Outline

I. Definitions and Terms:

Early Treatment
Early Treatment in z
z Preventive, Interceptive, Corrective
z Phase I, Phase II
Orthodontics II. Specific goals of early treatment

Dr. Suzan Ekim III. Non skeletal orthodontic issues:

z Crowding
ekimx001@umn.edu z Eruption Disturbances
Division of Orthodontics z Anterior Crossbites
University of Minnesota IV. Skeletal orthodontic issues:
2007 z Transverse problems
z Vertical problems
z Growth Modification

V. Summary and Cases

I. Definitions and Terms I. Definitions and Terms

z Early Treatment:
z Treatment initiated during the primary or mixed
dentition with the purpose to prevent, intercept
or correct a specific orthodontic problem or
problems, also known as, Phase I treatment.
z Preventive early treatment:
Patient education and maintenance of a favorable orthodontic
condition.
z e.g. patient education of stopping digit sucking habits, space
maintenance appliances.
z Interceptive early treatment:
Improvement of an orthodontic problem.
z e.g. Primary tooth guidance extractions, reduction of excessive overjet,
growth modification appliances, space redistribution, space creation,
deep bite reduction, habit appliances.

z Corrective:
Complete or nearly complete correction of an orthodontic problem.
z e.g. Expansion appliances, growth modification appliances, alignment
of anterior teeth.

II. Specific Goals of

I. Definitions and Terms
z Phase I
z Treatment initiated during the primary or mixed
dentition with the purpose to prevent, intercept or
correct an orthodontic problem, also known as, early
treatment.
z Phase II
z Treatment initiated during the permanent dentition
with a comprehensive approach to correcting the
orthodontic problems, also known as, comprehensive
treatment.
Early Treatment
Overall goal of early treatment:
z To improve or correct orthodontic problems
that would result in:
z Irreversible damage to the dentition and
supporting structures
z Progression into a more severe orthodontic
problem that would be more difficult to treatment
in Phase II.

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II. Specific Goals of II. Specific Goals of
Early Treatment Early Treatment
1. Improved Psychosocial Development
Specific goals of early treatment Self-Esteem, esthetics
z Clearly defined endpoints of phase I 2. Improved Occlusal Function
orthodontic treatment. Symmetry, shifts/slides, attrition
3. Manage potential for damage to dentition
Trauma, attrition, recession, injury, primary
Why is this important? tooth extractions.
4. Phase II simplification
z To prevent extended Phase I treatment times Growth modification, space
z Patient cooperation anticipated management, primary tooth extractions
5. Improved or corrected skeletal discrepancies
z Damage to unerupted teeth
Symmetry, reduce skeletal discrepancies,
z Phase II is still likely for most cases transverse problems.

II. Specific Goals of Benefits Risks

Early Treatment z Improved patient z Misdiagnosis
socialization z Extended
Consider the 4 factors in the development of z Better patient treatment time
the dentition: cooperation z Greater cost (time
z Earlier correction and money)
1. Eruption Guidance
z Sometimes z Patient burnout
2. Growth Orthopedics fewer extractions z Increased caries
3. Drift Space Control required risk
4. Equilibrium Habit Control z Sometimes less
orthognathic
surgery required

I. Definitions and Terms:

z Early Treatment
z Preventive, Interceptive, Corrective
z Phase I, Phase II
III. NON SKELETAL
II. Specific goals of early treatment ORTHODONTIC ISSUES
III. Non skeletal orthodontic issues:
z Crowding
z Crowding
z Anterior Crossbites
z Eruption Disturbances z Anterior Crossbites
z Eruption
IV. Skeletal orthodontic issues: Disturbances
z Transverse problems
z Vertical problems
z Growth Modification

V. Summary and Cases

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Classification of Mixed Classification of Mixed
Dentition Crowding Dentition Crowding
z Incisor Liability – mild amount of transitional z Moderate Transitional
crowding of the permanent incisors in a Crowding
mixed dentition (~2-3mm). ~ 4mm of anterior crowding

Permanent Mn incisor
widths = interdental spaces
of primary teeth + primate
spaces + permanent z Severe Transitional
incisor inclination Crowding
~ >4mm of anterior crowding

Crowding Management Leeway Space

Moyers –
z Treatment options for moderate and severe z 2.5mm per side in Mn
crowding in a mixed dentition depends on: z 2.0mm per side in Mx
z Preventing irreversible damage
z Promoting eruption of teeth into attached gingiva Proffit –
z 1.7mm per side in Mn
z Class I, II or III dental and skeletal growth pattern
z 0.9mm per side in Mx
z Incisor proclination
z Midline shifted or centered Used for:
z Esthetics z Crowding
z Leeway space available for crowding or molar z Molar drift
correction.

