university of glasgow
Interceptive orthodontics
Personal notes
Mohammed Almuzian
1/1/2013
.
ContentsDefinition.........................................................................................................................................4
Need for IO......................................................................................................................................4
General Aims of Interceptive Orthodontics......................................................................................4
Timing..............................................................................................................................................5
Interceptive orthodontics targets the following orthodontic problems..............................................5
Spacing and Crowding.....................................................................................................................6
Definition.........................................................................................................................................6
Type of Crowding............................................................................................................................6
1. Primary crowding..................................................................................................................6
2. Secondary crowding..............................................................................................................7
3. Tertiary or ‘late lower incisor crowding’...............................................................................7
Management of crowding in developing dentition...........................................................................7
Elective extraction............................................................................................................................7
Elective extraction of deciduous canines..........................................................................................7
Elective extraction of all 6's..............................................................................................................8
Wilkinson criteria (Wilkinson, 1940)...............................................................................................8
Elective extraction of the second molars..........................................................................................8
Disadvantages...................................................................................................................................8
Elective extraction of the premolars.................................................................................................9
Serial extraction................................................................................................................................9
Steps of serial extraction..................................................................................................................9
Indications:.....................................................................................................................................10
Advantages of Serial Extractions....................................................................................................10
Disadvantages of Serial Extractions...............................................................................................10
Modified serial extraction..............................................................................................................11
Space maintainer............................................................................................................................12
Advantages.....................................................................................................................................12
Disadvantages.................................................................................................................................12
Indications......................................................................................................................................12
Contraindication.............................................................................................................................13
Techniques.....................................................................................................................................13
Space regaining..............................................................................................................................14
Mohammed Almuzian, University of Glasgow, 2013 Page 1
Technique.......................................................................................................................................14
Management of Lee way space.......................................................................................................14
Balance and compensatory extraction............................................................................................14
Early loss of primary teeth..............................................................................................................14
RCSEng guidelines and Recommendations....................................................................................14
Forced extraction in poor prognosis 6s...........................................................................................15
Guidelines for forced first molar extraction (RCSEng. By Cobourne 2009)..................................15
Class I cases with minimal crowding (3mm)..................................................................................15
Class I cases with crowding............................................................................................................16
Class II case with crowding............................................................................................................17
Abnormality in tooth position.........................................................................................................18
Infra-occlusion...............................................................................................................................18
Management...................................................................................................................................18
Impacted incisors............................................................................................................................19
SIGN recommendations (Yaqoob et al 2010):................................................................................19
Ectopic canine................................................................................................................................20
Methods.........................................................................................................................................20
Impacted 6s....................................................................................................................................24
Treatment options, Kennedy 1987..................................................................................................24
IO treatment...................................................................................................................................24
Treatment to disimpact the molars..................................................................................................25
Treatment to regain space following early loss of E: Kurol and Bjerklin 1987..............................25
Asymmetric Dental Development..................................................................................................26
Prolong retention of primary teeth or Overretained Primary Teeth................................................26
Local factors...................................................................................................................................27
Enamel defects...............................................................................................................................27
Maxillary midline diastema............................................................................................................27
Abnormality in teeth shape, form & size........................................................................................28
Treatment.......................................................................................................................................28
Abnormality in teeth number..........................................................................................................28
Supernumerary teeth.......................................................................................................................28
Treatment.......................................................................................................................................28
Indications for Monitoring..............................................................................................................28
Indications for removal...................................................................................................................28
Mohammed Almuzian, University of Glasgow, 2013 Page 2
Hypodontia.....................................................................................................................................29
Treatment options...........................................................................................................................29
Traumatic loss of incisors...............................................................................................................30
Management...................................................................................................................................30
Displacements & crossbites............................................................................................................31
Anterior crossbites..........................................................................................................................31
Crossbite with Displacement..........................................................................................................31
Habits.............................................................................................................................................32
Management of digit-sucking habits...............................................................................................32
Prevention of digit-sucking habits, BOS guidelines 2000...............................................................32
Treatment of digit-sucking habits, BOS guidelines 2000...............................................................33
Increased and decreased Overjet.....................................................................................................34
Indications for IO treatment of increased OJ (early treatment of CLII problems)..........................34
1. Class II females with a significant skeletal discrepancy..........................................................34
2. An increased overjet, which is a source of teasing and bullying..............................................34
3. An increased overjet, which is at risk of trauma (often associated with gross lip incompetence and marked maxillary protrusion)...................................................................................................34
Advantages of early treatment........................................................................................................34
Disadvantages of early treatment....................................................................................................35
Evidences of poor outcome of early treatment versus late treatment..............................................35
Advantages of late IO for increase OJ............................................................................................37
Early treatment of Class III............................................................................................................37
Time...............................................................................................................................................37
Method...........................................................................................................................................37
Indication........................................................................................................................................37
Problems.........................................................................................................................................38
Richardson, 1999, screening for IO...............................................................................................38
Age.................................................................................................................................................38
Do...................................................................................................................................................38
Don’t..............................................................................................................................................38
Mohammed Almuzian, University of Glasgow, 2013 Page 3
Mohammed Almuzian, University of Glasgow, 2013 Page 4
Interceptive orthodontics
Definition
• Profit and Ackerman (1980) defined it as the treatment carried out to reduce
the need for further treatment.
• Any treatment which eliminates or reduces the severity of a developing
malocclusion in order to eliminate or simplify the need for future treatment
(Chung 1987)
Need for IO
1. 15% of developing malocclusions can be fully corrected in primary / mixed
dentitions with relatively simple means. Ackermann & Proffit, 1980
2. 1 in 3 community patients assessed as in need of IO, Only 20% of these
underwent IO, Al Nimri & Richardson, 2000
3. IO Particularly useful in following patient groups:
Medically compromised
Physically or mentally retarded.
Children with cleft of lip/palate.
Poor co-operators patients.
General Aims of Interceptive Orthodontics
1. Minimize psychological implications like teasing.
2. Prevent trauma.
3. Prevent the occurrence of dental pathology
4. Eliminate crossbites associated with displacement.
5. Minimize crowding.
6. Maintain Class I incisor relationship.
7. Maintain centrelines.
Mohammed Almuzian, University of Glasgow, 2013 Page 5
Timing
The most suitable ages for screening the child population for interceptive
orthodontics is 9 years and 11 years(Al Nimri & Richardson, 2000)
The Interception Gauge is useful in categorizing children in respect of
features of the dentition which are quantifiable.
