Professional Documents
Culture Documents
***
The indirect bonding technique is more complex and technique sensitiv and requirs extra precautions
f. The conhol of"tfrsh" (e&ess of resin) not only makes clean up easy but also the controlled
ofit
lmportent:
l. All orthodontic appliances obey Newton's Third Law: There ir in equel and opposite rcaction to every
rction.
2. For each appliance, the sum ofthe forces and the sum ofthe moments acting on it sum to zero.
3. T,?es ofappliances
. Equal and opposite forcs: an elastic band stretched between two brackets produces equal and oppo_
site forces (the sum ofthe forces equals zero).
. One.couple applirnces: inserted into a bmcket at one end and tied as a point contact at the other
end. A couple is produced only at the engagd end. The sum of the forces is zero.
. Two-couple appliances: inserted into a bracket at each end. Both a couple and a force are produced at
each end. The magnihrde ofthe couple is largest at the end closer to the bend in the wire The sum ofthe
forces is zero.
ORTHODONTICS
. Frankel
. Bionator
. Clark's Twin Block
. Herbst
. Activator
. Quad-Helix
Appliances
2.
space maintainr(s)
could be used in plac of this appliance that cannot be used in this case?
. Distal shoe
. \ance appliance
Copq'ghr
a<l
20ll :012
Dcntal D.cks
of
***
This frxed appliance, consists of4 helices (2 onterior and 2 posterior). Essettially, this appliposterior cross-bite cases with a digital-sucking habit.
Functional appliances are by definition ones that change the posture ofthe mandible, holding it
open or open and forward. Stretch ofthe muscles and soft tissues creates pressures transmitted to
the dental and skeletal struchrres, moving teeth and modifying growth. They are used to treat
Class
II
malocclusions,
Functional Appfian
ces
(in
biet
- Cl^ssified asi
. Tissu borne: The Frankel functional appliance is the only tissue bome functional appliance,
which serves to expand the arch by "padding" against the pressure ofthe lips and cheeks on the
teeth and postures the mandible forward and downward.
. Tooth borne:
. Activator: advances the mandible to an edge-lo-edge position to induce mandibular growth
for the correction ofClass ll malocclusion. The maxillary teeth arc prevented from erupting
by the acrylic shelfwhile mandibular posterior teeth are free to erupt. This improves the deep
bite seen in Class II cases.
. Bionator: similar to the activator in function but its design is a himmed-down version ofthe
activator to make it more comfortable to wear
. Herbst appliance: it can be fixed or partially removable. A metal rod and a tube-telescopic
apparatus is attached bilaterally to the maxillary first molars and mandibular first premolars.
This helps to posture the mandible forward and induce growth. Jasper modified the appliance
by replacing the telscopic apparahrs with a flexible plastic open coil spring.
. Twin block appliance: the two-piece acrylic appliance postures the mandible forward with
help ofocclusally inclined guiding planes and bite blocks. The vertical separation ofthejaws
is also configured by the height ofthe bite blocks. It postures the mandible forward to induce
lI malocclusions.
Note the small acrylic button thatwill restagainst the palatal tissue with thc Nanceappliance. Some clinicians object
to the button since it can create tissue irritation. Thc Nance applianc is used in situations where premature biltt-
Other appliances:
. Lower lingual arch: may be fixed or rernovable and is effective in maintaining mandibular leeway space while
still allowing horizontal and vertical growlh changes jn thc positions ofmolars and incisors.
. Lip bumper: is a removablc appliancc uscd in growing children to create and save thc space necessary to accommodate the adult teeth without extraction. The lip bumper hamesscs thc nahrml forces ofthe muscles surrounding thc lowcr teeth to broaden and lenglhen thc dcntal arch. By keeping lhe lip pressurc away fiom thc lowc.
front teeth, the longuc prcssuro is allowed to gradually move the ftont teeth forward to "unravel" or align the
crooked teeth- The constant prcssure ofthc lower lip against the front pad of the lip bumpcr exerts a force to gently push thc molar leeth backward. The lip bumpcr will gradually "strctch" thc dental arch to makc room for thc
crupting adult tccth.
. Anchorage
. Traction
. Both anchorage and traction
. Neither anchorage or traction
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Coplrighr O 201l-2012 - DenlalDecl6
. Lingual archwires
. Whip-spring appliances
. Palate-separating devices
. Frankel's appliances
. Edgewise mechanisms
. Light-wire appliances
Coplright O
201 1-201 2
- Denral Decfts
*** Anchorage
space.
Headgear is used to modiry growah ofthe maxtlla, to dislalize (retracl, or protract maxillary teeth, or to rein-
force anchorage.
Headgear is an orthopedic appliance that allows orthodontists to:
Optim!l
usage of headgear:
. wom rcgularly lor 10-12 hours per day, minimum is 8 hours per day
llagnitude oI Force:
\ote: One ofthe greatest advantages ofusing extraoral anchomge fl.e., headgear) is that it permits posterior
mo\ement ofteetb in one arch without adversely disturbing the opposile arch.
***
Fixed orthodontic appliances offer controlled tooth movement in all 3 planes ofspace. Examples i[clude: lingual archwire, fixed space maintainen, palate-separuting devices, the edgewise
mechanism, light-wire appliances as well as other fixed appliances (i.e., tv'int'ire appliance,
writersaI appliance).
amples include;
l. Active appliances
. Extra-oral traction devices: head gears, face masks, chin cups
. Lip bumpers
. Active plates: Schwartz appliance, antedor spring aligners
. Vacuum formed appliances
2. Passive appliances
stainless steel
. Beta titanium
. Nickel-titanium
. Vitalium
6
coplright
20ll-2012,
Denlal Decks
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Copright O20ll-2012
- Dental
Dck
The proprties ofan ideal wire material for orthodontic purposes can be described largely in terms ofthe following criteria. It should possess: (1) High strenglh (2) Low stifliess (3) High working range and (4) High
formability
In addition, the material should be weldable or solderatrle, so that hooks or stops can be attached to the wire.
Loops and helices are incorporated into archwires to increas the activation range.
St.inless steel wires are very popular because oftheir good mechanical properties, excellent corrosion resistance, and low cost. Tle ry?ical formulation for orthodontic use has l8% chromium and 8% nickel.
Note: Stainless steel exhibits the highest modulus ofelasticiry frltlresr/ and lowest springback.
Nickel-titanium alloys offer a highly desirable combination of a very low modulus ofelasticity and an extremely wide working range.
Beta titanium wires are also known as TMA (tilanium-molybdenum d//o', wires. They offer a highly desirable combination ofstrength and springiness (i-e., excellent resilience) and reasonably Sood formabiliry
by a
Note: Each of the major elastic properties (i.e., strength, stillness/springiness, and range) is
^ffected
change in the lenglh and cross section ofa wire. Doubling the length of a wire decrease its strength by half,
makes it I times less stiff, and gives it 4 times the range. Similarly, when lhe diameter of a wire is doubled,
its strength is increased by 8 times, its stifiness by 16 timcs, and its working range is decreased by half.
Rmember: Strength: Stiffness x Range
\r]
. Effects on the pulp: light forces should have little ifany effect on
To overcome the dcficiencies ofthe bbon arch (trhich was an eotlier Angle appliance) Angle reoriented the
slot from vertical to hoizontal and inserted a rectangularwire rotated 90 degres to the orientation it had with
the ribbon arch, thus the name "edgewise." The dimensions ofthe slot were altered to 0.022 x 0.028' and a
0.022 x 0.028 precious metalwire was used. These dimensions allowed excellent control of cro"{'n and root
position in all three plans ofspace.
The contemporary edgewise appliance has evolved far from the original design while retaining th basic principle of a rcctangular wire in a rectangular slot. Major steps in the evolution of cdgewise appliances include:
. Automatic rotNtional controli this is accomplished either by using twin brackets on the labial surface,
or single brackets with extension wings that contact the arch wire to conffol and correct rotations.
. Horizontal control: this is accomplished by varying the relative thickness ofth bracketbase for teeth of
differenr thickness. Note: In the original edgewise appliance this was accomplishedby applying first-order
bends ,liliolitgual bcnd! in the arch wire.
. ltlesiodistal tip control: is accomplished by angulating th bracket or bracket slot to provide the proper
tipping movement lor each tooth. Note: In the original edgewise appliance this was accomplished by apthe arch wire.
. Torque: is accomplished by having the bracket slots inclined to compensate fbr the inclination ofthe facial surface..\-ote: [n the original edgewise appliance this was accomplished by applying third-order bends
\Nie.
(r'aning btist in segments ofeach rcctangular arch rire) in the
^rah
Brackets are the attachments through which forces are appliedto the teeth and they allow the placement
of arch* ire and other accessodes to b ng about the desircd tooth movement. The brackets most commonly used are the Edgewise brackets - single and double edgewise- and the Begg brackets. Edgewise
b.ackets have an archwire channel which is rectangular in cross-section, with the largest dimension horizontally. These brackets can also be usd with round cross-section archwires. The slot sizes commonly
used are 0.022 inch 10.JJ md) and 0.018 inch (0.45 hm).Thebftcket has tie-wings on opposite sides of
the archwire slot for engaging a ligature that is used to bind the archwire to the bracket.