Crowding Management Lower Lingual Holding Arch

z Options: z LLHA
z No treatment and monitor
Maintains
z Space Maintainers current arch
z Extract primary canines ± z Holds arch
perimeter
LLHA perimeter as the
permanent teeth
z Arch width expansion erupt.
z Incisor proclination Increases arch
z Distalizers – lip bumpers, perimeter
headgear etc.

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Severe Transitional Crowding Serial Extraction
Signs: Definition:
A planned sequence of tooth removal during the
z Lack of interdental spaces in transition from primary to permanent dentition to promote
primary dentition. eruption of teeth through attached gingiva (keratinized
z >4mm of crowding of tissue) and reduce the severity of crowding.
permanent incisors.
z Early loss of primary canine Eruption sequence of the permanent dentition:
by ectopic eruption of lateral Maxilla: 61245378
incisor. Mandible: 6 1 2 (3 4) 5 7 8
z Ectopic eruption of upper
first permanent molars.

Serial Extraction
Serial Extraction

Ideal Case Selection Requirements:

1. No skeletal disproportions; balanced
AP, V, T dimensions
2. Class I molar
3. Non-retrusive lip profile Timing of extraction:
4. Normal overbite z ½ to ¾ root development
of 1st PMs to accelerate
5. Coincident midlines eruption.
6. Severe crowding warranting z Phase II full braces for
extractions. alignment, bite and root
parallelism.

Anterior Crossbites
III. NON SKELETAL
z Lingual eruption of a
ORTHODONTIC ISSUES maxillary incisor
relative to the
z Crowding mandibular incisor.
z Anterior Crossbites z With or without a shift
z Eruption Disturbances z Traumatic occlusion
z Ectopic eruption of maxillary first possible
permanent molars
z Lower anterior
z Mesiodens
recession possible
z Ankylosed primary molars

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 Ectopic Eruption of Maxillary
First Molar
III. NON SKELETAL
ORTHODONTIC ISSUES z Ectopic eruption is a
developmental disturbance
in the eruption of the
z Crowding
permanent dentition where
z Anterior Crossbites the first permanent molar
z Eruption Disturbances erupts with a mesial
z Ectopic eruption of maxillary first angulation and resorbs the
permanent molars distal root aspect of the
z Mesiodens primary second molar.
z Ankylosed primary molars

Ectopic Eruption of Maxillary

First Molar Ectopic Molar Appliance

z Reversible z Usually in young

z Spontaneous correction children
z Irreversible z Treatment sometimes
z Without treatment will continue to not possible due to
resorb the primary molar towards cooperation or
early exfoliation and compete for
arch space with the second compliance.
premolar.
z Effective if molar is
z Prevalence of 4% accessible

Mesiodens What is happening here?

Presentation:
z Delayed eruption of
incisors
z Diastema

z Severely displaced incisor

z Ectopic or asymmetric
eruption of central incisors
z Erupted supernumerary
tooth in midline

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Ankylosed Primary Molars
z Prevalence of 9-13% III. NON SKELETAL
z Presentation:
z Submerging primary molar
ORTHODONTIC ISSUES
z Primary molar below occlusal plane
z Crowding
z Issues:
z Missing successor
z Anterior Crossbites
z Delayed eruption of successor z Eruption Disturbances
z Progressive infraocclusion z Ectopic eruption of maxillary first
z Loss of arch length permanent molars
z Difficult extraction with potential
z Mesiodens
bony defect if no successor.
z Posterior lateral open bite
z Ankylosed primary molars

I. Definitions and Terms:

z Early Treatment
z Preventive, Interceptive, Corrective
z Phase I, Phase II III. SKELETAL
II. Specific goals of early treatment ORTHODONTIC ISSUES
III. Non skeletal orthodontic issues:
z Crowding z Transverse problems
z Anterior Crossbites z Vertical Problems
z Eruption Disturbances
z Growth Modification
IV. Skeletal orthodontic issues:
z Transverse problems
z Vertical problems
z Growth Modification

V. Summary and Cases

Transverse Problems in the

Expander Appliances
Mixed Dentition
How do they work?
z Rapid or slow expansion
Definition: Posterior Crossbite z Turning frequency
z When the upper teeth bite on the inside of the
z Skeletal expansion: Separates the:
lower teeth. z midpalatal suture
z circumzygomatic and
Classification: z circummaxillary sutures.
z Creates a diastema
z Unilateral or Bilateral

z With or without a shift z Dental expansion:

z Tipping, therefore overcorrection.
z Dental or Skeletal
z Cannot accomplish skeletal expansion once suture is fused.

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Expander Appliances
Vertical Problems in
the Mixed Dentition

• Open Bites
• Deep Bites

Hyrax Appliance Bonded Expander

Open Bites Habit Reminder Appliances

z Dental open bite
z Related to a digit habit
z Reversibility related to the age the habit is stopped.
z 80% spontaneously correct if stopped before 9yo.
z Otherwise, may consider a habit reminder
appliance.

z Skeletal open bite

z Increased dentoalveolar height
z Supereruption of maxillary teeth
z Phenotype: short posterior face height, long anterior
face height, high MPA, retruded mandible, maxillary Anterior Crib Appliance Blue Grass Appliance
constriction.