Interceptive orthodontics targets the following orthodontic problems
1. Crowding management
Elective extraction of C, 4, 6 or 7s
Serial extraction
Modified serial extraction
2. Space management
Space maintainer
Space regaining
Management of Lee way space (should be called D and E space and not
include C because we loss space with C)
3. Balance and compensatory extraction
in primary teeth due to early loss of primary teeth
Forced extraction in poor prognosis 6s
4. Abnormality in tooth position and eruption
Infra-occlusion
Impacted incisors
Ectopic canine
Impacted 6s
Asymmetric dental development
Prolong retention of primary teeth
5. Local factors
Mohammed Almuzian, University of Glasgow, 2013 Page 6
enamel defects
Maxillary midline diastema and labial frenum
Abnormality in teeth shape, form & size
Abnormality in teeth number
I. Supernumerary teeth
II. Hypodontia
III. Traumatic loss of incisors
6. Displacements & crossbites
Anterior crossbites
Posterior crossbite with Displacement
7. Habits
8. Increased and decreased overjet
Spacing and Crowding
Definition
As faulty relationship bet MD of teeth, jaw size and arch perimeter. Jaw size
determine the available space for teeth apices, arch perimeter determine the
available space for teeth crown while MD falls in between them. Richardson,
1999
Type of Crowding
Crowding can be categorized into three distinctively different types according
to aetiology.
1. Primary crowding refers to tooth size and arch size discrepancy, with this
ratio being more often increased (causing crowding) than reduced (which
results in spacing), and this is genetically determined.
Mohammed Almuzian, University of Glasgow, 2013 Page 7
2. Secondary crowding is caused by premature loss of primary molars, which
is environmental in origin.
3. Tertiary or ‘late lower incisor crowding’ is a phenomenon that has both
genetic and environmental contributions, the main determinant being
differential late jaw growth.
Management of crowding in developing dentition
Elective extraction
Elective extraction of deciduous canines
1. Extraction of lower deciduous canines has been suggested for the correction
of mild lower incisor crowding. Houston and Tulley (1989) state that in
general terms this allows some correction of the incisor crowding. Stephens
(1989), reported that the ideal age group for this would be 9-10 years of age
to allow full development of the intercanine width. Proffit (1993) however
warns that this may result in the lower incisors tipping lingually further
reducing arch length.
2. Provide space for palatally lateral incisors.
3. Provide space for incisors whose eruption is late due to supernumeries.
4. Extraction of upper deciduous canines is often suggested in order to attempt
to encourage a palatally placed canine to erupt into a normal position.
Research has shown that this indeed is quite successful with 70% erupting
into favourable positions (Ericsson and Kurol, 1988).
5. Extraction of lower C`s may help in treatment mandibular displacement.
6. Serial extraction
7. Balance extraction for maintaining ML integrity
Mohammed Almuzian, University of Glasgow, 2013 Page 8
Elective extraction of all 6's
Wilkinson criteria (Wilkinson, 1940)
1. All successional teeth present and third molars present
2. Lower second molar bifurcation beginning to form.
3. Angle between long axis of crypts of 6 and 7 = 15-30 degree and crypt of
lower 7 overlaps the root of lower 6.
4. CIass I
5. Mild anterior segment crowding
6. Moderate posterior crowding
Elective extraction of the second molars
1. Relief of premolar crowding in a vertically impacted premolar in the line of
the arch where early extraction indicated for spontaneous correction.
Richardson 1992
2. Provide space for the third molars. Richardson 1983
3. Interceptive treatment of the existing or anticipated arch length deficiency.
Extraction in early permanent dentition may prevent or at least limit late
lower arch crowding. Richardson 1983. Requirements for second molar
prophylactic extraction (Lehman, 1979):
All third molars are present and of normal size and shape.
Third molars should be of 15 – 30 degrees with the long axis of the first
molar and its root not developed yet.
Disadvantages
1. 3rd molars may erupt into an unsatisfactory position, rarely with proper
angulation and contact relationship in 4% Richardson and Richardson (1993)
Mohammed Almuzian, University of Glasgow, 2013 Page 9
2. Difficult to predict which 3rd molars will erupt unsatisfactory (Thomas and
Sandy, 1995).
3. Second course of treatment to orthodontically upright the 3rd molar may be
required (Orton and Jones, 1987).
Elective extraction of the premolars
1. Early loss of 4`s with mesially inclined 3`s can spontaneously improve
certain malocclusions and can reduce time with active appliances.
2. Extraction of 4`s with space maintenance can allow impacted 5`s to erupt.
Serial extraction
Popularised in Europe in the 1930’s and recorded by Kjellgren (1947), the
early philosophy behind serial extractions was to attempt to align severely
crowded teeth without further need for treatment.
Steps of serial extraction
Relieve of crowding in the lower incisor region by extraction of upper and
lower c’s
Extraction of D’s when half their roots are resorbed to fasten eruption of the
first permanent premolars. This is in an attempt to encourage early eruption
of particularly 4s that it erupts before 3s. If extracted too early this may delay
eruption and cause excessive space loss.
There is no guarantee that the lower premolar will erupt before the canine and
as such the latter may be impacted. If this occurs extraction of the second
deciduous molars may be an option with Holtz (1970) advocating the
provision of a lingual arch retainer for space maintenance. The latter author
also recommends disking of the second deciduous molars to provide space
for premolar teeth
Extraction of 4s on eruption to allow alignment of 3s.
Mohammed Almuzian, University of Glasgow, 2013 Page 10
Indications:
Sever crowding in:
1. 8-9 yrs old
2. skeletal Class I
3. normal OJ and OB
4. 4`s developmentally ahead of 3`s
5. First permanent molars of good prognosis
6. all permanent teeth present
Advantages of Serial Extractions
in theory no appliance treatment needed
appliance may be simpler and shorter 50% reduction in the treatment time
(Little 1990)
Better stability and retention since tooth completes its formation in a site
where it will remain when treatment is completed (Graber, 2011)
Disadvantages of Serial Extractions
1. Exposed to multiple extractions (12 teeth)
2. No guarantee, extractions of D`s can lead to impaction of 4`s if the 3s erupt
ahead of the 4s. Removal of twelve teeth is a traumatic experience and there
is no guarantee that the lower premolar will erupt before the canine and as
such the latter may be impacted. If this occurs extraction of the second
deciduous molars may be an option with Holtz (1970) advocating the
provision of a lingual arch retainer for space maintenance. The latter author
also recommends disking of the second deciduous molars to provide space
for premolar teeth.
