1. BY
DR.JUNAID DAYAR

2. Orthodontic procedures can be divided as:
 Preventive
 Interceptive
 comprehensive

3. Preventive orthodontics
 Preventive procedures are undertaken
in anticipation of development of a
problem
 Patient and parent education ,
supervision of growth and development
of dentition and craniofacial structures ,
the diagnostic procedures undertaken to
predict the appearance of malocclusion
and treatment procedures instituted to
prevent the onset of malocclusion

4. Interceptive orthodontics
 Procedure are undertaken when the
problem has already manifested.

5. Orthodontic problems in children can be
divided conveniently into
non skeletal (dental) and skeletal
problems , which are treated by tooth
movement and by growth modification,
respectively.

6. Preventive orthodontics
 Natal teeth
 Occlusal relationship problems
 Eruption Problems
 Space maintainence

7. Natal teeth
 Present at birth or erupt shortly after
birth
 Most frequent in lower incisor region
 Only 10% are supernumerary therefore
removed only when interfere with
feeding or causing tongue ulceration

8. Occlusal relationship problems
a)Cross bites of Dental Origin
b) Oral Habits and Open Bites

9. Occlusal relationship problems
Cross bites of Dental Origin:
Correction of dental crossbites in the
mixed dentition is recommended
because it eliminates functional shifts

10. Minor canine interference
leading to mandibular shift

11. Non skeletal anterior Crossbites
The most common etiologic factor for non
skeletal anterior Crossbites is lack of space
for the permanent incisors, and it is
important to focus the treatment plan on
management of the total space situation,
not just the crossbite.
If the developing crossbite is discovered
before eruption is complete and overbite
has not been established the adjacent
primary teeth can be extracted to provide
the necessary space

12. Non skeletal anterior Crossbites
Dental anterior crossbites typically develop
as the permanent incisors erupt.
Those diagnosed after overbite is
established require appliance therapy for
correction.
The first concern is adequate space for
tooth movement, which usually requires:
1: Bilateral disking,
2: Extraction of the adjacent primary teeth,
3: Or opening space for tooth movement.

13. Non skeletal anterior Crossbites

14. Non skeletal anterior Crossbites

16. Dental posterior cross bite
 early loss of a second deciduous molar
causing a second premolar to erupt
palatally/lingually
 retention of a primary tooth can deflect
the eruption of the permanent successor
leading to a cross bite.

17. Dental posterior cross bite

18. Dental posterior cross bite

19. Dental posterior cross bite

20. Oral Habits and Open Bites
Open bite in a preadolescent child has
several possible causes:
1: The normal transition as primary teeth
are replaced by the permanent teeth
2: A habit like finger sucking
3: Tooth displacement by resting soft
tissues

21. Open bite observed during the
transitional dentition years

22. Effects of Sucking Habits
The effect of such a habit on the hard and
soft tissues depends on its :
1: Frequency(hours per day)
2: Duration (months/years)
 With frequent and prolonged sucking,
maxillary incisors are tipped facially,
mandibular incisors are tipped lingually ,
and eruption of some incisors is
impeded

23. Effects of Sucking Habits

24. Effects of Sucking Habits
As long as the habit stops before the
eruption of the permanent incisor, most
of the changes resolve spontaneously.

25. Effects of Sucking Habits
Non-dental Intervention:
As the time of eruption of
the permanent incisors approaches, the
simplest approach to habit therapy is a
straightforward discussion between the
child and the dentist that expresses
concern and includes an explanation by
the dentist.

27. Eruption problems
 Over-Retained Primary Teeth
 Supernumerary teeth
 Delayed Incisor eruption
 Ankylosed Primary Teeth
 Ectopic eruptions
 Transposition
 Primary failure of eruption
 Roots shortened by radiation therapy

28. Over-Retained Primary Teeth
A permanent tooth should replace its primary
predecessor when approximately three fourths of
the root of the permanent tooth has formed, whether
or not resorption of the primary roots is to the point of
spontaneous exfoliation.
A primary tooth that is retained beyond this point
should be removed.
An over-retained primary tooth leads to:
 Gingival inflammation
 Hyperplasia that causes pain and bleeding
 And sets the stage for deflected eruption paths
that can result in:
(a) irregularity, (b) crowding, (c) crossbite

29. Over-Retained Primary Teeth
Once the primary tooth is
out, if space is adequate,
moderately abnormal facial
or lingual positioning will
usually be corrected by the
equilibrium forces of the lip,
cheeks and tongue

