Traetment Planning in Mixed Dentition 4

Treatment of Complex/Skeletal
problems in Mixed Dentition

BDS 19 Online lecture
Dr Abdullah Jan
Considerations for Distal molar movement
• Candidates for molar distalization
• Normal or short face
• 4-5 mm discrepancy
• Majority of teeth erupted or at least 1st molars should be erupted
• Retrusive or normal lips. Protrusive lips lead to anchorage loss
• Increased nasolabial angle
• Methods
• Preserve space
• Jackscrew
• Lingual arch/ TPA
Serial Extraction
Mx of ant crowding
• In Serial extractions, first premolar is extracted for alignment of ant
teeth
• During serial extraction, first premolar should erupt before canine for
ideal results.
• If canine erupts before, it will block the 1st premolar.
• Extract the premolar via surgical mdeans but bone defect will result
• After procedure, arch length should be maintained by nance arch,
lingual arch or TPA
Skeletal Problems
• Growth modification
• Too early
• Too late
• Compliance
• Crowding and Overjet
• In this patient, the nasolabial angle is obtuse.
So correcting the overjet via extraction of first
premolar is not a good idea as the angle will
become more obtuse and damage the soft
tissue paradigm.
• Rather the pt is given functional appliance
Different Planes & Different Timings
• Transverse- as early as possible. But may lead to iatrogenic damage.
Rx should be done before adolescence.
• Anteroposterior- CVM 3
• Vertical CVM 3
• CVM 1-2; Class III
• Compliance
• Transverse Maxillary constriction
• Should be done before adolescent spurt
• Primary and early mixed dentition?
• Retainer after expansion
• Rapid palatal expansion; expansion 1 month. Retention 4 months
• Slow expansion; expansion 2.5-3 months, retention 2 months
• Retention should be given the same day as removal of appliance.
Class III problems
• Maxilla deficient
• Mandibular excess
• Combination
• Frankel III
Treatment time
Ideal CVM 1
Sometimes CVM 2
• Reverse pull Head gear
(Face Mask)
(Banded or bonded assembly)
Class III elastics

• When a restraining force is applied on mandible, it rotates forward
and backward
• Mand growth cannot be stopped only modified
• Head gear usually used for Class II but can be used for Class III with
cervical assembly
Skeletal Anchorage for Class III
• BAMP
• Force from Protraction Face Mask
• Ankylosed Primary teeth
Mandibular excess
• Chin Cup/ Cap ???
• Face Mask+
• Bone anchors, elastics
• Head Gear ??
Class II Problems
• Maxillary excess
• Mandibular deficiency
• Combination
• CVM 3 is ideal time for Class II correction
Truth about Functional Appliance
European vs US approach
• Modest increase 0.16mm
• Head gear effect, restraint of maxillary growth
• Downward direction of maxillary growth
• Twin block- easier to talk

• Bionator- bulkier
• Frankel- tissue born. Causes soft tissue irritation but pt can speak so
full time wear is possible
• Class II elastics
• Fixed functional appliances

• Only 2 produce ideal skeletal
results;
• Herbst appliance
• MARA appliance
• Since both are fixed, pt can talk
and are compliance free
Response to Class II Func
Parts of a functional Appliance
• Stabilization components
• Passive components
• Active components
• Functional appliance produce occlusal interferences, which causes pt

to protrude mand all the time
• True functional appl produce skeletal effects instead of dentoalveolar
effects
Occlusal Stops
• Functions
• Prevent mand ant teeth from
protruding or erupting thus
prevents dentoalveolar effects
• Creates post open bite and making
it convenient for mand to mov fwd
• To maintain vertical dimensionof
face, lower surface of appl is
trimmed allowing lower teeth to
erupt
Lingual shield
restricts tongue
pressure on teeth,
thus maintaining
equilibrium
Lingual Pad and
Lingual Flanges;
Translation of mand
fwd
Restricts tongue
pressure on dentition
Tipping of lower ant
teeth to decrease
overjet
Retention by clasps, labial bow
Retention by clasps and labial bow
• Clasps helps to stabilize functional appliance such as head gear tube
• Labial bow help guide the appliance into proper position rather than
tipping of ant teeth
• Bow is adjusted so it doesnot touch the teeth while appliance is
seated
Lip Pads and Buccal Shield
• Remove pressure of lip and cheek from lower
teeth thus favouring translation of mand fwd
• Used for correction of post crossbite
• Constricted maxilla
• Crowding is relieved
• Dentoalveolar growth occurs
Occlusal coverage and Screws for tooth
movement
Tooth movement before functional appliance
treatment in Div 2
after achieving adequate overjet and
necessary decompensation, functional
appliance is given
Wax Bite
• Incisal interferences to be removed
• Symmetry of face and midlines- soft tissue
midline is more imp
• Bite height = 4-5 mm (bionator) or 5-6 mm (twin
block, activator)- depends on type of appliance
• Protrusion = 4-6 mm
• Protrusion more than this will cause Pain
• Encourage to wear appliance for aprox 12hrs
Management of Functional Appliance
• Start with less time wear; Compliance
• Duration of wear- 12hrs
• Time of wear- 8pm to 1pm
Fixed Functional
• Incremental increase to
correct overjet (shims)

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Traetment Planning in Mixed Dentition 4

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Treatment of Complex/Skeletal

problems in Mixed Dentition

Class III elastics

• Twin block- easier to talk

• Fixed functional appliances

• Functional appliance produce occlusal interferences, which causes pt

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