Mohammed Almuzian, University of Glasgow, 2013 Page 11
3. Growth prediction problems: difficult to predict amount of incisor crowding
because ICW between 8-10yrs i.e. lower incisor crowding may resolve
spontaneously
4. Space loss with extractions of C`s and especially D`s, by mesial drift of
buccal segments, lower incisors tip lingually, both of these reduces arch
length
5. Tipping of teeth into extractions site especially anterior teeth causing OB
increasing. Little 1990
6. There was no difference between the serial extraction sample and a matched
sample extracted and treated after full eruption except shorter time for active
orthodontic treatment (Little 1987, 1990): Little (1987) observed lower labial
segment relapse 10 years post treatment in patients who had undergone
premolar extraction in the mixed dentition, serial extractions, non-extraction
with expansion, no treatment normals and patients with spaced dentition. He
concluded that serial extractions were still a good idea as it reduced further
treatment time (50% reduction in treatment time compared with the late
premolar extraction group) and allowed teeth to erupt through attached
gingivae. Little continued his research into serial extraction with a paper in
1990 which compared patients undergoing serial extractions with the
provision later of fixed appliances and patients with late premolar extractions
and fixed appliances. Diagnostic records were available for the following
stages: pre-extraction, start of active treatment, end of active treatment, and a
minimum of 10 years postretention. All cases were treated with standard
edgewise mechanics and were judged clinically satisfactory by the end of
active treatment. Twenty-two of the 30 cases (73%) demonstrated clinically
unsatisfactory mandibular anterior alignment postretention. Intercanine width
and arch length decreased in 29 of the 30 cases by the postretention stage.
There was no difference between the serial extraction sample and a matched
sample extracted and treated after full eruption.
Mohammed Almuzian, University of Glasgow, 2013 Page 12
Modified serial extraction1. Serial extraction has no real role in modern orthodontics
2. Modified form, by applying stage 3+4 only extraction of Ds and 4s and
Space maintainer
Advantages
1. Prevent potential mesial drift of permanent molars and the development of
secondary crowding.
2. Prevent distal drift of incisors
3. Prevent mid-line deviations
4. Prevent overeruption of the opposing teeth.
5. Use Leeway space for relieving of the crowding.
6. Aesthetic purposes
Disadvantages
1. Need to insert immediately
2. Perceived long treatment
3. No guarantee it will prevent later treatment
4. Compliance,
5. Oral hygiene,
6. Regular inspection
Indications
1. Good OH
2. Low caries rate is essential
3. Compliant patient.
4. Loss of central incisor for aesthetic purposes
5. Unilateral loss of c
6. Early loss of E before eruption of 6
7. Early loss of D
8. Difficult to assess clinically the occlusion at the current stage.
Mohammed Almuzian, University of Glasgow, 2013 Page 13
9. In an occlusion with only mild crowding where any further space loss would
result in the need for more complex orthodontic treatment
10.In an occlusion with severe crowding where any further space loss would
result in more than a single tooth unit of space being required.
Contraindication
1. If a permanent successor will erupt within 6 months (i.e., if more than one-
half to two-thirds of its root has formed), a space maintainer is unnecessary.
2. If there is not enough space for the permanent tooth or if it is missing, space
maintenance alone is inadequate or inappropriate
Techniques
1. Band and loop; used with one tooth missing in the posterior area
2. Bonded rigid wire across the space
3. URA and partial denture; used if more than one tooth is lost and to replace
anterior tooth
4. Lingual arch
5. Transpalatal arches or fixed-removable lingual and palatal arch eg 3D Wilson
lingual arch
6. Distal Shoe Space Maintainers:
The distal shoe has a unique application and is the appliance of choice when a
primary second molar is lost before eruption of the permanent first molar.
It consists of a metal or plastic guide plane along which the permanent molar
erupts. The guide plane is attached to a fixed or removable retaining device
To be effective, the guide plane must extend into the alveolar process so that
it is located approximately 1 mm below the mesial marginal ridge of the
permanent first molar, at or before its emergence from the bone.
When fixed, the distal shoe is usually retained with a band instead of a
stainless steel crown so that it can be replaced by another type of space
maintainer after the permanent first molar erupts.
Mohammed Almuzian, University of Glasgow, 2013 Page 14
If primary first and second molars are missing, the appliance must be
removable and the guide plane is incorporated into a partial denture because
of the length of the edentulous span.
It is contraindicated in patients who are at risk for sub-acute bacterial
endocarditis
Space regaining
Procedures can be employed if space has been lost due to drifting regained
space is limited to 3mm or less of space regaining.
Technique
1. Sectional fixed appliance
2. URA
3. Lip bumper
4. HG
5. Molar distalization technique can be used to regain space
Management of Lee way space
Brennan & Gianelly 2000
1. If a lingual arch is placed during the mixed dentition only an arch length
decrease of 0.44 mm has been reported with gaining of 4.44 mm Leeway
space.
2. Also the stability were good after lingual arch treatment
3. However it was shown that intercanine is increased after using lingual
arch and this bec the 3s migrate distally toward a wider arch.
Mohammed Almuzian, University of Glasgow, 2013 Page 15
Balance and compensatory extraction
Early loss of primary teeth
RCSEng guidelines and Recommendations
Radiographic screening is highly desirable before extracting primary molars
to check for the presence, position and correct formation of the crowns and
roots of successional teeth. Potential problems indicate the need to seek an
orthodontic opinion before teeth are removed.
1. Loss of primary incisors – Early loss of primary incisors has little effect
upon the permanent dentition although it does detract from appearance. It is
not necessary to balance or compensate the loss of a primary incisor.
2. Loss of primary canines– Early loss of a primary canine in all but
spaced dentitions is likely to have most effect on centre lines. The more
crowded the dentition, the more the need for balance.
3. Loss of primary first molars –With regard to a primary first molar, a
balancing extraction may be needed in a crowded arch but compensation is
not needed.
4. Loss of primary second molars – There is no need to balance the loss of
a primary second molar because this will have no appreciable effect on
centreline coincidence. However when a primary second molar has to be
extracted consideration should be given to fitting a space maintainer
Forced extraction in poor prognosis 6s
The 6s are the more caries prone teeth because
They are erupted early and exposed to oral environment
Also they are more commonly affected by hypoplasia than other teeth.
