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Lecture# 2 28-1-2014

Interceptive Orthodontics
Definition: any procedure that eliminates or reduces the severity of malocclusion in the developing dentition. So you need to spot the problem early, at young age, so you do an interceptive treatment to make the problem less severe. Aetiology of malocclusion: it can originate either from skeletal or soft tissue origin. General factors: 1) Soft tissue factor 2) Skeletal factor Local factors: For example a child with delayed eruption of upper central permanent incisor, although the upper laterals are there, In this case you need to suspect that there is something wrong, because this is not the right sequence of eruption. Or for example if one upper central erupted while the contralateral central didn't erupt (you should know that if one tooth was erupted or started to erupt, the contralateral tooth should erupt, at most, within 6 months). So the upper central incisor is considered to be delayed if: The contralateral tooth was fully erupted. Teeth later in the usual eruption sequence were present. And the treatment should be done by eliminating the cause... ** Supernumerary teeth: This is the most common cause of teeth impaction in the anterior area. You need to start with taking X-rays; to see if there is any supernumerary tooth like mesodense which is the most common tooth to be presented there.
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You need to remove this tooth to allow the impacted central incisor to erupt by itself. The interceptive treatment: removal of the supernumerary tooth, with or without surgical tooth exposure. The timing of treatment: as soon as the supernumerary tooth is detected. .. Some people say that if the supernumerary is affecting the eruption of the upper central incisor then the surgical removal of this tooth will allow the central incisor to erupt by itself in more than 70% of cases. .. Others say that what if the central incisor didn't erupt? This means that I'll have to do another surgery to expose the tooth and fix a gold chain to align the tooth in its normal place. So in order for the patient not to go through two surgeries, some schools say that in the same surgery I remove the supernumerary tooth and fix the golden chain to the central incisor. So in case the central didn't erupt by itself it will be ready for the orthodontic effort to pull it down to its place. Now if we don't treat this patient, there will be space loss and no space for the central to erupt. That's why we need an interceptive treatment at early age, otherwise the treatment will be difficult. ** Retained deciduous teeth: The deciduous tooth is considered to be over retained if it makes enamel contact with its successor. The interceptive treatment: extraction of the deciduous tooth. but you need to be sure that the successor tooth is there. If the successor tooth is missing then you have the option to leave the deciduous tooth, or you extract it and replace it, or extract it and close the space.

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For example if a 15 years old patient came to your clinic and you found that the lower 5 was missing (this is the most common tooth to be missing, followed by upper laterals), and the lower E was retained. You 1st must take X-rays to see if the lower 5 is there, so if it's there you will extract the E. And if it's missing then you have many options: 1. extract E and replace it. 2. Extract E and close the space, for example if there's crowding you will consider the missing 5 as a tooth that you need to extract to relief the crowding. 3. You leave E, if there's no crowding. Specially when the patient is young and implants are not a good option, so you leave E as a space maintainer, and it will also reserve the bone around it for future implant. ** Infra-occlusion: (used to be termed submerged tooth) For example a lower 5 may get infra-occluded, usually because of ankylosis. So the adjacent teeth will keep erupting bringing up the bone with them so the 5 will look as if it's infra-occluded. So the tooth looses its vertical position relative to the adjacent teeth and assumes a position below the occlusal plane. Frequent sites: lower 1st and 2nd primary molars. The 2nd premolar is the most
common tooth to be missing so usually because of this the E becomes infra-occluded.

The interceptive treatment: nothing. Unless the permanent successor is absent or the infra-occluded tooth is likely to disappear. So if the successor is there you extract the infra-occluded tooth, if not then the options are: 1. Extract the tooth and close the space, for example if there's crowding. 2. You leave the infra-occluded tooth, if there's no crowding.

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3. If you decided to leave the tooth but the patient came to you and his tooth is starting to disappear and the adjacent teeth started to tilt to close the space. So in this case you either build it up with composite or whatever or extract it and replace it. ** Unilateral retained deciduous canine: If the primary canine on one side was lost prematurely and you left it without any treatment this will lead to 1) space loss. 2) midline shift. The interceptive treatment: either you put a space maintainer or you extract the contralateral C to maintain the midline in its position.