Thc Begg bracket has a narrow slot whre an archwire is looscly fitted and held in place with a locking pin.
Unlike the Edgewise brackets, these Begg brackets can only be used with round cross_seclion archwires.
i',Fon
For infomarion.
.onhd
licens@-uqash
. Both the statement and the reason are correct but NOT related
. The statement is corlect, but the reason is NOT
. Extrusion
.Intrusion
. Translation
Cop)riShr@
20ll 2012
Dental Decks
*** Multiple
appliances can use the palate for anchorage. The true reason that the Hawley retainer is the most common is because ofthe varietv ofbenefits it has and can have when used
properly.
The palatal coverage ofa removable plate like a Hawley retainer makes it possible to incorporate a bite plane lingual to the upper incisors to control the bite depth. This design considention is important for ary patient who once had an excessive overbite. This palatal coverage
(agylic) is the major source of anchorage in th Hawley appliance,
A Hawley retainer can be made for the upper or lower arch. The lower retainer is somewhat
fragile and may be difficult to insert because ofundercuts in the premolar region. Note: Apatient may have difficulty pronouncing linguoalveolar consonants for a few days after receiving a maxillary Hawley appliance until the tongue adapts to the palatal covemge.
llajor
l. Retentiv component: retains the appliance in function: consist olvarious clasps. The
best example is Adam's crib.
2. A framework or baseplate: usually acrylic. This provides anchorage.
3. Tooth-moving elements: typically either springs or screws.
'1. Anchorag component: resists force ofactive components (e.g., Acrylic base-plate).
5. -{ctive components or tooth moving components: springs, screws or elastics.
lndications for removable appliances:
. Retention after comprehensive treatment
. Limited tipping movements
. Gronth modification during the mixed dentition
\ote:
bing
The best method for tipping maxillary and mandibular anterior teeth is with linger springs. These fingcr springs are attached to a removable appliance. Tte most common problems associated with these
simple removable appliances are lack ofpatient cooperation, poor design leading to lack ofretention, and
improper activation. An undesimble common side effect ofa finger spring is the tendency for the root
apex to move in the direction opposite from the crcwn.
Z-springs can also be used but they deliver excessively heary forces and lack rang ofmotion.
Important: Ma,\illary incisor rotation is not commonly treated during the stage of mixed dentition. It
is best teated after all permanent teeth have efl)pted (earll permanent dentition). This is usually accomplished with a simple removable appliance. Howevet ifthe incisor is in crossbite, it should be corrected as soon as possible (while il is erupling).
r' - , -,
Lwhen using buccal coil springs to try and regain space by pushing
,.:Note{ii tally, be careful because what commonly occurs is rotation of that tooth instead of actual
i;,r::,,,,,':: movement.
*tt
2. Th" fo."" generated in the spring is directly proportional to the distance (d) that an orthodontic spring is deflected and the radius (r) ofthe wire. It is inversely propo(ional to the
length ofthe spring.
Importanti Pe.iodontal disease dudng orthodontic therapy is preventable and is controllable and in
conrinuous studies affer orthodontic therapy has been completed, it has bcen shown that under the properly controlled regimen oftreatment the destruction to the periodontal tissues ofthe teeth is not accentuated to a statistically significant degree as greatr than that which occurs during the same intedm
\r'ithout orthodontic therapy. Note: When a patrent (young or old) )s in active orthodontic heatment and
the gingiva is inflamed. the dentist should encourage better oral hygiene. It may be useful to recommend
the use ofwater irrigation devices to help flush food debris away from the brackets.
ORTHODONTICS
10
Copyflghr C
ORTHODONTICS
ol $hsh
a simple appliance
maxillary expander
11
***
When placing bands, eitherglass ionomerorzinc phosphate cements are used and do not require etching.
The tooth surface must not be contaminated with saliva, which promotes immediate remineralization, until
bonding is completed; otherwise re-etching is required. Topicalfluoride should not be used before etching because fluoride decreases the solubility ofenamel. Remember: After etching, the tooth surface should have a
frosted appearance. Note: 37% phosphoric acid is the most commonly used etching agcnt.
lndications for using bands instead ofbonded brackets:
. To provide better anchorage for greaier tooth movement
. For teeth that will need both lingual and labial attachment
. Teeth with short clinical crowns
f/
Ideally, this anterior crossbite should be corrected before it reached the occlusal plane (vhile il !'as
erupting). The rnost probable etiologic factor for this happening is prolonged retention ofthe primary
maxillary incisors.
Cross-elastics from the maxillary lingual to the mandibular labial can be used to conect a single-tooth
crossbite. A maxillary removable appliance can also be used. When elastics are used to move teeth they
should be attached directly to the appliance components.
-{nterior crossbite, particularly crossbite of the incisors' is mrely found in children rvho do not have a
skeletal Class IIIjaw relationship. A crossbite relationship ofone or two anterior teeth, however, may
derelop in a child who has good facial proportions. The maxillary lateral incisors tend to erupt to the linglal and may become trapped in that location, especially in the presence ofscvere crowding. In this situarion. extmcting the adjacent primary canines usually leads to spontaneous corection ofthe crossbite.
Ir is important to evaluate the space situation before attempting to correct any antedor crossbite. If enough
space is available to accomplish the movement, a maxillary removable appliance is usually the best
mechanism to concct a simple anterior crossbite that requires a tipping movement.
Remember: Anterior crossbite in a primary dentition usually indicates a skelet.l growth problem.
Note: The permanent antcrior tooth that is most often atypical in size is the maxillary lateral incisor
Elastics are available as rubber bands, elastic thread, and formed shapes for specific purposes. They are
used to move teeth, to ligate archwires to brackets, for intermaxillary traction, and for separation. Elastics are aiways attached to bmckets and archwires, never around a naked tooth.
. Cl.ss I elastics (intramdxillary)r nsed for traction between tceth and groups of teeth within the
same arch.
. Class II elastics (in termaxillary\: :js]'J,ally are wom from a tooth in the anterior part of the ma,{illa
(i.e., the petlnd ent canine) to a looth located in the posterior part ofthe mandible fi.e.,jirst perma'
nent molar).Usedto correct Class II malocclusion.
. Class III elastics (irtemaxillary)r usually are wom from a tooth in the posterior part ofthe maxilla (i.e., the pennanentjirst molar) to a tooth located in the anterior part ofthe mandlble (i.e., permanent canine).Vsed to improve the overjet in an edge-to-edge or ante.ior crossbite situation.
. Crossbite elastics: are wom from the lingual ofonc or more maxillary teeth to the buccal ofone or
more teeth in the mandible to helD correct crossbites.
12
Cop!.righr O 201 l-2012 - Dental Decks
. Straight-pull
headgear
. Reverse-pull
headgear
. Cervical-pull
headgear
. High-pull headgear
13
CopFight O20ll-2012 - Dental Deck
Orthodontic forces can be treated mathematically as vectors. When mor than one force is applied to a tooth,
the forces can be combined !o determine a single overall resultant. Forces can also be divided into components
in order to determine effects parallel and perpendicular to the occlusal plane, Franlfort horizontal, or the long
axis ofthe tooth. Forces produce eithr translation (bodib movement), rotation, or a combination oftranslation and rotation, depending upon the relationship ofthe line ofaction of the force to the center of resistance
oftbe tooth. The tendency to rotat is due to the moment ofthe force, which is equal to force magnitude multipliedby the perpendicular distance offhe lin ofaction to the center ofresistance. The only force system lhat
can produce pure rctation (a mome t *-ith no netforce) is a cottple, which is two equal and opposite, noncoflinear but paralfel forces. The movement of a tooth (or a set of teet ) can be described through the use ofa
center ofrotation. The mtio between the net moment and net force on a toolh (M/F ratio) \nith reference to the
center ofresistance determines the center ofrotation. Since most forces are applied at the bracket, it is necessary to compute equivalent forc systems at the center ofresistance in o.der to predict tooth movment. A
graph ofthe M/F ratio plotted againsi lhe cnter of rotation illusirates the precision rcquired for controlled
tooth movement.
. Forc:
is a load applicd to an object that will tend to move it to a different position in spac- A force has
magnitude, point ofapplication, and direction. Therefore, forces are rpresented and treated mathemati-
cally as vectors.
. Cnter ofresistance: a point at which aesistance to movement can be concentmted for mathematic analysis. In single-rooted teeth, the center ofresistance is on the long axis ofthe tooth one-third to one-halfthe
'!\ ay ftom the alveolai crest to the apex. [n multirooted teeth it isjust apically to the furcation. Note: A force
rhrough the center ofrsistance causes all points ofthe tooth to move the same amount in the same direcdon. Tlris RDe ofmovement is called translation or bodily movement.
. Rotation: occurs when a force is applied away from the center ofresistatce. Thc potential for rotalion is
rermed a moment. Note: A force, applied by a bmcket that does not act through the center ofresistance,
causes rotation ofa tooth. This tendency to rotate is measured in moments and is calledthe momentofthe
force.
. C ou ple: is rwo equal and oppos ite, noncol inear but paral lel forces. Thc result of applying two forces in
lhis \r'ay produces pure rotation without translation, Note: Couples are usually applied by engaging awire
in an edgewise bracket slot.