Skeletal Open Bite

early treatment?
z Partial braces (2x4 appliances)
z High Pull Headgear
z Chin Cup
z Transpalatal arch (TPA)
z Lower lingual arch (LLA)
z Tonsillectomy/adenoidnectomy

z Variable results with skeletal early treatments

z Many are case reports
z Long term stability is questionable
z May need to monitor growth and consider Lower Lingual Arch Transpalatal Arch
orthognathic surgery in the future.

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 Deep Bites
Vertical Problems in
the Mixed Dentition z Dental deep bite
z Extrusion of anterior teeth
z Skeletal deep bite
z Lack of alveolar development
• Open Bites z Overclosure

• Deep Bites
z Deep bites range from:
z Slightly excessive (50%)
z Palatally impinging (100%)

Deep bite early treatment

III. SKELETAL
ORTHODONTIC ISSUES
z Anterior bite plate
z Transverse problems
z Partial braces
z 2x4 appliances
z Vertical Problems
z Growth Modification

The Bite Plate Effect

Class II Growth Modification

z Class II
Growth Modification z Mandibular deficiency, maxillary
excess or combination
z Class II z Profile: retrognathic, convex
z Class III z Molar classification: Class II
z Skeletal discrepancy of jaw
growth
z Commonly measured using the
ANB angle

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Class II Growth Modification Class II Growth Modification

z Indications for Phase I treatment:

z For psychosocial benefit (evidence to Skeletal/Orthopedic appliances:
support) z Headgears
z Decreased risk of tooth fracture if
accident occurs. (evidence to support) z Functional appliances

z For better cooperation (some evidence

to support) Dental appliances:
z To take advantage of an earlier growth z Pendulum
spurt (some evidence to support, but
growth is so variable that it is difficult to z Partial braces
select cases)

Orthopedic Appliances: HG Orthopedic Appliances: FA

Herbst - Fixed
Bionator (Removable)

Dental Distalizers

Growth Modification
z Class II
z Class III

Pendulum Appliance Pendex Appliance

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Class III Growth Modification Class III Growth Modification
Findings: z Indications for Phase I treatment:
z Negative ANB angle z For psychosocial benefit
z Removal of shift
z Mandibular prognathism
z Pseudo class III
z Maxillary deficient z Incisal wear risk
z Combination
z For better cooperation
z Negative overjet
z To avoid future need for surgery?

Treatment Appliances Protraction facemask ± RME

Skeletal/Orthopedic Options:
z Protraction Facemask ± RME

z Chin cup

Dental options:
z Expansion
“Early Class III treatment is one of
z 2x4 appliances the most difficult undertakings
mainly due to the uncertainty of
the outcome’s stability after active
growth.” Westwood et al.

I. Definitions and Terms: Summary:

z Early Treatment
z Preventive, Interceptive, Corrective z Anterior Crossbites
z Phase I, Phase II z Primary molar ankylosis
II. Specific goals of early treatment z Impinging deep OB
z Ectopic eruption
III. Non skeletal orthodontic issues:
z Crowding
z Severe crowding
z Anterior Crossbites z Loss of arch space or symmetry
z Eruption Disturbances
z Excessive overjets
IV. Skeletal orthodontic issues: z Habits
z Transverse problems
z Open bites
z Vertical problems
z Growth Modification z Posterior Crossbites
z Growth discrepancies
V. Summary and Cases

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Milestone appointments:
z 7yo – first orthodontic evaluation
z Supernumerary or missing teeth

z Growth pattern, eruption schedule

z 8yo –
CASES
Possible need
z Degree of crowding
for Phase I
z Posterior or Anterior Crossbites treatment
z Class I, II or III

z Deep bite, open bite, habits

z 10yo – Look for permanent canine

position
Possible need for
Phase II or
z 11yo – late mixed dentition comprehensive
treatment

Open Bites: Anterior Crossbites:

What are some differences? What are some differences?

Deep Bites: What early treatment issues do you see?

What would you check next?

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What early treatment issues I. Definitions and Terms:
z Early Treatment
do you see? z Preventive, Interceptive, Corrective
z Phase I, Phase II

II. Specific goals of early treatment

III. Non skeletal orthodontic issues:

z Crowding
z Eruption Disturbances
z Anterior Crossbites

IV. Skeletal orthodontic issues:

z Transverse problems
z Vertical problems
z Growth Modification

V. Summary and Cases

Early Treatment in
Orthodontics
Dr. Suzan Ekim
ekimx001@umn.edu
Division of Orthodontics
University of Minnesota
2007

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