Management of developing occlusion

INTRODUCTION
www.indiandentalacademy.com

Contents
• Definitions
• Need to take care of developing dentition?
• Importance of deciduous dentition
• Reasons for early intervention
• Benefits & difficulties
• Indications & contraindications
• Preventive management of developing occlusion
• Planning Space maintenance
• Clinical assessment for space management
• Space maintenance

• Interceptive orthodontics
• Anterior cross bite in primary and mixed dentition
• Posterior cross bite in primary and mixed
dentition
• Problems related to eruption of teeth
• Regaining space
• Serial extraction
• Conclusion
• References

DEFINITIONS
• Preventive orthodontics :
“action taken to preserve the integrity of what
appears to be normal occlusion at a specific time”
( Graber -1966 )
• Interceptive orthodontics :
“ that phase of science and art of orthodontics
employed to recognize and eliminate the potential
irregularities and malpositions in the developing
dentofacial complex”
( AAO - 1969)

Boucher`s clinical dental terminology –
• Space Maintainer is a fixed or removable appliance
designed to preserve the space created by the
premature loss of a tooth.
• Space maintenance is provision of an appliance
which is concerned only with control of space loss.
• Space Control refers to a careful supervision of the
developing dentition and includes measures that
diagnose and prevent / intercept situations so as to
guide the development of dentition and occlusion
• Space Regainer is a fixed or removable appliance
capable of moving a displaced permanent tooth into its
proper position in the dental arch.

Need ……
Importance of deciduous dentition
( Premature loss implications )
Space loss
Speech
EstheticsPsychological effect
Mastication
Growth retardation

Reasons for early intervention
• Does not impede growth of dentition
• Facilitates guidance of developing occlusion
• If not intervened early,
• Crowding progressively gets worse
• Premature loss causes asymmetry of arch
• Rotated teeth affect stability of correction later
• More favorable condylar position & growth ( Cl. III)
• Trains tongue to act like functional appliance
• Extraction of permanent teeth reduced
• Non compliance of adolescent years avoided
• Majority Cl.II problems corrected in 6-8 months
• Early management or Prevention of oral habits

Benefits of Early Diagnosis & Treatment
• Possibility of achieving better results
• Some forms of RX can only be done at an early age
• Early RX of deleterious habits is easier
• Psychological advantage in some children
Difficulties in early treatment
• Misperceptions exist
• Improper early treatment can be harmful
• Diphasic RX may lengthen chronological treatment time
• More tentative during active growth and tricky to predict

Indications for Early Intervention
 Primary Dentition :
Anterior and posterior crossbite
Tooth lost due to caries and space loss may
result
Unduly retained primary teeth
Malpositioned teeth
Deleterious habits which may distort growth

Indications for Early Intervention…….
 Mixed Dentition :
Loss of primary teeth endangering available space
Space loss
Malpositioned teeth,
Faulty eruption pattern
Supernumerary teeth
Cross bites of permanent teeth

Malocclusions from deleterious habits
Oligodontia
Midline diastemas
 Labioversion of upper incisors
Cl. II – skeletal, dental, functional
Serial extraction cases
Indications for Early Intervention…….

Contraindications
• When ,
† No assurance of sustained results
† Better result can be achieved later with effort
† Socially immature child
† Patient unwilling to cooperate for RX

Preventive Management
• Parent education
• Caries control
• Maintenance of tooth shedding time table
• Maintenance of dental arch integrity
• Other measures ( maintenance of occlusal
equilibration, Xn of ankylosed / supernumerary
tooth )

Planning for Space Maintenance
• Variables influencing space control :
• Oral musculature & habits
• Time elapsed since extraction
• Dental age & bony covering
• Available space
• Interdigitation
• Anomalies ( supernumerary tooth )
• Sequence of eruption
• Existing malocclusion
• Stage of occlusal development
• Congenital absence

Clinical assessment for space management
 AAPD….
• Intra oral examination to :
• Assess overall health status
• Determine status of patient’s occlusion
• Facial analysis
• Determine asymmetric growth patterns
• Determine skeletal, dental growth
• Dental and skeletal (occlusal) abnormalities
• Functional assessment
• Functional factors
• Habits
• Detect TMJ dysfunction

