Prevention Of Malocclusion Question And Answers

Epidemiology Etiology And Prevention Of Malocclusion

Question 1. Write short note on Preventive Orthodontics.
Answer. It is defined as “the action taken to preserve the integrity of what appears to be the normal occlusion at a specific time”. —Graber

Procedures Undertaken in Preventive Orthodontics

Procedures to be undertaken are divided into two types:

• Preventive procedures without appliances:
  • Parental education
  • Predental procedures
  • Oral hygiene
  • Caries control
  • Care of deciduous dentition
  • Management of ankylosed teeth
  • Maintenance of occlusal equilibrium
  • Removal of supernumerary tooth
  • Restoration of decayed teeth
  • Habit correction
  • Disking
  • Management of tongue tie
  • Locked permanent first molar
• Preventive procedures with appliances
  • Space maintenance
  • Mouth protector

Read And Learn More: Public Health Dentistry Question And Answers

Preventive Procedures without Appliances

Parent Education

• Preventive orthodontics should begin before the birth of child.
• The expecting mother should be educated on matters such as nutrition.
• After birth mother should be educated on proper nursing and care of the child.
• When bottled mother advised to use physiologic nipple not conventional nipple.
• The parents should educated for maintenance of good oral hygiene (to prevent nursing bottle syndrome).

Predental Procedures

• Preventive procedures should be started before teeth eruption.
• Malocclusion occurs because of improper selection of feeding nipple for baby and also because of improper positioning of bottle.
• Physiologic nipple should be used.

Oral Hygiene

Oral hygiene measures should be taught to the parents and children.

• Infants (0–1 year): Brushing should be advocated with eruption of first deciduous tooth. Moist gauge or moist cloth is used for massaging the gums and cleaning the teeth.
• Toddlers (1–3 year): Toothbrushing should be done with low fluoridated toothpaste. Parent should brush for the child.
• (3–6 years): Brushing of children is carried out under the supervision of parents. Fluoridated toothpaste should be introduced.
• School age (6–12 years): Brushing technique used should be proper and regular brushing is done.

Caries Control

Provisional caries should be detected properly and proper restoration should be undertaken immediately to prevent mesial movement of adjacent teeth and thus prevent loss of arch length.

Care of Deciduous Dentition

• Resorption pattern of primary teeth should be checked properly which causes establishment of nice occlusion.
• Abnormality in resorption leads to space deficiency.
• Deciduous canines and second deciduous molars are subjected to aberrant absorption
• After shedding of primary tooth, permanent tooth erupt in 3–6 months.

Management of Ankylosed Tooth

• Ankylosed deciduous teeth deflect permanent teeth to abnormal location.
• They should be diagnosed and remove surgically at proper time.

Maintenance of Occlusal Equilibrium

This is to be done as preventive, interceptive and corrective orthodontic procedure.

• Functional shifts causing pseudo class III as well as crossbite should be checked and eliminated.
• Overextended restorations should be reduced since they lead to occlusal prematurities.

Removal of Supernumerary Tooth

• Supernumerary and supplemental teeth can interfere with the eruption of nearly normal teeth.
• Supernumerary teeth should be identified and extracted before they cause displacement of other teeth.

Restoration of Decayed Teeth

• Interproximal fillings should be done to prevent loss of space.
• Overextended restoration changes occlusal relationship.

Habit Correction

• Early correction should be done which eliminate unfavorable sequelae of habits which leads to malocclusion.
• Habits such as tongue thrusting, mouth breathing etc. should be recognized and treated.

Disking

• It is to be done in oversized first or second deciduous molars.
• It facilitate eruption of permanent teeth.

Management of Tongue Tie

• It occurs because of thickening of genioglossus muscle which join midline of tongue where it gets elevated in vertical fold.
• It disappears after 4 years of age
• In case if it remains after 4 years, frenectomy is done.
• Tongue tie causes difficulty in feeding.

Locked Permanent First Molar

• Tooth can be slightly or deeply locked.
• Deeply locked tooth require extraction of second deciduous molar and space maintenance for second molars.
• Slightly locked permanent first molar erupts without any treatment.

Mouth Protectors

• It provides protection against injuries to teeth in thecontact sports.
• They are of two types i.e. prefabricated and custom made.

