Radiograph: A labeled diagram of a molar tooth structure showing the outline of the crown and root, with red dots indicating the locations of the First Order and Third Order contacts. Click to add title Third Order First order TOOTH Thumbnail slide 56: Dental arch image Thumbnail slide 57: Tooth alignment diagram Thumbnail slide 58: Tooth alignment diagram Thumbnail slide 59: Dental arch diagram with highlighted tooth  #### Third Order #### First Order #### Tooth - Thumbnail slide 56: Dental arch image - Thumbnail slide 57: Tooth alignment diagram - Thumbnail slide 58: Tooth alignment diagram - Thumbnail slide 59: Dental arch diagram with highlighted tooth A labelled diagram illustrating a dental arch with a large, highlighted section of the jawbone. The figure specifically identifies a 'Third Order' tooth within this highlighted area and points to a separate 'First order' tooth. DMD Level 3 Unit B: Space Management in Preadolescent Children THE UNIVERSITY OF WESTERN AUSTRALIA 1. Discuss the indications and contraindications for the selection of space maintaining appliances. 2. Discuss the indications and contraindications for the selection of various space regaining appliances. 3. Discuss the construction of different appliances. 4. Describe the timing and sequence of treatment. 5. Identify the possible causes of midline diastemas and spacing. 6. Discuss the relationship between spacing and protrusion  1. Discuss the indications and contraindications for the selection of space maintaining appliances. 2. Discuss the indications and contraindications for the selection of various space regaining appliances. 3. Discuss the construction of different appliances. 4. Describe the timing and sequence of treatment. 5. Identify the possible causes of midline diastemas and spacing. 6. Discuss the relationship between spacing and protrusion Labelled diagram: A slide layout from a presentation titled 'DMD Level 3 Unit B: Space Management in Preadolescent Children' containing a numbered list of six discussion points regarding dental appliances and spacing. **DMD Level 3** **Unit B: Space Management in Preadolescent Children** 1. Discuss the indications and contraindications for the selection of space maintaining appliances. 2. Discuss the indications and contraindications for the selection of various space regaining appliances. 3. Discuss the construction of different appliances. 4. Describe the timing and sequence of treatment. 5. Identify the possible causes of midline diastemas and spacing. 6. Discuss the relationship between spacing and protrusion Logo: **THE UNIVERSITY OF WESTERN AUSTRALIA** 1 1. Discuss the indications and contraindications for the selection of space maintaining appliances. 2. Discuss the indications and contraindications for the selection of various space regaining appliances. 3. Discuss the construction of different appliances. 4. Describe the timing and sequence of treatment. 5. Identify the possible causes of midline diastemas and spacing. 6. Discuss the relationship between spacing and protrusion # Space Management in Preadolescent Children 1. Discuss the indications and contraindications for the selection of space maintaining appliances. [space analysis] **Fixed** - Band and loop - Lingual arch - Nance holding arch - Distal shoe **Removable** 1. Discuss the indications and contraindications for the selection of space maintaining appliances. [space analysis] **Fixed** - Band and loop - Lingual arch - Nance holding arch - Distal shoe **Removable** # Posterior Space Maintenance—Pathways of Care ```mermaid graph TD A["Early loss of primary molar(s)<br/>in patients with adequate space"] --> B{"Missing only one<br/>primary posterior tooth?"} B -- Yes --> C{"First primary<br/>molar?"} B -- No --> D["Missing multiple<br/>primary posterior<br/>teeth"] C -- Yes --> E["Band and loop or transpalatal<br/>arch or lingual arch if incisors<br/>are erupted"] C -- No --> F["Second primary<br/>molar"] F --> G{"Permanent first<br/>molar erupted?"} G -- Yes --> E G -- No --> H["Fixed distal shoe"] D --> I{"Permanent first<br/>molar erupted?"} I -- Yes --> J{"Permanent<br/>incisors erupted?"} I -- No --> K{"At least one<br/>primary second<br/>molar lost?"} J -- No --> L{"Mandibular?"} L -- No --> M{"Maxillary?"} L --> N["Removable<br/>partial denture"] M --> O["Removable<br/>partial denture or<br/>Nance appliance"] J -- Yes --> P{"Maxillary?"} J -- Yes --> Q{"Mandibular?"} P --> R["Lingual arch, Nance,<br/>or removable partial<br/>denture"] Q --> S["Lingual arch"] K -- Yes --> T{"Bilateral<br/>primary second<br/>molars only?"} K -- No --> U["Bilateral band and loops<br/>or transpalatal or lingual arch<br/>if incisors are erupted"] T -- No --> V["Removable<br/>partial denture<br/>with distal shoe"] T -- Yes --> W["Bilateral fixed<br/>distal shoes"] ```  ```mermaid graph TD A["Early loss of primary molar(s)<br/>in patients with adequate space"] --> B{"Missing only one<br/>primary posterior tooth?"} B -- Yes --> C{"First primary<br/>molar?"} B -- No --> D["Missing multiple<br/>primary posterior<br/>teeth"] C -- Yes --> E["Band and loop or transpalatal<br/>arch or lingual arch if incisors<br/>are erupted"] C -- No --> F["Second primary<br/>molar"] F --> G{"Permanent first<br/>molar erupted?"} G -- Yes --> E G -- No --> H["Fixed distal shoe"] D --> I{"Permanent first<br/>molar erupted?"} I -- Yes --> J{"Permanent<br/>incisors erupted?"} I -- No --> K{"At least one<br/>primary second<br/>molar lost?"} J -- No --> L{"Mandibular?"} L -- No --> M{"Maxillary?"} L --> N["Removable<br/>partial denture"] M --> O["Removable<br/>partial denture or<br/>Nance appliance"] J -- Yes --> P{"Maxillary?"} J -- Yes --> Q{"Mandibular?"} P --> R["Lingual arch, Nance,<br/>or removable partial<br/>denture"] Q --> S["Lingual arch"] K -- Yes --> T{"Bilateral<br/>primary second<br/>molars only?"