Preventive orthodontics

preventive dentistry

1. PRESENTED BY : ASHISH KHATIWADA GUIDED BY : DR. GUNJAN KR. SHRESTHA PREVENTIVE ORTHODONTICS

2. DEFINITION Prevention is not only better than cure but more stable and cheaper as well Graber (1966)- has defined preventive orthodontics as the action taken to preserve the integrity of what appears to be a normal occlusion at a specific time. Proffitt and Ackermann(1980)- has defined it as prevention of potential interference with occlusal development .

3. PREVENTIVE ORTHODONTIC PROCEDURE Parent education Caries control Care of deciduous dentition Management of ankylosed tooth Maintenance of quadrant wise tooth shedding time table Checkup for oral habits and habit breaking appliance if necessary Occlusal equilibrium if there are any occlusal prematurities Prevention of damage to occlusion.eg:- milwaukee braces Extraction of supernumerary teeth Space maintenance Management of deeply locked first permanent molar Management of abnormal frenal attachments

4. PARENT EDUCATION Ideally much before birth of child Expecting mother- nutrition,ideal environment for developing fetus. Soon after birth—Proper nursing and care of child. If bottle fed---use physiologic nipple and not conventional nipple which are non physiologic( ie,do not permit suckling by movement of tongue and lower jaw).leading to various orthodontic problems of teeth.

5. Do not use pacifiers for a long time . Prevention of nursing bottle syndrome(due to bottle feeding during night….upper teeth caries..but lower no caries ) Need for maintaining good oral hygiene Correct method of brushing teeth Most procedure are carried out on patient who are 3- 12 years of age

6. Physiologic nipples Pacifiers Nursing bottle caries

7. Caries control Caries in proximal surface of deciduous teeth if not restored leads to loss of arch length by movement of adjacent teeth into the space and thus cause discrepancies between arch length and tooth material when larger permanent teeth erupt into the oral cavity.

8. Care of deciduous dentition Prevention and timely restoration of carious teeth. All efforts to prevent early loss of deciduous teeth(they are natural space maintainers) Simple preventive procedures like: Application of topical fluorides,Pit & fissure sealnts etc.

9. Extraction of supernumerary teeth Supernumerary & supplemental teeth can interfere with eruption of nearby normal teeth They deflect adjacent teeth and erupt in abnormal positions They should be identified and extracted before they cause crowding or spacing or displacement of other teeth

10. Supernumerary teeth:

11. Eliminating Occlusal Interferance These lead to deviations in mandibular path of closure and also predispose to bruxism. Detected by using articulating paper and premature contact removed by selective grinding is carried out.

12. Maintenance of tooth shedding time table: Not more than 3 months difference in shedding of deciduous teeth and eruption of permanent teeth in one quadrant as compared to other. Delayed eruption due to: Over retained deciduous teeth roots Unresorbed deciduous root fragments Supernumerary tooth Cysts and tumors Over hanging restoration (deciduous teeth) Fibrosis of gingiva Ankylosed primary teeth

13. Management of akylosed teeth: Absence of PDL membrane in a small area or whole of the root surface. They do not resorb---prevent permanent teeth from erupting or deflect them to erupt in abnormal positions. Presence of a deeply submerged tooth can also cause tipping of adjacent teeth and supraeruption of the opposing teeth. Diagnose such tooth and surgical removal removal at an appropriate time for permanent tooth eruption.

14. Managemnet of abnormal frenal attachments: Thick and fleshy maxillary labial frenum leads to midline diastema. Diagnosis –blanch test.Treated at an early stage for prevention. Ankyloglossia or tongue tie -abnormal development of tongue. Difficulty in speech and swallowing and breastfeeding problem:-surgically treated.

15. Oral habits ,checkups and educating patients and parents. Identify and stop habits such as Thumb sucking ,nail biting ,tongue thrusting and lip biting Prevention starts with proper nursing nipple and pacifiers to enhance normal functional and deglutitional activity.

16. Preventing MILWAUKEE Brace Damage : Orthopedic appliance used for correction of scoliosis. It applies tremendous force on the mandible and the developing occlusion leading to retardation of mandibular growth and possible deformities W henever such appliance used, occlusion should be protected using functional appliance or positioners Made of soft materials

17. MILWAUKEE BRACES

18. Deeply locked permanent first molars: Ocasionally the deciduous second molar have a prominent distal bulge which prevents the eruption of the first permanent molars.Slicing these distal surface helps in guiding the eruption of first permanent molars.

