Good morning

DR. SOMANI DHAVALKUMAR

BAPUJI DENTAL COLLEGE & HOSPITAL

2
CONTENTS: DAY 1
 INTRODUCTION
 STEPS OF TREATMENT PLANNING
 EVOLUTION OF TREATMENT PLANNING
 ORTHODONTIC TRIAGE
 ENVELOP OF DISCREPANCY
 ANCHORAGE PLANNING
 TREATMENT PLANNING IN PRIMARY DENTITION
 TREATMENT PLANNING IN EARLY MIXED DENTITION
 FOR MINOR & MODERATE PROBLEMS
 FOR SEVERE PROBLEMS

3
DAY 2
 TREATMENT PLANNING IN LATE MIXED & EARLY
PERMANENT DENTITION
 FOR PATIENTS WITH DENTAL PROBLEMS
 TREATMENT PLANNING FOR PATIENTS WITH SKELETAL
PROBLEMS
 GROWTH MODULATION
 ORTHODONTIC CAMOUFLAGE FOR SKELETAL DISCREPANCIES
 ORTHOGNATHIC SURGERY
 INTERDISCIPLINARY POTOCOLS
 PLANNING TREATMENT FOR MAXIMAL ESTHETIC IMPROVEMENT
 MACRO-ESTHETIC CONSIDERATIONS
 MINI-ESTHETIC CONSIDERATIONS
 MICROESTHETIC CONSIDERATIONS
 CONCLUSION
 REFERENCES 4
 Treatment plan is simply a series of stepwise
procedures designed to correct a mal-
relationships 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.

5
 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.

6
 History
Clinical Problem list
Database classification
Examination ( Diagnosis)
Analysis of
diagnostic records

Pathology
Orthodontic (developmental) (caries,
problems perio) treat
Priority order Possible Patient first
solutions Evaluate parent input
A -------------------- A Interaction Alternate Informed
B----------------------B Compromise plans consent
C---------------------C Cost-benefit
D---------------------D
Effectiveness
Treatment Plan Efficiency Treatment
details plan
concept 7
 Orthodontic diagnosis is complete when a
comprehensive list of the patient’s problems
has been developed and pathologic and
developmental problems have been separated

8
9
 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.

10
 The goal of treatment planning is not a
scientific truth, but Wisdom
the plan that a wise and prudent clinician
would follow to maximize benefit for the
patient.

11
12
 The answer has shifted over years.
 From the perspective of the patients,

The appearance of teeth and face has always been

important.

13
 In 1920’s
Angle’s concept -
for each individual
the ideal facial
esthetics would
result when teeth
were placed into
ideal occlusion
whether the patient
liked it or not.

Edward Hartley Angle

(1855-1930) 14
 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 should mesh in ideal articulation with the
teeth in opposing jaw

15
 When this natural dentitional state occurs, the
face also should be in perfect harmony and
balance and the stomatognathic system should
function ideally

16
 Angles concepts were based on those of
Bonwill (a 19th century dentist in Philadelphia
during the time that Angle was a student
there.)
 He theorized that nature ordained the dental
arches and articulation of the teeth to be in
perfect alignment, harmony and function.

17
 Non Extraction Extraction

MARTIN DEWEY CALVIN CASE

Angles followers won that day but current

perspective leaves the impression that Calvin Case
had the better argument. 18
 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.

19
 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

20
 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 by
crooked teeth & poor facial proportions &
achieving benefits to well being through
improved dental & facial esthetics

21
 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

22
 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 relationships.
 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

23
24
 DISTINGUISHING
MODERATE FROM SEVERE PROBLEMS

25
 This process was used in
military and emergency
medicine.
 Triage was used to
separate casualities by
the severity of their
injuries.

26
 Its purpose was to separate the patients who
can be treated at the scene of injury, from
those who need transportation to specialized
facilities and to develop a sequence for
handling patients.
 So that those most likely to benefit from
immediate treatment will be treated first.

27
 Triage is important for
primary care dentist to
distinguish moderate from
severe 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.

