Orthodontics & Orthopedics PDF

ORTHODONTICS & ORTHOPEDICS Partial 1 DENTAL ERUPTION Dental eruption: The sequence of tooth eruption. ​ 1st time: Deciduous teeth ​ 2nd time: Permanent teeth Dental eruption is a physiological p...

ORTHODONTICS & ORTHOPEDICS Partial 1 DENTAL ERUPTION Dental eruption: The sequence of tooth eruption. ​ 1st time: Deciduous teeth ​ 2nd time: Permanent teeth Dental eruption is a physiological process associated with growth in which the tooth moves from its original position either in the maxilla or mandible to its final position in the oral cavity but this process can be affected by multiple congenital or environmental causes. Deciduous/Temporary Tooth 1.​ The eruption should be considered as the result of a multiracial phenomenon: ○​ Root development ○​ Alveolar bone growth ○​ Eruption sequence Dental organs can vary in size, shape and location. These differences allow the dental organs to work together to aid chewing, phonation and also help giving shape and structure to the face. Present the main factors involved in the dental eruption. In the process of tooth eruption, there are 3 phases in which the dental organ travels a long journey from the place of formation to Its occlusal establishment with the antagonist. Phases of tooth eruption: 1.​ Pre-eruptive phase: It takes place inside the bone and there is only a lateral displacement from the point of origin of the dental lamina towards the covering gum. ​ Differentiated area in bone tissue. ​ Calcification of the crown. ​ Fully outlined crown. Dental lamina: The precursor of the dental eruption is developed. Importance of the gubernacular cord during the eruption process: ​ This cord has connective tissue and remains of the dental lamina that cross the bone during the eruption of the tooth. ​ Many osteoclasts appear in the gubernacular cord that will enlarge this canal for the passage of the tooth. ​ The reduced epithelia will join to the oral epithelium and then the fused epithelia are formed, and when the apoptosis occurs (due to avascularization) it allows the tooth to emerge. 2.​ Pre-functional phase: ➔​ It begins when 50%-75% of the tooth root is formed. ➔​ There is an intense vertical displacement which allows the tooth to move towards the mucosa. 3.​ Functional phase:  ➔​ It begins at the moment the tooth makes contact with the antagonist and begins to perform the chewing function. ➔​ The duration of this phase is the entire life of the tooth, since the chewing functionality produces abrasion on the occlusal surfaces and contact points between the teeth. There are many factors that will affect the tooth eruption process: ​ Craniofacial growth and development process. ​ Heredity. ​ Genetic control of the growth peak and sequence of dental development. ​ Calcification pattern. NOLLA’S TABLE: Delay or normal. 0. Absence of the Crypt. 1. Presence of the Crypt. 2. Initial calcification. 3. One thrid of the crown completed. 4. Two thrids of the crown completed. 5. Crown almost completed. 6. Complete crown. 7. One third of the entire root. 8. Two thirds of the root completed. 9. Root almost completed, open apex. 10. Completed root apex. CHRONOLOGY OF THE DENTAL DEVELOPMENT IN PERMANENT DENTITION: Variations in the eruption chronology: ​ Dental anomalies occur as a consequence of alterations that affect the normal process of odontogenesis. ○​ Depending on the stage in which they occur the deciduous teeth the permanent teeth or both may be compromised. ○​ Depending on the stage and altered genes the number, size, shape, structure and color of some or all of the teeth may be affected. DENTAL ANOMALIES Anomalies of number such as supernumerary teeth or hyperodontia (formation of a greater number of teeth), and congenital absences or hypodontia (decrease in the number of teeth), constitute one of the local factors associated with the etiology of malocclusions can cause alterations in dental alignment and create more complex malocclusion problems. Dental anomalies represent a negative factor for the development of occlusion, producing: They produce some malocclusion. ​ Delay in the normal eruption of teeth. ​ Ectopic eruption of adjacent teeth. ​ Changes in the dental midline ​ Transpositions. ​ Rotations. ​ Abnormal spacing. ​ Decrease in arc length. ​ Lack of development of the alveolar bone. (agenesis). The most common anomaly is the “clove” shaped in upper laterals (diente en forma de clavo). AGENESIS: It is the absence of one or more dental organs and is a common developmental anomaly in both dentitions (deciduous and permanent) it is the result of a disorder of the dental lamina which prevents the formation of the tooth germ. The absence is often bilateral. The most frequently absent dental organs are: ​ Third molars. ​ Upper lateral incisors. ​ Lower second premolars. ECTOPIC ERUPTION: It is an alteration in the eruptive trajectory of the dental organ leading to its impaction against the adjacent tooth. Ectopic teeth are found in unusual positions or displaced from their normal anatomical location. The presence of an ectopic tooth can lead to malocclusion. It is more common in: ​ 1st molars and permanent canines. ​ Lower canine, lower 2nd premolar. ​ Upper lateral incisors. Sigue el trayecto de erupción pero no logrará salir porque hay un diente deciduo aún. TRANSPOSITION: It is the change in the position of two adjacent teeth