19. Space Maintenance : Premature loss of deciduous teeth causes drifting of adjacent teeth.This cause abnormal axial inclination of teeth,spacing & shift in midline. Premature loss of deciduous anteriors leads to very little orthodontic changes. Premature loss of permanent 1st molars-shift of anteriors takes place.

20. Premature loss of permanent 2nd molar--first permanent molar migrate mesially.results in insufficient space for erupting premolars & hence impaction . Space maintainers—maintains space created by premature loss of deciduous teeth.

21. Ideal requirements of space maintainers: Maintain entire mesio -distal space created by loss of teeth. Restore function as far as possible . Prevent over-eruption of opposing tooth . Simple in construction . Strong enough to withstand functional forces.

22. Should not exert excessive stress on opposing teeth . Permit maintenance of oral hygiene . Must not restrict normal growth and development & natural adjustments which takes place during transition from deciduous to permanent dentition . It should not come in the way of other functions

23. Classification of Space maintainers According to Hitchcock: Removable or fixed or semifixed With bands or without bands Active or passive Functional or non functional combinations of the above According to Raymond C. Thurow : 1.Removable 2.Complete arch- LingualArch Extra-oral Anchorage 3.Individual tooth.

24. According to Hinrichsen : 1.Fixed space maintainers: Class I a)Non-functional types i )Bar type ii)Loop type b)Functional types i )Pontic type ii)Lingual arch type. Class II-Cantilever type (distal shoe,band & loop) 2.Removable Space maintainer: Acrylic partial dentures

25. Removable space maintainers Removed & reinserted by patient It can be functional or non-functional Functional----teeth provided to aid in mastication, speech and esthetics Non functional----only an acrylic extension over edentulous area to prevent space closure

26. Indications: When esthetics is of importance When abutment teeth cannot support fixed appliance Cleft palate patients---for obturarion of palatal defects If radiographs reveal that the unerupted permanent tooth is not going to erupt in less than 5 months If permanent teeth is not fully erupted.so a band cannot be adapted Multiple losses of deciduous teeth requiring functional replacement in the form of either partial or complete denture

27. Contraindications: Lack of patient co-operation Allergy to acrylic Epileptic patients having uncontrolled seizures Advantage: They are easy to clean and permit maintenance of proper oral hygiene They maintain or restore the vertical dimension They can be worn part time allowing circulation of the blood to the soft tissue They serve other important functions like mastication ,esthetics and phonetics Dental check-up for caries detection can be undertaken easily They stimulate eruption of permanent teeth

28. Room can be made for permanent teeth to erupt without changing the appliance Band construction is not necessary They help in preventing development of tongue thrust habit into the extraction space DISADVANTAGE: They may be lost or broken by the patient Unco -operative patients may not wear the appliance Lateral jaw growth can be restricted if clasps are incorpated They may cause irritation of the underlying soft tissue

29. Some commonly used removable space maintainers: Acrylic partial dentures Have been used successfully in patients who have undergone multiple extraction It can be easily adjusted to allow the eruption of teeth Inclusion of artificial teeth in the denture restore masticatory function Clasp can be fabricated for retention

30. Full or complete dentures Used in case where all primary teeth are cannot be restored due to rampant caries Restore masticatory function and esthetics Guide the first permanent molars into their correct position The posterior border of denture should be placed over the area approximating the mesial surface of the unerupted first permanent molar

31. Removable distal shoe space maintainers It has been used to guide the first permanent molar into position when the deciduous second molar is lost shortly before the eruption of first permanent molar The tooth to be extracted is cut away from the stone model and depression is cut into the stone model to allow the fabrication of the acrylic extension The acrylic will extend into the alveolus after the removal of the primary teeth

32. Fixed Space Maintainers: Space mainainers that are fixed or fitted onto the teeth are called fixed space maintainers. Advantages: Bands & crowns are used.So ,minimum or no tooth preparation Do not interfere with passive eruption of abutment teeth. Jaw growth is not hampered The succedaneous permanent teeth are free erupt into the oral cavity Useful in uncooperative patients Masticatory function is restored if pontics are placed

33. Disadvantages : Elaborate instrumentation Experts skill May result in decalcification of tooth material under bands Supra eruption of opposing tooth if no pontics are placed If pontics used ,it may interfere with vertical eruption of abutment teeth & may prevent eruption of replacing permanent teeth,If the patient fails to report.