} K -- No --> U["Bilateral band and loops<br/>or transpalatal or lingual arch<br/>if incisors are erupted"] T -- No --> V["Removable<br/>partial denture<br/>with distal shoe"] T -- Yes --> W["Bilateral fixed<br/>distal shoes"] ``` This figure is a flowchart titled 'Posterior Space Maintenance—Pathways of Care' that outlines clinical decision-making for managing early loss of primary molars. It guides practitioners through specific treatment options, such as band and loops or removable partial dentures, based on variables including the number of missing teeth, which specific primary molars are lost, and the eruption status of permanent teeth. # Space Management in Preadolescent Children 2 Discuss the indications and contraindications for the selection of various space regaining appliances. **Up to 3mm** Fixed - Spring appliances with braces - Active lingual arches - Fixed distalising appliances Removable - URA with spring - URA with screw - Lip bumper      2. Discuss the indications and contraindications for the selection of various space regaining appliances. **Up to 3mm** **Fixed** - Spring appliances with braces - Active lingual arches - Fixed distalising appliances **Removable** - URA with spring - URA with screw - Lip bumper Radiograph showing a preadolescent child's dental arches, illustrating the management of space in the lower jaw. Clinical photo: This figure shows a removable orthodontic appliance, specifically a URA (Upper Removable Appliance), likely with springs or screws as listed in the slide text for space management. Clinical photo: An intraoral view of a patient's mandibular arch demonstrating an active lingual arch appliance. The image highlights the fixed wire framework along the palate and the anchorage points on the first molars, illustrating a space management device used in preadolescent children. # Space Management in Preadolescent Children ## 3 Discuss the construction of different appliances. Removable- **Impression** → Insertion Fixed Separators → Fit bands → placed in impression → wire bent and soldered → Cemented in Mouth      3. Discuss the construction of different appliances. **Removable** - Impression → Insertion **Fixed** Separators → Fit bands → placed in impression → wire bent and soldered → Cemented in Mouth Clinical photo of the upper dental arch showing a fixed orthodontic appliance, specifically a Hawley retainer or similar wire-and-acrylic device, cemented to the teeth. Clinical photo: This image displays an intraoral view of a patient's mouth during the fabrication of a fixed space maintainer. It shows separators placed between the posterior teeth, which are used to create space for fitting bands before they are cemented into place. Clinical photo showing a blue impression material with a metal ring and wire structure embedded within it, illustrating the step where separators are placed in an impression for fixed appliance construction. Clinical photo showing the components for constructing a fixed appliance: a yellow tray containing an impression of teeth with white material, alongside bottles of cement and separator. Space Management in Preadolescent Children 4 Describe the timing and sequence of treatment. URA Fixed space maintainer URAs are removable appliances used in pediatric dentistry to manage space, maintain occlusion, and improve esthetics. A fixed space maintainer is an appliance that is placed in the mouth to maintain space for a missing tooth     4. Describe the timing and sequence of treatment. **URA** **Fixed space maintainer** URAs are removable appliances used in pediatric dentistry to manage space, maintain occlusion, and improve esthetics. A fixed space maintainer is an appliance that is placed in the mouth to maintain space for a missing tooth. Clinical photo: This image displays the maxillary arch of a preadolescent child, showing a fixed space maintainer appliance (likely a band and loop) installed to maintain the space for a missing tooth. Clinical photo of the upper jaw showing a removable appliance, specifically an Upper Removable Appliance (URA), fitted over the maxillary teeth. The device appears to be a space maintainer or functional appliance used in pediatric dentistry. Clinical photo: A close-up view of a fixed space maintainer, specifically a band and loop appliance, positioned on the lower right quadrant. The image shows a metal band cemented to a molar tooth with an attached wire loop extending into the edentulous space. # Space Management in Preadolescent Children ## 5. Identify the possible causes of midline diastemas and spacing.  5. Identify the possible causes of midline diastemas and spacing. Clinical photo showing the anterior maxillary dentition with a visible midline diastema between the central incisors. The image illustrates the spacing issue identified in the slide's context regarding causes of midline diastemas. # Space Management in Preadolescent Children ## 6. Discuss the relationship between spacing and protrusion <img>Dental photo of anterior teeth with spacing and protrusion <img>Proclination/Protrusion: overestimate the space available  6. Discuss the relationship between spacing and protrusion Proclination/Protrusion: overestimate the space available Clinical photo: An intraoral view of a preadolescent child's anterior dentition showing mixed dentition with significant spacing and labial protrusion. The image visually demonstrates the concept that dental proclination often leads to an overestimation of available space. # Potential Crowding & Space Maintenance 1. Describe diagnostic information necessary to make decisions concerning space maintenance or management. - **If deciduous tooth lost early (When?)** - **How much space loss? (>3mm?)** - **Dental age and future eruption/growth changes (6 months)** - **Agenesis? (maintenance for prosthetic or closure?)** - **Facial form- lip competence and fullness (regain space by exs)** 1. Describe diagnostic information necessary to make decisions concerning space maintenance or management. - **If deciduous tooth lost early (When?)** - **How much space loss? (>3mm?)** - **Dental age and future eruption/growth changes (6 months)** - **Agenesis? (maintenance for prosthetic or closure?)** - **Facial form - lip competence and fullness (regain space by exs)** # Potential Crowding & Space Maintenance 2. **Identify and discuss alternative space analysis procedures.** - **Measuring radiographs and teeth** - **Using tables** - **Correlation tables, measuring incisors and predicting 3-4-5** - **Moyers** - **Tanaka and Johnston** 2. **Identify and discuss alternative space analysis procedures.** - **Measuring radiographs and teeth** - **Using tables** - **Correlation tables, measuring incisors and predicting 3-4-5** - **Moyers** - **Tanaka and Johnston** # Crossbites and Vertical Problems in Children 1. Identify skeletal contributions to anterior crossbites. 2. Identify dental contributions to anterior crossbites. 3. Identify the significance of functional shifts in anterior crossbites. 4. Evaluate space, tooth orientation and position, intermaxillary relationships, and eruption timing and sequence regarding the teeth involved in the anterior crossbites as etiologic and treatment factors. 5. State rationale for correcting anterior crossbites. 6. Recommend appropriate treatment for anterior crossbites including timing and appliance design. 7. Explain the relevance of facial form to posterior crossbite diagnosis. 8. List the etiologic factors of posterior crossbite. 9. Describe the clinical findings consistent with a bilateral maxillary constriction, a bilateral constriction accompanied by a mandibular shift, and a true unilateral maxillary constriction. 