30. Supernumerary teeth
Supernumerary teeth can disrupt both the
normal eruption of other teeth and their
alignment and spacing.
The most common location for supernumerary
teeth is the anterior maxilla .
Treatment is aimed at:
 Extraction of the supernumeraries before
problems arise
 OR at minimizing the effect if other teeth
have already been displaced

31. Supernumerary teeth

32. Delayed Incisor Eruption
Sometimes incisors fail to erupt even when there is no
retained or overlying primary tooth or supernumerary
teeth present.
Changes in the overlying keratinized tissue occur in
long-standing edentulous region
If the delayed incisor is located
superficially it can be exposed with a simple soft
tissue excision
and usually will erupt rapidly .
When the tooth is more deeply
positioned, the overlying and adjacent tissue can be
repositioned apically and the crown exposed, which
usually leads to normal eruption or the tooth can have
an attachment placed and repositioned orthodontically

33. Delayed Incisor Eruption

34. Delayed Incisor Eruption

35. Ankylosed Primary Teeth
Appropriate management of an ankylosed
primary molar consists of:
maintaining it until an interference with
eruption or drift of other teeth begins to
occur, then extracting it and placing a
lingual arch or other appropriate fixed
appliance if needed

36. Ankylosed Primary Teeth
This radiograph demonstrates both anterior and
posterior teeth tipping over adjacent ankylosed
primary molars. The ankylosed teeth should be
removed if significant tipping and space loss are
occurring

37. Ectopic eruption
Eruption is ectopic when a permanent
tooth causes either:
Resorption of a primary tooth other than
the one it is supposed to replace
OR resorption of an adjacent permanent
tooth.

38. Ectopic eruption of Lateral
incisors
Loss of one or both primary canines from ectopic
eruption usually indicates lack of enough space
for all the permanent incisors, but occasionally may
result solely from an aberrant eruption path of the
lateral incisor.
When one primary canine is lost, treatment is needed
to prevent or correct a shift of the midline.
Depending on the overall assessment ;the dentist
can either:
remove the contralateral canine or
maintain the position of the lateral incisor on the
side of the canine loss, using a lingual arch with
a spur

40. If both mandibular primary canines are
lost, the permanent incisors tip lingually,
which reduces the arch circumference
and increases the apparent crowding.
A passive lingual arch to prevent the
lingual tipping, or an active lingual arch
for expansion may be indicated.

41. Ectopic eruption of Maxillary
First Molars
When only small amounts of resorption
are observed, a period of watchful
waiting is indicated because self-
correction is possible.
If the blockage of eruption persists for 6
months or if resorption continues to
increase, treatment is indicated.
Lack of timely intervention may cause
loss of the primary molar and space loss
as the permanent molar erupts mesially.

43. A 20mil brass wire looped and tightened
around the contact between the primary
second molar and the permanent molar
is suggested.
The brass wire should be tightened
approximately every 2 weeks

45. Some other options:
A steel spring clip separator, available
commercially, may work if only a small
amount of resorption of the primary
molar roots exists.
A simple fixed appliance can be
fabricated to move the molar distally.

46. An Arkansas spring

48. Ectopic eruption of Maxillary
Canines
Ectopic eruption of maxillary canines
occurs relatively frequently and can lead
to either or both of two problems:
( I )impaction of the canine and/or (2)
resorption of permanent lateral incisor
roots.
There appears to be a genetic basis for
this eruption phenomenon, and in some
cases it is related to small or missing
maxillary lateral incisors

49. At age 10, if the primary canine is not mobile and
there
is no observable or palpable facial canine bulge,a
panoramic,occlusal,or periapical radiograph is
indicated

50. Ericson and Kurol found that if the permanent
canine crown was overlapping less than half
of the root of the lateral incisor extract the
overlying primary canine there was an
excellent chance(91%) of normalization of the
path of eruption.
When more than half of the lateral incisor root
was overlapped,
Early Extraction of the primary tooth
resulted in a 64% chance of normal eruption
and likely improvement in the position of the
canine even if it was not totally corrected

52. If the canine is not redirected by this
procedure,it most likely will remain
unerupted in a palatal position or erupt
lingual to the maxillary incisors, but another
consequence can be the beginning of
resorption of the permanent incisor roots.
If that occurs, usually it is necessary to
surgically expose the permanent canine
and use orthodontic force to bring it to its
correct position

54. Transposition
Transposition is a positional interchange
of two adjacent teeth.
Often the best approach is to move a
partially transposed tooth to a total
transposed position, or to leave fully
transposed teeth in that position

55. Transposition

56. Primary failure of eruption
 Diagnosis of primary failure of eruption
often occurs in the late mixed dentition
period when some or all the permanent
first molars still have not erupted
 there is a genetic component to this
problem.
 The affected teeth are not ankylosed,
but do not erupt and do not respond
normally to orthodontic force.