in relation to their roots in the same quadrant of the dental arch which can lead and inverted eruption position and alter the normal sequence of eruption. They are generally unilateral, more frequent in the upper arch. Este no sigue el trayecto de la erupción y se pasa de 1 a 2 dientes de donde debería de salir. IMPACTED TEETH: Impacted teeth, despite of having been fully formed they have not emerged in the mouth during the usual period, and they can remain partially or completely inside the jaw bone. It is more common in: ​ Lower third molars. ​ Upper canines. Systemic Factors: ​ Formation abnormalities may be due to systemic alterations that begin in childhood or early adolescence. ​ Tooth abnormalities caused by systemic diseases include: alterations in the number of teeth, structural defects of enamel, dentin and cementum and in some cases variations in tooth size. Genetic Factors: ​ The appearance of skeletal development disorders due to hereditary factors in some cases manifests at birth and in others they develop during childhood or adolescence. ○​ Example: Klinefelter syndrome and Down syndrome where taurodontism can occur. Environmental Factors: ​ Dental anomalies can also occur due to a local cause for example: specific blow, such as trauma during tooth development or it may be of idiopathic etiology. MALOCCLUSION Definition: Any alteration in the bone growth of the maxilla or mandible and in the dental positions that impede the correct function of the chewing system with the subsequent consequences that this dysfunction has on the teeth themselves the gums and the bones that support them, the temporomandibular joint and facial aesthetics. Etiology: It could be caused by any other habit. ​ Onicofagia ​ Mouth breathing ​ Limp chained ​ Thumb sucking ​ I'M MISSING ONE Classification of ethnological factors: ​ General factors: ○​ Hereditary ○​ Congenital defects ○​ Oral habits ○​ Trauma and accidents ​ Local factors: ○​ Anomalies in the number of teeth. ​ Missing teeth: Agenesis (congenital absence or loss due to accidents, cavities, etc.) ​ Supernumerary teeth. ○​ Anomalies in tooth size. ○​ Anomalies in dental shape. ○​ Premature loss of deciduous teeth. ○​ Late eruption of permanent teeth. ○​ Prolonged retention of deciduous teeth. ○​ Cavities. ○​ Inadequate dental restorations. Edward H. Angle: What he did was the malocclusion classification MOLAR CLASSIFICATION: ​ Class I: Mesiobuccal cuspid of the 1st permanent upper molar teeth occludes with the buccal groove of the 1st permanent lower molar. ​ Class II: Mesiobuccal cuspid of the 1st permanent upper molar occludes IN FRONT of the buccal groove of the 1st permanent permanent lower molar.  ​ Class III: Mesiobuccal cuspid of the 1st permanent upper molar occludes BEHIND the buccal groove of the 1st permanent lower molar. CANINE CLASSIFICATION: It is the anteroposterior relationship between the upper and lower permanent canines. ​ Clase I: The cusp of the upper canine occludes between the canine embrasure and the lower first premolar. ​ Clase II: The cusp of the upper canine occludes IN FRONT the embrasure of the canine and the lower first premolar. ​ Class III: The cusp of the upper canine occludes BEHIND the embrasure of the canine and lower first premolar Embrasure: Are occupied by the dental papilla. DENTAL ANOMALIES Classification of dental anomalies: Dental anomalies are fundamentally based on the periods of dental development: ​ Anomalies in the number of tooth. ​ Anomalies in the tooth size. ​ Shape anomalies. ​ Structure anomalies. ​ Eruption anomalies. Characteristics: ​ The absence of teeth can be seen in both arches. ​ The absence is usually bilateral. ​ Agenesis is more common in permanent teeth ANOMALIES IN THE NUMBER OF TOOTH: They would be divided into: ​ Agenesis: ○​ Hypodontia: Is the absence of formation of three or more dental organs ​ The most common ones: ​ Third molars. ​ Upper lateral incisors. ​ Second premolars. ​ Hypodontia is one of the fundamental concerns of pediatric dentists and orthodontists due to the occlusal problems it generates, causing functional and aesthetic problems over time. ○​ Anodontia: ​ Disorder in which there are no temporary or permanent teeth because of the congenital absence of tooth germs.  Vemos en la primer foto de la riada inferior hypodontia y en la arcada inferior también es hypodontia. Agenesis de dos dientes Las dos imágenes tienen agenesia. La primera es aquella hay ausencia de 2 terceros molares y la segunda solo es agenesis. ​ Supernumerary teeth ○​ Characteristics: ​ Also called hyperodontia it is characterized by having more teeth than the regular number of teeth. ​ Hyperodontia is due to the hyperactivity of the dental lamina with the consequent formation of additional tooth germs. The supernumerary teeth: ​ They appear more frequently in the maxilla. ​ When the affected region is located in the midline of the palate between the two upper central incisors it is called mesiodens. ​ Hereditary seems to play a more significant role in cases of missing teeth and also in supernumerary teeth. Types of supernumerary teeth: ​ Supplementary teeth: It has a normal morphology and size. They appear in permanent dentition as extra upper lateral incisor or as lower incisor. ​ Conical teeth: They present a conical crown and smaller root than a normal tooth. When it is located in the premaxilla