Ortho Sheet #1 By Muna Sawwan

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Ortho Sheet #1 By Muna Sawwan

Post by Sura on 23/9/2012, 11:07 pm


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تاريخ التسجيل : 2010-09-29

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Re: Ortho Sheet #1 By Muna Sawwan

Post by Sura on 1/10/2012, 12:36 am

correction By Muna Sawwan :
pg 4.. first question..
the question should be why are do we extract the D's

In the same page.. disadvtantages
we may need "SEVERAL general anesthesia"

pg 6.. q 3..
Why do we extract upper teeth to compensate for lower teeth extraction and not the opposite?
thanx for Mohammad Abukar

عدد المساهمات : 484
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Re: Ortho Sheet #1 By Muna Sawwan

Post by Shadi Jarrar on 18/12/2012, 2:42 pm

Ortho lec. # 1
Dr.Zaid Albitar
Done by: Muna Sawwan
W were given a lecture last year talking about LOCAL FACTORS, D. said that you have to study it very well ! and this lecture is a continuous it. We talked about the etiology and effects, and we will talk now about the management. " note: we will be asked about the local factors in the exam ".

-areas ( in 2 lectures )

REFERENCES >> L. Mitchell text book

Houston text book


What is interceptive orthodontics ?

It’s a treatment designed to minimize the extent of malocclusion and to limit the adverse effect of the local factors.

So basically ,, when a problems arises early , if you don’t treat it , it might become a bigger problem later on , which make the treatment later on lengthy or more complicated. SO IF WE INTERCEPT EARLIER , either the treatment on a later stage will not be needed or will be simpler and less complex.

Preventive Orthodontics:

It’s a special case of INTERCEPTIVE ORTHODONTICS which is : action taking to preserve the integrity of a normal occlusion.

The best example for this is when a child come with a perfect occlusion ( e.g 5 years old ) but he lost his E early . NOW if he didn’t lose his E's , then he has a very good chance to develop a perfect occlusion with his permanent dentition. BUT after losing the E , he might has a problems later on . like he might has impaction of ( 5 ) , but if we INTERCEPT early and place a space maintainer , treatment will not be needed later on and the arch will be preserved. J

AMERICAN ASSOCIATION OF ORTHODONTICS, recommend that all children should have a check up visit with an orthodontist not later than 7 years of age to apply these interceptive measures.

Why 7 yaers ? because 6's are erupted so we can have an idea about molar relation ship.

Also incisors are erupted so we know the incisor relation ship and if there is any crowding !

General dentists have an important role in interceptive orthodontics , some times they are the first people to recognize a problem, they can treat it, or if its beyond their capability they can refer him to a specialist .

( so refresh your self and revise the lecture talking about development of normal occlusion )


Problems of crowding , extractions , space management , displacement , cross bite and local factors.

You can summarize it in one word >> LOCAL FACTORS J

Some text books include ( crowding and extraction under local factors )

Skeletal problems : some consider it under interceptive measures like functional appliances, but others don’t, Dr. personally , think that it’s an interceptive measures, because you are intervening early and safe the patient from undertaking a complex treatment or jaw surgery.

We will talk later about skeletal factors when talking about class 2 div 1, class 2 div 2 ……..


Remember talking about local factors, they were 5 categories:

Variation in tooth form

Variation in tooth number ( increase or decrease )

Variation in tooth position

Local abnormalities in soft tissues

Local pathologies.

We will talk about :

- effect of early loss of deciduous teeth.

- Balancing and compensating extraction.

- Serial extractions.

- Interceptive treatment for a patient has early loss of permanent incisor.

- Interceptive treatment for a patient has early loss of permanent first molar.

- Space maintainers. J J

- effect of early loss of deciduous teeth.

It depends on site of loss is it primary A, B , C, D or E

Degree of crowding

Age of the patient


Note: usually they called interceptive treatment >> mixed dentition treatment because usually its done for mixed dentition ( early or late ).

