Prevention and interception in ODF

1.  Introduction :

Preventive and interceptive orthodontics represents the set of measures which make it possible to avoid the appearance, aggravation and extension of maxillofacial dysmorphoses.

It is aimed at healthy subjects at the beginning of their life and constitutes an indisputable philosophy allowing to reduce the cost price and the duration and complexity of treatments, whether multi-band or surgical, so one should not wait for the anomaly to set in to treat it but rather avoid its installation.

2.  Definitions:

* Prevention

In ODF, prevention consists of anticipating dental malposition or maxillary dysmorphosis in order to prevent it and prevent it from occurring. According to Château and All, “It is the set of measures taken to prevent what can be predicted . “

* Interception

In ODF, interception concerns the treatment of existing lesions, but at an early stage before they are definitively stabilized; it is often early and its best allies are time and growth. Indeed, the earlier a malocclusion is corrected, the more stable the new situation will be over time.

3.  Growth reminder:

3 -1 Growth of the middle floor of the face

The face develops in two ways: sutural growth and growth by remodeling. Sutures are syndesmoses that unite bones of primarily membranous origin. They have no growth potential of their own but, as with the calvaria, they behave, according to Delaire, as “expansion joints with automatic catch-up by adaptive connective tissue proliferation and marginal ossification.”

2.  Growth of the mandible

The mandible is primarily a membrane bone that develops around the Meckel’s cartilage, which serves as its support but which subsequently disappears. The growth of the mandible occurs partly through the activity of the condylar cartilage and partly through the remodeling process.

3. Growth of alveolar processes

It is commonly said that alveolar bone is born and disappears with the teeth. The dental arches develop through considerable bone apposition linked to the development of the dentition. The arches diverge backward and their diameter increases posteriorly, which allows the development of molars.

-The growth of the alveolar processes plays an important role in facial height. Once formed, the arches have roughly constant transverse diameters – the canine diameter is fixed between 8 and 10 years of age.

4)- Mechanisms of installation of orthodontic anomalies

There are two types of mechanisms depending on the primary or secondary origin of the anomaly

• For anomalies of primary origin , it is the hereditary factors which are expressed during embryogenesis, morphogenesis and throughout growth, and are at the origin of orthopedic dysmorphoses in the three spatial directions, DDM and dental anomalies.
• For anomalies of secondary origin : the installation mechanism is governed by local causes and the functional adaptation that they entail.

5)-The optimum time for treatment:

The planning of dentofacial orthopedic and orthodontic treatments is carefully established, based on chronological age, degree of bone maturation and stage of dentition.

The first two types of prevention belong to this branch: I, II areas

1. Primary prevention:
   1. Prenatal prevention : this involves monitoring the health of the future mother by her doctor and her dental surgeon;

*The influence of diet on the formation of teeth and bone development of your child (vitamin-folic acid-calcium).

*Treatment of maternal illnesses (tuberculosis-flu-rubella).

*Hormonal balancing (diabetes-hypo and hyper athyroidism).

*Avoid drug prescriptions, especially during the first ^trimester (teratogenic risk).

*Monitoring of oral diseases (caries-gingivitis).

*Avoid ionizing radiation.

*Obstetric trauma such as; mandibular dislocations, asymmetry due to flattening.

*Feeding behaviors: Favor an ideal position during breastfeeding that promotes normal mandibular growth (forming a 90º angle between the breast and the baby’s suckle. Breastfeeding prevents atypical swallowing, interposition of the tongue, and finger sucking…. it constitutes a real preventive therapy for mandibular retrognathia, mouth breathing, and atony of the masticatory muscles.

*Infant Head Position: Laying the infant on its side and not in a ventral position, promotes mouth breathing and the persistence of neonatal mandibular retrognathia. This position also reduces the risk of sudden infant death syndrome.

*Active monitoring of nasal ventilation maintenance: Rigorous hygiene, prevention and treatment of upper respiratory tract, which may lead to the establishment of mouth breathing.

*It is essential to modify eating behaviors and introduce harder and harder foods to develop the child’s chewing function once the teeth erupt.

*Educate parents about the harmfulness of sweets if eaten without brushing.