If the 6s are poorly restored or decayed then the it is better to consider earl
extraction to allow spontaneous space closure or use of the space for
orthodontic purposes.
Mohammed Almuzian, University of Glasgow, 2013 Page 16
Guidelines for forced first molar extraction (RCSEng. By Cobourne
2009)
A number of general guidelines on treatment planning first permanent molar
extraction cases for a number of malocclusions are available
As a general rule, if in doubt, get the patient out of pain, try and maintain
the teeth and refer for an orthodontic opinion.
Class I cases
Class I cases with minimal crowding (3mm)
Aim for extraction at the optimal time for eruption of the second molars
into a good position.
Do not balance unilateral first molar extraction in either the upper or
lower arches with healthy first molars.
If the lower first molar is to be lost, compensating extraction of the upper
first molar should be considered to avoid overeruption of this tooth, unless
the lower second molar has already erupted and the upper first molar is in
occlusal contact with it.
If the upper first molar is to be lost, do not compensate with extraction of
the lower first molar if it is healthy.
Class I cases with crowding
First molar extractions can be delayed until the second molars have
erupted and then the extraction space used for alignment with fixed
appliances.
Alternatively, first molars can be extracted at the optimum time and the
crowding treated once in the permanent dentition. If premolar extractions are
likely to be required at this stage, the third molars should be present. If the
buccal segment crowding is bilateral, consider balancing extraction to
provide suitable relief and maintain the centreline. Compensating extraction
Mohammed Almuzian, University of Glasgow, 2013 Page 17
of upper first molars should be considered to prevent overeruption or relieve
premolar crowding
Class II cases
The main complicating factors often involve the upper arch because of the
need for space to correct the incisor relationship.
Class II cases with minimal crowding
Lower first molar extraction
It should be carried out at the ideal time for successful eruption of the
second permanent molar and control of the second premolar. Regarding
compensating and balancing extraction:
a) Compensating and balancing extraction of healthy lower first molars are not
indicated. So that, if the upper first molars are to be left unopposed, a simple
removable appliance may be required to prevent their over-eruption, whilst
waiting for the second molars to erupt. Alternatively, a functional appliance
can be used immediately to correct the incisor relationship prior to extraction
of the first molars and fixed appliances.
b) If the upper first permanent molar is sound, elective extraction may be
indicated if it is at risk of over-erupting; however, the third molars should
ideally be present radiographically.
c) If there is no sign of upper third molar development, an appliance to prevent
the over-eruption of sound upper first molars should be considered.
Upper first molar extraction
In the upper arch, space will often be required to correct the incisor
relationship: If the upper first permanent molars require immediate
extraction, orthodontic treatment may be instituted to correct the incisor
relationship. A functional appliance or removable appliance and headgear can
be used to correct the buccal segment relationship, followed by fixed
appliances if required.
Mohammed Almuzian, University of Glasgow, 2013 Page 18
If the upper first permanent molars can be temporised or restored, then
their extraction can be delayed until the second permanent molars have
erupted. The resultant extraction space can then be used to correct the
malocclusion with fixed appliances.
Alternatively, after extraction of the upper first permanent molars, the
second permanent molars can be allowed to erupt and the incisor relationship
corrected then by the loss of two upper premolars teeth. But as a condition,
there should be a radiographic evidence of third molar development.
Class II case with crowding.
Lower first molar extraction
Space will also be required in the lower arch for the relief of crowding. If
the third molars are present radiographically, lower first molars can be
extracted at the optimum time to allow second molar eruption and then
premolars extracted at a later stage for the correction of crowding. In these
cases, fixed appliances will usually be required.
Alternatively, first molars can be extracted after second molar eruption
and the space used directly for the correction of crowding with fixed
appliances.
Balancing and compensating extraction of lower first molars are not
generally required.
Upper first molar extraction
Space requirements in the upper arch can be significant. The upper first
permanent molars should be temporised or restored and the child referred to a
specialist orthodontist whenever possible.
If the upper first permanent molar is unopposed, at risk of over-erupting
and third molars are present radiographically, then extraction of the upper
first molar may be indicated. The patient should be counselled that additional
Mohammed Almuzian, University of Glasgow, 2013 Page 19
premolar extractions in the upper arch may be required in the future to create
sufficient space for crowding relief and incisor correction.
Class III cases
Class III cases are often even more difficult to manage and ideally require the
opinion of a specialist orthodontist before any first permanent molars are
extracted. As a general rule, extraction of maxillary molars should be avoided
if at all possible, whilst balancing and compensating extractions are not
recommended in class III cases.
Abnormality in tooth position
Infra-occlusion
Management
1. In the presence of a permanent successor
A. Minimal infraocclusion, the ankylosed tooth can usually be left under
observation to exfoliate naturally.
B. Significant infraocclusion can lead to adjacent teeth displacement, tipping
and overeruption of adjacent teeth. In these circumstances, consideration
should be given to either restoring the vertical dimension or extracting the
affected tooth with lingual or palatal arch to maintain the space until the
permanent teeth erupt.
2. In the absence of a permanent successor ,
A. Early Extraction to facilitate spontaneous space closure to allow permanent
teeth to drift into the edentulous space and bring bone with them, and then
reposition the teeth prior to implant or prosthetic replacement, so that large
periodontal defects do not develop.
B. Premolaizing the E and accepting it in the place permanently.
C. Slicing and space closure
Mohammed Almuzian, University of Glasgow, 2013 Page 20
D. Extraction and prosthetic replacement;
E. Retention of the second deciduous molar.
Impacted incisors
SIGN recommendations (Yaqoob et al 2010):
1. Children under nine years with incomplete root development of
permanent incisor:
Remove obstruction.
Create space if required.
Maintain the space
Do not uncover bone from unerupted incisor maintain integrity of follicle.
Monitor eruption for 18 months – 80% erupt spontaneously
If exposure required then expose minimally to eliminate soft tissue
obstruction and wait for 6 months. If tooth is still high, expose and bond
bracket.
2. Children above nine years with complete or nearly complete apex:
Remove obstruction.
Create space if required.
Maintain the space
If permanent incisor high then monitor eruption for 12 months.
If tooth still unerupted at 12 months, expose and bond bracket as required.
3. Children referred late (over 10 years):
Remove obstruction.
Create space if required.