Question 2. Write short note on Interceptive orthodontics.
Answer. It is defined as “that phase of science and art of orthodontics employed to recognize and eliminate potential irregularities and malpositions in developing dentofacial complex” —Graber

The Procedures Undertaken in Interceptive Orthodontics

• Serial extraction.
• Correction of developing cross bite.
• Space regaining.
• Control of abnormal habits.
• Muscle exercises.
• Interception of skeletal malrelation.
• Removal of soft tissues or bony barrier to enable eruption of teeth.

Serial Extraction

“It is a procedure where some deciduous teeth followed by permanent teeth were extracted to guide the rest of teeth into normal occlusion”. —Kjellgren

Correction of Developing Crossbite

• Anterior crossbite should be intercepted and treated at an early stage to prevent orthodontic problem.
• Dentoalveolar crossbite is treated by using tongue blades, Catalan’s appliance and double cantilever spring with posterior bite plate.
• Functional anterior crossbite is corrected by eliminating occlusal prematurities.

Space Regainer

• “It is a device used to regain the space lost by tipping movement of a tooth into extracted space.”
• It should be used at an early age.

Control of Abnormal Habits

Some of the habits which affect oral structures are thumb sucking, tongue thrusting and mouth breathing. Such habits are to be controlled

Muscle Exercises

Muscle exercise improves aberrant muscle function.

Interception of Skeletal Malrelation

• Skeletal malrelation should be diagnosed at an early age and is intercepted to reduce the severity of malocclusion.
• It normalizes the skeletal relationship.

Removal of Soft Tissue and Bony Barriers

• As permanent tooth fail to erupt at its particular time its eruption is stimulated by surgically exposing the crown.
• In surgical procedure soft tissues are removed and bone is removed which overlie the crown of unerupted tooth.

Question 3. Write short note on space maintainers.
Or
Write in brief on space maintainers.
Answer. “Space maintainer is a device used to maintain the space created by the loss of a deciduous tooth.”

Classification of Space Maintainers

According of Hitchcock

• Removable or fixed or semifixed.
• With band or without band.
• Functional or nonfunctional.
• Active or passive
• Certain combination of the above.

According to Raymond C. Thurow

• Removable
• Complete arch
  • Lingual arch
  • Extra-oral anchorage
• Individual tooth

According to Hinrichsen

• Fixed space maintainers.
  Class 1:
  • Nonfunctional types
    • Bar type
    • Loop type
  • Functional type
  • Pontic type
  • lingual arch type

Class 2: Cantilever type (distal shoe, band and loop).

• Removable space maintainers
• Acrylic partial dentures
• Complete dentures
• Removable distal shoe
• Space maintainer

Requirements of Space Maintainer

• It should maintain the entire mesiodistal space createdby lost tooth.
• It must restore the function and must prevent over eruption of opposing teeth.
• It should be strong enough to withstand the functional forces.
• It should not exert excessive stress on adjoining teeth.
• It must permit maintenance of oral hygiene.
• It should be simple to construct.
• It must not restrict normal growth and development and natural adjustments which occur during the transition from deciduous to permanent dentition.
• It should not come in the way of other functions.

Contraindications of Space Maintainer

• Mesiodistal width of underlying permanent tooth is less than space.
• When permanent tooth is near the crest of alveolar edge.
• When underlying permanent teeth is missing.
• Patient and parents are not interested.
• Oral hygiene maintenance is poor.
• Patient is mentally retarded.

Types of Space Maintainer

There are two types of space maintainer i.e. removable space maintainer and fixed space maintainers.

Removable space maintainer: These are the space maintainers which can be removed or inserted in oral cavity by the patient at his/her will. They are classified as functional and nonfunctional. Commonly used removable space maintainers are acrylic partial dentures, removable distal shoe space maintainers, etc.

