Board Review

Rene S. Johe, DMD UMDNJ-NJDS

Drift of Teeth
Mesial and occlusal Throughout life Slows down in adults With missing teeth posterior segments tip mesially or supererupt, necessitating molar/premolar uprighting

Eruption
Permanent incisors erupt lingually compared to their primary counterpart Permanent canines usually erupt buccally compared to their primary counterpart Permanent incisors erupt in a labial direction (greater inclination), resulting in increased arch circumference Permanent canines erupt slightly more distally than their primary counterpart.

Malocclusions
Know Class I, II, and III malocclusion concepts Class I malocclusion has a well related skeleton, rotated and/or crowded teeth Class II relationship
Mandibular canines DISTAL to maxillary canines

Growth Concepts
Sites of Growth
Maxillary tuberosity Mandibular lingual tuberosity (Ramus) Alveolar growth

Growth and Deposition / Resorption

V principle Remodeling / Relocation

Growth Concepts
Dimensions of Growth
Width mostly set by age 6 A/P (Depth) grows to age 18 Vertical variable can grow longest

Facial Types
Brachycephalic short face Dolichocephalic long face

Class III cases

Anterior crossbites
Correct as soon as possible

Skeletal problem Late growth Maxillary crowding probable May be associated with a shift (pseudo-class III occlusion)

Cephalometric Radiographs
Landmarks (magnified ~9%)
Sella, Pogonion, Menton, Orbitale, A point, B point, etc

ANB values
>5 degrees Skeletal Class II <0 degrees Skeletal Class III

Value Norms
SNA maxilla - 82 deg SNB mandible - 80 deg ANB maxilla to mandible 2 deg

Cephalometric Radiographs
Wits Denture bases 0 to -1 Inc. to NA or NB - Incisor position Growth Direction Y axis, mand plane angle, occiput (0,32, 23) Proportions rule of 1/3s, UFH to LFH Soft tissue S line, E line, H angle

Analyses to assess lip position

(A) Ricketts analysis: a reference line, the E line, is drawn from the tip of the nose to the soft tissue pogonion. The distances from the upper lip and lower lip to the E line are measured in millimeters. (B) Steiner analysis: the upper reference point is at the center of the Sshaped curve between the subnasale and the nasal tip. The inferior landmark is soft tissue pogonion. The distances from the upper lip and lower lip to the reference line are measured. (C) Holdaway analysis: an angle, termed the H angle, between the soft tissue facial plane (N-Pog) and a line tangent to the upper lip and soft tissue pogonion (H line), and the distance from the lower lip to H line are measured. (D) Merrifield analysis: the inner angle between the profile line (tangent to the soft tissue chin and the more prominent point of the upper lip or lower lip) and the FH plane are measured, called the Z angle

Moyers / Space Analysis

Moyers Analysis measures LOWER INCISORS and predicts CANINES and PREMOLARS Bolton Analysis evaluates a tooth size discrepancy
Ratio LESS than normal - relative maxillary excess Ratio MORE than normal - relative mandibular excess

Molar Uprighting
Typically due to missing teeth (premolars) Involves fixed appliances Problems encountered
Periodontal defects Occlusion (open bite problems) Long treatment time

Class II types
Class II div I
Normal growth tendency Maxillary incisors proclined, large overjet

Class II div II
Horizontal growth tendency Maxillary central incisors retroclined, maxillary laterals proclined Deep bite

Supernumerary teeth
Vast majority in the maxilla (90%) Most common is mesiodens, then paramolars Others include
Maxillary lateral incisors Maxillary premolars Mandibular premolars

Feature of Cleidocranial Dysplasia

Oligodontia
Also called (partial) anodontia, hypodontia Most common missing teeth are
Third molars Maxillary lateral incisors tied with Mandibular 2nd premolars

Feature of Ectodermal Dysplasia

Tooth Movement
PDL
Elastic, reactive tissue
Biologic Electric theory Pressure Tension theory