28
1. Syndromes and developmental abnormalities
Facial disproportions and asymmetries
2. Facial profile analysis
Antero-posterior and vertical problems
Excessive dental Protrusion or Retrusion
3. Problems involving Dental development
4. Space problems
5. Other occlusal discrepancies

29
 STEP 1
UNUSUAL FACIAL APPEARANCE

ANALYSIS OF FULL FACE

PROPORTIONS

CRANIOFACIAL DEFORMITY OR TRUE FACIAL ASYMMETRY

SYNDROMES

COMPLETE EVALUATION BY • HISTORY OF TRAUMA

•EXCESS OR DEFICIENT GROWTH
SPECIAL TEAM WITH MEDICAL
CONSULT

30
 ANTEROPOSTERIOR AND VERTICAL PROBLEMS
 Skeletal class II and class III problems and

vertical deformities regardless of their cause

are considered as severe problems.
 Before puberty the treatment for these

patients should be aimed at modifying the jaw

growth.

31
 After puberty amount of growth remaining is
usually insufficient to allow correction.
 Then the treatment plan must distinguish

between the possibility of camouflage of jaw

discrepancy and surgical repositioning of the
jaw.

32
 STEP 2

SYMMETRIC FACE

FACIAL PROFILE ANALYSIS

A-P OR VERTICAL JAW EXCESSIVE PROTRUSION OR

DISCREPANCIES RETRUSION OF INCISORS

GROWTH MODIFICATION • EXTRACTION

CAMOUFLAGE
SURGERY
33
 GOOD FACIAL PROPORTION
Review intra oral
radiograph for
abnormalities of dental
development

1. ABNORMAL SEQUENCE OF DENTAL

DEVELOPMENT
2. MISSING PERMANENT TEETH
3. SUPERNUMERARY TEETH
4. ECTOPIC ERUPTION & ANKYLOSED TEETH

34
 SEVERE PROBLEMS

MONITOR: ASYMMETRIC SEQUENCE

SELECTIVE OF PATTERN OF DENTAL
EXTRACTION DEVELOPMENT

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

35
 SEVERE PROBLEMS

Combined surgical – ANKYLOSED PERMANENT

orthodontic treatment TEETH

SUPERNUMERARY
Extract supernumerary TEETH
Reposition other teeth (complicated by
position or number)

36
 MODERATE PROBLEMS

SINGLE EXTACT
SUPERNUMERARY SUPERNUMERARY
TEETH TEETH
(with uncomplicated
position)

MONITOR:
RETAINED OR ANKYLOSED
EXTRACTION AND
PRIMARY TEETH
SPACE MAINTAINANCE

MONITOR:
ECTOPIC ERUPTION REPOSITION
EXTRACTION
SPACE REGAINING

37
 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.

38
 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 well positioned over the basal
bone & then rotate , or tip labially or lingually.

In such cases potential crowding is expressed as

actual crowding & is often difficult to miss.

39
2. Theother possibility, is for the crowded teeth
to align themselves completely or partially on
the expense of the lip, displacing it forwards,
interfering with lip closure

40
 On basis of space analysis results, children in
mixed dentition who do not have incisor
protrusion can be divided into 3 groups

1. Those with adequate space

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

41
 MODERATE PROBLEMS

THOSE WITH
ADEQUATE SPACE SPACE MAINTENANCE
-MISSING PRIMARY
CANINE OR MOLAR

- Reduce width of
SPACE DEFICIENCY NOT primary teeth
MORE THAN 4mm - 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

42
 SEVERE PROBLEMS

- SPACE DEFICIENCY GREATER THAN

EXPANSION 4 MM IN EACH ARCH OR
EXTRACTION - INCISOR PROTRUSION WITH
SMALLER SPACE DISCREPANCIES.