Edentulous stage : the baby has only gum pad, usually we don’t interfere unless he has severe skeletal problem like Pierre Robin syndrome ( baby has difficulty in breathing ) so we interfere to facilitate breathing to avoid death ! or if he has natal and neonatal teeth !

In primary dentition: we treat problems related to:

- cross bite : and its usually limited to GRINDING of primary teeth like canines. If we want to construct an appliance we wait till first molar erupt ( some orthodontic schools in some countries construct an appliance when only primary teeth are present .

- para functional habits.

- Early loss of primary teeth ( like E's )

- Degree of crowding : when degree of crowding INCREASE , the effect or early loss of primary teeth INCREASE . so if patient has a spaced arch , the degree of effect of loss will be less. NATURE HATES SPACES , so teeth will be arranged in the spaces.

- Age of the patient : if a patient ( 5 years old ) came , with early loss of E's , and another patient ( 11 years old ) also with early loss of E's ,,, the effect of loss will be more in the younger patient . SO WHEN THE LOSS IS EARLIER , THE EFFECT IS GREATER.

- Inter cuspation : it’s a factor , BUT ITS NOT A VERY RELIABLE FACTOR !!

e.g : patient has early loss of E's but with a good molar relation ship ,, the effect will be less . or if he ha s a worn out tooth with no good occlusion !!!! but again its not a very reliable factor.


BALANCING EXTRACTION : extraction of a tooth in the opposite side from the same arch , designed to minimize centre line shift J

Because if there is early loss of one tooth on one side , there is a good chance that teeth in will be shifted to the side of loss , so CENTRE LINE SHIFT L !! SO we extract the same tooth on the other side to minimize the effect !!

COMPENSATING EXTRACTION : extraction of the same tooth lost from the OPPOSING arch , TO MAINTAIN THE OCCLUSION RELATION SHIP ! its rarely applied in primary dentition , usually its done in the permanent dentition for 6's .

Now we will talk about every single tooth ,,


Usually the effect is very little because the arch is spaced , unless the cause is trauma we have to investigate the underlying permanent tooth , if ankylosis or dilacerations or arrest of development happened !

While if the loss is due to caries, the effect usually is minimal , so we usually don’t need space maintainers and we don’t need to compensate or balance ( extraction ).


If it happened in any arch ( upper or lower ) centre line shift will occur ( toward the affected tooth ) , in addition to space loss . and when the crowding is more, the need of balance will be more .

So, if C is lost, we better extract the C in the other side of the arch to prevent centre line shift , in addition to placing a space maintainer ( lingual arch or transpalatal arch ) .

Again ,, when C is lost >>>> balancing extraction + space maintainer

When D is lost >>>> space maintainer ( like band and loop ).


Function of E : guides the eruption of 6 , and hold the space for 5 J

So early loss of E , ultimately cause impaction of 5,, but usually no centre line shift because its far from the anterior teeth. We usually don’t balancing it , but we put space maintainer to hold the space for 5 .

" revise the lecture taking about space maintainers and the variables in choosing the type " .

The tooth is the best space maintainer , and its better than introducing a foreign body.

We have to balance the space maintainer with the patient oral hygiene , if its not that well ,, we defer space maintainer till it improves.

Types of space maintainers:

The tooth itself

Band and loop

Lingual arch

Trans-palatal arch

Upper removable appliance

Distal shoe

Glass fiber re-inforced composite resin " you light cure it, so it became rigid , then hold the space "

An interceptive measure to deal with crowding >>> SERIAL EXTRACTION :

It began an 1745 , but it became more popular in 1948 by Kjellgren .

It’s a sequenced extraction of a primary and permanent teeth, to resolve ( at the first stage ) the crowding in the labial segment , ( and in the second stage ) to resolve crowding in the buccal segment .

They start it usually when the patient is 8.5- 9.5 years old and the patient ha severe crowding

We extract the C's once the lateral incisors are emerging. so it aims that the lateral incisors will take the space of the C's so it become aligned, BUT now the CANINE WILL HAS NO SPACE because it’s the latest to erupt ! SOOO what we do is we extract the D's when the roots of 4 are half-formed. ( nearly about 1 year later ) so we will guarantee that 4's will erupt before 3's ( specially in the lower arch ). So in this way , no impaction of 4 will occur , and no need for surgical extraction .. IT’S THE MOST IMPORTANT STEP.