57. Roots shortened by
radiotherapy
Some of the irradiated teeth
fail to develop, others fail to erupt, and
some may erupt even though they have
extremely limited root development.
Although the roots are short, light forces
can be used to reposition these
teeth and achieve better occlusion
without fear of tooth loss

58. Space maintenance
 Early loss of a primary tooth presents a
potential alignment problem because
drift of permanent or other primary teeth
is likely unless it is prevented

59. IDEAL REQUIREMENTS OF
SPACE MAINTAINERS
 Should maintain the desired mesiodistal
dimensions of the space.
 Should not interfere with the eruption of
the permanent teeth.
 Maintenance of functional movement
(physiological) of the teeth.
 Should allow for space regainence,
when required

60. Different types of space
maintainers
 Band and Loop Space Maintainers
 Partial Denture Space Maintainers
 Distal Shoe Space Maintainers
 Lingual Arch Space Maintainers

61. Different types of space
maintainers

62. Different types of space
maintainers

63. Interceptive orthodontics
 Procedure are undertaken when the
problem has already manifested.

64. Traumatic displacement of
teeth
Prior to treatment, multiple radiographs
at numerous vertical and horizontal
angulations should be obtained to rule
out vertical, and horizontal root fractures
that may make it impossible to save the
tooth.

65.  Vertical displacement of teeth is a major
indication for post-trauma orthodontics
All severely intruded teeth with mature
apices become nonvital and fail to erupt.
Early repositioning is critical to reduce the
chance of ankylosis, improve access for
endodontic

66. Traumatic displacement of
teeth
Vertical displacement of teeth is a major
indication for post-trauma orthodontics .
All severely intruded teeth with mature
apices become nonvital and fail
to erupt.
Early repositioning is critical to reduce
the chance of ankylosis, improve
access for

67. Traumatic displacement of
teeth
Within 2 weeks of the injury, the intruded
tooth
should have been moved enough to
allow endodontic
access-ideally, it would be at or near the
pre-trauma position.

68. Traumatic displacement of
teeth
Pulp therapy is best instituted within 2 weeks
to reduce the possibility of resorption.
if further tooth movement of an
endodontically-treated tooth will be needed
during a second stage of comprehensive
treatment, calcium hydroxide can be
retained in the pulp chamber until active
tooth movement is completed, as a hedge
against root resorption

69. Traumatic displacement of
teeth

70. Traumatic displacement of
teeth
The prognosis for pulp vitality is better in
teeth that were not intruded when they
were displaced, and in teeth with open
apices
follow-up periapical radiographs should
be taken at 2 to 3 weeks, 6 to 8 weeks,
and 1 year post-injury to check for
pathologic changes

71. Traumatic displacement of
teeth
Teeth that were extruded at the time of injury
and not immediately reduced pose a
difficult problem. These teeth have reduced
bony support and a poor crown root ratio.
Attempts to intrude them result in bony
defects between the teeth, so orthodontic
intrusion is not a good plan. When the
discrepancy is minor to moderate,
reshaping the elongated tooth by crown
reduction may be the best plan

72. Space related problems
Excess space:
Midline diastema:
A small maxillary midline diastema, which is
present in many children, is not necessarily an
indication for orthodontic treatment.The unerupted
permanent canines often lie superior and distal to
the lateral incisor roots, which forces the lateral
and central incisor roots toward the midline of
dental development

73. Ugly duckling stage
The spaces between the incisors, including
the midline diastema, decrease and often
completely disappear when the canines
erupt .
while their crowns diverge distally this
condition of flared and spaced incisors is
called the "ugly duckling" stage of
development
These spaces tend to close spontaneously
when the canines erupt and the incisor root
and crown positions change

74. The ugly duckling phase

75. Midline diastema
A small but unesthetic diastema (2 mm
or less) can be closed in the early mixed
dentition by tipping the central incisors
together.

76. Midline diastema(2mm/less)

77. When a larger diastema
(>2mm) is present
Causes can be:
1. A midline supernumerary tooth
2. Missing permanent lateral incisors
3. digit-sucking habits
What to do:
 Maxillary occlusal or periapical radiograph
 Bodily mesiodistal movement, an anterior
segmental archwire from central to central
incisor or the classic 2 x 4 appliance

79. Permanent retention
A fixed retainer to maintain diastema closure.
A bonded 17.5mil multistrand wire with loops bent into the ends
is bonded to the lingual surfaces of anterior teeth to serve as a
Permanent retainer. This flexible wire allows physiologic mobility
Of the teeth and reduces bond failure but can be used onlv when
the overbite is not excessive.

