1. Interceptive Orthodontics
Dr Jean-Marc Retrouvey
Dr Donald Taylor

2. Objectives
• Discuss most common orthodontic problems in
young patients
• Present different modalities of treatment.
• Identify the proper timing of treatment

3. Topics to be addressed …..
1. Dental crowding
2. Eruption problems
3. Posterior crossbites
4. Increased overjet
5. Anterior crossbites
6. Oral habits

4. 1. Dental crowding
A. Space maintenance
B. Control of Leeway space
C. Dental extractions

5. A. Space maintenance

6. Indications
Why maintain space?
– Allow optimal dental
alignment
– Allow permanent teeth
to erupt into their
normal space
– Conserve an acceptable
occlusion
– Prevent supra eruption
of antagonists

7. Bilateral Space maintenance:
Lingual arch
In this case we use the primary second molars to compensate for the
loss of a deciduous cuspid

8. Space maintenance on the upper
arch: Fixed Nance appliance

9. B. Control of Leeway space
Very important in interceptive
orthodontics
Most predictable way to reduce the
need for bicuspid extractions

11. Note the difference in width
between #75 and #45

12. A lower lingual arch acts as a
space maintainer
• If the Leeway space is maintained 75 % of
cases can be treated without extractions and
without proclination of the lower incisors. (Dr
Gianelly)

13. Premature loss of the deciduous
cuspids

14. A. Passive lingual arch
Expansion of the maxillary arch done concurrently

15. Result…..

16. B. Reduction of mesial aspect of
the second deciduous molars
• Another way to take
advantage of the
Leeway space
• Allows spontaneous
alignment of the lower
incisors
• Simple and efficient
procedure (Cozzani:
JCO 1994)

17. Indications
• Moderate crowding of the lower arch
(example: loss of a deciduous cuspid)
– Timing is most important
• wait until there is almost total resorption of the roots of
the deciduous second molars

18. Too soon!

19. Proper timing!

20. Results

21. C. If Leeway space is not
sufficient for proper alignment
•Selective extractions
•Enucleation of bicuspids

22. Example: Serial Extractions

23. 1. Extraction of primary cuspids

24. 2. Improvement in the position of
the incisors

25. The incisors are well positioned

26. Enucleation

27. 2. Dental Eruption Problems
A. Early or delayed eruption
B. Ectopic eruption
C. Missing teeth
D. Ankylosed teeth
E. Impacted teeth (maxillary cuspids)

28. A. Early or delayed eruption
A panorex is indicated at the age of 7 to 8

29. Abnormal sequence of eruption:
Take a panorex please….supernumary upper cental incisors

30. B. Ectopic eruption

31. Ectopic # 45

32. Follicular cyst

33. Example: Nine year old patient
presenting with #34 erupting
ectopically
Patient complaint : my front teeth are too far ahead

35. Treatment: extract # 75 and place
an active lingual arch
• Spring to tip the
crown of # 34
mesially
• The cuspid had
already began to
drift distally

36. Retention

37. C. Missing teeth

38. Agenesis
• This problem is seen relatively frequently
• Which teeth are most often missing?
– Third molars
– Upper lateral incisors (Caucasian)
– Lower central incisors ( Asian)
– Lower second premolars

39. Thirteen year old girl

40. Panorex

41. This case is one which will require a combination of orthodontics
and prosthodontics. It will require extensive planning
Treatment options:
• Extract the deciduous second bicuspids and protract the permanent molars or maintain the
deciduous bicuspids long term, Replace absent #22 with an implant
•Increase the width of #12 reduce #23, intrude and crown #24 to make it look like a cuspid
It is also imperative to conserve the profile

42. D. Ankylosed Primary teeth
Often found with congenitally absent
permanent bicuspids and lack of
growth of the corpus of the mandible

43. Ankylosed teeth should be extracted
when…
 The permanent molar begins to tip mesially
 A periodontal problem begins to develop at
the mesial of the permanent molar
An open bite develops at the bicuspid and
molar area

44. Ankylosed deciduous
second premolar
This is a case where #65 should have been removed

46. Ankylosed teeth may be
maintained…
• …If the ankylosed teeth
are in the plane of
occlusion.
…Especially if the roots
are not resorbing.

47. E. Impacted teeth
Difficult to treat. Prognosis is
guarded

48. 16 impacted teeth!