Cervical-pull headgear consists of a cervical oeck strap (as ahchorage.) and a standard facebow inserting into the headgear tubes of the maxillary first molar aftachments The objeotives of treatment
with these types ofheadgear are to rcstrict anterior growth ofthe maxilla and to distalize and erupt maxillary molars. A major disadvantage of treatment using cervical headgear is possible extrusion of the
maxillary molars. Likely results include: opening the bite, first molars will move distally and forward
growth ofthe maxilla will decrease. Indications: Class II malocclusions with deep bite
High-pull headgear consists ofa high-pull headstrap and a standard facebow inserting into the headgear
ofthc maxillary fi.st molar attachments. The objectives oftreatment with these typcs ofheadgear
ar restriction ofanterior and downward maxillary gowth and/or molar distalization and control ofmaxillary molar eruption.These types ofheadgear have a more direct effect on the anterior segmcnt ofthe
tubes
II malocclusions. with
Straight-pull headgear is similar to the cervical-pull headgear. Howevet this appliance places
a force
in a straight distal direction from the maxillary molar Like cervical-pull headgear, the indications are
Class II, Division I malocclusions (wlen bite ope i g is undesirable).
Reverse-pull headgearunlike all ofthe otherheadgears above, has an extraoral component that is supported by the chin, cheeks, forehead or a combination ofthese structures. [t consists of two pads that rest
on the soft tissue ofthese structurcs. These pads are connected to a midline framework and are adjustable.
Side effects include downward and backward rotation of the mandible. Indications: Class lll maloccllJsions (\rhere protraction ofthe maxilla is desirable).
Chin ctp (chin capl ar devices to utilize cxtra-oral traction to restrain or alter mandibular growth. Indications: Class II maloccltJsions (due to excessive mandibular powth).
a functional
shift
14
coplright
15
coplright O
Posterior crossbite:
is
It is important to correct poste or crossbites (which are related to lhe t|ansverse plane ofrpdcel and mild
anterior crossbites in the first stage oftreatment, even ifthe permanent first molars have not yet cruptod. Severe anterior crossbites, in contrast, are usually not corrected until the second stage ofconventional treatment,
Important: The most common rype ofactive toolh movement in the primary dentition is to correct a poste.
. Quad-hefix, W-arch:
these consist ofhealy stainless steel wire with fonr (quad-helix) or three (ty arch)
hcljces rhat are incorporated to increase the range and flexibility. Tlley can be usd to corect unilateral or
bilareral crossbites and for corecting rotated molars.
. Transpalatal arch AP,4): is a thin wire that goes across the roofofthe mouth from first molar to first
molar. TPA is used to maintain expansion in the molars. An omega loop is tlpically included making the appliance useful in rotating and widening the molars.
as
smoolh clo-
Prolonged sucking habits often produce a mildly narrow maxillary arch and a tendency toward bitateral crossbite. Children with this condition usually shift the mandible
to one side on closure to gain better function, which can guide permanent molars, or later,
premolars into a crossbite relationship.
A young child who has a tendency toward a Class III malocclusion will have end-to-end
contact ofthe primary incisors. A true anterior crossbite in the primary dentition is quite
rare because mandibular growth lags behind maxillary growth. The primary incisors wear
down rapidly, and an anterior shift ofthe mandible to escape occlusal interferences rarely
occurs until the permanent incisors begin to erupt. A pattem of anterior displacement of
the mandible may develop when the permanent incisors come into contact, however' producing an anterior crossbite ftom the shift.
. Both
't6
Coptrighr O 20ll-2012 'Denial Decks
Class
II malocclusion
17
Cop)'righr O 201l-2012 - Dental Decks
. Both the statement and the reason are correct and related
. Both
the statement and the reason are correct but NOT related
. The statement
18
Cop)'right O 20ll-2012 - Dntal
. Prognathic; retrognathic;
. Retrognathic; prognathic;
Class
Deks
II
Class
III
. Prognathic; prognathic;
Class
II
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coplrighr o 20ll-2012 - Dental Dcks
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Coplyighr O 201 I '2012 - Dental Deckj
21
The facial profile analysis delineates the same information as that obtained through
lateral cephalometric radiographs. The difference lies in the detail obtained through the
latter method, however, the former is considered a vital diagnostic technique for primary
evaluation. It is a quick and simple (also cheap) technique which readily gives the
following information:
1. Anteroposterior position/proportion ofthejaws relative to each other
2. Lip posture (competent/incompetant) and incisor prominence
3. Vertical facial proportions
4. Inclination ofthe mandibular plane angle
Note: Within the lower third of anterior face height the mouth should be about one-third
ofthe way between the nose and the chin.
Important: The most stable area from which to evaluate craniofacial growth is the an-
The mandibular plane angle can be visualized clinically by placing a mirror handle or
other instrument along the border ofthe mandible.
Important: A flat mandibular plane angle correlates with short anterior facial vertical dimensions (height) and anterior deep bite malocclusion.
The angle between the mandibular plane (Go-Me line) and the maxillary plane
flN,t-PNS
line) rs called the maxillary-mandibular plane angle (MMPA).lts normal value is:
27'(+/- 4"). The greater value indicates a longer anterior face height.
There is also an interaction between face height and the anteroposterior position of the
mandible; all other things being equal, a long face predisposes the patient to Class II
malocclusion. a short face to Class III malocclusion.
. Adjustment in kilovoltage
. Adjustment in milliamperage
. A soft tissue shield
. A hard tissue shield
22
coplright (] 201I ?012 Doral Deck
n--J
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CoDright O 201l-2012 - Denbl Decks
The lateral head radiograph (cephalometric x-ray) must be compared with the "normal" lateral radiographs form an accepted norm. Linear and angular measurements are
obtained utilizing known anatomical landmarks in the lateral head radiography ofthe patient. These measurements are then compared with those considered within normal limits and in that way enable the orthodontist to assess aberration in the dentition and jaw
structures, which result in malocclusion.
Aaalysis ofcephalometric radiographs is not limited to the hard structures such as bone
and teeth, but also includes measurements of soft tissue structures such as the nose, lips
and soft tissue chin.
Superimposition in longitudinal cephalometric studies is generally on a reference plane
and a registration point. This will best demonstrate the groMh ofstructures furthest from
the plane and the point. The most stable area from which to evaluate craniofacial growth
is the anterior cranial base because ofits early cessation ofgrowth.
Cephalometrics is useful in assessing tooth-to-tooth, bone-to-bone and tooth-to-bone
relationships. Serial cephalometric films can show the amount and direction of gro{th.
),Iote: A lateral cephalograph usually shows magnification with up to 7-8olo magnification
considered acceptable. The resuldng double shadows are traced and the average is used
for measurements.
Cephalometric studies show that, on the average:
. The maxilla, during growth, is translated in a downward and forward direction
. llandibular growth stops after maxillary gowth
***
l. Bolton (Bo): highest point in the upward curvature of the retrocondylar fossa ofthe occipital bone.
2.Basion (Ba):,lowest point on the anterior margin olthe foramen magnum, at the base of
the clivus.
3. Articulare (,4r): the intersection of three radiographic shadows, the inferior surface of
the cranial base and the posterior surfaces ofthe necks ofthe condyles of the mandible.
4. Porion (Po): midpoint ofthe upper contour ofths metal ear rod ofthe cephalometer.
5. Spheno-occipital synchondrosis (SO): junction between the occipital and basisphenoid
bones.
6. Sella /S): midpoint of the cavity ofsella turcica.
7. Pterygomaxillary fissure (Przr): point at base of fissure where anterior and posterior
walls meet.
8. Orbitale for: lowest point on the inferior margin ofthe orbit.
9. Anterior nasal spine (lNS): tip ofthe anterior nasal spine.
10. Point A fsabsprrale/: innermost point on contour ofpremaxilla between anterior nasal
spine and incisor tooth.
Il.PointB (Suplamentqle)| ifi.rmost point on contour ofmandible between incisor tooth
and bony chin.
12. Pogonion fPog): most anterior point ofthe contour ofthe chin.
13. Menton (Me): most inferior point on the mandibular symphysis, the bottom ofthe chin.
Gonion (Go): lowest most posterior point on the mandible with the teeth in occlusion.
Nasion fNa): anterior point of the inte$ection between the nasal and frontal bones.
Important: The most stabl point in a growing skull from a cephalometric standpoint is
slla turcica, the center ofthe pituitary fossa in the cranial base.
14.
15.
. A wrist-hand radiogaph
. Height-weight tables
. Presence ofsecondary sex characteristics
21
Coprighr O
201
l'2012'
Denral Decks
Uuv.nity of wrd,i.sron Allrisbt r6ded Acc.s b theArlis of Pediadc Dcnhsry $ govemed by a hceGe
Un.ulhonrcd.ccs or rcprcdud,m is fd.f iddcn wInoui rhe pno. \riftcn pmission ofrhe UnikBity of w$hngion. Ior inromatoo. con
dd: l'.65.!9u.sa\hington edu
Coptrisht 2000.2004
25
Cop}{ight O 20ll-2012 'Denlal Decks
6d.d Aas
2004
lo lh Ad,s of Pedi.tic
The physiologic age or developmental age can be judged by finding out the skeletal development. The wrist-hand radiograph offers the best aid for this purpose. By looking at the ossification and development ofthe carpal bones ofthe wrist, the metacarpals ofthe hands and
the phalanges ofthe finge$ the orthodontist can have an idea about the cbronology ofskeletal development. Comparing the overall pattem observed in the hand-wrist radiograph, with
age standards in a reference atlas, does this. Important: Dental age refers to the state of dental maturation.