Maintain the space
Expose and bond bracket at first operation.
Mohammed Almuzian, University of Glasgow, 2013 Page 21
Ectopic canine
The principles of interceptive treatment for palatal canines are:
1. Remove any obstruction – this usually means removal of the deciduous
canine
2. Ensure adequate space for eruption
Methods1. Extraction of the
primary canines at the age between 10 and 13 year.
Ericson and Kurol, 1988
78% success rate
2. Extraction of the primary canines in crowded and uncrowded cases
Power and Short, 1993.
In general 62% showed improvement in eruptive position. In crowded cases the success rate was 14% as opposed to 86% in un-crowded cases
3. The extraction of the deciduous canine and creation of excess space for the impacted tooth
Olive, 2002 94% success rate.
4. Extraction of C + HG. RCT
Leonardi et al., 2004
HG+exo 80% Exo 50%, Control 34%
5. Extraction of C + HG. RCT by
Baccetti et al., 2008,
HG+exo 88% Exo 65%, Control 36%
6. Cochrane review by Parkin, 2009 There is currently no evidence to support the extraction of the deciduous maxillary canine to facilitate the eruption of the palatally ectopic maxillary permanent canine.
7. Effect of RME and headgear treatment on the eruption of
Armi & Baccetti, 2011
RME+HG+EXO 86 % HG+EXO 83%, Control 36%.
Mohammed Almuzian, University of Glasgow, 2013 Page 22
palatally displaced canines. RCT
8. Effects of RME and TPA treatment associated with deciduous canine extraction on the eruption of palatally displaced canines RCT by
Bacceti 2011 RME+TPA+EXO 80%, TPA+EXO 79% EXO 62.5% Control 28%
9. A systematic review of the interceptive treatment of palatally displaced maxillary canines, ,
Kurol 2011 No evidence-based conclusions could be drawn due to the few studies identified, the heterogeneity in study design, and the unequivocal results
10. Preventive treatment of ectopically erupting maxillary permanent canines by extraction of C & Ds: RCT
Bonetti 2011,
50% of canines in the TG improved position by one sector and 13% by two sectors, while on 32% of the canines in CG improved by one sector and none by two sectors.
Extraction of the primary canines at the age between 10 and 13 year,
Ericson and Kurol, 1988. 46 consecutive ectopic palatally placed maxillary
canines were studied. In (78%) the palatal eruption changed to normal after
12 months. It suggest that extraction of the primary canine is the treatment of
choice in young individuals (10-13 years) to correct palatally ectopically
erupting maxillary canines provided that normal space conditions are present
and no incisor root resorption are found.
Extraction of the primary canines in crowded and uncrowded cases by
Power and Short, 1993. 9 consecutive patients of mean age 11.2 years. In
general 62% showed improvement in eruptive position. In crowded cases the
success rate was 14% as opposed to 86% in un-crowded cases. Horizontal
overlap of the nearest incisor was found to be the most significant factor. If
Mohammed Almuzian, University of Glasgow, 2013 Page 23
this exceeded half the tooth width, success was unlikely. The presence of
crowding was found to affect adversely the favourable eruption of the
canine.
The extraction of the deciduous canine and creation of excess space for
the impacted tooth Olive, 2002. The space created was 1 cm with the
incisors being proclined and displaced up to 3mm across the midline. The
results were impressive 94% success rate.
Extraction of C + HG. RCT by Leonardi et al., 2004, groups1) with
extraction of C only, groups2) extraction C + HG (to increase arch length)
groups3 control; results were 50%, 80% an 34% respectively.
Extraction of C + HG. RCT by Baccetti et al., 2008, 1) with Xtn of C only,
2) Xtn C + HG, group 2) control, group 3) successful eruption of 3. 65%,
88% and 36% successful eruption of 3 resepectively.
Cochrane review by Parkin, 2009, Extraction of primary (baby) teeth for
unerupted palatally displaced permanent canine teeth in children. There is
currently no evidence to support the extraction of the deciduous maxillary
canine to facilitate the eruption of the palatally ectopic maxillary permanent
canine. Two randomised controlled trials were identified but unfortunately,
due to deficiencies in reporting, they cannot be included in the review at the
present time.
Effect of RME and headgear treatment on the eruption of palatally
displaced canines. RCT by Armi & Baccetti, 2011, The randomized
prospective design comprised 64 subjects three groups: cervical pull headgear
(HG); rapid maxillary expansion and cervical pull headgear (RME/HG);
untreated control group (CG). The prevalence of successful eruption was
83%, 86 % and 36% respectively.
Effects of RME and TPA treatment associated with deciduous canine
extraction on the eruption of palatally displaced canines RCT by Bacceti
2011, Hundred and twenty subjects were enrolled in an RCT based on PDCs
Mohammed Almuzian, University of Glasgow, 2013 Page 24
diagnosed on panoramic radiographs and they were randomly assigned to one
of four study groups. Three treatment groups (TGs) (RME followed by TPA
therapy plus extraction of deciduous canines, TPA therapy plus extraction of
deciduous canines, extraction of deciduous canines, EC group. The
prevalence of canine eruption was 80%, 79%, 62.5% and 28% respectively.
The use of a TPA in absence of RME can be equally effective than the
RME/TPA combination in PDC cases not requiring maxillary expansion, thus
reducing the burden of treatment for the patient.
A systematic review of the interceptive treatment of palatally displaced
maxillary canines, Kurol 2011, No evidence-based conclusions could be
drawn due to the few studies identified, the heterogeneity in study design, and
the unequivocal results
Preventive treatment of ectopically erupting maxillary permanent
canines by extraction of C & Ds: RCT by Bonetti 2011, 50% of canines in
the TG improved position by one sector and 13% by two sectors, while on
32% of the canines in CG improved by one sector and none by two sectors.
The extraction of maxillary first deciduous molars, in addition to the
deciduous canines, appears to create more space and allow canines, at risk
from impaction, to improve their position spontaneously.