near the midline between the upper central incisors is known as MESIODENS. ​ Mesiodens ANOMALIES OF THE TOOTH SIZE: ​ The tooth size is genetically determined. ​ Men tend to have more square dimensions and women show a greater reduction in bucco-lingual size than in mesio-distal size. ​ In relation to tooth size it is observed that men's teeth are larger than women's. It’s classificated in: ​ Microdontia: The term microdontia is applied to teeth that are smaller than the limits of variation considered normal. ○​ There are 3 types of microdontia: ​ True generalized microdontia ​ De 3 a 6 ​ Relative generalized microdontia ​ 1 maximum 2 ​ Localized microdontia ​ It is the most common and it usually affects the upper lateral incisors and third molars. ​ All of them (teeth) Diastema Espacio entre dientes anteriores Tremas: Espacio de dientes posteriores ​ Macrodontia: The term macrodontia is applied to teeth that are bigger than the limits of variation considered normal. ○​ There are 3 types of macrodontia: ​ True generalized macrodontia: It is a very rare condition and has been observed in some cases of pituitary gigantism and hemifacial hypertrophy. ​ Crecimiento anormal del maxilar y la mandíbula al igual que de los dientes. ​ Relative generalized macrodontia: It is the result of a bone-dental discrepancy where the size of the teeth is bigger related to the jaws. ​ Localized macrodontia: It is not common and its etiology is unknown; it mainly affects the upper central incisors. The macrodontic tooth is a normal tooth in all aspects, except its size. ​ El tamaño es mucho más grande, pero la cámara pulpar y todo los demás es igual SHAPE ANOMALIES Characteristics: ​ Dental morphology is determined by genetics. ​ Alterations in the shape of the teeth can be present in any dental group. Classification in the dental form: ​ Fusion: Is the union of two developing teeth into a single structure. Fused teeth may have two independent pulp canals. ​ Germination: From a single enamel organ two teeth form or attempt to form and normally there is only one pulp canal. ​ Dilaceration: Its an excessive root angulation and may be the result of a trauma in the deciduous dentition. ​ Dens in dente: Also called an invaginated tooth. This developmental anomaly is a lingual invagination of the enamel and can occur in primary and permanent teeth Eruption: PREMATURE LOSS OF DECIDUOUS TEETH: ​ Premature loss: Refers to the early loss of primary teeth that can compromise the natural maintenance of the perimeter or arch length and therefore the eruption of the substitute tooth.  ​ The deciduous teeth not only serve as dental organs for chewing they also serve as "space maintainers" for the permanent teeth. ​ They also help keep the antagonist teeth in their correct occlusal level. ​ The temporary dentition must kept intact until the moment of replacement, they help to maintain the space that the permanent tooth will need to erupt. The premature loss of primary teeth is a severe problem that causes in the future: ​ Loss of dental balance. ​ Shortening of the arch length due to mesialization of the posterior tooth. ​ Extrusion of the antagonist tooth. ​ Problems in the TMJ. ​ Early prosthetic treatments. There are multiple causes of premature loss of primary teeth the most common are: ​ Diseases such as: dental caries, periodontitis, atypical root resorptions ​ Involuntary causes such ass trauma observed in the crown or the roat (falls, accidents) which most frequently affects the upper anterior teeth ​ Bad oral habits: which produce tooth mobility and tooth loss before the expected date Before removing any primary dental organ it is necessary to obtain periapical X-rays. The presence and position of the permanent successor must be established as well as the state of the root formation of the primary tooth to be extracted. PROLONGED RETENTION OF DECIDUOUS TEETH: ➔​ Prolonged retention of deciduous teeth also constitutes a disorder in the development of the dentition, ➔​ Mechanical interference can cause a bad position and this would lead a malocclusion. ➔​ The eruption of primary and permanent teeth can present variations of more or less than six months and it can be considered normal. ➔​ But if a delay of more than six months occurs we may be facing a cause of prolonged retention of the primary tooth or delayed eruption. It occurs with greater prevalence in: Second primary molars, canines and the common causes of this abnormality are agenesis, impaction of the permanent successor or dental ankylosis, which is also common in the deciduous dentition preventing the normal exfoliation of the deciduous and the eruption of the permanent successor. The etiology of prolonged retention of primary moles is eel red to hereditary and environment and local factors. The permanence of temporary teeth in the mouth and their lack of exfoliation may also be due to the agenesis of the permanent teeth in turn. Delay of the eruption of the dental teeth / of the permanent teeth: This may be due to physical barriers such as: dense tissues, bone crypts at the line of eruption of the permanent tooth, supernumerary teeth that prevent the eruption. In these cases there may also be physical barriers that affect the direction of eruption and establish an abnormal eruption pathway. These barriers can be: ​ Supernumerary teeth. ​ Deciduous roots.  ​ Bone barriers. Ankylosis: ​ Ankylosis of a tooth is defined as the union/fusion between a tooth and the alveolar bone. ​ This is due to some type of injury, which causes perforation of the periodontal ligament and the formation of a "bone bridge" joining the cement and the hard sheet. Cavities: Caries can be considered one of the many local factors that can cause a malocclusion. This can lead to: ​ Premature loss of deciduous or permanent teeth. ​ Subsequent displacement of adjacent teeth. ​ Abnormal axial inclination ​ Loss of arch length. Relationship between cavities and malocclusions: Interproximal cavities in the primary dentition represent one of the most common causes of space loss, since the neighboring tooth migrates towards the cavity producing a shortening of the length of the arch and breaking the balance of the forces that keep the tooth in occlusion. ANOMALIES IN THE DENTAL STRUCTURE ​ Imperfect amelogenesis ​ Imperfect dentogenesis ​ Dentin dysplasia Imperfect amelogenisis: Its a hereditary disorder of enamel formation affecting primary and permanent dentition. ​ There are 3 types of imperfect amelogenesis: ○​ Hypoplasic: The enamel does not have normal thickness in certain areas or in its entirety. ○​ Hypocalcified: the enamel has a normal thickness but is fragile and can be easily removed. ​ Está se renueve con el explorador ○​ Hypomaduration: the thickness of the enamel is normal but it doesn't have a normal hardness and transparency and opaque spots appear on the incisal edges of the teeth. Imperfect dentogenesis: It consists of opalescent teeth made up of irregularly formed and hypomineralized dentin that obliterates the coronal root and pulp chambers. The teeth range in color from bluish gray to yellowish. The dentin is abnormally soft, despite the exposure of dentin the teeth are not especially prone to dental caries. Dentin dysplasia: It is an inherited disorder characterized by abnormal dentin formation and abnormal pulp morphology. This has been divided into: ​ Type 1: Root dentin dysplasia ○​ Teeth are affected in both dentitions. The teeth have a normal color and in some cases may present a bluish or brown transparency in the cervical region. The roots of the teeth are shan, blunt, bulging, conical, or absent. ​ Type 2: Coronal dentin dysplasia ○​ Both the primary and permanent dentition are affected in this type of dysplasia, however the appearance of the temporary teeth is different from the permanent teeth. Primary teeth dinically show a blush gray, brown or yellowish color and have a translucent or opalescent appearance, the permanent teeth appear clinically normal and the roots in both dentitions are normal. Conclusion: All of these problems cause alterations in arch length, occlusion or aesthetics so its important to detect problems in time to guide the occlusion towards normality as long as possible. THE HISTORY OF ORTHOTICS Orthodontia ​ Orthos (Straight) ​ Odontos (Dentition) ○​ Orthodontia Ancient Civilizations: ​ Egyptians (400 BC) ​ Romans and Greeks (400 BC) ​ (770 to 220 BC) NORMAN W. KINGSLEY (1879): ​ He was a major contributor in the early development of orthodontic treatments and cleft palate therapy. ​ He designed fixed removable inclined planes, to connect class II malocclusion ​ He was the first person in 1880 to introduce the concept of “jumping the bite” for patient with a retruded mandible Modern Era (1900) - Orthodontics EDWARD H. ANGLE: ​ The first simple classification system of malocclusion. ​ He based his classification on the relative position of the permanent maxillary first molar.* ​ In 1988 he demostrated for the first time the expansion arch and its auxiliaries. ​ 1900 started the first school of Orthodontics. ​ Strong opposition against extraction teeth as part of an orthodontic treatment. "Orthodontics" is that specific area of dental practice that has as its responsibility the study and supervision of the growth and the development of the dentition and its related anatomical structures from birth to dental maturity, including all preventive and corrective procedures of dental irregularities requiring positioning of teeth by functional or mechanics to establish normal occlusion and pleasing facial contours. El diente invaginado siempre estará por detrás del diente. ​ Prevention and correction of malocclusions ​ Treatment and dento-facial abnormalities ​ Growth of the craniofacial complex ​ Development of malocclusion PREVENTIVE ORTHODONTICS: The objective is to act before the appearance of malocclusions when the diagnosis indicates that they are going to occur and will alter the normal development of the dental and maxillary/mandible organs. It is usually applied at young ages to avoid possible malocclusion. Characteristics: ​ Cries control and care of deciduous dentition ​ Eruption monitoring and space maintenance  ​ Early recognition of oral habits ​ Removal of supernumerary and retained deciduous teeth SPACE MAINTAINERS: ​ Nance button ○​ Palatal ○​ Bilateral ○​ Maxilar ​ Lingual arch ○​ Bilateral ○​ Mandibular ​ Band and loop ○​ It can be placed upper or lower ○​ Unilateral space INTERCEPTIVE ORTHODONTICS: The aimed is to correct bad dental positions or habits that are occurring but they can still be treated to change their evolution. It is used when a bad position or habit have already been established but they can still be corrected. It serves to prevent the