teeth prior to implant or prosthetic replacement, so that large periodontal defects do not develop. B. Premolaizing the E and accepting it in the place permanently. C. Slicing and space closure Mohammed Almuzian, University of Glasgow, 2013, Page 19D. Extraction and prosthetic replacement; E. Retention of the second deciduous molar. Impacted incisors SIGN recommendations (Yaqoob et al 2010): 1. Children under nine years with incomplete root development of permanent incisor: © Remove obstruction. © Create space if required, © Maintain the space © Do not uncover bone from unerupted incisor maintain integrity of follicle. * Monitor eruption for [IB months = 80% ehipt Spontaneously © Ifexposure required then expose minimally to eliminate soft tissue obstruction and wait for 6 months. If tooth is still high, expose and bond bracket. 2. Children above nine years with complete or nearly complete apex: * Remove obstruction. © Create space if required, * Maintain the space Ifpermanent incisor high then monitor eruption for 12 months, © If tooth still unerupted at 12 months, expose and bond bracket as required. 3. Children referred late (over 10 years): © Remove obstruction. © Create space if required. * Maintain the space © Expose and bond bracket at first operation. Mohammed Almuzian, University of Glasgow, 2013 Page 20Ectopic canine The principles of interceptive treatment for palatal canines are: 1, Remove any obstruction — this usually means removal of the deciduous canine 2. Ensure adequate space for eruption Methods 1] Extraction of the primary canines at the age between 10 and 13 year, 78% success rate 4 Extraction of the primary canines in crowded and uncrowded cases In general 62% showed improvement in eruptive position. In crowded cases the success rate was 14% as opposed to 86% in un- crowded cases 3) The extraction of the deciduous canine and creation of excess space for the impacted tooth Extraction of C + HG. 94% success rate, HG+exo 80% Cochrane review by le RCT @ Exo 50%, le Control 34% 5} Extraction of C + HG. le HG+exo 88% RCT by in le Exo 65%, s_ Control 36% There is currently no evidence to support the extraction of the deciduous maxillary canine to facilitate the eruption of the palatally ectopic maxillary permanent canine. 7| ‘Effect of RME and headgear treatment on the eruption of RME+HG+EXO 86 % HG+EXO 83%, Mohammed Almuzian, University of Glasgow, 2013 Page 21palatally displaced l= Control 36%. canines. RCT Effects of RME and Baceen20I) |» RME+TPAtEXO 80%, TPA treatment © TPAtEXO 79% associated with ls EXO 62.5% deciduous canine © Control 28% extraction on the eruption of palatally displaced canines RCT b A systematic review of | Runol20I0 No evidence-based the interceptive conclusions could be drawn treatment of palatally due to the few studies displaced maxillary identified, the heterogeneity canines, , in study design, and the unequivocal results I] Preventive treatment 50% of canines in the TG of ectopically erupting improved position by one maxillary permanent sector and 13% by two canines by extraction sectors, while on 32% of the of C & Ds: RCT canines in CG improved by one sectorand none by two sectors. ©) Extraction of the primary canines at the age between 10 and 13 year, BricS6n and Kuro, 1988. 46 consecutive ectopic palatally placed maxillary canines were studied. In (78%) the palatal eruption changed to normal after 12 months. It suggest that extraction of the primary canine is the treatment of choice in young individuals (10-13 years) to correct palatally ectopically erupting maxillary canines provided that normal space conditions are present and no incisor root resorption are found. * Extraction of the primary canines in crowded and uncrowded cases by Power and) Short) 1993; 9consecutive patients of mean age 11.2 years. In general 62% showed improvement in eruptive position. In crowded cases the success rate was 14% as opposed to 86% in un-crowded cases. Horizontal Mohammed Almuzian, University of Glasgow, 2013, Page 22overlap ofthe nearest incisor was found to be the most significant factor. If this exceeded half the tooth width, success was unlikely. The presence of crowding was found to affect adversely the favourable eruption of the canine. © The extraction of the deciduous canine and creation of excess space for the impacted tooth GHVEP2O02. The space created was | cm with the incisors being proclined and displaced upto 3mm across the midline. The results were impressive 94% success rate, © Extraction of C + HG. RCT by ERGHaFdTERAILZOO4 crops!) with extraction of C only, groups2) extraction C + HG (to increase arch length) groups3 control; results were 50%, 80% an 34% respectively © Extraction of C+ HG, RCT by BRGCEHIEEMIN 200) 1) with Xtn of C only, 2) Xm C+ HG, group 2) control, group 3) suecessfuleruption of 3, 65%, 88% and 36% successful eruption of 3 resepectively. © Cochrane review by Parkin) 2009) Extraction of primary (baby) teeth for unerupted