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Early and Interceptive orthodontic treatment

INDIAN DENTAL ACADEMY Leader in continuing dental education

Indications Rationale Preventive orthodontic Procedures Interceptive orthodontic Procedures Intervention of Skeletal malocclusion

EARLY TREATMENT Refers to treatment that precedes the conventional treatment protocol in which brackets and bands are placed on teeth. Begins during primary or transitional dentition period so as to intercept malocclusion in a manner that will lead to a better, more stable result than that which would be achieved by starting treatment later. Goal is to reduce time and complexity of fixed appliance therapy.

Indications 1) Posterior and anterior crossbites - Not only for the functional improvement brought about by therapy but also for the improved esthetics that occurs with the anterior crossbite correction . 2) Ankylosed teeth seldom self-corrects , best not to treat this condition too early because space maintenance will usually be needed for several months or even years. By the time the companion permanent tooth on the opposite side of the mouth is ready to erupt, the ankylosed tooth should be extracted and the underlying permanent tooth uncovered if necessary.

3) Excessive protrusions and diastemas that invite injury or avulsions need treatment at an early age to avoid permanent damage to the dentition. 4) Severe anterior and lateral open bites are often found accompanied by digit or tongue habits. Failure to completely eradicate these anomalies often leads to a lifetime of malocclusion that eventually becomes impossible to treat without the benefit of orthognathic surgery.

5) Ectopic molars are best treated when discovered. Failure to address this problem early enough greatly reduces the arch length for the permanent dentition. 6) Severe arch length discrepancies – Serial extraction procedure can be initiated. 7) Patients with cleft palates 8) Pseudo Class III patients, Class III malocclusions that are true maxillary retrusions are probably best handled during the mixed dentition stage because osseous tissues are best modified during the times when rapid growth is occurring.

As suggested by Gianelly, (AJO 1995) the late mixed dentition offers the best time for intervention for several reasons: a) The E space still exists. b) Approximately 80% of the patients are still treatable by nonextraction. c) The treatment can be completed in one phase. d) The orthodontist can still capitalize on growth.



PREVENTIVE ORTHODONTICS Graber (1966) defined it as the action taken to preserve the integrity of what appears to be a normal occlusion at a specific time. Proffit & Ackerman (1980) has defined it as prevention of potential interference with occlusal development.

Maintaining the integrity of deciduous teeth and occlusion forms one of the most important steps in preventive orthodontics. Some procedures and concept of preventive and interceptive orthodontics are common but the time of application pertaining to the stage of dental development are different.

INTERCEPTIVE ORTHODONTICS Council on Orthodontic Education of the American Association of Orthodontists has defined it as that phase of science & art of orthodontics employed to recognize & eliminate potential irregularities & malpositions in dentofacial complex. Corrective measures may be necessary to prevent a potential irregularity from progressing into a more severe malocclusion.

Preventive measures 1) Caries control. 2) Parent counselling. 3) Space maintenance. 4) Abnormal frenal attachments. 5) Treatment of locked first molars. 6) Abnormal oral musculature & related habits. 7) Others – Care of deciduous teeth, timing of exfoliation. Occlusal equilibration Extraction of supernumerary

Interceptive measures 1) Serial extraction. 2) Space regaining. 3) Correction of anterior & posterior crossbites. 4) Oral habits elimination. 5) Muscle exercises. 6) Removal of soft or hard tissue impediments to path of eruption. 7) Resolution of crowding 8) Interception of developing skeletal malocclusion.

CARIES CONTROL - Proximal caries if not restored is main cause of malocclusion. Leads to loss of arch length, thereby resulting in lesser space for succedaneous teeth to erupt in right position. Fluoride mouth rinses can be prescribed. PARENTAL COUNSELLING – Most neglected but most effective method to practice preventive orthodontics.

Divided into – A) Prenatal Counselling – Importance of oral hygiene conveyed to parents. B) Postnatal Counselling – Can be associated with clinical examination of child at 1) 6 months to 1yr of age. 2) 2 yrs of age. 3) 3 yrs of age. 4) 5 – 6 yrs of age.

SPACE MAINTENANCE The process of maintaining the space in a given arch, previously occupied by a tooth or a group of teeth. It is appropriate only when adequate space is available & all unerupted teeth are present and at proper stage of development. If there is not enough space or if succedaneous teeth are missing, space maintenance alone is inadequate.