The last step is to extract all 4's when 3's are erupting J

Questions from the students :

1) " sorry cant hear the q. "

The answer : we want to extract it to accelerate the eruption of 4 !!

This procedure has certain requirements !

-Should be at early stage ( 8-9 years )

-Should be severe crowding ,, 10 mm per arch

-Normal incisor relation ship " class 1 ,, so normal overjet "

-Normal molar relation ship

-No skeletal problem

-Normal or reduced over bite : " because the space when teeth will be arranged to close ,,,, the teeth will be more retroclined " to close the space " so will increase the overbite

- when all teeth are present and in a good health ,, " its not logical to extract the 4's , while 5's are heavily carious !!!

- 4's should be closer to eruption than 3's : " the most important point specially in the lower arch "


-We might need GA because the patient is too young ! and we are extracting 12 teeth….

-Lower 3's might erupt ahead of 4's >> then we need surgical inoculation of 4 !!

-We cant accurately predict the crowding by the age of 8 , because intercanine width keeps growing till the age of 11 or 12 , so , the crowding that was severe at the age of 8 became less later on ,

- extracting the lower C's ,, so the anterior teeth became lingualy tilted , so tending to increase the over bite !!!

- might need fixed appliances later on .

We don’t apply it as it 100% , because of its disadvantages ,, Dr. Zaid use it only when he is 100% sure that the patient cant wear an appliance like patient with mental disability , he cant co-operate with the appliance,,, has contraindication to appliances .



We only extract C's "not like serial " , when lateral incisor is crowded but not yet erupted , so laterals become aligned ,,, then we don’t have to extract the D's ,, we can use head-gears .

-Also if laterals are in a cross bite , we extract the C's to align the laterals J

-Or lower incisors are in severe crowding and if we don’t extract the C's ,, so sever proclination occur in incisors and Dehiscence in incisors " loss of attachment " .

-un-erupted upper incisors with supernumerary teeth , we remove supernumerary and in order to provide space for the centrals we extract the C's .

- when upper canines are palately impacted " you will have a full lecture about impacted canine later on "

If we diagnose it early and we extract the C's ,, there is a good chance that it will erupt in good occlusion and good alignment .

Dr. is pointing to the pictures :

-When we extract the lower C's , the laterals will be aligned by the tongue pressure.

- palately impacted canine > if we ectract the C's early there is a good chance to erupt ,, up to 70 % .



Loss of PERMENANT incisors lead to space loss ,,, NOT LIKE THE PRIMARY ONES ,

So if we lost upper centrals due to severe caries or trauma , we have to intervene early .

We have more than one option ,THE BEST OPTION is RE-PLANTATION " you should know about replantation"

Or if we have crowding else where in the arch , we can auto transplant premolar and we modify it to look like central . or we maintain the space by resin retained bridge !! or removable appliance to replace it later by implant , or if we can , we build up the laterals with a veneer " if its big enough "

PICTURES : -this is a premolar , modified to replace central

-removable appliance to replace missing centrals "spoon denture " ( you will use it in pedo)


You know it’s the most tooth prone to caries , because it’s the first to erupt.

Some times we can intervene by extracting the 6 , in a certain stage or time , so we can help the 7 to erupt in the place of the 6 with out using an appliance . BUT ,, BEFORE WE APPLY THIS INTERCIPTIVE MEASURE we have to look for many things :

-restorative state of the tooth , do we really need to extract it or not ??

-age of the patient



- Presence and condition of the other teeth ,, its NOT logical to extract the 6's when the patient is having already missing teeth !!