Impacted 6s
Treatment options, Kennedy 1987
80% self-correct by age 7yrs while 10% self-correct at age 8 or 9yrs
The optimal treatment approach depends on a number of factors
including
1. The clinical eruption status of 6
2. The change in position of 6
3. The amount of enamel ledge of 6/El
Mohammed Almuzian, University of Glasgow, 2013 Page 25
4. The mobility of /El,
5. The presence of pain or infection.
IO treatment
a. If resorption of E <1.5mm:
• observe 3-6mths (to establish if reversible)
• if no resorption and vertical position improved: monitor eruption
• if no resorption and vertical position not improved: expose unerupted 6 and
wait for 3 months
• if still <1.5mm resorption: treatment to move the impacted tooth distally (see
below)
b. If resorption of E >1.5mm:
• if E symptomatic or mobility >1mm consider Xtn and management of space
problem once 6 erupts
• If E asymptomatic and mobility <1mm and 6 partially erupted: treatment to
move the impacted tooth distally
• If E asymptomatic and mobility <1mm and 6 unerupted: expose 6 and
commence treatment to move the impacted tooth distally
Treatment to disimpact the molars
A.6 is partially erupted
1. brass wire ligature
2. elastomeric
3. steel spring clip separators
4. orthodontic band on E with attached distal spring +/-
transpalatal arch when maximal anchorage required
(Halterman appliance)
5. Humphrey appliance. A bonded button is placed on
the first permanent molar at the same time the
appliance is cemented on the second primary molar.
Mohammed Almuzian, University of Glasgow, 2013 Page 26
The free arm engages on the mesial side of the button using reciprocal
anchorage to distalize the permanent molar. Activation at 3 to 4-week
intervals is made with three-prong pliers until overcorrection occurs.
6. orthodontic band on the E and a bonded bracket on the exposed cusp of 6,
with an open coil spring
b. 6 is unerupted: surgically expose and try above techniques or distal
extension attached to SS crown
Treatment to regain space following early loss of E: Kurol and Bjerklin
1987
1. Cervical headgear but not in AOB or Cl3
2. A removable appliance with a spring or expansion screw to distalize
maxillary first molar (When there is extensive space loss, an anterior
biteplate may be needed to free up the occlusion to permit uprighting of
the tilted permanent molar)
3. Combination (he removable appliance acts to tip the crown of the molar
distally while the high-pull headgear, directed above the center of
rotation of the molar, acts to distalize the root. (Nudger appliance)
Asymmetric Dental Development
Asymmetric eruption (one side ahead of the other by 6 months or more) is
significant. It requires careful monitoring of the situation, and in the absence
of outright pathology, often requires early treatment such as selective
extraction of primary or permanent teeth.
A few patients with asymmetric dental development have a history of
childhood radiation therapy to the head and neck or traumatic injury.
Surgical and orthodontic treatment for these patients must be planned and
timed carefully and may require tooth removal or tooth reorientation.
Mohammed Almuzian, University of Glasgow, 2013 Page 27
Some of these teeth have severely dilacerated roots and will not be candidates
for orthodontics these situations definitely fall into the complex category and
usually require early intervention.
Prolong retention of primary teeth or 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,
but a primary tooth that is retained beyond this point should be removed
because it often leads to gingival inflammation and hyperplasia that cause
pain and bleeding and sets the stage for deflected eruption paths of the
permanent teeth that can result in irregularity, crowding, and crossbite.
If a portion of the permanent tooth crown is visible and the primary tooth is
mobile to the extent that the crown will move 1 mm in the facial and lingual
direction, it is probably advisable to encourage the child to “wiggle” the tooth
out. If that cannot be accomplished in a few days, extraction is indicated.
Most overretained primary maxillary molars have either the buccal roots or
the large lingual root intact; most over-retained primary mandibular molars
have either the mesial or distal root still intact and hindering exfoliation
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.
Local factors
Enamel defects
Monitor,
Restore temporary,
Extract if sever
Mohammed Almuzian, University of Glasgow, 2013 Page 28
Maxillary midline diastema
It depends primarily upon the removal of the underlying cause.
A. in the deciduous dentition , no treatment
B. in mixed dentition just reassure
C. in permanent dentition
1. Aesthetic build-up of the centrals
2. Active orthodontic treatment to close a diastema is usually carried out in the
permanent dentition. Using:
• URA
• FA
3. Long-term retention is usually mandatory. For this reason, particularly for a
minor diastema, persuading the patient that it is a feature of individuality that
does not require closing can be advantageous.
4. Adjunctive procedure like
Frenectomy but this is not recommended anymore according to Jensen et al
1973 but Edward 1977 mentioned the opposite.
Composite build-up of the small teeth.
Abnormality in teeth shape, form & size
Treatment
1. No treatment
2. Inter-Proximal Stripping
3. Composite
4. or veneer reshaping
5. Intentional RCT, Extraction and prosthetic replacement (implant, bridge,
implant). VERY UNSUAL AND DESTRUCTIVE
Mohammed Almuzian, University of Glasgow, 2013 Page 29
Abnormality in teeth number
Supernumerary teeth
Treatment
leave it and monitor
extract +ortho
Indications for Monitoring
1. There is no associated pathology;
2. Satisfactory eruption of related teeth has occurred and no active orthodontic
treatment is planned;
3. Removal would prejudice the vitality of the related teeth.
Indications for removal
1. Supernumerary caused aesthetic problem.
2. Supernumerary prevent eruption of permanent teeth.
3. Supernumerary caused diastema or displacement.
4. Supernumerary caused pathology
5. Active orthodontic alignment of an incisor in close proximity to the
supernumerary is envisaged;
6. Its presence would compromise secondary alveolar bone grafting in cleft lip
and palate patients;
7. The tooth is present in bone designated for implant placement;
Hypodontia
Treatment options
A. Treatment for hypodontia in primary dentition
No treatment is indicated at this stage.
Mohammed Almuzian, University of Glasgow, 2013 Page 30
However removable dentures for psychological and functional reasons might
be used but it will require regular adjustments during growth. Retention and
stability may be problematic in those with poorly developed alveolar ridges.
B. Mixed dentition (involve mainly the interceptive treatment)
1. Extract 1o tooth early allow space closure. Some recommend extracting
primary tooth, allowing permanent teeth to erupt and close space, then reopen
space at adulthood, so by this way we preserve the bone.