** Double teeth: Two types: gemination & fusion; Gemination: the attempt of a single tooth bud to form two distinct morphological entities. Complete number of teeth. One big root with two crowns. Fusion: the result of joining two adjacent tooth buds. One missing tooth when counting teeth. Two roots with one crown. For any of the gemination or fusion in the deciduous dentition, double teeth are usually associated with absent permanent successor ectopic or delayed eruption of the permanent successor if it was present there. The treatment involves the extraction of the malformed tooth in case the permanent successor is present. Now double teeth in the permanent dentition , you cannot extract the malformed tooth and that's it, so the treatment options are either to 1) split the teeth if they are fused, and restore each part for aesthetics. 2) extraction,,, when it's aesthetically unacceptable.
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** Ectopic eruption of the permanent 1 molar: It is the most common ectopic eruption, more common than the maxillary canine. The 1st molars usually erupt with mesial angle more than the usual. So they will be opposed by the roots of E. This will result in: 1) The 1st molar will start resorbing the roots of E, this leads to the loss of E, so loss of the space of the permanent 2nd premolar... this is called Irreversible/Hold. 2) The 1st molar will start to hit the roots of E and then it will correct its path of eruption... this is called Reversible/Jump. How can I know if this case is "jump" or "hold"? by taking two X-rays at different times. The treatment: extraction of E and then later on regain the space for 5, but if there's crowding then you just remove E. Or distalization of the permanent molar, even when it's still in, usually the distal part will be partially erupted, so we put elastic separators (or wires) deep inside and move the tooth distally by tipping movement. But when the case is "jump" no treatment is needed. ** Hypodontia: Definition: missing one or two teeth, maximum. Oligodontia: at least 6 teeth are missing. Anodontia: all teeth are missing.

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The treatment: close the space, specially if there's crowding or I need this space for my orthodontic treatment, or space maintenance to replace the tooth later on.

** Diastema: Definition: space between upper central incisors in the midline. The aetiology: supernumerary tooth or odontomas, or high labial fraenum, or generalized spacing. The treatment: usually you look for the aetiology, remove it and wait. If a supernumerary tooth is the problem I extract it. If it's the high labial fraenum, i do frenectomy.
2009 script

frenectomy just before final step of space closure so first you put retainer to close space and at the end before space closes by 1mm you do frenectomy because if you do frenectomy while space is still there you will end up with scar tissue and this scar tissue act as barrier prevents continuous space closure.

** Ectopic upper canine: (we used to call it "impacted canine" but now we call it "displaced
canine")

We stopped calling it impacted because in many cases we see generalized spacing where there's enough space for the canine to erupt, so there's nothing to physically prevent the canine from eruption, and still the canine is unerupted. Definition: the canine erupts out of its normal eruption path.

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Diagnosis: if the canine was not palpable in the buccal sulcus as buccal bulge after the age of 10 years, you need to do something about it because the canine is more likely to be palatally displaced. The treatment: - If the primary tooth is mobile, you do nothing. Because this means that resorption of the primary tooth root is going on and so the permanent canine is trying to erupt. - If the canine is not palpable in the buccal sulcus and the primary tooth is firm, this means that the canine is displaced. So you take X-rays to locate the canine, using the SLOB/Parallex technique). It may be missing and this is very rare. It is ectopic which is common, the canine could be ectopic buccally (15%) or palatally (85%).

Addition studies were made to find out what can be between the (15% buccal and 85% palatal) displacements, and they found that not less than 30% of the erupted canines are found within the line of the arch. you don't have to memorize this info. Palatal displacement causes: the exact cause is unknown coz sometimes there can be more than enough space for the canine to erupt, that even some studies linked spacing with the canines' palatal displacement. Suggested causes: 1) long path of eruption (the tooth is found at the infra-orbital foramen). 2) endocrinal problems, hormonal problems, malnutrition.