49. Impacted upper central incisors
• Most often caused by
trauma to the deciduous
tooth. Root can become
dilacerated
• Infection of deciduous
central
• Cyst
• Supernumary tooth

50. Case treated at MCH

51. Nine year old patient presented at MCH for a
routine dental exam: What would you do?
If the sequence of eruption is altered you need to ask questions and
investigate radiographically

52. Space maintenance was
prescribed by the family dentist

53. Oups!
• An upper central incisor
was impacted
• The parents did not
recall a history of
trauma…

54. Maintained for three months
24 months
later!

55. Another case of an impacted upper
central incisor
• Young patient followed by
his family dentist presented
at the emergency of the
MCH because of swelling of
the upper lip
• No history of trauma or pain
• The treating dentist found
no problems during a
routine exam 3 months
previously and apparently
the swelling increased
gradually

56. Extent of the lesion
• The central incisor is
impacted
• The lateral incisor is
displaced laterally and
distally
• The cuspid is severely
impacted mesially

57. Transverse cut: CT scan

58. Surgery prior to orthodontic
treatment

59. Intraoral view
• Altered sequence of
eruption
• Severe swelling

60. Second problem: Canine is resorbing the
lateral incisor

61. Progression:

62. Final Result
Surgical scar

63. E. Ectopic eruption of upper
canines
Be attentive of buccally impacted upper cuspids
as resorption of the roots of the lateral incisors
is seen frequently

64. Impacted cuspids
• Upper cuspids are the teeth most often
impacted (3 to 4%)
• Treatment is difficult and costly
• Can we reduce the incidence of this problem?

65. Etiology (Theories)
1. Narrow upper arch
causes a strong
probability of
impaction. Not valid in
the majority of cases
2. A combination of
genetics and familial
tendencies
3. Missing or small
lateral incisors, but a
normally sized arch

67. Excellent result but a lot of work
required

68. Prevention of palatally impacted
cuspids
• Early diagnosis: palpation at age 9 . Should
feel a bulge at the labial of the deciduous
upper cuspids
• Screening Panorex at age 9 years
• Extraction of primary canines if necessary
• Extraoral traction in Class II cases
• Palatal expansion if the upper arch is narrow

69. Potential Treatment Options
1. Dr Kurol demonstrated that 65% of canines
presenting with a mesial angulation will erupt
normally once the deciduous cuspids have been
removed
2. Dr Taylor showed that 85% of canines will erupt
normally if , in Class II cases, molars are
distalized into a Class I relationship
3. Dr Baccetti found similar results after palatal
expansion

70. Normal cephalometric values

73. Extraction 53
Extraction 83

74. Extraction 63

76. Date of removal of braces

77. 3. Posterior crossbites
Bilateral
Unilateral
• Functional
• Non functional

78. Bilateral posterior crossbite
• This type of malocclusion does not have a functional
origin

79. Unilateral Crossbite
Centric occlusion

80. Centric relation

81. Rapid Palatal Expansion
• The best method to open the midline palatal
suture and increase the width of the maxilla
orthopedically
• Maxillary expansion is now being prescribed
in younger patients
– Some authors are proponents of RPE therapy in
the primary dentition…..

82. Types of appliances:
Hyrax, Hass or Bonded

83. Correction of a
posterior unilateral
crossbite

84. At the 24 month follow-up this patient will
most likely not require further orthodontics

85. Expansion without a crossbite
• Potential Indications:
– Narrow and triangular
maxilla
– Lack of transverse
development
– Moderate crowding
– Teeth of normal width

87. Crowding in the mixed dentition:
What would you do?
1. I don’t know
much…
2. Extraction of
deciduous
canines?
3. Expansion of the
maxilla?

88. Expansion only!
(18 months later)
No treatment on the lower arch

89. 4. Oral habits
• Thumb sucking
• Low tongue posture
• Oral respiration
Photographie: Dre Stéphane Schwartz MCH

90. Deformation of the alveolar
processes even in the deciduous
dentition

91. Treatment options
• Psychology
• Speech therapy
• Treatment
– Fixed appliance
– Removable
appliance

92. Anterior position of the tongue.
Mother wanted something fixed….

93. Four months of treatment with a
palatal expansion appliance and a
tongue crib

94. The occlusion and smile have
improved including in the vertical
dimension (smile line)

95. 5. Excess overjet
• Etiology:
• Oral habits: upper incisors proclined and spaced
• Class II skeletal with dentoalveolar factors
– Growth modification
• HG
• Twin block , bionator
• Forsus
• Genetic origin. Patient in which growth is or has been unfavorable
– Surgery or camouflage

96. Cephalometric analysis is very
important
Differential Diagnosis
• Skeletal relationship
– Maxillary
– Mandibular
– Vertical
• Dentoalveolar
relationship
– Inclination of the upper
and lower incisors

97. Dentoalveolr protrusion or
skeletal dysplasia?
Dentoalveolar Protrusion :
•Normal skeletal measurements
•Excess overjet
•Space between the upper incisors
•Proclined upper incisors

98. Dentoalveolar protrusion or skeletal
dysplasia?
Skeletal dysplasia:
• Abnormal skeletal measurements
•Excess overjet
•No space present between the upper incisors
•Full cusp Class II molars

99. Dentoalveolar Protrusion Case
• 10 mm overget
• Mainly of dentoalveolar origin
(ANB=3.5)

100. Treatment
• Compromised
treatment
• Bands on permanent
molars
• Brackets on the 6 upper
anteriors
• Cervical extra oral
traction
It was necessary to avoid the use of a removable appliance because
the upper incisors would extrude, an unfavorable result even if the
overjet was reduced