2. Composite build-ups to improve aesthetics of microdont permanent
teeth or worn deciduous teeth
3. Removable dentures
4. Simple orthodontic treatment for space redistribution
5. Retain primary tooth:
As long as possible & replace with prosthesis after cession of the growth, this
will help in preserving alveolar bone
Permanently, retain the primary tooth (if the Es survive until 20yrs then they
appear to have a good prognosis for long term survival Bjerklin &
Bennett,2000)
MissingClass I Class II Class III
2 If closing space
xtn E to allow
mesial drift of
buccal segments
Can be used as part of
treatment
Space should be
preserved and
regained to allow
proclination
lower 5 Xtn LE early (9yrs)
to allow mesial
drift
Keep LE as long as
possible lower
arch should be as big
as possible
May be used as part
of xnt to treat
malocclusion
Mohammed Almuzian, University of Glasgow, 2013 Page 31
Traumatic loss of incisors Traumatic loss of a maxillary central incisor is seen in around of 3% of
children
usually occurs unilaterally, in the mixed dentition and in a child with an
increased overjet
Management
Short term management
Short term space maintenance can be achieved with a simple upper partial
denture.
Alternatively, the space can be allowed to close and reopened in the
permanent dentition prior to prosthetic replacement. This allows preservation
of alveolar bone, but will require fixed appliance treatment and often space
creation in the upper arch.
Long term management
1. Space closure and build up laterals
2. Space opening with
Resin-retained bridge
Implant,
Autotransplantation of premolar and subsequent coronal modification
3. In cases of bilateral loss, if space is required to reduce an overjet or
relieve crowding and the lateral incisors are of a reasonable size and form,
consideration can be given to moving them into the position vacated by the
centrals
Displacements & crossbites
Anterior crossbites
1. if dental Xbite then
Mohammed Almuzian, University of Glasgow, 2013 Page 32
selective grinding
extraction of the opposing primary
Bodily movement use fixed appliance 2*4 appliance
Simple tipping movement use URA with posterior capping, Z spring,
double cantilever spring, crossed cantilever spring, screw plate
2. Dentoalveolar or mild skeletal then
Chincap
Frankle 3 (Functional)
Crossbite with Displacement
Recommendations
1. Encourage habit to stop
2. Removal of premature contacts of the baby teeth
3. Posterior onlay
4. Extraction if it is associated with severely displaced single tooth
5. expand upper arch with:
URA with midpalatal screw, success rates is 50%
Coffin spring + posterior capping,
Quad. (QH and RME success rates is 100%)
According to the Cochrane review byHarrison and Ashby, 2008
Cochrane
The evidence from the trials reported by Lindner (1989); Thilander (1984)
suggests that
A. Removal of premature contacts of the baby teeth is effective in preventing a
posterior crossbite from being perpetuated to the mixed dentition and adult
teeth.
Mohammed Almuzian, University of Glasgow, 2013 Page 33
B. When grinding alone is not effective, using an upper removable expansion
plate to expand the top teeth will decrease the risk of a posterior crossbite
from being perpetuated to the permanent dentition.
No evidence of a difference in treatment effect (molar and canine expansion)
between the test and control intervention was found in the trials which
compared
A. Banded versus bonded
B. Banded versus bonded slow maxillary expansion,
C. Two point versus four point rapid maxillary expansion,
D. Transpalatal arch with/without buccal root torque,
E. Upper removable expansion appliance versus quadhelix.
Habits
Management of digit-sucking habits
Prevention of digit-sucking habits, BOS guidelines 2000
1. If a dummy is provided, there appear to be fewer problems in the long-term,
because the majority of dummy sucking habits are self-limiting and stop
before eruption of the permanent teeth. Any persistent dummy sucking habit
is easily broken by removal of the dummy.
2. It has been suggested that if a digit-sucking habit is noticed, a dummy should
be given to the child.
3. If a dummy is used it must not be sweetened. After the age of 2, to prevent
problems with speech development, it should be used as little as possible
during the day
Treatment of digit-sucking habits, BOS guidelines 2000
1. The child must want to stop otherwise any approach is likely to be
unsuccessful.
Mohammed Almuzian, University of Glasgow, 2013 Page 34
2. A child who is undergoing severe psychological trauma is unlikely to respond
to habit breaking. A psychologist’s input may be required
3. The use of orthodontic pacifiers which is oval shape and has a vent to reduce
the effect of dummies
4. The following methods for breaking the habit are listed in the order in which
they should be used:
A. Non-physical methods
Explanation
Reward
Habit reversal
Teach the child to carry out alternative activities when they have the urge to
suck the digit
B. Physical methods
Reminder therapy like finger bandage, finger paint, boxing gloves or
thermoplastic finger post
C. Intra-oral appliances
These deterrent appliances have been shown to be effective within 10
months.
They must be fitted with the full understanding and co-operation of the child
and must not compromise compliance with any future orthodontic treatment.
Intraoral appliance
1. Removable appliance
2. Fixed appliance like palatal appliance with crib or Blue grass appliance
3. Functional appliance can stop habit
Mohammed Almuzian, University of Glasgow, 2013 Page 35
Increased and decreased Overjet
Indications for IO treatment of increased OJ (early treatment of CLII
problems)
1. Class II females with a significant skeletal discrepancy.
2. An increased overjet, which is a source of teasing and bullying.
3. An increased overjet, which is at risk of trauma (often associated with gross
lip incompetence and marked maxillary protrusion).
Advantages of early treatment
The believed advantages of early treatment, King 1990 are:
1. Better cooperation (True, O’Brien 2003 with regard to TB treatment early
treatment 16% failure but late 33%)
2. Psychosocial advantages if patient is treated early. Sandler and DiBiase 2001
showed that the increased OJ is the most unattractive feature. However, The
treatment itself may introduce a new source of bullying, (true, O’Brien 2003),
latest Cochrane review by Thiuroventrachachari 2013 showed that early
treatment reduce risk of trauma.
3. Craniofacial tissues more malleable. Questionable?
4. Favourable changes in skeletal and dental AP relationship achieved but may
not be clinically significant. (true for short term, Tulloch, 1998, Keeling,
1998, O’Brien 2003)
5. improved prognosis for adolescent treatment but not significant (not true,
O’Brien, 2003)
6. Elimination of gingival/palatal trauma. Questionable?
7. Less root resorption than one phase (Brin 2003 use the data of UNC and
prove that)
Mohammed Almuzian, University of Glasgow, 2013 Page 36
8. Eliminate growth/local disturbances before they have had time to act fully.
Questionable?
9. Better stability measured using PAR index (Pavlow 2008)
High trauma with increased overjets >9mm (Todd & Dodd 1983) (45% 10 yr
olds with OJ more than 9mm have traumatised incisors compared to 27% if
the OJ was less than 9mm especially if the lip is incompetent) however RCT
comparing early versus late treatment (Koroluk et al 2003)concluded all
groups experienced trauma. But the latest Cochrane review showed that
early Oj reduction would reduce the chance of trauma (Badri
Thiruvenkatachari, 2013).