Remembr: The ulnar sesamoid or hamate bones are considered as landmarks to obtain an
estimate ofthe timing ofthe adolescent growth spurl Wrist-hand radiographs in the dental
office can be obtained by using a standard cephalometric cassette and dental x-ray.
The state ofphysical maturity or skeletal development co-relates well with the jaw groMh.
fthodontists use this information to predict how much jaw growth can be expected.
Note: After sexual maturity much less growth is expected and therefore growth modification
is not attempted.
Remember: Hand-wrist radiographs are less useful in evaluating whether growth has stopped
A midline supemumerury tooth (mesioderu) in the mandibular arch is shown. Mesiodens usually
occur in the maxillary arch. However, you will see them occasionally in the lower arah. Note the
crowding of the mandibular permanent incisors. Extraction of the msiodens is the heatment of
choice. Important For the best therapeutic result, orthodontic treatment to close the space may be
necessary.
CotFghr 2a0G20Ol UnileGiry of Wahinsron. all risht lt3d.d As b $. Arla orPrdi.ttc Ddristry
ii sovo.d by r licre. U.rutfnizcd aacs or rep'tdcrioD is foi'iddf, wil])out iE prtd qino pmisid
ofd. Univm'ty of wGhinclon, Fd infom.rio, co.ilct li.6g@uv8ri4rd.cd!
. Primary canines
. Band
2
. Complete crown preparation and fabrication
. Complete crown lenglhening procedure
Separate
. Upright
1
3
27
Cop)'.aghr O 201 | '2012
Serial extraction is the orderly removal of selected primary and permanent teeth in a predetermined sequence. It is indicated primarily in severe Class I malocclusion in the
mixed dentition that has insullicint arch length. This procedure primarily benefits children who demonstrate an arch-length discrepancy.
Stages in serial extraction: The primary canines are the first to be removed, followed by
the primary first molars, and then the permanent flrst premolars (usually). Six to fifteen
months is the interval between extractions. To aid in support and retention during this
time, a lingual arch should be used in the mandible and a Hawley appliance in the
maxilla. This is usually followed by full orthodontic treatment. Note: The key to success
is extraction ofthe first premolars before the permanent canines erupt.
In serial extraction procedures, concems about eruption sequence are usually related to
the eruption pattern of the permanent rnandibular canines and first premolars.
Note: After extraction ofthe maxillary first premolar in a serial extraction procedure, the
maxillary canines path of eruption will usually be downward and backward.
Remember: Severe arch space deficiency in the prmanent dentitton (over l0 mm)
almost always require extractions to properly align teeth.
will
A common dental condition that can benefit from orlhodontic treatment prior to prosthetic
treatment is the long-term loss ofa rnandibular permanent lirst molar. The loss ofthe
first molar results in tipping, migration and rotation of the adjacent teeth into the edentulous space. Note: The best way to upright a second molar that had drifted mesially is by tipping its crown distally and opening up space for a pontic to replace the missing first molar,
rather than attempting to move the second molar mesially to close the space.
Important: A high mandibular plane angle is one ofthe most significant complications of
molar uprighting, because if the molar is uprighted unsuccessfully, it can lead to an increased open bite and loss ofanterior guidance.
A normal angulation ofa molar is desirable since it:
. Improves the direction and distribution of occlusal forces
. Decreases the amount oftooth reduction required for parallelism ofthe abutrnents
. Decreases the possibility of endodontic, periodontic or more complex prosthodontic
procedures
20
Cop)'righr @ 201 I '2012 - Dental Decks
. Tipping
. Translation
. Pulling
. Extrusion
. Intrusion
. Torque
. Rotation
29
Coplright O 201l-2012 - Dental Dck
l. Ifa permanent first molar is extracted on a child tlefore the eruption ofthe
permanent second molar, the best approach is to allow the eruption of the
second molar and the mesial drifting to occur naturally. This
2. A
Very important:
N.fr.d
Acccs to
rhc
Arld
rctoducrion is
fodiddcn $nhout !h. tnor rrittm psmkion or rh. Univdi.y orqlshirglon For in
fomation, conhd liccns(4u Kshine1on.edu
ofPcd$tic D.n.s!a
is
goremed by
The optimal force levels for orthodontic tooth movement should bejust high enough to partially but not completely occlude blood vessels in the periodontal ligament. Both the amount of force delivered to a tooth and
also the area ofthe periodontal ligament overwhich that force is distributed are important. The PDL response
is determined not by force alone, but by force petunit area, or pressure.
Thc periodontal lig|ment is a well-organized connective fibrous tissue andremodels significantly during orthodontic movement. Under normal physiologic conditions, the PDL is rich in collagen fibers organized to resist the forces ofmastication.
Important: On th side toward which the tooth is being moved, youwill find "osteoclastic activity" that result in bone rasorption. This is called the pressure ot compression side. on the side ofthe root from which
the tooth moves, you will find "osteoblastic activity" that rcsults id bone apposition. This is called the tension side.
Types
due
to rotation or pivoting ofthe tooth around the axis ofresistance or axis of rotalion (localed somewhere in
the apical o e-thitd of the root). This $eates two areas of compression and tension. Most readily accomplished with a removable appliance. Accomplishd most easily with Nnterior incisor teeth.
2.'Ir^nslsJtioln (bodily movement): a force lhrough the center ofresistance causes all points ofthe tooth to
move the same amount in the same directioD. This Bpe ofmovemcnt is called translrtion orttodily movement. This creates one area ofcompression aad one arca of tension. Very difficult to accomplish.
3. Ertrusiotr: displacement ofthe tooth from the socket in the direction oferuption.
4. Intrusion; movement into the socket along the long axis ofthe tooth. Very dillicult to accomplish.
5. Torque: controlled root movement labiolingually or mesiodistally while the crown is held relatively
stable (mesial-distal root movenlent is also termed "uprightingr.
6. RotAtion: the only force system that can prcduce pure rot.tion fd moment with no netJbrce) is aotr^
ple, which is two equal and opposite, noncolinear but parallel forces. Recuning tooth rotations after orthodontic cofiection occur because ofthe persistence of the elastic supracrestal gingival fibers (mainly free
gingival and transseptal.fbels). Importsnt: Need adequrte retention to prevent rclapse.
ofthe crou'n caused by the force. The center ofthe rctation is at the root apex.
Root movement occurs when a forc is applied at the bracket and an even larger couple is applied to more than
negate the tipping of the crown caused by the force. The center of rotation is at the crown of the tooth.
. Both
30
CoplriSht O
20ll
2012
' De.talDecks
31
12
- Denral Decks
One of the most importart aspects of orthodontic therapy is retention. After malposed
teeth have been moved into the desired position, they must be mechanically supported
until the hard and soft tissues have been thoroughly modified
in structure and in
function
meet the demands of the new position. Once the -both
desired occlusal results are
achieved and the hard tissues are in normal function, the next step is to maintain or to
modify the soft tissues in the retention phase. Important: Most clinicians believe that
the collagen fibers in the supra-alveolar tissue are signifrcantly responsible for the relapse oforthodontically rotated teeth as well as the redevelopment ofspaces between orthodontically moved teeth.
-to
Remember: Collagen fibers are the primary components ofthe attached gingiva. When
teeth are orthodontically moved, the fibers stretch like rubber bands to adjust to the new
position. However, like rubber bands, they have a strong tendency to retum to their
former position, pulling teeth with them as they go.
The circumferential supracrestal fibrotomy is a minor surgical procedure. A simple
incision in the sulcus is made to the crest of the bone. This incises all of the collagen
fibers that are inserted into the root ofthe tooth. By cutting the collagen fibers, two things
are accomplished:
1. Eliminate the polential for relapse due to collagen fiber retraction.
2. Allow new fibers to form that will help retain the tooth in its new position.
\ote:
a rotated
Maintainins the treatment result followins orthodontic treatment is one of the most
difficult aspects ofthe entire treatment process. Retention is necessary in orthodontics for
the following reasons:
l. The gingival and periodontal tissues are affected by orthodontic tooth movement
and require time for reorganization when the appliances are removed.
2. Changes produced by growth may alter the orthodontic treatment result.
3. The teeth may be in an inherently unstable position after the treatment, so that the
soft tissue pressures constantly produce a tendency for relapse.
In the last situation, gradual withdrawal ofan orthodontic appliance is ofno value. The
only possibilities are accepting relapse or using permanent retention. Fortunately, only
the first two reasons apply to most orthodontic patients, and maintaining the position of
the teeth until remodeling ofthe supporting tissues is completed and growth has essentially
ceased allows a stable orthodontic result without further retention.