101. 12 months post treatment

102. Skeletal Class II

103. Skeletal Class II
• Should we intervene at a young age?
– Two phase treatment vs single phase
• Scientific literature supports a single phase
treatment
–However many clinicians still practice 2
phase treatment
• Clinical judgment is important because each
case Is different

104. ClassII division 1 ,11 year old female patient

105. Retrusive mandible
• Deficient lip seal
• Good facial proportions
• Favorable growth
potential

106. Myofunctional Appliance
• Promotes
– Protraction of the
mandible
– Maximum expression
of mandibular
growth
– Bite opening
– Maxillary expansion

107. Twin Block Appliance
• Appliance to protract • Other myofunctional
the mandible appliances perform
• Maxillary expansion essentially the same
• Bite opening functions

108. Excellent response by the patient
• Compliant patient
• Favorable
mandibular growth
• Good dentoalveolar
response

109. Same type of response in our patient
(12 months of Twin Block)

110. Types of treatment
• « Timing is almost everything »
• Dentoalveolar compensations must be
favorable
• Whatever we do, optimal mandibular growth
is primordial
• Disclusion of the dentition is extremely
important

111. Fixed appliances
• Type « Herbst » or
Forcus…
• Pistons position the
mandible in an anterior
position
• Generally slightly more
efficient than
myofunctional appliances
• Correction is mainly
dentoalveolar

112. Genetic mandibular retrusion
• Regardless of the type of
appliance used ythe
chances of success are
limited
• The family must be aware
that mandibular
advancement surgery will
most likely be necessary if
a reasonable result is
contemplated

113. 6. Anterior crossbite
• Functional origin
– Easily corrected with a
removable appliance
• Dentoalveolar origin
– Palatal expansion and
traction
• Skeletal origin
– Surgery probably
required

114. Differential diagnosis
• Anterior crossbite:
Class III vs pseudo Class III
– Manipulation:
centric occlusion – centric relation
– Facial profile (concavity of middle third of face)
– Dentoalveolar compensations :
• Verify the angulation of the upper and lower incisors

115. Functional anterior crossbite
Centric occlusion Centric relation
Manipulate the condyles in their
physiologic rest position. If the
occlusion is end to end it is probable
that the crossbite is functional

117. Appliance of choice to correct a
functional anterior crossbite
• Hawley with
posterior bite pads
• Finger springs or
microscrews on
the lingual of the
upper incisors

119. Skeletal Class III Treatment
Examination Treatment
1. Analysis of records • Rapid maxillary Expansion
2. Estimation of the severity • Maxillary traction with
of the malocclusion Delaire facemask or bone
3. Prediction of growth plates (new approach)
– Direction • Brackets on upper incisors
– Potential, amplitude • Long term retention

120. 2008
Mainly, a retruded
maxilla
The lower incisors are
not retroclined

121. Rapid Palatal Expansion
21 to 28 days of activation, 1 turn of screw per day

122. Sleep Apnea in the child and
adolescent
Le rôle de l’orthodontiste dans l’amélioration de la respiration chez l’enfant et
le jeune adulte affligé d’apnée du sommeil
Dr Jean Marc Retrouvey
Director of Orthodontics
McGill University

123. Snoring: Benign condition and
annoying but without danger
(snoring)
UARS: Disturbance of sleep
without oxygen desaturation
(no cardiopathy
OSA: Trouble sleeping + oxygen
desaturation of (cardiac
disorders, vascular
accidents, hypertension, arythmia
s, death)
C*Collpo N. Semin Respir Crit Care Med 2005; 26(1): 13-24
Irit Care Med 2005; 26(1): 13-24

124. Most frequent contributing factors
1. Environment
– Diet = Obesity
– Allergies
2. Genetic
– Skeletal malocclusion
3. Combination

125. Observations frequently seen
• Hypertrophied tonsils
and adenoids seen in
young patients
presenting with UARS
or OSA
http://kidshealth.org.nz/index.php/ps_pagename/contentpag
e/pi_id/303

126. Obesity

127. Typical appearance of a child
who suffers from sleep apnea
1.Extraoral exam
 Facial type
 “Saucers” under the
eyes
 Retrusive mandible
(Classe II malocclusion)
 Retrusive maxilla?

128. Normal
Apneic
•Retrusive mandible
•Increased anterior face
height
•Underdeveloped ramus
of mandible
•Obtuse gonial angle

129. Role of the dentist:
Rapid palatal expansion
• Literature supports RPE
at a young age for OSA
• A skeletal expansion of
an average of 4,5 to 6
mm is obtained
• The earlier the
intervention, the
greater the benefits

130. Conclusions
• A detailed orthodontic examination is essential
for every child
• Interceptive orthodontics is one of the most
important aspects of pediatric dentistry
• Simple, well coordinated treatment regimen, will
be very beneficial for your patients.
• This presentation was an overview of interceptive
orthodontics. Hopefully it has given information
to allow better communication with your
patients, parents and friendly orthodontist!