*Eliminate parafunctions: various thumb and tongue sucking, lower lip biting, nail biting. Among the devices used:

• Removable or functional plates have relative effectiveness, good cooperation and motivation are required.
• Quad helix with front arm preventing thumb sucking, a fixed anti-thumb grid system can also be installed.
• The BONNET nocturnal lingual envelope plays an important role in forcing the patient to stop sucking their thumb and to re-educate the tongue.

2. Secondary prevention : It extends from 3 years of age until at least pre-puberty.
   1.  Functional corrections :

-Re-educate persistent primary swallowing given its consequences on the orofacial sphere: pro-alveoli, endo-alveoli, infralveoli, etc.

Swallowing rehabilitation is done before the age of 8-9 and requires the child’s motivation; the latter must become aware of his body schema and acquire physiological movements through repeated exercises.

-In the event of shortness of the lingual frenulum, resection of this frenulum should be carried out as soon as possible, followed by rehabilitation of the lingual posture in order to allow the tongue to play its morphogenetic role.

-In the absence of the stomion due to hypotonicity, functional myotherapy is used to develop the deficient muscles such as:

• Hold a metal blade between your lips for one minute, then increase the duration and weight.
• Bring the corners of your mouth together while the two fingers oppose this movement.

-Use musical instruments: trumpet.

-In the event of hypotonicity of the masseter muscles:

• Prescribe a hard diet.
• Chewing gum for 45 minutes to two hours a day for a year significantly increases occlusal force and muscle activity.

2.  Prevention of dental factors

* Caries : Caries must be diagnosed and treated early, as proximal caries will have the effect of reducing the arch perimeter by molar mesioposition.

Prevention consists of:

-Periodic consultation with the dentist from the age of 3.

-Prevention of caries by fluoridation: topical application.

-Early prophylactic observations, application of varnish.

-Care and filling of proximal caries by reconstructing the contact points.

*Early loss of temporary teeth : The most serious consequences of early loss of temporary teeth are the loss of space needed for permanent teeth, as well as delayed eruption and even retention of the replacement tooth.

Prevention consists of:

– Place space maintainers (palatal plate with replacement teeth, lingual arch, Nance arch).

-Do not extract a tooth until root resorption has reached two-thirds.

Interception consists of detecting, evaluating, controlling and neutralizing the mechanisms that worsen an initial malocclusion.

Unlocking concept

Mechanical and functional locks in dentofacial orthopedics, a lock is a blockage that, acting on the alveolodental drawer or on the bony bases, hinders the normal course of growth of the masticatory system. Blockages can be of various natures and at various levels with repercussions on other anatomical parts (skeletal, alveolodental, TMJ, posture), on aesthetics or psychology.

There are three main categories of locks: mechanical, functional and psychological

(Gugino 1980). We will only examine the first two.

Unlocking means the elimination of all blockages and constraints, both mechanical and functional, on the maxilla or mandible.

1. Interception of dental anomalies:

• Early eruption : Clinically, it manifests itself by the appearance of transient crowding due to the discrepancy between bone age and dental age. The therapeutic approach consists of making a good diagnosis and then extracting the temporary teeth in a symmetrical manner; this aims to align the teeth while waiting for bone growth.

*Late eruption : The delay may be due to local causes such as:

(Pericoronary cyst of eruption – an odontoma or a supernumerary tooth – Late persistence of a temporary tooth without pathological cause – mesiodens …)

The delay can also be due to general causes:

Genotypic delay, deficiency (rickets), endocrine disorders (congenital myxedema, vitamin deficiencies, etc.), major syndromes (cleidocranial dysostosis,

Crouzon, etc.). The therapeutic approach in this case is to wait for the eruption while maintaining the space reserved for the teeth if the baby teeth are lost.

*Shape anomalies (geminal teeth, melanodontia, dyschromia, dysplasia, fluoride intoxication, Hutchinson’s tooth, accessory tubercles) do not present indications for extraction and their therapies are exclusively for aesthetic purposes and will be delayed.

*Number anomalies 

By default (Agenesis): the interception will consist of:

• Maintain the temporary tooth on the arch, thus providing space for possible prosthetic correction later. (Upper lateral incisor most often).
• Or extract the temporary teeth, close the diastema by migration of the neighboring teeth, plan later a prosthetic reconstruction or a coronoplasty.

Excessive number: The treatment consists of extracting the germ or the supernumerary tooth. The correction of malpositions will be done by using fixed techniques which will allow the alignment of the teeth.