10. Describe the rationale for correcting posterior crossbites. 11. Describe the appropriate timing and appliance design for posterior crossbite treatment. 1. Identify skeletal contributions to anterior crossbites. 2. Identify dental contributions to anterior crossbites. 3. Identify the significance of functional shifts in anterior crossbites. 4. Evaluate space, tooth orientation and position, intermaxillary relationships, and eruption timing and sequence regarding the teeth involved in the anterior crossbites as etiologic and treatment factors. 5. State rationale for correcting anterior crossbites. 6. Recommend appropriate treatment for anterior crossbites including timing and appliance design. 7. Explain the relevance of facial form to posterior crossbite diagnosis. 8. List the etiologic factors of posterior crossbite. 9. Describe the clinical findings consistent with a bilateral maxillary constriction, a bilateral constriction accompanied by a mandibular shift, and a true unilateral maxillary constriction. 10. Describe the rationale for correcting posterior crossbites. 11. Describe the appropriate timing and appliance design for posterior crossbite treatment. # Crossbites and Vertical Problems in Children 1. Identify skeletal contributions to anterior crossbites. 1. Identify skeletal contributions to anterior crossbites.  Clinical photo: A side-profile view of a patient's head and neck with the face partially obscured by black censor bars. Several colored rectangular overlays are placed over the cheek and jawline, alongside a vertical orange line tracing the facial profile.  Clinical photo: A profile view of a person's head with an orange vertical line drawn along the side of the nose to indicate a facial reference plane. Several colored rectangular overlays are placed on the cheek and jaw area, likely marking specific anatomical landmarks for measurement or analysis. Maxilla **back** Mandible **forward**  Maxilla **back** Mandible **forward** Clinical photo of a patient's profile view with facial landmarks annotated by colored bars and an orange vertical line, illustrating the skeletal relationship where the maxilla is positioned back and the mandible is positioned forward. Maxilla vertically deficient Mandible rotated up and forward  Maxilla vertically deficient Mandible rotated up and forward Clinical photo of a patient's profile demonstrating the described skeletal discrepancy, featuring an orange vertical line as a reference for facial alignment. <img>Side profile view of patient<img> Maxillary teeth back  Maxillary teeth back Clinical photo: Side profile view of a patient with facial landmarks obscured by colored bars and an orange vertical line. Mandibular teeth forward  Mandibular teeth forward Clinical photo showing a profile view of a patient's head with the mandible moved forward. The image includes overlaid colored rectangular bars on the cheek area and an orange vertical line along the nose to illustrate jaw alignment. Maxillary teeth back Mandibular teeth forward  Maxillary teeth back Mandibular teeth forward Clinical photo showing a lateral profile of a patient's head and neck with the mandibular teeth positioned forward relative to the maxillary teeth. **Pseudo Class III’s are special** **Teeth hit edge to edge in Retruded Contact Position** **Pseudo Class III's are special** **Teeth hit edge to edge in Retruded Contact Position** Dental Class III   Dental Class III Clinical photo showing a close-up of the patient's anterior teeth and gingiva, likely illustrating the dental Class III malocclusion mentioned in the slide text. Clinical photo showing a close-up view of the patient's anterior dentition and gingiva. The image illustrates the dental malocclusion associated with Class III malocclusion, characterized by the lower incisors being positioned in front of the upper incisors (anterior crossbite). **PELVIS RIGHT LATERAL** **PELVIS LEFT LATERAL** **2100151**  **PELVIS RIGHT LATERAL** **PELVIS LEFT LATERAL** **2100151** Radiograph:     Clinical photo showing an intraoral view of the upper right quadrant with fixed orthodontic brackets on the molars and premolars. A dental mirror is being used to retract the cheek, revealing the buccal gingiva and a dark gap between the teeth. Clinical photo of the upper dental arch showing a fixed orthodontic appliance, specifically metal brackets bonded to the teeth and connected by an archwire. Clinical photo showing a close-up view of the maxillary anterior region, specifically highlighting a missing central incisor with adjacent teeth. Clinical photo of the maxillary and mandibular anterior dentition showing a Class I molar relationship with crowding in both arches. Anterior crossbite in centric occlusion Assess occlusion in excursive motion Class I molar, canine, and one or more incisors in crossbite? Yes → Class I malocclusion, fixed/mandibular or removable prosthesis to eliminate crossbite No → Proceed to next decision Class I molar, canine, and most incisors in crossbite? Yes → Pseudo Class II malocclusion (?): fixed mandibular or removable prosthesis to alter non-interference No → [Pathway not shown] Class III molar, canine, and negative cusp? → Complete malocclusion due to Class III malocclusion; requires evaluation by specialist Review progress with patient ↓ Select treatment method Interdental increase in incisor protrusion and occlusion? Yes → No treatment of this arch No → Proceed Mandibular incisor(s) also retroclined and/or crowded? Yes → Incisors are truly malpositioned or rotated?  → Yes → Removable and bonded fixed appliance  → No → Mandibular lingual arch with lingual springs No → Patient cooperation to compliance problems anticipated?  → Yes → Mandibular lingual arch with lingual springs  → No → Mandibular removable appliance with tongue- breakage and/or mandibular removable appliance with total bite  Anterior crossbite in centric occlusion Assess occlusion in excursive motion Class I molar, canine, and one or more incisors in crossbite? - Yes → Class I malocclusion, fixed/mandibular or removable prosthesis to eliminate crossbite - No → Proceed to next decision Class I molar, canine, and most incisors in crossbite? - Yes → Pseudo Class II malocclusion (?): fixed mandibular or removable prosthesis to alter non-interference - No → [Pathway not shown] Class III molar, canine, and negative cusp? → Complete malocclusion due to Class III malocclusion; requires evaluation by specialist Review progress with patient ↓ Select treatment method Interdental increase in incisor protrusion and occlusion? - Yes → No treatment of this arch - No → Proceed Mandibular incisor(s) also retroclined and/or crowded? - Yes → Incisors are truly malpositioned or rotated? - Yes → Removable and bonded fixed appliance - No → Mandibular lingual arch with lingual springs - No → Patient cooperation to compliance problems anticipated? - Yes → Mandibular lingual arch with lingual springs - No → Mandibular removable appliance with tongue-breakage and/or mandibular removable appliance with total bite A flowchart titled 'Anterior Crossbite—Pathways of Care' that outlines clinical decision-making for treating anterior crossbites. It branches based on specific dental conditions, such as the presence of Class I or Class III malocclusions and incisor positioning, leading to various treatment options like fixed appliances, removable prosthesis, or mandibular lingual arches. # Crossbites and Vertical Problems in Children **5** State rationale for correcting anterior crossbites. * Prevent displacement and aberrant movement patt ers/wear * Prevent perio problems * Function RCP/MI problems * Create space for alignment- expand anteriorly  #### Rationale for Correcting Anterior Crossbites - Prevent displacement and aberrant movement patterns/wear - Prevent perio problems - Function RCP/MI problems - Create space for alignment - expand anteriorly Clinical photos showing the anterior teeth and gingiva, illustrating a severe malocclusion with significant crowding and misalignment. The images depict the upper and lower dental arches in close proximity, highlighting the vertical and horizontal discrepancies associated with crossbites. # Crossbites and Vertical Problems in Children 6 Recommend appropriate treatment for anterior crossbites including timing and appliance design. - Single tooth- URA ASAP/inclined bite plate- Space? Strip, extract - Multiple teeth ? Class III ? Shift - URA or Facemask protraction - Part bands- comprehensive treatment    #### Treatment for Anterior Crossbites - Single tooth - URA ASAP/inclined bite plate - Space? Strip, extract - Multiple teeth? Class III? Shift - URA or Facemask protraction - Part bands - comprehensive treatment Clinical photo: A close-up view of an acrylic orthodontic appliance, specifically a URA (Upper Removable Appliance), viewed from the palatal side. The image highlights the metal springs attached to the acrylic base, which are used for tooth movement or expansion. This figure displays a plaster dental cast of an upper jaw (maxillary arch) with orthodontic appliances fitted. The appliance features Adam's clasps on the posterior teeth and a labial bow extending across the front, consistent with the context of treating anterior crossbites in children. Clinical photo of a child in profile wearing an orthodontic appliance, specifically a facemask protraction device with headgear straps and nasal cups. This figure illustrates the 'Facemask protraction' treatment option mentioned in the slide text for managing anterior crossbites. # Adult Class III ## 2 blue arrows pointing to 2 boxes | **Compensation** | **Surgery** | | ---------------- | ----------- | | - Elastics\_Extractions\_TADS | - Orthognathics\_Distraction | | **Compensation** | **Surgery** | | ---------------- | ----------- | | - Elastics, Extractions, TADS | - Orthognathics, Distraction | Elastics  Elastics Labelled diagram showing the application of interarch elastics (rubber bands) between upper and lower braces to correct malocclusion. The image illustrates the specific connection points on the brackets and demonstrates the direction of force applied by the elastic. **End to end occlusion RCP** **MANDIBLE HAS** **MOVED** **FORWARDS** **ON RIGHT** **Shift to right** **ICP** **End to end occlusion RCP** **MANDIBLE HAS MOVED FORWARDS ON RIGHT** Shift to right ICP  Clinical photo: An intraoral view of the anterior teeth displaying a crossbite malocclusion, indicated by a white arrow pointing to the upper left canine and premolar region. A blue vertical line is superimposed over the midline to highlight the dental discrepancy. # Differential diagnosis • **Skeletal crossbite** • **Dental crossbite** - **Skeletal crossbite** - **Dental crossbite** TRANSVERSE RELATIONSHIPS 44  TRANSVERSE RELATIONSHIPS 44 A labelled diagram illustrating the measurement of palatal width on a dental arch. It depicts two views (frontal and lateral) showing red arrows indicating linear measurements labeled 'AB' for the anterior width and 'CD' for the posterior width between the maxillary molars. **Posterior Crossbite—Pathways of Care** | Step/Box | Content | | --- | --- | | Top Box | Posterior crossbite in centric occlusion | | Second Box | Assess occlusion in centric relation | | Diamond 1 (Left) | CR – CO with a bilateral posterior crossbite? | | Diamond 2 (Middle) | CR = CO? Bilateral posterior crossbite in CR and shift to a unilateral posterior crossbite in CO? | | Diamond 3 (Right) | CR = CR with a unilateral posterior crossbite? | | Next Diamond (Center) | Maxillary arch is symmetric? | - Yes Path: | | <ul><li>Posterior crossbite due to various amounts of bilateral maxillary constriction</li><li>Patient has longer working heals?</li><li>(No): Right arm or Quad helix</li><li>(Yes): Quad helix</li></ul> | - No Path: | <ul><li>True unilateral crossbite due to unilateral maxillary constricture</li><li>Patient is complicated with the presence of maxillary midpalatal suture closure?</li><li>(No): Consider expansion with appliances (ortho treatment required)</li><li>(Yes): Unpalta Quad helix or W-arch or asymmetrically localization orthodontic appliance</li></ul> |  #### Posterior Crossbite - Pathways of Care Posterior crossbite in centric occlusion Assess occlusion in centric relation - CR - CO with a bilateral posterior crossbite? - CR = CO? Bilateral posterior crossbite in CR and shift to a unilateral posterior crossbite in CO? - CR = CR with a unilateral posterior crossbite? Maxillary arch is symmetric? - Yes: - Posterior crossbite due to various amounts of bilateral maxillary constriction - Patient has longer working heals? - No: Right arm or Quad helix - Yes: Quad helix - No: - True unilateral crossbite due to unilateral maxillary constricture - Patient is complicated with the presence of maxillary midpalatal suture closure? - No: Consider expansion with appliances (ortho treatment required) - Yes: Unpalta Quad helix or W-arch or asymmetrically localization orthodontic appliance A flowchart titled 'Posterior Crossbite—Pathways of Care' that outlines a diagnostic algorithm. The diagram begins with an assessment of occlusion in centric relation versus centric occlusion and branches into decision diamonds asking about bilateral or unilateral crossbites and maxillary arch symmetry to determine the appropriate treatment pathway. # Crossbites and Vertical Problems in