growth of the craniofacial complex from developing abnormally and its applications have to do with both the teeth and the entire maxillary/mandibular complex. Procedures: ​ Serial extraction ○​ It’s a planned secuencial extraction so we can guide the permanent tooth eruption ​ It could be from premolars ​ Or other deciduous teeth ​ Correction of developing crossbite ​ Control of oral habits ○​ Bad oral habits: ​ Thumb sucking ​ Mouth breather ​ Tongue thrusting ​ Lip sucking - lip chewing - lip biting ​ Onychophagia ​ Removable OD supernumerary and ankylosed teeth CORRECTIVE ORTHODONTICS: It is applied when the malocclusion has already been established and has altered the normal course of the dentofacial complex. Fixed appliances (braces) are used to restore functional and aesthetic anatomical normality. Types of orthodontics appliances: ​ Metallic ​ Ceramic/Sapphire ​ Self-lighting ​ Lingual ​ Invisalign Orthodontics goals: ​ Facial aesthetics ​ Dental aesthetics ​ Functional occlusion ​ Periodontal health and stability PREVENTIVE ORTHODONTICS: ​ Space maintenance and space maintainers: ○​ Introduction: The importance of maintaining the integrity of the dental arch from the most premature period in the development of the human being allows a normal occlusion, ​ Guide to eruption for the permanent teeth. ​ Adequate establishment of occlusion in permanent dentition. ​ Phonetic function. ​ Chewing function. ​ Aesthetic function. ​ Prevention of oral habits. The most common space loss occurs within 6 consecutive months atter the loss of a primary tooth. Children may experience PREMATURE TOOTH LOSS: Local: Systemic: Caries Premature birth Trauma Cerebral palsy Syndrome/Disorders Teeth have a strong tendency to move mesially even before they erupt into the mouth; this phenomenon has been called the "mesial thrust tendency." SPACE MAINTAINERS Space maintainers have been used as a solution to this problem but the premises for their use depend on: ​ Dental age of the patient. ​ Tooth eruption sequence. ​ Time lapsed since extraction. ​ Degree of crowding and available space. ​ Anomalies or absence of permanent teeth. ​ Tooth type and position.  Space Maintenance: Space Maintainers: The provision of an appliance which is concerned Appliances used to maintain space or regain the only with the control of space loss, considering mayor amount of space so that they can guide the measures to supervise the dentition development. eruption of the permanent teeth into a proper position. ​ The most important function of space maintenance Is to maintain the mesiodistal relationship. ​ The maintenance of the arch length in the primary and early permanent dentition Is Important for the normal development of the occlusion. ​ Premature loss of primary teeth can result in the loss of the arch length leading a malocclusion. ​ The pattern of space loss depends on many factors including: age, stage of development in which teeth has been lost, the presence of crowding or spacing, and occlusal relationships. Space Maintainers Functions: ​ Maintain arch length and perimeter ​ Prevent space loss ​ Prevent the development of a malocclusion or reduce it's severity. Requirements that a space maintainer must have: 1.​ Maintain the desired proximal space. 2.​ It should not interfere with the eruption of the permanent successor tooth. 3.​ It should not interfere with the opposite tooth. 4.​ It must provide enough mesiodistal space for permanent teeth. 5.​ It should not interfere with phonation, chewing or functional jaw movement. 6.​ They should be simple in design. 7.​ They should be easy to clean and maintain. Ideal characters of the space maintainers: ​ Simple ​ Sponge and stable ​ Passive (not cause teeth movement) ​ Do not increase the risk of caries development General considerations for the placement: ​ Time lapsed after the tooth loss: space closure usually occurs in the first six months, therefore the space maintainer should be placed as soon as possible. ​ Patient's dental age: the stage of roof development of the successor tooth should be evaluated, regardless of the child's age. ​ Amount of space lost: in situations in which 2/3 of the existing space for the correct positioning of the permanent tooth has been lost, there will be a need for orthodontic treatment to correct these derivations. ​ Tooth eruption sequence: The relationship of the developing teeth and adjacent eruptions must be observed in the space created by the premature loss of any dental organ. ​ Late eruption of permanent teeth: in these cases it occurs due to partial impaction or deviation in the eruption path of the permanent successor tooth. In this case, extraction of the temporary tooth and placement of the space maintainer are almost indicated. Consequences of premature loss: ​ Decrease in the perimeter and length of the arch with the consequent deviation from the midline. ​ Causing malocclusions such as crowding, ectopic eruption or impaction of permanent teeth.  ​ Alteration of the molar and canine relationship. ​ Changes in the vertical plane such as deep bites, and in the transverse plane such as crossbites. However not every premature loss of a temporary tooth will be treated systematically by placing a space maintainer and they not always have the same characteristics, It is necessary to carry out a study of the patient's occlusion and choose the most convenient type of maintainer depending on the specific situation that occurs. Planning for the space maintainance: This planning should a general vision of the patient seeking to preserve the total perimeter of the dental arch and maintain the space of the tooth lost prematurely, For an adequate planning, the diagnostic must be analyzed with the aim of individualizing each case the most appropriate way. Diagnostic references: ​ Clinical exams ​ X-rays ​ Dental cast Types of space maintainers: ​ Unilateral: Loss of one tooth ​ Bilateral: Lost of more than 2 tooth’s UNILATERAL SPACE MAINTENANCE: ​ Band and loop: ○​ The indication for placement of a band and loop space maintainer is for loss of the first primary molar. ○​ It is indicated to maintain the space for a missing second primary molar, only if we have the presence of the first permanent molar. ○​ Advantages: ​ Allows the eruption of permanent teeth. ​ Easy to construct and adjust. ​ Not expensive. ​ Non-invasive or painful. ○​ A band is placed on the second primary molar and a wire loop exiends distaly to the primary cuspid.  ○​ The band and loop would extend from the first permanent molar to the first primary molar to maintain space for the second premolar. BILATERAL SPACE MAINTAINERS: ​ Lower lingual arch: ○​ The indications for a lingual arch space maintainer are: ​ Bilateral loss of the mandibular primary molars after eruption of the permanent incisors. ​ Unilateral loss of more than one tooth in the mandibular arch. ○​ Its design is made of bilateral bands on molars that are connected by a heavy wire that rests on the cingulum of the anterior incisors. ​ Nance Appliance: ○​ The indications for a Nance appliance are: ​ Bilateral loss of the maxillary primary molars. ​ Unilateral loss of more than one posterior tooth in the maxillary arch. ○​ Its design is made of bilateral bands on the first molars that are connected by a heavy wire, the arch wire is directed toward the palatal surface and is embedded in an acrylic button resting on the soft tissue. ​ Pérdida de órganos posteriores superiores ​ Transpalatal Arch: ○​ The indications for a Transpalatal Arch appliance: ​ Loss of 1 maxillary molar and one anterior teeth. ​ Unilateral loss of more than one anterior tooth in the maxillary arch. ○​ Its design is made of bilateral bands on the first molars that are connected by a heavy wire that fransverse the hard palate without touching soft fissue. Although it is easier to clean than the Nance appliance but it is not as stable, especially when bilateral second primary molars are missing. ​ Pérdida de órganos un posterior y un anterior superior ​ Removable acrylic appliance:  ○​ Removable acrylic appliance is indicated: ​ There has been a loss of more than one tooth in a quadrant, and the permanent molars havent erupted yet. ​ In the mandibular primary dentition, a loss of the second primary molars along with the both first primary molars, will indicate the placement of an acrylic appliance. In the maxillary it may be also fabricated. SERIAL EXTRACTION Introduction: It is a procedure within the field of Interceptive Orthodontics that can be applied in cases of bone-dental discrepancy where the supporting bone is less than the sum of the size of the dental material. Pierre Fauchard was the first to propose in one of his dental treatises, the extraction of deciduous teeth to achieve greater alignment of the permanent dentition. Serial extraction: It's an Interceptive Orthodontic procedure. ​ It's a timed planned sequential extraction of certain deciduous leeth followed by the removal of specific permanent teeth in order to guide the eruption permanent teeth into a favorable position. Is based on 2 basic principles: 1.​ Arch Length /tooth size discrepancy: a.​ When there is an excess of tooth material, compared to the arch length, specific extraction of some teeth have to be done so that the rest of the teeth can be guided to a normal occlusion. 2.​ Physiologic tooth movement. a.​ Human dentition shows a physiologic tendency to move toward an extraction space. But if we choose to remove some specific teeth, the rest of them which are in the eruption process, will be guided by the natural forces into extraction spaces. Indications: ​ Premature kiss of primary teeth ​ Arch length deficiency and tooth side discrepancy ​ Crowded maxillary and mandibular incisors ​ Class I Malocclusion Contraindications: ​ Severe Class Il or Class III malocclusion ​ Cleft palate cases ​ Extensive caries of first permanent molar Serial extraction methods: ​ Dewey method: ○​ Extraction of deciduous canines, followed by deciduous first molars an finally first premolars. ​ Este procedimiento se realiza entre los 9-10 años y máximo a los 11. ​ El proceso en específico se llama ENUCLEACIÓN, dónde solo se quita el germen del diente sin que aún esté formado. ​ Tweed method: ○​ Extraction of deciduous first molar, followed by first premolars and then deciduos canines. ​ Nance method: ○​ Extraction of deciduous first molar, followed by the first premolars then the decidivos canines and laterals. BAD ORAL HABITS Harmful habits: ​ Thumb sucking ​ Mouth breather ​ Tongue thrusting ​ Lip / Sucking biting ​ Nail biting / Onychophagia ​ Bruxism Clinical findings of the thumb sucking habit: ​ Proclined upper incisors. ​ Retroclined lower incisors. ​ Finger involved (dry chapped skin) and calloused digits. Clinical findings in lip biting habit: ​ Proclined upper incisors. ​ Retroclined lower incisors. ​ Enlarged, red lower lip. Clinical findings on the nail biting habit: ​ Anterior spacing and misalignment. ​ Exposed nail beds. Clinical findings on the mouth breather habit: ​ Narrow upper arch. ​ Posterior crossbite and anterior open bite. ​ Incompetent dry pale lips. Clinical findings on the bruxism habit: ​ Tooth fractures. ​ Prominent masseter muscles. ​ Jaw's pain. A bad oral habit is NOT A DISEASE it's a CONDITION. Introduction: A habit is a routine behavior that is repeated regularly and tends to occur unconsciously.  