*Dental inclusion :

-Treatment of inter-incisor diastema: Is done according to the cause, frenumectomy or extraction of the mesiodens.

-Extraction of supernumerary teeth.

– Piloted extractions in case of severe DDM.

-Remove the obstacle (supernumerary, odontoma)

-Expansion of the dental arches

*Interception of dento-maxillary disharmony 

a-DDM by relative macrodontia

1. Primary congestion:

•  Low or transient DDM with footprint up to 4 mm:

Extractions are contraindicated. The main objective of interceptive treatment is to prevent any loss of space in the dental arch to ensure alignment of the permanent dentition. The mesial drift space can be used to resolve crowding. To maintain it, it is recommended to use anchoring means such as a Nance arch or arch.

lingual associated or not with an interproximal enamel reduction “stripping” of the temporary teeth including the sequence proposed by Van der Linden.

*DDM between 4 mm and 7 mm: Before deciding whether or not to extract, the arch perimeter must be recovered by expansion: (a quad helix-Crozat, a removable expansion device with jack, a bi helix, a bi helix Crozat, the Fränkel device, a lip bumper, the Fränkel device, incisor advancement arch.

*DDM with space requirement greater than 7-8 mm:

2 possibilities are possible:

🡺Refrain from treating mixed dentition; treat permanent dentition by extracting permanent teeth and especially.

🡺Practice, as recommended by some authors, the extraction method

“programmed” or “piloted”. (See course of DDM therapy).

2. Secondary congestion:

This type of crowding can occur following: Reduction of the arch perimeter, lingual version of the lower incisors, poor sequence of exfoliation of baby teeth.

*Reduction of the arcade perimeter:

Immediately after the loss or extraction of the second baby molar (if the first permanent molar is on the arch) the space must be maintained with one of these appliances:

A space maintainer – A Nance palatal arch – The lip bumper – The removable appliance with jack or spring to distalize the molar – the basic arch – The extraoral force – mini-screw.

*Linguoversion of the lower incisors : Generally the etiology is functional: sucking of a finger or the lower lip, position of the tongue hooked on the lower incisors. We can use:

Lip bumper – Bonnet lingual night wrap (ELN). – Fränkel function regulator.

2. DDM by relative microdontia

*In primary teeth : diastemas must be considered positively.

*In mixed dentition : diastemas are rare. When they are present, the cause must be sought.

Treatment is done by tongue reeducation, and/or the use of the nocturnal lingual envelope (NLE) – frenulumectomy.

2. Interception of alveolar-dental and skeletal anomalies:
   1. In the sagittal direction:
      1.  Interception of superior proalveolus with diastemas

Generally, the etiology is to be sought in deforming habits (digital sucking or sucking of the lower lip or a foreign body followed by lingual interposition at rest and in function with

impulse on the anterior teeth The interception is done:

*By psychological action

* Corrective measures: Hinz mouthguards – an anti-thumb grid welded onto molar bands – a device comprising the Tucat bead – ELN – Quadhelix with grid. To move the incisors back, a basic retraction arch.

2-1-2 Interception of the anterior crossbites:

-Extract the baby tooth and use a removable appliance with slight lateral elevation planes and vestibules or a posterior-anterior action jack.

-Removable plate with raising planes and three-way jack from Bertoni.

-Quadhélix Crozat with possible lateral elevation plan.

3.  Skeletal Class II Interception

*Class II 1

The Principle: consists of obtaining as soon as possible the orthopedic effect and the transformation of class II into class I.

Interception : Correction of the sagittal shift must be achieved by slowing down the growth of the maxilla, stimulating the growth of the mandible or both combined. Depending on the origin of the anomaly, the means

used are:

• Extraoral forces;
• The activators
• The combination of the two.
• The Distal active concept DAC technique.
• The twin block.
• Herbest’s connecting rod

*Class II 2

The Principle :  Early treatment of Cl II/2

skeletal finds its indication in the correction of overbite and palatoversion and in the correction of retrognathia.

In deciduous teeth: Class II type track plates

In mixed dentition :

Is carried out by a Ricketts base arc, or using an Andersen Cl II/2 activator

4. Interception of functional class III (mandibular sliding):

*Device-free interceptive processing:

– Rebalances the joint by selectively grinding the temporary teeth (Planas)

-Functional rehabilitation of the tongue.

– Resection of the lingual frenulum in the case of ankyloglossia.