• Advantages of removable space maintainers
  • They are easy to clean and should also permit the maintenance of proper oral hygiene.
  • They should maintain or restore vertical dimension.
  • These can be worn part time which allows circulation of blood to soft tissues.
  • They fulfill other important functions such as mastication, aesthetics and phonetics.
  • Since they are removable, dental check-up for caries detection can be done easily.
  • Space can be created for permanent teeth to erupt without changing the appliance.
  • These appliances stimulate eruption of permanent teeth.
  • In these, band construction is not necessary.
  • They help in preventing development of tongue thrust habit into the extraction space.
• Disadvantages of removable space maintainers
  • They can be lost or broken by patient.
  • Uncooperative patients can not wear the appliance.
  • If clasps are incorporated, lateral jaw growth may be restricted.
  • They may lead to irritation of underlying soft tissues.
• Commonly used removable space maintainers
  • Acrylic partial dentures: They can be readily adjusted to allow eruption of teeth. They restores the masticatory function. Clasps in them can be inclusion of artificial teeth in the denture which is fabricated on deciduous canines and molars for retention.
  • Complete dentures: They not only restore masticatory function and the esthetics, but also help in guiding the first permanent molars in their correct position. In these posterior border of denture should be placed over the area which approximates the mesial surface of an unerupted first permanent molar. Denture will have to be adjusted and a portion of it should be cut away as permanent incisors erupt, posterior border should be contoured to guide the first permanent molars into their real position.
  • Removable distal shoe space maintainers: It guide the first permanent molar into position when the deciduous second molar is lost shortly before eruption of first permanent molar. Tooth which has to be extracted should be cut away from stone model and a depression is given into the stone model which allows the fabrication of acrylic extension. Acrylic will extend into the alveolus after removal of primary tooth. Extension can be removed after eruption of permanent tooth.

Fixed space maintainers

These are the space maintainers which are to be fitted in teeth. They cannot be removed at patient’s own will. Various fixed space maintainer are band and loop, crown and loop, lingual arch pace maintainer etc.

• Advantages of fixed space maintainers
  • Bands and crowns are used which need minimum or no tooth preparation.
  • They never interfere with the passive eruption of abutment teeth.
  • Jaw growth is not hampered.
  • Succedaneous permanent teeth are free to erupt inside oral cavity.
  • They can be used in uncooperative patients.
  • If pontics are placed masticatory function is restored
• Disadvantages of fixed space maintainers
  • Elaborate instrumentation along with the expert skill is needed.
  • They can cause decalcification of tooth material under the bands.
  • Supra-eruption of opposing teeth can occur if pontics are not used.
  • If pontics are used they can interfere with the vertical eruption of abutment tooth and can prevent eruption of replacing permanent teeth it patient fails to report.
• Commonly used fixed space maintainers
• Band and loop space maintainer: They are the most common space controlling appliances which are used in dental practice. Tooth distal to extraction space should be banded and a loop of thick stainless steel wire is soldered to it along with its mesial end which touches the tooth mesial to extraction space. This is a unilateral fixed appliance which is indicated for space maintenance in the posterior region when a single tooth gets lost.
• Crown and loop space maintainer: They are similar to band and loop space maintainers in all aspect except that a stainless steel crown is used for abutment tooth. The crown is used in preference to the band if the abutment tooth is highly carious, exhibits hypoplasia or pulpotomized.
• The lingual arch space maintainer: It is the most effective appliance for space maintenance in mandibular arch. Classical mandibular lingual arch has two bands which are cemented on first permanent molars or on the primary second deciduous molars, which are joined via a stainless steel wire which contact the lingual surface of all the four mandibular incisors. It is used to preserve the spaces which are created by multiple loss of primary molars. This helps in maintaining the arch perimeter by preventing the mesial drifting of molars and also the lingual collapse of anterior teeth.
• Distal shoe space maintainer: It is also called as intra alveolar appliance. Distal surface of second primary molar guides the unerupted first permanent molar. As the second primary molar is removed before eruption of the first permanent molar this appliance provides greater control of path of eruption of an unerupted tooth and also prevents undesirable mesial migration of erupting tooth. These days the appliance which is used in dental practice is Roche’s distal shoe or its modifications by using crown and band appliances with a distal intra-gingival extension.

Question 4. Write short note on thumb sucking in children.
Answer. “It is the placement of thumb or one or more fingers in varying depth into the mouth”. —Gellin

Classification of Thumb Sucking

According to ‘Cook’

• α-group: The thumb pushes the palate in a vertical direction and displace only little buccal wall contraction.
• β-group: Strong buccal wall contractions are seen and a negative pressure is created resulting in posterior crossbite.
• γ-group: Alternate positive and negative pressure is created.

Theories explaining thumb sucking habit:

• Psychosexual theory: According to this theory, thumb sucking habit evolves from an inherent psychosexual drive.
• Oral drive theory: According to this theory prolongation of nursing strengthens the oral drive and child begins thumb sucking.
• Learning theory: Thumb sucking is acquired as a result of learning.

Clinical Features of Thumb Sucking Habit in Children

• Labial flaring of maxillary anterior teeth.
• Lingual collapse of mandibular anterior teeth.
• Hypotonic upper lip and hyperactive upper lip.
• Tongue placed posteriorly leading to posterior crossbite.
• Fungal infection on the thumb.