Children 10 Describe the rationale for correcting posterior crossbites. - **Abnormal soft tissue growth modification** - **Abnormal wear** - **Dental Compensation** - **Insufficient space- narrow arches** #### Rationale for Correcting Posterior Crossbites - **Abnormal soft tissue growth modification** - **Abnormal wear** - **Dental Compensation** - **Insufficient space - narrow arches** # <u>Crossbites and Vertical Problems in Children</u> 11. Describe the appropriate timing and appliance design for posterior crossbite treatment. Suture morphology   #### Timing and Appliance Design for Posterior Crossbite Treatment Suture morphology A diagram illustrating the morphological progression of sutures, specifically showing a 'Late teens' stage where the suture has transformed into a distinct zig-zag or serrated pattern. **OPTIONS** **FOR** **APPLIANCE** **RAPID MAXILLARY EXPANDER** **QUAD HELIX and W-ARCH** **SLOW EXPANSION PLATE**    **OPTIONS FOR APPLIANCE** - RAPID MAXILLARY EXPANDER - QUAD HELIX and W-ARCH - SLOW EXPANSION PLATE Clinical photo of a Rapid Maxillary Expander (RME) appliance fitted to the upper dental arch. The device features metal bands cemented around the first molars, connected by a central expansion screw and transverse arms. A model of a maxillary arch fitted with a removable orthodontic appliance featuring four helical springs and a central transverse bar, illustrating the design of a Quad Helix or W-Arch used for slow expansion. Clinical photo: An occlusal view of a dental appliance, specifically a Quad Helix and W-Arch, fitted inside the upper arch. The image shows the metal wires wrapped around the molars on both sides and extending across the palate to apply pressure for slow expansion. # Vertical Problems / Habits 1. Define vertical problem and its classification, i.e., dental, skeletal, and possible etiologies. 2. Describe epidemiology relating to vertical problems and malocclusion. 3. Identify skeletal patterns predisposing patients to deep bite and open bite. 4. Explain oral-facial growth patterns and physiology as they relate to vertical problems. 5. Identify treatment and timing for vertical problems. - Define vertical problem and its classification, i.e., dental, skeletal, and possible etiologies. - Describe epidemiology relating to vertical problems and malocclusion. - Identify skeletal patterns predisposing patients to deep bite and open bite. - Explain oral-facial growth patterns and physiology as they relate to vertical problems. - Identify treatment and timing for vertical problems. **Vertical Problems / Habits** 1. Define vertical problem and its classification, i.e., dental, skeletal, and possible etiologies. OpenBite → Skeletal OpenBite → Dental OpenBite → Both Deep Bite → Skeletal Deep Bite → Dental Deep Bite → Both 1. Define vertical problem and its classification, i.e., dental, skeletal, and possible etiologies. Open Bite → Skeletal Open Bite → Dental Open Bite → Both Deep Bite → Skeletal Deep Bite → Dental Deep Bite → Both **MAXILLA OVER-**DEVELOPED **FACIAL HEIGHT INCREASED** **CHIN** **RETRUSIVE** **MANDIBLE ROTATES** **BACK**  **MAXILLA OVER-DEVELOPED** **FACIAL HEIGHT INCREASED** **CHIN RETRUSIVE** **MANDIBLE ROTATES BACK** Labelled diagram: This figure illustrates the skeletal changes associated with a specific facial profile, showing an over-developed maxilla, increased facial height, and a retrusive chin resulting in a mandible that rotates back. 2 yr old THUMB SUCKING 6 MONTHS AFTER CEASING  2 yr old THUMB SUCKING 6 MONTHS AFTER CEASING Clinical photos of a 2-year-old child's dentition illustrating the effects of thumb sucking. The images display an anterior view of the teeth, revealing malocclusion and spacing consistent with prolonged oral habits. ANTI- HABIT APPLIANCE   ANTI-HABIT APPLIANCE Clinical photo of a removable anti-habit appliance (palatal crib) fitted in the maxillary arch, featuring metal clasps engaging the posterior teeth and a wire structure extending across the palate. Clinical photo: A close-up view of the anterior dentition showing a Class II malocclusion with significant overjet and an edge-to-edge relationship between the maxillary central incisors and mandibular lateral incisors. Metal brackets are visible bonded to the lower anterior teeth, indicating active orthodontic treatment. **HEADGEAR** **ELASTICS** **OLDER CHILD** **HEADGEAR** **ELASTICS** **OLDER CHILD** <h1>HEADGEAR</h1> ADD HEADGEAR TO INTRUDE POSTERIOR TEETH  **HEADGEAR** ADD HEADGEAR TO INTRUDE POSTERIOR TEETH Clinical photo of a dental cast demonstrating a removable appliance with a palatal strap. A large blue arrow points to the distal end of the upper archwire, illustrating how it is positioned to intrude the posterior teeth.  A labelled diagram illustrating a dental occlusion model with orthodontic appliances, showing upper and lower arches connected by green lines representing the occlusal plane. **DEEP OVERBITE** **POSTERIOR** **EXTRUSION** Perhaps **BP** Needs condylar growth **DEEP OVERBITE** **POSTERIOR EXTRUSION** Perhaps **BP** Needs condylar growth # Adjunctive Orthodontic Treatment Procedures 1. Describe indications for repositioning anterior teeth in adults. 2. Discuss use of diagnostic set-ups in planning adjunctive incisor positioning. 3. Describe indications and methods for extrusion of fractured teeth. 4. Describe periodontal implications of orthodontic treatment in adults. 5. Explain the indications for molar uprighting in adjunctive orthodontic treatment as part of general dental care. 6. Describe the technique used to upright a tipped molar. 7. Identify appropriate appliances for different clinical problems. 8. Explain types of appliances, in terms of active and reactive units. 9. Explain appliance placement, adjustments and timing. 10. Identify potential side effects or sequela of treatment. 11. Describe patient tolerance of the appliances. 12. Identify expected treatment time. 13. Describe retention procedures. 1. Describe indications for repositioning anterior teeth in adults. 2. Discuss use of diagnostic set-ups in planning adjunctive incisor positioning. 3. Describe indications and methods for extrusion of fractured teeth. 4. Describe periodontal implications of orthodontic treatment in adults. 5. Explain the indications for molar uprighting in adjunctive orthodontic treatment as part of general dental care. 6. Describe the technique used to upright a tipped molar. 7. Identify appropriate appliances for different clinical problems. 8. Explain types of appliances, in terms of active and reactive units. 9. Explain appliance placement, adjustments and timing. 10. Identify potential side effects or sequela of treatment. 11. Describe patient tolerance of the appliances. 