palitally displaced permanent canine teeth in children. There is currently no evidence to support the extraction of the deciduous maxillary canine to facilitate the eruption of the palatally ectopic maxillary permanent canine, Two randomised controlled trials were identified but unfortunately, due to deficiencies in reporting, they cannot be invluded in the review at the present time, © Effectof RME and headgear treatment on the eruption of palatally displaced canines. RCT by AFM @E\BACCaZON, The randomized prospective design comprised 64 subjects three groups: cervical pull headgear (HG); rapid maxillary expansion and cervical pull headgear (RME/HG); untreated control group (CG). The prevalence of successful eruption was 83%, 86% and 36% respectively. Mohammed Almuzian, University of Glasgow, 2013 Page 23© Effects of RME and TPA treatment associated with deciduous canine extraction on the eruption of palatally displaced canines RCT by Bacceti 2077 Hundred and twenty subjects were enrolled in an RCT based on PDCs diagnosed on panoramic radiographs and they were randomly assigned to one of four study groups. Three treatment groups (TGs) (RME followed by TPA therapy plus extraction of deciduous canines, TPA therapy plus extraction of deciduous canines, extraction of deciduous canines, EC group. The prevalence of canine eruption was 80%, 79%, 62.5% and 28% respectively, The use ofa TPA in absence of RME can be equally effective than the RME/TPA combination in PDC cases not requiring maxillary expansion, thus reducing the burden of treatment for the patient. © A systematic review of the interceptive treatment of palatally displaced maxillary canines, RWPOIZON No evidence-based conclusions could be drawn due to the few studies identified, the heterogeneity in study design, and the unequivocal results * Preventive treatment of ectopically erupting maxillary permanent canines by extraction of C & Ds: RCT by BOHeti20IM, 50% of canines in the TG improved position by one sectorand 13% by two sectors, while on 32% of the canines in CG improved by one sector and none by two sectors. The extraction of maxillary first deciduous molars, in addition to the deciduous canines, appears to create more space and allow canines, at risk from impaction, to improve their position spontaneously, Impacted 6s Treatment options, ERUNGanmanE * 80% self-correct by age Tyrs while 10% self-correct at age 8 or 9yrs. * The optimal treatment approach depends on a timber of factors including Mohammed Almuzian, University of Glasgow, 2013 Page 241. The clinical eruption status of 6 . The change in position of 6 The amount of enamel ledge of 6/El | The mobility of /El, . The presence of pain or infection. we 10 treatment a. If resorption of E <1.5mm: * observe 3-6mths (to establish if reversible) * if no resorption and vertical position improved: monitor eruption © if no resorption and vertical position not improved: expose unerupted 6 and wait for 3 months © if still <1.5mm resorption: treatment to move the impacted tooth distally (see below) b. If resorption of E >1.5mm: © if E symptomatic or mobility >Imm consider Xtn and management of space problem once 6 erupts If E asymptomatic and mobility <1mm and 6 partially erupted: treatment to move the impacted tooth distally * If E asymptomatic and mobility . in permanent dentition 1. Aesthetic build-up of the centrals 2. Active orthodontic treatment to close a diastema is usually carried out in the permanent dentition. Using: * URA ° FA 3. Long-term retention is usually mandatory, Forthis reason, particularly fora minor diastema, persuading the patient that it is a feature of individuality that does not require closing can be advantageous, 4. Adjunctive procedure like © Frenectomy but this is not recommended anymore according to Jensen et al 1973 but Edward 1977 mentioned the opposite. © Composite build-up of the small teeth. Abnormality in teeth shape, form & size Treatment 1. No treatment 2. Inter-Proximal Stripping 3. Composite Mohammed Almuzian, University of Glasgow, 2013 Page 284, orveneer reshaping 5. Intentional RCT, Extraction and prosthetic replacement (implant, bridge, implant), VERY UNSUAL AND DESTRUCTIVE Abnormality in teeth number Supernumerary teeth ‘Treatment * leave it and monitor * extract tortho Indications for Monitoring 1. There is no associated pathology; 2. Satisfactory eruption of related teeth has occurred and no active orthodontic treatment is planned; 3. Removal would prejudice the vitality of the related teeth. Indications for removal 1, Supernumerary caused aesthetic problem. . Supernumerary prevent cruption of permanent teeth. . Supernumerary caused diastema or displacement. . Supermumerary caused pathology were Active orthodontic alignment ofan incisor in close proximity to the supernumerary is envisaged; 6. Its presence would compromise secondary alveolar bone grafting _in_cleft lip and palate patients; 7. The tooth is present in bone designated for