– Partial glossectomy in the case of macroglossia.

-Tonsillectomy.

-Removal of adenoid vegetations.

*Interceptive treatment with device:

– PLANAS track plates – BALTERS Bionator type 3 – a plate with vestibulization springs or pushers – Crozat quadhelix – an Eschler vestibular strip .

5. Skeletal Class III

Postero-anterior traction is obtained using the Delaire mask welded onto rings or onto a gutter – HICKHAM SLING – FEO on 36 46

NB: this orthopedic treatment must be preceded by ENT care in the event of orofacial dysfunctions, such as a low tongue associated with hypertrophy of the tonsils or removal of the lymphoid tissues involved.

2.  In the vertical direction
   1.  Overbite

The interceptive therapeutic attitude consists of:

* Egression of posterior teeth : palatal plate with unilateral posterior elevation.

*Or the intrusion of the incisors: Ricketts’ basic arch.

A palatal plate with a retro-incisal bite plane to promote extrusion of the lateral sectors and prevent extrusion of the lower incisors

2.  The gap

*Functional open bites: The main aim of interception will be to eliminate the interposition if necessary by means of an anti-thumb and anti-tongue grid or by using an ELN, a quad helix with an anti-tongue grid, an upper or lower base arch for incisor egression. A lingual shield or with the Fränkel function regulator which opposes the interposition of the cheeks.

NB – ventilation problems will also be investigated and treated before any treatment with equipment.

*Skeletal gaps

The interception:

• High extraoral force on splint;
• A molar elevation plate to cause possible alveolar-dental compensation.
• Monobloc, removable appliance with a quantity of resin that fills and goes beyond the free space of inocclusion to slow the process of eruption of the posterior dentition.
• Vertical chin slings are not recommended because of the risk of joint compression (Ricketts).

3.  In the transverse direction

Transverse anomalies should be corrected as early as possible, even in primary teeth. A non-interventionist approach can lead to serious consequences.

: deviation from normal growth, mandibular asymmetry and, in some cases, TMJ problems with dentoalveolar compensations.

The treatment must be etiological. The corrective treatment is functional and/or mechanical :

• Correction of functional matrix problems (oral ventilation, atypical swallowing, posture, etc.);

– Elimination of distorting habits.

A slight transverse anomaly (symmetrical endoalveolitis with or without latero-deviation) at the start of installation can be treated by means

functional such as:

*Functional rehabilitation using the PLANAS method Mechanical means that can be used:

In primary teeth :

*Removable plate with central jack

* Quadhelix built on rings (55 and 65) In mixed teeth :

In cases of symmetrical maxillary endoalveolism with and without mandibular lateral deviation, the following are preferred:

(The quadhelix – the transpalatal bar – the removable expansion plates with jack – the Frankel, function regulator)

In symmetrical maxillary endognathia:

the expansion will be of the orthopedic type:

* Breakers with or without occlusal splint.

• The quadhelix with correct activation of the radiculo torque

-vestibular

• In unilateral endognathia or endoalveolia :

treat the etiological factor(s), and use a removable plate

• In mandibular exognathia : Correct oral ventilation with low position of the tongue; advance

possibly the maxilla, if it is in a retrusive position, by a Delaire orthopedic mask.

• Functional lateral deviations :

These functional lateral deviations may, if they are not intercepted early, give rise to structural asymmetries.

Etiological treatment:

-Stop distorting habits.

– Allow the child to breathe through the nose (elimination of obstacles, rehabilitation).

-Grinding of milk canines.

-Reforming the maxilla to allow the refocusing of the mandible (expansion).

*Mandibular lateropositioning and TMJ pathologies:

-Orthopedic repositioning splint

*Mandibular laterognathia:

-Interceptive treatment is possible if the origin is functional, using repositioning and symmetrization gutters.

-Genetic laterognathia should not be treated orthodontically

III – Conclusion

“Prevention is better than cure” in ODF this expression is widely used because the prevention of dysmorphoses and malocclusions allows the child on the one hand to preserve facial and dento-alveolar harmony and growth.

These early treatments have demonstrated their effectiveness thanks to the progress made in the diagnosis, especially etiological, as well as growth prediction.

Prevention and interception in ODF

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Interdental brushes remove food debris between teeth.
Adequate hydration helps maintain healthy saliva, which is essential for dental health.

Prevention and interception in ODF