43
 Posterior crossbite
 Anterior crossbite
 Anterior openbite and deepbite

44
 A skeletal posterior crossbite, revealed by a
narrow palatal vault is categorized as severe
problem,
 dental crossbite falls in moderate problem (if
no other complicating factors like severe
crowding are present).
 Treatment Planning-
◦ Skeletal crossbite = opening the mid palatal
suture
◦ Dental crossbite = tip the teeth outward into
proper position

45
 SEVERE PROBLEM MODERATE PROBLEM

POSTERIOR CROSSBITE

SKELETAL DENTAL

TREATMENT TREATMENT
PLANNING PLANNING

opening the mid palatal TIP THE TEETH INTO

suture PROPER POSITION

46
 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.

47
 Anterior open bite in a young child with good
facial proportions usually needs no treatment,
because there is good chance of spontaneous
correction . (moderate problems)

 A complex open bite ( one with skeletal

involvement) or any open bite in an older
patient is severe problem, as deep bite at all
ages .

48
49
 The treatment modalities that are feasible for
patients are determined by the nature and
severity of the orthodontic problem.
 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

50
1. An amount that can be accomplished by tooth
movement alone
2. A larger amount that can be achieved by tooth
movement plus functional or orthopedic
treatment
3. A still larger amount that requires surgery

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 4

2 7
2

52
 6

5 12

53
 10

10 15

15
54
 4

3
5 2

55
 6

5
10

56
 10

12 25

15
57
 10

3
Palatal 2 4 Buccal
2 3
7 4 3 3
4

10

58
 10

4
3
Lingual 5 4 Buccal
2 1 2 3
2
4

10

59
 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.

60
61
• Anchorage is defined by 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 movement.”

62
 According to Nanda, based on treatment
approach, anchorage is classified in to three
types

63
 Anchorage control should be considered in
three planes:
Horizontally,
Vertically and
Transversely.
Horizontally, anchorage control is used to
achieve a correct antero-posterior position of
the teeth in the profile at the end of the
treatment.

64
 Vertically, anchorage control involves the
need to try to influence vertical skeletal and
dental development in the posterior segments
and sometimes to limit vertical eruption of
anterior segments or even intrude these
segments.

65
 Transversely, anchorage control involves
maintenance of expansion procedures,
primarily in the maxillary arches and the
avoidance of tipping and extrusion of the
posterior teeth during any expansion phase.

66
 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.

67
In adults - The orthodontic mechanics may
need to be modified.

 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.

68
 Anchorage is difficult to obtain if the posterior
teeth are periodontally compromised and very
light forces have to be applied.

In periodontally compromised patients,

anchorage 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.

69
 Long face syndrome is among the most difficult
problems encountered in the practice of
orthodontics.

 Unless orthodontic treatments are carefully

monitored and controlled, patients with long face
syndrome risk developing even more severe
characteristics of the syndrome.

70
Long face syndrome can be controlled by
Minimising the extrusion 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.

71
Anchorage enhancement
 Is another way that maxillary molar extrusion
can be prevented.
 Transpalatal 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.

72
 High-pull headgear prevents maxillary molar
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

73
Bonded RME
 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.

74
Interaction between sagittal and vertical
components of anchorage.

 Most concepts of anchorage focus only on

sagittal relationship.

 Vertical changes occuring in the molar

region during treatment influence the sagittal
relationship significantly.

 Even minor extrusion of posterior teeth

results in a posterior rotation of mandible.

75
 Anchorage requirements must be established in
each clinical situations.
In critical cases-
Reinforcement -.
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.

76
 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

77
 Reinforcement may also include forces
derived from structures outside the 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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79
 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 biomechanical forces are quite
effective.

 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
 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 growth and improve the
occlusal relationship.

81
 In a normal primary dentition especially 5-6
yrs of age spacing between incisors is normal
and in fact is necessary if permanent incisors
are to be properly aligned when they erupt

82
 If the primary incisors contact each other
proximally one can confidently predict that
permanent incisors will be crowded & irregular.

 Crowding in primary dentition is rare, when

this is observed extremely severe crowding will
be present later in permanent dentition.