Space Maintainers Fixed or removable appliances designed to preserve the space created by the premature loss of a deciduous tooth Appliances used to maintain space or regain minor amounts of space lost, so as to guide the unerupted tooth into a proper position in the arch Best space maintainer ??? Natural tooth with proper mesio distal width

Objectives of Space Maintenance Preserve space created by premature loss Preserve integrity of dental arch Preserve normal occlusion Preserve esthetics Aid in phonetics Prevent abnormal habits

Ideal Requirements of Space Maintainers Simple, sturdy, easy construction Occupy less space Cost effective Durable Modifiable Universal application

Removable space maintainers Can be removed by patients Functional or nonfunctional Indications – Esthetic demands Abutments have poor strength and health Multiple loss of deciduous teeth Contraindications – Lack of patient cooperation Acrylic allergy Epileptic patients

Fixed space maintainers Bonded or cemented Cannot be removed by patient Non functional or functional. Ex – Band & loop, Crown & loop, Nance holding arch, Transpalatal arch, Lingual arch.

Band and Loop Space Maintainer Unilateral, fixed, non functional, passive Indicated in unilateral loss of single posterior deciduous tooth with distal abutment Contraindications Severe crowding High caries activity Risk of decalcification

Nance Palatal Arch Maxillary lingual arch Approximates anterior palate, not teeth Indications: Bilateral loss of maxillary deciduous molars

Transpalatal Arch Extends from one maxillary molar along contour of palate to molar on opposite side. Made from .036 inch stainless steel wire. Main function – To prevent mesial migration of molars.

Prevents molar rotation Rigid

Lingual arch space maintainer [Fixed, Non functional, passive] Control anteroposterior movements Prevents arch perimeter distortion Prevents lingual collapse of anteriors Indications – Bilateral loss of single / multiple posterior teeth in the lower arch after eruption of permanent anteriors Minor tooth movement Space regaining

Should not interfere with normal occlusal development / adjustments Should not cause stress on adjacent teeth or interfere with their eruption Maintain individual functional movement of each tooth Simple, sturdy, easy to construct and less space occupying Should not restrict normal growth of arches or functions

Distal Shoe Space Maintainer Intra alveolar appliance Molar guidance appliance Indication: Loss of ‘E; before eruption of ‘6’

Contra indications – Inadequate abutments Poor oral hygiene or parent/ patient cooperation Medically compromised patients – CHD, RF, DIABETES, HEMOPHILIA, GENERALISED DEBILITATION

Abnormal frenal attachments Presence of thick & fleshy maxillary labial frenum – MIDLINE DIASTEMA. Blanch test helps in diagnosing a thick frenum. Presence of ankyloglossia or tongue tie prevents normal functions of tongue – abnormalities in speech & swallowing. Should be surgically treated to prevent full fledged malocclusions.

Exfoliation of deciduous teeth Deciduous teeth should exfoliate in about 3 months of exfoliation of one in contralateral arch. Delay ,than rule out – Over retained teeth, fibrous gingiva, ankylosed teeth, supernumerary teeth. Supernumerary teeth should be immediately removed – can lead to ectopic eruption of permanent teeth.

l Space created because of extraction of

ankylosed teeth should be maintained till eruption of succedaneous teeth.

l Locked Permanent first molars -

Permanent first molars may get locked beneath distal bulge of 2nd deciduous molars at times, Slight distal stripping of teeth allows the permanent first molar to erupt in right place.

Midline Diastema Normal in developing dentition, till permanent maxillary canines have erupt. If persist after that determine the underlying cause which could beFibrous attachment of labial frenum, Mesiodens, Midline cysts, Habits, Microdontia. Removal of causative factor can close the space on its own or a removable appliance can be used where autonomous closure of space is not expected.

Abnormal Oral habits In the orthodontic sense refers to certain actions involving the teeth & other oral or perioral structures which are repeated often enough by some patients to have a profound & deleterious effect on positions of teeth & occlusion. Can effect growth of jaws also. Ex – Constriction of maxilla, downward & backward growth of mandible. Common oral habits include mouth breathing, tongue thrusting, thumb sucking, lip sucking etc.

Studies have linked the development of class II malocclusions to these habits. Lead to an imbalance in forces acting on teeth, causing development of malocclusion. Lead to abnormal functioning of tongue, aberrant lip & perioral musculature, development of unfavorable V shape & high palatal arches.