implant placement; Mohammed Almuzian, University of Glasgow, 2013, Page 29Hypodontia Treatment options A. Treatment for hypodontia in primary dentition * No treatment is indicated at this stage. ¢ However removable dentures for psychological and functional reasons might be used but it will require regular adjustments during growth, Retention and stability may be problematic in those with poorly developed alveolar ridges. B. Mixed dentition (involve mainly the interceptive treatment) 1, Extract 1° tooth early —» allow space closure. Some recommend extracting primary tooth, allowing permanent teeth to erupt and close space, then reopen space at adulthood, so by this way we preserve the bone. 2. Composite build-ups to improve aesthetics of microdont permanent teeth or worn deciduous teeth 3. Removable dentures 4. Simple orthodontic treatment for space redistribution 5. Retain primary tooth: As long as possible & replace with prosthesis after cession of the growth, this will help in preserving alveolar bone Permanently, retain the primary tooth (if the Es survive until 20yrs then they appear to have a good prognosis for long term survival BRSHRINE woes Class I ‘Class IL Class HI Missing z If closing space > | Can be used as part of xin E to allow] treatment mesial drift of buccal segments. Space should be preserved and regained to allow proclination Tower 5 | Xin LE early Oyrs)| Keep LE as long as May be used as part Mohammed Almuzian, University of Glasgow, 2013, Page 30to allow mesial] possible — lower] of xt to treat drift arch should be as big} malocclusion as possible Traumatic loss ofincisors * Traumatic loss ofa maxillary central incisor is seen in around of 3% of children © usually occurs unilaterally, in the mixed dentition and in a child with an increased overjet Management Short term management Short term space maintenance can be achieved with a simple upper partial denture. * Alternatively, the space can be allowed to close and reopened in the permanent dentition prior to prosthetic replacement. This allows preservation of alveolar bone, but will require fixed appliance treatment and often space creation in the upper arch. Long term management 1. Spaceclosure and build up laterals 2. Space opening with © Resin-retained bridge e Implant, © Autotransplantation of premolar and subsequent coronal modification 3. In cases of bilateral loss, if space is required to reduce an overjet or relieve crowding and the lateral incisors are of a reasonable size and form, Mohammed Almuzian, University of Glasgow, 2013 Page 31consideration can be given to moving them into the position vacated by the centrals Displacements & crossbites Anterior crossbites if dental Xbite then * selective grinding * extraction of the opposing primary © Bodily movement -> use fixed appliance 2*4 appliance * Simple tipping movement > use URA with posterior capping, Z spring, double cantilever spring, crossed cantilever spring, screw plate Dentoalveolar or mild skeletal then © Chincap * Frankle 3 (Functional) Crossbite with Displacement Recommendations 1. Encourage habit to stop vv . Removal of premature contacts of the baby teeth . Posterior onlay . Extraction if it is associated with severely displaced single tooth wae expand upper arch with: « URA with midpalatal screw, success rates is 50% © Coffin spring + posterior capping, * Quad. (QH and RME success rates is 100%) According to the Cochrane review byHarrison and Ashby, 2008 Cochrane Mohammed Almuzian, University of Glasgow, 2013 Page 32The evidence from the trials reported by Lindner (1989); Thilander (1984) suggests that A. Removal of premature contacts of the baby teeth is effective in preventing a posterior erossbite from being perpetuated to the mixed dentition and adult teeth. B. When grinding alone is not effective, using an upper removable expansion plate to expand the top teeth will decrease the risk ofa posterior crossbite from being perpetuated to the permanent dentition. * No evidence ofa difference in treatment effect (molar and canine expansion) between the test and control intervention was found in the trials which compared Banded versus bonded Banded versus bonded slow miaxillary expansion, Two point versus four point rapid maxillary expansion, Transpalatal arch with/without buccal root torque, mpo p> Upper removable expansion appliance versus quadhelix. Habits Management of digit-sucking habits Prevention of digit-sucking habits, BOS guidelines 2000 . Ifa dummy is provided, there appear to be fewer probleins in the long-term, because the majority of dummy sucking habits are self-limiting and stop before eruption of the permanent teeth. Any persistent dummy sucking habit is easily broken by removal of the dummy. we . Ithas been suggested that if a digit-sucking habit is noticed, a dummy should be given to the child, Mohammed Almuzian, University of Glasgow, 2013 Page 333. Ifa dummy is used it must not be sweetened. After the age of 2, to prevent problems with speech development, it should be used as little as possible during the day Treatment of digit-sucking habits, BOS guidelines 2000 1. The child must want to stop otherwise any approachis likely to be unsuccessful. 