83
 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

84
 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.
 Therefore space maintenance is not necessary,
on the other hand, prosthetic replacement for
esthetics reasons may need to be considered
especially since the eruption of permanent
teeth will be delayed if primary tooth is lost at
an early age

85
 When the primary canine is lost, the incisor
teeth tend to shift laterally into this space,
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.

86
 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.

87
 Due to the early loss of primary first molar
particularly in mandible, a lateral and posterior
shift of the incisors may lead to development
of asymmetry within the arch
 Space maintenance in primary dentition should
be considered for prematurely lost primary first
molar.

88
 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 position.
 If the primary 2nd molar is lost prematurely,
the permanent 1st molar will usually migrate
mesially within the bone even before it
emerges into the oral cavity

89
 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.
 A distal shoe usually is indicated in such
situation.

90
 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.

91
 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
 Transverse problems usually manifests as
posterior cross bites from a narrow upper arch,
are relatively common in primary dentition.

 Sucking habits 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

93
 A unilateral crossbite almost always result,
not from a true skeletal or dental
asymmetry, but from a symmetrically
narrow maxilla with a functional shift.
 If both molar & canine widths are narrow,

expansion of the upper arch is indicated

94
 Primary molar relationships are classified
according to the relationship of the distal
surface of upper and lower second primary
molars:-
a) Flush terminal plane – is the normal
relationship
b) Distal step – here the lower molars are
distally positioned relative to upper molar
c) Mesial step - here the lower molar is
mesially positioned relative to upper molar.

95
Flush terminal Distal step Mesial step

96
 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
mandibular deficiency can be recognized at
the age of 3 yrs.

97
 Both deep bite and open bite malocclusion
occur in primary dentition.

Deep bite – it is usually associated with

skeletal proportions that predispose to this
condition
◦ A relatively short face
◦ Square gonial angle
◦ Flat mandibular plane

98
Open bite –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 when the sucking habits ends.
◦ Upto age of 5 yrs. sucking habits are unlikely to
cause any long term problem in children with
good skeletal proportions.

99
 It is also possible that an open bite results
from a skeletal jaw discrepancy of the long
face type characterized by-

◦ Increased lower anterior face height

◦ Increased gonial angle
spontaneous correction of such open bite is
not likely to occur .

Treatment – not required

- Results not stable
- Lot of growth is remaining

100
 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 the mixed

dentition.

101
 Posterior cross bites, particularly those with a
lateral shift of the mandible upon closure,
should be treated in primary dentition, either
by occlusal adjustment or by maxillary
expansion.

 An anterior cross bite caused by forward

mandibular shift should also be treated early.

102
 Although Skeletal 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
 Removable appliance
T-spring with
Bite block post.
Post Treatment
Moderate problems
Severe problems

107
 These consists entirely of dental problems
resulting from misplaced permanent teeth,
(with skeletal problems & severe crowding
problems excluded).

108
Missing primary teeth with adequate space:-

space maintenance
 If the primary 1st or 2nd molar is missing
& if there will be more than 6 months delay
before premolars erupt, & there is adequate
space (no space loss)

-Space maintenance is required

 Either fixed or removable appliance can be
used depending on patients co-operation.

109
 Early loss of a single primary canine in mixed
dentition requires space maintenance or
extraction of the contra lateral tooth to eliminate
the midline changes & development of arch
symmetry.

 If the contra lateral canine is extracted, a lingual

arch space maintainer may still be needed to
prevent lingual movement of incisors.

110
Localized space loss (3mm or less)
Space regaining:-
 Potential space problems can be created by

drift of permanent incisors or molars after

premature extraction of primary canines or
molars.
 In such cases lost space can be regained and

maintained

111
 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
 According to proffit if the primary molar has been
lost prematurely in a single quadrant, up to 3mm
of space can be regained by tipping the molar back
distally.

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

114
 Generalized Moderate Crowding
Space 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.
 These patients usually require

- Reduce width of primary teeth

- Selectively extract primary teeth
- Arch expansion

115
Spaced and flared maxillary incisors-
 In a child with spaced & flared or irregular

maxillary incisors, who has good molar

relationship, good facial proportions, the
space analysis should show that the space
available is excessive rather than deficient.