Habits are one of the major etiologic factors which Habits are the most frequent causes of these bad leads to bad formation in dentofacial structures. formations mostly seen in the early childhood and mixed dentition stages. A oral habit depends on: ​ Intensity: Is the amount of force that is applied to the teeth while the habit is performed. ​ Duration: Means the age af which the child get the habit, and the time spent by the child to do the habil per day. (hours/day). ​ Frequency: Means how many times the patient do the habit per day. DURATION: plays the most critical role in the tooth movement. 1.​ A child who sucks intermittently with high intensity, may not produce too much tooth movement. 2.​ A child who sucks continuously (for more than 6 hours) can cause more significant dental changes. Clinical and experimental evidence suggests that 4 to 6 hours of force per day are enough to cause tooth movement. The most important thing to remember before any kind of treatment is that the child must want to discontinue the habit so that the treatment can be successful. Each one of bad oral habits would show one or more occlusal problems: 1.​ Change in the inclination of upper and lower incisors. 2.​ Anterior open bite. 3.​ Constriction of maxillary arch (with posterior cross bite and crowding). Bad oral habits: ​ Thumb sucking: ○​ Is the placement of the thumb or more fingers in the oral cavity with repeated and forceful sucking movements associated with strong buccal and lip contraction. ○​ 2 types: ​ Active: ​ There is a heavy force by the muscles during sucking and if this habit continues for a long period the position of permanent teeth and the shape of mandible will be affected. ​ Passive: ​ The child puts his/her finger in the mouth but there is no force on teeth and mandible so this habit is not associated with skeletal changes. ​ Diagnosis: Determine the psychological or the causative factor involve: ​ Working mother. ​ Feeling lost. ​ Rebel. ​ Affention seeking. ​ Imitation. ​ Fear. Some important question to consider about the frequency intensity and duration of the habit: 1.​ How long does the child have had the habit? 2.​ When does he/she use the habit? Day or night? Constantly? 3.​ Does the child use the habit at school? Extraoral Features: ​ Digits (fingers): show redness, exceptionally clean, wrinkling, roughened wart, blister or ulceration and rarely deformity. ​ Lips: hypothonic upper lip and incompetent lips. ​ Facial form: mandible retrusion and maxillary protrusion. Intraoral Features: ​ Upper Arch: proclined maxillary incisors with or without diastema, constricted V-shaped arch with more constriction across the canines. ​ Lower Arch: retruded mandibular incisors. ​ Inter-arch: reduced overbite, increased overjet (open bite) and posterior crossbite. Anterior Open Bite: The anterior open bite develops because the digit rests directly in the lower incisors and this causes an increased vertical opening. Posterior cross bite: Constriction change the balance between the oral musculature and tongue. When the thumb is placed in the mouth the tongue is forced down away from the palate and without the tongue force in the palatal surface the posterior maxillary arch collapses into a crossbite. Facio-lingual movement of the incisors: Depends on how the thumb or finger is placed in the mouth. Usually the thumb is placed on the palatal surfaces of the upper incisors and on the labial surfaces of the lower incisors, the result of this positions is a increased overjet. Treatment: In most cases the treatment for a long sucking habit should be started between the age of 4 years and during the eruption of the permanent incisors. Treatment approaches of sucking habit include: ​ Direct Interview. ​ Reward System. ​ Reminder therapy appliance and non-appliance reminders. ​ Appliance Reminder Therapy, Direct interview: Reward System: Consists is a simple discussion between the child Provides a small daily noticeable reward. and the dentist in which they express the concerns and include an explanation by the dentist. Non-appliance reminder therapy: Appliance reminder therapy: This are for those patients who want to stop the ​ Removable Palatal Crib: These are passive  habit but they need the assistance to do it. Usually 6 appliances which are retained in the oral to 8 weeks of treatment should be enough. cavity by clasps and a acrylic baseplate with They Include: a palatal crib. ​ An adhesive bandage with waterproof tape ​ Fixed Palatal Crib: The design consists in on the finger that is sucked bilateral bands placed in the first molars ​ An elastic bandage that is wrapped around connected to a palatal arch with anterior the elbow to prevent the arm flex and the crib device. fingers from being