Mouth Breathing Can be obstructive due to nasal obstruction like nasal polyps, deviated nasal obstruction, enlarged adenoids. Can be habitual also. It affects the orofacial equilibrium due to lowered mandibular & tongue posture – LONG FACE. Interceptive procedure – Identification & removal of cause. Habitual mouth breathing – Use of oral screen.

Tongue thrusting Defined as placement of tongue tip forward between the incisors during swallowing. Clinically presents as open bite & anterior proclination. Should be intercepted using habit breaking appliances. Patient should be trained & educated on correct technique of swallowing.

Tongue exercises – To correct aberrant tongue swallow patterns. a) Elastic placed on tip of tongue & patient is asked to raise it to rugae area & swallow. b) 2 elastics are placed on dorsum of tongue. c) Elastic is placed ,patient is told to hold tongue on a spot over a definite period of time with lips closed.

Thumb Sucking Normal till 2 – 3 yrs. If persist, malocclusion characterized by flared & spaced maxillary incisors, anterior open bite,& narrow upper arch is likely to be present. Habit breakers could be of removable type or fixed type.

Vaishali Prasad, A.K.Utreja ( JCO 2005) have found oral screen to be highly effective in intercepting lip sucking habits in young child.

SERIAL EXTRACTION Planned & sequential extraction of certain teeth is undertaken to intercept a developing arch length deficiency in order to avoid the need for extensive orthodontic procedure. Hotz, Kjellgren,Nance, Dewel, Tweed popularized serial extraction. Instituted when patient is about 8 yrs of age.

Indications – 1) Arch length tooth size discrepancy with one of the following features : a) Absence of physiologic spacing. b) Ectopically erupted teeth. c) Mesial migration of buccal segment. 2) Skeletal class I malocclusion, straight profile. 3) Growth is not enough to overcome discrepancy.

Proffit cited a tooth size / arch length discrepancy of 10mm or greater as indication for serial extraction.

Ringenberg – Discrepancy of 7mm or more.

Contraindications 1) Spaced dentition. 2) Class II or III skeletal malocclusion. 3) Anodontia/ oligodontia. 4) Open bite / deep bite cases. 5) Mild arch length discrepancy.

Procedure A) Dewel’s Method – 1st step - extract deciduous canine to create space for alignment of incisors. 2nd step – extract deciduous first molars. 3rd step – extract 1st premolars to permit permanent canines to erupt.

B) Tweed’s method – Extraction of deciduous 1st molars followed by extraction of 1st premolars & deciduous canine.

Problems & complications – a) Ditching between canine & 2nd premolar in mandibular arch. b) Increased overbite may develop. c) Excess space. d) Congenital absence of 2nd premolar in mandibular arch. e) Impacted canines.

A study published by KINE (1975) comparing patients who had undergone 1 st premolar extraction as part of serial extraction procedure followed by orthodontic treatment & those who had undergone first premolar extraction in permanent dentition showed that serial extraction group exhibited a substantially smaller long term crowding.

Space Regaining If a primary molar is lost early & space maintainers are not used, reduction in arch length by mesial movement of 1st permanent molar can be expected. Space lost can be regained by distal movement of first molar. Estimation of space lost can be done by mixed dentition analysis. Upto 3mm of space can be regained. Space regaining procedures are preferably undertaken prior to eruption of 2nd permanent molar.

Appliances used 1 Gerber Space regainer – Consist of U shaped hollow tubing, in which U shaped rod is inserted. Tube is soldered on mesial aspect of molar to be moved distally, base of rod contacting tooth mesial to edentulous area. Open coil springs are placed around free ends of rod & inserted into tubing assembly. Forces generated by compressed coil spring moves molar distally.

2 Jack Screw – Helps to distalize molar, thereby gaining space. 3 Cantilever Spring – By using removable appliance that incorporate simple finger springs. 4 Lip bumper – Uses muscular force application to distalize molar & gain space. 5 Headgear – Frequently used to distalize molars ,can gain space upto 3mm.In case of unilateral space loss, asymmetric facebow can be used.

Interception of Skeletal Malocclusion.

Class I tooth arch size discrepancy – Early mixed dentition ideal time, after eruption of incisors. Class II malocclusion – Greater growth response when treatment is initiated during late mixed dentition. Class III malocclusion – Immediately as soon as detected. Early mixed dentition.