We extract the 6's with poor condition , to minimize the need of using an appliance , and to help the 7's to come in the place of 6's . ONLY WHEN :

- all teeth are present "" the most important tooth is the 7 ,,,, when the patient is 8-9 years , and the root is less than one third formed "" ,, this is the best stage to extract the 6 , so the 7 can get in its place !

it also relieves buccal segment crowding ,, of course it will not relieves crowding in the labial segment ,, " If we want to ,,, we have to use appliance ".

delay extraction if space is needed " GENERAL RULE "

means : if patient has crowding or problem in the over jet in the upper, and we need space ,,IF we extract the 6 ,, the 7 will get in its place but WITHOUT solving the problem !!! SOOO we wait till the eruption of 7 ,, then we extract the 6 AND PUT THE APPLIANCE ,, to benefit from the space and to solve the problem of the crowding and overjet J

consider compensating extraction if the lower molar is extracted and the other molar is questionable

I think dr mean enno from the opposing arch because he said compensating extraction !

If we extract a tooth in the lower and we don’t extract in the upper >>> over eruption of the upper tooth

And then its difficult for the 7 to get in the place of 6 "" I think he means in the lower arch , we extract the 6 to help 7 to erupt in its place , but because we didn’t extract the opposing one and its now "upper 6 " over erupted, the lower 7 cant erupt in the place of 6 ""

So we consider BALANCING extraction if we lost the lower ,,, we have to extract the upper ,,, but the oppsote is not true,,,,, if we lost the upper we may NOT EXTRACT THE LOWER . because its difficult for the lower to get over-erupted ! ok !! J

Consider balancing extraction when crowding is present and the other molar is questionable

Y3ne : if we extract 6 in one side of the arch ,, and there is crowding ,, and the other molar in the same arch is not healthy ,,we extract it ,, BUT if its SOUND tooth ,, we usually don’t use balancing " don’t extract it "

Questions J

1) sorry I cant hear the Q

the answer is we have to look to other factors ,, if its mild crowding ! but if its sever crowding we usually wait until the 7 erupts !

2) if we extract the lower 6 ,, then why to compensate by extracting the upper while it would be contacting other teeth " and will not over erupt !! "

the answer is : we have to assess the occlusion ,, we have study models , so we can tell that if we don’t extract it ,, it will over erupt ,, in certain cases like class 2 or 3 , it might happen ! but we are talking generally " it’s a general rule " ,, we need to consider it , but we need to discuss every case ,, so again , GENERALLY if we extract the lower , we compensate by extracting the upper , but if we extract the upper we usually don’t need to extract the lower J

3)يا جمااااعة اسفة كتييييييييير بس جد يا دوووووب صوت الطلاب مسموع !! يعني مش غلط تسالو بصوت عالي !! وسامحونا J

The answer is THE GRAVITY IS THE CAUSE , so for the upper to get down , its easy ,,, but its not for the lower to erupt against the gravity and because THE TONGUE WILL PREVENT IT .

4) I think the student asked about splinting the tooth instead of extracting it ! J

The answer : it’s a good q ,,but how would you splint it ?? and remember that you have at this age the primary teeth , D's and E's ,, ( 8 years ) you cant rely on it to hold the 6 ! J

And remember that we did all that , to minimize the use of appliance , so if you don’t extract it , and it became over erupted , then you have to use appliance to intrude it , then it will become complicated ,,,,, and again it’s a primary teeth you cant rely on !!


Many problems are associated with cross bite whether its anteriorly or posteriorly :

- possible TMJ problems if displacement happened "

- attrition

- periodontal problems

- it may persist in the permanent dentition .

to solve it , we can use removable appliances with many designs and using posterior bite plane.

Or using fixed appliance , screw , springs .

Cross bite usually needs our attention early !

Discussing some figures :

This is displacement because of a premature contact ,, one of the interceptive procedure if the arch is compatible, ( looking at the cast to know if the arches are compatible ) then what we do is just a grinding for the C's . or if the arches are not compatible , we need an appliance ( for upper arch expansion ) .

Q from a student ? what does ( arches are compatible ) mean ?

The answer : when you look at the cast ! you have a good occlusion , no cross bite or reduction of arch width J

LOCAL FACTORS : we will talk about soft tissue anomalies >> habits !

The habits we are talking about are dummy sucking habit or thumb sucking !