sucked. ​ Chemicals with hot flavored placed on the sucked digits. Time of therapy: ​ Six to eight months are usually enough as an active period for habit treatment. ​ If the habit appears the appliance should be retained for 3 more months to make sure the habit has truly stopped. ​ Tongue Thrusting: ○​ Abnormal tongue function and posture that cause many malocclusions. The effects and management at early stages may be helpful to prevent future severe skeletal malocclusions. ​ Tongue thrust is a bad oral habit pattern related to the persistence of a wrong childish swallow pattern during childhood and adolescence which produces an open bite and protrusion of the anterior tooth segment. ○​ Etiology: ​ Removing the etiology is the primary and the most important step in the correction of the tongue thrusting habit. ​ Fletcher: Has proposed the following factors that cause the tongue thrusting habit: ○​ Genetic: There are specific anatomic and neuromuscular variations in the orofacial area that can precipitate tongue thrust. ○​ Feeding practices: Long feeding bottle and wrong swallowing pattern can be attributed as one of the ethnological factors of tongue thrusting. ○​ Infections: Breathing tract infections such as: chronic tonsillitis and allergies can cause a decrease in the amount of space in the mouth which brings the tongue thrust swallow. Types of tongue thrusting: 1.​ Anterior tongue thrusting. 2.​ Posterior tongue thrusting. 3.​ Both: anterior/posterior tongue thrusting. 4.​ Lateral tongue thrusting. 5.​ Unilateral tongue thrusting. Intraoral features: ​ Presence of an anterior open bite. ​ Presence of posterior cross bite. ​ The simple tongue thrust Is characterized by a abnormal tooth contact during the swallowing. Extraoral features: ​ Usually have a Dolichocephalic face. ​ Incompetent lips. ​ Speech problems. Treatment: Different methods have been attempted to correct the tongue thrusting habit with variable success. The American Academy of Pediatric Dentistry states that the management of the tongue thrust may include: ​ Myofunctional therapy. ​ Simple habit control. ​ Habit-breaking appliance. Myofunctional exercises: The patient can be guided to have the correct posture of the tongue during swallowing, by different exercises: 1.​ The patient is asked to place the tip of the tongue in the rugged palatal area for 5 min and is asked to swallow. 2.​ Other exercises: a.​ Molar tap - reach the tongue tip back and "tap" each molar in succession, lower left, upper left, upper right and lower right and go again, b.​ ABC trace - pretend the tongue tip is a pencil and "trace" the alphabet on the roof of their mouth. c.​ Tongue trace - with lips closed, lick the inside of the lips around in a circle without opening the lips. Appliance therapy: ​ Removable appliance it has an active component bow as a remainder and the tongue crib has retentive components and acrylic base plate. ​ Nance palatal arch appliances which has an acrylic button that can be used to place the tongue in the correct position. ​ Using fixed appliances with fixed tongue cribs. ​ Mouth Breathing: ○​ Is the habitual breathing through the mouth instead of nose and It can be abnormal when the patient breathes through the mouth even during rest. ○​ In about 85% of cases mouth breathing represents an Involuntary subconscious adaptation to reduced patency of the nasal airway and mouth breathing is a simply requirement in order to get enough air. ​ Etiology: Mouth breathing has been classified according to etiology: ​ Obstructive: A complete obstruction of the normal flow of air through the nasal passages. ​ Habitual: Continuous breathing through the mouth by the habit force. ​ Anatomic: A short upper lip does not allow the correct closure of the lips. Breathing needs are the primary determinant of the jaw and tongue posture. If the patient has an altered breathing pattern it could change the posture of this structures. It could also change the balance between the jaw growth and teeth position. Face height would increase leading to adenold facial appearance. The posterior teeth would over-erupt and the mandible would rotale down and back leading in a anterior open bile and an increased overjet. Intraoral features: ​ Anterior dental protrusion. ​ Distal relationship between the mandible and the maxillary. ​ V-shapped maxillary arch and deep palatal vault. ​ Anterior open bite. Extraoral features: ​ Adenodlong face with increased facial height. ​ Incompetent lip posture with short upper lips. ​ Narrow external nares. Diagnosis: Medical Clinic History ​ Chronic nasopharyngeal obstruction. ​ Allergic rhinitis Treatment: Otorhinolaryngology referral… Almost all mouth-breathing patients should be referred to the specialist so that they can check the patency of nasal airway and management of any nasopharyngeal obstruction. Oral screen: ​ Oral screen, it should be used after the removal of the nasal obstruction. ​ One of the most effective ways to reestablish the nasal breathing Is prevenling the access of air through the oral cavity. ○​ Oral screen: It consist on a thin sheet of acrylic extending deep Into the vestibular sulcus and the labial & buccal breathing holes can be punch out so that they can allow the entrance of some amount of air Into the mouth. ○​ After 3-6 months of the treatment period a reduction in the anterior open bile could be seen.