Using Arch length analysis
radiographs, orthodontic study
models, prediction charts
• Linear arch length
• Tooth size
• Position of lower incisors over basal bone
• Crowding
• Depth of curve of spee
• Leeway space

OBJECTIVES OF SPACE MAINTENANCE
The Best space maintainer is the tooth itself
with proper mesiodistal diameter. (Graber)
- Preservation of primate space.
- Preservation of the integrity of the dental arches.
- Preservation of normal occlusal planes.
- Aid in Esthetics and phonetics.
Space maintenance

APPLIANCE SELECTION
• Patient cooperation
• Integrity of the appliance
• Maintenance
• Modifiability
• Limitations
• Cost

Patient cooperation:
- Greater patient cooperation is required with
removable appliance
Appliance integrity:
- Inherent flaws in the construction of appliance .
- Appliance integrity is better with fixed
appliances ( Wright and Kennedy 1968 )
APPLIANCE SELECTION

Maintenance:
- clasps of removable appliance may require minor
adjustments
- Periodic recementation for fixed appliances
- length of time an appliance is required and projected
maintenance
Modifiability:
- Anticipating future modifications can reduce
number of appliances required and influence
selection of appliance
APPLIANCE SELECTION

Limitations:
- Appliance has time limitations
Cost:
- Economic implications dictate nature of
treatment to some extent.
Directly bonded are best.
APPLIANCE SELECTION

Space maintenance
 Loss of primary canine or First or Second primary molar
(CDE) :
1. CROWN / BAND AND LOOP MAINTAINER
Contraindications:
• Extreme crowding / space loss
• High caries activity
Limitations / disadvantages :
• Nonfunctional
• Migration of loop gingivally
• Does not prevent supraeruption of
opposing tooth www.indiandentalacademy.com

2. PASSIVE LINGUAL
ARCH
Contraindications:
• Before eruption of
mandibular incisors
• May cause untoward
movement
• Loss of cementation and
solder

3. NANCE APPLIANCE
Contraindications :
• Palatal lesions
• Either of molars not erupted
Tissue hyperplasia / infection
4. TRANSPALATAL ARCH – UNILATERAL
LOSS

Loss of second primary molar before eruption of
first permanent molar
1. DISTAL SHOE APPLIANCE
• Contraindications
– Several teeth missing
– Absence of abutments
– Poor oral hygiene
– Lack of patient / parent cooperation
– Certain medical conditions (blood dyscrasias,
immunosuppression, rheumatic heart disease, diabetes..)

For the cases where the distal shoe is
contraindicated, two possibilities for treatment
exist :
– 1) to allow the tooth to erupt and regain space
later or
– 2) use a removable or fixed appliance that does
not penetrate the tissue but places pressure on the
ridge mesial to the unerupted permanent molar.

Loss of primary and permanent incisors
1. REMOVABLE PARTIAL DENTURES
Demerits :
• Depends entirely on patient cooperation
• May be lost / broken by patient
• Lateral jaw growth may be restricted
• Irritate tissues
2. FIXED APPLIANCES
Disadvantages :
•Cement loss / solder failures
•Tissue lesions
•Eruption interference ( lingual arch )

Space maintenance for Multiple tooth loss
1. ACRYLIC PARTIAL DENTURE
2. PASSIVE LINGUAL ARCH
3. FULL DENTURES

Loss of first permanent molar
• Before eruption of second permanent molar
– Acrylic Distal Shoe extension
– Second molar mesial drift
– Sometimes Xn of opposing tooth in
preference to prolonged space maintenance
& eventual fixed replacement

Loss of first permanent molar
• After eruption of second permanent molar
– Second molar mesial drift
– Space maintenance for replacement
prosthesis (band & loop ,conventional
/modified fixed bridgework, implant
prosthesis )

Primary dentition (Maxilla)
1. Unilateral loss of D - Band / crown and loop
2. Unilateral loss of E – Distal shoe until eruption of 6 , then
reverse band and loop until both 6 are completely erupted
3. Bilateral loss of D – Bilateral bands / crown and loop
4. Bilateral loss of E – Distal shoe until eruption of 6 , then
reverse band and loop until both 6 are completely erupted
5. Multiple bilateral loss of molars - RPD
To summarize……….