Note: Retention is accomplished with either fixed or removable retainers.
Remember:
. The corection ofan anterior crossbite is easily retained after orthodontic correction
by the overbite achieved during treatment.
. Supracrestal fibers are commonly associated with relapse following orthodontic rotation ofteeth.
. Both endochondral
with
32
Coplright O 20ll-2012, Dental Decks
In the cranial vault, the growth process is entirely the resuit ofpriosteal activity at the surfaces ofthe
bones. Remodeling and growth occur primarily at the pcriosteumlincd contact areas between skull
bones, the skeletal sutures, but periosteal activity also changes both the inner and outer Jurfaces ofthese
plateJike bones. Although the majority ofgrowth in the cranial vault occu^ at the sutures, thcre is a
tendency for bone to be removed from the inner surface ofthe cranial vault, while at the same time
new bone is added on the exterior surface.
In contrast to the cranial vault, the bones (i.e., elhmoid, sphenoid, ond occipitdl rores/ ofthe cranial
b.se are formed initially in cartilage and are later transformed by endochondral ossi{ication to bone.
As ossification proccds, bands ofcartilage called synchondroses remain between the centcrs ofossification. These important growth sites are the synchondrosis between the sphenoid and occipital bones,
or spheno-occipital slnchondrosis, the intersphenoid synchondrosis, between the two parts ofthe sphenoid bone, and the sphenoethmoidal synchondrosis, between the sphenoid and ethmoid bones- Eventually, these synchondroses bccome inactive. Note: The bones ofthe cranial base are not affected to a
great degree by growth ofthe brain (siace lhey are endochondral bones).
,'-....,
,t!{ote{t
1. After age 6, the greatest increase in size ofthe mandiblc occurs distal to the lirst molars,
2.The condyle ofthe mandible grows by proliferation of cartilage.
3. The chief factor in thc formation ofthe alveolar process is the eruption of teeth'
,1. Arch lengrh space for the eruption of pemanent mandibular second and third molars is created by resorption at the anterior border ofthe ramus.
5. At birth the greatest dimension ofthe face is width.
6. After a tooth has bcen moved from one position to another, thc resulting bone is transitional bone.
7. The dependencc oftooth development and tooth eruption upon growth ofbone and bones
is considerable.
8. Grow1h ofthe cranial base generally precedes growth ofthejaws.
ofg|orlr,
***
:. Endochondral ossification
\otcs
.-.,,.._,
L The growth ofthe cranial vault occurs almost entirely in response to growth ofthe
brain. Remember: The bones ofthc cranial base are not affccted to a great degree by
growth ofthebruilr' lsince thqt are endochondral bones).
2. Growth ofthe cnnial base is primarily the result ofendochondral growth and bony
rcplacment at the synchondroses, which have independent growth potential.
3. The greatest period ofcranial growth occurs between birth and 5 years ofagc.
4. ln fetal life , at about the third month, the head takes up almost 50% ofthe total body
length. At birth, the head is 30% ofthe body. In the adult, the head represnts about
ofthese changes, which are part ofthe normal growth
l2% ofthe total body lenglh
-all gradient of gro\ryth."
pattem, retlect the "cephalocaudal
5. In determining a patient's skeletal growth pattem, the most important factor is hereditv.
6. Remodcling ofbone occu.s on both endosteal and periosteal surlbces.
7. Remodeling ofbone rcsults in the histologic structurcs called osteo[s.
8. Deposition and resorption may not occur in cqual amounts.
. Apposition
. Sutural expansion
. Interstitial growth
. Endosteal remodeling
31
Coplrishr O 20ll-2012 - Dnbl Decks
. The statement
Coplright
in two ways:
l. Appositional by the recruitment of ftesh cells, chondrcblasts, from perichon&al stem cells and the addition ofnew matrix to the surface.
Note: The perichondrium consists ofa fibrous outer layer and chondroblastic inner layer
2. Interstitial by the mitotic division of, and deposition ofmore matrix around, chondrocytes already established in lhe cartilage. Examples ofsites that gow by interslitial growth include the mandibular condyle,
nasal septum and spheno-occipital synchondrosis.
Notei The "V" principle ofgrowth is illustrated by the maDdibular condyle.
Importanti Cartilagc tissue is pressure tolerant and able to providc flexible suppon bcause it
and contains an intacellular matrix ofproteoglycans.
is
avascular
Growth of bone:
.Appositionat below the covering periosieal layerofbone- Periosteum consists ofa fibrcus outr layerand
a cellular inner layer ofosteoblasts, which Iay down bone. Bccause ofits rigid structure, interstitial growth
is not possible.
Do not confus bone growth with bone formrtion. Bone foms by cither endochondral ossification or intmmembranous ossifi cation,
***
It is a truism that grollth is strongly influenced by gcnetic factors, but it can also be significantly allectcd by
the environment, in the form ofnutritional status, degee ofphysical activity. health or illness, and a number
of similar factors. Thre major theories havc atlcmpted to explain the determinants ofcraniofacial growth:
l. Bone, likc othcr tissues, is the primary determinant ofits own growth2. Cartilagc is the primary determinanr ofskeletal growrh, while bone responds secondarily and passively
J. The soft lissue matrix in which the skeletal elemnts are embedded is the primary determinant of grow1h,
and both bone and cartilage are secondary followers. Note: This theory is kno\Mr as the functional matrix
theory.
T}e major difference in the theories is the location at which genetic control is expressed. The first theory implics rhar gcnetic control is expressed directly at the level ofthe bone, and therefore its locus should be the periosteum. The second theoryor cartilage theory suggests that genetic control is expressed in the cartilagc, whilc
bone responds passively to being displaced. This indirect control is called epignetic' The third theory assumes gcnetic control is mediated to a large extent outside the skeletal system and occurs only in response to
srsnal from other tissues.
The bone ofthe alveolar prccess exists only to support the teeth. Ifa tooth fails to erupt, alveolar bone never
forms irl that area; and ifa tooth is extracted, the alveolus resorbs after the extmction until finally the alveolar
ridge completely atrophies.
The space betwen the jaws into wbich the teeth erupt is gene.ally considered to be provided by growth at
th mandibular condyles (especially the moldlt. The condyle is a major site of vertical growth in the
mandible. Many arguments have been made about the condyles function in mandibular gron'ih. Most authoriiies agree that sofFtissue development carries the mandible forward and downward, while condylar growth
fills in thc resultant space to maintain contact with the base ofthe skull.
In infancy, the ramus is located at about the spot whre the primary fir$ molar will erupt. Progressive posterior remodeling creates space for the second primary molar and then for the sequential eruption ofthe permanent molar teeth. More often than not, however, this growth ceases before enough space has been created for
eruprion oflhe third permanent molat which becomes impacted in the ramus. Note: After age 6, the greatelt increese in size ofthe mandibl occurs distal to the first molars.
In contrast to the maxilla both endochondral and periosteal aclivity are important in growth of
tbe mandible. Cartilage covcrs the surface ofthe mandibular condyl at the TMJ. Akhough this cartilage is
not like rhe cartilage at an epiphyseal plate or a synchondrosis, hlperplasia, hypenropht and endochondral
replacemnt do occur there. All other aras ofthe mandible are formed and grow by direct surface appos!
Irnportlnt:
..
rda,
.
';e;
. Palate
. Tuberosity
. Incisor
. Zygomatic
36
CoplriShr O
201 |
The bony maxillary arch lengthens horizontally in a posterior direction. Bone has been deposited on the posterior-facing cortical surface ofthe maxillary tuberosity. Resorption occurs on the opposite side ofthe same cortical plate, which is the inside surface ofthe maxilla
modeling.
l$ote$j
'k;
migrates downward and forward away from the cranial base and
undergoes significant surfac remodeling. This surface remodeling includes resorption of bone anteriorly and apposition of bone inferioriy.
2. Much ofthe anterior movement ofthe maxilla is negatedby anterior resorption,
and downward migration is augmented by inferior apposition ofbone.
3. As growth of sunounding soft tissues translates the maxilla downward and forward, opening up space at its supedor and postedor sutural attachments, new bone
is added on both sides ofthe suturs.
4. As the maxillary tuberosity grows and lengthens posteriorly, the whole maxilla
is simultaneously carried anteriorly.
.
.
.
.
nasomaxillary complex
anterior cranial fossa
The
The
The
The
palate
body ofthe mandible
Thc cunent concept is that late incisor crowding develops as thc mandibular incisors, and perhaps the
entirc mandibular dentition, move distally relative to thc body ofthe mandible late in mandibular growth.
Late incisor crowding does occur in individuals with no third molars at all, and so the presence ofthesc
teeth is not a c tical variable
extent oflate mandibular growth is a critical variable.
-the
Cephalocaudal gradient of growthi simply means that there is an axis of increased growth extending
from the head toward the feet. When the facial growth pattem is vierved against the perspective ofthc
cephalocaudal gradient, jt is not surprising that the mandible, being further away from the brain, tends
to gro$ more than the maxilla, which is closer. Remember: The mandibl can and does undergo more
Important:
L The maxilla, follows
show that groMh in height is very rapid after birth but decelerates quickly to
louer, more consistent level in childhood. Growth accelerates again around puberty before slowing and
vifually stopping at maturiry Key point: The timing of $owth spurts is important in orthodontics.