But the most accepted two theories are: Guidance theory: canine eruption needs guidance because of its long path of eruption. So this guidance is the lateral aspect of the lateral incisor root. So this theory relates the palatal displacement of the canine
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to some problem in the root of the lateral incisor (can be missing or anomalous). Genetic theory: it relates the palatal canine displacement to hereditary factors, as they found that for the patient with palatal canine displacement, his family history reveals that many of his family members also have the same problem. The interceptive treatment: extraction of the primary canine. in around 78% of cases the canine erupts into its place by itself. This depends on the position of the canine itself, or the rate of eruption of the permanent canine after the extraction of the primary canine depends on the amount by which the canine overlaps the root of the lateral incisor; if the canine is crossing less than 1/2 of the upper lateral incisor root (the canine is behind the lateral root long access), then the chance for the interceptive treatment to success is high (91%). While if the canine is crossing more than 1/2 of the lateral incisor root; that is the canine has crossed the long access of the lateral root, then the chance is low (64%). ** thumb sucking: It leads to the development of: 1) Anterior open bite. 2) Cross bite. 3) High palatal vault. 4) Proclination of the upper incisors and Retroclination of the lower incisors; so increased overjet.
2009 script

The effect of sucking depend on 1)frequency 2)duration (most important) 3) direction (usually cause anterior open bite asymmetric)

The interceptive treatment: removing the cause. Stop thumb sucking habit. - The approach usually is the adult approach: to talk to the patient, advice him and tell him that this habit will affect your teeth later on... and as the
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doctor said: ( .( )"" - so the other approach is to use what is called: habit breakers (appliances). It can be removable or fixed. If the patient sucks his thumb unconsciously then I will use the removable habit breaker; because it will act as a reminder. Otherwise (if the patient sucks his thumb consciously) I'll use the fixed habit breaker. They have found that thumb sucking: 1) 2) 3) 4) Doesn't affect the occlusion in 14.6% of the cases. Causes anterior open bite in 48%. Causes posterior cross bite in around 7% of the cases. Anterior open bite + posterior cross bite: 30%.

Habit breaker types: Tongue crib. Goal-post it's a wire in acryl that is placed on the palat that whenever the patient puts his thumb he will feel it and remove his thumb. Tongue clip: zig-zag shaped wire with acryl. To lose the sensation at that area.
2009 script

-provided the habit is abandoned so you should stop the habit because treatment won't be successful if the habit still there (you need to eliminate the cause) -thilander1984 suggested that once you stop the habit there will be spontaneous correction and no need for active orthodontic like expansion the maxilla -kurol and bergland 1992claim that this spontaneous correction will take place on eruption of permanent teeth around 45% of patient NOTEIN PRIMARY DENTITION STOPE THE HABITSPONTANOUS CORRECTION IS HIGH **If there's no improvement for treatment we need to put orthodontic like expansion screw in maxilla (removable appliance)
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now the question is: When do I stop using the habit breaker? Many researchers suggested age limits; profit for example suggested that 7 years of age is the limit (because upper incisors erupt at the age of 6-7, after this the anterior open bite becomes fixed). Other researchers say that the limit is up to 10 years. Huston for example said that the limit is 7-8 years. But let's stay that in general the limit is 10 years. So with time, if we don't stop the habit, the chance of spontaneous correction of occlusion will become less. And after 10 yrs of age, correction needs orthodontic treatment. And if the habit continues even after the ortho. treatment then we will need orthognathic surgery to correct the malocclusion. ** tooth transposition: Definition: unusual type of ectopic eruption where two permanent teeth had interchanged their location in the dental arch. The most common teeth to be affected with transposition are the teeth in the last series "upper canines and 1st premolars" & "lower canines and lateral incisors". The interceptive treatment: either you accept or you extract the transposed tooth. For example, upper canine erupted in the place of upper 4, so in this case either you extract the 4 {as a part of an ortho. treatment} and then align the teeth by bringing the canine to its place. Or you accept it and change the shape of the 4 to 3, and you don't need to change the shape of 3 because it already looks like the 4. Now what if the patient is still young and I took X-rays and found the 3 and the 4 are transposed, and they are not fully erupted, in this case you extract the 4 and allow the canine to erupt in its normal place. The end
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