2. Achild who is undergoing severe psychological trauma is unlikely to respond to habit breaking. A psychologist’s input may be required 3. The use of orthodontic pacifiers which is oval shape and has a vent to reduce the effect of dummies 4, The following methods for breaking the habit are listed in the order in which they should be used: A. Non-physical methods * Explanation * Reward © Habit reversal Teach the child to carry out alternative activities when they have the urge to suck the digit B. Physical methods Reminder therapy like finger bandage, finger paint, boxing gloves or thermoplastic finger post C. Inira-oral appliances These deterrent appliances have been shown to be effective within 10 months. They must be fitted with the full understanding and co-operation of the child and must not compromise compliance with any future orthodontic treatment. Intraoral appliance 1. Removable appliance Mohammed Almuzian, University of Glasgow, 2013, Page 342. Fixed appliance like palatal appliance with crib or Blue grass appliance 3. Functional appliance can stop habit Increased and decreased Overjet Indications for 10 treatment of increased OJ (carly treatment of CLIT problems) . Cass Il females with a significant skeletal discrepancy. 2, An increased overjet, which is a source of teasing and bullying. 3. An increased overjet, which is at risk of trauma (often associated with gross lip incompetence and marked maxillary protrusion). Advantages of early treatment The believed advantages of early treatment, RiGg1990 are: 1. Better cooperation (Truc, O’Brien 2003 with regard to TB treatment early treatment 16% failure but late 33%) 2. Psychosocial advantages if patient is treated early. Sandler and DiBiase 2001 showed that the increased OJ is the most unattractive feature, However, The treatment itself may introduce a new source of bullying, (true, O’Brien 2003), latest Cochrane review by Thiuroventrachachari 2013 showed that early treatment reduce risk of trauma. 3. Craniofacial tissues more malleable. Questionable? 4. Favourable changes in skeletal and dental AP relationship achieved but may not be clinically significant, (true for short term, Tulloch, 1998, Keeling, 1998, O° Brien 2003) 5. improved prognosis for adolescent treatment but not significant (not true, O’Brien, 2003) 6. Elimination of gingival/palatal trauma. Questionable? Mohammed Almuzian, University of Glasgow, 2013 Page 357. Less root resorption than one phase (Brin 2003 use the data of UNC and prove that) 8. Eliminate growth/local disturbances before they have had time to act fully. Questionable? Better stability measured using PAR index (Paviow 2008. © High trauma with increased overjets >9mm ((P6UdSEDSdE IBS) (45% 10 yr olds with QJ more than 9mm have traumatised incisors compared to 27% if 2 the OJ was less than 9mm especially if the lip is incompetent) however RCT comparing early versus late treatment (KOtHK lal 2003)concluded all groups experienced trauma. But the latest Cochrane review showed that early Oj reduction would reduce the chance of trauma (Badri Thiruvenkatachari, 2013). Disadvantages of early treatment . Early start and late finish therefore prolonged course of treatment 2 Risk of burning patient co-operation. Patient has time expiry approximately 3yrs which can be lost in the first phase leaving no compliance in the second phase. Limited long term benefits skeletal and dentoalveolar effect compared to one stag, 4. Choice of Xtn is diffieult whilst young 5, Softtissues do not mature until 12-L4yrs with vertical growth of lips this might affects stability of corrected OJ 6 Arch length not maintained in permanent dentition . Evidences of poor outcome of early treatment versus late treatment . An old review of the literature was unable to establish whether early or late treatment provided the most benefit overall: 'we lack definitive cost-benefit information, King etal., 1990 Mohammed Almuzian, University of Glasgow, 2013, Page 362. O'Brien 2009 RCT study * The aim of this study was to evaluate the effectiveness of early orthodontic treatment with the Twin-block appliance for the treatment of Class II Di nm | malocclusion. © This was a multi-center, randomized, controlled wial with subjects from 14 orthodontic clinics in the United Kingdom. The study included 174 children aged 8 to 10 years with Class II Division | malocclusion; they were randomly allocated to receive treatment with a Twin-block appliance orto an initially untreated control group. «The subjects in both groups were then followed until all orthodontic treatment was completed by FA. « Final skeletal pattern, number of attendances, duration of orthodontic treatment, extraction rate, costoftreatment, and the child's self-concept were considered, * Atthe end of the 10-year study, 141 patients either completed treatment or accepted their occlusion. Data analysis showed that there were no differences between those who received early Twin-block treatment and those who had | course of treatment in adolescence with respect to skeletal pattern, extraction rate, and self-esteem. © Conclusions: Twin-block treatment when a child is 8 to 9 years old has no advantages over treatment started at an average age of 12.4 years. Those who had early treatment had more attendances, received treatment for longer times, and incurred more costs than the adolescent treatment group, They also had significantly poorer final dental occlusion. 