Tooth Arch Size discrepancy Treatment Strategies – a) Serial extractions. b) Orthopedic expansion. c) Mandibular decompensation. Orthopedic expansion: Cornerstone is RME. Ideal transpalatal width is 33 – 35mm in mixed dentition. In case of restricted width RME is initiated. Aimed at overcorrection, so that maxillary arch is in buccal crossbite with mandibular arch.

Passive expansion – When forces of buccal & labial musculature are shielded from occlusion, widening of dental arches occur. Ex- FR-2. Mandibular dental decompensation – Done in patients whose lower arches exhibit moderate crowding, or anterior & posterior teeth are tipped lingually. Appliances used – Schwarz appliance & Lip bumper. By decompensating mandibular dental arch, greater arch expansion of maxilla can be achieved.

Preserving leeway space – In his experience, Gianelly has found that management of leeway space alone can resolve the crowding problems in more than 80% of orthodontic patients.

Class II malocclusion Primarily a sagittal & vertical problem. Many cases have a strong transverse component. Treatment Available - Extraoral traction, arch expansion ,functional jaw orthopedics. Extra oral traction – Most common for true maxillary skeletal protrusion.

Cervical facebow most commonly used. Numerous clinical studies (Kloehn 1953, Wieslander 1975, McNamara 1996 ) have shown that forward movement of maxilla can be inhibited with use of headgear. Functional Jaw Orthopedics – Appliances most commonly used in case of mandibular skeletal retrusion. Ex – Activator, Bionator, FR, Twin block, Herbst, Jasper Jumper.

All appliances have one thing in common, they induce a forward mandibular positioning. This alteration in the postural activity of the muscles of craniofacial complex ultimately leading to changes in both skeletal & dental changes. FR-2 particularly useful in patients with significant neuromuscular imbalances such as hyperactive mentalis, hypertonic buccal musculature.

Expansion appliances – As most class II malocclusions have tendency of posterior crossbite, maxilla is overexpanded .This disrupts the occlusion. It appears that patient become more comfortable by positioning jaw forward, thus eliminating tendency toward buccal crossbite & at same time improving overall sagittal occlusal relationship. Teeth themselves act as an endogenous functional appliance, encouraging a change in mandibular posture & ultimately change in maxillomandibular occlusal relationship.

The effects of early preorthodontic trainer treatment on Class II, division 1 patients Usumez S (2004 ) The aim of this study was to clarify the dentoskeletal treatment effects induced by a preorthodontic trainer appliance treatment on Class II, division 1 cases . Study demonstrates that the preorthodontic trainer application induces basically dentoalveolar changes that result in significant reduction of overjet and can be used with appropriate patient selection

Outcomes in a 2-phase randomized clinical trial of early Class II treatment. Tulloch JF, Proffit WR, Phillips C. (Am J Orthod Dentofacial Orthop. 2004)

In a 2-phased, parallel, randomized trial of early (preadolescent) versus later (adolescent) treatment for children with severe (>7 mm overjet) Class II malocclusions. Favorable growth changes were observed in about 75% of those receiving early treatment with either a headgear or a functional appliance. After a second phase of fixed appliance treatment for both the previously treated children and the untreated controls, however, early treatment had little effect on the subsequent treatment outcomes

Early treatment also appears to be less efficient, in that it produced no reduction in the average time a child is in fixed appliances during a second stage of treatment, and it did not decrease the proportion of complex treatments involving extractions or orthognathic surgery

Effectiveness of early orthodontic treatment with the Twin-block appliance: a multicenter, randomized, controlled trial. O'Brien K (Am J Orthod Dentofacial Orthop. 2003)

The aims of this project were to evaluate whether early orthodontic treatment with the Twin-block appliance for the developing Class II Division 1 malocclusion resulted in any psychosocial benefits. Results showed that early treatment with Twinblock appliances resulted in an increase in selfconcept and a reduction of negative social experiences.

Anteroposterior skeletal and dental changes after early Class II treatment with bionators and headgear Stephen D. Keeling (Am J Orthod Dentofacial Orthop1998)

In this study authors examined anteroposterior cephalometric changes in children enrolled in a randomized controlled trial of early treatment for Class II malocclusion. Children, aged 9.6Âą 6 0.8 years at the start of study, were randomly assigned to control (n= 581), bionator (n= 578), and headgear/biteplane (n =590) treatments. Cephalograms were obtained initially, after Class I molars were obtained or 2 years had elapsed, after an additional 6 months during which treated subjects were randomized to retention or no retention and after a final 6 months without appliances.