34. Examples of fixed space maintainers Band and loop space maintainers Most commonly used appliance Tooth distal to the extraction space is banded and a loop of thick stainless steel wire is soldered to it With its mesial end touching the tooth mesial to the extraction space It is a unilateral fixed appliance indicated for space maintenance in the posterior segments when a single tooth is lost

35. Crown & loop appliance Similar to band and loop space maintainer except that a stainless steel crown is used for the abutment tooth It is used when the abutment tooth is highly carious , exhibit marked hypoplasia or is pulpotomized

36. Lingual arch space maintainer Most effective for space maintenance in lower arch Two band on the 2 mandibular first molars/second deciduous molars,which are joined by a stainless steel wire contacting the lingual surface of 4 mandibular incisors Incisors used to preserve space created by multiple loss of primary molars Helps in maintaining the arch perimeter by preventing mesial drift of the molars& also lingual collapse of anteriors .

37. Platal arch appliance(Nance holding arch) Similar to lingual arches . They are designed to prevent mesial migrationof maxillary molars. They are constructed using 0.036 inch diameter hard stainless steel wire The Nance holding arch is maxillary lingual arch that does not contact the anterior teeth It incorporate an acrylic button in the anterior region that contact the palatal tissue They are mainly used when there is bilateral loss of maxillary molar

38. Transpalatal arch: For stabilizing maxillary first permanent molars It is mainly recommended for stabilizing the maxillary first permanent molars when the primary molar require extraction It consist of a thick stainless steel wire that spans the palate connecting the first permanent molars of one side with the others Indicated when one side of the arch is intact ,and several primary teeth on the other side are missing

39. Esthetic anterior space maintainer It was described by Steffen,Miller and Johnson in 1971 Consist of a plastic tooth fixed onto a lingual arch that in turn is attached to molar bands

40. Band and Bar type space maintainer This type of space maintainer is called crown and bar space maintainer In this type abutment teeth on either side of the extraction space are banded and connected to each other by a bar

41. Distal shoe space maintainer: Intra alveolar appliance The distal surface of the second primary molar guides the unerupted first permanent molars when the second primary molar is removed prior to eruption of permanent 1st molar ,the intra-alveolar appliance provides greater control of the path of eruption of the unerupted tooth and provides undesirable mesial migration The appliance now used in practice is Roche’s distal shoe or it’s modifications using crown and band appliance with a distal intra-gingival extension.

42. DESIGN OF WIRE LOOP In lower arch , the contact area of distal extension of the appliance should have slight lingual position over the crest of the alveolar ridge To engage the mesial contact area of the 1 st permanent molar which begins its mesial and lingual movement The contact area of distal extension of the maxillary appliance should be slightly facial to the crest of the alveolar ridge Gingival extension should extend about 1 mm below the mesial margin of 1 st permanent molar or just sufficient to capture its mesial surface Before final placement of space maintainer ,a radiograph is taken

43. INDICATION: Premature loss or extraction of the second primary molar prior to the eruption of the first permanent molar Advanced root resorption and periapical bone loss of the second primary molar prior to the eruption of first permanent molar A primary second molar with advanced caries that is not restorable Ectopic eruption of the permanent first molar Ankylosis of the primary second molar

44. CONTRAINDICATION: Inadequate abutment due to multiple loss of teeth Poor patients or parent cooperation Missing permanent first molar Systemic disease that affect healing such as DM Cardiac anomalies that require antibiotics prophylaxis prior to dental treatment

45. Preformed bonded space maintainer It consist of two bondable mess pads that are bonded to teeth on either side of lost tooth

46. Planning for space maintainers: 1.Time elapsed since loss of tooth 2.Dental age of patient 3.Thickness of bone covering the unerupted teeth 4.Sequence of eruption of teeth 5.Congenital absence of permanent teeth

47. References Orthodontics The art and science ( 6 th Edition)- S.I. Bhalajhi Textbook of Pediatric Dentistry ( 3 rd Edition)- Nikhil Marwah