.,. l
,,Noteql'
*' --
The average peak growth for girls is around age 12, for boys it is around age 14.
2. Generally speaking, the earlier the growth spurt, the shorter the duration ofthe growth
.lun and the less overall the grourh will be.
3. Girls will generally start growth sooner, grow for a shorter amorult of time, and will grow
less than boys.
4. Because of time and variability, chronologic age often is not a good indicator
dividual's crowth status.
ofthe in-
.78%
'
98o/o
49Yo
38
CoDriglt
***
The cause
. A tooth-size discrepancy
. A mesiodens
. An abnormal frenum attachment
. A normal stage ofdevelopment
The spaces tend to close as the permanent canines erupt. The greater the amount ofspacing, the less the likeIihood that a maxillary central diastema will totally close on its own. As a general guideline, a maxillary central diastema of 2 mm or less will probably close spontaneously, while total closure of a diastema initially
garer than 2 mm is unlikely. Note: lfthe space is 2 mm or less and the maxillary laterals are in a good position, it is most likely the result ofa normal developmental proccss.
Ifit is caused by an rbnormal frenum, it is best to align the teeth orthodontically and then do
Usually this is not done until the permanenl caoines erupt.
Accepted methods ofclosing
frenectomy.
a diastema:
springs
.I
\ote:
likely to occur following early loss ofa primary maxillary central incisor.
clefting ofthe lip and/or palate occurs in I of 700 - I,000 bifihs, making
i! the most common craniofacial birth defect.
2. The lip and primarJ- palat begin to develop at four to five weks gestational age. The two medial nasal swellings and the maxillary s$'ellings fuse io form the upper lip. Failure ofthis fusion
rcsults in clcft lip. Clefts ofthe lip are more frequent in malcs. Cleft lip involvement is more frequent on the left side than the right.
3.The secondary palate develops at approximately nine weeks devlopmental age. Tle paired
palatal shelves arise from the iDtraoral maxillary processes. These shelves, originally in a vertical
1. In rhe United States,
\oL3,
'
_
'-'
a horizontal position as the tongue assumes a more inferior position. Thc palatal
shelvcs fuse with one another andwith the primarypalate anteriorlt which, in tum arises from the
fusion ofmaxillary and mandibular processes. Failure of fusion results in a cleft palatc. Clcft
position, reorientto
Remembr: The maxillary arch is slightly longer in length compared to the mandibular
arch. The reason is the sum ofthe M-D diameter ofthe maxillary permanent teeth is approximately 128 mm, whereas the sum of the M-D diameter of the mandibular
permanent teeth is approximately 126 mm.
\ot
2.
3.The grand design of the human face is the result of remodeling and displacement which interact to produce the final result.
4. Displacement and remodeling can occur in opposite directions.
5. The functional matrix theory (the 3rcl theory o the back oJ card #34)
holds that:
r Qnft ticc,re ic
.. ,nrim
--..-4ry
. Bone is responsive to soft tissue
. Both
40
Cop)'dght O
20ll-2012
Denta! Decks
second molar
41
***
Failure ofa permanent tooth to erupt may cause damage to roots of other teeth and also
create a severe orthodontic problem. Orthodontic consultation is indicated when first observed on an x-ray. An impacted canine or other tooth in a teenage patient can usually be
brought into the arch by orthodontic traction after being surgically exposed. In older patients, there is an increasing risk that the impacted tooth has become ankylosed. Even
adolescents have a risk that surgical exposure ofa tooth will lead to ankylosis.
It{ote: Research suggests the association of impacted canines with missing lateral inci
sors or shortened roots oflateral incisors. The distal aspect ol the root of lateral incisors
suides the eruotion ofcanines.
This separating device (brass wire) will cause the permanent first molar to be tipped
distally.
Ectopic eruption occurs when a tooth erupts in the wrong place. It is most likely
in the eruption of maxillary first molars and mandibular incisors. Its occurrence
more common in the ma"rilla and is often associated with a developing skeletal
pattern. It is seen in about 2-6Yo of the population and spontaneously corrects
about 60olo ofcases.
to occur
is much
Class
II
itself in
Ifthe eruption path ofthe maxillary lirst molar carries far too mesially at an early stage,
the permanent molar is unable to erupl and the root of the primary molar may be
damaged. The mesial position of the permanent molar means that the arch will be
crorvded unless the child receives treatment. Remember: This mesially inclined position
ofthe permanent molar makes it susceptible to decay. If it shows signs ofcaries, extract
the adjacent primary second molar immediately. The resultant space can then be
maintained as part of orthodontic treatment.
Ectopic eruption of mandibular lateral incisors, which occurs more frequently than
mandibular first molars, may lead to transposition ofthe lateral incisor and canine. A poor
eruption direction of the canine, sometimes leading to impaction, is observed often but
usually is due to the eruption path being altered by a lack ofspace.
1.
. 2-3 weeks
. l-2 months
. 2-6 rnonths
. 6-12 months
. 2-3 years
42
Coplrighl
aq
201l-2012
Denial Decks
ORTHODONTICS
Normal occlusion
Class I malocclusion
Class
II malocclusion
Class
III malocclusion
*** A severely tipped molar or one that requires mesial movemmt to shorten the pontic space requires a longer
treatment time.
A fixed edgewise orthodontic appliance is usually used for molar uprighting. The bracket slot size of0.022
inch allows a wide mnge of wire sizes to be used. The altemate slot size is 0.018 inch, which can also upright
the molar, but limits the wire sizes available. The tipped second molar should be banded because ofthe considerable posterior masticatory forces produced can easily shear offbonded brackets.
Facts about molar uprighting:
. A severely lingually tipped mandibular molar is more difficult to control and upright proPrly.
. Molar uprighting treatment in high angls cases will tend to result in excessive bite opening (increases
vertic a I d imens i on of occ lusion).
. stebilization should lasi until the lamin{ durr and PDL reorganize. This ranges ftom approximately 2
months (simple uprightind to 6 monrhs (uprighting plus osseous s rgery, grafts, etc.).
. Retention (slabilization) can be provided by an appliance or by a well-fitting provisional restoration,
which will stabilize the tooth positions. This will allow for reorganization ofthe PDL.
\ote:
Slow progess in molar uprighting in an adult patient is most likely due to occlusal intrfrences.
a tooth, t\do scena os can develop depending on whether the force
. Heavy force:
- lniti^l peiiod (from secoruls to weeks)t causes
n?crosis.) and
lamina dura). When this occun an inevitable delay in tooth movement occurs.
-Secondary period oftooth movement fdfer lhe above happens)t lhe PDL heals and there is secondary tooth movement. Note: It is best to Nvoid excessive orthodontic force.
. Light force: the use ofliglt forces causes smooth continuous tooth movement without formation ofa sig_
nificamly hyalinized zone in the PDL. Osteoclasts attack the adjacent lamina dura, removing bone in the
process of"fiontal resorption" which begins tooth movement. As a result teeth start to move earlier and
in a more physiologic way than do teeth subjected to hea\y forces.
Important: For a tooth to move, osteoclastic cells must be formed, which will remove bone from the area adjacent to compression ofthe PDL. Osteoblasts also must form newbone on the tension side, but the timing of
osteoclestiq not osteoblaslic, activify is critical.
Normal occlusion = C
The triangular ridge ofthe mesiobuccal cusp ofthe maxillary first molar articulates in the buccal groove ofthe mandibular first permanent molar.
Classlmalocclusion=D
Class I malocclusion has the normal molar relationship but the incorrect line ofocclusion.
Class
II
malocclusion = A
Class II malocclusion has the mandibular molar placed behind or posterior to the maxillary
molar.
Class
III
rnalocclusion = B
Class III malocclusion has the mandibular molar olaced forward or anterior to the maxillary
molar.
44
Cop),right O 201l-2012 - De.tal Dcks
. Class I
Class
. Class
II, Division I
III
kr
l'cosd4u ahinebn.ertu
45
Copyrighr
201 I
There may be a dispropo.tion between the size ofthe maxilla and mandible or between the jaws and tooth
size resulting in overcrowding ofteeth or i1r abnormal bite pattems. Supemumerary teeth, malformed
teeth, impacted or lost teeth and teeth that eiupt in an abnormal direction may contribute to malocclusion. Less fiequent causes ofmalocclusion include habits such as thr-rmb sucking or tongue thrusting-
'.,
/Noae*lil
- - I
;
..
l.The significance of the lack of sp.cing relates to the increased mesiodistal width of the
Permanentteeth.
2. Arch perimeter does increase after eruption ofthe incisors. Howeveq it is a small increase
rn the maxilla, and essentially non-existent in the mandible. Therefore, the minimal arch
grofih does not usually contribute to further dental alignment.
3.The premature loss ofthe mandibul.r primary canine reflects insuflicient arch size in
the anterior region. As such, the crowns ofthe lateral incisors, during eruption. impingc on
the roots ofthe primary canines causing them to resorb. When the canine is shed, the midIine will shift in thc direction ofthe lost tooth. You will have lateral and lingual migration of
the mandibular incisors.