3. Tulloch et al 2004 RCT where the patient allocated at early stage to functional or HG or control. The results that all benefit from first stage was lost and that early Mohammed Almuzian, University of Glasgow, 2013, Page 37treatment or two stage treatment didn’t affect extraction prevalence nor sending to orthognathic surgery. 4, Dolee et al 2007 (completion of Keeling study 1998): compare two stage treatment with | stage treatment and found no skeletal difference between both 5. Recent Cochrane review suggests that early treatment is no more effective than orthodontic treatment in early adolescence Harrison et al., 2007 (this was involving 185 publications, then only 105 paper used and then 8 trials included (4 early treatment and 4 late weatment) the result show that there is no difference between early and late treatment regarding OJ, ANB, PAR, trauma, incidence of extraction, but the self-esteem has been improved. 6. Koroluk 2003, show that no reduction in incisor trauma 7. Bl, O*Brion, 2003, show benefit from psychological point of view Advantages of late 10 for increase OF 1. One phase treatment rs) . Growth still present Extraction decision is easy . Espace can be used . Better final occlusion (O’Brien, 2009) No difference from carly treatment (Tulloch 2004, O’Brien 2009, Dolce 2007, Harrison, 2007) 7. However, comparing the effect of functional appliance with no treatment in aw Ew adult is an ethical issue because of the equipoise idea, Harrison 2007 quoted two studies (Cura & Sarac 1997) who compare Dynamax with control and Mao and Zaho 1997 who compared bionator/Hg to control. These studies suffered from weakness in their design. In general comparing functional appliance to no treatment conclude that the former reduce O4 and ANB by 2.27. so it is the clinician philosophy to use it or lose it. Again comparing TB Mohammed Almuzian, University of Glasgow, 2013 Page 38,with other functional like bionator or Dynamax showed that TB reduce ANB by 0.68 more than others. I should mentioned that comparing HG with untreated was not taken before. Early treatment of Class HII Time Before the age of 8 to achieve skeletal correction. Method Chin cups or reverse pull HG. Indication 1. Growing cooperative patient 2 Skeletal class I, or only mildly class III; 3. Anaverage or reduced lower face height; 4. Allarge anterior displacement on closing. s. Ineisor inclinations normal 6 Average/increased overbite that will retain the correction In the mild Class Ill case in the mixed dentition the patient may benefit from early correction of the incisor relationship so that further mandibular growth may be counterbalanced by dento-alveolar compensation Problems Unfavourable growth. Soft tissue relapse after maturity 3. Long treatment and retention times. 4. Forward movement of the maxillary teeth, Mohammed Almuzian, University of Glasgow, 2013, Page 39s. Retroclination of the lower labial segment Richardson, 1999, screening for 10 Wee Do Don't At Do: Encourage caries prevention Don’t: worry about birth abnormal gum pad relationship age Do: look for early signs of malocelusion Don’t: worry about 3 Do: expect crowded permanent if no lisping spaceexist between primary Don’t:About spacing Do: Discourage habits Don"t:About flush Do: Treat abormal path of closure terminal relationship age Do: treat pathology Don’t: worry about 7-9 | Do: observecrowding by sligh post-normality + Maintain space of molars - Observing and use Lee way space for Don’t: ugly duckling crowded cases space + Consider serial extraction or first molar of | Don't: slight AOB Poor prognosis Do: observe local disturbance by + Extract primary if the permenant is missing + Treating impacted 6s + Extract Transposed teeth + Extract retained primary * Extract supernumeray Mohammed Almuzian, University of Glasgow, 2013 Page 40Do: discourage habit Do: observe cross bite and displacement Do: treat pathology Don’t: about buccal Do: observecrowding by crowding if 22mm Extraction of FPM or second molar space available Extract retained primary between lateral and Extract Cs in ectopic canine 68 Do: discourage habit Don't: Rotated Do: Treat cross bite premolar when erupt Do: Excise large frenaum Don’t: Minor submerging Mohammed Almuzian, University of Glasgow, 2013 Page 41