Primary dentition (Mandible)
1. Unilateral loss of D – Band / crown & loop
2. Unilateral loss of E – Distal shoe until eruption of 6 &
incisors then reverse band and loop until both 6 are
completely erupted
3. Bilateral loss of D – Bilateral band / crown & loop
4. Bilateral loss of E -- Bilateral distal shoes until eruption of 6
& incisors then reverse band and loop until both 6 are
completely erupted
5. Multiple bilateral loss of primary molars- Saddle appliance
until eruption of 6 & incisors,www.indiandentalacademy.com

EARLY MIXED DENTITION (Maxilla)
1. Unilateral loss of D – Band / crown & loop
2. Unilateral loss E – Transpalatal arch
3. Bilateral loss D – Band / crown & loop
4. Bilateral loss of E – Nance
5. Multiple bilateral loss of molars - Nance
EARLY MIXED DENTITION (Mandible)
1. Uni / Bilateral loss of D –Band / crown & loop
2. Unilateral loss of E – Band & loop until eruption of incisors, then Lingual
arch
3. Bilateral loss E – Bilateral bands & loops until eruption of incisors, then
Lingual arch
4. Multiple loss – Saddle appliance until eruption of incisors,then Lingual
arch

LATE MIXED DENTITION: (Maxilla)
1. Uni / Bilateral loss D – BAND AND LOOP
2. Unilateral loss E – Transpalatal arch
3. Bilateral loss of E – Nance
4. Multiple loss – Nance
LATE MIXED DENTITION (Mandible)
1.Uni/ Bilateral Loss D –BAND AND LOOP
2. Unilateral loss of E – Lingual arch
3. Bilateral loss of E – Lingual arch
4. Multiple loss – Lingual arch

Interceptive orthodontics
Anterior crossbite in primary and mixed dentition
Etiology :
 Labially positioned supernumerary tooth
 Trauma to anterior primary tooth
 Prolonged retention
 Arch length deficiency
May lead to :
 Developing Cl.III malocclusion
 Traumatic occlusion
 Stripping of gingival tissue & pocket formation labially
 Wear facets on incisal & labial surfaces

• Treatment :
Occlusal equilibration Tongue blade therapy
Composite inclines
Fixed appliances
Acrylic lower inclined plane Palatal appliances
Anterior crossbite in primary and mixed dentition Interceptive
orthodontics

Posterior crossbite in primary and mixed dentition
• 3 types :
•SKELETAL
• Etiology –discrepancy in width of arches
• RX: palatal expansion appliance ,RME
•DENTAL
• Etiology – faulty eruption pattern
• RX: W-arch or Quad helix or Cross elastics
•FUNCTIONAL
• Etiology – shift of mandible into abnormal position
• RX: occlusal equilibration , comprehensive ortho RX
Interceptive
orthodontics

Problems related to eruption of teeth
1. Ectopic Eruption of First / Second Permanent
Molars :
RX :
• Early stage -- Distal shoe appliance
• Band and S-shaped loop ( Humphrey )
Interceptive
orthodontics

• Halterman appliance
• Kesling’s self locking separating spring

2. Ectopic Eruption of Permanent Lateral Incisors :
RX:
Unilateral loss & no midline shift –
band and loop or lingual arch
Unilateral loss , crowding & midline shift –
Xn of opposite side canine & lingual arch placed
3. Impaction & delayed eruption of Permanent canines:
RX:
Primary canine present– Extracted
Impacted permanent canine – surgical exposure /
orthodontic movement
Interceptive
orthodontics

4. Supernumerary teeth and accompanying occlusion
Etiology : continued budding of enamel organ
Maxilla : mandible – 8:1
Maxillary Incisor region - common
RX:
Does not interfere – observation
Delayed eruption of adjacent teeth – surgical removal
5. Anterior diastemas
Etiology : heavy labial frenum, supernumerary teeth, habits..
RX postponed until complete eruption of canines.
Interceptive
orthodontics