Movement
High Force
Blood vessels occluded (Hyalinized), Undermining Resorption

Low Force
Blood Vessels not occluded, Frontal Resorption

Ideal force depends on root area, type of movement, and other factors

Orthodontic forces
Ideal forces are light
Different forces are ideal for different teeth, depending on root surface area The bone will remodel with ideal light forces

Strong forces
Produces undermining resorption Produces hyalinized connective tissue

Properties of Wires
Stainless steel
High stiffness, high load/deflection curve, Martensitic phase hardest but brittle

Nickel titanium
Low stiffness, low load/deflection ratio Exhibits hysteresis
Deactivation force less than activation force

Martensite (soft, pseudoelastic) vs Austenite

Space Maintainers
Fixed
Band and Loop Distal Shoe Lingual Arch Nance Appliance / TPA appliance

Removable (some space regaining)

Lip Bumper Headgear

Primate spaces
Location
Mesial to maxillary canines, distal to mandibular canines Used up by erupting incisors

Primate Spaces

Primary to Mixed Dentition

Early Mesial shift spaces (including primate spaces) present, allows for shift to class I occlusion when molars erupt Late mesial shift no spaces present, leeway space allows for shift to class I occlusion when premolars exfoliate

Lower Incisor crowding

Normal in females age 7-11
Incisor liabilty

Later occurs due to mesial drift of teeth and late mandibular growth NOT related to 3rd molar eruption

Leeway space
Mandible 2.5mm / side Maxilla 1.5mm / side

Terminal Plane Relationships in Primary Dentition

Arch Width Changes (Skeletally)

Growth in width of both jaws, including the width of the dental arches, tends to be completed before the adolescent growth spurt and is affected minimally if at all by adolescent growth changes Intercanine width is more likely to decrease than increase after age 12

There is a partial exception to this rule, however. As the jaws grow in length posteriorly, they also grow wider.
For the maxilla, this affects primarily the width across the second molars, and if they are able to erupt, the third molars in the region of the tuberosity as well.

Average changes in mandibular canine and molar widths in both sexes during growth. Molar widths are shown in red, canine widths in black.

For the mandible, both molar and bicondylar widths show small increases until the end of growth in length

Arch Width Changes (Dental)

As growth continues, the teeth erupt not only
upward but also slightly outward
There is a slight increase in the width of the dental arch across the canines This increase is small, about 2 mm on the average, but it does contribute to the resolution of early crowding of the incisors. More width is gained in the maxillary arch than in the mandibular, and more is gained by boys than by girls. For this reason, girls have a greater liability to incisor crowding, particularly mandibular incisor crowding.

Incisor Liability

Etiology of Malocclusion
Genetics
Less than 50% cause

Epigenic (Epigenetic)
Habits Early primary tooth loss
Distal eruption of lateral incisor causing loss of primary canine Loss of primary second molar causing mesial drift of permanent 1st molar

Trauma

Etiology of Malocclusion
Missing teeth
Most common (max lateral, mand 2nd premolar) not acct for 3rd molars

Supernumerary teeth
Most common (mesiodens, lat inc, premolar)

Ankylosis
Most common, Primary 1st molar, most problematic, Primary 2nd molar

Appositional bone growth vs Interstitial bone growth

Interstitial
Occurs at sutures
two-sided periostial membrane Usually requires cartilage

Appositional
Enlarges the existing portions of bones
Does not require cartilage Requires periosteum and endosteum

Endochondral vs Intramembranous ossification

Cranial Base
Endochondral, some genetic control at synchondroses (spheno-occipital remains active well into childhood)

All other facial bones including Maxilla and Mandible

Intramembranous, little or no genetic control Condyle is secondary cartilage appositional growth

Steiner Values
SNA
82 degrees
< = retrognathic, > = prognathic

SNB
80 degrees
< = retrognathic, > = prognathic

ANB
2 degrees
< rel max retrognathia or mand prognathia < rel mand retrognathia or max prognathia

Overbite vs Overjet
Overbite
Can be Deep or Negative (Openbite) Changes with craniofacial growth Mandibular incisors touch palate Impinging overbite

Overjet
Can be due to
Incisor proclination or retroclination Skeletal discepancy Negative overjet = crossbite

Chronological vs Dental Age

Can vary by a significant amount It is possible for:
A 9 year old to have a full complement of permanent teeth A 14 year old to have 12 primary teeth remaining

Different races display different dental ages at set chronological ages.