80. Maxillary Dental Protrusion and
Spacing
 Treatment for maxillary dental protrusion
during the early mixed dentition is
indicated only when the maxillary
incisors protrude with spaces between
them and are esthetically objectionable
or in danger of traumatic injury
: it is often a sequel to prolonged thumb
sucking

81. Maxillary Dental Protrusion and
Spacing
 If there is adequate vertical clearance
and space within the arch, maxillary
incisors that have been displaced by a
sucking habit can be tipped lingually
with a removable or a fixed appliance

82. Maxillary Dental Protrusion and
Spacing

83. Missing Permanent Teeth
Missing Second Premolars:
 If the patient has an ideal or an acceptable
occlusion, maintaining the primary second
molars is a reasonable plan
 if the space profile and jaw Relationships
are good or some what
protrusive,i t is possible to extract primary
second molars that have no successor at
age 7 to 9 and allow the first molars to drift
mesially

84. Retention of primary molar

85. Extraction of primary molar to
allow mesial drift of permanent
molar

86. Missing Maxillary Lateral
Incisors
 two sequelae usually is observed:
1)the erupting permanent canine resorbs
the primary lateral incisor and
spontaneously substitutes for the missing
lateral incisor.
2) the primary lateral is retained when the
permanent canine erupts in its normal
position
 Long-term retention of primary laterals, in
contrast to primary molars, is almost never
an acceptable plan

87. Missing Maxillary Lateral
Incisors
 ultimate treatment is substitution of the
canine for the lateral or opening space
for a prosthetic replacement

88. Missing Maxillary Lateral
Incisors

89. Auto transplantation.
 In patients with a congenitally missing
tooth or teeth in one area but crowding
in another ,autotransplantation also is a
possible solution.
Teeth can be transplanted from one
position to another in the same mouth
with a good prognosis for long-term
success if this is done when the
transplanted tooth has approximately
one half of its root formed."

90. Auto transplantation
 Transplantation is most commonly used
to move premolars into the location of
missing incisors. It can also be used to
replace missing first molars with third
molars

91. Space Regaining
 After premature loss of a primary tooth,
space may be lost from drift of other
teeth
 Up to 3 mm of space can be
reestablished in a localized area with
relatively simple appliances and a good
prognosis

92. Maxillary Space Regaining
 Generally, space is easier to regain in
the maxillary than in the mandibular
arch, because of the increased
anchorage for
removable appliances afforded by the
palatal vault and the possibility for use of
extraoral force (headgear)

93. Maxillary Space Regaining

94. Maxillary Space Regaining
 A removable appliance retained with
Adams' clasps and incorporating a helical
fingerspring adjacent to the tooth to be
moved is very effective. This appliance is
the ideal design for tipping one molar .
 One posterior tooth can be moved up to 3
mm distally during 3 to 4 months of
full-time appliance wear. The spring is
activated approximately
2 mm to produce I mm of movement per
month

96.  For unilateral bodily space regaining, a
fixed intra-arch appliance is preferred

98. Maxillary Space Regaining
 If bodily movement of both permanent
maxillary first molars is necessary in
regaining space this can be accomplished
by using a banded and bonded fixed
appliance or headgear
 Sometimes both molars need to be moved
distally but one requires substantially more
movement than the other. To accomplish
this, an asymmetric facebow with a
neckstrap attachment can be used

99. Maxillary Space Regaining

100. Mandibular Space Regaining
 For unilateral mandibular space
regaining, the best choice is a fixed
appliance and an archwire
 a lingual arch can be used to support
the tooth movement and provide
anchorage when used in conjunction
with a segmental archwire and coil
spring

101. Mandibular Space Regaining

102. Mandibular Space Regaining
 If space has been lost bilaterally there
are two choice:
1) an adjustable lingual arch and
2) a lip bumper.

103. Mandibular Space Regaining

104. Mandibular Space Regaining

105. Serial extraction
Indications:
1.Straight profile
2.Class I malocclusion
3.Arch length discrepency in maxilla
should be 11 mm while in mandibular
arch 10.5 mm

106. Serial extraction
Contraindications:
1. Convex profile
2. Class II malocclusion
3. Low angle case
4. High angle case

107. Advantages of serial extraction
 Reduces the severity of malocclusion
 Reduces the extent of mechanotherapy
 Reduces the duration of treatment

108. Disadvantages of serial
extraction
 Chances of increasing overbite
 Canines may fail to migrate distally
 Anterior teeth may tip lingually

109. Methods of serial extraction
Dewel’s method (cd4)
Tweed’s method (d4c)

110. Q&A