Both bionator and head-gear treatments corrected Class II molar relationships, reduced overjet and apical base discrepancies, and caused posterior maxillary tooth movement. The skeletal changes, largely attributable to enhanced mandibular growth in both headgear and bionator subjects, were stable a year after the end of treatment, but dental movements relapsed

Headgear versus function regulator in the early treatment of Class II, Division 1 malocclusion: A randomized clinical trial J. Ghafari,F. S. Shofer, U. Jacobsson Hunt, D. L. Markowitz, and L. L. Lasterb A prospective randomized clinical trial was conducted to evaluate the early treatment of Class II, Division 1 malocclusion in prepubertal children. Facial and occlusal changes after treatment with either a headgear or a Frankel function regulator were reported.

The results indicate that both the headgear and function regulator were effective in correcting the malocclusion. Treatment in late childhood was as effective as that in mid childhood. This finding suggests that timing of treatment in developing malocclusions may be optimal in the late mixed dentition, thus avoiding a retention phase before a later stage of orthodontic treatment with fixed appliances.

Class III malocclusion Goals include – a) To prevent progressive irreversible soft tissue or bony changes. Ex- Anterior crossbite. b) To improve skeletal discrepancies & provide a more favorable environment for future growth. c) To improve occlusal function. d) To simplify phase II comprehensive treatment. Early treatment may eliminate necessity for orthognathic surgery.

Indications & Contraindications Turpin (1981) developed positive & negative factors for deciding when to intercept a developing class III malocclusion. Positive factors – Good facial esthetics, mild skeletal disharmony, no familial prognathism, symmetric condylar growth, growing patients with good cooperation. Negative factors – Severe skeletal disharmony, poor facial esthetics, asymmetric condylar growth, growth complete.. Early treatment is considered for patient with positive factors.

Chin Cup therapy – In relatively normal maxilla, with protrusive mandible. Provides growth inhibition or redirection & posterior positioning of mandible. To date there is no agreement in literature as to whether chin cup therapy may or may not inhibit the growth of mandible. Stability of chin cup treatment remains unclear, several investigators reported a tendency to return to original growth pattern after chin cup is discontinued.

Protraction facemask therapy – Where maxillary deficiency is present. Main objective of early treatment with facemask therapy is to enhance forward displacement of maxilla by sutural growth Clinically anterior crossbite can be corrected within 3 – 4 months of maxillary expansion & protraction depending on severity of malocclusion. Effective in primary, mixed & early permanent dentition. (Baccetti 1998, Ngan P 2001)

Anterior Cross Bite Should be intercepted & treated at an early age so as to prevent a minor orthodontic problem from progressing into a major dentofacial anomaly. “The best time to treat a crossbite is the first time it is seen”. Treatment – a) Use of tongue blade: Developing single tooth crossbite can be successfully treated. Used only if sufficient space is there for tooth to be brought out. Worn for 1- 2 hrs for 2 weeks

Catalan’s appliance / Lower anterior inclined plane – Can treat a single tooth or a segment of upper arch in cross bite. It is designed to have a 45˚angulation which forces maxillary teeth into a more labial position. Use of double cantilever spring ( Z spring) – Anterior crossbite involving 1 or 2 teeth.

Posterior Crossbite Other than correcting functional shifts in primary dentition by selective occlusal adjustment, it is recommended that treatment be postponed until early mixed dentition. Treatment decision is made on case by case basis & include consideration of following factors – presence or absence of lateral mandibular shift, degree of skeletal discrepancy, degree of posterior tooth compensation in each arch

Most common is to separate midpalatal suture with expansion appliance. Even if transverse discrepancy results from broad mandibular arch, it is better to expand maxilla. Other appliances – Quad helix, transpalatal arch, crossbite elastics. Unilateral Crossbite – A RME with reverse crossbite elastics on non crossbite side in conjunction with a lower lingual holding arch is recommended.

How much expansion? Mandibular arch limits the amount of maxillary expansion that can be achieved. Expansion of arches beyond point where mandibular molar crowns are upright is inherently unstable & not recommended. According to Little ( AJO 2002) arch widening in mixed dentition without lifetime retention yields unstable results.

Early Management of Impacted Canines Suggested preventive procedure for canine impaction is early extraction of corresponding deciduous canine. Linduaer (JADA 1992) found a relation between unerupted canine cusp tip & lateral incisor as it appeared on mixed dentition radiograph on basis of which it can be said that canine will be impacted in future or not.