4. The maxillary anterior primary teeth are about 7570 ofthe sizc oftheir permanent successors.
5. The
At birth, the alveolarprocesses are covered by gum pads, which soon are segmented to indicate the sites
of lhe developing teeth (called gum pad stage). The maxillary arch is horseshoe-shaped and the gums
rend !o extend buccally and labially beyond those in the mandible; furthermore, the mandibular arch
is posterior to the maxillary arch when the pads contact.
II, Division 2 is a malocclusion in which the body of the mandible and its
superimposed dental arch are also in distat relationship to the maxilla, and the molar and
canine occlusion are the same as Class II, Division I type. The distobuccal cusp ofthe
maxillary first molar occludes in the buccal developmental groove ofthe mandibular first
molar. and the maxillary canines occlude mesial to the mandibular canines. The big difference between Division I and Division II is in Division II the maxillary laterals have
tipped labially and mesially.
Class
Remember: Class II, Division I = maxillary incisors (centrqls qnd laterals) are in extreme labioversion. Anterior teeth are most likely to be fractured in children with this
n ne of mixed dentition malocclusion.
There is no set rule as to when a malocclusion should be treated. The age at
which it is treated depends on the problem involved.
2. Malocclusions are more identifiable in children 7 to 9 years old because the
eruption of permanent incisors reveals tooth-arch length discrepancies.
I
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5n. 45
.60; 35
70. ?5
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. Narrow face
. Narrow oropharyngeal space
. Chronic rhinitis: inflammation ofthe mucous membranes ofthe nose
. Chronic tonsillitis
. Allergies
. Deviated nasal septum
Note: The earliest possible diagnosis ofthis open bite is essential because the condition
is not self-correcting and usually worsens with time. Anterior open bites can be classified as a form of apertognathism (which neans open bite deJbrmity)
The mandibular incisors overlap anterior to the ma"\illary incisors. The maxillary canine is distal to mandibular canine. Class III is associated with a prognathtc (concave)
facial profile.
Note: The nasolabial angle is the angle between the base of the nose and the upper lip,
it should be perpendicular or slightly obtuse.
84o
4'
4A
. Both
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**x Remernber: An SNA Algle of> 84' indicates maxillary prognathism, An SNB angle
of < 78' indicates mandibular retrognathism and an ANB angle of < 4' indicates a harmonious skeletal profile. Note: The ANB angle describes the relation of the maxillary
and mandibular denture bases.
Severe mdocclusion may compromise all aspects oforal function. There may be difficulty
in masticating ifonly a few teeth meet, andjaw discrepancies may force adaptive alterations in swallowing. It can be difEcult or impossible to produce certain sounds in the
presence of severe malocclusion, and speech therapy may require some preliminary orthodontic treatment. Referral to a speech therapist is helpful because both patient and
parents are likely to benefit from the counseling. Even less severe malocclusions tend to
affect mastication, swallowing and speech; not so much by making the function impossible as by requiring physiologic compensation for the anatomic deformity.
*** A concave
.
\otes
1. An orthognathic profile is one in which the nose, lips and chin are harmoniously related. This relationship is usually accompanied by a Class I dental
a Class
III
of
of
lingually.
3. A rtrognathic profile is one in which there is a protruding upper lip or the
appearance of a recessive mandible and chin, or convex profile. The convexity is due to the relative prominence of the maxilla compared to the mandible.
The mandibular incisors will most likely be tipped forward. This relationship
is usually accompanied by a Class II malocclusion.
4. As children mature their profiles become less convex.
5. Speech is affected in severe malocclusions along with other oral fturctions
(i.e., swallowing and mastication). For example, patienls with a skeletal Class
III malocclusion sometimes have difficulty pronouncing "f' and "v" soutds.
Important: A bimaxillary dentoalveolar protrusion means that in both jaws the teeth
protrude. This condition is seen in facial appearances in 3 ways: excessive separation of
the lips at rest (rnco mpelence), severe lip strain @eeded to bring the lips into closure), and
prominence of lips in the profile view.
. Retrognathism only
. Overbite only
. Underbite only
. Overbite or retrognathism
. Underbite or prognathism
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. Class I malocclusion
Class
II malocclusion
Class
III malocclusion
. Normal occlusion
51
*** Subdivisions:
when the distoclusion occurs on one side ofthe dental arch only, the
unilateral distoclusion is referred to as a subdivision of its division. For example:
. Class II, Division I Subdivision: one side of the maxillary arch is in a Class II relationship with its occluding mandibular quadmnt while the other side is in a Class I relationship. The protruded maxillary incisors (centrals and laterals), maxillary overjet,
and other anterior aberrations, are usually confined to one side ofthe maxillary arch.
III malocclusions arc those in which the body ofthe mandible and its superimposed dental
arch are in a mesial relationship to the skull base and maxilla. The maxillary first molar therefore
occludes distal to the mandibular first molar, while the maxillary canine is an exaggerated distal
relationship to the mandibular canine. The mandibular incisors are usually tipped lingually and
forward to the maxillary incisors. Also characteristic ofthe "true" Class lll malocclusion is the
prognathic mandible. Class III subdivision is a Class III relationship of the teeth on one side
Class
pseudo-class III malocclusion is one in which the mandibular incisors are forward ofthe maxincisors when in centric occlusion, however, the patient has the ability to bring the mandible
back $ithout strain so that the mandibular incisors can touch the maxillary incisors (this ability
is ofren considered diagt?o.ttlc). This type is therefore a milder form ofthe "true" Class Ill malocclusion and more amenable to conservative orthodontic novement than the "true" Class lll malocclusion u,hich often requires sugrcal corection.
--\
illao
lll
malocclusion:
Dental factors:
,o
mehtal) factor, therefore the postnatal causative factors may not be the pnmary cause.
Class
I
1
Class
III
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the body ofthe mandible and its superimposed dental arch are in a distal relationship to the maxilla and the ma,rillary incisors are usually in a labial axial inclination. In addition, the relationship ofthe maxillary
first molars and canines to their mandibular counterparts is such that the distobuccal cusp
ofthe maxillary first molar occludes in the buccal developmental groove ofthe mandibular first molar and the maxillary canines occlude mesial to the mandibular canines. Besides the labial axial inclination ofthe maxillary incisors (overjet), various abenations in
the individual alignment ofthe teeth (for example, crowding) canbe superimposed upon
In most
cases Class
this class.
Remember: Class II, Division I Subdivision includes malocclusions, which have one
side ofthe maxillary arch in a Class II relationship with its occluding mandibular quadrant, while the other side is in a Class I relationship. The maxillary overjet or other anterior aberrations are usually confined to one side ofthe maxillary arch.
),{ote: Relative to a heterogeneous population, the incidence of malocclusion in a homogeneous population generally is lower.
III malocclusion) is an anteroposterior dentoalveolar relationship characmore anterior position ofthe mandibular dentition compared to the maxillary dentition.
Clinically. there are two types of mesio-occlusion. The first t,?e is considered to be a positional
form, as a result of a mesial displacement ofthe mandible into an anterior position and has been
named in a different ways (pseudo, functional or apparent).The other form of mesio-occlusion is
a truc skeletal Class lIL Thc characteristics ofthis malocclusion result from a combination ofskclelal and dentoalveolar features.
Mesio-occlusion 1Class
terized by
maxillary incisors.
T}le benefits attributed to the treatment ofpseudo-Class
lll
are:
crossbite can help lo ninimize adaptations that ate often seen in seyere late adolescent maloc-
ch6iotl)
and habits, such as bruxism that can develop from antenor or posterior interferences
. Gaining space for eruption ofcanines (lack of space could be catsed by retro-inclination of
upper incisors frequentlyfound in pseudo or Class III malocclusion)
. Avoiding the risk ofperiodontal problems to mandibular incisors caused by the traumatic occlusion due to the crossbite.
\ote:
The "Sunday bite" is a term given to the forward postural position ofthe mandible which
is adopted by people with Class II profiles in an effort to improve their esthetics.
Al
abnormal flenum
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. Rickets
. Hlperparathyroidism
The cephalometric analysis ofthe Class I occlusion would indicate an ANB angle ofless than
4 degrees signif ing a harmonious skeletal prohle and sagittal harmony between the maxillary
and mandibular dental arches. The most common cause ofClass I malocclusion is a discrepancy between tooth structue and the amount of supporting bone (length). Perhaps the most
prevalent characteristic ofClass I malocclusion is crowding (i.e., insulficient alveolar qrch
length to qccommodate all teeth in ideol alignment qnd in q good sqgittql position).
When a diagnosis is made that crowding does exist and this crowding exceeds 4 mm in the
mandibular arch, extractions are often required to attain an excellent, stable result. However,
the decision whether to exftact teeth depends greatly on a space analysis performed on the
mandible. Th patient should be refrred to the orthodontist for this analysis.
In general:
when the space lacking is less than 4mm, in most cases it can be obtained by carefully
stripping some interproximal enamel from each ofthe antedor teeth
. A space deficiency exceding 4mm usually indicates extraction for correction of the
malocclusion
***
The generalized eruption failure or "primary failure of eruption" is caused by the failure
ofthe eruption mechanism itself. Bone resorption proceeds normally, but involved teeth
simply do not follow the path that has been cleared. The involved teeth do not erupt spontaneously and are not amenable to any orthodonlic recourse. This condition is rare.