116
 If the upper incisors are flared & there is no
contact with lower incisors the protruding
upper incisors can be retracted quite
satisfactorily with a simple removable
appliance. (The presence or absence of excessive
overbite, must be evaluated)

 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
 A thumb or finger sucking habit should be
eliminated before attempting to retract the
incisors
 Physiologic adaptation to the space between
the anterior teeth requires that the tongue to
be placed in this area to seal off the gap for
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.

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

 The lower incisors biting against the lingual of

upper prevents them from 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

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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

spontaneous closure is unlikely.

 Persistent spacing between the incisors is

correlated with cleft in the alveolar process

between the incisors, to which fibres from
maxillary labial frenum insert.

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 For larger diastema it may be necessary to
surgically remove the frenal attachment to
obtain a stable closure of diastema .
 The best approach is to do nothing until the

permanent canine 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.

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 Crossbite of all the
incisors is rarely
found in children
who do not have
class III relation-
ship.
 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 in presence of severe
crowding.
 In this situation, extracting the adjacent
primary canines usually leads to
spontaneous correction of cross bite.
 Lingually positioned incisors limit lateral jaw
movements so early correction of the
crossbite is indicated.

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 Posterior cross bite in mixed dentition
children usually result from narrowing of
the maxillary arch & is often observed in
children who have prolonged sucking
habits.
 Both removable & fixed appliances can be
used for correction.
 According to proffit Whichever method is
used the maxillary arch should be over
expanded & then held passively in this
position for approximately 3 months
before appliance is removed.

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 A simple anterior open bite is one that is
limited to the anterior region in a child with
good facial proportions.
 Major cause of such an open bite is

prolonged thumb 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.
 It should be left in place for 3 – 6 months

after the habit has apparently been

eliminated.

126
 The eruption of permanent tooth can be
delayed if its predecessor is retained too long.
 This usually happens if the permanent tooth
bud is displaced.
 General guideline:-
A permanent tooth should erupt when
approximately ¾ of it’s root formation is
completed.

127
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.

128
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

region, where the second primary molar blocks the

first permanent molar and suffers root resorption
in the process.

129
Treatment options-
 If 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 consider extraction of E

followed by space regaining and then space

maintainer

130
Maxillary canine-
 Ectopic 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.
 Treatment options-
 When 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

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 The beginning of resorption of the 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 its correct position.

This comprehensive treatment will extend into the

early permanent dentition period

132
133
 Severe problems in mixed dentition falls into
3 major categories:-

 Dentofacial problems related to incisor

protrusion.
 Space discrepancy of 5mm or more.
 Skeletal jaw discrepancy.

134
 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.

135
 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
extraction, but may require extraction of
teeth
◦ 10 mm or greater = always require extraction

136
 Sequential removal of deciduous teeth to
facilitate the unimpeded eruption of permanent
teeth.
 Selective extraction of deciduous & permanent
teeth, reduces the severity of malocclusion .

137
In its classical form serial extraction applies
to patients who meet following criteria:-
1) No skeletal disproportions.
2) Class I molar relations.
3) Normal overbite.
4) Large arch perimeter deficiency (10mm).

138
According to proffit It has 4 steps:-
1. Extraction of primary lateral incisor as
permanent central incisors erupt. (if
necessary, since this often happens
spontaneously in severely crowded cases)
2. Extraction of primary canines as the lateral
erupts.
3. Extraction of primary 1st molar usually 6 -12
months before their normal exfoliation.
4. Extraction of permanent 1st premolars before
eruption of permanent canines.

139
1. Dewel`s method
 CD4

 2. Tweed`s method
 D4C

 3. Nance`s method
 D4C 

140
Dewel’s method

141
IF THE SPACE DISCREPANCY IS SMALL
 Simplified treatment.
 Fixed appliance therapy required to close

residual spaces.
IF THE SPACE DISCREPANCY IS LARGE
Serial extraction causes total space closure.
Fixed appliance is used just to achieve good

alignment, root paralleling.

142