Disadvantages of early treatment
1. Early start and late finish therefore prolonged course of treatment
2. Risk of burning patient co-operation. Patient has time expiry approximately
3yrs which can be lost in the first phase leaving no compliance in the second
phase.
3. Limited long term benefits skeletal and dentoalveolar effect compared to one
stag.
4. Choice of Xtn is difficult whilst young
5. Soft tissues do not mature until 12-14yrs with vertical growth of lips this
might affects stability of corrected OJ
6. Arch length not maintained in permanent dentition .
Evidences of poor outcome of early treatment versus late treatment
1. An old review of the literature was unable to establish whether early or late
treatment provided the most benefit overall: 'we lack definitive cost-benefit
information. King et al., 1990
2. O’Brien 2009 RCT study
Mohammed Almuzian, University of Glasgow, 2013 Page 37
The aim of this study was to evaluate the effectiveness of early orthodontic
treatment with the Twin-block appliance for the treatment of Class II
Division 1 malocclusion.
This was a multi-center, randomized, controlled trial with subjects from 14
orthodontic clinics in the United Kingdom. The study included 174 children
aged 8 to 10 years with Class II Division 1 malocclusion; they were
randomly allocated to receive treatment with a Twin-block appliance or to
an initially untreated control group.
The subjects in both groups were then followed until all orthodontic
treatment was completed by FA .
Final skeletal pattern, number of attendances, duration of orthodontic
treatment, extraction rate, cost of treatment, and the child's self-concept
were considered.
At the end of the 10-year study, 141 patients either completed treatment or
accepted their occlusion. Data analysis showed that there were no
differences between those who received early Twin-block treatment and
those who had 1 course of treatment in adolescence with respect to skeletal
pattern, extraction rate, and self-esteem.
Conclusions: Twin-block treatment when a child is 8 to 9 years old has no
advantages over treatment started at an average age of 12.4 years. Those
who had early treatment had more attendances, received treatment for
longer times, and incurred more costs than the adolescent treatment group.
They also had significantly poorer final dental occlusion.
3. Tulloch et al 2004
RCT where the patient allocated at early stage to functional or HG or
control. The results that all benefit from first stage was lost and that early
Mohammed Almuzian, University of Glasgow, 2013 Page 38
treatment or two stage treatment didn’t affect extraction prevalence nor
sending to orthognathic surgery.
4. Dolce et al 2007 (completion of Keeling study 1998): compare two stage
treatment with 1 stage treatment and found no skeletal difference between
both
5. Recent Cochrane review suggests that early treatment is no more effective
than orthodontic treatment in early adolescence Harrison et al., 2007 (this
was involving 185 publications, then only 105 paper used and then 8 trials
included (4 early treatment and 4 late treatment) the result show that there is
no difference between early and late treatment regarding OJ, ANB, PAR,
trauma, incidence of extraction, but the self-esteem has been improved.
6. Koroluk 2003, show that no reduction in incisor trauma
7. But, O’Brien, 2003, show benefit from psychological point of view
Advantages of late IO for increase OJ
1. One phase treatment
2. Growth still present
3. Extraction decision is easy
4. E space can be used
5. Better final occlusion (O’Brien, 2009)
6. No difference from early treatment (Tulloch 2004, O’Brien 2009, Dolce
2007, Harrison, 2007)
7. However, comparing the effect of functional appliance with no treatment in
adult is an ethical issue because of the equipoise idea. Harrison 2007 quoted
two studies (Cura & Sarac 1997) who compare Dynamax with control and
Mao and Zaho 1997who compared bionator/Hg to control. These studies
suffered from weakness in their design. In general comparing functional
appliance to no treatment conclude that the former reduce OJ and ANB by
2.27. so it is the clinician philosophy to use it or lose it. Again comparing TB
Mohammed Almuzian, University of Glasgow, 2013 Page 39
with other functional like bionator or Dynamax showed that TB reduce ANB
by 0.68 more than others. I should mentioned that comparing HG with
untreated was not taken before.
Early treatment of Class III
Time
Before the age of 8 to achieve skeletal correction.
Method
Chin cups or reverse pull HG.
Indication
1. Growing cooperative patient
2. Skeletal class I, or only mildly class III;
3. An average or reduced lower face height;
4. A large anterior displacement on closing.
5. Incisor inclinations normal
6. Average/increased overbite that will retain the correction
In the mild Class III case in the mixed dentition the patient may benefit from
early correction of the incisor relationship so that further mandibular growth
may be counterbalanced by dento-alveolar compensation.
Problems
1. Unfavourable growth.
2. Soft tissue relapse after maturity
3. Long treatment and retention times.
4. Forward movement of the maxillary teeth,
Mohammed Almuzian, University of Glasgow, 2013 Page 40
5. Retroclination of the lower labial segment
Richardson, 1999, screening for IO
Age Do Don’tAt
birth
Do: Encourage caries prevention Don’t: worry about
abnormal gum pad
relationship
age
3
Do: look for early signs of malocclusion
Do: expect crowded permanent if no
space exist between primary
Do: Discourage habits
Do: Treat abormal path of closure
Don’t: worry about
lisping
Don’t:About spacing
Don’t:About flush
terminal relationship
age
7-9
Do: treat pathology
Do: observe crowding by
• Maintain space
• Observing and use Lee way space for
crowded cases
• Consider serial extraction or first molar of
poor prognosis
Do: observe local disturbance by
• Extract primary if the permenant is
missing
• Treating impacted 6s
• Extract Transposed teeth
• Extract retained primary
• Extract supernumeray
Do: discourage habit
Don’t: worry about
sligh post-normality
of molars
Don’t: ugly duckling
space
Don’t: slight AOB
Mohammed Almuzian, University of Glasgow, 2013 Page 41
Do: observe cross bite and displacement
age
11-
12
Do: treat pathology
Do: observe crowding by
• Extraction of FPM or second molar
• Extract retained primary
• Extract Cs in ectopic canine
Do: discourage habit
Do: Treat cross bite
Do: Excise large frenaum
Don’t: about buccal
crowding if 22mm
space available
between lateral and
6s
Don’t: Rotated
premolar when erupt
Don’t: Minor
submerging
Mohammed Almuzian, University of Glasgow, 2013 Page 42
Top Related