6. Congenitally missing teeth
RX:
One or both maxillary lateral incisors missing:
prosthetic replacement, implants or drifting
canine mesially and reshaping it to resemble the lateral
One premolar missing :
prosthetic replacement, implants
3 or 4 premolars missing :
Orthodontic RX and prosthetic replacement
Interceptive
orthodontics

7. Crowding
• Dependent on several Factors :
• Inter dental spacing
• Inter canine arch width
• Inclinations of permanent incisors
• Ratio of size b/w perm and primary teeth
• Management :
• Observe
• Disking
• Extraction

Regaining Space….
Diagnostic considerations:
- Alignment and space needs of the other teeth in the
arch
- Relationship of the teeth with the denture base
- Transverse and sagittal relationship
- Vertical denture relationships
- Skeletal relationship of the denture base to the
cranium
- Profile of the tissues

Diagnostic aids:
- Study models
- Radiograph of all the periapical structures
- Clinical assessment of the facial symmetry and
proportions
- Possibly cephalometric analysis
Regaining Space….

Radiographs and study models:Radiographs and study models:
- To Assess space needs and tooth alignment
- Proximity of the adjacent erupting teeth
- Estimation of rotation. Slipped contacts, facial – lingual
displacement of teeth from arch circumference
- Permit visualization of vertical, transverse, and sagittal
dental relationships.
Regaining Space….

Classification
Space Regainer
Removable Fixed
Free endloop
Splitsaddle
Jack screw
Sling shot
Open coil SR
Gerber SM
Hotz L Arch
Sectional arch
Lip bumper
Anterior SR

Fixed space regainers
Open Coil Space Regainer
•Reciprocal active fixed regainer
•Spaced coil spring 2-3 mm longer
than distance from anterior stop to
molar tube.
•Wire and spring replaced with longer
sections at 4 week intervals

Anterior Space Maintainer And Regainer
- Standard labial tubes are bonded
- .014” wire inserted into Lateral incisor tube,
- Wire then inserted into open coil Spring passed
through central incisor tube

Split Saddle Space Regainer
- Formed of .028” wire
- In 2 segments
- Most successful for
regaining 1 – 2 mm lost space
- Appliance is sturdy, durable

Sling Shot Space Regainer :
- Consists of an S bend in
a continuous 0.036” wire
on both buccal and
lingual sides
- Top curve of S bend is
used as elastic hook
- Hook is placed adjacent
to the developmental
groove on lingual side
- Distal to the
developmental groove on
buccal side www.indiandentalacademy.com

Space Regainer Utilizing Jack-screw :
- Open the jack screw ¼
turn (0.25 mm) twice a day
until the appliance is
difficult to seat
- ¼ turn every 2nd
or 3rd
day

SERIAL EXTRACTION
 Term coined by Kjellgren (1929)
 Father of serial extraction Nance (1940)
 Definition :
correctly timed, planned removal of certain
deciduous and permanent teeth in mixed dentition cases
with dento-alveolar disproportion in order to :
• Alleviate crowding of incisor teeth
• Allow unerupted teeth to guide themselves into
improved positions
• Lessen the period of active appliance therapy or
eliminate it

Indications
Class I with anterior crowding ( >10mm space
loss)
Lingual eruption of lateral incisors
Midline shift potential due to unilateral canine
loss
Crowded arches accompanied with extreme
proclination
Abnormal primary canine root resorption
Lack of developmental spacing
Anomalies such as ankylosis, ectopic eruption

Contraindications
Mild to moderate crowding (8mm or less)
Congenital absence of teeth
Extensive caries of first permanent molars
requires their removal
Deep or open bites without correction
Severe class II, III of dental / skeletal origin
Cleft lip and palate cases

Dewel’s method (1978)
CD4

Tweed (1966)
DC4

Conclusion

References…..
• Dentistry for the child and adolescent –
McDonald, Avery, Dean( 8th
edition )
• Text book of Pedodontics – Shobha tandon
• Pediatric Dentistry : Total Patient Care –
Stephen H.Y.Wei
• Orthodontics –Art and Science -
S.I.Bhalajhi
• DCNA 1978

Management of developing occlusion

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