12. Identify expected treatment time. 13. Describe retention procedures. Adjunctive Orthodontic Treatment Procedures 2 Discuss use of diagnostic set-ups in planning adjunctive incisor positioning.         2. Discuss use of diagnostic set-ups in planning adjunctive incisor positioning. Lateral cephalometric radiograph showing the skull, cervical spine, and mandibular dentition with orthodontic brackets. Clinical photo showing three diagnostic set-ups (study models) of a dental arch. The figure illustrates the use of these sets in planning adjunctive incisor positioning, displaying variations in tooth alignment and spacing. A cropped image of a diagnostic dental setup (study model) displaying the maxillary arch. The figure illustrates the arrangement of teeth in a cast, likely used to demonstrate incisor positioning or occlusion. Clinical photo: This figure shows a diagnostic dental set-up, displaying the upper and lower dental arches with teeth arranged in an occlusal view. It illustrates the use of such models for planning adjunctive incisor positioning. Clinical photo: This figure shows a close-up view of the anterior teeth and gingiva, likely illustrating the incisor positioning or alignment discussed in the context of adjunctive orthodontic treatment. Clinical photo: A frontal view of a dental cast displaying the lower arch, likely illustrating the use of diagnostic set-ups for planning adjunctive incisor positioning. Clinical photo of a patient's anterior dentition, likely demonstrating incisor positioning or spacing issues discussed in the context of diagnostic set-ups. Clinical photo: A close-up view of the upper anterior teeth demonstrating incisor positioning and gingival display. Adjunctive Orthodontic Treatment Procedures 5 Explain the indications for molar uprighting in adjunctive orthodontic treatment as part of general dental care. 5. Explain the indications for molar uprighting in adjunctive orthodontic treatment as part of general dental care. **Tipped Molars** - Wise, R.J. and Kramer, G. M. (1983). Predetermination of osseous changes associated with uprighting tipped molars by probing. *International Journal of Periodontics and Restorative Dentistry*, **3**, 68-81. **Tipped Molars** - Wise, R.J. and Kramer, G. M. (1983). Predetermination of osseous changes associated with uprighting tipped molars by probing. *International Journal of Periodontics and Restorative Dentistry*, **3**, 68-81. Tipped Molars  Tipped Molars A diagram showing a dental implant positioned next to a tipped molar, illustrating the treatment option of replacing or restoring the tooth with an implant. Adjunctive Orthodontic Treatment Procedures 6 Describe the technique used to upright a tipped molar. 6. Describe the technique used to upright a tipped molar. <h1>Helical uprighting spring "hooked" over segmental arch wire</h1> **3,4,5 feels this** **40 g** **40 g** **1000gmm** **25 mm** **Helical uprighting spring "hooked" over segmental arch wire** - 3,4,5 feels this - 40 g - 40 g - 1000 gmm - 25 mm ## Case: Management of mild anterior crowding using leeway space ### Question **Scenario:** A patient presents with mild anterior crowding in the lower arch and no history of early tooth loss. **What's shown:** The patient's dental arches showing significant primary second molars ("big E's") providing substantial leeway space, alongside mild anterior crowding. **Consider:** How to utilize the available space to resolve the anterior crowding without extracting teeth or losing space to molar drift. ### Answer **Observations:** - Mild anterior crowding in the lower arch. - Large primary second molars (E's) present, providing approximately 3 mm of leeway space per side. - No early loss of primary teeth. **Reasoning:** By placing a lower lingual arch, the mesial drift of the permanent first molars (sixes) is prevented. This preserves the leeway space, which can then be transferred to the anterior segment of the arch to resolve the crowding. (Note: This prevents the molars from settling into a Class I relationship, which may require subsequent distalization of the upper molars). **Takeaway:** A lower lingual arch can be used to prevent mesial molar drift and transfer leeway space to the anterior segment to resolve mild anterior crowding, even in the absence of early tooth loss. ## Case: Correction of a functional anterior shift (pseudo Class III) ### Question **Scenario:** A patient presents with an anterior crossbite and a Class I molar relationship. **What's shown:** Clinical and cephalometric findings showing an anterior crossbite in the intercuspal position (ICP), but an edge-to-edge incisor relationship when the mandible is manipulated into the retruded contact position (RCP). Point A and Point B indicate a Class I skeletal relationship. **Consider:** How to diagnose the cause of the anterior crossbite and determine the appropriate treatment approach. ### Answer **Observations:** - Anterior crossbite in ICP. - Edge-to-edge incisor relationship in RCP. - Class I molar relationship. - Class I skeletal relationship (normal Point A and Point B). **Reasoning:** The discrepancy between ICP and RCP, combined with a Class I skeletal base, indicates that the anterior crossbite is not a true skeletal Class III. Instead, it is a "pseudo Class III" caused by a functional anterior shift of the mandible to achieve a comfortable bite from an unstable edge-to-edge position. Treatment involves using partial braces on the incisors and molars, activating the archwire to procline the retroclined upper incisors, thereby eliminating the crossbite and the functional shift while maintaining the Class I molar relationship. **Takeaway:** An anterior crossbite with a Class I skeletal and molar relationship that resolves to edge-to-edge in RCP is a functional shift (pseudo Class III), which can be corrected by proclining the upper incisors with partial braces. ## Case: Functional shift causing apparent asymmetry in posterior crossbite ### Question **Scenario:** A patient presents with a unilateral posterior crossbite on the left side and apparent facial asymmetry. **What's shown:** A clinical picture showing the chin deviated to the right and a lower midline deviation to the right. When the patient is manipulated into the retruded contact position (RCP), the posterior teeth exhibit an edge-to-edge relationship. **Consider:** How to interpret the facial asymmetry and midline deviation, and how to treat the posterior crossbite. ## Case: Management of mild anterior crowding using leeway space ### Question **Scenario:** A patient presents with mild anterior crowding in the lower arch and no history of early tooth loss. **What's shown:** The patient's dental arches showing significant primary second molars ("big E's") providing substantial leeway space, alongside mild anterior crowding. **Consider:** How to utilize the available space to resolve the anterior crowding without extracting teeth or losing space to molar drift.    ### Answer **Observations:** - Mild anterior crowding in the lower arch. - Large primary second molars (E's) present, providing approximately 3 mm of leeway space per side. - No early loss of primary teeth. **Reasoning:** By placing a lower lingual arch, the mesial drift of the permanent first molars (sixes) is prevented. This preserves the leeway space, which can then be transferred to the anterior segment of the arch to resolve the crowding. (Note: This prevents the molars from settling into a Class I relationship, which may require subsequent distalization of the upper molars). **Takeaway:** A lower lingual arch can be used to prevent mesial molar drift and transfer leeway space to the anterior segment to resolve mild anterior crowding, even in the absence of early tooth loss. ## Case: Correction of a functional anterior shift (pseudo Class III) ### Question **Scenario:** A patient presents with an anterior crossbite and a Class I molar relationship. **What's shown:** Clinical and cephalometric findings showing an anterior crossbite in the intercuspal position (ICP), but an edge-to-edge incisor relationship when the mandible is manipulated into the retruded contact position (RCP). Point A and Point B indicate a Class I skeletal relationship. **Consider:** How to diagnose the cause of the anterior crossbite and determine the appropriate treatment approach.    ### Answer **Observations:** - Anterior crossbite in ICP. - Edge-to-edge incisor relationship in RCP. - Class I molar relationship. - Class I skeletal relationship (normal Point A and Point B). **Reasoning:** The discrepancy between ICP and RCP, combined with a Class I skeletal base, indicates that the anterior crossbite is not a true skeletal Class III. Instead, it is a "pseudo Class III" caused by a functional anterior shift of the mandible to achieve a comfortable bite from an unstable edge-to-edge position. Treatment involves using partial braces on the incisors and molars, activating the archwire to procline the retroclined upper incisors, thereby eliminating the crossbite and the functional shift while maintaining the Class I molar relationship. **Takeaway:** An anterior crossbite with a Class I skeletal and molar relationship that resolves to edge-to-edge in RCP is a functional shift (pseudo Class III), which can be corrected by proclining the upper incisors with partial braces. ## Case: Functional shift causing apparent asymmetry in posterior crossbite ### Question **Scenario:** A patient presents with a unilateral posterior crossbite on the left side and apparent facial asymmetry. **What's shown:** A clinical picture showing the chin deviated to the right and a lower midline deviation to the right. When the patient is manipulated into the retruded contact position (RCP), the posterior teeth exhibit an edge-to-edge relationship. **Consider:** How to interpret the facial asymmetry and midline deviation, and how to treat the posterior crossbite.   Case: Management of mild anterior crowding using leeway space Clinical photo of the upper jaw showing a removable appliance, specifically an Upper Removable Appliance (URA), fitted over the maxillary teeth. The device appears to be a space maintainer or functional appliance used in pediatric dentistry. Clinical photo: This image displays the maxillary arch of a preadolescent child, showing a fixed space maintainer appliance (likely a band and loop) installed to maintain the space for a missing tooth. Clinical photo: A close-up view of a fixed space maintainer, specifically a band and loop appliance, positioned on the lower right quadrant. The image shows a metal band cemented to a molar tooth with an attached wire loop extending into the edentulous space. Clinical photo showing a close-up of the patient's anterior teeth and gingiva, likely illustrating the dental Class III malocclusion mentioned in the slide text. Clinical photo of the maxillary and mandibular anterior dentition showing a Class I molar relationship with crowding in both arches. Anterior Crossbite—Pathways of Care A flowchart titled 'Anterior Crossbite—Pathways of Care' that outlines clinical decision-making for treating anterior crossbites. It branches based on specific dental conditions, such as the presence of Class I or Class III malocclusions and incisor positioning, leading to various treatment options like fixed appliances, removable prosthesis, or mandibular lingual arches. CROSSBITE Clinical photo: An intraoral view of the anterior teeth displaying a crossbite malocclusion, indicated by a white arrow pointing to the upper left canine and premolar region. A blue vertical line is superimposed over the midline to highlight the dental discrepancy. Posterior Crossbite—Pathways of Care A flowchart titled 'Posterior Crossbite—Pathways of Care' that outlines a diagnostic algorithm. The diagram begins with an assessment of occlusion in centric relation versus centric occlusion and branches into decision diamonds asking about bilateral or unilateral crossbites and maxillary arch symmetry to determine the appropriate treatment pathway. ### Answer **Observations:** - Chin deviation to the right. - Lower midline deviation to the right. - Unilateral posterior crossbite on the left in ICP. - Edge-to-edge posterior relationship in RCP. **Reasoning:** The apparent facial asymmetry and lower midline deviation are not true skeletal asymmetries. They are the result of a functional shift of the mandible to the right to achieve a stable intercuspal position from an unstable edge-to-edge posterior relationship. Treatment involves expanding the upper arch (e.g., with a rapid maxillary expander) to eliminate the edge-to-edge relationship, which removes the functional shift and resolves the apparent asymmetry. **Takeaway:** Apparent facial asymmetry and midline deviation associated with a unilateral posterior crossbite can be caused by a functional shift from an unstable edge-to-edge posterior relationship, which is resolved by maxillary expansion. ## Case: Simultaneous correction of posterior and anterior crossbites ### Question **Scenario:** A patient presents with both a dental posterior crossbite and an anterior crossbite of a lateral incisor. **What's shown:** A custom orthodontic appliance featuring an expansion mechanism (similar to a quad-helix or W-arch) with an extended arm and a soldered spring. **Consider:** How to efficiently treat both the posterior and anterior crossbites using a single appliance. ### Answer **Observations:** - A modified expansion appliance. - An extended arm with a soldered spring designed to engage the lateral incisor. **Reasoning:** By combining the expansion arms with an extended spring, the single device can simultaneously expand the posterior arch to correct the posterior crossbite and procline the lateral incisor to correct the anterior crossbite. This approach addresses both issues and eliminates the associated functional shifts in approximately two months. **Takeaway:** A modified expansion appliance with an extended soldered spring can efficiently correct concurrent dental posterior and anterior crossbites in a single device. ## Case: Biomechanics of uprighting a proclined molar with a cantilever spring ### Question **Scenario:** A patient requires uprighting of a proclined (mesially tipped) first molar, either to unblock a premolar or to prepare the site for a bridge or dental implant. **What's shown:** A biomechanical setup using a cantilever spring (cancellable lever) anchored to the canine and both premolars to upright the proclined first molar. A force of 40 grams is applied at a distance of 25 mm from the molar. **Consider:** How to calculate the forces and moments applied to the molar and the anchor teeth when using this cantilever setup. ### Answer **Observations:** - A proclined first molar being uprighted using a cantilever spring. - The spring is anchored to the canine and both premolars. - An applied force of 40 grams at a distance of 25 mm from the molar. **Reasoning:** The moment applied to the molar is calculated by multiplying the force by the distance (40 grams x 25 mm = 1000 gram-mm). Because the force is applied far from the molar's center of resistance, the reactive intrusive force on the anchor segment (canine and premolars) is minimal (only 40 grams). This provides a sufficient moment to upright the molar without causing significant, unwanted intrusion of the anchor teeth. **Takeaway:** Using a cantilever spring with a long lever arm allows for the application of a large moment to upright a tipped molar while exerting minimal intrusive force on the anchor teeth. ### Answer **Observations:** - Chin deviation to the right. - Lower midline deviation to the right. - Unilateral posterior crossbite on the left in ICP. - Edge-to-edge posterior relationship in RCP. **Reasoning:** The apparent facial asymmetry and lower midline deviation are not true skeletal asymmetries. They are the result of a functional shift of the mandible to the right to achieve a stable intercuspal position from an unstable edge-to-edge posterior relationship. Treatment involves expanding the upper arch (e.g., with a rapid maxillary expander) to eliminate the edge-to-edge relationship, which removes the functional shift and resolves the apparent asymmetry. **Takeaway:** Apparent facial asymmetry and midline deviation associated with a unilateral posterior crossbite can be caused by a functional shift from an unstable edge-to-edge posterior relationship, which is resolved by maxillary expansion. ## Case: Simultaneous correction of posterior and anterior crossbites ### Question **Scenario:** A patient presents with both a dental posterior crossbite and an anterior crossbite of a lateral incisor. **What's shown:** A custom orthodontic appliance featuring an expansion mechanism (similar to a quad-helix or W-arch) with an extended arm and a soldered spring. **Consider:** How to efficiently treat both the posterior and anterior crossbites using a single appliance.    ### Answer **Observations:** - A modified expansion appliance. - An extended arm with a soldered spring designed to engage the lateral incisor. **Reasoning:** By combining the expansion arms with an extended spring, the single device can simultaneously expand the posterior arch to correct the posterior crossbite and procline the lateral incisor to correct the anterior crossbite. This approach addresses both issues and eliminates the associated functional shifts in approximately two months. **Takeaway:** A modified expansion appliance with an extended soldered spring can efficiently correct concurrent dental posterior and anterior crossbites in a single device. ## Case: Biomechanics of uprighting a proclined molar with a cantilever spring ### Question **Scenario:** A patient requires uprighting of a proclined (mesially tipped) first molar, either to unblock a premolar or to prepare the site for a bridge or dental implant. **What's shown:** A biomechanical setup using a cantilever spring (cancellable lever) anchored to the canine and both premolars to upright the proclined first molar. A force of 40 grams is applied at a distance of 25 mm from the molar. **Consider:** How to calculate the forces and moments applied to the molar and the anchor teeth when using this cantilever setup.  ### Answer **Observations:** - A proclined first molar being uprighted using a cantilever spring. - The spring is anchored to the canine and both premolars. - An applied force of 40 grams at a distance of 25 mm from the molar. **Reasoning:** The moment applied to the molar is calculated by multiplying the force by the distance (40 grams x 25 mm = 1000 gram-mm). Because the force is applied far from the molar's center of resistance, the reactive intrusive force on the anchor segment (canine and premolars) is minimal (only 40 grams). This provides a sufficient moment to upright the molar without causing significant, unwanted intrusion of the anchor teeth. **Takeaway:** Using a cantilever spring with a long lever arm allows for the application of a large moment to upright a tipped molar while exerting minimal intrusive force on the anchor teeth. Case: Functional shift causing apparent asymmetry in posterior crossbite > Answer RAPID MAXILLARY EXPANDER Clinical photo of a Rapid Maxillary Expander (RME) appliance fitted to the upper dental arch. The device features metal bands cemented around the first molars, connected by a central expansion screw and transverse arms. QUAD HELIX and W-ARCH A model of a maxillary arch fitted with a removable orthodontic appliance featuring four helical springs and a central transverse bar, illustrating the design of a Quad Helix or W-Arch used for slow expansion. SLOW EXPANSION PLATE Clinical photo: An occlusal view of a dental appliance, specifically a Quad Helix and W-Arch, fitted inside the upper arch. The image shows the metal wires wrapped around the molars on both sides and extending across the palate to apply pressure for slow expansion. Or Implant A diagram showing a dental implant positioned next to a tipped molar, illustrating the treatment option of replacing or restoring the tooth with an implant. 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