Its in western world up to 90% and its 1:1 ( male :female ) till the age of 1 year ,, and after that its more in females .

Usually the habit began in the first 3 months and its considered normal ,, and no one can construct an appliance for habit removal or start breaking the habit for a child who is less than 1 year.

Actually some researches talking about SUDDEN INFANT DEATH SYNDROME ,, American association of pediatric dentistry recommend dummies during the first year of life !! because its found that it reduces the risk of sudden infant death syndrome !

SIDS : no known cause , but the child " specially in the first year of life " dies suddenly during sleeping !

They realized that the babies ( using the dummy ) have a lower risk than those who don’t ! because it helps the air way to be patent while he is sleeping .

من غير ما يربطوها بخيط !! لانو بخافو من الاختناق ! وصار حالات متل هيك !!!!!!!!

2 theories for dummy sucking habit:

a- signs of emotional disturbance.

b-a learned behavior.

الدكتور : شافوا انو الطفل وهو ب بطن امه بكون عنده هاي العادة ! لذلك هو ما بتوقع يكون عنده مشاكل عاطفية !

So the second theory is more acceptable! A LEARNED BEHAVIOR ,, satisfaction !


-depends whether its dummy or thumb




When intensity and duration increase , the effect is more .

Effect of DUMMY sucking habit :

*Effect mainly in primary dentition , its rarely to see a child 15 years , and he still doing that !

*anterior open bite , and its symmetrical , because its in the middle usually.

*tongue comes to a lower position , so , constriction to the upper arch, which lead to cross bite with displacement in the primary dentition.

*usually no anterior posterior effect because there is no anterior posterior vector of force so NO overjet problems.

Effect of DIGIT sucking habit :

Its MORE SERIUOS problem !

*it proclines the upper incisors.

*might rertocline the lower incisor and might not, because the tongue comes to a lower position.

*anterior open bite , and might cause overjet due to proclination .

*uni-lateral cross bite with displacement , but usually its limited to the anterior teeth ( open bite) and doesn’t extend too much to the posteriors , and its asymmetric , EXCEPT if he is sucking 2 fingers it might be symmetrical.

* eczema ( on childs finger ! )

Both habits might cause acquisition or spread of infection , so its always important for the child younger than 1 yaer , to clean the dummy with a sterilizer .


Its preferable to discourage the dummy if the child is 2 years to prevent the problems from occurring .

طبعا ما في اشي بالقوة !! ممكن يصير في نتائج عكسية ! يعني المفروض نفهم الطفل العواقب للعادة ونفهم الاهل ! و بس نتدخل اذا الطفل كان بدو يتخلص من العادة ، في ناس بحطوا شطة !!! وهاد الحكي غلط ! ممكن يعمل مشاكل نفسية عند الطفل !!!!!

Its preferable to break the habit by the age of 6 , before the centrals erupt.

The child who is undergoing under severe PSYCHOLOGICAL trauma is unlikely to respond , he needs counseling.

There is physical and non-physical methods ,,, we usually start with the non-physical methods : we explain and rewards,,,, then the physical methods :gloves in the pajama or stickers or bandage on elbow to remind him !

IF ALL THESE methods didn’t give us positive results , we use an appliance , might be fixed or removable, but the fixed one is better because the patient cant remove it ,,,

It looks like Nance appliance but modified to make the patient feel uncomfortable while sucking .

We usually put it for 3 months , and then when the patient stop the habit and we are sure that he did , we remove it.

There is a good chance that if he stop the habit early , the open bite problem will be solved, but IF cross bite already happened with arch constriction, we usually need appliance to expand the arch later on.

Q from a student : why its not bilateral cross bite ?

A: the arch constricts equally , but the patient used to bite to one side to get good occlusion ,to has good intercuspation , so he has to shift to one side.




Tuesday 18-SEP-2012


Shadi Jarrar
مشرف عام

عدد المساهمات : 997
النشاط : 12
تاريخ التسجيل : 2009-08-28
العمر : 27
الموقع : Amman-Jordan


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