Fixed vs Removable Appliances

Removable Appliances

head gear lip bumper face mask Schwartz

Standard Edgewise Straight Wire Hyrax, Haas expanders Crozat appliance

Fixed Appliances

Hawley Retainer
Most commonly utilized retainer Advantages
Anterior tooth control Allows some settling of occlusion Easy to adjust

Disadvantages
Canine control Occlusal interferences Extraction treatment relapse concerns with clasps

Dental Spacing
Can be normal
Mixed dentition in maxillary arch

Can be due to
Small teeth (tooth size discrepancy) Frenum Habits (tongue thrust, thumb sucking)

Causes of Open Bites

Skeletal
Vertical growth can be due to genetics, mouth breathing

Habits
Tongue thrust Thumb sucking

Serial Extraction
A planned sequence of tooth removal that can reduce crowding and irregularity during the transition from the primary to the permanent dentition.
Used in severe crowding cases where transverse expansion in the mixed dentition will likely be unsuccessful.

Indications for Serial Extraction

1) No skeletal problem exists 2) Large space discrepancy 3) Normal overbite

Impactions
Most common
Maxillary canines Mandibular third molars

Less common
Incisors Mandibular canines Premolars

Usually require exposure Tooth may become ankylosed

Headgear Types + Effects

Cervical and High Pull Headgear Straight Pull is a combination of both

Fixed appliances
Brackets are bonded to the teeth. Archwires are wires that connect all the teeth in one arch. Ties (metal or rubber) hold the archwires into the brackets.

The Andrews design

The straight wire appliance was designed to incorporate all 1st, 2nd, and 3rd order bends. This includes in/out step (first order), tip (second order), torque (third order), up/down step, antirotation, and anti-tip. It utilizes the LA point and relates this point to the appliances.

The straight wire concept relies on three points being on that same plane, namely the LA point, the base point, and the slot point.

Six Keys to Occlusion

Molar relationship Crown angulation (tip) Crown inclination (torque) Rotations Contacts Curve of Spee

Alignment and leveling

Goals Bring teeth into alignment Correct vertical discrepancies Derotate teeth where necessary Establish a more ideal arch shape

Correction of molar relationship and space closure

Goals Correction to Class I molar relationship if 4 bicuspids were extracted or non-extraction treatment Correction to Class I canine relationship Close (extraction) spaces if present Correct overjet relationship

Finishing
Goals Parallel tooth roots Align tooth marginal ridges Idealize occlusion Idealize esthetics and function Utilize elastics as necessary

Types of tooth Movements

Intrusion Extrusion Tip Rotation Torque

Removable Appliances
Clasps
Adams, C clasps, Ball clasps Labial bow Springs (finger, mattress, etc) Screws (expansion, mini)

Posterior Crossbites
Skeletal
Narrow maxilla Molars not tipped palatally

Dental
Normal maxillary base Molars tipped palatally Associated with habits / soft tissue

Retention
Growth throughout life Reactive and passive, not active Transseptal and Supracrestal fibers Intercanine width Overcorrection Relapse is not predictable Third molars do not cause incisor crowding

Soft tissue Appearance of Skeletal Problems

Class III
Scleral Display Lack of Zygoma Midface deficiency Vertical Growth

Class II
Small mandible (90%) Horizontal Growth

Transseptal and supracrestal Fibers

Attached to cementum Elastic fibers Are difficult to remodel Increase risk of relapse Necessitates either:
Overcorrection Fiberotomy

Speech Effects
Several malocclusion characteristics can have speech effects. Their etiology can be different. The most common are:
Open bites Spacing Incisor irregularity

Iatrogenic Orthodontic Problems

All orthodontics is intrusive and can therefore have iatrogenic side effects such as:
Irritation Pain Plaque problems Allergic reactions

Elastics
Utilized to:
Correct molar/canine relationship Intercuspate occlusion Different types for different malocclusions
Class I Class II Class III