Management of Thumb Sucking Habit

Discussion with the Child

• No threats or shaming is done.
• Friendly attempts are made to learn about child’s attitude towards the habit.

Discussion with the Parents

The habit should not be made the topic of discussion at the home and the child should not be ridiculed.

Use of Habit Reminders

Bitter substance/nail polish is applied on the thumb and can also be used as reminder.

Question 5. Write short note on preschool child parent counseling.
Answer. Preschool child is of 3–6 years.

In this age group children frequently exhibits gingivitis and can experience rampant caries.

So, following counseling should be carried out in preschool child parent:

• Patients should be educated about role of diet and their ill effect in initiation of caries.
• Food items to be recommended are safe snacks, i.e. cheese, peanuts, milk, Sugarless gum and raw vegetables. Food items to be avoided are sugared gum, dried fruit, fruit juice, sugared soft drinks, cakes and candies.
• Most important dietary advice is to limit number of carbohydrate exposures per day rather than to limit total number of carbohydrate consumed.
• Preschool child require parental assistance to achieve effective plaque control.
• Parents are instructed to brush for child at least once for the day and to clean between any teeth which are in contact with each other by dental floss. Parents should be told that bedtime is the ideal time to establish the routine.
• Parents should be asked to use fluoride containing toothpaste. Parents are instructed to dispensed only a pea-sized amount for their child. Child should brush under the supervision of parent so that they monitor to ensure expectoration. Other times child should brush with non-fluoridated toothpaste.
• Parents are educated that in primary teeth caries progress at high rate due to the developmental changes and timings of visit may be critical for initiating preventive measures.
• Semiannual dental visits should start at the age of 3 years and continue till childhood and adolescence.

Question 6. Write short answer on management of thumb sucking habit.
Answer. Following is the management of thumb sucking habit:

Psychosocial Therapy

Screen the patient for underlying psychological disturbances that sustain a thumb sucking habit. Once psychosocial dependently is suspected, the child is referred to professionals for counseling.

Thumb sucking between the age of 4–8 years need reassurance, positive reinforcement and friendly reminders.

β-hypothesis or Dunlop Hypothesis

He believed that if a subject can be forced to concentrate on the performance of the act at the time he practices it, he could learn to stop performing the act. Forced purposeful repetition of habit eventually associates with unpleasant reactions and the habit is abandoned. The child should be asked to sit in front of the mirror and asked to observe himself as he indulges in the habit.

Reminder Therapy or Mechanical Therapy

Extraoral Approach

Mechanical restrains applied to hand and digit like splints, adhesive tapes. Thumb guard is most effective extra-oral appliance for control of habit.

Intraoral Approach

The optimal time for appliance placement is between ages of 3–1.5 years preferably during spring or summer, when child is at its peak and sucking desires can be sublimated in outdoor play and social activities. Following appliances are recommended.

Fixed Intraoral Anti-thumb Sucking Appliance

It is most effective mechanical method to thumb sucking which is attached to upper teeth by means of hands fitted to primary second molars and permanent first molars. A lingual arch forms base of appliance to which are added interlacing wires in anterior portion in area of anterior part of hard palate. It works by preventing the patient from putting palmer surface of thumb in contact with palatal gingiva, thereby robbing the pleasure of sucking.

Blue Grass Appliance

The appliance is for children with the continued thumb sucking habit which is affecting the permanent or mixed dentition. It consists of modified six sided roller machine from teflon. This is slipped over a 0.045 stainless steel wire soldered to molar orthodontic bands. Appliance is placed for 3 to 6 months.

Instructions are given to turn the roller instead of sucking the digit. Thumb sucking is often seen to stop immediately.

Oral Screen

It is a functional appliance. It produces its affect by redirecting the pressure of muscular and soft tissue curtain of cheeks and lips. It prevents the child from placing thumb or fingers into oral cavity during sleeping hours.

Increasing the Arm Length of Night Suit

It is useful in children who sincerely want to discontinue habit and only perform during their sleep. Arms of night suit are lengthened so that, they cannot reach thumb during night.

Chemical Approach

• By use of bitter tasting and foul smelling preparations placed on thumb, i.e. sucked can make the habit distasteful.
• Various commonly used agents are pepper dissolved in volatile medium, Quinine, Asafoetida, etc.