Lateral incisor root on OPG is divide into 4 sectors using modified method of Ericson & Kurol.

Psychological influences on the timing of orthodontic treatment (Asuman Kiyak AJO 98) Psychologic development during the preadolescent & adolescent stages may influence the child's motive for, understanding of & adherence to treatment regimen. Children have reported that the appearance of their teeth is a common target of teasing .Overjet, extreme deep bite & crowding are associated with most unfavorable self perception of teeth.

Treatment during preadolescence is concerned with adherence. Girls are more likely to adhere to treatment recommendations than boys. Preadolescents generally seek approval of significant adult role models ( Parents, orthodontist), as a result more compliant with removable appliance, adhere to rules & routine established by adults. Younger children are good candidates for Phase I orthodontics, have high self-esteem and bodyimage, and expect orthodontics to improve their lives.

Much misunderstanding of “preventive orthodontics” and “interceptive orthodontics” stems from the implication that “early” treatment of malocclusion in children precludes the need for later orthodontic treatment. As facial and dental development continues throughout childhood and adolescence the longterm impact of early treatment may not be predicted. Yet early intervention may help develop a normal occlusion and facial harmony.

REFERENCES 1 Zahid Lalani, Ashima Valiathan -Interceptive Orthodontics.JICD 1993 vol 33 (7-15). 2 Vaishali Prasad, A.K. Utreja – An oral screen for early intervention in lower lip sucking habits. JCO Feb 2005 vol 39 (97 -100). 3 Peter Ngan – Early timely treatment of class III malocclusion. Semin.Orthod 2005, 11(140 – 145). 4 Steven D Marshall, Thomas Southhard – Early transverse treatment. Semin.Orthod 2005, 11(130 -139).

5 Peter Ngan, Bryan Weaver - Early timely Management of ectopically erupting maxillary canine. Semin.Orthod 2005, 11(152 -163). 6 G.Thomas Kleumper, Cynthia Beeman, E.Preston Hicks – Early Orthodontic treatment: What are the imperatives.? JADA 2000,131(613620). 7Usumez S, Uysal T, Sari Z, Basciftci FA, Karaman AI - . The effects of early preorthodontic trainer treatment on Class II, division 1 patients. AJO 2004 Jul;126(1):2332.

8 Tulloch JF, Proffit WR, Phillips C.Outcomes in a 2-phase randomized clinical trial of early Class II treatment. AJO 2004 Jun;125(6):657-67 . 9 Mantysaari R, Kantomaa T, Pirttiniemi P, Pykalainen A - The effects of early headgear treatment on dental arches and craniofacial morphology: a report of a 2 year randomized study .EJO 2004 Feb;26(1):59-64. 10 O'Brien K, Wright J, Conboy F, Chadwick S, Connolly I, Cook P - Effectiveness of early orthodontic treatment with the Twin-block appliance: a multicenter, randomized, controlled trial. Part 2: Psychosocial effects. AJO 2003 Nov;124(5):488-94

11 Larry White - Early orthodontic intervention. AJO 1998 Volume 113, No. 1 12 Michael G. Arvystas - The rationale for early orthodontic treatment. AJO 1998 Volume 113, No. 1 13 J. Ghafari, F. S. Shofer,b U. JacobssonHunt, D. L. Markowitz, L.Lasterb - Headgear versus function regulator in the early treatment of Class II, Division 1 malocclusion:A randomized clinical trial. AJO 1998;113 (51-61.).

14 Stephen D. Keeling, Timothy T. Wheeler, Gregory J. King, Cynthia W. Garvan Anteroposterior skeletal and dental changes after early Class II treatment with bionators and headgear. AJO 1998;113:(40-50.). 15 William R Proffit: Contemporary Orthodontics.3 edtn, Mosby, St.Louis. Pg – 451 – 468. 16 Thomas Graber, Robert Vanarsdall – Orthodontics : Current Principles & techniques. 3rd edtn, Mosby St.Louis. Pg -521-557

17 Thomas P George, Valiathan Ashima, Arji I George & Denny J Payyappilly: Oral habits (Part II) Tongue thrusting. Kerala Dental Association. 1992; 15(3 & 4): 721-724. 18 Gurkeerat Singh : Textbook of orthodontics. 1st edtn, Jaypee, New Delhi. Pg – 511– 532. Leader in continuing dental education

Early and interceptive treatment / dental implant courses by Indian dental academy  
Early and interceptive treatment / dental implant courses by Indian dental academy  

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