The localized causes of failure of eruption or the delayed eruption of the teeth include:
. Congenital absence
. Abnormal position ofthe crypt
. Lack of space in the arch (crowding)
. Supemumerary teeth
. Dilacerated roots
Remember: Anodontia, diagnosed in a 5 year old child, primarily affects the growth of
*** The bone
the alveolar bone fas opposed to the midface, maxilla, or mandible, etc.).
ofthe alveolar process exists only to support the teeth. Ifa tooth fails to erupt, alveolar
bone never forms in that area; and ifa tooth is extracted, the alveolus resorbs after the extraction until finally the alveolar ridge completely atrophies.
. A non-nutritive sucking habit leads to malocclusion only if it continues during the mixed
dentition stage
. Negative pressure created within the mouth during sucking is not considered
constriction of the maxillary arch
a cause
of
. "Adenoids" which lead to mouth breathing, cannot be indicted with certainty as an etiologic agent ofa long-face pattem ofmalocclusion because studies show that the majority ofthe long-face population have no nasal obstruction
56
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. In the maxillary
arch, the primate space is located between the central incisors and
lareral incisors
. In the maxillary
arch, the primate space is located between the lateral incisors and
canines
.In
the mandibular arch, the primate space is located between the canines and first
molars
.ln
the mandibular arch, the primate space is located between the lateral incisors and
canines
Recent studies indicate that "tongue tbrust swallowing" can not be blamed for an open bite
as it was shown that there is no tongue-force on the teeth during swallowing even though
the tip ofthe tongue is placed forward.
The tendency to place the tongue forward between the teeth (in cases ofanterior open bite)
appears to originate from the need to attain an oral seal during swallowing. So, the for-
ward position ofthe tongue during swallowing is due to the arterior open bite, the reverse is not true
tongue thrust swallow therefore should be considered the result
-"A not the cause."
ofdisplaced incisors,
A sucking habit that is stopped prior to mixed dentition has not been shown
to lead to malocclusion.
2. The negative pressure created within the mouth during sucking is not what
causes the maxillary constriction. It is the force from the buccinator muscles
1.
that does.
r**
t$o locations.
These primale spaces are normally present from the time the teeth erupt. Developmental spaces between the
incisors arc often present from the beginniDg, but become somewhat larger as the child gtows and the alveo_
lar processes expand. Generalized spacing ofthe primary teeth is a requireme[t for proper alignment ofthe
permanent incisors. This slacing is most frequently caused by the growth ofthe dental arches.
If spacing is present, there is a possibility that dritting ofthe adjacent teeth will occur if there is a loss of a
primary incisor. However, if there is no spacing present and the primary anterior teeth were in contact before
the loss, a collapse in the arch after the loss ofone ofthe primary incisors is almost certain.
lmportrnt: This is not true in the case ofa lost permanent incisor. Space closure occun mpidly whether spacing is present or not prior to the loss. Space maintenance would be indicated.
Remember: One ofthe most common cruses of malocclusion is inadequate space management following
the early loss of primary teeth.
Class relationships
Step relationships
. Primitive relationships
. Occlusion relationships
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In these cases (ie/ashlerminal-plane),the fiIst permanent molars do not erupt immediately into
normal relationship. As you can see, the first permanent molars are in a Class Il relationship. The
Class II relationship usually is temporary until the second pdmary molars are lost and the permaE
nent nolars move into a Class I relationship. This occurs at approximately age ten or eleven and
is called the late mesial shift, Both the mesial-step and flush-terminal-plane relationships usually
result in the development of a Class I permanent molar occlusion, although the flush-terminalplane relationship can result in a Class ll relationship ifthe late mesial shift does not occur Another stcp relationship involves a situation where the distal suface of the mandibular primary
second molar is located to the distal ofthe distal surface ofthe maxillary primary second molar.
This is termed a distal-step relationship. In these cases, the permanent molars erupt into a Class ll
relationship. lmportant: The terminal plane relationship ofprimary second molars detennines
the future anteroposterior positions ofpermaneot firct molars.
a
Sometimes the permanent mandibular canines erupt facially relative to th primary canines.
However, often they are right in line with the primary canines. Ifthere are problems in eruption. these teeth can be displaced either lingually or labially, but usually they are displaced labially ifthere is not enough room to accommodate them within the arch.
.. , l. The mesial inclined plane ofthe primary maxillary canine articulates with the
,\oto* distal inclined plane of the primary mandibular canine. This is the normal rela'*aii' tionship.
2. In both the maxillary and mandibular arches, the permanent incisor tooth buds
lie lingual as well as apical (inferior) to the primary incisors. The result is a tendency for the mandibular permanent incisors to erupt somewhat lingually and in a
slightly inegular position. This occurs even in children who have normal dental
arches and normal spacing within the arches.
3. Permanent teeth normally move occlusally and buccally while erupting.
4. Remember: The maxillary arch is sli glttly longer (approximately 128 mm) than
the mandibular arch (approximqteu 126 mm )-
. Both
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***
ImportsDt:
l. The primary anterior teeth (ihcisots ahd canines) are narrower than their permanent successors
mesiodistally.
2. The primary molars are wider than their permanent successors mesiodistally.
*** This size di{ference has clinical significance. The diffrence is called the leeway space.
The mandibular leway space avemges about 2.5 mm on esch side while the maxillary leeway space
averages about 1.5 mm on e.ch sid. The important factor is that some space will be avaihble in the
posterior palt ofthe mouth. This leeway space serves to at least accommodate the permanent canines,
which are generally larger than the primary canines.
During the canine-premolar transition period, the permanent first molars generally move mesially
into the leeway space after the primary second molars are shed, thus causing a loss in arch length.
Note: This is referred to as "the late mesial shift ofa permanent first molar."
On occasion, the permanent incisors "spread out" due to spacing. This is referred to as the
"ugly duckling stage"of development. With the eruption of the permanent canines, the
spaces often
will
will probably
mm is unlikely.
2. The permanent dentition stage begins when the last primary tooth is lost.
3. For the maxilla and mandible: Crowth in the width is completed first, then growth in
length, and finally glowth in height.
4. Maxillary and mandibular arch widths increase and this is completed before the adolescent growth spurt
5. The dental arch perimeter (length) decreases a surprising amount during the late adolescent and young adult periods due to the late mesial shift ofthe permanent molan into the
leeway space, the mesial drift tendency ofthe posterior teeth in general, and the lingual positioning of the incisors.
6. Increases in the vertical height ofthe jaws and face continue until 17 or l8 in girls and
in the earlv twenties in bovs.
Overbite
(deep bite)
ndts
li
Overbite is the vertical overlapping ofthe maxillary anterior teeth over the mandibular
anterior teeth. Overbite is generally is 10ok to 2jo/"but can vary up to 50olo.
Overjet
Overjet is the horizontal projection ofthe maxillary anterior teeth beyond the mandibular anterior teeth (labial axial inclination of the maxillary incisors). Normal overjet is 23 mm.
. Mandibular incisors
. Maxillary incisors
12
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. It
. It
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A mixed dentition an^lysis (transitional dentition analysis) detemines space available versus space
required. The analysis is based on a cofielation oftooth size; one may measure a tooth or a group ofteeth
and predict accurately the size
same mouth.
In thc Moyers' mixed dentition analysis, the size ofthe unerupted canines and premoJars is predicted
from knowledge ofthe siz,e (nesiodistal \|idth) ofthe mandibular incisors that have already erupted into
the mouth early in the mixed dentition. The maxillary incisors are not used in any ofthe predictive procedures, since they show too much variability in size.
Notei The mandibular incisors are measured to predict the size ofmaxillary
as
terior teeth.
lf mandibular antcrior crowding is notcd during thc mixcd dcntition phase, thc most appropriate approach to management is to take study models and perform an arch length analysis. This mandibular incisor crowding usually results from a tooth size-arch length discrepancy,
Mired dentition stage:
. That period during which primary and permanent teeth are in the mouth together, the earliest indication ofa mixed dentition consists ofthe prirnary dentition and the permanent mandibular first
molars.
. Supervision ofa child's development ofocclusion is most critical during this mixed dentition
stage.
there are two very important aspects to the mixed dentition period:
:.
\'ention.
. \ormal characteristics ofthe mixed dentition stage: molar and canine relationships are Class l;
lec$ay space is present; well-aligned incisors or up to moderate crowding ofthe incisors; proximal
contacts are tight.
. The total leeway space is the important clinical consideration and the method
leeway space is the key factor in th transitional dentition.
***
ofutilization ofthe
L \4easure the mesial-distal diameter ofthe mandibular incisors and add them together
2. Veasure the space available for the rrandibular incisors
3. Subract # I from #2
*** A negative number indicates crowding in the incisor region
\leasure the space available lor the canine and premolars on each side ofthe arch
5. Calculate ftom the prediction table the size olthe canine and premolars
6. Subtract #5 from #4 on each side
""" Once again, a negative number indicates crowding
-1.
as described